1 COMMUNICABLE DISEASES

Communicable Diseases: are diseases caused by pathogenic microorganisms (MO) which can be transmitted from an infected person to a susceptible person by: a. Direct-meaning it comes in contact with infected person or person-person transmission Example: 1. Droplets where MO remain in the surface with limitation of its distance of at least 3 feet; face to face encounter with an individual 2. Through kissing, sexual contact and skin to skin contact b. Indirect-meaning from the source of infection to a new host with intermediary object (a bridge that connects you to an infected person) in the form of: 1. Vehicle-borne =non-living things such as water and fomites 2. Vector-borne =living things but non human such as insects c. Break in the skin integrity (nakakahawa) through inoculation Example: Sharp needles and blood transfusions Airborne where MO are suspended in air with no limitation with regards to its distance (not a direct mode of transmission)

Infectious Diseases: are diseases caused by living microorganisms which may not be transmitted through ordinary contact Contagious Diseases: are diseases that can be easily transmitted (madaling mahawa) All communicable diseases are infectious because they are caused by MO but not contagious because not all of them are easily transmitted. All infectious diseases are communicable but not all infectious diseases are contagious All contagious diseases are both communicable and infectious Example: Diphtheria is communicable, infectious and contagious Malaria is communicable and infectious but not contagious Tetanus is not communicable, not contagious but infectious

Epidemiologic Triad of a Disease:

A. Host is a man or an animal where its susceptibility (degree of resistance) is considered

4 Types of Host: 1. Patient-is an individual who is infected with signs and symptoms 2. Carrier-is an individual who harbors the MO but dont show signs and symptoms 3. Suspect-is an individual whose medical history & symptoms suggest that he may be developing a specific infection 4. Contact-is an individual who comes in close association, in contact or exposed to an infected person who can be a source of infection Patient is considered the least source of infection because he is being isolated and treated (all precautionary measures have been applied) Carrier is a potential source of infection In San Lazaro Hospital (SLH), nurses are considered Contact thats why they are not allowed to enter the OR, DR and Nursery. Its necessary for them to take a bath immediately upon reaching their home.

2 B. Agent pertains to MOs that has the greatest population on earth but are taken for granted because they
cannot be seen by the naked eye Virulence- is the strength and power of the microorganism to cause infection Pathogenicity- is the capability of the microorganism to cause infection Virulence + Pathogenicity = Infection

Therefore, not all are susceptible, not all are virulent or pathogenic. 2 Microorganisms: 1. Viruses can only multiply in living things as its reservoir can pass through filters of the body: blood brain barrier and placental barrier because they are very small Viral Infections are self limiting diseases, have time frame, if not treated complication ensues Example: Colds is for 2-3 days with watery nasal discharge; if after 3 days a yellowish-green mucoid discharge develops complication ensues. Influenza last for 1 week but if it moves on, it develops into pneumonia patients are treated according to symptoms its the bodys own resistance that will fight the infections 2. Bacteria can multiply in both living and non living things cannot pass through filters of the body except for Treponema pallidum causing Syphilis which can pass placental barrier after the 16th week (4th month of pregnancy) a. Syphilis is fatal in last trimester b. German measles is fatal in first trimester c. Bacterial Infections can give you temporary immunity but can recur

C. Environment-should be conducive and favorable to the growth & multiplication of the microorganism
Example: Susceptible host, virulent clostridium tetani, oxygenated environment no disease because clostridium tetani is anaerobic Immunity is a state of being resistant to infection or a state of being free from infection 2 Types of Immunity: A. Natural Immunity is inherent in individual body tissues and fluids (born & die with it); very rare Example: Race-its within the genes or chromosomes B. Acquired Immunity is able to get it and produce antibodies; common type 2 Types of Acquired Immunity: 1. Active Acquired Immunity-theres actual participation of the individual body tissues and fluids in producing immunity; you are the one who produce the antibodies 2 ways to produce antibody: a. Naturally acquired active immunity-is by natural means, unintentional production of antibodies or there is a previous attack of the disease Examples: 1) Chickenpox, mumps and measles 2) Subclinical immunity-immunity acquired due to constant exposure to disease such are the workers in SLH 3) Taong grasa-they eat garbage

3 b. Artificially acquired active immunity-is intentionally acquired so that the body produces
antibodies Examples: 1) Vaccines are attenuated or weakened MO that stimulate the body to produce antibody One should use cool boiled water in cleaning site of injection before vaccination Dont use alcohol because its a disinfectant which may act against weakened microorganism of vaccine. If ever alcohol is used, let it dry first before injecting. 2) Toxoids-are attenuated toxins or weakened poison produce by the MO Toxins-are poisonous substances produce by microorganism Passive Acquired Immunity-develop immunity due to presence of antibodies within the serum which is not coming from the individual himself; you dont produce it yourself 2 Ways: a. Naturally acquired passive immunity 1) Maternal transfer or placental transfer of antibodies thats why infants below 6 months dont develop infectious diseases because of mothers antibodies 2) Colostrum through breastfeeding thats why infants seldom develop infectious diseases because it contains antibodies b. Artificially acquired passive immunity-intentionally given so that theres an immediate protection from infection Example: 1. Antiserum 2. Antitoxin 3. Gamma globulin 4. Immunoglobulin

2.

If a pregnant woman receives TT, the baby would get a naturally acquired passive immunity; For pregnant woman receiving TT, she gets artificially acquired active immunity All types of Passive Acquired Immunity will give you immediate action or protection but it is temporary because you dont produce the antibodies yourself Active Acquired Immunity is long lasting type of immunity; it is available anytime the body needs it Example: If you are bitten by a dog, you have an exposure and you will be given active and passive form of vaccine; If you have an infection, just the passive vaccine is given (antiserum and antitoxin) Chain (Cycle) of the Infectious Process: 6 Factors: 1. Causative agent-pertains to microorganism Example: Dengue-arbovirus while aedes agypti is the vector

2. Reservoir-pertains to place where microorganism can live, multiply and grow

Example: Treponema pallidum- human (genitourinary) Clostridium tetani- soil Yellow fever/Brussanosis/Brucellosis- animals Measles- human (nasopharynx) Salmonella typhosa- human (peyers patches of small intestine)

3. Portal of Exit-pertains to from reservoir to way out corresponds to the body system
Example: Treponema pallidum- GU/reproductive system Measles- Respiratory system Salmonella typhosa- GI/ digestive system

4. Mode of transmission: pertains to means of transportation

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2 General modes of transmission: a. Horizontal transmission-microorganism can be transferred in horizontal position 1) Direct mode of transmission- person to person Example: Droplet which acquired within 3 feet and remains in surface through coughing, sneezing & talking, kissing, sexual contact & skin to skin contact Airborne microorganism is suspended in air and has no limit in distance 2) Indirect mode of transmission- from the source of infections to a new host with an intermediary object (a bridge) a) Vehicle-borne- non living things Example: bed linens, tubings, catheter and eating utensils b) Vector-borne- living but non human Example: insects, rodents, flies, mosquitoes and cockroaches c) Break in skin integrity through inoculation and percutaneous Example: wounds, blood transfusions, needle punctures & animal bites b. Vertical transmission-from top to bottom Example: mother to child transmission- transplacental or perinatal Treponema pallidum- horizontal and direct- sexual contact Measles-horizontal and direct-airborne Salmonella-horizontal and indirect thru vehicle (5 Fs-food, feces, fingers, flies and fomites) Treponema pallidum- GU Measles- Respiratory Salmonella- GI Causative Agent ---------------------------------------------------------- Susceptible Host Reservoir Portal of Entry Portal of Exit Mode of Transmission

5. Portal of entry-pertains to individual body system

Example:

6. Susceptible Host

Typhoid fever is transmitted through fecal oral transmission (from portal of exit to portal of entry) To break the chain of infection, choose the weakest link which is the mode of transmission

3 Nursing Concerns in dealing with a patient with communicable disease: 1. Know the causative agent 2. Know what body secretion harbors the microorganism 3. Know the mode of transmission General Nursing Care for Patients with Communicable Diseases: I. Preventive Aspect- there is no infection yet; not to allow infection to occur Measures: A. Health Education Goal: The person will have a change in knowledge, skills and attitude which eventually lead to change in behavior towards health or do some modification of behavior. The doctor is the primary giver of health education (main responsibility) The nurse is the key provider of information B. Immunization 3 Laws of Immunization:

5 1. Expanded Program on Immunization (EPI) -PD # 996 2. UN Goal: Universal Child Immunization (UCI) -Proclamation # 6 3. Health for Filipino CY 2000: National Immunization Day (NID)-Proc. # 46 Goal: To prevent 7 Childhood Diseases for children under 5 years old

a. TB -BCG b. DPT (Diptheria, Pertussis and Tetanus) -DPT vaccine c. Poliomyelitis -OPV d. Hepatitis B e. Measles 4 Temporary Contraindications for Immunization: 1. Pregnancy do not give live vaccine 2. Immuno-compromised situation 3. Very severe disease immediately needs hospitalization 4. Recently received blood products 2 Permanent Contraindications for Immunization: 1. Allergy 2. Encephalopathy without known cause or convulsions within 7 days after pertussis vaccine In DOH, Cholera, Dysentery, Typhoid (CDT) vaccine is not included in EPI for it only gives 6 months immunity or protection & usually given when there is an epidemic: Children below 10: 0.25 cc IM Vastus lateralis muscle Adult: 0.50 cc IM Deltoid muscle Anti-rabies vaccine target population are animals and they are brought in the barangay and schedule for vaccination In health centers or government hospitals, patients with fever, colds and diarrhea are still given vaccination but private physicians dont give C. Environmental Sanitation 1. PD 856 -integrated all those working in night clubs and beer gardens to submit themselves for STD examination at least once a month and for gonorrhea at least twice a month 2. PD 825 -anti-littering law or proper disposal of garbage Fine: P2,000-5,000 or 6 months-1 year imprisonment D. Proper Supervision of Food Handlers 1. DOH responsibility 2. BFAD monitor food and drugs for safe consumption II. Control Aspect theres already infection but control or limit the spread of infection Measures: A. Isolationseparation of infected person during the period of communicability 2 Ways of Isolation: 1. Strict isolation protecting other persons by containing the microorganism within the patient 2. Protective isolation protecting the patient wherein microorganism will be away from the patient 2 Revised Isolation Precaution to be practiced: 1. Standard Precaution is the primary strategy for preventing nosocomial infection and it slowly took the place of Universal Standard because it has a double standard choosing its patients. a. applies to all patients irregardless of their diagnosis; b. applies to all body fluids, secretions and excretions except sweat c. applies to non intact skin and mucous membrane 3 Elements of Standard Precaution: a. Hand washing before & after coming in contact with the patient at least 10 to 15 seconds of friction applied in scrubbing 1) Medical Asepsishands should be lower than elbow 2) Surgical Asepsishands are upward; elbow is the dirtiest and hand is cleanest

6 b. Use of protective barrier mask must be worn first, goggles, cap, gown and lastly the gloves; c.
when leaving the room, remove the gloves first, do hand washing then remove the rest up to mask, then hand washing again Avoidance of inadvertent needle stick and sharp injury 1) Do not recap needles 2) Do not manipulate broken or bended needles 3) Be sure to have a puncture resistant dispenser 4) If you prick yourself, wash hand with soap and water, then apply antiseptic and inform your supervisor

2. Transmission Based Precautionis instituted to patients infected with highly transmissible infections;
precautions are beyond those set forth in standard precaution; in addition to standard precaution. 3 Ways to Practice Transmission Based Precaution: a. Airborne precaution protective barrier is used; use of respiratory protection such as special type of mask=ultra filter mask or particulate mask Example: Measles, TB, Chicken pox, SARS are airborne diseases b. Droplet precaution contact to the conjunctiva, nasal or oral mucosa; used ordinary mask and goggles Example: Diptheria, Pertussis, Meningitis, Mumps, Pneumonia, German measles and HiB infection c. Contact precaution activities that require physical contact; contact with inanimate objects; used gloves and gowns Example: GI infections- cholera, amoebiasis Skin infections- scabies, ringworm, hepatitis & ebola infxn.

