Communicable and Infectious Disease Emergencies

CHAPTER 19 Communicable and Infectious Disease Emergencies



Amy Smith Peard, MSN, ENP, CEN, CNS



MAJOR TOPICS



General Strategy


Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Communicable and Infectious Disease Emergencies


Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Diphtheria

Encephalitis

Hepatitis

Herpes: Disseminated

Measles

Meningitis

Mononucleosis

Mumps

Pertussis

Varicella (Chickenpox)

Shingles (Herpes Zoster)

Global/Pandemic Illness

Tuberculosis

Skin Infestations

Lice

Scabies

Myiasis


I. GENERAL STRATEGY



A. Assessment




1. Primary and secondary assessment/resuscitation (see Chapter 1)


2. Focused assessment


a. Subjective data collection

1) History of present illness/chief complaint
a) Pain: PQRST (see Chapter 9)

b) Fatigue, malaise

c) Vomiting

d) Altered mental status or decreased level of consciousness

e) Fever

f) Shortness of breath

g) Rash

h) Edema: location and type

i) Weakness

j) Weight loss

k) Cough

l) Sore throat

m) Other symptoms: anorexia, pruritus, diarrhea, swollen lymph nodes

n) Efforts to relieve symptoms
(1) Home remedies

(2) Alternative therapies

(3) Medications
(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history
a) Current or preexisting diseases/illness
(1) Human immunodeficiency virus (HIV) infection

(2) Diabetes

(3) Alcoholism

(4) Renal disease

(5) Cardiovascular: hypertension

(6) Cancer

(7) Tuberculosis (TB) or exposure

b) Recent major injury

c) Surgical procedures (i.e., splenectomy)

d) Previous similar episodes

e) Recent animal, vector, or tick bites

f) Blood transfusions, hemodialysis

g) Recent out-of-country travel

h) Previous measles, mumps, varicella

i) Vaccine failure in high school and college students

j) Smoking history

k) Substance and/or alcohol use/abuse

l) Last normal menstrual period: female patients of childbearing age

m) Current medications
(1) Prescription
(a) Anticoagulants

(b) Insulin or oral hypoglycemic agents

(c) Thyroid hormone

(d) Diuretics

(e) Oral contraceptives

(f) Antiretroviral agents and protease inhibitors

(g) Steroids or cancer drugs

(2) Over-the-counter/herbal
(a) Acetaminophen (Tylenol) or aspirin

n) Allergies

o) Immunization status (for current schedule, see http://www.cdc.gov/nip/recs/child-schedule.htm)

3) Psychological/social/environmental factors
a) Age: illness more severe in very young and elderly

b) Family history

c) Race, culture, and socioeconomic status: may determine increased incidence

d) Possible/actual abuse, assault, intimate partner violence situations (see Chapter 3)

e) Lifestyle
(1) Alcohol and street drug, especially intravenous (IV) use

(2) Homosexual or bisexual sexually active men

(3) Acquired immunodeficiency syndrome (AIDS) or HIV infection in patient, family member, or sexual partner

(4) Bisexual or IV drug user sexual partner

(5) Sexual practices, multiple sexual partners

(6) Body piercing or tattooing

(7) Intrauterine exposure of fetus

(8) Prostitution: male or female

(9) High-risk occupation for disease contact

(10) Daycare center utilization

(11) Military recruit camp residence

(12) Homelessness, institutional residence

(13) Crowded living conditions

(14) Personal hygiene: handwashing, sharing bed/clothes/utensils

f) Emigration from country with high incidence of TB

g) Climate or environment

b. Objective data collection

1) General appearance
a) Level of consciousness, behavior, affect

b) Vital signs, including orthostatic blood pressure/pulse

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection
a) Neck veins

b) Skin rash/lesions/petechiae

c) Skin color

d) Edema

e) Eye signs

f) Meningeal signs

g) Voice sounds

h) Mucous membranes

i) Evidence of trauma

j) Areas of erythema

k) Head and pubic hair for nits (lice eggs)

