0133427269 Module09 Infection LectureOutline

Module 9 Infection The Concept of Infection Infection invasion of body tissue by microorganisms with the potential to cause illness or disease Immune system is bodys major defense mechanism against infectious organisms and abnormal or damaged cells Infection control is a central tenet of quality nursing care Microorganisms exist everywhere See Table 91 EXAMPLES OF COMMON RESIDENT MICROORGANISMS, p. 522 Asymptomatic, subclinical infection ( no evidence of disease Communicable disease ( illness directly transmitted (one person or animal to another by contact with body fluids) or indirectly transmitted (contact with contaminated objects of vectors, e.g., insects) Infectious disease ( any communicable disease caused by microorganisms, transmitted from one person to another or from animal to person Normal presentation Microorganisms vary in virulence (strength of ability to produce disease) Pathogenicity ( ability to produce disease Pathogen is microorganism that causes disease Opportunistic pathogen causes disease only in susceptible individuals Infectious disease major cause of death worldwide Asepsis ( absences of disease-causing microorganisms Medical asepsis ( all practices intended to confine a specific microorganism to a specific area ( limiting number, growth, transmission of microorganisms Clean ( almost all microorganisms are absent Dirty ( microorganisms likely to be present Surgical asepsis (sterile technique) ( refers to practices that keep area, object free of all microorganisms ( some destroy all microorganisms and spores Sepsis ( whole-body inflammatory process, resulting in acute illness Types of microorganisms causing infections Four categories of microorganisms that cause infection in humans Bacteria ( most common infection-causing microorganisms Viruses ( consist primarily of nucleic acid, must enter living cells to reproduce Fungi ( includes yeasts, molds Parasites ( live on other organisms Types of infections Colonization ( process by which strains of microorganisms become resident flora ( grow and multiply, do not cause disease Infection occurs ( when newly introduced resident microorganisms succeed in invading a part of the body where hosts defense mechanisms are ineffective Local infection ( limited to specific part of body where microorganisms remain Systemic infection ( microorganisms spread, damage different parts of body Culture of persons blood reveals microorganisms ( bacteremia Acute infections ( generally appear suddenly, last a short time Chronic infections ( develop slowly, over long period of time Chain of infection Six linkssee Figure 91 THE CHAIN OF INFECTION, p. 523 Etiological agent ( depends of the number of microorganisms present, virulence, potency (pathogenicity), ability of microorganisms to enter body, susceptibility of host, ability of microorganisms to live in hosts body Some microorganisms ( have ability to infect almost all susceptible people after exposure Reservoir ( sources of microorganisms Carrier ( human, animal reservoir of specific infectious agent that usually does not manifest any clinical signs of disease Portal of exit from reservoir ( microorganism must leave reservoir See Table 92 HUMAN BODY AREA RESERVOIRS, COMMON INFECTIOUS MICROORGANISMS, AND PORTALS OF EXIT, p. 524 Method of transmission Direct transmission ( immediate and direct transfer Droplet within 3 feet Indirect transmission Vehicle-borne transmission ( substance serves as intermediate means to transport, introduce infectious agent into susceptible host Vector-borne transmission ( vector ( animal, insect that serves as intermediate means of transporting infectious agent Airborne transmission Droplet nuclei ( remain in air for long periods of time Portal of entry to the susceptible host Skin is barrier to infectious agent Susceptible host Person at risk for infection Infants, young children ( immune systems not fully matured Compromised host ( person at increased risk See Table 93 NURSING INTERVENTIONS THAT BREAK CHAIN OF INFECTION, p. 526 Physiology review Individuals normally have defenses that protect body from infection Nonspecific defenses ( anatomic, physiological barriers, inflammatory response Specific defenses ( immune system ( antigen induces a state of sensitivity, antibodies respond to contain or destroy antigen Intact skin, mucous membranes first line of defense Nasal passages ( cilia and moist mucous membranes trap microorganisms, dust, foreign materials Oral cavity ( sheds mucosal epithelium to rid mouth of colonizers Eye ( tears continually wash microorganisms away GI tract ( acidity, resident flora, peristalsis Vagina ( pH inhibits growth Urine flow ( flushing, bacteriostatic action Genetic and lifespan considerations Host susceptibility ( affected by many factors Age ( immunizations Newborns ( immature immune systems Older adults ( immune responses become weak Heredity ( deficient in serum immunoglobulins Physical, emotional stressors Stressors elevate blood cortisone ( prolonged elevation decreases anti-inflammatory responses Nutritional status Medical therapies ( may predispose person to infection Radiation Medications ( increase susceptibility to infection Diseases lower bodys defenses against infection See LIFESPAN CONSIDERATIONS Infections, p. 528 Infectious process in older adults Older adults at greater risk Physiological changes Cardiovascular changes Respiratory system changes Genitourinary changes Gastrointestinal system changes Skin and subcutaneous tissue changes Immune changes Other factors Decreased activity levels Poor nutrition, increased risk of dehydration Chronic diseases Chronic medication use Lack of recent immunizations Altered mentation, dementias Hospitalization, residence in long-term care facility Presence of invasive devices Thymus gland atrophies ( cell-mediated immune function declines Antibody responses decline with aging Do not exhibit classic manifestations of inflammation ( classic signs of infection may be absent Supporting the defenses of a susceptible host Persons susceptibility to infection can be reduced by hygiene, nutrition, fluid, sleep, reducing stress, immunizations Alterations Microorganisms invade human body, proliferate, when undetected, uncontrolled, not eliminated by inflammatory, immune responses Resident bacteria part of defenses ( can become opportunistic pathogens in immunocompromised hosts Modern medicine Antibiotic therapy, immunizations, other public health measures Infectious diseases ( antibiotic-resistant strains of microorganisms Immunosuppressive therapy ( open to infection Poor hygiene in young children, caregivers ( fecal-oral, respiratory Pathogens Bacteria Mycoplasma Rickettsia and chlamydia Viruses Fungi Parasites See Box 9-1 PATHOGENIC ORGANISMS, p. 530 Mechanisms have evolved in pathogens to facilitate transmission Resistance to drying Producing toxins or enzymes to facilitate invasion Adhesion factors Toxins that alter, destroy normal function of host cells Exotoxins ( soluble proteins that microorganisms secrete into surrounding tissue ( poisonous, causing cell death or dysfunction Endotoxins ( found in cell wall of gram-negative bacteria, released when cell disrupted Stages of the infectious process Incubation stage ( pathogen begins active replication but does not yet cause symptoms Prodromal stage ( symptoms begin to appear ( often nonspecific Acute stage ( maximal impact of infectious process ( pathogen proliferates, disseminates rapidly Manifestations more pronounced If infectious process prolonged ( manifestations of continuing immune response apparent Convalescent stage ( infection contained, pathogen eliminated Carrier state ( host defenses eliminate infectious disease, organism continues to multiply on mucosal site See CONCEPTS RELATED TO INFECTION, p. 529 Alterations and manifestations Complications of infectious diseases Typically specific to infecting organisms, body system affected Acute invasion of blood by certain microorganisms ( septicemia, septic shock Systemic disease Shock ( hypotension, impaired organ perfusion Diffuse cell, tissue injury ( potential organ failure Healthcare-associated infections Healthcare-associated infections (HAIs)( infections associated with delivery of healthcare services in a facility Manifest after 48 hours of hospitalization Urinary tract infection ( most common HAI, most common cause of gram-negative septicemia in hospitalized clients Pneumonia Bacteremia associated with intravascular, urinary catheters Healthcare personnel at risk Believed to involve 2 million clients ( 90,000 deaths Source of microorganisms Endogenous ( client themselves Exogenous ( hospital environment, personnel Iatrogenic infections ( direct result of diagnostic, therapeutic procedures Compromised host Surgery Illness Antibiotic therapy altered bodys natural defenses Other pharmacologic therapy Invasive procedures Healthcare-associated pneumonia ( ICU residency, mechanical ventilation Insufficient hand cleansing Preventing HAIs Effective hand washing is the single most important measure in infection control Invasive equipment, procedures only when absolutely necessary Meticulous medical and surgical asepsis Critical thinking, agency policy ( rings, artificial nails Hand hygiene for client, nurse Antibiotic-resistant bacteria Due to prolonged, inappropriate use of antibiotic therapy ( sometimes a few bacteria survive Current resistant strains Methicillin-resistant Staphylococcus aureus (MRSA) Multidrug-resistant tuberculosis (MDR-TB) Penicillin-resistant Streptococcus pneumoniae (PRSP) Fluoroquinolone-resistant Neisseria meningitides Vancomycin-resistant Enterococcus (VRE) Vancomycin-intermediate or -resistant Staphylococcus aureus (VISA or VRSA) Extended-spectrum beta-lactamase (ESBL) Carbapenem-resistant Enterobacteriaceae Multidrug-resistant Pseudomonas aeruginosa MRSA ( becoming more prevalent in community settings ( colonizes in the nares, skin Vancomycin for hospital acquired MRSA Community acquired sensitive to other antibiotics Client with MRSA, VISA, VRSA ( private room, contact precautions VRE Enterococci part of normal flora of GI and female genital tract Contact precautions ( alone or with other VRE-infected clients Penicillin-resistant S. pneumoniae (PRSP) ( droplets ( transmission based droplet precautions