Acute- Management of Patients with Immune System Disorders and Infectious Disease

5-10 x 10^9/L

what are the normal leukocyte counts

leukocytosis

> 11 x 10^9/L, presence of acute infection or may be present with inflammation

leukopenia

<4 x 10^9/L, altered immunity or presence of infection that exhausts supplies of WBC

neutropenia

<1.5 x 10^9/L, typically caused by a stem cell dysfunction but may be viral/bacterial infection

WBC, differential WBC, antibody testing, PCR

what labs should you review when examining the immune system

differential WBC count

measures %s of 5 different types of WBC to help differentiate between various types of infections

symptoms based approach

what are PT implications with abnormal leukocyte counts (WBC)

neutropenic precautions

what precautions would you implement for someone with abnormal leukocyte counts

vigorous/high intensity activity

what might you avoid if someone has a high fever

may not tolerate exercise; may hold PT

a patient with a high fever of 104...

private room with closed door, handwashing is required upon entering room, no gowns or gloves are required, no fresh fruits, vegetables, or flowers may be taken into the room, no visitors or staff with infectious illness may enter the room, no special precautions must be taken with articles leaving the room

what are neutropenic precautions

centesis

perforating body cavity or organ with hollow needle or cannula to draw out fluid; to collect fluid for further study (ID infection, inflammation, malignancy, or combo) or drain excessive fluid

thoracentesis

needle/catheter is inserted into the pleural cavity through the chest wall, and is indicated with pleural effusion or lung infections

pericardiocentrsis

needle/catheter is inserted into the pericardial space around the heart and is indicated by pericardial effusion or cardiac tamponade

paracentesis

needle/catheter is inserted into the peritoneal cavity (abdomen); and is indicated by ascites, abdominal trauma, or hepatic/systematic diseases

arthrocentesis

needle/catheter is inserted into the joint capsule and is indicated by infections, rheumatic disease, and/or OA

check chart to see patients post procedures to ensure any mobility restrictions have been lifted, watch for signs and symptoms of infection at puncture site, patient may experience some pain/discomfort at puncture site following, watch for possibility of pneumothorax (thoracentesis, pericardiocentesis)

what are PT implications of centesis

blue, gasping for air, nose flaring

what are signs and symptoms of pneumothorax?

call medical team (not a code)

what would you actually do if a pneumothorax occurred in the hospital setting

x-rays, CT, PET, MRI

what imaging helps to ID and monitor infectious lesions

may be NPO, may be fatigued

what are some PT considerations for patients waiting an image to help ID and monitor infectious lesions

PLOF, current function/symptoms, barriers and supports (environment and assistance available)

what are areas to focus in in the inpatient patient interview when assessing a patient with suspected immune system dysfunction

fatigue, constitutional symptoms such as fever, cough, SOB, and onset, duration, and nature of symptoms

what are areas to focus in in the outpatient patient interview when assessing a patient with suspected immune system dysfunction

protect yourself and other patients, screen to be able to refer appropriately, able to take proper precautions/implications

what would you do with the info you obtained from the history

sweat, redness in specific area, rash, weakness, fatigue, chills, inflammation, swelling

what are some common physical findings that you may be able to observe with immune system/infectious diseases

lymph nodes

what might you be able to palpate potentially "abnormal" in individuals with immune system/infectious diseases

increased HR, BP can increase or decrease

what might you expect to see with vitals with immune system/infectious diseases

>100.4 F or 38 C

what is considered the temperature for a fever

fever

not a contraindication to treatment, however, patient may be less likely to tolerate physical activity

caution/graded approach

fever is not a contraindication to treatment, however, patient may be less likely to tolerate physical activity and we should use a

heart and lungs auscultation

you may wish to include what to rule out potential involvement

myalgic encephalomyelitis

chronic fatigue syndrome

activity management; must balance rest and activity to avoid flare ups, must ID individual limits, stay within the energy envelope, education on energy conservation, ergonomics, sleep hygiene, exercise

what are key interventions for myalgic encephalomyelitis

prioritize, plan, pace, position

what are the 4 p's of energy conservation

cognitive behavioral therapy, stress management and nutrition, support groups

what referrals may be needed for myalgic encephalomyelitis

exercise

what is somewhat controversial, with some concerns for worsening symptoms of myalgic encephalomyelitis

start easy (low intensity, short duration), progress slowly, avoiding overexertion, monitor symptoms during and also for at least 24 hours after

what are some important considerations for exercise with myalgic encephalomyelitis

may see large fluctuations in HR and BP inconsistent with position/movement

what may you see when monitoring vitals in myalgic encephalomyelitis

orthostatic hypotension

what commonly occurs to BP in myalgic encephalomyelitis

may benefit from use of RPE scale

what considerations should you take when monitoring HR in myalgic encephalomyelitis

avoid overexertion, be aware that even if patient tolerates session well, symptoms may increase after session (so move even more slowly than you think you may need to)

what are precautions for myalgic encephalomyelitis

integumentary, neurological, cardiopulmonary, musculoskeletal, other systems

what systems are affected by HIV/AIDs

rash resembling rosacia in acute, delayed wound healing, dermatitis, herpes zoster, fungal infections (oral thrush)

what are possible integumentary presentations with HIV/AIDs

issues with pain, may restrict ROM depending on site of pain

what are potential PT implications with the integumentary system and HIV/AIDs

headaches, peripheral neuropathies, cognitive changes- motor functioning, planning disturbances, attention, concentration, memory, seizure risk

