N213: Health Differences Across the Lifespan 3 Study Guide
Chapter One: Infectious and Communicable Diseases Infectious and communicable diseases are illnesses that can be spread from one person to another. These are also commonly referred to as contagious diseases. The causative organisms are bacteria, viruses, parasites, fungi, and protozoa. The person who catches one of these causative organisms becomes known as the host . In order for someone to get acutely ill with an infectious or communicable disease, all the conditions have to be in place. Let’s take a look at how that happens: 1.1 Infections Chain of Infection The person who gets sick or catches a communicable disease goes through a cycle known as the “chain of infection.” This is when the causative organisms, that cause infectious and communicable disease, leave one host by “mode of transmission” and enter another host. There is a “portal of exit” out of one host and a “portal of entry” into the new host.
Portal of Exit
Portal of Entry
Mode of Transmission
The chain of infection first starts with an organism, and then a reservoir. It then finds a way out of the reservoir and travels on a mode of transmission. This is when the organism goes through a portal of entry into a susceptible host. With infectious and communicable diseases, this cycle can repeat itself over and over spreading illness.
N213: Health Differences Across the Lifespan 3 Study Guide Example A fourteen-year-old boy goes to school withmeningitis. He just picked it up a few days ago and doesn’t feel any symptoms yet. The organism is present in his body and he is the reservoir . He then coughs on another classmate, which is the mode of transmission . The other classmate breathes in droplets from his cough, which is the portal of entry . This classmate has not been getting enough rest, is not eating right, and is under a lot of stress. This makes the exposed classmate a susceptible host and this person also becomes ill withmeningitis. This is how the chain of infection works. All of the steps need to be in place in order for someone to become ill with a communicable disease. Modes of Transmission Modes of transmission are the different ways that infectious and communicable diseases are spread. These include respiratory droplets (droplet contact), sexual contact, indirect contact (touching a surface that contains an organism), and fecal-oral route. Respiratory droplets (droplet contact): • Tuberculosis • Mononucleosis • Rubeola (Measles) • Streptococcal infections • Rubella (German Measles) • Varicella • Respiratory Syncytial Virus • Haemophilus Influenza • Swine Flu (H1N1) • Mumps • Epiglottitis • Otitis Media • Pertussis (Whooping Cough) • Avian Influenza (H5N1) • Legionnaires’ disease Direct and sexual contact (body fluids and blood): • Hepatitis B and C • HIV/AIDS • Herpes Simplex • Cytomegalovirus • Sexually transmitted diseases (Syphilis, Gonorrhea, and Chlamydia) • Conjunctivitis Fecal-Oral Route: • Infectious diarrhea • Pinworms • Giardiasis • Hepatitis A Another mode of transmission is vector born transmission . Examples include being bit by a mosquito that carries the West Nile Virus or a tick that is carrying Lyme disease.
N213: Health Differences Across the Lifespan 3 Study Guide Another infectious disease type with a few different modes of transmission is nosocomial infection . These are infections that patients acquire during hospitalization. The modes of transmission can be lack of hand washing by medical personnel, contaminated instruments or needles, or a current infectious disease not being isolated properly in hospitals. This is why hand washing is the number one defense against the spread of infection. Vector borne infections: • Lyme disease • Encephalitis (mosquito-borne) Nosocomial infections: • MRSA (Methicillin Resistant Staphylococcus Aureus) • VRE (Vancomycin Resistant Enterococcus) Other contagious infections: • Staphylococcal Infections • Scabies • Rabies Complications of Infectious Diseases Without proper and prompt treatment, infectious diseases can have serious complications. In babies, young children, the elderly, and the immunocompromised, complications could often be fatal. Any infections, whether viral or bacterial, need to be evaluated by a physician, treated promptly, and monitored closely for changes or worsening of symptoms. Septic shock (gram-negative bacteremia), meningitis, and rheumatic fever are all results of an overwhelming infection in the body. At Risk Populations for Infectious Disease Communicable diseases can affect anyone at any time. There are populations in society that are at higher risk of complications from certain infectious diseases. It is important for nurses to look at certain populations in regard to developing a care plan and giving the most appropriate care. The at-risk populations for serious complications include: • Newborn infants • Small children under the age of five • Anyone with chronic health conditions • People on immunosuppressant medications • Health care workers
