Infectious Disease and

ImmuneBy: Diana Blum MSN

Metropolitan Community CollegeNURS 2150

• http://www.youtube.com/watch?v=TteIB1oo4C0&feature=related

History

• Protects the body against infection and cancer development

• Stimulates tissue growth and repair after injury• Inflammation causes damage• Are able to fail to recognize self and launch a

defense against own cells= autoimmune response

• Those compromised include but are limited to: cancer pts, HIV patients, etc.

Immune System

Anatomy Parts• Bone Marrow• Granulocytes

o Neutrophilso Basophilso Eosinophils

• NonGranulocyteso Monocyteso Lymphocytes

• Lymph Systemo Nodes o Tonsils and adenoidso spleen

Natural Immunity• Body provides its own protection• Includes

o Skino MMo Gastric pH

Acquired Immunity• After birth includes:

o Antibodieso Tcellso Bcellso cytokines

• Activeo Production of antibodies in response to foreign antigen. o Get by getting disease or vaccineo Involves lymphocytes

• Aka: Allergyo Responds to antigen that we have been exposed too; ex. Cat dandero s/s: itchy, watery eyes, sneezing..to more life threatening like asthma,

anaphylaxis, bronchoconstriction, or circulatory collapse• Example: allergic rhinitis

Contact can be: inhaled, ingested, injected, tactile

Life threatening like anaphylaxis involve blood vessel and bronchial smooth muscle with systemic dilation, decreased cardiac output, and bronchoconstriction

Hypersensitivity

5 types1: rapid IgE hypersensitivity: most common, increase in IgE, causes release of histamine from basophils, eosinophils, and mast cells

anaphylaxis, asthma, etccaused from hay fever, latex allergy, peanuts, bees, etc.

2: cytotoxic: rx of IgG w/ host cell membrane; ex. Myasthenia gravis, blood transfusions

3: immune complex: formation of immune complex in walls of blood vessels; ex lupus, rheumatoid arthritis

4: delayed or cell mediated: rx of sensitized T cells w/ antigen and release of lymphokines that induce inflammation; ex. Poison ivy, positive TB test, graft rejection

5: stimulated: rx of auto antibodies with normal cell surface receptors that cause an overreaction of the target cell; ex. Graves’ dx

Immunocompromised Population

• Ask for onset, duration, and detailed history• Ask about, work, school, hobbies, home, sports• Ask about allergies of family members b/c some

are inherited• Assess for rhinorrhea, itchy watery eyes,

headache especially over sinuses, dry scratchy throat

• Obtain CBC, Immunoglobin E level, scratch test, perform a food challenge

assessment

• Avoidance of allergen• Symptom relief• Medications: antihistamines, mast cell stabilizers,

decongestants, corticosteroids, allergy shots

interventions

• Most life threatening• Affects many organs within seconds• Not that common• Teach avoidance of allergen• If food related instruct to ask if present in foods at

restaurants• Epinephrine shots should be carried with them

Anaphylaxis

• s/s: impending doom, weakness, apprehension, general itching, hives, angioedema (lips, eyes, tongue), audible wheezes, anxiety, stridor, respiratory failure may occur, may be hypotensive, may have rapid irregular pulse, confusion may occur

• Eventually could lose consciousness and cardiac arrest

• Treatmento Assess respiratory function firsto This is an EMERGENCY, CALL 911o Establish airway if neededo CPR may be neededo Administer epinephrine 0.3 to 0.5ml of the 1:1000 concentrationo Benadryl given IV 25-100mgo Oxygen as neededo Monitor sats

• May be contact type• May be anaphylactic like

• Healthcare workers, clients with spina bifida, and those that use latex condoms are most at risk

• Tx: use non latex items

Latex Allergy

Respiratory interventions for immunity

• Excess fluid in lungs from inflammatory process• May be nosocomial in nature• If untreated it can go to blood and cause sepsis• s/s: atelectasis, hypoxemia, flushed cheeks,

myalgia, chills, fever, cough, tachycardia, dyspnea, sputum production, pain, crackles

• Causes: bacteria, virus, fungi, protozoa, helminths, etc. , toxic gases, smoke, aspiration

• Tx: sputum culture, cbc, HIV, abg’s, cxr, bronchoscopy, biospy, antibiotics,

Pneumonia

• Highly infectious• Transmitted via airborne route when someone

infected laughs, coughs, sneezes, whistles, or sings.