C. difficile common cause of nosocomial diarrhea ( usually treated with metronidazole, vancomycin Extended-spectrum beta-lactamase-producing microorganisms ( resistant to third-generation cephalosporins Klebsiella, E. coli Indwelling urinary catheters, gastrostomies Universal precautions, hand washing, modest use of antibiotics ( critical actions for stopping spread of antibiotic-resistant bacteria CDC 12-step Campaign to Prevent Antimicrobial Resistance in Healthcare Settings Biological threat infections Increased level of concern about use of biological weapons Most likely pathogens( anthrax, smallpox, botulism, pneumonic plague, viral hemorrhagic fevers State public health systems charged with responsibility ( identifying cases, controlling spread of infection, preparing local/state responses Disease surveillance ( monitoring patterns of disease occurrence Pediatric infectious and communicable diseases Reducing number of preventable childhood illness major national goal in Healthy People 2020 Specific objectives Elimination ( rubella, congenital rubella syndrome, diphtheria, Haemophilus influenzae type b, measles, mumps, polio, tetanus Reduction ( pertussis, hepatitis B, varicella, food-borne pathogens, HIV See Table 9-5 SELECTED INFECTIOUS AND COMMUNICABLE DISEASES IN CHILDREN, pp. 533 - 542 Prevalence Healthcare workers at risk for infection Risk varies widely Genetic considerations and nonmodifiable risk factors Some medical therapies may predispose an individual to infection Radiation therapy Diagnostic tests Medications Any disease that lowers the bodys defenses places client at risk Chronic pulmonary disease Peripheral vascular disease Diabetes Older adults with multiple chronic disease Case Study Part 1 ( Sam Werner is a 58-year-old black man who comes to the emergency department because he is coughing up blood. Prevention Healthcare worker precautions Prevention of infection is a vital nursing role Nurses take multiple precautions to prevent infection in clients and in themselves Disinfecting and sterilizing Etiological agent and reservoir ( interrupted by use of antiseptics (inhibit growth), disinfectants (destroy pathogens other than spores), sterilization Disinfecting Disinfectant ( chemical preparation used on inanimate objects Antiseptic ( chemical preparation used on skin or tissue Bactericidal agent ( destroys bacteria Bacteriostatic agent ( prevents growth, reproduction of some bacteria Nursing considerations when disinfecting Type and number of organisms Recommended concentration of the disinfectant, duration of contact Presence of soap Presence of organic materials Surface area to be treated See Table 96 COMMONLY USED ANTISEPTICS AND DISINFECTANTS THEIR EFFECTIVENESS AND USE, p. 544 Sterilizing Sterilization ( process that destroys all microorganisms, including spores and viruses Moist heat Gas Boiling water Radiation Isolation precautions Isolation ( measures to prevent spread of infection, potentially infectious microorganisms to health personnel, clients, visitors Category specific ( strict isolation, contact isolation, respiratory isolation, tuberculosis isolation, enteric precautions, drainage/secretion precautions, blood/body fluid precautions Disease-specific Universal precautions (UP) ( techniques to decrease risk of transmitting pathogens Obstruct bloodborne pathogens Body substance isolation (BSI) (employs generic infection control for all clients, airborne ( based on three premises All people have increased risk of infection from microorganisms entering through mucous membranes and nonintact skin All people likely have potentially infectious microorganisms in all of their moist body sites and substances Unknown portion of clients, healthcare workers will always be colonized, infected with potentially infectious microorganisms in blood, other moist body sites Body substances ( blood, body fluids, urine, feces, wound drainage, oral secretions Avoid injury from sharp instruments, exposure measures, communication of biohazard information to employees Centers for Disease Control and Prevention (CDC) HICPAC isolation precautions Hospital Infection Control Practices Advisory Committee (HICPAC) of CDC ( new guidelines for isolation precautions Standard precautions ( used in care of all hospitalized persons regardless of diagnosis, infection status Transmission based ( used in addition to standard precautions for clients with known, suspected transmission Airborne precautions ( clients known to have, suspected of having serious illness transmitted by airborne droplet smaller than 5 microns Measles Varicella Tuberculosis Droplet precautions ( clients known to have, suspected of having serious illness transmitted by particle droplets larger than 5 microns Diphtheria Mycoplasma pneumonia Pertussis Mumps Rubella Contact precautions ( used for clients who are known or suspected to have serious illnesses that are easily transmitted by direct client contact, contact with items in clients environment Clostridium difficile Enterohemorrhagic Escherichia coli 0157H7 Shigella Hepatitis A (diapered, incontinent clients) Respiratory syncytial virus (RSV) Herpes simplex virus Impetigo Isolation practices Initiation of isolation practices generally a nursing responsibility ( based on comprehensive assessment of client In addition to precautions ( aseptic precautions Use strict aseptic technique when performing any invasive procedure Change intravenous tubing and solution containers per hospital policy Check all sterile supplies for expiration date, intact packaging Prevent urinary infections ( maintain closed drainage system with downhill flow of urine Implement measures to prevent impaired skin integrity and accumulation of secretions in the lungs Personal protective equipment Gloves Protect hands in case of need to handle any body substances Reduce likelihood of nurses transmitting microorganisms to clients Reduce likelihood that nurses hands will transmit microorganisms or a fomite from one client to another Gloves are changed between client contact Nurses should clean hands each time they remove gloves Latex allergy issues Gowns Clean or disposable impervious gowns, plastic aprons worn ( procedures when uniform likely to become soiled Sterile gowns ( changing dressings of client with extensive wounds Single-use gown technique ( usual practice Face masks Reduce risk of transmitting organisms by droplet, airborne routes Worn by Those close to client if infection transmitted by large-particle aerosols All persons entering room if infection transmitted by small-particle aerosols Types of masks Single-use disposable ( change if wet, soiled Disposable particulate respirators N95( 95 efficiency ( meets control criteria for tuberculosis and severe acute respiratory syndrome (SARS) Surgical asepsis ( masks worn to prevent spread of organisms to wound, protect nurse from splashes Eyewear Protective eyewear worn over prescription eyewear Disposal of soiled equipment and supplies Specific policies, procedures for handling soiled equipment Bagging Articles that are contaminated, likely to have been contaminated ( enclosed in bag impervious to microorganisms before removed from room of client Single bag if sturdy, impervious to microorganisms, articles can be placed in bag without soiling or contaminating its outside Double bagging if above conditions not met Agency policy or CDC guidelines Place garbage and soiled disposable equipment in plastic bag that lines the waste container. Place nondisposable or reusable equipment that is visibly soiled in a labeled bag before removing it from clients room ( send to central processing area for decontamination Disassemble special procedure trays into component parts Bag soiled clothing before sending it home or to agency laundry Linens Handled as little as possible to limit agitation before placing in laundry hamper Bag closed before sending to laundry in accordance with agency policy Laboratory specimens Placed in leakproof container with secure lid ( labeled as biohazard Dishes No special precautions Blood pressure equipment No special precautions unless it becomes contaminated If contaminated ( agency policy Thermometers Disinfected after use Disposable needles, syringes, sharps Place needles, syringes, sharps ( puncture-resistant container Transporting clients with infection Avoid transporting outside room unless absolutely necessary Cover wound Surgical mask Psychosocial needs of isolation clients Sensory deprivation ( environment lacks normal stimuli Decreased self-esteem ( from perception of infection itself, or required precautions and related isolation Nursing interventions Assess individuals need for stimulation Initiate measures to help meet needs for stimulation, including regular communication with client, diversionary activities Explain infection, associated procedures to help client families, caregivers understand and accept situation Demonstrate warm, accepting behavior Do not use stricter precautions than are indicated by diagnosis Sterile technique Sterile ( free of all microorganisms Operating rooms Procedures ( injections, changing wound dressings, performing urinary catheterizations, administering IV therapy See Table 97 PRINCIPLES AND PRACTICES OF SURGICAL ASEPSIS, p. 550 Sterile field ( microorganism-free area Supplies wrapped in variety of materials Sterile gloves ( donned by open or closed methods Packaged with cuff of approx. 