N213: Health Differences Across the Lifespan 3 Study Guide
IV drug users People who have unprotected sex
• Elderly patients (Note: Elderly patients may exhibit symptoms that are unusual for infection. Confusion, altered mental status, tachycardia, Tachypnea, sub-normal body temperature, and hypotension may signal infection in an elderly patient.) Newborn infants are at risk for exposure from diseases from their mother, nosocomial infections in the hospital, and infectious disease in the general public after discharge. Certain infectious disease antibodies in the mother do provide some protection in the infant for up to the first six months, but early immunizations are necessary to protect them from communicable disease. Small children under the age of five are at risk from communicable disease in daycare centers, physician’s offices, and other public places. Before children start school, they tend to have less mature immune systems. Once they start school, they are exposed to a number of viruses and bacteria, which allow their bodies to begin to build up immunities. Also, schools require immunizations to protect them from certain communicable diseases that are known to cause severe complications. Older children with health conditions are at risk for severe complications from communicable disease, which makes immunizations necessary and also the use of isolation precautions when appropriate. The elderly patient is at risk due to an aging immune system and length of time since immunizations were given. The CDC now recommends booster immunizations for zoster (shingles) and annual flu shots for older people. Immunosuppressant medications in anyone can raise the risk of catching a communicable disease, and even with immunizations, this population needs to be protected with strict infectious control and isolation precautions. Health care workers must practice good hand washing, needle safety, and use personal protective equipment (PPE) at all times to protect themselves from infection and transmission. IV drug users and people who practice unprotected sex with multiple partners place themselves at high risk for disease transmission from blood and body fluids. Taking these factors into consideration when working with infectious diseases will remind you to always practice universal precautions on a daily basis in your work. Always regard every patient as “potentially infectious” with any possible communicable disease and you will reduce the risks of infection and transmission. 1.2 Mode of Transmission: Respiratory or Droplet Contact Infectious diseases that are transmitted by respiratory or droplet contact are spread by coughing, sneezing, talking, kissing, sharing utensils or cups, and sometimes even just breathing. These diseases need to be contained with the use of masks, tissues when coughing or sneezing, or even isolating the ill person. Because of this type of transmission, you will probably need to wear a hospital mask or be asked to “gown, mask, and glove” for certain procedures, or when exposure to infections is a possibility.
N213: Health Differences Across the Lifespan 3 Study Guide
Tuberculosis Mycobacterium tuberculosis, also known as TB, is a contagious disease that is spread when someone who has it coughs, sneezes, or breaths on someone else. Usually, for someone to catch TB, they need to be in constant and frequent contact with a patient who has tuberculosis. TB can be very hard to cure and may require long periods of several different antibiotics due to drug resistance. Also, a large number of patients with TB do not take their medications like they are supposed to. There is high incidence of TB in low income populations, jails, convalescent hospitals, and mental illness treatment facilities. Tuberculosis gets its name from where the infection occurs. The mycobacterium that causes the infection goes into the alveoli in the lungs and forms lesions, called tubercles. The infected person develops a cough that lasts for weeks or months. The incubation period for tuberculosis is an average of two to 12 weeks. People with compromised immune systems from HIV/AIDS, Autoimmune conditions, advanced age or other illnesses will almost always develop active tuberculosis if exposed. In healthy people, exposure does not