• More are infected than have active version• Caseation Necrotic tissue can be turned into a

granular mass in the center of the lesion..if found on xray it is called ghon tubercle or prime lesion

• The lesions then calcify or liquefy

TB

• Greatest risk: frequent contact, immune suppressed, HIV, those that live in crowded areas, homeless, drug users, low social class, foreign immigrants

• Assess: country of origin, travels, previous hx, anyone with BCG vaccine will test positive

• s/s: fatigue, lethargy, nausea, anorexia, wt loss, irregular menses, fever, night sweats, cough, bloody purulent sputum, chest tightness, local wheezing

• Diagnostics: culture, gram stain, TB tine, cxr

• Once positive always positive• Place in negative pressure room. • Airborne precautions• Wear n95 mask when working with client• Teach prevention • Vitamin c, iron , and protein are important for

those infected• Watch client swallow meds• Tx: meds

• Inflamed mucous membranes• Causes: deviated septum, polyps, tumors,

cocaine, facial trauma, nasal intubation, dental infection, decreased immune response

• s/s: obstructive swelling, facial pressure, pain, fever, headache, congestion, cough, tenderness, drainage

• Complications: meningitis, abcesses, cellulitis• Most common in frontal and maxillary sinuses• Tx: broad spectrum antibx, analgesics, humidity,

saline irrigation, lavage, removal of infection by way of surgery

Sinusitis

• Sore throat• Causes: group a strep or virus• Highest incidence b/w late fall and spring in colder

climates• s/s: dry sore throat, pain w/ swallowing, dysphagia,

fever, hypermia (redness), may or may not have enlarged tonsils, drainage can be thin or thick and even purulent

• Tx: throat cultures, cbc, lozenges, antibiotics• Instruct client to complete full course of antibx tx• If it does not improve, the client should check on

getting HIV testing or the client could be immunosuppressed

Pharyngitis

HIV/AIDSBy: Diana Blum RN BSN

Metropolitan Community CollegeNursing 2150

Immune System• Helps prevent infection• Failure is caused by 1 of 2 things

o Congenital abnormalities• Present at birth

o Acquired after birth• Infection, toxin, medical therapy

HIV/AIDs

Death is Result of Opportunistic infection

FoundIn 1981

AttacksCD4/ T cell

Class=Retro-virus

Poor prognosis

AidsAids

HIV

• http://video.google.com/videoplay?docid=-5219920342681496180&q=hiv+%22aids%22+educational+duration%3Amedium+is%3Afree&pr=goog-sl

3 categories

1. HIV positive 2. Asymptomatic Or 3. Persistent

Lymphadenopathy 4. Prone to Acute infections

1. HIV positive 2. Asymptomatic Or 3. Persistent

Lymphadenopathy 4. Prone to Acute infections

AA

B B 1. Bacterial Endocarditis, pneumonia or sepsis 2. Candidiasis for 1 or more months 3. Severe cervical dysplasia or carcinoma4. Fever or diarrhea x 1month or more 5.Oral hairy leukoplakia 6.Shingles (Herpes Zoster)7.Idiopathic thrombocytopenic purpura8. Pelvic inflammatory disease 9.Peripheral

neuropathy

1. Bacterial Endocarditis, pneumonia or sepsis 2. Candidiasis for 1 or more months 3. Severe cervical dysplasia or carcinoma4. Fever or diarrhea x 1month or more 5.Oral hairy leukoplakia 6.Shingles (Herpes Zoster)7.Idiopathic thrombocytopenic purpura8. Pelvic inflammatory disease 9.Peripheral

neuropathy

C C • 1. Pulmonary candidiasis• 2. Invasive cervical cancer• 3. Cytomegaly virus• 4. HIV related encephalopathy• 5.Herpes simplex • 6.Kaposi’s Sarcoma• 7. Lymphoma• 8. Tuberculosis• 9. Pneumocystis Carinii pneumonia• 10. Toxoplasmosis• 11. Wasting syndrome• 12.Salmonella Septicemia