B. Quarantine is limitation of freedom of movement of a well person during the longest incubation period;
quarantine of person with no disease but exposed, no signs and symptoms yet

C. Disinfection is killing of pathogenic MO by physical or chemical means

2 Ways of Attaining Disinfection:

1. Concurrent is done when the person is still a source of infection

Example: All things of the patient should be boiled while confined 2. Terminal is done when the patient is no longer a source of infection Example: Upon discharge of patient, the room is disinfected with UV or Lysol. In OR, disinfection of surgical table by wiping with alcohol and floors with Zephiran Sterilization is killing of all MO including spores which is more extensive Disinfestation is killing of undesirable small animal forms such as arthropods and rodents by physical or chemical means Example: Killing of mosquitoes, roaches and rats by poisoning Fumigation is killing of arthropods and rodents using gaseous agent D. Medical Asepsis 1. Hand washing (the #1 principle) 2. Use of barrier protectors (Personal Protective Equipment): masks, goggles, cap, gown and gloves 3. Placarding: No smoking sign, right arm precaution and protective isolation

DIFFERENT COMMUNICABLE DISEASES Central Nervous System Diseases

Bacterial Etiology: Tetanus Meningitis Viral Etiology: Encephalitis Poliomyelitis

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Rabies TETANUS a.k.a. LOCKJAW: an infectious disease characterized by painful muscle spasms (leg cramps) affecting the gastrocnemius muscle pain in tetanus is 10x the leg cramps almost all muscle have spasm Causative Agent: Clostridium tetani anaerobic, abundantly found in soil, clothing and even in dust Normal Habitat: Found on the intestines of plant eating animals=herbivores such as cow, carabao and sheep as well as in their manure. It can survive outside the body in the form of a spore, thats why it is hard to disinfect, instead sterilization is done to kill it. Spores are protected from oxygen, but when inside the body, it assumes a vegetative form, thus it is easily killed by oxygen. Mode of Transmission: Break in Skin Integrity such as wound splinter (saludsod), tooth decay, human & animal bite, pricking of pimple and poor cord care in NB results to tetanus neonotarum MO stays in the wound and releases toxins that travel to the blood which produces the Signs and Symptoms of Tetanus Toxins released by the MO are: 1. Tetanolysin that dissolves RBC causing anemia 2. Tetanospasmin brings about muscle spasm affecting all the muscle particularly the myoneural junction of muscle and internuncial fibers of spinal cord & brain Immunity: No permanent immunity because it is bacterial Incubation Period: 3 days-1 month; 3-4 weeks=moderate, 3 days=severe The shorter the IP, the poorer the prognosis Signs and Symptoms: 1. Initial signs of wound inflammation such as rubor (redness), calor (heat), dolor (pain), tumor (swelling) and loss of function 2. Increase muscle tone near the wound 3. Tachycardia and profuse sweating 4. Low grade fever 5. Painful involuntary muscle contraction and muscles affected are: a. Massetermuscle of mastication (strongest closing muscle of mouth) when affected it produces Lockjaw or Trismus b. Facial muscleRisus sardonicus=sardonic smile or grin; smiling but eyebrows are raised (ngiting aso) c. Muscle of spineOpisthotonus position=arching of the back (liyad) d. Respiratory muscleDOB/dyspnea=complains of chest pain e. GUTUrinary retention=patient should be catheterized f. GITConstipation g. Abdominal musclerigidity described as board like, if soft=recovery h. Extremity musclestiffness of extremity=difficulty in flexing it; if observed to have robot gait, it means recovery Diagnosis: Wound history, clinical observation and examination Wound culture if there is presence of fresh wound

3 Objectives in Medical Management of Tetanus: 1. To neutralize the toxin so signs and symptoms will be lessen a. Anti-tetanus serum (ATS)/Tetanus antitoxin (TAT)

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comes from horse serum so do skin testing first b. Tetanus immunoglobulin comes from human serum given when patient is allergic to horse serum If theres no choice, horse serum can be given in fractional dose every 30 minutes or after the other when no adverse reaction occur 1st dose .01 vaccine .99 NSS 2nd dose .05 vaccine .99 NSS 3rd dose.10 vaccine .90 NSS Give epinephrine and corticosteroid to counteract any delayed reaction because it could lead to severe hypersensitivity (anaphylaxis) death. 2. To kill the microorganism a. Give the least toxic antibiotic (Penicillin) which is bactericidal b. For fresh wounds, daily cleansing with hydrogen peroxide then apply antiseptic (Betadine) and cover with thin dressing or gauze to allow air to circulate or better not put cover 3. To prevent and control spasms by providing patient with muscle relaxant such as a. Diazepam (Valium) via IV b. Diazepam drip by incorporating it in IVF and titrated according to spasm (frequent spasm=fast regulation of IVF) c. If patient can tolerate oral form: Methocarbamol (Robaxin or Roboxisal) Baclofen (Lioresal) Epirisone (Myonal) 3 Objectives in Nursing Management of Tetanus: 1. To prevent patient from having spasm, the nurse should know the possible stimuli that predisposes patient to spasm such as: a. Exteroceptive stimuli -is coming from external or outside environment of patient such as bright lights and noise Measures: 1) Place patient on a dim and quiet environment 2) Practice minimal handling of patient & avoid unnecessary disturbance of patient by organizing your activities-Cluster Care=do all nursing care in one setting or at one time for (vital sign monitoring, giving medications and talking to patient at one setting-8:00 am) 3) Practice gentle handling of patient by informing patient first about the procedure such as turning and vital sign monitoring before touching him b. Interoceptive stimuli is coming from within the patient such as stress, pain, fatigue, coughing and flatulence c. Propioceptive stimuli theres participation of patient and another person such as touching and turning the patient and jarring the bed of patient. Reason why patient with tetanus is isolated to prevent exposing him to these 3 types of stimuli despite being not communicable 2. To prevent patient from having injury a. Respiratory injury 1) Airway obstruction a) Put a padded tongue depressor prior to spasm to prevent tongue from drawing back which obstruct airway. If no tongue depressor is available, use the handle of a spoon or fork or a small piece of cloth b) Stay with patient during spasm because if cyanosis occurs, administer oxygen with nasal catheter 2) Respiratory infection brought about by not turning patient on his sides that tends to pooling of secretions in his mouth 3) Respiratory aspiration-when patient is capable of eating, give small frequent feeding and discouraged overeating which is an interoceptive stimuli causing over fullness and leads to vomiting b. Falls

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1) Dont leave patient alone 2) Put up padded side rails 3) Call light must be near patients reach 4) Assist patient when walking-fatigue is an interoceptive stimuli Fracture due to restraining of patient when having spasm

c.

3. To provide comfort measures to patient such as oral care by using cotton swab or gauze swab to clean inner cheek and teeth of patient preventing mouth sores Preventive Measures: 1. Immunization a. DPT is given 6 weeks after birth for 3 doses at one month interval Dose: 0.50 ml IM Vastus lateralis Health Teachings: 1) Tell mother to expect fever to set in-give Paracetamol 2) If swelling and tenderness occurs on the site apply cold compress within 24 hours for vasoconstriction followed by warm compress for vasodilation to stop swelling MDs advice: immediate warm compress to promote vasodilation which tend to spread the vaccine followed by immediate cold compress to prevent swelling 3) Observe for any sign of convulsions within 7 days which is a reaction to Pertussis component of the drug thus there is a possibility to develop a neurologic disorder after DPT-crying inconsolably b. Tetanus Toxoid given to pregnant women on the 2nd trimester of pregnancy 2 doses with one month interval and booster doses given every pregnancy Dose: 0.50 ml IM Deltoid muscle c. Tetanus Toxoid given for persons in high risk to tetanus such as the carpenter or construction workers not covered by DOH for 5 doses 1st dose 10-26-05 2nd dose1 month after 11-26-05 3rd dose6 months after from last dose 05-26-06 4th dose1 year after from last dose 05-26-07 5th dose1 year after from last dose 05-26-08 for high risk-give booster dose every 5 years (construction workers) for low risk-give booster dose every 10 years (mothers) 2. Proper wound care a. Wash wounds immediately with soap and water b. Apply antiseptic solution c. Use band aid to cover but not plaster 3. Avoid wounds to prevent portal of entry MENINGITIS: is the inflammation of the meninges (covering of the brain and spinal cord) 3 Coverings: 1. Dura mater 2. Arachnoid-subarachnoid spaces (found in between meninges) 3. Pia mater Causative Agents: 1. Viruses: Cytomegalovirus (CMV) viral meningitis Example: AIDS an opportunistic agent 2. Fungus: Cryptococcal meningitis Source of infection: excreta of fowls or feathered animals

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3. Bacteria: the most common cause a. TB meningitis tubercle bacilli b. Staphylococcal meningitis secondary to skin infection c. Hemophilus influenza B common in USA Meningococcal Meningitis/Spotted Fever/Meningococcemia: highly fatal and highly contagious type of meningitis vascular system is affected resulting to vascular collapse (DIC) within 24-48 hours fulminant (occurring suddenly and with great severity=Waterhouse Friderichsen Syndrome) death caused by bacteria not accepted by most hospitals if exposed to patient with meningococcemia, nurse should received prophylaxis: Rifampicin 450 mg once/day for 3 days Ciprobay 500 mg once/day for 3 days Causative agent: Neisseria meningitides Mode of Transmission: Droplet infection (direct) Immunity: No permanent immunity Incubation Period: 2-10 days Portal of Entry: Respiratory system via the nasopharynx Signs and Symptoms: similar to Upper Respiratory Tract Infection such as fever, sore throat, headache, cough, colds and body malaise Neisseria meningitides Nasopharynx----Upper Respiratory Tract infection (URTI) Bloodstream-----Vascular Changes: Petechial Formation (pinpoint red spots on skin) Ecchymosis (blotchy purpuric lesions-pantal-pantal-reddish violet or bluish violet) on the wrist or ankle/upper and lower extremity Only in meningococcemia that you can find petechia & ecchymosis Spotted fever Meninges-------Theres meningeal irritation manifested by: a. Nuchal rigidity (characteristic sign of meningitis) is the stiffening of the entire neck---cant flex, extend and turn neck from side to side b. There are abnormal reflexes: (+) kernig sign: Place patient on supine position, flex both knees toward abdomen then ask patient to extend both legs. If theres pain and difficulty of extending legs after flexing knees- (+) kernigs (+) Brudzinski sign: In supine position, flex neck of patient towards chest and theres involuntary drawing up of hips and lower extremity upon flexion of neck. Normally, if neck is flexed, it has no reaction- (-) brudzinski Theres an increase intracranial pressure due to accumulation of CSF in the subarachnoid space due to inflammation of meninges:

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Manifestations: a. Severe headache b. Projectile vomiting -2 to 3 feet away from patient c. Altered vital signs: Increase T, decrease PR, decrease RR, increase systolic but normal diastolic BP=widening of pulse pressure d. Convulsions e. Diplopia (double vision) due to choking of optic nerve/disc patient sees 1 finger as 2 fingers when ask to count f. Altered level of consciousness (LOC) Diagnostic Examination: 1. Lumbar puncture tap or aspirate CSF to evaluate a. Color: yellowish, turbid, cloudy---means bacterial etiology clear CSF-means normal or may also mean viral infection b. Laboratory Examination: increase CHON, increase WBC, decrease sugar c. Culture & Sensitivity: To determine causative agent & specific drug to kill microorganism d. Counter Immuno Electrophoresis (CIE) if CSF is clear it tells you if microorganism is viral or protozoa Contraindication of Lumbar Puncture for patient with CNS Infection: Patient with highly increased ICP because it causes herniation (going to the back) of the brain death Normal ICP: 10-11 It is very important to do physical assessment first on the patient before doing lumbar puncture 2. Blood culture done if lumbar puncture cant be done yet because microorganism travels to the blood stream Medical Management: 1. Antimicrobials drugs a. Viral supportive treatment b. Fungus antifungal c. Bacteria antibiotic 2. Corticosteroid Dexamethasone or Solu-cortef but not prednisone because it does not across the blood brain barrier thus it causes sodium retention=ICP 3. Mannitol osmotic diuretic commonly used because it removes excess CSF monitor intake and output to assess or evaluate effectiveness of drug 2-3 hours after mannitol administration---increase UO by 30-50 ml assess hydration of patient check BP of patient before mannitol administration because it can cause hypotension or low BP 4. Anticonvulsant drug Phenytoin (Dilantin) is given per IV or per orem and never by IM because it is irritating to tissues and causes erratic effects Nursing Responsibilities: If Phenytoin is given by IV, it should be sandwich with NSS (NSS-Dilantin-NSS) because when mixed with IVF produces crystallization causing obstruction If given per orem, do oral care and gum massage because it causes gingival hyperplasia Nursing Care for Meningitis: symptomatic and supportive Nursing Diagnosis: 1. Altered temperature/Hyperthermia To lower temperature:

a. TSB b. Apply cold compress c. Wear light/loose clothing d. Increase fluid intake if not contraindicated e. Provide adequate rest

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f. Give Paracetamol 2. Potential for injury due to convulsions Never leave patient alone Provide padded side rails Put call line near patient 3. Altered level of consciousness for diplopia 4. Alteration in comfort (pain) 4 types of massages: 1) Petrissageuse of 2 fingers or thumb pressure over the head or joints intended for headache 2) Tapottementkarate style massage 3) Kneadingas in kneading a dough 4) Effleurage figure 8 massage or circular manner for back and chest a) Apply cold compress b) Elevate head of patient 15-20 degrees 5. Risk for fluid and electrolyte imbalance through projectile vomiting a. Assess for signs of fluid-electrolyte imbalance b. Monitor fluid intake and output c. Proper regulation of IVF d. Provide adequate fluid Preventive Measures: 1. Immunization its not a permanent immunity In USA: Hemophilus B Conjugated Vaccine (HBCV) In Philippines: BCG immunization for TB Meningitis Source of infection: Nasopharygeal secretions 3. Proper disposal Proper procedure: Place tissue paper in plastic bag and knot before throwing Best way of disposing nasopharygeal secretion: Swallowing because it will be eliminated in the stool 3. Covering of mouth and nose of patient when coughing or sneezing. Patient must wear mask whenever you transfer him from one area to another But if patient is in his room, remove his mask, visitor then wear mask ENCEPHALITIS a.k.a. BRAIN FEVER: inflammation of the encephalon or brain Causative Agent: Arbovirus from root word arthropod borne virus where disease is transferred from one person to another by an arthropod Classification of Encephalitis: 1. Primary encephalitis the virus attacks the brain directly the type of encephalitis which is communicable St. Louise, Japan B, Australian X, Equine X (Eastern & Western) MOT: mosquito bites-a. Aedes solicitans b. Culex tarsalis Source of Infection: ticks of horses or migratory birds 2. Secondary encephalitis before the brain was infected there was: a. Previous infection- a complication of some diseases Example: Measles, Chicken pox and mumps b. Post vaccine-anti-rabies vaccine (active form) 3. Toxic Encephalitis-not cause by virus but by metal poisoning a. Lead poisoning b. Mercury poisoning