necessarily mean they will develop active tuberculosis, but it may elicit a positive skin test regardless. Tuberculosis is diagnosed with a thorough assessment, skin test, and chest x-rays. Once diagnosed it is treated with an antibiotic regimen that lasts for up to one year, though sometimes as little as six months. For the first two to three weeks, TB patients are isolated until the bacterium is considered sterile from the antibiotics and no longer contagious. Patients must continue on antibiotic therapy for the full course of treatment to prevent complications, such as the spread of TB throughout the body, pneumonia, pleural effusion, drug resistance, meningitis, lung collapse, and coughing up blood. Long-term health care facilities will test all patients upon admission to a facility and nurses will be tested for TB upon any new nursing employment. This is to protect nurses and future patients in case someone has been exposed but does not show any symptoms of the infection. For example, Mr. Jones was in the admission process at XYC Convalescent Hospital. He had not yet had his TB skin testing done but complained of fevers, night sweats, and a bad cough that lasted for about six weeks. He was admitted and tested within the first 24 hours and the test was positive. The physician ordered isolation and treatment, but all the other residents and employees that came in contact with the patient needed prophylactic treatment with antibiotics as well. Signs and symptoms of tuberculosis: • Cough • Weight loss • Fatigue • Anorexia • Low-Grade Fever with spikes • Indigestion • Flu-like symptoms • Pleuritic chest pain • Dyspnea • Crackles • Hemoptysis • Night sweats
N213: Health Differences Across the Lifespan 3 Study Guide Further examination may reveal additional signs of lesions elsewhere in the body including lymph nodes, urinary tract, around the heart, or in the central nervous system. These are usually not found until the disease is quite advanced and early treatment can help prevent the spread of lesions. The biggest concern with the signs and symptoms of TB is the length of time the patient has been experiencing symptoms and the risk of exposure to others. This is where public health nursing can be a great resource for outbreaks of tuberculosis in communities. Health care providers are required by law to report any suspected or confirmed diagnoses of TB to the Centers for Disease Control (CDC) and the local health department within a timely manner. The county where the incident was reported will then assign a public health nurse to the patient’s case, who will take over and monitor for medication compliance, isolation precautions, and check for potential spread of the infection. Nursing assessment for tuberculosis: • Head to Toe General Assessment o Symptoms o Respiratory assessment focusing on character of cough and sputum with auscultation of breath sounds o Exposure history (employment, recent hospitalization, socioeconomic status, and living situation) • Review laboratory and radiographic data o Two or three step PPD test Positive past testing Positive previous chest x-ray o Chest x-ray Ordered for all positive PPD Ordered for positive exposures o Sputum cultures X 3 o TB blood testing (IGRA’s), interferon-gamma release essays, or (NAA) nucleic acid amplification, which are rapid TB tests that can be done in the lab Nursing diagnosis for tuberculosis: • Ineffective breathing pattern related to decreased lung capacity • Ineffective airway clearance related to increasing mucoid/mucopurulent sputum • Activity intolerance related to fatigue and poor nutritional status • Altered nutrition, low body requirements related to anorexia, fatigue, and decreased respiratory reserves • Risk for ineffective management of therapeutic regimen related to lack of knowledge of the disease process, prevention, and the need for adherence to treatment
N213: Health Differences Across the Lifespan 3 Study Guide Nursing interventions for tuberculosis: • Assess patients for respiratory status, nutritional status, fever, and medication compliance o Non-hospitalized patients may require public health or home health nursing care • Follow doctor’s treatment orders o Isolation for up to the first three weeks of drug therapy o Drug therapy for up to twelve months with: Rifampin (RIF): Sometimes used alone or in combination therapies; this drug may cause hepatotoxicity; tell patient it may turn urine and sweat orange Isoniazid (INH): Used alone or in combination therapy; have patient take on an empty stomach; side effects may include nausea, vomiting, and upset stomach; adverse effects may include neurotoxicity and