5 cm, palms facing upward when package open Latex, latex-free sterile gloves available Latex, nitrile more flexible ( reseals tiny punctures automatically Sterile gowns Operating and delivery rooms Closed method of gloving ( sterile gown ( gloves handled through gown sleeves Preventing healthcare-associated infections Prevention is most important control measure for HAIs Pathogens are transmitted primarily by contact with hospital personnel and contaminated objects Meticulous use of medical and surgical asepsis is necessary Infection control for healthcare workers National Institute for Occupational Safety and Health (NIOSH) ( part of CDC Occupational Safety and Health Administration (OSHA) ( part of U.S. Department of Labor ( publishes, enforces regulations to protect healthcare workers Occupational exposure ( skin, eye, mucous membrane, or parenteral contact with blood, other potentially infectious materials that may result from performance of employees duties Three modes of transmission in clinical setting Puncture wounds from contaminated needles or other sharps Skin contact Mucous membrane contact Proper precautions ( significantly less risk Prevention of hepatitis C primary goal ( no vaccine, postexposure prophylaxis OSHA ( healthcare employers make hepatitis B vaccine, vaccination series available to all employees Role of infection control nurse Specially trained ( knowledgeable about preventing, detecting, treating infections All infections reported to infection control nurse Employee education Client precautions Modifiable risk factors ( these measures can reduce susceptibility to infection Good hygiene Good nutrition Adequate intake and output Adequate sleep Lowering levels of stress Immunizations Should begin shortly after birth Annual influenza vaccine Pneumococcal vaccine for older adults Assessment Nursing assessment Nursing history Review chart, create interview to collect data ( existing disease process, history of recurrent infections, medications, stressors, nutritional status, immunizations See ASSESSMENT INTERVIEW CLIENT AT RISK FOR INFECTION, p. 552 Physical assessment See INFECTION ASSESSMENT, pp. 554 - 555 Signs, symptoms vary according to body area involved Skin and mucous membranes Localized swelling Localized redness Pain, tenderness with palpation or movement Palpable heat at infected area Loss of function of body part affected Drainage from wounds Signs of systemic infection Fever Increased pulse and respiratory rate Malaise and loss of energy Loss of appetite, nausea, vomiting Enlargement, tenderness of lymph nodes that drain area of infection Lifespan and cultural considerations Infections manifest in a variety of ways in infants, newborns, and children See Table 9-8 CLINICAL MANIFESTATIONS OF INFECTION IN INFANTS AND CHILDREN, p. 553 Pregnant women need special consideration Culture can also play a role Diagnostic tests White blood cell (WBC) count WBC differential See Table 99 WHITE BLOOD CELL COUNT AND DIFFERENTIAL, p. 555 Procalcitonin (CTpr) ( precursor of hormone calcitonin Cultures ( wound, blood, other infected body fluids Growth of microorganisms Identification by shape, growth patterns, Gram staining Subjected to various antibiotics ( what will be most effective ( sensitivity testing Serological testing ( antibody titers ( HIV, hepatitis B Direct antigen detection methods See Box 93 MONOCLONAL ANTIBODIES, p. 556 Antibiotic peak and trough levels Therapeutic range Toxic Radiological examination of the chest, abdomen, urinary system Lumbar puncture Ultrasonic examination ( echocardiogram, renal ultrasonography Urinalysis Case Study Part 2 ( Mr. Werner is prescribed acetaminophen for his fever and IV fluids to prevent dehydration Interventions and therapies Identify organ system affected, causative agent ( achieve cure by least toxic method Body part, organ system ( often obvious from history, presenting signs, symptoms History of recent activities Therapy tailored to clients needs Supportive for viral Topical for skin infections Independent All skills and treatments performed ( prevent possible infection of client Hand hygiene Basic medical asepsis Use of standard precautions Isolation techniques Sterile field Culture specimen collection Use of personal protective equipment (PPE) and decontamination Collaborative Many interventions performed in collaboration with other healthcare professionals Once diagnosis is made, nurses administer ordered medications See MEDICATIONS Antimicrobial Agents, p. 558-559 Review The Concept of Infection Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Student Nursing Resources Reflect Case Study Part 3 ( After one week in the hospital, Mr. Werner is finally going home. Exemplar 9.1 Cellulitis Overview Cellulitis ( acute bacterial infection of the dermis, underlying connective tissue Red, lilac, tender, warm, edematous skin Chief symptom ( inflammation ( pain, heat, redness, swelling Localized or entire limb Increase in WBCs, lymphadenopathy ( may not be present in frail, older clients Pathophysiology and etiology Normal flora gain entry into dermis through a break in the skin Multiply ( inflammation ( erythema (redness), pain, warmth at site, edema Erysipelas ( superficial cellulitis of skin caused by group A Streptococcus Usually affects lower extremities, face Bright red, raised, well-defined borders Antibiotic therapy Predispose to septicemia Etiology Common causative organisms Staphylococcus aureus Hemolytic Streptococci Streptococcus pneumoniae Haemophilus influenzae Risk factors Children ( history of trauma, impetigo, folliculitis, untreated tooth decay, recent otitis media Older adults ( thinner skin, susceptible to breakage Illnesses that increase risk of infection, such as diabetes Tinea pedis Prevention Individuals with skin wounds are at high risk Good wound care is vital Clinical manifestations Clients with cellulitis experience rapid onset and appear ill Erythema, edema of face or infected limb, warmth, tenderness around infected site Fever, chills, malaise, enlargement of tenderness of regional lymph nodes Lymphangitis ( inflammation of a lymph vessel Lifespan and cultural considerations Children with wounds or insect bites often have difficulty not picking or scratching Older adults and adults with poor circulation are at risk Individuals with darker skin tones may have trouble seeing the characteristic redness Collaboration Reducing infection, promoting comfort, preventing complications Diagnostic tests Blood studies may show increased WBCs Cultures taken to identify causative organisms Blood cultures if client has toxic appearance Pharmacologic therapy Cellulitis on trunk, limbs, or perianal area ( usually treated with oral antibiotics on an outpatient basis Clients with severe cases or large affected areas ( usually treated with systemic antibiotics and analgesics in the hospital Nonpharmacologic therapy Adequate rest Elevation of affected area Infection control measures Sterile saline dressings Nursing process Assessment Recognition of infection ( documentation of location, tracing border Monitor vital signs Diagnosis Impaired Skin Integrity related to mechanical factors Acute Pain related to destruction of tissue due to infection Interrupted Family Processes related to home care needs of child with acute illness Planning Client will report pain of 3 or lower, on scale of 110 Client will describe situations requiring contact with the provider Client will explain how to take antibiotics and analgesics properly Implementation Administer prescribed antibiotics as scheduled Supportive care Warm compresses to affected area 4 times a day Elevation of affected limb Bed rest Advise client about possible complications such as abscess formation Advise contact with healthcare provider if following develops Spread of infected area in 24- to 48-hour period after start of treatment Temperature of 38.3( Increased lethargy Evaluation Trace outer edges of wound ( monitor progression Review Cellulitis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 9.2 Conjunctivitis Overview Conjunctiva ( thin transparent membrane that covers anterior surface of the eye, lines inner surfaces of eyelids Conjunctivitis ( bacterial or viral ( most common eye disease All neonates in United States receive prophylactic treatment to prevent conjunctivitis Pathophysiology and etiology Several types ( depends on cause of inflammation Conjunctiva ( becomes edematous, inflamed, reddened, yellow or white discharge Infant under 30 days of age ( called ophthalmia neonatorum Chlamydia trachomatis, Neisseria gonorrhoeae Bacterial conjunctivitis ( common in older children Edema of eyelid, reddened conjunctiva, enlarged preauricular lymph glands, mucopurulent discharge, itching or burning, mild photophobia, feeling of scratching under lids Several infectious organisms ( caused by hand-to-eye contact Viral conjunctivitis ( commonly bilateral Adenovirus common Herpes simplex virus (HSV) conjunctivitis ( often accompanied by vesicular lesions on the skin of face Prompt treatment ( prevent eye injury, blindness Commonly recurs Allergic conjunctivitis Itching, reddened eyes, watery discharge Trachoma ( chronic conjunctivitis cause by Chlamydia trachomatis ( significant preventable cause of blindness worldwide Etiology Bacterial, viral, fungal Bacterial ( pink eye ( highly contagious Adenovirus leading cause of conjunctivitis in adults Risk factors Contact lens wearers Young children in school, day care Clients with compromised immune response Prevention Bacterial and viral conjunctivitis is highly contagious Infection control strategies are vital Vaccines are available for conjunctivitis related to rubella, measles, chickenpox, shingles, and Streptococcus pneumonia and Haemophilus influenza type b Clinical manifestations Affected eye Itching, redness Scratchy, burning, gritty sensation Photophobia Tearing, discharge Watery, purulent, mucoid Trachoma Redness, eyelid edema, tearing, photophobia Small conjunctival follicles develop on upper lid Collaboration Ophthalmologist if disruption to the cornea is suspected School or day care education Diagnostic tests Accurate diagnosis ( vision-threatening conditions can cause red eye Uveitis ( inflammation of middle layer of eye Acute angle-closure glaucoma Procedures Culture and sensitivity of exudates Fluorescein stain with slit lamp examination Conjunctival scrapings Additional laboratory testing to identify underlying infectious or autoimmune processes Pharmacologic therapy Treated with antibiotic, antiviral, anti-inflammatory drugs as appropriate Topical anti-infectives ( erythromycin, gentamicin, penicillin, bacitracin, sulfacetamide, amphotericin B, idoxuridine Severe infections, cellulitis ( orally, subconjunctival injection, systemic IV infusion Gonococcal conjunctivitis in newborns ( ceftriaxone Chlamydial infections ( oral erythromycin, tetracycline HSV infections of eye ( topical drugs combined with systemic antiviral, acyclovir Allergic ( antihistamines, topical steroids, vasoconstrictors Nonpharmacologic therapy Comfort measures Clean drainage with warm clean cloth Avoid bright lights Avoid reading Cool compresses applied can help relieve feeling of eye irritation Frequent eye irrigations to remove