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Manifestations: same as meningitis s/sxs=fever, headache, projectile vomiting but has an immediate altered level of consciousness-lethargic state of consciousness where patient is abnormally sleepy or difficult to awaken and with changes in behavior Diagnostic Examination: 1. Lumbar Puncture-CSF clear: increase protein, increase WBC and normal sugar 2. Electroencephalogram (EEG)-to determine extent of brain involvement or damage=epilepsy Medical Management: no specific treatment; patient is treated symptomatically Nursing Care: Supportive and Symptomatic Preventive Measures: to eradicate the mosquitoes by practicing the CLEAN program of DOH: C-hemically treated mosquito net using Permithrim then dry for 3-6 mons. L-arvivorous fishes (they eat the larvae of mosquitoes) E-nviromental sanitation: clean the surroundings A-nti-mosquito soap such as basil N-eem tree or eucalyptus tree plant (it drives away mosquitoes) Immunity: Encephalitis does not give a permanent immunity POLIOMYELITIS: also known as Infantile Paralysis or Heine-Medins disease usually affected are infants because it brings about paralysis high risk are children below 10 years old Causative Agent: Legio debilitans virus which has 3 strains: 1. Type 1-Brunhilde--gives permanent immunity (common in PI) 2. Type 2-Lansing--- gives temporary immunity 3. Type 3-Leon-------gives temporary immunity Mode of Transmission: 1. Early Stage of infection Source of infection: nasopharygeal secretions MOT: droplet Portal of entry: respiratory system by the nasopharynx 2. Late Stage of infection Source of infection: found in stool MOT: fecal-oral route Portal of entry: digestive system by the mouth Poliomyelitis Legio debilitans --------- --------------------------------------------- Nasopharynx Mouth Tonsils: Peyers patches of Intestine Sore throat Abdominal pain & anorexia Fever & chills Nausea & vomiting HA & body malaise Diarrhea or constipation Stages of Poliomyelitis: 1. Invasive or Abortive-stage when virus invades the host and S/Sxs disappear

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Cervical Lymph Node (CLN)Blood streamMesenteric Lymph Node (MLN) CNS a. Severe muscle pain-apply warm compress, avoid turning, touching or massaging patient & give analgesic (Codeine not Morphine because it causes respiratory distress) b. Stiffness of hamstring especially back of thigh c. Presence of Hoyres sign-head drop d. Poker spine-Opisthotonus with head retraction (patient assumes a tripod position when sitting where hands are placed at his back) 2. Pre-paralytic stage-theres already involvement of CNS but without paralysis

3. Paralytic stage-theres paralysis of patient where he appears flaccid (soft, flabby and limp)=pathognomonic
sign of Poliomyelitis 3 Types of Paralysis: a. Bulbar type-CN 9th (glossopharygeal) and 10th (Vagus) are affected S/Sxs: a. Swallowing paralysis (choking & drooling of saliva) b. Vocal cord paralysis c. Respiratory paralysis b. Spinal type-most common type where anterior horn cells are affected S/Sxs: a. Paralysis of the upper and lower extremities-may be unilateral or bilateral b. Paralysis of the intercostals muscles-difficulty in breathing c. Bulbo-spinal type-cranial nerves and anterior horn cells are both affected Diagnostic Examinations: 1. Lumbar Puncture-(+) Pandy Test=increase protein, increase WBC and normal sugar 2. Muscle Testing to determine what specific muscle is affected 3. Electromyelogram (EMG) to determine extent of muscle involvement 4. Stool Examination is done only 10 days after being infected because the virus is found in the late stage of infection 5. Throat Washing Medical Management: 1. No specific treatment, symptomatically only 2. If (+) respiratory paralysis, patient is placed in a mechanical ventilator called Iron Lung Machine that looks like a capsular coffin which has a window, port holes and light to keep patient warm. The body of the patient is in the machine and the head is supported by the metal plate. Patient stays in it for 6-9 months until his death. It works on the principle of negative pressure breathing without endotracheal and tracheostomy tube. It serves as lifesaving machine. Nursing Care: 1. Supportive and Symptomatic 2. Psychological Aspect of Care including relatives Preventive Measures: 1. Immunization by Oral Polio Vaccine (OPV-Sabin vaccine) given 6 weeks after birth in 3 doses at one month interval, 2-3 drops per orem Instructions to the mother: a. Dont feed child 30 minutes after administration to promote better absorption b. If vomiting occurs, repeat dose of OPV c. Be careful in handling the stool of the child who had received OPV because the virus will be eliminated through the stool

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d. Dont administer to patient with immunocompromised family because the member might be infected instead give Inactivated Polio Vaccine (IPV-Salk vaccine) 0.5 cc IM vastus lateralis in 3 doses at one month interval 2. Avoid mode of transmission a. Proper disposal of nasopharygeal secretions b. Hand washing and proper disposal of feces c. Dont put anything in the mouth especially in children below 10 years old RABIES: also known as Hydrophobia, Lyssa and LA Rage a disease of low form of animal that is accidentally transmitted to man through animal bites (canines, cats, bats, skunks, fox, dogs and wolves) Bats are the main source of virus Causative Agent: Neurotropic virus-has special affinity to neurons/CNS Rhabdo virus-transferred from animal to man 2 Pathways for Virus to Travel: Rhabdo Virus --------------------------------------------Peripheral Nerves Efferent Nerves CNS Salivary Glands of Animals inclusion bodies develop called Negri Bodies which are pathologic lesions formed when microorganism multiplies.

Mode of Transmission: Contact with saliva of a rabid animal, scratching, licking of wounds by dogs or corneal transplantation Incubation Period: For animals=3-8 weeks; For humans=10 days-years 2 Stages of Manifestations in Animals: 1. Dumb Stage-complete change in disposition (nagbabago ng ugali) a. Depressive Behavior-animal will be withdrawn, stays in one corner and remain quiet b. Manic Behavior-animal is overly affectionate, walking to & fro and hyperactive 2. Furious Stage-animal is easily agitated, will easily bite, fierceful or vicious look and drooling of saliva-----later will die 3 Stages of Manifestation in Human: 1. Invasive Stage-the virus is easily transferred through saliva, by direct or indirect contact (Example: sharing sandwich, bottle or glass) S/Sxs: a. Numbness on site b. Sore throat c. Marked insomnia d. Restlessness, irritable and apprehensive e. Flu-like symptoms f. Slight photosensitivity 2. Excitement Stage-stage when patient is confined in the hospital Signs/Symptoms: a. Aerophobia (fear of air) & Hydrophobia (fear of water) will predispose patient to painful pharyngolaryngeal spasm

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b. Drooling of saliva and spitting=patient will not eat or swallow saliva c. Photosensitive d. Maniacal Behavior=fierceful look, agitated, bites, jumps out of window and runs like a rabid dog Mgt: Haloperidol (Haldol) with Benadryl is given to calm the patient Paralytic Stage-stage when spasm is no longer observed because paralysis sets in and within 24-72 hours patient will die

3.

Diagnostic Examinations: done only for animals before S/Sxs appear 1. Brain Biopsy of Animal to identify presence of negri bodies (10% of rabid animals has absence of negri bodies because its in the saliva) 2. Direct Flourescent Antibody Test (DFAT) 3. Observation of the animal for 10 days if animal develops behavioral changes or die within 10 days, it has rabies Factors to consider in observing the animal: a. Site of the bite-if from waist up, patient must receive vaccine because of proximity of bite to the brain (virus travels 3 mm/hour once in the body) b. Extent of bite-if multiple, deep or big bite, patient must receive vaccine immediately because theres possibility that several virus have entered the body c. Reason for the bite-if provoke=less worry (fight & flight instinct of the dog) if unprovoked=must worry Medical Management: Giving vaccines is a post exposure prophylaxis only to lessen chances of developing rabies 1. Active form of Vaccine Types: a. Purified Duck Embryo Vaccine (PDEV)-Lyssavac=1 cc/vial b. Purified Vero Cell Vaccine (PVCV) -Verorab =0.5 cc/vial c. Purified Chick Embryo Vaccine (PCEV) 2 Ways of Administration: a. Per intramuscular (IM)-do skin testing first;deltoid & vastus lateralis m. Day 0 -2 vials=1 vial for each site=one on Right & one on Left Day 7 -1 vial =1 vial for one site =either right or left Day 21 -1 vial =1 vial for one site =start counting from first dose if 3 doses is given, it gives 3 years immunity if after 2nd dose the dog didnt die, give 3rd dose to benefit with 3 years immunity because of chances of being bitten again if the dog dies or disappears, give booster dose of 1 vial-----BD 90 b. Per intradermal (ID)-deltoid & vastus lateralis muscle Day 0---------Day 3 PDEV 0.2 cc on each site=0.4 cc, Verorab (given to pedia) Day 7---------0.1 cc on each site Day 28-30---- 0.2 cc on one site 0.1 cc on one site Day 90 ----- once the vaccine is reconstituted (lyssavac), its potent only for 8 hours 2. Passive form of Vaccine antibodies are given for immediate protection it is given in single dose by IM in the buttocks dosage is computed according to body weight, it should be given within 7 days because after 7 days the body has already produce antibodies from active vaccine injection never give active & passive form of vaccine in one site Example: one in deltoid and one in gluteus muscle Types: a. From animal serum: Equine Rabies Immunoglobulin (ERIg)

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Example: Anti-rabies serum ARS (P.B.)-Hyper Rab, Berna and Favirab Dose: 0.2 cc/kg Do skin testing before animal serum Patient weighs 50 kg x 2 cc=10 cc b. Human serum: Human Rabies Immunoglobulin (HRIg) Example: Imogam and Rabuman Dose: 0.133 cc/kgBW Patient weighs 50 kg x .133=6.650 cc A passive vaccine (10 cc=0 1 2 of it is given on buttock and is given on the site of bite for the body to fight microorganism) SEMPLE vaccine-old vaccine given 2 cc/dose/day for 14 doses SQ around the abdominal wall=2 booster doses: no longer use 2 1 4 3 --------------------------------------12 6 5 14 8 7 -------------------------------------10 9

11 15 cc 13

7.5 -buttocks 7.5 -site of bite

Nursing Care: 1. Place patient in a dim (photosensitivity) and quiet room (for easily agitated) 2. Room of patient should be away from sub-utility room (where you wash articles in the ward) 3. Before maniacal behavior sets in, restrain the patient because he may run after you or youll run after patient 4. Wear complete protective barriers when entering the room because patient may spit on you and saliva will predispose you to rabies Preventive Measures: 1. Immunization-all dogs should be given immunization in the Barangay Centers 2. Keep away from stray dogs because they are mostly infected with rabies 3. Keep animal caged or chained. Less exposure to virus, less chance of biting man 4. If bitten by a dog, wash with soap and running water to wash away virus then use strong antiseptic solution (betadine or iodine) and observe the dog Virus in rabies can easy be destroyed with a T of 60C at 35 seconds Rabies in puppy & dog has the same virulence

Diseases of the Circulatory System

Viral Etiology: Dengue Hemorrhagic Fever Protozoal Etiology: Malaria DENGUE HEMORRHAGIC FEVER: Dengue Fever is not the same with Hemorrhagic fever Dengue Fever has affinity to circulatory system without bleeding (a mild form of hemorrhagic fever) Dengue Hemorrhagic Fever has affinity to circulatory system with bleeding (severe form of hemorrhagic fever) Causative Agent: Arbovirus-Dengue virus=Type 1, 2, 3 and 4 Onyong-nyong virus Chikungunya virus

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West Nile virus Flavivirus-brought epidemic in the Philippines Mode of Transmission: 1. Mosquito Bites of Aedes aegypti and Aedes albopictus are biological transmitter wherein after biting an infected person, mosquito is able to transfer DHF virus after 8-11 days from one person to another until it dies. Thus the virus becomes part of the system of mosquito 2. Mosquito bite of Culex fatigan is a mechanical transmitter wherein after mosquito has bitten an infected person, the very first person it will bite will be the only one infected with DHF (Lifespan of mosquitoes: up to 4 months) Characteristics of Aedes aegypti: 1. Day biting mosquito-from the time the sun rises to the time the sun sets 2. Low flying mosquito-bites on lower extremities 3. Breed in a clear stagnant water 4. Geographical location: urban area (flower base or old tires) 5. It has white stripes on legs, grey wings and lands on surface (body is on horizontal position and pair of legs is raised) Mosquito (Aedes aegypti) Blood stream (multiply) Creates multiple lesions in the blood stream ----------------------------------------------------- Increase capillary fragility (easily bleeds) Increase capillary permeability (allows shifting of fluid from one compartment to another) Thrombocytopenia Edema, ascitis and hemoconcentration Signs and Symptoms of DHF according to Grade/Classification: 1. DHF Grade 1 a. Persistent high grade fever which lasts for 3-5 days even with antipyretics b. Complains of pain: Headache, periorbital pain, abdominal, joint & bone pains c. Nausea and vomiting d. Pathological Vascular Changes: 1) Petechiae formation 2) Herman Sign-generalized flushing/redness of the skin e. Diagnosed as Dengue Fever or Dandy Fever or Breakbone Fever 2. DHF Grade 2 a. Persistence of S/Sx of DHF Grade 1 + Bleeding b. Bleeding from: 1) Nose-epistaxis 2) Gum-gum bleeding 3) Stomach: a) Hematemesis-coffee ground vomitus b) Melena-black starry stool (upper GIT) c) Hematochezia-fresh blood in stool (lower GIT) 3. DHF Grade 3 a. Persistence of S/Sxs of DHF Grade 2 + Circulatory Failure b. Cold clammy skin c. Check for capillary refill by applying pressure on nail beds then release it, take note when the blood goes back (normal capillary pressure=less than 3 seconds) d. Check vital signs: Low Blood Pressure (hypotension), very rapid weak pulse and rapid respiration