• 1. Pulmonary candidiasis• 2. Invasive cervical cancer• 3. Cytomegaly virus• 4. HIV related encephalopathy• 5.Herpes simplex • 6.Kaposi’s Sarcoma• 7. Lymphoma• 8. Tuberculosis• 9. Pneumocystis Carinii pneumonia• 10. Toxoplasmosis• 11. Wasting syndrome• 12.Salmonella Septicemia

Pictures of cell with HIV/AIDS

Causes• Sexual: genital, anal, or oral

sex with exposure of the mucous membranes to infected semen or vaginal secretions

• Parenteral: sharing of needles or equipment contaminated with infected blood or receiving contaminated blood products

• Perinatal: from the placenta. from contact with maternal blood and body fluids during birth or from breast milk from infected mother to the child

HIV and the Healthcare Worker

• # 1 transmission between healthcare worker and client is NEEDLE STICKS

• ALWAYS use standard precautions

• Page 1926

Staging• Initial: lasts 4-8 weeks

o High levels in bloodo Flulike symptoms

• Latent: inactive until a virus presents than replication beginso Lasts 2-12 yearso Asymptomatic

• Third stage=opportunistic infectionso 2-3 years

S/S• Flu like symptoms• Fever• Night sweats• Swollen lymph nodes• Headache• Skin lesions that don’t

heal• Sore throat• Dyspnea• Burning with urination• diarrhea

• Fatigue• Weight loss

Complications

Opportunistic Infections

• These occur because Aids patients are immune suppressed

• More than one can occur at the same time

• Can be o Protozoano Fungalo Bacterial o Viral

Protozoan • Pneumocystitis carinii pneumonia

o DOE, tachypnea, persistent dry cough, fever, fatigue, wt loss• Toxoplasmosis encephalitis

o Caused by toxoplasma gondii contact w/ cat feces or undercooked meat

o Change in mental status, neurological deficits, HA, fever, diff speaking, vision and gait problems, seizures, lethargy, confusion

• Cryptosporidiosiso Intestinal infection caused by cryptosporidium organismso Mild diarrhea to severe wasting with electrolyte imbalances

Fungal• Candida albicanspart of natural flora in GI

tract (Stomatitis or esophagitits is common in the AIDS pt.)o Overgrowth in AIDS clients

• Cottage cheese like yellow/white plaques and inflammation (mouth), pruritis, perineal irritation, thick white vaginal discharge

• Frequent yeast infections is common in the female AIDS pt.

• Cryptococcosis mengititiso Fever, HA, blurred vision, N/V, nuchal rigidity,

confusion, seizures• Histoplasmosisbegins as respiratory

infection then to systemic infectiono Dyspnea, fever, cough weight loss, enlarged

lymph nodes spleen and liver

Bacterial• Recurrent Pneumonia

o CP, productive cough, fever, dyspnea

• Mycobacterium avium complex is most commono Affects respiratory and GI tracto + cultures are found in blood, bone marrow, and

lymph nodeso s/sfever, debility, wt loss, malaise, swollen lymph

glands and/or organs

• TBo Fever, chills, night sweats, wt loss, anorexia, cough

dyspnea, CP,

Viral• CMV (cytomegaly virus) can be in eyes, lungs, GI

tract, and CNSo Fever, malaise, wt loss, fatigue, swollen lymph glands,

blindness, colitis, diarrhea, abd bloating, discomfort, encephalitis, pneumonitis, adrenalitis, hepatitis, etc.