copious purulent discharge Soaking lids with warm saline compresses Nursing process Assessment Health history Presence of redness, discomfort, tearing, photophobia, drainage Symptom onset Care measures Exposure Travels History Presence of chronic diseases Physical assessment Visual acuity Inspect eyelids, conjunctiva, sclera, cornea Vital signs Diagnosis Risk for Infection Impaired Comfort Readiness for Enhanced Knowledge Planning Client will demonstrate proper hand hygiene Client will avoid contaminating unaffected eye or other family members Client will experience no visual complications following recovery Implementation Prevent infection Infant in hospital ( isolated ( highly contagious Managed in community ( teaching Not return to school until 24 hours on antibiotics Avoid sharing towels Mittens for young children Teach client to wash hands thoroughly before instilling eye medications Teach client how to instill prescribed eyedrops as ordered Discuss the importance of avoiding contact lens use until infectious process cleared Promote comfort Emphasize to family ways to prevent transmission of infection Safety and medical asepsis when cleansing the eye Instillation of prescribed eyedrops and ointments Comfort measures such as reducing lighting intensity and wearing sunglasses Avoidance of activities such as excessive reading while eye is inflamed Evaluation Resolution of infection ( conjunctiva normal white, absence of drainage, elimination of symptoms Review Conjunctivitis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 9.3 Influenza Overview The flu ( highly contagious, viral respiratory disease Coryza ( inflammation of mucous membranes lining nose Fever Cough Systemic symptoms ( headache, malaise Usually occurs as an epidemic ( widespread outbreak of infectious disease Pandemic ( global epidemic Identified strains Avian influenza, H1N1 influenza ( raised concerns about future pandemic Tends to be mild, self-limited in healthy adults Pathophysiology and etiology Incubation period (1872 hours Infects respiratory epithelium ( leads to necrosis, shedding of serous and ciliated cells of respiratory tract ( allows extracellular fluid to escape ( producing rhinorrhea Respiratory epithelial necrosis ( increases risk for secondary bacterial infections Linked to increased risk for pneumonia ( young and old Primary viral influenza pneumonia ( rare ( serious ( may be fatal Bacterial pneumonia more likely ( older adult ( presents as relapse Exacerbations of chronic obstructive pulmonary disease (COPD), chronic bronchitis, asthma Reye syndrome ( neurological disease typically following a viral infection More likely to affect children Associated with administration of aspirin products to children with any viral infection Other potential complications of influenza ( myositis, myocarditis, CNS disorders Etiology Transmitted by airborne droplet and direct contact Three strains ( A, B, C New strains ( named according to strain, geographic origin, year identified Type A influenza viruses ( birds, pigs, whales, human Risk factors Increased risk ( infants, young children, over 50 Residents of nursing home Chronic disorders Pregnant women Compromised immune systems Healthcare providers Prevention Primary focus ( preventing community outbreaks and protecting vulnerable populations Influenza vaccine recommended for all individuals, especially those at-risk Clinical manifestations Influenza produces one of three syndromes Uncomplicated nasopharyngeal inflammation Viral upper respiratory infection followed by bacterial infection Viral pneumonia Onset ( rapid, profound malaise may develop in matter of minutes Chills and fever Malaise, muscle aches, and headache Dry nonproductive cough, sore throat, substernal burning, coryza See CLINICAL MANIFESTATIONS AND THERAPIES INFLUENZA, p. 573 Collaboration Diagnostic tests History Clinical findings Knowledge of influenza outbreak in community Chest x-ray WBC count Pharmacologic therapy Antiviral drugs ( amantadine (Symmetrel) or rimantadine (Flumadine) ( prophylaxis in people exposed not vaccinated Amantadine, rimantadine, zanamivir (Relenza), oseltamivir (Tamiflu), ribavirin (Virazole) ( used to reduce duration, severity of flu symptoms Over-the-counter (OTC) analgesics ( aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) ( symptomatic relief of fever, muscle ache Aspirin (ASA) ( never given to children because of risk of Reye syndrome Antitussives Antibiotics only if secondary bacterial infection occurs Nonpharmacologic therapy Bed rest Adequate fluid intake Good hygiene to prevent spread of infection Nursing process Assessment Health history Known exposure Current symptoms Physical examination Diagnosis Ineffective Breathing Pattern Ineffective Airway Clearance Disturbed Sleep Patterns Risk for Infection Fatigue Deficient Community Health Planning Temperature remains within normal limits Client maintains normal fluid balance by increasing fluid intake Oxygen saturation remains within acceptable limits Client maintains patent airway Implementation Maintain patent airway Maintain adequate hydration Increase the humidity of inspired air with a bedside humidifier Teach effective cough techniques Ensure effective ventilation Pace activities to provide for periods of rest Elevate head of the bed Promote sleep hygiene Assess sleep patterns using subjective and objective information Provide antipyretic and analgesic medications at or shortly before bedtime Prevent infection Use standard precautions, encourage all staff and visitors to frequently wash hands Instruct clients and visitors to control respiratory secretions by using tissues and to maintain distance of at least 3 feet from others when coughing or sneezing Use droplet precautions for clients with suspected or confirmed influenza Community-based care Increase rest during the acute, febrile phase of the illness Maintain a liberal fluid intake, even if anorexic Appropriately use OTC medications for symptom relief Employ hygiene measures, such as using disposable tissues and frequent hand washing, to reduce spread of the disease Know the manifestations of potential complications of influenza to report to the primary care provider Evaluation Evaluate client for airway patency, breathing pattern, oxygenation Evaluate for thermoregulation Review Influenza Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 9.4 Otitis Media Overview Ear can be infected in any of three chambers Otitis externa ( inflammation of the ear canal Otitis interna ( labyrinthitis, inflammation of the inner ear Otitis media ( inflammation of middle ear Ear infection ( one of most common childhood illnesses ( not always accompanied by an actual infection Pathophysiology and etiology Tympanic membrane ( separates middle ear from external auditory canal ( protects middle ear from external environment Eustachian tube ( connects middle ear with nasopharynx to help equalize pressure in middle ear with atmospheric pressure Provides route ( infectious organisms can enter middle ear Upper respiratory infection (URI) often precedes development of otitis media ( mucous membranes of Eustachian tube become edematous ( air flow to middle ear blocked ( space filled with fluid ( medium for growth of pathogens Types of otitis media Serous otitis media (otitis media with effusion) ( Eustachian tube obstructed for prolonged time ( air gradually absorbed ( serous fluid moves from capillaries into space Acute otitis media Eustachian tube ( provides route for entry of pathogens into normal sterile middle ear ( edema impairs drainage of middle ear Chronic otitis media Involves permanent perforation of tympanic membrane, with or without recurrent pus formation Marginal perforation ( associated with cholesteatoma Benign, slow-growing tumors Perforation can be repaired with tympanoplasty ( restore sound conduction, integrity of middle ear Etiology 70 of infants have at least one case of otitis media during first year of life ( peak during first 2 years of life Specific cause unknown ( Eustachian tube dysfunction URI, allergies ( predispose client to serous otitis media Barotraumas ( cannot adapt to rapid changes in barometric pressure ( flight, underwater diving Viral URI may predispose client to acute otitis media ( bacteria account for most cases of otitis media in adults Causes pus formation ( increase middle ear pressure Risk factors More frequently among boys Children in day care centers Allergies Exposed to tobacco smoke Winter months Breastfeeding seems to be protective Prevention For infants and children Breastfeeding for 12 months or more Bottle feeding in upright position Keeping up to date with immunizations Avoiding air pollution especially secondhand smoke Using a small daycare or private child care rather than a large center Clinical manifestations In adult ( decreased hearing in affected ear, complaints of snapping, popping in ear Tympanic membrane ( decreased mobility, bulging Severe pressure differences ( barotraumas ( pain, hemorrhage into middle ear, vertigo Hemotympanum ( bleeding into or behind tympanic membrane Otoscope ( hand-held instrument with light, cone-shaped attachment known as ear speculum Acute otitis media ( typically experiences mild to severe pain, temperature often elevated Diminished hearing, dizziness, vertigo, tinnitus Pus within mastoid air cells Tympanic membrane appears red ( see Figure 914 A RED, BULGING TYMPANIC MEMBRANE OF OTITIS MEDIA, p. 578 Spontaneous rupture of tympanic membrane releases purulent discharge Acute otitis media ( diagnosed in pediatric clients Acute onset of ear pain, marked redness of tympanic membrane on otoscopy, middle ear effusion Serous otitis media ( evidenced by fluid in middle ear without inflammation Diarrhea, vomiting, fever Pulling at ear ( sign of ear pain Irritability, acting out Collaboration Several professionals Nurse, audiologist( conduct hearing screening Nurse, speech pathologist, classroom teacher ( assist parent with understanding importance of verbal communication, reading in home Preventive practices in classroom ( frequent hand washing, increase fluid intake Diagnostic tests Impedance audiometry ( tympanometry ( accurate diagnostic test ( measures compliance of tympanic membrane CBC Tympanocentesis or myringotomy ( if tympanic membrane has ruptured Special gradient acoustic