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4. DHF Grade 4-persistence of S/Sxs of DHF Grade 3 + Hypovolemic Shock because of excessive blood loss due to uncontrolled bleeding-----DEATH Diagnostic Examination: 1. Tourniquet Test or Rumpel Leede Test test for capillary fragility only a presumptive test for DHF 3 Criteria before performing Tourniquet Test: a. Individual should be 6 months older b. Fever of more than 3 days c. No other signs of DHF-fever of 3 days use BP cuff and get BP=S + D/2=? Mm hg=amount of pressure youll inflate leave the cuff inflated in patients arm: Pedia-5 minutes (pedia cuff) Adults-10 minutes release the cuff, check and count the petechial formation per one square inch, if more than or equal to 20 petechial formation=(+) tourniquet test 2. Platelet Count-decrease in DHF (NV: 150,000-400,000 mm3); definitive test 3. Hematocrit (Hct) determination-increase in DHF due to hemoconcentration (NV: 0.37-0.54=37-54%) Medical Management: Symptomatic treatment 1. Antipyretic for fever but never give Aspirin or Acetyl Salicylic (ASA) because it is a platelet inhibitor/deaggregator and leads to bleeding Aspirin is not given to children below 12 years old because it causes Reyes Syndrome-a neurologic disorder associated with viral infection 2. Vitamin K (Aquamephyton, Phytomenadion, Synkavit and Konakion) for bleeding to promote clotting or coagulation 3. Vitamin C preparation to increase capillary resistance 4. Blood Transfusion to replace blood loss Nursing Care: 1. To prevent and control bleeding which is a nursing priority a. Epistaxis-instruct patient to avoid forceful blowing of nose or for parents to do gentle nasal care Control Measures: 1) Apply ice pack/ice compress over nose bridge for vasoconstriction 2) Place patient in upright position, leaning forward, ante-flexion then apply pressure on nose bridge 3) MD will do nasal packing (gauze) to stop bleeding b. Gum bleeding Control Measures: 1) Give ice chips/ice cold NSS gargle or water gargle 2) Use warm NSS as mouth gargle TID 3) Use oral antiseptic solution as gargle BID 4) Use cotton swab as mouth care OD 5) Use soft bristle toothbrush c. Hematemesis Control Measures: 1) Place ice pack over epigastric region 2) NPO because eating can stimulate contraction of stomach 3) Place patient in upright position to prevent aspiration 4) Provide oral care 5) Refer to MD to perform NGT for gastric lavage using ice cold NSS (isotonic solution) and never water it causes water intoxication d. Melena Inform patient to avoid dark colored food and drinks Dont give iron preparation

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2. Supportive & Symptomatic 3. Increase body resistance of patient by proper nutrition and adequate rest Preventive Measures: practice CLEAN program of DOH Immunity: DHF gives no permanent immunity MALARIA a.k.a. AGUE: king of tropical diseases manifested by indefinite period of fever and chills Causative Agent: Protozoa-Plasmodium which has 4 Species: 1. Plasmodium vivax 2. Plasmodium falciparum-most fatal 3. Plasmodium malariae 4. Plasmodium ovale only female mosquitoes suck blood for fertilizing egg while male mosquitoes get their food from nectar of plants P. vivax and P. falciparum are both most common causes in the Philippines Mode of Transmission: 1. Mosquito bite-Anopheles mosquito 2. Blood transfusion Characteristics of Anopheles mosquito: 1. Night biting mosquito from dusk to dawn 2. Breeds in a clear slow flowing water 3. Geographical location: rural, mountainous and forested areas 4. Lands on surface-45 degrees angle/slanting If infected by mosquito Blood stream ------------------------------------ RBC is penetrated (MO reproduce) Liver (MO stay for 3-5 years) RBC 3 Stages of Manifestation of Malaria: 1. Cold Stage-Chilling sensation: shaking of body & chattering of lips that lasts for 10-15 minutes Nursing Care: Provide blanket to keep patient warm Apply hot water bag over soles of feet Expose to heat lamp or drop light Provide warm drinks 2. Hot Stage-Fever, headache, vomiting and abdominal pain lasts for 4-6 hours Nursing Care: TSB to lower body temperature Cold Compress Increase fluid intake Provide adequate rest Loose and light clothing

3. Wet Stage-Profuse or excessive sweating, feeling of weakness

Nursing Care: Make patient comfortable in bed Keep patient warm Increase fluid intake to prevent dehydration

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Chills followed by fever because of rupturing of membrane of Plasmodium In P. falciparum, theres severe anemia because of rapid destruction of RBC causing Cerebral Hypoxia resulting to restlessness, confusion, delirium, convulsions, loss of consciousness and coma=Black Water Fever because patient will be passing out black or dark red urine due to rapid destruction of RBC

Diagnostic Examinations: 1. Malarial Smear/Blood Smear-blood is extracted at peak of fever because MO is in the blood stream already 2. Quantitative Buffy Count (QBC)-rapid test for malaria because theres no need to wait for the height of fever to set in Medical Management: Chloroquine (Aralen) -mainstay drug of malaria Other Drugs: Primaquine, Atabrine, Fansidar and Quinine (a reserve drug for severe cases) Cautiously used for pregnant women because of its abortive effect and it crosses the placental barrier causing severe anemia to the child Immunity: Malaria gives no permanent immunity

Diseases of the Integumentary System

Viral Etiology: Measles German Measles Chicken pox Herpes zoster Bacterial Etiology: Leprosy 2 Kinds of Eruptions: are Eruptive fever because all are manifested by eruptions or rashes

1. Enanthem found in mucous membrane 2. Exanthem found in skin 4 Characteristics of Rashes: 1. Macule flat rashes 2. Papule elevated rashes 3. Vesicle elevated rashes filled with fluid 4. Pustule elevated rashes filled with pus In chicken pox, all of these 4 characteristics of rashes can be seen at the same time MEASLES a.k.a. RUBEOLA: Also known as Morbilli, Little Red Disease, 7 Day Measles, 9 Day Measles, Hard Measles or First Disease 6 Rash forming diseases in USA: 1. Measles 2. Scarlet fever 3. German measles 4. Duke/ Filatov 5. Erythema infection, Slapped cheek diseases or Hungarian Measles 6. Roseola infantum, Exanthem cuticum, Exanthem sobitum (Tigdas hangin) NCLEX and CGFNS Question: Fifth Disease Causative Agent: Paramyxovirus rubeola virus (specific virus) Mode of Transmission: Airborne 3 Stages of Measles: 1. Pre-eruptive stage

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stage before rashes appear highly contagious stage Manifestations: a. High grade fever which last for 3-4 days b. 3 Cs: 1) Cough 2) Colds 3) Conjunctivitis inflammation of the conjunctiva redness of the eyes but differs from sore eyes due to presence of excessive mucopurulent lacrimal discharges (muta) formerly called as Stimson Sign=puffiness of the eyelid with linear congestion of the lower conjunctiva (red horizontal line) photosensitivity c. Presence of enathem called Kopliks spot (pathognomonic sign of measles) =fine red spots with bluish white spot at the center found in the inner cheek just opposite the molars

2. Eruptive stage after appearance of kopliks spot, rashes will appear that is characterized as maculopapular, reddish in
color and blotchy in appearance (pantal) thats why it is also called Little Disease rashes appear first on the hairline, behind the ears, face, neck, trunk and extremities or from head to toe=Cephalocaudal in distribution rashes appear on the third day of illness, within 2-3 days the entire body is completely covered

3. Post-eruptive stage
rashes start to disappear by having a fine branny desquamation (peeling off) from red color rashes, it will fade to brown then it peels off excluding the skin

Diagnostic Examination: by clinical observation and physical examination Medical Management: 1. Symptomatic because it is viral 2. Antibiotics are given for treatment of secondary infections only Nursing Care: Supportive and Symptomatic 1. Increase or maintain body resistance of patient by providing adequate rest and nutrition-increasing fluid intake especially rich in Vitamin C 2. No diet restrictions provided patient is not hypersensitive to hyper-allergenic food like seafood and poultry products 3. Keep patient warm and dry to prevent patient from exposure to draft (hamog, huwag malamigan) because this may lead to colds and cough which is a good medium for growth of microorganism in the respiratory area due to increase respiratory mucous secretion leading to pneumonia or respiratory distress (a common complication of measles) and encephalitis Hygienic Measures: 1. Skin care rashes of measles are not itchy in itself but it becomes itchy because of lack of skin care use tap or lukewarm water to bath or sponge for 15-20 minutes, make sure windows are close or air conditions are off and provide curtain to prevent draft exposure expose only body parts to be sponged, cover other parts and wipe it dry thoroughly remove clothing of child when sponging and provide bath blanket and bed linen avoid culantro because it causes burning of the skin in high concentration 2. Eye care

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clean by removing the discharge (muta) to prevent eye complication-infectious conjunctivitis protect eye from sunlight because of photosensitivity 3. Ear care to prevent otitis media 4. Oral and nasal care in order to remove some organism lodging in the nose and mouth of patient that might be a source of infection Immunity: Measles will give a permanent immunity It is highly contagious during 4 days before the appearance of rashes and 5 days after appearance of rashes

Preventive Measures: 1. Immunization with a. Anti-measles vaccine (AMV) given to 9 months old, 0.5 cc SQ Deltoid muscle Instructions to mother after immunization: 1) Child may experience fever=give paracetamol 2) Child may experience or develop mild rash formation 3-4 days after immunization which is a normal reaction to the vaccine b. Private physician gives MMR between 12-15 months old, 0.5 cc SQ Deltoid m. Instructions to mother after MMR: 1) Ask mother if child has allergy to eggs and neomycin because MMR has chick embryo and neomycin component 2) If allergic to egg, MD may still give MMR but if neomycin is the allergen dont give MMR because of higher neomycin component causing anaphylaxis 3) If given on adolescence or female child bearing age, dont get pregnant within 3 months after MMR immunization because it may bring about congenital anomalies 2. Proper disposal of nasopharygeal secretions 3. Covering of mouth and nose when sneezing and coughing Measles is not fatal but the complication of pneumonia and encephalitis is fatal. GERMAN MEASLES a. k. a. RUBELLA: also known as Roteln, 3 Day disease because duration of illness is 3 days Causative Agent: Pseudoparamyxovirus=Rubella virus or Togavirus Mode of Transmission: Droplet (direct) 3 Stages of German Measles: 1. Pre-eruptive stage presence or absence of fever, if present it lasts for 1-2 days mild cough or mild colds presence of enathem called Forscheimer spots=fine red or petechial spots found on soft palate before rashes come out 2. Eruptive stage a. Presence of rashes described as maculopapular, pinkish in color with discrete appearance (pino at disimulado) or finer to look at, not blotchy, smaller than measles rashes cephalo-caudal in distribution the entire body is completely covered with rashes within 24 hours b. Enlargement of lymph nodes=lymphadenopathy (#1 factor to differentiate GM from measles) 1) Sub-occipital lymph nodes 2) Posterior auricular lymph nodes 3) Posterior cervical lymph nodes 3. Post-eruptive stage occurs after 24 hours where rashes start to disappear and enlarged lymph nodes subside=road to recovery Preventive Measures: similar to measles

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Immunity: German measles gives permanent immunity It is communicable during the entire course of the disease=3 days Not fatal but could be on a pregnant woman during the 1st trimester of pregnancy because of chances of Congenital Anomaly 4 Possible Major Congenital Anomaly: 1. Microcephaly 2. Congenital Heart Disease=Tetralogy of Fallot 3. Congenital Cataract then it leads to blindness 4. Deafness and Mutism If pregnant and exposed to German Measles, give gamma globulin 1 ampule or depending upon the weight of patient within 72 hours which gives temporary immunity. CHICKEN POX a.k.a. VARICELLA: Causative Agent: Varicella zoster virus found in both nasophargeal secretions and secretions of rashes it causes infection if it enters the nasopharynx Mode of Transmission: Airborneonly the secretions from the nasopharynx are infectious Duration of Illness: 2 weeks Signs and Symptoms: 1. Pre-eruptive stage presence or absence of low grade fever, body malaise, muscle pain and headache which lasts for 24-48 hours 2. Eruptive stage the lesion begins as a macule about 5-10 crops then it become a papule later into vesicle then pustule while new macules come out on the same time during these different phases. This means that crops (macules, papules, vesicles and pustules) can be seen in the body at the same time presence of rashes is characterized as vesiculo-pustular which are itchy & scratching the vesicle will rupture it developing into a boil and worst into a cellulitis and leave behind a permanent scar called Pox Mark provide skin care: dont rub or apply soap directly into skin, instead form a lather in your hand then apply to skin anti-itch lotion has a temporary effect only so bath the patient using tap water may give antihistamine for children to prevent itchiness rashes have generalized distribution all over the body, it appears first on covered body parts (trunk and scalp) rashes have unifocular appearance, focus one at a time and never fuses together contagious from the time rashes appear until the last rash have dried or crusted

3. Post-eruptive stage
rashes start to dry or crust and eventually fall or peel off by itself Diagnostic Examination: by clinical observation and physical examination Medical Management: 1. Treated symptomatically 2. Antiviral agent may be given=Zovirax (Ayclovir) which will shorten the disease process but wont give a permanent immunity 3. Anti-histamine or anti-pruritic agents Nursing Care:

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1. Skin care to prevent skin infection: cut fingernails, use mittens and daily bathing 2. Increase resistance and adequate rest and nutrition to prevent encephalitis Immunity: Chicken pox gives a permanent immunity Preventive Measures: 1. Immunization using Varicella vaccine (Varivax) given at 12 months old, 0.5 cc SQ, children below 13=single dose children above 13=2 doses in 1 month interval 2. Proper disposal of nasopharygeal secretions 3. Cover mouth and nose when sneezing and coughing deltoid, if given to

Some virus may remain in the body, it will travel to the peripheral nerves, becoming dormant or inactive. Once activated, it will become Herpes Zoster A person can not acquire Herpes Zoster unless he had Chicken Pox first.