hepatotoxicity Streptomycin(SM): Due to widespread drug resistance, this drug is not often used; adverse effects include ototoxicity Pyrazinamide (PZA): This drug is often used in combination with other therapies to prevent drug resistance; a side effect is stomach upset; adverse effects are hepatotoxicity Ethambutol (EMB): A combination drug that is often used with Rifampin and Pyrazinamide; side effects include blindness, joint pain, nystagmus, and color blindness; assess vision often with this drug; isoniazid (INH) should be given to anyone exposed and at risk for infection for six months after exposure • Address interventions to ineffective airway clearance first o Position patient to assist with drainage of secretions o Encourage patient to turn, cough, and take deep breaths (TCDB) o Provide oxygen and monitor O2 saturations and arterial blood gases per MDorders o Assess breath sounds frequently o Encourage increased fluid intake o Provide humidity • Offer antipyretics for fever, encourage increased rest for fatigue, and increased fluids for dehydration • For altered nutritional status, offer small, frequent meals, pleasant environment, easy to eat foods, and encourage rest after meals; avoid gassy foods and provide oxygen duringmeals • For ineffective management of therapeutic regimen, patient teaching is the first line of preventative care. Teaching points should include: o Complete teaching about tuberculosis, how it is transmitted, effects on the body, and complications; prevention of transmission by using tissues, handwashing, and isolation precautions o Assist patient with setting up medications; clarify times and dosage, side-effects to watch for, when to call the doctor, and how long to take the medication; instruct about possible drug resistance if medication is stopped too early
N213: Health Differences Across the Lifespan 3 Study Guide • Teach patients how to cope with activity intolerance o Encourage patient to take frequent rest periods and schedule activities to allow forrest o Instruct patient to rest after meals to allow for digestion o Encourage patient to pace themselves and not overdo things withtoo many activities Expected outcomes for tuberculosis: • Patient has relief of symptoms • Patient has a clear and airway • Patient can verbalize and demonstrate transmission prevention • Patient understands and verbalizes medication compliance Mononucleosis Mononucleosis is also known as “the kissing disease,” or “mono,” and is most often seen in children and young adults. This disease is most often transmitted via saliva and can be spread by kissing, sharing cups or utensils, and less often coughing or sneezing. It is most often seen in areas where young adults live in close proximity such as college dormitories and summer camps. The infectious organism is the Eppstein-Barr virus, which can have severe and profound effects on the spleen and other lymphatic organs in the body. It is actually a type of Herpes virus. If a patient with mono does not rest, the spleen can become enlarged and even rupture. Often, a patient does not even know they have mono for several weeks after infection. After transmitted, the virus incubates in the body for up to six weeks before acute infection begins. The active infection can last for weeks and months. After the acute phase, the virus can remain in the body and symptoms can return at any time under periods of stress. Mononucleosis is usually self-limiting and clears up with strict rest. Patients must be extremely cautious to avoid complications which include lymphadenopathy, enlarged spleen with possible ruptures, pneumonia, and impaired airway. The Eppstein-Barr virus is also suspected to be in connection with chronic fatigue syndrome, although it hasn’t been proven. Signs and symptoms of mononucleosis: • Sore throat • Throat swelling • High fever • Swollen glands • Anorexia • Myalgia • Glandular pain • Maculopapular eruptions • Extreme fatigue
N213: Health Differences Across the Lifespan 3 Study Guide
Nursing assessment for mononucleosis: • Head to toe general assessment o Symptoms