reflectometry ( measures response to sound of tympanic membrane Flat tympanogram ( indicates absence of normal movement for tympanic membrane Culture and sensitivity Audiological testing Surgery Myringotomy, tympanocentesis ( relieve excess pressure Tympanocentesis ( physician inserts 20-gauge spinal needle through inferior portion of tympanic membrane Myringotomy with insertion of tympanostomy tubes for clients who do not respond to antibiotic therapy Avoid water in ear canal ( water can enter middle ear space Pharmacologic therapy Concern over increasing appearance of drug-resistant microbes ( now treated with antibiotic therapy for 10 days in children under 6, 57 days for children 6 and older Choice of antibiotics depends on probable agent, ease of administration, previous effectiveness, history of allergies Amoxicillin ( 8090 mg/kg/day Amoxicillin with clavulanate or cefuroxime second line Treatment in adults ( antibiotic therapy Amoxicillin, trimethoprimsulfamethoxazole, cefaclor, azithromycin ( 510 days Symptomatic relief Serous otitis media ( not treated with antibiotics Decongestants, antihistamines ( not shown to be effective Persistent ( myringotomy tympanostomy tubes Hib vaccine ( reduced incidence of disease Complementary and alternative therapy Anesthetic eardrops Naturopathic herbal ear drops compare well with prescription ear drops Nursing process Assessment Health history Physical examination Temperature, hearing test, inspect tympanic membrane Parents assist with examination Under age of 4 ( pull tragus down and back Assess tympanic membrane for color, opacity, mobility, position, presence of fluid or other abnormal findings Use speculum that fits tightly into ear canal ( gently press bulb insufflator to assess tympanic membrane mobility Normal tympanic membrane ( pearly gray, transparent, mobile, neutral position Otitis media ( orange-yellow, decreased mobility, full Serous otitis media ( amber, immobile, neutral to full position Diagnosis Acute Pain Infection Risk for Caregiver Role Strain Knowledge Deficit Risk for Delayed Growth and Development Risk for Imbalanced Body Temperature Hyperthermia Fatigue Impaired Verbal Communication Planning Client of parent will indicate absence of pain Client will be infection-free following the course of treatment Caregivers will manage childs condition with minimal stress Client or parents will state their understanding of preventive measures Child will have normal hearing Child will have normal motor and language development Implementation Focused on pain management, teaching, prevention Manage and control pain Assess clients pain for severity, quality, location Encourage client to use mild analgesics, such as ibuprofen, acetaminophen every 4 hours as needed Advise client to apply heat to affected side unless contraindicated Instruct client to avoid air travel, rapid changes in elevation, or diving Instruct client to report promptly an abrupt relief of pain to primary care provider ( may indicate spontaneous perforation of tympanic membrane Support caregivers Reassure parents that as child grows older, recurrent infections eventually will cease Provide pain-relief techniques Provide age-appropriate education to clients and family members Discuss with the client and family antibiotic therapy and potential side effects, importance of completing all ordered doses, follow-up examination in 24 weeks, importance of avoiding getting water in ears Emphasize preventive measures Teach client and family members about the surgery and postoperative care Inform parents that the child who is having tympanostomy tubes inserted is generally treated in day surgery setting Explain to parents problem of developing resistant strains of bacteria Explain to parents of children with serous otitis media that antibiotics, steroids, antihistamines/decongestants not effective, most children improve in 3 months without medication Encourage parents to bring child back for care if condition worsens or has not improved in recommended time Facilitate communication Provide hearing and language examinations at regular intervals Inform parents of results, refer to audiology specialist if hearing problems identified Evaluation Child will return to normal sleep and feeding patterns Child will maintain normal hearing and speech development Child will be free of pain and fever Parents will indicate adequate understanding of treatment regimen Review Otitis Media Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 9.5 Pneumonia Overview Inflammation of lung parenchyma ( pneumonia Respiratory system constantly open to possibility of infection Pathophysiology and etiology Disorders affecting lower respiratory system (below the larynx) ( affect ability to effectively move air into and out of lungs (ventilation), exchange of oxygen and carbon dioxide across alveolar-capillary membrane (respiration), as well as ability to maintain clear and patent airways and to ventilate lungs Organisms enter lungs in several ways Aspiration of microbe containing secretions Inhaled following release from cough Inhalation of contaminated aerosolized water Through bloodstream from infection elsewhere in body Invading microorganisms colonize alveoli ( initiate inflammatory, immune response See Figure 919 IN PNEUMONIA, THE INFLAMMATORY RESPONSE, p. 585 Causes fluid to accumulate in alveoli ( edema ( alveolar capillaries dilate ( fluid leaks into interstitial tissues Develops in four patterns Lobar pneumonia Bronchopneumonia Interstitial pneumonia Miliary pneumonia See Table 911 PATTERNS OF LUNG INVOLVEMENT IN PNEUMONIA, p. 585 Pathological process varies according to infective organism Bacterial pathogens circulate through bloodstream ( lungs ( damage cells Unilateral lobar pneumonia Viruses frequently enter from upper respiratory tract ( infiltrating alveoli nearest bronchi of one or both lungs Scattered patchy pattern of bronchopneumonia Aspiration of food, emesis, gastric reflux, hydrocarbons ( chemical injury ( inflammatory response ( open to bacterial invasion May be infectious or noninfectious Bacteria, viruses, fungi, protozoa, other microbes Aspiration of gastric contents, inhalation of toxic or irritating gases Community acquired, nosocomial, opportunistic See Table 912 COMMON ORGANISMS CAUSING PNEUMONIA IN ADULTS, p. 586 Children older than 5 ( pneumonia caused by bacteria Etiology Acute bacterial pneumonia Pathogenesis of pneumococcal pneumonia best understood Bacteria reside in upper respiratory tract of up to 70 of adults Inflammatory response ( causes alveolar edema, formation of exudate ( consolidation of lung tissue Typically resolves uneventfully ( normal lung structure restored on completion of process Pleuritis ( local extension of infection to involve pleura ( common Pleural effusion ( accumulation of excess fluid in pleural cavity Lung abscess ( local area of necrosis, pus formation within the lung itself Empyema ( accumulation of purulent exudate in pleural cavity Thoracentesis ( insertion of needle into pleural space to remove fluid accumulation ( or chest tube to remove purulent exudates Presentation ( usually acute ( shaking chills, fever, cough productive of rust-colored or purulent sputum Chest aching, pleuritic pain (sharp, localized chest pain that increases with breathing and coughing) Bronchopneumonia ( insidious onset ( low-grade fever, cough, scattered crackles Legionnaires disease Bronchopneumonia caused by Legionella pneumophila ( gram-negative bacterium widely found in water Develops gradually ( 210 days after exposure Consolidation of lung tissue ( patchy, lobar Primary atypical pneumonia Mycoplasma pneumoniae ( presentation, course differ from other bacterial pneumonias Patchy inflammatory changes in alveolar septum, interstitial tissue of lung Highly contagious Viral pneumonia Influenza and adenovirus most common organisms Typically mild disease Pneumocystis jiroveci pneumonia People with AIDs, significant immunocompromise ( at risk for this opportunistic pneumonia Patchy involvement throughout lungs ( alveoli thicken, become edematous, fill with foamy protein-rich fluid Abrupt onset See Table 913 MANIFESTATIONS OF INFECTIOUS PNEUMONIAS, p. 587 Aspiration pneumonia Aspiration of gastric contents into lungs ( chemical and bacterial pneumonia Risk factors ( emergency surgery, obstetric procedures, depressed cough and gag reflexes, impaired swallowing Low pH of gastric contents ( severe inflammatory response when aspirated into respiratory tract Complications ( abscesses, bronchiectasis, gangrene of pulmonary tissue Risk factors Immature immune system of infants, young children, older adults (risk Diminished gag, cough reflexes Compromised immune system, debilitated condition Exposure to cigarette smoke, alcohol, drug abuse High risk of adverse outcomes from bacterial pneumonia ( 65 and older, chronic cardiac or respiratory conditions, diabetes mellitus, alcoholism, immunocompromised Prevention Prevention is key component in managing pneumonia Pneumococcal vaccine offers protection from bacterial pneumonia Influenza vaccine helps prevent pneumonia Clinical manifestations Infection of lower respiratory tract Local effects ( cough, excess mucus production, dyspnea, hemoptysis, chest pain Systemic effects ( fever, diminished appetite, malaise, cyanosis, other manifestations of impaired gas exchange Lifespan and cultural considerations Children Childs airway shorter, narrower ( greater potential for obstruction Trachea increases in length rather than diameter in first 5 years of life Narrower airway causes greater increase in airway resistance ( any condition causing edema of airway, accumulation of secretions See Figure 923 THE DIAMETER OF AN INFANTS AIRWAY, p. 589 At birth ( only about 25 million alveoli, not fully developed Disease of small number of alveoli ( greater impact on clinical condition Pneumonia often resolves much sooner than in adults ( early recognition Children under 6 use diaphragm to breathe ( negative pressure that results from diaphragm movement causes chest wall to be drawn inward ( retractions Retractions can be early manifestation in children See Figure 924 RETRACTIONS MAY OCCUR, p. 590 Oxygen consumption higher in children ( accessory muscles used ( more rapid fatigue ( become hypoxic more quickly than adults Tachypnea, retractions, nasal