HERPES ZOSTER a.k.a. SHINGLES: also known as Zona, Acute Posterior Ganglionitis because it affects the ganglion of posterior nerve root adults are usually affected inactive or dormant type of chicken pox Causative Agent: Dormant varicella zoster virus Mode of Transmission: Airborne and droplet Duration of Illness: 2 weeks Signs and Symptoms: same as Chicken Pox---vesiculo-pustular rashes are present but painful instead of itchy because it affects nerve endings and the pain persists within 2 months even if patient had recovered rashes have unilateral distribution following the nerve pathway which is vertical or longitudinal (only 1 side of the body is affected) appearing in clusters if rashes appear in the abdomen, it follows dermatone or skin pathway it gives a temporary immunity period of communicability is the same as chicken pox when all rashes dried complications of herpes zoster: skin infection and encephalitis Diagnostic Examination: Clinical observations and physical examination Medical Management: 1. MDs recommend applications of Potassium Permanganate (KMNO4) compress over rashes of the patient---3 Fold Effects of KMNO4: A-Astringent------------dries rashes B-Bactericidal----------decrease chance of skin infection O-Oxidizing Effect----deodorizes the rashes 2. Analgesics for pain 3. If rashes are on the abdominal area-----turn the patient on affected side to prevent stretching of the nerves----less pain 4. Zovirax can also be given Nursing Care and Preventive Measures: same as Chicken Pox LEPROSY/HANSENS DISEASE: also known as Hansenosis

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discovered by Dr. Hansen where he called patients as Hansenites

Causative Agent: Mycobacterium leprae-an acid fast bacilli Incubation Period: 3 months-8 years 3 Hypothesis in Mode of Transmission: 1. Prolonged intimate skin to skin contact (for intact skin) with MO in the lesion 2. Droplet infection (from nasopharygeal secretions) 3. Fomites (non-living things) but not proven yet 3 Cardinal Signs of Leprosy: 1. Peripheral nerve enlargement 2. Loss of sensation on affected parts 3. (+) Skin smear test for Mycobacterium leprae 4 Types of Leprosy: 1. Indeterminate 2. Tuberculoid or Benign or Non-infectious few microorganisms 3. Lepromatous or Malignant or Infectious plenty of Mycobacterium leprae in lesions 4. Borderline possesses some characteristics of tuberculoid and lepromatous Early Manifestations of Leprosy: 1. Color changes on the skin which does not disappear even with treatment (mamumuti, mamumula, maging brown) 2. Skin ulcers which does not heal even with treatment 3. Patient have muscle weakness & paralysis of extremities 4. Pain and redness of the eyes 5. Nasal obstruction and nose bleeding 6. Loss of sensation on affected area, loss of hair growth & anhydrosis (absence of sweating on affected parts) Late Manifestations of Leprosy: 1. Lagopthalmusinability to close eyelids, half open when sleeping 2. Madarosisfalling off of eyebrows 3. Sinking of the bridge of the nose due to microorganism that absorbs small bones like bridge of the nose, cartilages of the ears, fingers and toesundergo natural amputation that is painless because of loss of sensation 4. Leonine face resembling a lions face because of madarosis & sinking of the nose 5. Chronic skin ulcers 6. Contractures such as clawing of fingers & toes 7. Gynecomastiaenlargement of the breasts seen on male patients Diagnostic Examination: 1. Skin Smear Test or Skin Lesion Biopsy 2. Lepromin Testis similar to skin testing by introducing the microorganism through antigen & done to identify what type of leprosy the patient has 3. Wasserman Reaction Testblood examination Medical Management: Use of Multiple Drug Therapy (MDT) -combination of drugs Advantages of MDT: a. To prevent drug resistance to Dapsone (mainstay drug of leprosy) b. To hasten recovery c. To lessen period of communicability after 2 weeks of MDT, patient is no longer communicable 2 Approaches in MDT depending on Mycobacterium leprae (+):

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1) Paucibacillary approach for indeterminate and tuberculoid leprosy few Mycobacterium leprae in skin lesions Rifampicin once a month and Dapsone once a day for 6-9 months 2) Multibacillary approach for lepromatous and borderline leprosy plenty Mycobacterium leprae in skin lesions Rifampicin once a month, Dapsone once a day and Lamprene once a day for 24-30 months (2-2 years) drugs are free from DOH-patient should get it every 28th day of the month in the health center Nursing Care: 1. Psychological aspect because patient has low self esteem due to altered body image and social stigma 2. Skin care to prevent skin injury due to loss of sensation supervise patient when handling sharp objects and extreme temperature 3. Provide active & passive exercises because in Early stage-it strengthens muscles Late stage-it prevent contractures 4. Provide adequate information regarding drug therapy by informing patient on the advantages of MDT and to motivate patient to comply 5. Discuss side effects of drug therapy that are harmless Example: Rifampicin-tears, sweat, saliva and urine becomes orange and soft contact lenses can be stained permanently Lamprenetemporary hyperpigmentation of skin (blackish in color) 6. Tell patient under MDT that he can have Leprae Reaction to MDT due to microorganism that release toxins a. Mild Leprae Reaction: R eddening in and around the nodules/lesions E dema S udden increase in # of lesions T enderness or pain on nerves b. Severe Leprae Reaction: I ritis (inflammation of iris) S udden acute paralysis A cute orchitis (inflammation of testes) Leprosy is not hereditary but can be acquired It does not affect fetus in pregnant women because the bacteria does not cross placental barrier MDT can not be given immediately because Rifampicin has a teratogenic effect on the fetus After giving birth, separate mother from child for 1-2 weeks Dont breastfeed baby because milk is contaminated with the drugs which can be passed on to the baby

Preventive Measure: 1. Immunization with BCG 2. Proper disposal of nasopharygeal secretions 3. Cover mouth and nose when sneezing and coughing to avoid MOT 4. Avoid intimate contact with individual with leprosy (skin to skin)

Diseases Affecting Respiratory System

Bacterial Etiology: Diphtheria Pertusis Tuberculosis Pneumonia Viral Etiology: Colds Influenza

DIPHTHERIA:

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Affects the following: 1. Respiratory Tract =Respiratory Diphtheria (most common type) 2. Mucous Membrane=Cutaneous Diphtheria: a. Conjunctiva Conjunctival diphtheria b. Vaginal mucosa Vaginal diphtheria c. Prepuce or uncircumcised male Diphtheria of the prepuce 3. Wounds of Individual=Wound Diphtheria Example: Burn patients Cutaneous diphtheria and Wounds are rare diphtheria Causative Agent: Corynebacterium diphtheria or Klebs-Loeffler bacillus the bacillus is not pathogenic but diphtheria is highly contagious or infectious because it releases toxins that could circulate in the bloodstream causing generalized toxemia Mode of Transmission: Droplet (direct contact) it affects all ages 3 Types of Respiratory Diphtheria: 1. Nasal type affects the nasal passages Manifestations: a. Presence of irritating nasal discharge characterized by serosanguinous secretion which has a foul mousy odor, white with blood tinged b. With upper lip & nasal excoriations caused by irritation of nose due to nasal discharge c. Presence of pseudomembrane (contains necrotic tissue), grayish white membrane (like an ash of a cigarette) found in the nasal septum. Pathognomonic sign of diphtheria=presence of pseudomembrane that can be seen by using a nasal speculum to see if covered by nasal secretion

2. Pharygeal or faucial type

affects the pharynx and tonsils Manifestations: a. Presence of sore throat resulting to dysphagia (difficulty or pain in swallowing) b. Presence of pseudomembrane found in the soft palate, uvula & pillars of tonsils c. Presence of bull neck appearance brought about by inflammation and enlargement of anterior upper cervical lymph node which is warm to touch, red, painful and tender to touch

3. Larygeal type
most fatal type affects the larynx (voice box) Manifestations: a. Hoarseness of voice b. Presence of aphoniatemporary loss of voice c. Presence of dyspnea (difficulty of breathing) because larynx also serves as an airway passage If DOB occurs, body compensate by using the accessory muscles for breathing producing chest in drawing and sternal retractions which is observed in the lower subcostal region of chest wall Nursing Care: Make sure that the child is calm, not breast/bottle feeding & not crying when checking respiration because chest in drawing is always present in whatever position the patient is d. Presence of pseudomembrane in the larynx causes airway obstruction resulting to respiratory distress and arrest so tracheostomy is done by the MD e. Coughing described as barking cough, dry metallic cough, husky or croupy

Diagnostic Examination: 1. Nose and Throat Swab/Culture done to identify microorganism

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to determine if patient is still communicable patient is communicable until 3 consecutive negative results definitive/confirmatory test of diphtheria 2. Schicks Test done to determine immunity or susceptibility to diphtheria 3. Moloney Test done to determine hypersensitivity to diphtheria anti-toxin 3 Objectives of Medical Management: 1. Neutralize the toxin through the use of Equine Anti-Diptheria Serum (horse serum) because it is a horse serum, do skin testing first to determine if vaccine maybe given in bolus or small dose to desensitize when giving horse serum, always prepare epinephrine & corticosteroid to counteract the delayed reaction to the anti-toxin 2. Kill the microorganism by giving antibiotics use the least toxic antibiotic which is Penicillin if patient can tolerate per orem, give it 1 hour before meals or 2 hours after meals because if given with food, it would decrease absorption of penicillin give it on an empty stomach followed by 1 full glass of water dont give it with fruit juices especially citrus juices because it will destroy the chemical component of penicillin altering its effect 3. Prevent respiratory obstruction perform emergency tracheostomy Nursing Care: 1. Place patient in complete bed rest until 2 weeks after recovery to prevent the # 1 complication that brings about death=Myocarditis because the toxins released by the microorganism has affinity to heart muscles Signs and Symptoms of Myocarditis: a. Mark facial pallor b. Very irregular pulse rate c. Hypotension d. Chest or epigastric pain 2. Maintenance of patent airway a. Positioning of patient semi-fowlers or upright for adequate lung expansion b. Deep breathing & coughing exercises breath in through the nose and exhale through pursed lip breathing c. Perform chest physiotherapy chest clapping (from down to up) d. Increase fluid intake to liquefy fluid secretions e. Turning patient every 2 hours to avoid pooling of respiratory secretions in one side f. With MDs orders: 1) Oxygen inhalation therapy 2) Postural drainage 3) Suctioning of secretions if patient is not capable of expelling phlegm 3. Provide adequate and nutritious diet soft diet due to dysphagia 4. Symptomatic and supportive treatment decrease body temperature 5. Provide comfort measures such as oral and nasal care Immunity: Diptheria is highly contagious and gives no permanent immunity

Preventive Measures: 1. Immunization with DPT given 6 weeks after birth in 3 doses of 1 month interval Dose: 0.5 cc IM, vastus lateralis Instructions to Mother: a. Expect fever to set in b. Cold compress if theres swelling c. Warm compress immediately to prevent swelling

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d. Observe for inconsolable crying-neurologic rxn. 2. Proper disposal of nasopharygeal secretions 3. Cover nose and mouth when sneezing and coughing 4. Never kiss the patient PERTUSSIS: also known as Whooping cough and Chin cough affects children below 6 years old above 6 years old has lesser risk for being infected Causative Agent: Coccobacillus a. Bordetella pertussis b. Hemophilus pertussis both are aerobic and anaerobic (can survive with or without O2)

Incubation Period: 7-10 days Mode of Transmission: Droplet 3 Stages of Pertussis: 1. Catarrhal stage stage which is considered to be highly contagious child stays at home Signs and Symptoms: a. Presence of colds b. Nocturnal coughing c. Fever d. Tiredness and listlessness (matamlay) 2. Spasmodic or Paroxysmal stage 5-10 successive forceful coughing which ends on a prolonged inspiratory phase or whoop thats why it is called whooping cough followed by vomiting theres production of mucus (tenacious) plug on airway passage so when patient cough, he chokes on his mucus inducing vomiting Other Manifestations when too much effort in coughing: a. Congested face b. Congested tongue purple in color because of pressure of coughing c. Teary red eyes with protrusion of eyeballs d. Distended face and neck veins e. Involuntary micturition and defecation f. Abdominal/inguinal hernia g. Deafness due to hemorrhage of vestibular apparatus of ear When patient exerts effort in coughing, he chokes on his mucus that induces vomiting resulting to electrolyte imbalances causing metabolic alkalosis and later goes into convulsions This is the time when the mother brings the patient in the hospital

3. Convalescent stage
Signs and symptoms start to disappear Patient is no longer communicable Patient is on the road to recovery