3) Auscultation
a) Breath sounds: clear, wheezes, crackles, other sounds

b) Bowel sounds: normal, hyperactive, hypoactive, absent

c) Heart sounds: S1 and S2, other sounds (e.g., murmurs)

4) Palpation/percussion
a) Sinus tenderness

b) Areas of tenderness

c) Areas of edema

d) Abdominal distention

e) Organomegaly

f) Areas of hyperthermia

g) Lymph nodes

h) Chest: tone of percussion note

3. Diagnostic procedures


a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), creatinine

3) Arterial blood gas (ABG)

4) Urinalysis; pregnancy test in female patients of childbearing age

5) Alcohol level

6) Serum and urine toxicology screen: therapeutic level and toxic ingestions

7) Coagulation profile: clotting studies, partial thromboplastin time (PTT), and prothrombin time/international normalized ratio (PT/INR)

8) Blood type and crossmatch

9) Liver function tests

10) Heterophile antibody titer (Monospot)

11) TB skin test and sputum

12) Hepatitis screen

13) Viral serology

14) Cerebrospinal fluid: cell count, glucose and protein content, lactic acid, culture, Gram stain

15) Cultures: blood, sputum, wound, throat, nasopharyngeal, viral

16) HIV
a) Enzyme-linked immunosorbent assay (ELISA): initial screening test

b) Simple/rapid (S/R) assays: initial screening test, used more in mass screenings

c) Western blot: confirmatory test, expensive

d) Indirect immunofluorescent antibody (IFA): confirmatory test, expensive

e) Line immunoassays (LIAs): confirmatory tests, less expensive than Western blot or IFA

17) Cluster of differentiation 4 (CD4+) cell count

18) Skin scrapings

b. Imaging studies

1) Chest radiograph

2) Skull and cervical spine radiographs

3) Computed tomography (CT) scan

4) Magnetic resonance imaging (MRI) scan

c. Other

1) 12- to 15-lead electrocardiogram (ECG)

2) Electroencephalogram (EEG)


B. Analysis: Differential Nursing Diagnoses/Collaborative Problems




1. Ineffective airway clearance


2. Ineffective breathing pattern


3. Impaired gas exchange


4. Decreased cardiac output


5. Deficient fluid volume


6. Ineffective tissue perfusion


7. Impaired skin integrity


8. Impaired verbal communication


9. Knowledge deficit


10. Acute pain


11. Anxiety/fear


12. Risk for aspiration


13. Risk for injury


14. Risk for infection



C. Planning and Implementation/Interventions




1. Determine priorities of care


a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluid/blood products/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension


3. Allow significant others to remain with patient if supportive


4. Educate patient and significant others



D. Evaluation and Ongoing Monitoring (see Appendix B)




1. Continuously monitor and treat as indicated


2. Monitor patient’s responses/outcomes, and modify nursing care plan as appropriate


3. If positive outcomes are not demonstrated, reevaluate assessment and/or plan of care



E. Documentation of Interventions and Patient Response




F. Age-Related Considerations




1. Pediatrics


a. Growth or development related

1) Neonates, infants, and toddlers are more susceptible to illness and injury but also have more recuperative capacity

2) Immune systems are not completely developed

3) At birth, newborns possess varying degrees of nonspecific and specific immunity, which lasts from 1 to 8 months of age

4) Brain development is not complete until about age 20 years, so more susceptibility to injury exists

5) Frequent exposure to illness: children are exposed to daycare attendees, siblings, classmates; understanding of hygiene and infection control is lacking

6) Fluid and electrolyte composition: 75% to 80% of body weight in infants is fluid, thus making them more susceptible to dehydration

b. “Pearls”

1) Pediatric patients are developmentally unable to care for themselves during illness (e.g., maintaining adequate fluid intake)

2) Parents know their children better than anyone: listen to them

3) Most therapeutic choice is often reassurance

2. Geriatric


a. Aging related

1) In healthy elderly people, physiologic decreases in function are usually apparent only under stress