• Herpes Simplex Virusoccurs in perirectal, oral, and genital areaso Longer lastingo Numbness/tingling at site of infection, lesions that are

painful, fever, bleeding, lymph node enlargement, headache, myalgia, malaise

• Varicella Zoster (shingles)(chicken pox)o HA, fever, pain, rash,fluid filled blisters sometimes

Malignancies• Kaposi’s Sarcomamost common

o Related to herpes viruso Small purplish brown raised lesion that are not

usually painful or itchyo Lesions found in lymph nodes, intestinal tract,

lungso Diagnosed by biopsyo Assess #, size, and location of lesions and monitor

progression• Lymphomas non Hodgkin’s B cell lymphoma,

immunoblastic lymphoma (Burkitt’s) and primary brain lymphomao Weight loss, fever, night sweats

Endocrine Complications

• Gonadal dysfunction change in libido• Body shape changes buffalo humps or abd fat,

other areas of body appear to be wasting away• Adrenal insufficiency manifests as fatigue, wt

loss, N/V, hypotension, electrolyte imbalances• DM• Hypercholesterolemia

• Men with AIDS tend to have low testosterone levels

• Women with AIDS tend to have irregular menstrual cycles

OTHER Complications• Dementia may be from infection,

medicationo Neuropathies, pain, gait disturbance, confusion

• Wasting Syndrome not because of any one problem, usually from metabolism issueo Diarrhea, malabsorption, anorexia, oral and

esophageal lesions

• Skin changes dry, itchy skin with possible rasheso Low platelet level can mean petechiae or

bleeding gums may also be present

TESTING• Positive ELIZA test• Positive Western Blot test• Lymphocyte Counts• CD4/CD8 Counts• Antibody tests• Viral Culture• Viral Loading Test• Quantitative RNA Assays• P24 Assay

• See pages 1934-1935

Treatment• No cure• Treat symptoms• Prevent infections• Encourage to eat balanced diet• Exercise regularly• Maintain good dental hygiene• Smoking/illegal drug cessation• Limit alcohol• Minimize stress• Practice safe sex

Nursing Care• Early stages- usually treated outpatient• Late stages- more intensive in nature• Infection is the leading cause of death in those

with HIV

• Education!• Education!• Education!

• This is the key!!!

• The higher the blood level of HIV (Viremia) the greater risk of transmission!!!

Client education• Use latex condoms • Store condoms in a cool dry place• DON’T use condoms from a damaged package• Handle condoms with care so as to not puncture

them• Teach clients how to properly apply condoms and

to use adequate water based lubricant• Replace a broken condom immediately• Follow recommended drug regimens• Encourage ways to maintain immune function

o Diet• Avoid raw or rare fish fowl or meat• Thoroughly was fruit and veggies

o Adequate resto Exerciseo Stress reduction

Nursing Diagnosis• Ineffective therapeutic regimen• Anxiety• Infection• Impaired oral mucosa• Imbalanced nutrition less than body requirements• Disturbed thought process• pain

Interventions• Provide education• Offer support group• Encourage questions • Encourage them to express self• Anti infectives• Medication education• Encourage regular dental hygiene• Have dietician see• Appetite stimulants• Saftey precautions• Monitor pain

• Your client is a 32 year old white male who is new to the outpatient clinic. He presents with fatigue, abd pain, low grade fever, nausea, and anorexia. Upon assessment you notice yellowing eyes and darkening urine. He states, “I try to eat right, take vitamins, and get rest.” he feels like he is getting worse. He was in a monogamous gay relationship for 6 yrs that recently broke up. He had unprotected sex 2 weeks ago. His last HIV test was 1 year ago and it was negative.

• He asks if his current symptoms are related to his recent sexual encounter. How do you respond?

• Wound you counsel this man to have an HIV test? Why or why not?

• Should you teach the client about safe sex practices? Why or why not?

• You are the charge nurse on a busy med surg unit at the hospital. Right before change of shift, one of the new hires tell you that she was giving her 78/f client insulin and accidentally stuck herself when placing the needle in the sharps container…in talking with other nurses she doubts that this is a high risk needle stick and thinks she will be fine. She washes off the blood throroughly and applies betadine to her finger. She wants to fill out the incident report and go home.

• How will you consel this nurse about needle stick injuries?

• What rights and obligations does she have?• What other blood borne diseases could she have

been exposed to?• Should the nurse notify her sexual partner(s) of

this incident? Why or why not?