flaring, increased effort of breathing ( periods of apnea Clinical manifestations in children ( fever, tachypnea, rhonchi, crackles, wheezes, cough, dyspnea, nasal flaring, restlessness, chest pain, malaise Older adults Several changes associated with aging affect respiratory function Number of cilia decreases Gag and cough reflexes diminish Greater risk of dehydration Immune function declines Collaboration Nurses, doctors, phlebotomists, respiratory therapists, radiologists, infectious disease specialists, pulmonologists Spiritual support Diagnostic tests History and physical Common diagnostic tests ( chest x-ray, computed tomography, sputum Gram stain, sputum culture and sensitivity, CBC with WBC differential, serology testing, pulse oximetry, arterial blood gas, fiberoptic bronchoscopy Pharmacologic therapy Medications may include antibiotics, bronchodilators Antibiotic ( after Gram stain, pattern of lung involvement Inflammatory response ( bronchospasm, constriction ( bronchodilators Sympathomimetic drugs or methylxanthines Agent to break up mucus, reduce viscosity may be prescribed Acetylcysteine (Mucomyst), potassium iodide, guaifenesin Increasing fluid intake Oxygen therapy ( may be indicated for tachypneic, hypoxemic client Depending on degree of hypoxia ( low-flow or high-flow system Low-flow ( nasal cannula, simple face mask, partial rebreathing mask, nonrebreathing mask High-flow ( Venturi mask Nonpharmacologic therapy Symptomatic therapy and supportive care Increasing fluid intake to help liquefy secretions Incentive spirometry Chest physiotherapy Percussion ( rhythmically striking or clapping the chest wall with cupped hands, using rapid wrist flexion and extension ( hollow popping sound Vibration ( repeatedly tensing arm and hand muscles while maintaining firm but gentle pressure over affected area with flat of the hand See Figure 927 PERCUSSING (CLAPPING), p. 593 Postural drainage ( uses gravity to facilitate removal of secretions ( client positioned with segment to be drained superior to trachea or mainstem bronchus See Figure 928 POSITIONS FOR POSTURAL DRAINAGE..., p. 594 Complementary and alternative therapy Do not replace conventional ( promote comfort, speed recovery Herb echinacea ( mixed results Ma huang ( in ephedra ( relieve bronchospasm ( dangerous ( banned Nursing process Assessment Health history Current symptoms, duration Recent URI, chronic diseases, medications Physical examination Presentation, apparent distress Pediatric client different (See Table 915 ASSESSMENT GUIDELINES FOR THE CHILD WITH A RESPIRATORY CONDITION, p. 596) Diagnosis Ineffective Airway Clearance Ineffective Breathing Pattern Hyperthermia Activity Intolerance Anxiety related to hypoxia Imbalanced Nutrition Less Than Body Requirements related to altered breathing pattern Disturbed Sleep Pattern related to orthopnea Planning Client maintains normal temperature for 24 hours Client obtains adequate sleep, rest without interruption from coughing or orthopnea Client maintains adequate fluid and caloric intake Client demonstrates strong cough sufficient to clear airway Client maintains oxygen saturation greater than 90 Client does not require supplemental oxygen to maintain saturations of 90 Implementation Prioritized base on most important nursing diagnoses Maintain airway patency Assess respiratory status at least every 4 hours Assess cough and sputum Monitor arterial blood gas results Place in Fowler or high-Fowler position Assist to cough, deep breathe, and use assistive devices Provide fluid intake of at least 2,5003,000 mL/day for adult client. See Table 916 DAILY MAINTENANCE FLUID REQUIREMENTS FOR THE PEDIATRIC CLIENT, p. 597 Work with physician, respiratory therapist to provide pulmonary hygiene measures Administer prescribed medications as ordered, monitor effects Ensure effective ventilation Provide for rest periods Assess for pleuritic discomfort Teach client how to splint the chest by hugging a small pillow, teddy bear Provide reassurance during periods of respiratory distress Administer oxygen as ordered Teach slow abdominal breathing Teach use of relaxation techniques Promote balance between activity and rest Assess activity tolerance Assist with self-care activities Provide assistive devices, such as an overhead trapeze Enlist familys help to minimize stress and anxiety levels Perform active or passive range-of-motion exercises Provide emotional support and reassurance that strength and energy will return to normal when infectious process has resolved Community-based care Importance of completing prescribed medication regimen as ordered Recommendations for limiting activities and increasing rest Importance of maintaining adequate fluid intake to keep mucus thin Ways to maintain adequate nutritional intake Importance of avoiding smoking, exposure to secondhand smoke Manifestations to report to physician Evaluation Usually treated in community Teach caregivers to evaluate signs and symptoms requiring immediate consultation with primary care provider Review Pneumonia Relates Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 9.6 Sepsis Overview Definitions Systemic inflammatory response syndrome (SIRS) ( whole-body inflammatory process resulting in acute critical illness Bodys response to a critical illness that can result from an infectious or noninfectious cause precipitating a whole-body inflammatory response Sepsis ( SIRS resulting from an infection Severe sepsis ( sepsis with acute associated organ failures Septic shock ( persistently low mean arterial blood pressure despite adequate fluid resuscitation Refractory septic shock ( persistently low mean arterial blood pressure despite vasopressor therapy and adequate fluid resuscitation Sepsis ( can occur as complication of any infection of any body tissue if pathogen enters bloodstream and travels to other tissues Pathophysiology and etiology Septic shock begins with septicemia ( bacteremia first Endotoxins directly damage endothelial lining of small blood vessels first ( increased capillary permeability and vasodilatation ( fluids from intravascular space to interstitial space ( hypovolemia Toxic shock syndrome ( especially virulent form Disseminated intravascular coagulation ( risk in septic shock Simultaneous bleeding and clotting Etiology Leading cause of death in noncoronary ICUs and 10th leading cause of death in United States Incidence of gram-negative sepsis greatly increased over past 10 years Portals of entry Urinary system Respiratory system Gastrointestinal system Integumentary system Risk factors Clients at risk ( hospitalized, debilitating chronic illnesses, poor nutritional status, invasive procedures, surgery, older adults, immunocompromised Infant with infectious process ( watched closely for early signs of sepsis Prevention Infants with infectious process must be watched carefully for early signs of sepsis Clients with cancer must be monitored carefully Pneumococcal immunizations Aseptic techniques for catheters, IVs Clinical manifestations Include ( fever or hypothermia, tachycardia, tachypnea, peripheral vasodilatation, septic shock, and mental status changes Lab results ( abnormal CBC alteration in clotting factors elevated liver enzymes, C-reactive protein, creatinine Hypophosphatemia and positive blood culture anticipated Early phase Warm phase ( vasodilation results in weakness, warm, flushed skin( septicemia often causes high fever and chills Late septic shock Cold phase ( hypovolemia and activity of compensatory mechanisms result in typical shock manifestations ( cold, moist skin, oliguria, changes in mental status Death from respiratory failure, cardiac failure, and/or renal failure Lifespan and cultural considerations Infants Infants ( temperature instability, abdominal distention, poor feeding, lethargy, respiratory distress, hepatomegaly, vomiting, and/or jaundice Infants under 3 months of age ( diagnostic testing to rule out sepsis ( at risk because of immature immune systems Older adults Cardiac changes decrease compensatory responses to septic shock Decreased immune system response increases risk of septic shock Collaboration Early aggressive therapy improves outcomes Diagnostic tests Hemoglobin and hematocrit Arterial blood gas Serum electrolytes Blood urea nitrogen (BUN), serum creatinine levels, urine specific gravity, osmolality Blood cultures White blood cell count and differential Serum enzymes Hemodynamic monitoring X-ray studies Pharmacologic therapy Antimicrobials if infection caused by bacteria or fungi Broad-spectrum, multidrug therapy ( until culture results are final Fluid replacement for shock ( vasoactive drugs and inotropic drugs Oxygen therapy Establish, maintain patent airway Ensure adequate oxygenation Fluid replacement Most effective treatment for client in septic shock ( IV fluids or blood Nursing process Assessment Vital signs ( baseline, frequent monitoring Hemodynamic monitoring Renal function Pulmonary competence Diagnosis Risk for Shock Impaired Gas Exchange Risk for Ineffective Renal Perfusion Ineffective Peripheral Tissue Perfusion Risk for Imbalanced Fluid Volume Planning Client maintains adequate renal perfusion ( produces minimum of 30 mL urine/hour Client maintains oxygen saturation 90 and PaO2 within normal limits Client responds to fluid resuscitation ( mean arterial blood pressure in normal range Implementation Monitor skin color, temperature, turgor, and moisture Monitor cardiopulmonary function by assessing/monitoring the following Blood pressure Rate and depth of respirations Lung sounds Pulse oximetry Peripheral pulses Monitor jugular vein distention Take central venous pressure (CVP) measurements Monitor body temperature Monitor urinary output per Foley catheter hourly, using urometer Assess mental status and level of consciousness Evaluation Continuously and frequently reevaluated Fluid administrations ( increase BP, perfusion Fluid leaves intravascular space ( condition may decline again Review Sepsis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 9.7 Tuberculosis Overview Tuberculosis (TB) is chronic, recurrent infectious disease ( caused by Mycobacterium tuberculosis Slow-growing, slender, rod-shaped, acid-fast organism Continuing public health threat ( resistant strains, inadequate access to health care for high-risk populations Pathophysiology and