2) Reserve capacity for responding to stress decreases

3) Immune system is compromised

4) Reduced ability to metabolize and clear medications leads to frequent occurrence of toxicity and adverse reactions

5) Neurologic system: loss of nonreplicating cells (neurons) may lead to permanent deficit
a) Dopaminergic neurons are lost, impairing gait and balance and increasing susceptibility to side effects of medication

b) Loss of other neurotransmitter systems leads to autonomic dysfunction and alterations in neuroendocrine control and mental function

6) Cardiovascular system
a) Decreases in heart rate are accompanied by increased end-diastolic and end-systolic volumes: reserve mechanisms to increase cardiac output are used routinely and may be overwhelmed by illness

b) Baroreceptor reflex sensitivity decreases, altering response of system to changes in intravascular volume; orthostasis is more prevalent

7) Pulmonary system: elasticity of small airways is lost, with increased tendency for alveoli to collapse

8) Endocrine system
a) Glucose intolerance, insulin resistance, and abnormal regulation of insulin secretion occur

b) Metabolic clearance of thyroid hormone decreases: in thyroid disease, must decrease dose of exogenous thyroxine (thyroid medication)

c) Decreased estrogen level alters bone metabolism, leading to osteoporosis

9) Fluid and electrolytes: adaptive mechanisms are impaired, although balance (volume and number of solutes) is unchanged
a) Nephron loss and decrease in renin and aldosterone levels contribute to increased sodium loss before compensatory mechanisms can be fully activated

b) Decreased glomerular filtration rate, baroreceptor reflex sensitivity, and insulin and beta-adrenergic responsiveness increase risk of hyperkalemia

c) Water conservation and urine-concentrating ability, as well as thirst mechanism, are impaired, resulting in increased susceptibility to dehydration

d) Increased osmoreceptor sensitivity with higher set point for vasopressin (antidiuretic hormone) increases risk of syndrome of inappropriate antidiuretic hormone (SIADH) in patients taking certain drugs and in pulmonary and neurologic diseases

10) Renal system: renal blood flow, glomerular filtration rate, and creatinine clearance are decreased

11) Vision and hearing
a) Decreased visual acuity, changes in refractive power, loss of accommodation, cataracts, and decreased tear secretion influence ability to see adequately

b) Hearing loss occurs as a result of changes in peripheral auditory system and cerebral cortex

b. “Pearls”

1) Decreased activity and less emotional involvement in activity or roles occur

2) Elderly patients have increased concern with immediate environment, health, and factors affecting them directly


II. SPECIFIC COMMUNICABLE AND INFECTIOUS DISEASE EMERGENCIES



A. Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome


Human immunodeficiency virus (HIV) results from infection by a retrovirus. Acquired immunodeficiency syndrome (AIDS) is a life-threatening disease, which is the late stage of HIV infection and the addition of opportunistic infections. Transmission occurs by direct contact of a person’s blood or body secretions with the blood or body secretions of a person infected with HIV. Antibody seroconversion usually takes place within 45 days of exposure but may not occur for up to 6 months after infection. Acute HIV infection is characterized by a mononucleosis-like or other viral-like syndrome occurring 2 to 6 weeks after exposure. This is followed by a clinically asymptomatic period lasting months to years, during which time the virus replicates, mutates, and destroys the immune system. Then development of persistent generalized lymphadenopathy occurs, and finally the opportunistic diseases develop, including constitutional disorders, neurologic disorders, secondary infections, secondary cancers, and other infections such as pneumonitis. Development of these problems signals the beginning of AIDS. Currently, it is believed that all HIV infection will at some point result in AIDS. At present, the mean length of time between exposure to HIV and development of AIDS is about 10 years. The sooner treatment begins after infection, the better a person’s long-term survival will be.