Diagnostic Examination: 1. Nasal Swab 2. Bordet-Gengou Test3. Agar Plate

use nasopharygeal secretions for specimen

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4. Cough Plate---------Medical Management: 1. Immunization: Pertussis Immune Globulin 2. Antibiotics: Erythromycin is the drug of choice but if allergic use Penicillin 3. Fluid and Electrolyte Replacement to prevent dehydration 4. Mild form of Sedation: Codeine Nursing Care: 1. Complete Bed Rest (CBR) to conserve energy of patient decreasing oxygen demand and consumption 2. Maintain Fluid and Electrolyte Balances by: proper regulation of IVF, monitoring input and output of patient to prevent dehydration 3. Provide adequate nutrition 4. Proper positioning (upright) of patient when feeding to prevent aspiration If bottle feeding, nipples should have small holes or medicine dropper With hold feeding if theres continuous coughing during spasmodic attack 5. Provide abdominal binder to prevent hernia Preventive Measure: same as Diptheria Immunity: No permanent immunity but 2nd attack is rare because child will not remain 6 years old TUBERCULOSIS: also known as Kochs Infection, Phthisis (wasting disease involving all or part of the body), PTB and Galloping Consumption Causative Agent: Acid Fast Bacillia. Mycobacterium tuberculosis or tubercle bacilli b. Mycobacterium bovis TB of cattle c. Mycobacterium avium/avis TB of birds

Mode of Transmission: 1. Airborne and droplet 2. Ingestion of infected milk of cows that are not properly pasteurized or boiled 3. Inhalation from birds 4. Mycobacterium avian complex (MAC) Incubation Period: 1-2 months (4-8 weeks) Signs and Symptoms of TB: 1. Low grade fever with night sweats 2. Anorexia and weight loss 3. Fatigability and body malaise 4. Chest pain and dyspnea 5. Productive cough and hemoptysis 6. Back and epigastric pain 7. Anemia and amenorrhea in female for severe cases Diagnostic Examination: 1. Screening test for TB Tuberculin Testing A presumptive test (+) means exposure to TB and not infected If consecutively (+) means sensitive to microorganism Things to Consider: a. Uses Purified Protein Derivative (PPD) b. Introduced intradermally (ID) c. Interpretation after 48-72 hours

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d. (+) result show > 10 mm induration If patient has HIV, (+) result show >5 mm induration 3 Ways/Techniques of Tuberculin Testing: a. Mantoux Test most accurate and easiest way of TT just like doing skin testing with PPD at volar surface of the arm interpret after 48-72 hours induration is observed b. Tine/Multipuncture Test puncture the volar surface of the arm for 6-8 times in circular manner with a needle soaked in PPD for 3-4 hours Tine Test Kit uses a special syringe with 4 needles c. Vollmer & Perquet Test scratch the volar surface of the arm then cover and tape the gauze with PPD over it for 3-4 days (72-96 hours) then removed it and wait for another 48-72 hours to interpret the result skin scratch and patch test takes 5-7 days to get the result 2. Confirmatory test for TB sputum examination a. a definitive test that identifies the microorganism b. the best time to collect the sputum is in the morning, upon rising and before oral care c. instruct patient to do deep breathing for 3-4 times then ask patient to open mouth widely with tongue place behind lower teeth then ask patient to cough out sputum 3. Chest X-ray is not a definitive test because it tells only the extent of involvement of the lungs Classification of TB: 1. According to extent of disease based on cavitations within the lungs a. Minimal b. Moderately advance c. Advance presence of cavitations within the lungs 2. According to clinical manifestations a. Active PTB infected with signs and symptoms b. Inactive PTB infected without signs and symptoms 3. According to American Pulmonary Society a. TB 0 (-) exposure (-) infection (-) tuberculin testing Example: Newborns Preventive Mgt: BCG immunization b. TB I (+) exposure (-) infection (-) tuberculin testing Example: Health care providers Preventive Mgt: Increase body resistance by giving adequate nutrition rest and take multivitamins especially Vitamin C Provide medical asepsis c. TB II (+) exposure (+) infection (+) tuberculin testing (-) S/Sxs Example: Carriers and Inactive TB patients Prophylaxis treatment Isoniazid (INH) d. TB III-(+) exposure (+) infection (+) tuberculin testing (+) S/Sxs Curative Mgt: Anti-TB drugs in combination to prevent resistance to INH Medical Management: 1. Short Course Chemotherapy Rifampicin, Isoniazid, Pyrazinamide=RIP (E, S) a. Isoniazid (INH) is the mainstay drug of TB: 6 months for carrier & inactive adult patients 9 months for children 12 months for immunocompromised patients Side Effects of INH: 1) Peripheral neuropathy/neuritis

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a) instruct patient to eat food rich in Vit B6-beans b) give vitamin B6 (pyridoxine) to counteract neuritis 2) Hepatotoxicity a) monitor liver enzymes b) avoid alcoholic beverages b. Rifampicin (R) it causes orange color of tears, urine and stool it causes permanent staining of soft contact lenses it is hepatotoxic also so avoid alcoholic beverages c. Pyrazinamide (P) it causes hyperurecemia that predisposed to kidney stone formation instruct patient to increase fluid intake instruct patient to eat lots of vegetables to alkalinize the urine d. Ethambutol (E) it causes irreversible optic neuritis that brings about blindness-patient had difficulty differentiating red from green color 2. Standard Regimen (SR) Streptomycin, Isoniazid and Ethambutol=SI (E) a. Streptomycin (S) 1) Nephrotoxicity so monitor creatinine and BUN level of kidney monitor intake and output of patient 2) Ototoxicity CN 8th is affected theres tinnitus=ringing or buzzing of the ear vertigo is also experienced (nahihilo) 3 Important Aspects of Nursing Care: D iet =small and frequent nutritious food D rugs =adequate drug and emphasize compliance R est =to conserve energy Contraindicated Nursing Care: Dont do chest physiotherapy (CPT) for patient with TB because it will stimulate or aggravate hemoptysis Preventive Measures: 1. Immunization with BCG immediately after birth 0.5 cc ID right deltoid area for infants Instruction to mother: a. Dont massage site of injection because it will spill the drug b. The child may experience fever c. There will be abscess formation on the site of injection which will heal and develop into a scar within 2-3 months. If theres still an abscess after 3, 4 or 5 months=Indolent abscess which may be due to wrong technique by nurse (napalalim ang injection) and exposure to patient with active TB Tell mother to bring child to health center for incision & drainage Then give child prophylaxis of INH preparation for 9 months Booster Dose: School entrants (6-7 years old) 0.1 cc ID left deltoid muscle 2. Proper disposal of nasopharygeal secretions 3. Covering of mouth and nose when coughing and sneezing 4. Proper pasteurization Immunity: Gives temporary immunity PNEUMONIA: inflammation of the lung parenchyma Causative Agents: 1. Microorganisms such as

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a. Virus Cytomegalovirus (CMV)=opportunistic infection of AIDS patients SARS=atypical pneumonia caused by corona virus b. Protozoa Pneumocystis carinii pneumonia (PCP)=opportunistic in AIDS patients c. Bacteria Streptococcus (most common cause of pneumonia in PI); Hemophilus B (in USA) Inhalation of noxious chemical, oil is inhaled and vomitus enters the respiratory system=Lipid pneumonia Example: Cleaning the nose of a child with cotton buds and oil should not be used because oil can be inhaled. When inserting tube into the nose, use water based lubricants like KY jelly

2.

Mode of Transmission: Droplet 5 Cardinal Signs of Pneumonia: 1. Rapid or gradual onset of fever 2. Shaking chills 3. Productive cough 4. Sputum production: a. Rusty -Streptococcus pneumonia b. Creamy Yellow -Staphylococcus c. Currant Jelly (like lychees)-Klebsiella d. Greenish -Pseudomonas e. Clear -no infection (Aspiration or Lipid pneumonia) 5. Chest or pleuritic pain aggravated by coughing a. Apply chest binders so it lessens pain when patient coughs b. Fast breathing: if child is 2 weeks old-2 months =60 bpm 2 months-12 months =50 bpm 12 months-5 years old =40 bpm In community setting, Integrated Management of Childhood Illnesses (IMCI), assess the child for 4 General Danger Signs: 1. Is the child able to drink or breastfeed? 2. Check if the child vomits everything (what comes in, goes out immediately) 3. Presence of convulsions (recent attack only) 4. Check if child is abnormally sleepy or difficult to awaken a. Check for the presence of chest in-drawing: observe the subcostal area or lower part of chest wall b. Check for the presence of stridor (abnormal harsh breath sounds heard during inspiration even without stethoscope) respiratory grunting the sound heard during expiration if any one of the above 4 is present, classify patient as having severe pneumonia-----refer patient to hospital if none is present, check for RR or fast breathing Example: 12 months with 41 bpm: patient is fast breathing=pneumonia Mgt: Cotrimoxazole BID x 5 days 12 months with 35 bpm: patient is not fast breathing=colds & cough only Mgt: Ginger ale for cough 11 months & 29 days: he will be considered in 2 months-12 months range Diagnostic Examination: 1. Physical examination by: a. doing percussion=dullness is observed b. auscultation=able to hear abnormal BS such as crackles and rhonchi c. decrease breath sounds and decrease vocal fremitus 2. Chest X-ray=presence of lung consolidation or patchy infiltration that confirms pneumonia 3. Sputum examination=to determine specific microorganism that causes the disease Medical Management:

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1. Antibiotic-antimicrobial agents depending upon causative agent (bacteria or viral) a. PCP =Pentamidine b. Virus =Symptomatic c. Bacteria=Cotrimoxazole 2. Inhalation Therapy-ineffective airway clearance because of copious sputum 3. Bronchodilators 4. Mucolytics Nursing Diagnosis: Ineffective airway clearance due to sputum (causes airway obstruction) production Nursing Care: similar with Diptheria 1. Complete Bed Rest to conserve energy 2. Maintain patent airway 3. Increase body resistance by adequate rest and nutrition 4. Provide comfort measures Preventive Measures: 1. Immunization by Immunovirax 2. Proper disposal of nasopharygeal secretions 3. Cover nose and mouth when sneezing and coughing Immunity: No permanent immunity

Diseases of Gastro-Intestinal Tract

Bacterial Etiology: Typhoid Bacillary dysentery Cholera Leptospirosis Amebiasis Metazoal Etiology: Schistosomiasis Viral Etiology: Hepatitis Mumps Helminthic Etiology: Parasitism

Protozoal Etiology:

TYPHOID FEVER: Causative Agent: Salmonella typhosa invades Peyers patches (target organ) Mode of Transmission: Fecal-oral transmission Sources of Infection: 5 Fs-Feces, fingers, food, flies and fomites 4 Stages of Manifestations of Typhoid Fever: 1. Prodromal stage only time you expect microorganism is found in the blood stream fever, dull headache, nausea & vomiting, abdominal pain diarrhea or constipation 2. Fastigial/Pyrexial stage stage when the MO invades the payers patches Patient will be manifesting 3 Clinical Features of Typhoid Fever: a. Rose spots are light pink red spots found in the abdomen and sometimes seen on the face in children=pathognomonic sign b. Ladder like fever c. Splenomegaly d. Typhoid Psychosis-increase body temperature due to release of toxins 1) Patient have a coma vigil look (staring but without seeing) 2) Difficulty in protruding tongue

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patient experience ulcer formation---intestinal perforation that causes bleeding or hemorrhage---spillage in peritoneal cavity=peritonitis Signs and Symptoms of Peritonitis: a. sudden and severe abdominal pain b. persistence of fever c. board-like rigid abdomen Convalescent/Lysis stage signs/symptoms start to subside patient is on the road to recovery still have to observe patient because he may develop relapses

4.

