2 Infection Concept Review Infection—disease state resulting from the presence of pathogens in the body. May be acute or chronicPathogens—disease-producing microorganisms—bacteria, viruses, fungi, parasites. The presence of these pathogens usually produces an inflammatory response as well.
3 Course of InfectionIncubation period—time between entry of pathogen and onset of sxProdromal stage—nonspecific sx, most infectiousIllness stage—worst sxConvalescence—recovery timeLength of each stage depends on type of infection—may be local or systemic
4 Chain or Cycle of Infection Infectious agent (pathogen)Reservoir (place it lives)Portal of exit (orifices or breaks)Mode of transmission (how it moves)Portal of entry (orifices or breaks)Susceptible host (stressors)
5 Defenses Against Infection Normal body floraBody system defensesInflammatory responseVascular and cellular responsesFormation of exudatesTissue repair
6 The Susceptible Host Changes in normal body flora Breakdown in body systemsFlawed inflammatory responseProblems with tissue repairStressors
7 Clinical Appearance of Infection LocalizedWarmthSwellingRednessDrainagePain/tendernessRestricted movementSystemicChanges in VSFatigueN/V/DMalaiseLymphadenopathyConfusion
8 Laboratory DataWBC (Totals and differentials) Amount elevated usually indicates severity.“Left shift” (high neutrophils) usually indicates a severe infection.Total elevation not seen in viral infections. May see a “right shift” (high lymphocytes) in some viral infections+Cultures and gram stains
9 Interventions Protect clients Educate clients Maintain own worker healthGive antimicrobialsBe aware of S&S of infectionPractice medical and surgical asepsis
10 Exemplar # 1: Influenza (205, 221-222, 2122, 2131) Acute viral respiratory diseaseCaused by different strains of A, B, or C virusFlu shot is made from 2 A strains and 1 B strainSpread by droplet. Incubation 24-72hA leading cause of morbidity and mortality; most deaths occur in over 60 age group.
11 High-risk Groups Any age with chronic illness Residents of long term careImmunocompromisedPregnantAlso recommended for 6 mo-5 yrs, over 50Required for healthcare workers
12 ManifestationsAbrupt onset with cough, fever, myalgia, HA, sore throatResolution within 7d unless complications develop. Most common complication is PNConvalescent phase may include malaise and hyperactive airways
13 Collaborative CareRelieve sx with mild analgesics and cough meds and prevent pneumonia.Antivirals shorten course of illness and inhibit spread of virus to other cells—should be given within 2d of onset of sx or can be given prophylactically.Older adults may be hospitalized. Vaccine is less effective in this group.Encourage flu vaccine esp. in high-risk groups.Reactions to vaccine required to be reported.Pandemics should be planned for by HC agencies.
14 Exemplar # 2: Pneumonia (PN) p. 554 Acute inflammation of lung caused by microbial organismLeading cause of death in the United States from infectious diseaseMost common type is streptococcalCauses: aspiration, inhalation of microbes, or spread thru blood from a primary infection site
16 Risk Factors Impaired immunity Chronic respiratory conditions Hospitalization (HCPs, respiratory equipment, NG or ET tubes)ImmobilitySmoking/pollutionMeds that cause respiratory depression↓ Cough and epiglottal reflexesMalnutritionPneumonitis
17 Types of PNCommunity-acquired (CAP)—usually streptococcal. Occurs in community or within 48h after hospitalizationHospital-acquired (HAP)—occurs after 48h. Most common are the antibiotic-resistant organismsAspiration—usually streptococcal (normal flora in oropharynx)Pneumonia in the Immunocompromised Host (formally Opportunistic)—fungal, PCP, TB
18 Pathophysiology of Pneumonia Organism enters respiratory tract and releases toxins causing inflammationIn alveoli, serous fluid and mucus are released and bacteria multiply rapidly in the fluidCapillaries dilate adding red cells to alveolar fluid along with bacteria, white cells, and fibrinVenous blood entering the lungs doesn’t get proper oxygenation leading to hypoxemiaLobar involves entire lobe; bronchopneumonia is patchy
19 Clinical Manifestations Common to mostSudden onset of fever, chillsTachycardia, tachypnea, orthopneaCough productive of purulent sputum unless dehydration is present. Color of sputum not necessarily indicative of organismPleuritic chest painConfusion or stupor in elderly or symptoms may not be readily apparent
20 Clinical Manifestations Lung examination findingsDullness to percussion↑ Fremitus (vibration)Usually fine cracklesBronchial breath sounds—high-pitched and loud, normally only heard around the trachea. No air exchange in the alveoli causes no vesicular sounds to be heard and the high-pitch sound that is heard is from the tracheobronchial tree and being transmitted to the chest wall.