HIV infection causes a defect in cell-mediated immunity and results in decreased resistance to other opportunistic infections. Specifically, it attacks the CD4 cell, which is the cornerstone of the immune system that identifies everyday infections and starts an immune response. All patients are profoundly immunodeficient at the onset of AIDS. There is aberration in the number and function of T lymphocytes, with a decrease in T-helper cells, B lymphocytes, and macrophages. Syphilis and drug-resistant TB frequently occur. Extrapulmonary TB is more common in HIV-infected patients, particularly TB affecting the meninges, bones, joints, and urinary tract. Opportunistic infections, commonly Pneumocystis carinii pneumonia, cytomegalovirus (CMV) infection, and Kaposi’s sarcoma, are the usual causes of death.




1. Assessment


a. Subjective data collection

1) History of present illness/chief complaint
a) Generalized lymphadenopathy, persistent

b) Fever for longer than 1 month
(1) Episodic spiking

(2) Persistent low-grade fever

c) Diarrhea for longer than 1 month

d) Weight loss

e) Anorexia

f) Dyspnea

g) Night sweats

h) Malaise or fatigue, arthralgias, myalgias

i) Mild opportunistic infections
(1) Oral candidiasis

(2) Herpes zoster

(3) Tinea

j) Skin lesions, rashes

k) Cough

l) Broad range of neurologic complaints, both focal and global, including dementia

2) Past medical history
a) Current or preexisting diseases/illness
(1) HIV diagnosis

(2) Blood transfusions, especially before 1985

(3) Hemophilia

(4) Tissue transplantation

(5) Infant with HIV-positive mother

b) Occupational needle sticks, blood exposure

c) IV drug use

d) Sexual contact
(1) Sexually transmitted diseases (STDs)

(2) Sexual contact with IV drug user

(3) Sexual contact with HIV-positive partner

(4) Sexual practices including multiple partners, anal sex, oral-anal sex, local repetitive trauma

e) Recent TB exposure

f) Medications
(1) Antiretroviral agents

(2) Antibiotics

(3) Antifungals

(4) Protease inhibitors

g) Allergies

h) Immunization status

b. Objective data collection

1) Physical examination
a) General appearance
(1) Level of consciousness, behavior, affect: withdrawn, irritable, apathetic, depressed, dementia

(2) Chronically ill appearance, wasting syndrome; signs of volume depletion

(3) Gait: slow, unsteady; weakness; poor coordination

(4) Possible elevated temperature

(5) Mild to acute distress/discomfort

b) Inspection
(1) Kaposi’s sarcoma skin lesions

c) Palpation
(1) Lymphadenopathy

d) Auscultation
(1) Breath sounds: crackles and wheezes

2) Diagnostic procedures
a) CBC with differential
(1) Anemia: blood loss or bone marrow infection

(2) Lymphopenia

(3) Thrombocytopenia

b) ABGs

c) Serum chemistries, liver function tests

d) Determination of HIV antibodies (e.g., via ELISA and Western blot confirmatory analysis)

e) CD4+ cell count: decreased

f) Immunologic studies

g) Blood cultures: if recurrent fever without source

h) Urinalysis; pregnancy test in female patients of childbearing age

i) Stool culture, ova and parasites

j) TB skin test (purified protein derivative [PPD]): 5 mm is positive in HIV-infected person

k) Lumbar puncture if neurologic deficits or headache present

l) Chest radiograph

m) Head CT scan if neurologic deficits or headache present

2. Analysis: differential nursing diagnoses/collaborative problems


a. Impaired gas exchange

b. Risk for infection

c. Deficient knowledge

d. Anxiety/fear

3. Planning and implementation/interventions


a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen

1) Rapid-sequence intubation (RSI) and ventilatory support in patients with respiratory distress

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluid/medications

d. Prepare for/assist with medical interventions

1) Advanced airway management
a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g., cricothyrotomy)

2) Minimize contact with blood and body secretions: use standard precautions with every patient

3) Wear respiratory masks if patient is coughing

4) Institute cardiac and pulse oximetry monitoring

5) Insert gastric tube and attach to suction

6) Insert indwelling urinary catheter

7) Assist with hospital admission

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Antipyretics

3) Antibiotics

f. Educate patient and significant others

1) Health care workers who have percutaneous exposure from known HIV should receive as prophylaxis mono-antiretroviral or combination antiretroviral therapy until testing completed