Inquire about time frame of symptoms; when they began andseverity Ask about behavior, such as sharing cups, utensils, toothbrushes, and kissing Inquire about friends and relatives who may be infected or possibly exposed o Check airway patency if pharyngitis is present • Review laboratory and radiology reports o A CBC may be checked for lymphocytosis o MonoSpot is the most commonly ordered test since it detects heterophilic antibodies High degree of false negatives or positives Only effective during the acute phase of the illness o IgM: A test for anti-bodies to the Eppstein-Barr Virus; peaks in acute phase then declines o IgG: A test for anti-bodies to Eppstein-Barr; peaks after onset and stays detectable indefinitely o Ultrasound, CT Scan, and MRI: These tests can check for lymphadenopathy, including an enlarged spleen Nursing diagnosis for mononucleosis: • Activity intolerance related to fatigue and fever • Altered nutritional status related to throat pain and infectious process • Ineffective management of therapeutic regimen related to lack of knowledge of the disease Nursing interventions for mononucleosis: • Assess patients for symptoms, activity intolerance, nutritional status, and understanding of disease • Give supportive care for symptoms: o Encourage increased fluids o Instruct patient to use warm salt rinses o Analgesics/Antipyretics for pain and fever o Soft diet for throat pain • Encourage increased rest for activity intolerance o Provide a quiet place to rest o Encourage limiting activities, especially heavy lifting if spleen is involved during the acute phase o Help patient with ADLs if necessary
N213: Health Differences Across the Lifespan 3 Study Guide • Teach patient about disease process, transmission, and management of symptoms o Teach the importance of not sharing cups or eating utensils and avoiding contact with saliva o Teach about complications due to inadequate rest and heavy lifting o Explain that the Eppstein-Barr virus can be long lasting and even permanent, but can be managed with adequate rest Expected outcomes for mononucleosis: • Verbalizes reduction in symptoms • Demonstrates knowledge of disease management and prevention of transmission • Verbalizes reduction in fatigue • Demonstrates the ability to pace self and manage activity levels Rubeola (Measles) Measles are one of the infectious diseases that most children are immunized for. This disease still poses quite a large health risk due to lack of immunizations in some, or reduction in immunity over a period of years after immunizations were given. Measles are caused by the Rubeola virus. The virus is highly contagious among non-immunized children, teenagers, and adults. It can be very harmful to pregnant women and their fetus because it is responsible for some birth defects. Complications in infected children are very rare, but can include otitis media, pneumonia, encephalitis, bronchiolitis, laryngitis, and mastoiditis. The virus is spread by coughing and sneezing and is a respiratory virus, even though there is a rash present. Once exposed, measles incubation can last up to two weeks before the acute phase of illness. The duration of the illness usually lasts anywhere from seven to 10 days. Signs and symptoms of rubeola (measles): • Fatigue • Lethargy • Fever • Cough, runny nose, and cold-like symptoms • Conjunctivitis • Maculopapular rash from head to toe • Photosensitivity • White spots in the mouth (Koplik’s spots)
N213: Health Differences Across the Lifespan 3 Study Guide
Nursing assessment for rubeola (measles): • Head to toe general assessment o Length of symptoms o Check temperature o Listen to breath sounds o
Look for appearance of Koplik’s spots in the mouth and rash on trunk, face, and arms • Inquire about exposure history, outbreak in school, family members, or daycare centers • Ask about immunizations; current, completed series • Inquire about general health status of patient and health conditions Nursing interventions for rubeola (measles): • Assess patient frequently for respiratory, fever, and skin issues • Encourage adequate fluids • Antipyretics for fever; instruct no aspirin products for virus in children • Offer frequent rest periods • Keep room dark and quiet • Give adequate skin care to prevent scratching • Patient teaching for immunizations • Instruct for isolation precautions, especially from pregnant women • Teach about complications Expected outcomes for rubeola (measles): • Demonstrates adequate airway clearance • Verbalizes reduction in symptoms • Verbalizes knowledge of immunizations • Ineffective airway clearance related to increased secretions • Knowledge deficit related to compliance with immunizations • Risk for altered body temperature Streptococcal Infection Streptococcal infections are caused by Group A Streptococci and are a very contagious and common infection. The most common symptom is pharyngitis, but strep can infect any part of the body. The Strep bacteria can be the cause of skin infections, pneumonia, and kidney inflammation (glomulonephritis). If strep goes undiagnosed, one main complication is septicemia. Other complications can include rheumatic fever, otitis media, sinusitis, and damage to the heart valves.