• s/s: dry eyes, dry mm of nose and mouth, vaginal dryness, blurred vision, diff swallowing, epistaxis, enlarged lymph nodes, may have swollen painful joints,

• Fibromyalagia can also occur with this• Insufficient tears cause corneal inflammation and

ulcerations• Decrease in digestion of carbs, promotes tooth

decay• Tx: no cure, chemo like drugs,

immunosuppressives, tx symptoms

Sjogren’s Dx

MENINGITIS

• INFLAMMATION OF ARACHNOID AND PIA MATER OF THE BRAIN, CSF, AND SPINAL CORD

• Can be bacterial or viral, fungal, or protozoalo Bacterial and viral are the more common typeso Viral is self limiting (not life threatening)

• Organism enters via bloodstream

Most commonMay occur with herpes simplex or zosterNo organisms present in CSFTx: treat symptoms, acyclovir if genital

lesionsS/S:

◦ Fever◦ Photophobia◦ Headache◦ Myalgias◦ Nausea◦ Poss. Genital lesions◦ Rash

Viral

• Cryptococcus is most common fuguso Especially in AIDS patients

• S/S: vary but can include fungal sinusitis, fever, headache, nausea, vomiting, decrease LOC

• Tx: treat symptoms, IV antifungal agents

Fungal

• Medical emergency• Mortality rate of 25%• Most in fall/winter• Culprits: streptococcus pneumoniae and neisseria

meningitidis• Approx. 17,500 new cases each year in the USA• Meningococcal meningitis is the only bacterial

type that has outbreaks

Bacterial

• S/So Headacheo N/Vo Fevero Photphobiao Increased ICP that causes hydrocephaluso Nuchal rigidity (neck stiffness)o Seizureo Decreased LOCo Poss. gangrene

Bacterial

• Diagnosticso Lumbar puncture w/ broad spectrum antibx prioro Counterimmunoelectrophoresis- looks for virus/protozoao C&S of blood,urine, throat, and noseo CBCo BMPo Chest, sinus,mastoid xrayso MRI and/or CT to look for increased ICP

bacterial

Treatment◦ Neuro checks q 4 hours◦ Isolation◦ Broad spectrum antibx til cultures back◦ Possible to be on steroids◦ Monitor for complications

Septic emboli Temp, color, pulse,cap refill Hand circulation is the most affected

Shock Coag disorders Bacterial endocarditis Prolonged fever

Bacterial

• Inflammation of the brain parenchyma and meninges

• Affects brainstem, cerebrum, and cerebellum• Virus invades brain tissue and reproduces causing

and inflammatory process• Demyelination of axons occur• Widespread edema leads to increased ICP

Encephalitis

• Arboviruses: example west nileo Transmitted by infected tick or mosquitoo Usually asymptomatic otherwise flu like symptomso Has IGM antibody affectedo Incubation 3-12 days after biteo Transmitted thru breast milk , blood, organ trasplant

• enterovirus: examples:chickenpox, herpes zoster, mumps are most common causes.

• Amebae: virus found in warm fresh watero Enters nasal mucosa when swimming

types

• Fever• n/v • Stiff neck• Changes in LOC• Fatigue• Motor dysfunction• Increased ICP• Weakness• Hemiplegia• Seizure activity

• Monitor vitals• TCDB q2 hrs• Suction as ordered• Neuro check q 2 hrs• Meds

Assessment/interventions

• Pus like Infection of the brain • Organisms come from ear, sinus, mastoid• Can occur with septic emboli• Can be from penetrating trauma• Usually occurs deep within the cerebral

hemisphere and involves white matter• Most occur in frontal and temporal lobes

Brain Abcess

• s/s: headache, fever, lethargy, confusion, increased ICP, decreased LOC, airway and respirations may be affected

• Assess neuro function• Assess visual fields for blindness• Assess gait• CBC, CT, EEG, MRI, lumbar puncture

Assessments/diagnostics

• Antibiotics• Antiepileptics• Burr hole surgery to relieve pressure and drain• Crainiotomy