2) Disinfect body fluid spills (e.g., with 10% solution of household bleach in water): teach procedure to patient and family

3) Adhere to safer health and sex practices
a) Know your sexual partner

b) Engage in mutually monogamous sexual relationship

c) Use condoms if sexually active

d) Do not share drug paraphernalia

e) Do not share razors, toothbrushes

f) Avoid pregnancy to prevent fetal transmission

g) Avoid high-risk sexual practices

4) Report any fever, cough, or unusual fatigue immediately to health care provider

5) Avoid contact with persons who are ill

6) Take medications correctly

7) Drink adequate oral fluids and eat a healthy diet

8) Encourage smoking cessation and minimizing/stopping other types of substance abuse (alcohol, recreational drug use)

4. Evaluation and ongoing monitoring (see Appendix B)


a. Hemodynamic status

b. Breath sounds and pulse oximetry

c. Cardiac rate and rhythm

d. Intake and output


B. Diphtheria


Diphtheria is an acute, highly contagious disease caused by a gram-negative bacillus, Corynebacterium diphtheriae, which produces a systemic toxin and usually causes membranous nasopharyngitis or obstructive laryngotracheitis. Cutaneous lesions may also occur. Diphtheria is spread by airborne respiratory droplets or by direct contact with respiratory secretions or skin lesion exudate. The exotoxin of this rapidly progressive illness can result in widespread organ damage and complications, including myocarditis, thrombocytopenia, vocal cord paralysis, acute tubular necrosis, and an ascending paralysis similar to Guillain-Barré syndrome. Diphtheria is rare in the United States and seen most often in the South and the Pacific Northwest among urban and rural poor populations. It occurs in immunized as well as nonimmunized persons, and the severity of illness is directly related to immunization status. The only effective control of this disease is universal immunization. The incidence is greatest in fall and winter; transmission occurs by intimate contact, typically in crowded living conditions. The incubation period is 2 to 5 days. Treated illness is communicable for up to 4 days; untreated illness can be spread for up to 2 weeks. Occurrence of active disease does not confer immunity. Pseudomembranous inflammation develops on mucosal surfaces of the throat, which may lead to airway obstruction. Death usually results from respiratory (asphyxia) or cardiac (myocarditis) complications. Death is most common in the very young and elderly, usually within 3 or 4 days of the onset of illness.




1. Assessment


a. Subjective data collection

1) History of present illness/chief complaint
a) Onset lasting 1 to 2 days

b) Sore throat

c) Difficulty in swallowing or breathing

d) Fever: low grade or high (rarely greater than 103°F [39.4°C]), chills

e) Headache

f) Nausea

g) Malaise

h) Travel to endemic areas in previous week

i) Crowded living conditions

2) Past medical history
a) Current or preexisting diseases/illness

b) Childhood diseases

c) Medications

d) Allergies

e) Immunization status

b. Objective data collection

1) Physical examination
a) General appearance
(1) Alteration in neurologic functions
(a) Level of consciousness, behavior, affect: lethargy, withdrawal, confusion

(b) Cranial nerve neuropathies

(2) Tachycardia, tachypnea

(3) Elevated temperature: fever greater than 101°F (38.3°C)

(4) Stridor

(5) Severe distress/discomfort, critically ill

b) Inspection
(1) Dirty, gray-white, rubbery membrane covering structures of pharynx and larynx (removal of membrane leaves a bleeding surface)