N213: Health Differences Across the Lifespan 3 Study Guide Strep is transmitted by direct contact with saliva or respiratory contact. Once infected, incubation takes up to three days. The duration of the illness usually lasts up to a week. When it manifests as pharyngitis it causes sore throat, febrile illness, and throat swelling. In pneumonia, it can cause severe coughing, dyspnea, and may be accompanied by phyaryngitis and otitis media. Untreated strep can travel to the glomeruli and cause an antigen-antibody reaction in the kidneys. This can lead to kidney failure. Septicemia can develop when the bacteria enters the bloodstream. This is a very severe complication and requires immediate intervention. This infection is a very common and highly contagious infection in children and adolescents. Nurses will see a lot of this infection when school is in session and in the warmer months. There will possibly be trends of strep infections due to outbreaks. When this happens, the doctor may often make the decision to treat the infection in even suspected cases of strep. Signs and symptoms of streptococcal infections: • Sore throat • Fever above 101⁰ F • Malaise • Vomiting • Anorexia • Swollen lymph nodes • Red pharynx • Headache • Lesions on face and lips • Chills and cough • Tachycardia • Tachypnea (pneumonia) • Green/rust colored sputum • Decreased breath sounds • Dull chest percussion/crackles Nursing assessment for streptococcal infections: • Head to toe general assessment o Temperature o Breath sounds and airway patency o History of exposure and duration of symptoms o Nasopharynx assessment o Swallowing ability • Review laboratory and radiology reports o Rapid strep screen test (high degree of false negatives) o Complete blood count; cultures of blood and sputum o Arterial blood gas for suspected pneumonia o Chest x-ray
N213: Health Differences Across the Lifespan 3 Study Guide Nursing diagnosis for streptococcal infections: • Impaired gas exchange related to inflammation and infection of the airway, especially distal air spaces • Risk for altered body temperature • Pain related to the inflammatory process • Risk for fluid volume deficit related to difficulty swallowing • Activity intolerance related to hypoxia and weakness, secondary to altered respiratory function • Risk for ineffective management of a therapeutic regimen related to a knowledge deficit of the disease process Nursing interventions for streptococcal infections: • Provide antipyretics for pain and fever • Encourage increased fluids, popsicles, or ice chips • Administer orderedmedications: o Penicillin and Cephalosporin: These are the first line of treatment in people with no sensitivities or allergies to these drug classes o Erythromycin: Used for those who are allergic to Penicillin or Cephalosporin, but not a first line treatment as it may take longer to relieve symptoms • Instruct on medication compliance, encourage no smoking, and teach deep breathing exercises • For pneumonia, place the patient in an upright position to facilitatebreathing • Teach the patient to turn, cough and deep breathe (TCDB) every twohours • Give oxygen if ordered by MD • Check breath sounds frequently and 02 saturations if needed • Give salt water rinses for throat pain • Humidify the air in the room • Monitor for cyanosis, hypoxia, and signs of confusion • Offer a soft diet and small, frequent meals • Encourage rest periods or strict bed rest depending onseverity Expected outcomes for streptococcal infections: • Demonstrates no respiratory distress and maintains stable 02 saturations • Afrebrile with no alteration in body temperature • Verbalizes reduction in pain • Demonstrates adequate fluid intake and output • Able to tolerate increased activity • Demonstrates knowledge of disease process and medication compliance
N213: Health Differences Across the Lifespan 3 Study Guide
Rubella (German Measles) The Rubella Virus is the cause for the German measles and is also known as “three-day measles.” This illness is significantly shorter than Rubeola and less severe. This virus is prevalent in children in the spring and winter months. This virus is transmitted by coughing and by direct contact. Once infected, the incubation period is 14 to 21 days. After the incubation period ends, the duration of the illness only lasts up to five days, but more commonly three days. The period in which Rubella can be transmitted is seven days prior to the onset of the rash until about five days after the rash begins. Complications to an unborn fetus can be severe and include birth defects. When not infected, mothers may pass on immunity to Rubella during pregnancy from a previous infection. Complications in children and adults include encephalitis, thrombocytopenia, and arthritis. There is a rash that can almost mimic the measles and is called Roseola. Nurses will often be confronted by alarmed parents thinking their child has the measles, only to find after an evaluation by the doctor that the child actually has Roseola. This is a harmless rash that is caused by the immune system reacting to certain viral infections. Symptoms of rubella: • Prodromal stage: Low-grade fever, cough, fatigue, conjunctivitis, swollen glands (lymphadenopathy), throat pain, headache, cold-like symptoms; in very young children there may be no outward symptoms during this stage, which makes the illness easily spread among daycare and school populations • Acute stage: Rash that spreads from head downward, lymph nodes swell the day before the rash appears, spots on the soft palate (enanthem), low-grade fever, throat pain, fatigue, malaise Nursing assessment for rubella: • General head to toe assessment o Temperature o Breath sounds and airway patency o History of exposure and duration of symptoms o Lymph node assessment • Skin Assessment: monitor for itching and skinbreakdown Nursing diagnosis for rubella: • The diagnosis for rubella does not usually need laboratory or radiology reports • Risk for altered body temperature • Risk for altered nutrition related to throat pain • Risk for skin breakdown related to rash • Knowledge deficit related to immunizations