Diagnostic Examination: 1. Blood Culture-done only during the prodromal/initial stage of infection a. Widal test-most common type of test where it identifies the antigen left by MO Antigen O (Ag O) or Somatic antigen=patient is presently infected Antigen H (Ag H) or Flagellar antigen=patient was previously exposed to TF or has had an immunization b. Typhidot-uses blood specimen where it identifies antibodies 2. Stool and Urine examination Medical Management: 1. Antibiotic-Chloramphenicol: overdose or overuse leads to bone marrow depression 2. Fluid and Electrolyte Replacement Nursing Care: 1. Fluid and Electrolyte Management a. Assess patient for S/Sx of fluid loss-weight loss (#1 manifestation of dehydration and after 48 hours, patient shows sunken eyeball, dry eyes and lips and thirst) b. Monitor input and output of patient c. Proper regulation of IVF 2. Provide adequate nutrition a. If patient has vomiting= small, frequent feedings b. If patient has diarrhea=avoid fatty foods c. If patient has vomiting & diarrhea=keep patient NPO to rest GIT then after 48 hours give clear liquid and when tolerated may give general diet to full diet 3. Provide comfort measures Preventive Measures: 1. Immunization by Cholera, Dysentery and Typhoid vaccine (CDT) 2. Avoid 5 Fs: Feces-proper excreta disposal Fingers-handwashing Food-proper preparation, handling and storage; avoid eating in unsanitary places Flies-environmental sanitation Fomites-avoid putting anything in the mouth Immunity: No permanent immunity LEPTOSPIROSIS: also known as Mud Fever, Swamp Fever, Canicola Fever, Pre-tibial Fever, Weil Disease, Swineherd Disease and Ictero-Hemorrhagica Disease

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a disease of low form of animals found in farms such as pigs, swine cattle and rats that were accidentally transmitted to humans in the Philippines, rats are the most common cause

Source of Infection: Excreta of rats particularly urine Causative Agent: 4 Different Species of Leptospira: 1. Leptospira (Spirochete)-bacteria 2. Leptospira canicola 3. Leptospira hemorrhagica 4. Leptospira enterogans-more common in the Philippines because of rats Mode of Transmission: Skin penetration by entering pores of skin Incubation Period: 2 days-4 weeks People at Risk: Sewage workers, farmers, miners, slaughterhouses and Manila residents (because of walking in floods) Incidence: common during rainy season Organs of body most commonly affected are: 1. Striated muscles 2. Liver 3. Kidneys-MO have special affinity with kidneys thats why the most common cause of death is kidney failure Signs and Symptoms: 1. Fever, headache and vomiting 2. Muscle tenderness and pain particularly on calf muscle (gastrocnemius) 3. Jaundice with hemorrhages on skin & mucous membrane thats why it is also known as icter-hemorrhagic yellow and red orange skin, orange eyes (pathognomonic sign) 4. Oliguria to anuria if kidneys are affected Diagnostic Examination: Blood Examination: Leptospira agglutination test (LAT) Leptospira antigen-antibody test (LAAT) Microscopic agglutination test (MAT) Medical Management: 1. Antibiotics-Tetracycline is the drug of choice not given to: a. children below 8 years old because it causes staining of teeth b. pregnant women because of its teratogenic effect particularly on bone growth of fetus causes bone defect and stained teeth never give tetracycline together with calcium rich food, antacid & iron preparations and milk because it decreases absorption of drug never give expired tetracycline because it increases its toxic effect administer it with 1 full glass of water for better absorption store it away from sunlight because it causes decomposition of the drug 2. Give penicillin to patient allergic to tetracycline give it 1 hour before meals or 2 hours after meals or empty stomach because it binds with food decreasing its absorption Nursing Care: Symptomatic 1. Provide eye care for itchiness 2. Apply warm compress for muscle pain

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3. Monitor urine output, consistency, frequency and amount Preventive Measures: 1. Environmental sanitation by eradication of rats using poisons 2. Avoid walking through floods=wash immediately with soap and water DYSENTERIES: Synonyms Causative Agent Bacillary Dysentery Shigellosis Blood Fluke Shigella dysenteriae formerly Shiga Shigella flexneri Shigella boydi Shigella sonnei Mucoid stool blood streaked if severe because of endotoxin released by MO +/- of fever +/- of vomiting Abdominal pain with tenesmus Antibiotic: Co-trimoxazole ORT Violent Dysentery Cholera El tor Vibrio cholera (comma-shaped) Vibrio ogawa Vibrio inaba Vibrio el tor Yellow water to rice watery occurring one after the other because of the vibriolytic substance released by MO Abdominal pain Vomiting Washerwomans hand because of dehydration Antibiotic: Tetracycline IVT Amoebic Dysentery Amoebiasis Entamoeba histolytica-2 Stages: 1. Inactive- Cyst 2. ActiveTrophozoites Mucopurulent blood streaked with foul smelling odor & greenish color +/- of fever +/- of vomiting Diarrhea with tenesmus alternating with constipation Anti-amoebicMetronidazole Anti-protozoaChloroquine ORT

Characteristic of Stool

Signs and Symptoms

Medical Management

Mode of Transmission: Fecal-oral Diagnostic Examination: 1. Stool Examination to determine the microorganism for Amoebic dysentery, stool must be submitted fresh within 30 minutes to identify the immature amoeboid protozoa-trophozoites 2. Rectal Swab Nursing Care: 1. Maintain Fluid and Electrolyte Balance a. Monitor I and O b. Assess Signs & Symptoms of Dehydration c. Provide Fluids 2. Provide Adequate Nutrition a. Small frequent feedings b. Avoid fatty foods 3. Provide Comfort Measures Preventive Measures: 1. Immunization: Cholera, Dysentery, Typhoid Vaccine (CDT) given by DOH

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Example: Vivotif- capsule form 3 doses taken 1 hour before meal every other day which gives 3 years immunity 2. Avoid 5 Fs SCHISTOSOMIASIS: also known as Snail Fever or Bilharziasis Causative Agent: Metazoa in the form of Blood Flukes (parasitic flatworms) called Schistosoma3 Types: 1. Schistosoma japonicum-affects both man & animal intestines produces GI symptoms 2. Schistosoma mansoni- affects mans intestines only produces GI symptoms 3. Schistosoma haematobium-affects the choroids plexus of the urinary bladder producing urinary symptoms Mode of Transmission: Skin Penetration Cycle of Schistosoma (always in pairs): Heart Pulmonary Artery Capillary Skin/Mucous Membrane Larvae (Cercariae) Snail Oncomelania quadrasi 4-8 weeks Manifestations: 1. Itchiness on the entry site of MO (Swimmers itch) 2. Low grade fever, cough, myalgia 3. Dysentery like symptoms (mucoid) 4. Emaciated (skin & bones) 5. Abdominal distension or enlargement 6. Hepatomegaly & splenomegaly 7. Lymphadenopathy Diagnostic Examinations: 1. Stool Examination 2. Blood Examination: Circum Ova Precipitin Test (COPT)-confirmatory test Enzyme Link Immuno-Sorbent Assay Test (ELISA)-seldom done 3. Rectal Biopsy: an invasive examination Medical Management: 1. Anti-Blood Fluke Agent: 2. Snail Control Nursing Care: Supportive and Symptomatic Preventive Measures: 1. Snail Control a. Use of snail poisons or molluscides b. Proper irrigation & cultivation of lands to destroy the breeding place of snail c. Creation of fish ponds for snail eating fish (ex. milkfish) 2. Environmental Sanitation a. Proper excreta disposal a. Fuadin b. Praziquantrel Portal Circulation (maturation) Intestine (lay eggs) Feces (Eggs) Larvae (Miracidium) 24-48 hours to look for snail

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b. Proper wearing of footwear (ex. boots) c. Keep all animals caged or chained d. Creation of foot bridges 3. Health Education done by DOH MUMPS: also known as Infectious Parotitis an inflammation of the parotid glands Causative Agent: Paramyxovirus Source of Infection: Saliva of an infected individual Mode of Transmission: Droplet infection Manifestations: 1. Complains of earache 2. Presence of fever 3. Pain upon chewing or mastication 4. Swelling of the parotid gland Diagnostic Examination: Only through Clinical Observation & Physical Examination Medical Management: Symptomatic Nursing Care: 1. Complete Bed Rest until swelling subsides to prevent glandular complication such as: a. Female patients develop oophoritis (inflammation of the ovaries) b. Male patients develop orchitis (inflammation of the testes) thats why adult and adolescent patients are advice to wear a well fitted supporter to prevent the pulling of gravity on the testes and blood vessel resulting to sterility c. In children, the most common complication is Encephalitis 2. Provide adequate nutrition by giving soft & bland diet to lessen pain because it prevents stimulation of salivary gland (ex. apple juice or water) 3. Application of ice cap or ice collar over parotid gland lessens pain because it deadens the nerve endings (ex. aniel dye-tina & vinegar has cool effect) Preventive Measures: 1. Immunization: MMR 2. Cover nose and mouth 3. Proper disposal of oropharygeal secretions Immunity: Mumps give a permanent immunity HEPATITIS: inflammation of the liver Causes: 1. Alcoholism 2. Drug intoxication (ex. Rif and INH) 3. Chemical intoxication (ex. arsenic) 4. Microorganisms (ex. virus because it can be transferred from one to another) Classifications: Hepatitis A, B, C, D, E, G and H (non-pathogenic in man) Hepatitis A: also known as Infectious Hepatitis, Catarrhal Jaundice Hepatitis & Epidemic Hepatitis Causative Agent: Hepatitis A virus or RNA containing virus Body Secretions that harbor the disease: Feces MOT: Fecal-oral transmission

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People at Risk: Children, those living in unsanitary conditions & those who practices anal-oral sex Incubation Period: 2-6 weeks Hepatitis B also known as Serum Hepatitis, Homologous Hepatitis and Viral Hepatitis the deadliest and most fatal among the classifications Causative Agent: Hepatitis B virus or DNA containing virus Body Secretions that harbor the disease: Blood & Body Fluids Example: CSF, tears, saliva, milk, synovial, seminal & cervical fluid and sweat MOT: 1. Percutaneous (most common)-contaminated sharps & needles and blood transfusions 2. Oral to oral transmission-have to ingest 6-8 gallons of saliva 3. Sexual transmission-found in seminal and cervical fluid 4. Vertical transmission-placental barrier and amniotic fluid People at Risk: Health workers, blood recipients, hemodialying patient, drug addicts and promiscuous individuals Incubation Period: 6 weeks-6 months Hepatitis C: also known as Post transfusion Hepatitis Causative Agent: Hepatitis C virus Body Secretions that harbor the disease: Blood MOT: Percutaneous People at Risk: Health workers, blood recipients, hemodialying patients & drug addicts Incubation Period: 5 weeks-12 weeks Hepatitis D: dormant type of Hepatitis B Causative Agent: Hepatitis D virus or Delta virus (it needs Hep B virus to multiply) Body Secretions that harbor the disease, MOT and People at Risk: same as Hepatitis B Incubation Period: 3 weeks-13 weeks Hepatitis E: also known as Enteric Hepatitis Causative Agent: Hepatitis E virus Body Secretion that harbors the disease: Feces MOT: Fecal-oral transmission People at Risk: same as Hepatitis A Incubation Period: 3 weeks-6weeks Hepatitis G: Causative Agent: Hepatitis G virus Body Secretion that harbors the disease: Blood MOT: Percutaneous People at Risk: same as Hepatitis C Incubation Period: unknown 3 Stages of Manifestation of Hepatitis: 1. Pre-icteric Stage before jaundice arises Signs & Symptoms: a. Fever due to infection b. RUQ pain due to inflammation or infiltration of the liver c. Fatigability, weight loss and body malaise due to inability of the liver to convert glucose to glycogen (stored source of energy) d. Nausea, vomiting & anorexia due to inability of the liver to deaminase protein (another source of energy where its end product, amino acid, is eliminated in the liver) e. Signs of anemia because of decrease lifespan of RBC (Normal lifespan: 120 days)

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2. Icteric Stage presence of jaundice because of inability of liver to eliminate the normal amount of bilirubin Signs & Symptoms: a. Patient will have pruritus due to accumulation of bile salts in the skin b. Urine is tea colored or brown because of excess bilirubin thrown out by kidney into urine c. Patient is passing out acholic (clay colored or no color) stool due to absence of bilirubin that goes to the duodenum 2 Types of Bilirubin: 1) Conjugated-passed the liver and goes to the intestine 2) Unconjugated-goes to the kidney where it is filtered then goes to urine d. Persistence of symptoms of Pre-icteric Stage but to a lesser degree 3. Post-icteric Stage jaundice and other signs & symptoms start to disappear energy level starts to increase and patient is on the road to recovery it takes 3-4 months for the liver to recover so avoid alcoholic beverages for one year and over the counter drugs like acetaminophen and ASA Diagnostic Examination: 1. Liver Enzyme Tests to determine extent of liver damage Enzymes that can be check are: a. Alanine aminotransferase (ALT) formerly SGPT-very first indicator of liver problem b. Aspartate aminotransferase (AST) formerly SGOT-increase upon onset of jaundice c. Alkaline phosphatase (ALP)-obstructive jaundice as in cholecystitis and gallbladder stone d. Gamma glutamil transferase (GGT)-toxic hepatitis due to alcoholism or drug toxicity e. Lactic dehydrogenase (LDH)-liver organ damage 2. Serum Antigen-Antibody (Ag-Ab) Test a. Hepatitis A Hepatitis A Surface Antigen (HAsAg): (+) if 2 weeks after exposure to Hep A Anti HAV: Immunoglobulin G (Ig G) means you have some form of immunity; Immunoglobulin M (Ig M) means you are infected b. Hepatitis B 1) Hepatitis B Surface Antigen (HBsAg): (+) acute hepatitis B; during recovery, decrease HBsAg level & increase AntiHBs 2 Types of Carrier: a) Non-infectious-not capable of spreading the infection unless you have S/Sxs b) Infectious -capable of spreading the infection even without S/Sxs; -Increase HBsAg, Increase AntiHBs and Increase AntiHBe 2) Hepatitis B Protein Independent Antigen (HBeAg): (+) chronic hepatitis B 3) Hepatitis B Core Antigen (HBcAg) Hepatic Profile: (+) HBsAg, (-) Anti HBs =no vaccine given (-) HBsAg, (+)Anti HBs =carrier but no vaccine needed yet (-) HBsAg, (-) Anti HBs =give vaccine 3. Rountine Tests a. Bilirubin Testing b. Prothrombin Time Testing (PTT) c. Ultrasound or CT Scan of liver d. Urinalysis Medical Management: 1. Hepatic Protectors or Liver Aides contain vitamins, minerals and phospholipids