(2) Swelling of structures of pharynx

(3) Cyanosis

(4) Use of accessory muscles

(5) Nasal flaring

(6) Cardiac dysrhythmias on monitor
(a) First-degree atrioventricular block

(b) ST-segment and T-wave changes

c) Palpation
(1) Cervical lymphadenopathy

2) Diagnostic procedures
a) Throat culture: specimen swabbed from beneath membrane or piece of membrane; notify laboratory that C. diphtheriae is suspected: requires special media and handling
(1) Nasal and pharyngeal swabs of close contacts

b) CBC with differential: mild leukocytosis, thrombocytopenia

c) Serum antibodies to diphtheria toxin

d) Cardiac, liver enzymes: elevated aspartate aminotransferase (AST) parallels myocarditis severity

e) Urinalysis; pregnancy test in female patients of childbearing age

f) Chest radiograph: subglottic narrowing

g) ECG: ST-segment, T-wave changes, heart block, dysrhythmias with cardiac involvement

2. Analysis: differential nursing diagnosis/collaborative problems


a. Ineffective airway clearance

b. Pain

c. Anxiety/fear

d. Risk for aspiration

3. Planning and implementation/interventions


a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen

1) RSI and ventilatory support in patients with airway compromise

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluid/medications

d. Prepare for/assist with medical interventions

1) Advanced airway management
a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g., cricothyrotomy)

2) Maintain strict droplet precautions (per Centers for Disease Control and Prevention [CDC])

3) Institute cardiac and pulse oximetry monitoring

4) Assist with hospital admission

5) Report to appropriate health department officials

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Diphtheria antitoxin
a) Equine serum

b) Test for sensitivity (intradermal or mucous membrane) before administration

c) Often administered before diagnosis is confirmed because of virulence of disease

3) Antibiotic: erythromycin or penicillin G

4) Antitussives

5) Antipyretics

6) Topical anesthetic agents

f. Educate patient and significant others

1) Identify close contacts

2) Culture and prophylactic antibiotics

3) Booster of tetanus and diphtheria toxoid if none within 5 years

4) Active immunization for nonimmunized persons (series of three doses)

4. Evaluation and ongoing monitoring (see Appendix B)


a. Airway patency

b. Hemodynamic status

c. Breath sounds and pulse oximetry

d. Cardiac rate and rhythm


C. Encephalitis


Encephalitis is a viral infection of the brain that causes an inflammatory response of brain tissue. It often coexists with meningitis and has a broad range of signs and symptoms, ranging from unrecognized mild cases to profound neurologic involvement. Most cases in North America are caused by arboviruses, herpes simplex virus (HSV) type 1, varicella-zoster virus (VZV), Epstein-Barr virus (EBV), and rabies. Transmission may be by animal bites (rabies) or may occur seasonally from vectors (e.g., mosquitoes, ticks, and midges carry arboviruses, Lyme disease, Rocky Mountain spotted fever, and so on). The more common human viruses are airborne and are transmitted via droplet or lesion exudate to the person, in whom replication takes place. The virus then enters the nervous system through the blood. In the brain, the virus enters the neuron, where it causes inflammation, neurologic dysfunction, and damage. Encephalitis occurs in all age groups, and mortality ranges from 5% to 10% from arbovirus infection to nearly 100% for rabies.




1. Assessment


a. Subjective data collection

1) History of present illness/chief complaint
a) Fever

b) Headache

c) Photophobia

d) Nausea, vomiting

e) Confusion, lethargy, coma, other alterations in sensorium

f) New psychiatric symptoms

2) Past medical history
a) Current or preexisting diseases/illness
(1) Recent viral illness or herpes zoster

(2) Immune disorders

b) Recent animal or tick bite

c) Travel to endemic area; season of year

d) Medications

e) Allergies

f) Immunization status

b. Objective data collection

1) Physical examination
a) General appearance
(1) Level of consciousness, behavior, affect: confusion, seizures, comatose