etiology Pulmonary tuberculosis Minute droplet nucleus contains 13 bacilli ( enter lungs, implant in alveolus or respiratory bronchiole Inflammatory response ( isolates bacilli but does not destroy them Continue to multiply ( tubercle formed Infected tissue within tubercle dies ( caseation necrosis Some bacilli enter lymphatic system ( stimulate cellular-mediated immune response Infection may progress to active TB before skin test positive in infants, children ( immature immune response Scar tissue forms around tubercle ( bacilli remain encapsulated ( lesions calcify ( become evident on x-ray Client infected with TB but does not have active disease Tubercle ruptures ( tuberculosis pneumonia Primary tuberculosis ( granulomatous tissue may erode into bronchus or blood vessel ( disease can spread throughout lung, other organs Reactivation tuberculosis ( previously healed tuberculosis lesion reactivated when immune system suppressed Without treatment ( chronic tubercle formation, cavitation of lung tissue or death Chronic disease ( spread M. tuberculosis into environment Extrapulmonary tuberculosis Disease may spread through the blood and lymph systems ( other organs May become active lesion, or dormant Prevalent in people with HIV/AIDS Miliary tuberculosis ( hematogenous spread of bacilli throughout body Without appropriate treatment ( prognosis poor Kidney, genitourinary tract common extrapulmonary sites for tuberculosis Symptoms of urinary tract infection (UTI), epididymitis or prostatitis, pelvic inflammatory disuse, impaired fertility, ectopic pregnancy Tuberculosis meningitis ( spreads to subarachnoid space Usually reactivation of latent disease Tuberculosis of bones, joints ( most likely during childhood ( bone epiphyses are open, blood supply rich Etiology M. tuberculosis transmitted by droplet nuclei Incidence fell through 1980s ( increase ( HIV/AIDS, MDR strains, social factors Worldwide ( significant health problem ( estimated 2 billion people infected In U.S., more than 50 of new cases occur in individuals who are foreign born Risk factors In United States ( primarily affects immigrants, those with HIV/AIDS, disadvantaged populations Children under 5, ethnic minorities, foreign-born children more likely to develop Poor urban areas, overcrowded institutions MDR cases increasing ( approximately 39 of strains worldwide 7 extensively drug resistant (XDR) Risk for new infection ( characteristics of infectious person, extent of air contamination, duration of exposure, susceptibility of host Once infection has occurred ( clients with HIV/AIDS high risk for developing active tuberculosis Prevention Tuberculin test used to screen for tuberculosis infection CDC recommends screening those At high risk for HIV infection Who have close contact with someone already infected With medical risk factors such as ESRD, diabetes Born in countries with a high prevalence of TB Living in medically underserved areas ( low-income areas, homeless With alcoholism or who inject drugs Who are residents or staff of long-term residential facilities Clinical manifestations Symptoms Initial infection ( few symptoms ( unnoticed until tuberculin test becomes positive, calcified lesions noted on chest x-ray (CXR) Fatigue, weight loss, diminished appetite, low-grade afternoon fever, and night sweats are common Dry cough develops ( later becomes productive Tuberculosis empyema, bronchopleural fistula most serious complications When lesion ruptures ( bacilli may contaminate pleural space, pneumothorax Lifespan and cultural considerations Infants, children, adolescents with latent infection ( no symptoms Infants with active infection ( persistent cough, weight loss or failure to gain weight, low-grade fever, wheezing, decreased breath sounds Children with active infection ( fatigue, cough, diminished appetite, weight loss or growth delay, night sweats, chills, low-grade fever, enlarged lymph nodes Older adults ( symptoms are often vague, including cough, weight loss, diminished appetite, periodic fever Collaboration Interdisciplinary care focuses on Early detection Accurate diagnosis Effective disease treatment Preventing spread of tuberculosis to others Diagnostic tests Sputum tests Sputum smear ( examined for acid-fast bacilli Sputum culture 48 weeks Sensitivity testing Sensitivity testing To identify appropriate drug therapy Polymerase chain reaction ( rapid detection of DNA from M. tuberculosis Chest x-ray Prior to drug therapy ( baseline studies Liver function tests Vision examination Audiometric testing Pharmacologic therapy Goals Make disease noncommunicable to others Reduce symptoms of disease Effect cure in shortest possible time Prophylaxis Prevent active tuberculosis Recent skin test conversion ( other risk factors present Single drug therapy Isoniazid 300 mg /day for 612 months Isoniazid prophylaxis contraindicated ( Bacille Calmette-Gurin (BCG) vaccine Widely used in developing countries Positive reaction to tuberculin testing common Periodic chest x-rays for screening Treatment of active disease Mutates readily when only one anti-infective agent used Newly diagnosed typically treated with four oral medications for first 2 months Isoniazid Rifampin Pyrazinamide Ethambutol Followed by at least 4 months of isoniazid and rifampin In presence of HIV infection ( at least 9 months See MEDICATIONS Antituberculosis Drugs, p.612-613 Adherence Evaluated during follow up visits When adherence is a problem, medications are administered under direct supervision Follow-up Repeat sputum specimens Chest x-ray Most sputum cultures negative within 2 months of therapy Virtually all negative within 3 months if positive ( treatment failure, drug resistance Relapse rate less than 5 Nursing process Public health threat Education, screening major nursing strategies for prevention Increasing awareness of tuberculosis as reemerging threat Best prevention ( early diagnosis of infection Vaccine not widely used in United States Primary prevention in United States ( treatment of latent infection, prophylaxis for those HIV-infected and exposed to tuberculosis Assessment Health history Complaints Living circumstances Know exposure Alcohol and recreational drug use Physical examination Screening questions to identify children at risk See Box 96 SCREENING QUESTIONS TO IDENTIFY RISK FOR LATENT TUBERCULOSIS INFECTION, p. 612 Diagnosis Fatigue Imbalanced Nutrition Less Than Body Requirements Deficient Knowledge Ineffective Therapeutic Regimen Management Risk for Infection Deficient Community Health Social Isolation Planning Client demonstrates behaviors that reduce the risk of contamination of others Client describes required treatment and follow-up care Client has adequate resources available to obtain necessary medications and supplies Implementation Provide client education Assess knowledge about disease process, identify misperceptions, emotional reactions Assess ability, interest in learning, developmental level, obstacles to learning Identify clients support systems, include significant others in teaching Establish relationship of mutual trust with client and significant others Develop mutually acceptable learning goals with client and significant others Select appropriate teaching strategies Teach about tuberculosis and prescribed treatment including Nature of disease and its spread Purpose of treatment and follow-up procedures Measures to prevent spreading disease to others Importance of maintaining good general health Names, doses, purposes, and adverse effects of prescribed medications Importance of avoiding alcohol and other substances that may damage liver while taking chemotherapeutic drugs Fluid intake needs of 2.53.0 quarts of fluid per day Manifestations to report to physician Document teaching and level of understanding See CLIENT TEACHING MANAGING TUBERCULOSIS, p. 615 Promote effective therapeutic regimen management Assess self-care abilities and support systems Assess knowledge and understanding of disease, treatment, risks to others Work collaboratively to identify barriers, obstacles to managing prescribed treatment Assist client, significant other, and healthcare team members to develop a plan for managing the prescribed regimen Provide clear, appropriate verbal, written instructions at clients level Provide active intervention for homeless people, including shelter placement or other housing and ongoing follow-up by easily accessed healthcare provider Refer clients unlikely to comply with treatment regimen to public health department for management and follow-up Reduce risk for infection Place client in private room with airflow control use standard precautions and tuberculosis isolation as recommended by the CDC Discuss reasons for and importance of respiratory isolation procedures Place mask on client when transporting to other parts of the facility Inform all personnel having contact with client of diagnosis Assist visitors to mask before entering the room Teach the client how to limit transmitting the disease to others Always cough and expectorate into tissues Dispose of tissues properly, placing them in closed bag Wear a mask if you are sneezing, unable to control respiratory secretions Disease is not spread by touching inanimate objects ( no special precautions required for eating utensils, clothing, books, other objects Teach client how to collect sputum specimens Teach client the importance of complying with prescribed treatment for the entire course of therapy Maternity care Newly delivered woman found to have tuberculosis ( prevent direct contact with newborn until woman is noninfectious If maternal tuberculosis is inactive or mother on therapy long enough to prevent infection of newborn ( breastfeed and care for baby Evaluation Client with latent infection completes therapy, does not develop active tuberculosis Clients contacts are evaluated for tuberculosis and those infected are treated Review Tuberculosis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 9.8 Urinary Tract Infection Overview Urinary tract includes kidneys, ureters, urinary bladder, urethra Urinary tract infection (UTI) can interrupt urine production, waste elimination Interrupt urinary drainage system When caring for clients with UTIs ( consider clients modesty in voiding, possible difficulty discussing genitals, potential embarrassment about