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Action: The liver will not exert effort metabolizing by supplementing the body with nutrients that will make it relax and recover a. Essentiale for adults b. Jetipar or Silymarine for pedia 2. New Trends in treat Hepatitis a. Antiviral: Lamivudine-inhibits multiplication of virus given OD for 1 year b. Immuno-modulating drug: Interferon-increases defense of individual given parenterally 2-3 times a week for 6 months. Nursing Care: 1. Provide rest to promote liver regeneration or recovery decrease metabolism, decrease load to the liver 2. Low Fat Diet because liver has no enough bile to emulsify fat High CHON intake to spare protein metabolism so that the amino acid will not be converted into ammonia that predispose the patient to develop Hepatic Encephalopathy because of accumulation in the liver In USA, butterball diet is given because CHO is used as a source of energy Preventive Measures: 1. Immunization: Hepatitis B vaccine given at 6 weeks after birth, 3 doses at one month interval, Dose: 0.5 cc IM at the Vastus lateralis Instructions to the mother: a. Theres pain on the site of injection b. There will be a slight elevation of ALT if hepatic profile is done, normal reaction to vaccine if liver enzyme test is done 2. Avoid MOT 3. In USA, Needle Exchange Program is implemented by nurses for drug addicts Immunity: Hepatitis dont give a permanent immunity Even having recovered from Hepatitis B, after 20-30 years theres a chance to develop Cancer or Cirrhosis of Liver because Hepatitis B virus is left in liver PARASITISM: MOT: Ingestion-hand to mouth 1. Pinworm infection-Enterobiasis (Enterobius vermicularis), oxyuriasis & sitworm S/Sxs: Nocturnal Ani-itchiness of the anus at night time because female pinworm get out of the intestinal wall & lay eggs to the anus Diagnostic Examination: Cellophane Tape Test done in the morning upon rising before the child goes to the bathroom 2. Giant Round Worms/Ascaris-Ascariasis (Ascaris lumbricoides) causes intestinal obstruction 3. Whipworm/Trichuris-Trichuriasis 4. Roundworm/Trichinella spiralis-Trichinellosis/Trichiniasis/Trichinosis due to eating raw meat 5. Tapeworm Infection-Taeniasis a. Taenia saginata-raw beef (steak) b. Taenia solium-pork (BBQ) c. Diphyllobotrium latum-raw fish (sushi) d. Dwarf Tapeworm (Hymenolopsis nana) 6. Flatworm-Paragonimiasis westermani-crab/crayfish (talangka) S/Sxs: productive cough and hemoptysis MOT: Skin of feet or barefooted 1. Hookworm-Ancylostomiasis=signs & symptoms of pneumonitis 2. Threadworm-Strongyloidiasis Common Manifestations:

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1. 2. 3. 4. 5. 6. Voracious appetite Weakness Pot Belly Anemia Stunted Growth Apathetic a. Mebendazole b. Pyrantel pamoate (Combatrin)

Diagnostic Test: Stool Examination Medical Management: Antihelmitics: Nursing Management: Supportive

Preventive Measures: 1. Personal Hygiene: Hand washing and Proper wearing of footwear 2. Proper preparation of food

Diseases of the Genito-Urinary System

Sexually Transmitted Diseases (STD)/Sexually Transmitted Infection (STI): Bacterial Etiology: Gonorrhea Syphilis Viral Etiology: HIV/AIDS

GONORRHEA: also known as Jack, Gleet, Clap (because MO looks like hand clapping together), Strain (because male patients usually strain in urination because of pain), GC (gonococcus) and Morning Drop (abundant secretions in the morning) Causative Agent: Neisseria gonorrhea MOT: Sexual contact, transferred to baby during childbirth Incubation Period: 3-21 days Manifestations: Male has obvious manifestations because they develop urethritis Female has no obvious manifestations because they have cervicitis For Male: 1. Burning sensation upon urination dysuria (painful urination) 2. Redness & edema of urinary meatus acidic urine passes through causing burning sensation producing pain 3. Purulent urethral discharges abundant in the morning morning drop 4. Abscess forms on the Prostrate Gland Prostatitis Epidydimitis predisposing on the formation of scar on epidydimis obstructs flow of sperm cell Sterility For Female: 1. Dysuria and urinary frequency 2. Itchy, red and edematous meatus, if cervix is affected 3. If urethra is affected, there is burning pain and purulent discharges 4. Abscess forms on the Bartholins & Skenes Gland Endocervicitis & Endometritis patient will complain of hypogastric pain affecting the entire pelvic organ Pelvic Inflammatory Disease (PID) systemic symptoms of: fever, abdominal pain, nausea & vomiting and gonococcal infection 5. Constant scarring causes narrowing of fallopian tube Sterility If pregnant, it will cause: ectopic pregnancy or ophthalmia neonatorum in newborn thats why credes prophylaxis is practice immediately after birth to prevent blindness

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lesions Diagnostic Examination: 1. Culture & Sensitivity by mucosal scraping 2. Paps Smear or Vaginal Smear Medical Management: Antibiotic: a. Ceftriaxone (Rocephin) IV: diluent used is sterile water IM : diluent used is xylocaine b. Doxycycline (Tetracycline) Nursing Care: 1. Psychological aspect of care-patient has low self esteem because of social stigma 2. Health Education or Patient teaching about prevention measures: a. Safe Sex according to Center for Communicable Disease (CDC) 1) No sex 2) Long term mutual monogamous relationship 3) Mutual masturbation without direct contact b. Condom decreases the risk of having STD c. Behavior modification CHLAMYDIAL INFECTION: Twin sister of gonorrhea because if you have gonorrhea, you have also Chlamydia Manifestations: same as gonorrhea except discharges are clear and thinner Diagnostic Examination: 1. Culture & sensitivity: specimen is taken from discharges coming out from patient by mucosal scraping (aseptic technique) swab 2. Pap smear or vaginal smear is done for female without discharges Management: Antibiotic: a. Penicillin: Benzathine Pen G (Penadur) Never given per IV because it easily coagulates embolism death Given per IM: dilute it with 1 cc xylocaine & 4 cc sterile water=4 cc Benzathine & 1 cc xylocaine, using needle gauge 16 and inject it fast because it easily clots Given also to patient with Rheumatic Heart Disease (RHD) b. Cephalosporin: Ceftriaxone (Rocephin) 2 Kinds of Preparations: 1) Per IV: diluent is sterile water 2) Per IM: diluent is xylocaine-has a vasodilation effect on heart thats why it is also given to patient with dysrhythmias If preparation is interchanged, it causes tachycardia death c. Doxycycline (Tetracycline): given to patient with both gonorrhea & chlamydial infection Nursing Care: same as gonorrhea SYPHILIS: also known as Pox, Lues, SY and Bad Blood Disease (because of presence of MO in blood although in minimal amount)

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Causative Agent: Treponema pallidum-a spirochete that passes to the placental barrier during the 16 week of pregnancy (2nd & 3rd trimester) MOT: Sexual contact and vertical transmission Incubation Period: 10-90 days 3 Stages of Manifestation of Syphilis: 1. Primary Stage a. Patient have a characteristic lesion called Chancre, a painless papular lesion Found in the face, lips, tongue, under the breast, fingers & genitals that heals with or without treatment In males, it looks like a mole appearing like an elevated rash b. Regional lymphadenopathy 2. Secondary Stage: stage that is highly infectious & contagious because of flu-like Sxs: a. Fever and malaise b. Skin rashes & Dermatitis: dry, hard, wart like lesions found in the palms of hand, soles of feet, under the breast & genitalia that fused together called Condyloma lata c. Oral mucous patches d. Changes in hair growth: Alopecia-patchy, polka dot or moth eaten appearance of hair and thinning of pubic hair Before the 3rd Stage, the patient becomes asymptomatic for 1-2 years called Latent Phase of Syphilis but patient is still infectious 3. Tertiary Stage a. Patient have a characteristic lesion called Gumma described as an infiltrating lesion found on deeper tissues & body organs such as skin, bone and liver b. It involves the heart=cardiovascular syphilis aortitis & aneurysm c. It involves the CNS=neurosyphilis paresthesias, abnormal reflexes, dementia and psychosis Diagnostic Examinations: 1. Culture & Sensitivity by mucosal scraping 2. Dark Field Microscope 3. Serologic (Blood Exam) Test a. Venereal Disease Research Laboratory (VDRL): non specific for syphilis b. Flourescent Treponema Antibody Absorption Test (FTA-ABS)-confirmatory/definitive test of Syphilis c. Rapid Plasma Reaction (RPR) Medical Management: Antibiotic: Benzathine Penicillin G (Penadur) given IM only because it easily coagulates embolism death use g 19 or 18 and introduce it fast Dilute it with 4cc water + 1cc lidocaine/xylocaine=4cc Benzathine, 1cc xylocaine given to patients with Rheumatic Heart Disease (RHD) it causes congenital anomaly (anterior bowing of the tibia) if given 2 years after birth Nursing Care & Preventive Measures: same as gonorrhea HIV and AIDS: HIV infection means one is infected with AIDS virus, the initial stage of AIDS AIDS=infected by virus + incompetent immuno-response an opportunistic infection develops, the end stage of HIV infection

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Causative Agent: Human Immuno-Deficiency Virus (HIV)-retrovirus It is very fragile because it is easily destroyed by 70% alcohol, chlorine, 56 degrees C and ordinary bleaching soap (Sodium Hypocloride such as Chlorox, Zonrox, Purex & Domex) with a preparation of 1:10 (1 part NaHCL & 10 parts Water) It is capable of living outside the body for only 4 hours The virus is alive if it goes out with fresh blood If patient dies of AIDS, the virus stays in the body as long as it is humid so they are not allowed to be embalmed. It lives on a decomposing body so the body must be sealed in a metal coffin or cremated within 24 hours MOT: 1. Blood transfusion-single exposure will make you 90% (+) 2. Sexual contact-single exposure will give you 0.1-1% infected with HIV but becomes the # 1 MOT worldwide because of repeated acts 3. Exposure to infected blood, products or tissues will give you 0.5% 4. Vertical (mother to child) or Perinatal (Pregnancy, Delivery & Breastfeeding) transmission will give you 30% if mother has HIV, the newborn undergo HIV testing if (+), it means maternal antibodies, but up to 18 months only if after 18 months still (+), it means the baby is infected 5. Sharing needles will give 65% Normal Immune Response: MO---------------detected by Macrophage---------------Alert T Cells HIV Antibodies stimulate B cells The microorganism is detected by macrophage that alerts the T-cells and sends Helper T-cell to stimulate B-cells that will multiply and release antibodies which destroy the microorganism by antigen-antibody reaction. Once HIV enters the body, it directly goes to T-cells. The virus will release reverse transferase that resembles the genetic cells of T-cells. Then T-cells will not destroy the virus leaving it to multiply and damage T-cells. Virus leaves the T-cells then retrovert to its own genetic sequence-not enough T-cells-not enough stimulation of B cellnot enough antigen-antibody reaction. Well Worried Infected with HIV-----Asymptomatic Window Period (+) HIV Infection-----ARC Symptoms Adult Child----------------------AIDS 2 Major 2 1 Minor 2 Well worried person is infected with HIV: he will be asymptomatic because it takes time to produce antibodies. After 6 weeks to 6 months, he will be (+) to HIV infection because it takes about 6 months to produce antibodies known as Window Period (time interval between infection of an individual to production of antibody)AID Syndrome. AIDS Related Complex (ARC) Symptoms: 1. Fever with night sweat without a cause 2. Enlargement of lymph nodes (neck, axillary & inguinal) without a cause

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3. Fatigability 4. Weight Loss 5. Altered sleeping patterns 6. Temporary memory loss 7. Altered gait Adults: 2 Major symptoms & 1 Minor symptom Children: 2 Major symptoms & 2 Minor symptoms 3 Major Symptoms: 1. Fever-1 month & above 2. Diarrhea-1 month & above 3. 10% Weight Loss/Stunted Growth for Pedia 6 Minor Symptoms: 1. Persistent Cough-1 month & above 2. Persistent Generalized Lympadenopathy 3. Generalized Pruritic Dermatitis (kamot ng kamot) 4. Oropharygeal Candidiasis 5. Recurrent Herpes Zoster 6. Progressive Disseminated Herpes Zoster (singaw na pabalik balik at palaki ng palaki) An Opportunistic Infection: TB is the most common of the Avium type (from birds) Pneumocystis carinii pneumonia (PCP) Cytomegalovirus (CMV) protozoa CNS Lungs Eyes (Retinal destruction) Cancer: Kaposi Sarcoma malignancy of blood vessel manifested through the skin appearing as pink/purple painless spots on the skin called Leopard Look Diagnostic Examination: 1. Enzyme Link Immunosorbent Assay (ELISA) Test-screening test for HIV 2. Western Blot-confirmatory test for HIV 3. Viral Load Testing-monitors the replicating activity of the virus 4. CD4 & T-Cell Count-identifies the stage of infection: If more than or equal to 200=patient is HIV infected If less than 200=AIDS 5. Blood Examination/CBC-anemia, thrombocytopenia, leukopenia 6. Blood Culture for pediatrics 7. Immunocomplex dissociation (P24 assay) for pediatrics Medical Management: 1. Nucleoside Analogs are cocktail drugs that prevent the virus to multiply during the initial phase of cell division: a. Nucleoside Reverse Transcriptase Inhibitor (NRTI) 1) Azidothymidine (AZT)-Zidovudin, Retrovir 2) Lamivudine-3TC, Epion 3) Stavudine-Cd4T, Zerit 4) Dideoxyinosine (DDI)-Didanosine 5) Dideoxycytidine (DDC)-Zalcitabine, Hivid b. Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) 1) Delavirdine 2) Nevirapine 2. Protease Inhibitor (PI) prevents virus to multiply during the last phase of cell division a. Indinavir b. Retonavir c. Saquinavir d. Nalfinavir

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3. Fusion Inhibitor-Fuseon (Enfuritide) Nursing Care: Supportive & Symptomatic 1. Promote knowledge & understanding 2. Promote quality of life 3. Provide self care & comfort Preventive Measures: 1. Practice ABCD of HIV A-bstinence B-e Faithful C-ondom D-ont use drug

2. Education 3. Counseling 4. Behavior Modification

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