(2) Elevated temperature

(3) Moderate to severe distress, critically ill

b) Inspection
(1) Rash specific to cause

(2) Abnormal muscle movements

(3) Meningismus

(4) Focal neurologic findings

c) Palpation/percussion
(1) Altered reflexes

2) Diagnostic procedures
a) CBC with differential: results variable, depending on cause

b) Blood cultures

c) Serum chemistries

d) Viral serology: aid in identifying arbovirus

e) Coagulation profile

f) Urinalysis; pregnancy test in female patients of childbearing age

g) Lumbar puncture

h) Head CT scan, MRI

i) EEG

j) ECG

2. Analysis: differential nursing diagnoses/collaborative problems


a. Risk for injury

b. Risk for ineffective airway clearance

c. Impaired verbal communication

3. Planning and implementation/interventions


a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen

1) RSI and ventilatory support in a patient with a compromised airway

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluid/medications

1) Minimize fluid overload to avoid cerebral edema

d. Prepare for/assist with medical interventions

1) Institute standard precautions and isolation until causative agent identified

2) Advanced airway management
a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g., cricothyrotomy)

3) Elevate head of bed 30 degrees

4) Institute seizure precautions

5) Institute cardiac and pulse oximetry monitoring

6) Insert gastric tube and attach to suction as indicated

7) Insert indwelling urinary catheter as indicated

8) Maintain normothermic body temperature

9) Assist with hospital admission

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Antibiotics

3) Antivirals

4) Steroids

5) Diuretics

4. Evaluation and ongoing monitoring (see Appendix B)


a. Airway patency

b. Level of consciousness

c. Hemodynamic status

d. Breath sounds and pulse oximetry

e. Cardiac rate and rhythm

f. Intake and output


D. Hepatitis


Hepatitis is a viral syndrome involving the hepatic triad (bile duct, hepatic venule, and arteriole) and the central vein area. Cellular inflammation leads to disruption of the hepatic architecture. Types of hepatitis viruses are identified by letters and vary in incubation and duration periods. Hepatitis A virus (Table 19-1) is transmitted primarily through the fecal-oral route. It is found in serum and stool and is infectious 2 weeks before and 1 to 2 weeks after the appearance of jaundice. Hepatitis B virus (HBV) (see Table 19-1) is transmitted most commonly by IV drug use, sexual contact, and less frequently through blood transfusions since testing of the blood supply began. Hepatitis B surface antigen (HBsAg) appears early in the disease process. Hepatitis B e antigen (HBeAg), thought to be a degradation product of the hepatitis B core antigen (HBcAg), also appears about the same time. Antibodies are produced for each antigen. Persistence of core antibodies indicates chronic infection. Persistence of surface antibodies indicates immunity to reinfection. HBsAg in the serum without symptoms is indicative of a carrier state. Hepatitis C virus (see Table 19-1) is transmitted mostly through IV drug use and blood transfusions and is identified by the presence of antihepatitis C virus antibodies. As many as 50% of hepatitis C infections become chronic, and there is no immunity. Hepatitis C causes approximately 60% of hepatitis cases transmitted by blood transfusion. Hepatitis D is found only in patients with acute or chronic HBV infection and is transmitted most commonly by IV drug use and sexual contact. Hepatitis E is an endemic, enterically transmitted infection caused by eating or drinking contaminated food or water and is similar to hepatitis A. Patients with all forms of hepatitis present with the same clinical features; laboratory testing determines the specific origin. Hepatitis A usually resolves in 4 to 8 weeks and hepatitis E in 6 to 9 months. The remaining types can all continue in a chronic state, which may result in cirrhosis and liver cancer. At this time, there is no cure; however, treatments using interferons and ribavirin are showing success in management of the diseases.



Table 19-1 COMPARISON OF HEPATITIS A, B, AND C

image



1. Assessment


a. Subjective data collection

1) History of present illness/chief complaint
a) Prodrome: preicteric phase, occurs 1 week before jaundice
(1) Low-grade fever

(2) Malaise: earliest, most common symptom

(3) Arthralgias

(4) Headache

(5) Pharyngitis

(6) Nausea, vomiting

(7) Rash, with hepatitis B usually

(8) May or may not progress to icteric phase

(9) Incubation and duration

b) Icteric phase
(1) Disappearance of other symptoms

(2) Anorexia

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Nov 8, 2016 | Posted by in NURSING | Comments Off on Communicable and Infectious Disease Emergencies

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