being exposed for examination and testing, fear of changes in body function Nursing interventions for clients with UTIs directed toward primary prevention, early detection, management of disorder through health teaching and nursing care Bacterial infection of urinary tract common reason for seeking health services Community-acquired UTIs common in young women, unusual in men under age 50 Most community-acquired UTIs caused by Escherichia coli Catheter-associated UTIs often involve other gram-negative bacteria Pathophysiology and etiology Urinary tract normally sterile above urethra Peristaltic activity of ureters, competent vesicoureteral junction ( maintain sterility of upper urinary tract Intravesicular pressure compresses ureter during voiding ( preventing reflux UTIs ( bacterial, viral, fungal Lower urinary tract ( urethritis, prostatitis, cystitis Upper urinary tract ( pyelonephritis Superficial tissues ( bladder mucosa, prostate tissue, renal tissue Community acquired or nosocomial Acute or chronic Cystitis most common Pyelonephritis ( inflammation of renal pelvis and parenchyma Acute pyelonephritis ( bacterial infection of kidney usually from an infection that ascends to kidney from lower urinary tract Asymptomatic bacteriuria, pregnancy, urinary tract obstruction, malformations, reflux Infection spreads from renal pelvis to renal cortex Onset typically rapid ( fever, chills, malaise, vomiting, flank pain, costovertebral tenderness, urinary frequency, symptoms of cystitis Older adult may present with change in behavior, acute confusion, incontinence, general deterioration in condition Chronic ( associated with nonbacterial infections, inflammatory processes Etiology Second most common infection in children Pathogens usually enter urinary tract by ascending from mucous membranes of perineal area into lower urinary tract From bladder ( bacteria continue to ascend urinary tract to parenchyma of kidneys 1015 of hospitalized clients with indwelling urinary catheters develop bacteria Vesicoureteral reflux ( backflow of urine from bladder into kidneys Renal scarring from hydronephrosis, or pyelonephritis ( inflammatory and ischemic effects of infection Risk of kidney damage increases in following cases UTI in infant less than 1 year of age Delay in diagnosis, effective antibacterial treatment Anatomic obstruction or nerve supply interruption Recurrent episodes of upper UTIs Risk factors Predisposed to UTI Adult females Risk increases with sexual activity Spermicidal compounds alter normal bacterial flora of vagina and perineal tissues ( further increase risk Pressure of diaphragm on urethra Lack of normally protective mucosal enzyme Personal hygiene Voluntary urinary retention Males Prostatic hypertrophy Bacterial prostatitis Circumcision protective Anal intercourse Urinary stasis ( neurogenic bladder Children ( infrequent voiding Asymptomatic bacteriuria (ASB) 30 of pregnant women with ASB will develop UTIs Almost always caused by E. coli Congenital and acquired factors Urinary tract obstruction ( tumors, calculi, strictures Instrumentation of urinary tract Older clients have increased incidence Increases in men ( hypertrophy of prostate Women ( loss of elasticity, weakening of perineal muscles ( cystocele, rectocele Increased risk during pregnancy Second trimester Increased risk of preeclampsia ASB ( pyelonephritis ( increased risk of premature birth, intrauterine growth restriction Postpartum ( postpartal dieresis, increased bladder capacity, decreased bladder sensitivity Prevention Good personal hygiene See CLIENT TEACHING PREVENTION OF UTIs, p. 621 Clinical manifestations Symptoms depend on infections location and clients age Infant ( nonspecific ( fever, failure to thrive, poor feeding, vomiting and diarrhea, strong-smelling urine, irritability Child younger than 2 ( fever of unknown origin ( tested for UTI Typical presenting symptoms of cystitis Dysuria Urinary frequency and urgency Nocturia Foul odor of urine Cloudy urine ( pyuria Bloody urine ( hematuria Suprapubic pain, tenderness Lifespan and cultural considerations Older clients ( nonspecific manifestations Nocturia Incontinence Confusion, behavior change Lethargy Loss of appetite Just not feeling right Fever or hypothermia Urgency and frequency may be age-related Many UTIs asymptomatic Cystitis usually uncomplicated ( readily responds to treatment Catheter-associated UTIs often asymptomatic Intermittent catheterization carries lower risk of infection than indwelling Instillation of anesthetic lubricating gel into urethra prior to catheter insertion ( reduces risk by dilating urethra, reducing trauma Collaboration Eliminating causative organism, preventing relapse or reinfection, identifying and correct contributing factors Diagnostic tests Urinalysis Nitrite dipstick Urine culture and sensitivity tests Gram stain WBC with differential Recurrent infections, persistent bacteriuria ( additional diagnostic testing Intravenous pyelography (IVP) Voiding cystourethrography Cystoscopy Manual pelvic or prostate examinations Renal and bladder ultrasound and DMSA (dimercaptosuccinic acid) scanning Surgery Indicated if testing indicates Calculi Structural anomalies Strictures Ureteroplasty ( surgical repair of ureter Ureteral stent ( thin catheter inserted into ureter to provide for urine flow, ureteral support See Box 97 URETERAL STENT, p. 624 Follow-up cultures Pharmacologic therapy Uncomplicated lower urinary tract infections ( short course of antibiotic therapy Upper urinary tract ( longer treatment Antibiotic selected based on age of client, sensitivity of cultured organism, renal function, clients signs and symptoms Follow-up culture 4872 hours after drug therapy started in pediatric client who is still febrile Short-course therapy reduces cost, increases compliance, lower rate of side effects Pyelonephritis, urinary tract abnormalities or stones, history of previous infection with antibiotic-resistant infections 7- to 10-day course Trimethoprimsulfamethoxazole (TMP-SMX) Ciprofloxacin, ofloxacin Severe illness may require hospitalization and IV antibiotics Children ( appear ill, cannot tolerate oral antibiotics, often hospitalized for rehydration and parenteral antibiotics Frequent symptomatic UTIs ( prophylactic antibiotic therapy ASB in catheterized clients Remove catheter ( 10- to 14-day course of antibiotic therapy Nonpharmacologic therapy Helpful in preventing and treating UTIs Drinking adequate fluids Drinking cranberry juice Avoiding caffeinated beverages, alcohol, soft drinks with citrus Complementary and alternative therapy Aromatherapy, herbal preparations Low-sugar cranberry juice, blueberry juice Bergamot, sandalwood, lavender, juniper oil to bathwater may help relieve discomfort of UTI Some contraindicated Nursing process Assessment Health history ( symptoms, history of UTIs, pregnancy, birth control used, medications, allergies Physical examination ( general health, vital signs, tenderness Pediatric considerations ( see LIFESPAN CONSIDERATIONS UTI ASSESSMENT Signs of acute or chronic illness Examine genitourinary system Collect urine specimen for culture Assess infant for toxic appearance, fever, oral fluid intake Measure height, weight ( plot on growth curve Palpate abdomen, suprapubic, costovertebral areas for masses, tenderness, distention Sexually active adolescent May deny symptoms for fear of disclosing sexual activity to parents Diagnosis Acute Pain Impaired Urinary Elimination Deficient Knowledge Risk for Disproportionate Growth (pediatric clients) Urinary Retention Risk for Deficient Fluid Volume Fear Planning Describes pain as 3 or lower on a 110 scale Regains normal voiding pattern, produces normal urine without blood, bacteria, protein Verbalizes understanding of disease process, proper method of taking medications, and required follow-up care Provides strategies for reducing the risk of another UTI Implementation Manage pain Common in both lower and upper UTIs Assess pain timing, quality, intensity, location, duration aggravating and alleviating factors Teach or provide comfort measures Increase fluid intake unless contraindicated Instruct client to notify primary care provider if pain and discomfort continue or intensify after therapy is initiated Community-based care Teaching is most important nursing intervention Risk factors Early manifestations Maintaining optimal immune system function Completing prescribed treatment Minimizing risk of UTIs from indwelling catheter Facilitate Effective urinary elimination Inflammation of bladder, urethral mucosa affects normal process and patterns Toilet-trained toddler may regress Older child may develop enuresis Monitor color, clarity, odor of urine Instruct clients with impaired urinary elimination to avoid caffeinated drinks, citrus juices, artificial sweeteners, alcoholic beverages Use strict aseptic technique and closed urinary drainage system when inserting straight or indwelling urinary catheter When possible, use intermittent straight catheterization to relieve urinary retention Maintain closed drainage system, use aseptic technique when emptying catheter drainage bag Provide perineal care on regular basis and following defecation Promote effective health maintenance Teach clients how to obtain midstream clean-catch urine specimen Assess knowledge about disease process, risk factors, preventive measures Discuss prescribed treatment plan, importance of taking all prescribed antibiotics Help client develop plan for taking medications Instruct clients to keep appointments for follow-up and urine culture Teach methods to prevent future UTI Evaluation Cure, as evidenced by absence of pathogens in urine, is desired outcome Unresolved bacteriuria ( fails to eradicate bacteria in urine Persistent bacteriuria ( persistent source of infection causes repeated infection Reinfection ( development of new infection with different pathogen Expected outcomes Client increases fluid intake and number of voidings each day Client completes prescribed course of antibiotic therapy Urine is free from bacteria following treatment Client experiences no recurrent UTIs for 1 year Client incorporates preventative self-care measures into daily regimen Review Urinary Tract Infection Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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