21 Diagnostic Tests Chest x-ray CBC, differential Chemistries (if indicated)Gram stain and C&S of sputumPulse oximetry and/or ABGsBlood cultures
22 Most Common Complications PleurisyAtelectasisPleural effusion—purulent fluid in pleural space. Usually is sterile and reabsorbed in 1 to 2 weeks or may require thoracentesis. Occurs in 40% of cases.SepsisShock and respiratory failure (delayed or inadequate tx or at risk populations)
25 Collaborative Care Assess ability to treat at home. HCP should check with Case Management to see if patient meets inpatient criteria.Ultimately, HCP can decide, but hospital may not get paid for inpatient stay.
26 Collaborative Care Antibiotic therapy (only if bacterial) Oxygen for hypoxemiaAnalgesics for chest painAntitussives for coughAntipyretics for feverMay need nebulizer treatmentsFluid intake at least 3 L per dayCaloric intake at least 1500 per day (high calorie fluids if severe anorexia is present)
28 Preventative Care Influenza drugs and influenza vaccine Pneumococcal vaccine indicated for those at risk:Chronic illness such as heart disease, lung disease, or diabetes mellitus, or aspleniaRecovering from severe illness65 or olderIn long-term care facility or other environments that may increase risk
29 Nursing Diagnoses Impaired gas exchange Ineffective breathing pattern Ineffective airway clearanceImpaired tissue perfusionAcute painImbalanced nutrition: Less than body requirementsActivity intoleranceDeficient fluid volumeDeficient knowledge
30 Planning: Outcome Criteria Clear breath soundsNormal breathing patternsNo signs of hypoxiaNormal chest x-rayNo complications related to pneumonia
31 Nursing ManagementAdmission history, med list, and physical assessmentIdentify risk factorsLabs and radiologyMonitor O2 status and oxygen therapyMonitor effects of respiratory therapyHOB elevatedPromote C&DB and use of ISMonitor IV fluids and encourage po fluidsAdminister and evaluate antibiotic therapyBalance rest and activityEvaluate activity toleranceMonitor for changes in status
32 Patient Education Causes Individual risk factors and how to minimize risk such as stopping smokingManaging symptomsImportance of med therapyS & S to reportKeeping FU apptsMay need to teach IV antibiotic therapyVaccines
33 Evaluation Dyspnea not present SpO2 ≥ 95 Free of adventitious breath soundsClears sputum from airwayReports pain controlVerbalizes causal factorsAdequate fluid and caloric intakePerforms activities of daily living
34 Developmental IssuesVery young and very old are more susceptible to the complications of PN and influenza. Both can become ill very quickly and mortality rates are generally higherBoth groups also become dehydrated quicker than adults.Remember that elderly may have atypical symptoms.Children have shorter, straighter passageways in their respiratory system, making spread of infectious organisms more rapid.
35 Cultural and Socioeconomic Issues Be sensitive to another cultures need to treat infections with alternative therapies and healers: herbal, acupuncture, hot-cold, prayer, charms, etc.Be aware that $ play an important role today with limited access to health care and expense of prescriptions. HCPs should try to be sensitive to what they prescribe.
36 Exemplar #3: Meningitis (1950-2) Inflammation of the lining around the brain and spinal cordCaused by bacteria or virus80% are caused by the bacteria Streptococcus pneumoniae and Neisseria meningitidesViral infections are usually caused by mumps, herpes, or mosquitoes or other insects.
37 Risk Factors Pneumonia Otitis media Mastoiditis URI AIDS Lyme Disease SmokingImmunosuppressionCrowded living conditionsFacial traumaInvasive procedures
40 Manifestations Fever HA Nuchal rigidity Photophobia Hemorrhagic rash Confusion, irritability, lethargy, decreased LOC+Kernig’s sign—flexed hip and knee cannot be extended+Brudzinski sign—neck flexion causes flexion of the hips and knees
41 Diagnostics CT or MRI to detect brain shift LP with evaluation of CSF Blood cultures
42 Preventative Management Hib vaccine has almost eradicated Hemophilus influenza, a past major cause of meningitis in children.Meningococcal vaccine should be given to all college-bound adolescents, especially those planning on living in dorms.People who have close contact with meningitis should get Rocephin.
43 Medical ManagementIV antibiotic therapy usually with Vancomycin and a cephalosporin such as Rocephin.Decadron steroid therapy decreases swelling and inflammationAntiseizure meds if indicatedContact precautions
44 Nursing Management VS and O2 sat Neuro checks Low lights Administration of meds (antibiotics, antiseizure, antipyretics, analgesics)Seizure precautionsMonitor IV therapy and fluid statusMaintain isolation precautionsPrevent complications from decreased mobilityFamily support