Treatments

• Reportable infection• 85% seen in new England, mid Atlantic, and upper Midwest,

and northern California• Caused by spirochete borrelia burgdorfori• From bite of deer tick• s/s:stage 1

o bulls eye rash is tell tale signo Malaise, fever, headache, muscle, joint ache/stiffness

• Stage 2: 2-12 weeks after tick biteo Carditis, dysrythmias, dizzy, palpitations, meningitis, facial

paralysis • Stage 3: weeks to yrs after bite

o Arthritis, permanent damage to joints• Tx: antibx

Lyme Disease

• a tickborne disease caused by the bacterium Rickettsia rickettsii. o is a cause of potentially fatal human illness in North and South America, and is transmitted

to humans by the bite of infected tick species. o In the United States, these include the American dog tick (Dermacentor variabilis),

Rocky Mountain wood tick (Dermacentor andersoni), and brown dog tick (Rhipicephalus sanguineus). 

• Symptoms: fever, headache, abdominal pain, vomiting, and muscle pain. A rash may also develop, but is often absent in the first few days, and in some patients, never develops. 

• can be a severe or even fatal illness if not treated in the first few days of symptoms.

• Tx: Doxycycline is the first line treatment for adults and children of all ages, and is most effective if started before the fifth day of symptoms

• Info from cdc

Rocky Mountain Spotted Fever

• Inflammation of the conjuctiva• Related to allergen exposure• Is not contagious unless from virus or bacteria

o Pink eye: blood shot eyes, edema, tears, discharge• Get cultures

• s/s: burning, engorged blood vessels, excessive tears, itching

• Tx: o Corticosteroids gttso Prevent spread if infectiouso Anti infectives if neededo Handwashing

Conjunctivitis

• 3 typeso Acute: r/t infection, sudden onseto Chronic: r/t infection, reoccuringo serous

• s/s: inflammation, swelling, irritation, possible purulent drainage, may cause permanent hearing loss if left untreated, ear pain, headaches, vertigo, may lead to perforated ear drum

• Tx: cultures, needle aspiration, cold therapy, heat therapy, antibiotics, analgesics, antihistamines, decongestants, surgery to place tubes

Otitis Media

• Infection of the mastoid air cells caused by otitis media

• May be acute or chronic• s/s: swelling behind the ear, pain, cellulitis, poss

perforated ear drum that is also red, and thick, tender enlarged lymph nodes behind the ear, fever, malaise, drainage, anorexia

• Tx: IV antibx, cultures, surgical removal of infected tissure

• Complications from surgery: damage to cranial nerves, decreased ability to look lateral, drooping mouth on affected side, vertigo, meningitis, brain abcess, wound infection

Mastoiditis

• Infection of the labyrinth which could be a result of otitis media.

• Infection is from erosion of bony capsule• May follow inner or middle ear surgery• May be viral in nature or related to mono• s/s: hearing loss, tinnitis, vertigo, nystagmus to

affected side, n/v• Meningitis is common complication• Tx: systemic antibx, antiemetics, stay in bed in

dark room until manifestations subside, gait training, PT

• Hearing loss may be permanent..provide support,

Labyrinthitis

• Tinnitus, one sided hearing loss, and vertigo• Attacks last several days• Unknown cause except that too much or too little

endolymphatic fluid is produced• Eventually hearing loss is permanant• Often occurs with infections, allergic reactions,

and fluid imbalance

Meniere’s Disease

• Neutropenic precautions• Thrombocytopenic precautions• Bleeding precautions• Protect from infections

Cancer

Skin Infection Management

• Contact---gown and gloves• Parasite---gown, gloves, cap, shoe covers, isolation,

hygiene, insecticide ointments, special shampoos, beding and clothes washed daily on hot water, dried in hot dryer

• Fungal— antifungals, culture, cool compress, skin off skin,

• Viral--- antiviral agents,treat symptoms, cryotherapy if warts, or duct tape for 2 months if wart

• Bacterial—antibiotics, potential debridement and drainage, cultures and senstivities, no sharing towels etc. Pain meds, rest contact precautions

Any Questions?