what are possible neurological presentations of HIV/AIDs

balance and gait problems, seizure protocol

what are PT implications for neurological presentations of HIV/AIDs

occurs in more advanced stages- carduomyopathy, CHF, pulmonary hypertension, decreased O2 transport

what are cardiopulmonary presentations of HIV/AIDs

decreased endurance

what are PT implications of cardiopulmonary presentations of HIV/AIDs

myalgias, arthralgias, lipodystrophy, wasting in face and accumulation at waist, osteoporosis/osteopenia

what are musculoskeletal presentations of HIV/AIDs

reduced muscle mass and strength, biomedical inefficiencies and postural abnormalities

what are PT implications of musculoskeletal presentations of HIV/AIDs

opportunistic infections, lymphasenopathy, oral thrush, fever, sore throat, weight loss, dementia, fatigue, cancer (karposkis sarcoma, lymphoma)

what are possible presentations of HIV/AIDs in other systems

decreased endurance/activity tolerance, delayed healing

what are PT implications of HIV/AIDs presentation in other systems

therapeutic exercise, joint and soft tissue mobilizations, modalities, functional gait and balance training, postural re-education, breathing techniques and energy conservation

PT needs and interventions vary by individual and stage of disease- some interventions include

nutritional counseling, social work, support groups

what are referrals for patients with HIV/AIDs

asymptomatic and maintain as disease progresses

the exercise guidelines for HIV/AIDs are that you should ideally begin when you

individual and stage

there is conflicting evidence on optimal type, intensity, frequency, and duration for HIV/AIDS, so you should consider the

with low symptoms/earlier stage

when should you increase exercise intensity with HIV/AIDs

acute illness

when should you decrease exercise intensity with HIV/AIDs

moderate intensities

ACSM guidelines for individuals with HIV/AIDS is generally ok for

acutely ill/stage 3

moderate intensity exercise should not be used with HIV/AIDs patients who are

check and protect skin, osteoporosis/osteopenia, monitor vitals, aquatics contraindicated, reduced intensity with active disease

what are precautions for HIV/AIDs

rash, hives, swelling, cyanotic, pale

what are integumentary signs of anaphylaxis that we should be aware of

increased HR, decreased BP, increased RR

what are changes in the cardiovascular pulmonary system that may indicate anaphylaxis

epipen, 911

what would you DO if you believe your patient is having an anaphylactic reaction in the hospital/outpatient setting

rashes, butterfly rash, redness around joints

what integumentary symptoms might you want to check for with systemic lupus erythema

joint pain

what musculoskeletal symptoms might you want to check for with systemic lupus erythema

memory changes, mood changes, peripheral neuropathy

what are neurologic symptoms you might want to check for with systemic lupus erythema

energy conservation, joint protection strategies, exercise (light to moderate and balance with rest)

what are interventions for systemic lupus erythema

be aware of medications and potential side effects, monitor vitals (HR, BP), monitor lab values/CBC-can lead to penias, ~50% may have kidney involvement- monitor BUN, Cr

what are precautions for systemic lupus erythema

exercise- low/moderaye intensity aerobic conditioning, muscle strengthening; education- stress management, lifestyle training; aquatic therapy; soft tissue techniques; modalities

what are interventions for fibromyalgia

aquatic therapy

may be effective for those with significant limitations due to fibromyalgia

gently and slowly

how should soft tissue techniques be applied on patient with fibromyalgia

continuous US, biofeedback, TENs, dry needling

what modalities should be used with firbomyalgia

monitor vitals, avoid cold

what are PT implications for fibromyalgia

increased HR

what might you see in someone with fibromyalgia when monitoring vitals

start small with low intensity, short duration, monitor carefully often 24 hours after, progress slowly, intermittent activity may be helpful, education

what are general principles for disorders altering immune function and that impact activity tolerance

heart, lungs, vasculature, joints, muscles

disorders altering immune function and that impact activity tolerance may have systemic effect so it is important to pay attention to

referrals/team approach

disorders altering immune function and that impact activity tolerance often benefit from

chain of infection

infectious diseases are spread through the

infectious agent, susceptible host, portal of entry, transmission, portal of exit, reservoir

what is the chain of infection

interrupt chain of transmission

the goal of infection control is to

standard precautions

what are methods for infection control

hand washing before and after each patient, contact with wounds, dressings, linens, clothing, secretions, personal care, anytime hands visibly soiled; personal protective equipment; sharps disposal/no recapping, avoid direct patient care and handling patients equipment when you have exudative lesions/weeping dermatitis; no eating, drinking, smoking in work areas; clean/disinfect/sterilize reusable equipment; respiratory hygiene/cough etiquette- cover nose/mouth, dispose of tissues promptly, mask, hand hygiene, and spatial separation in waiting areas

what are standard precautions

contact, droplet, airborne

what are common transmission modes

contact

may be direct (physical contact via skin to skin contact or between mucous membranes such as sex, biting, touching, kissing) or indirect (passive transfer via contaminated objects/surfaces

gown and gloves (don upon entry and discard prior to exiting room; use soap and water instead of alcohol based hand rub

what are contact precautions

C diff, E coli, MRSA, herpes simplex/zoster, norovirus, rotavirus, VRE

what are common potential pathogens with contact precautions

droplet

large particles fall out within 3' of source with cough/sneeze/talking

mask, face shield, or both; spatial separation > 3 feet when able; pull curtains in shared rooms; sometimes may require gown

what are droplet precautions

influenza, streptococcal, and mycoplasmal pneumonia, mumps, rubella, covid 19

what are common potential pathogens spread by droplets

airborne

small particles; float on air currents and remain suspended for hours; generally can travel >10 ft

respirator preferable or mask; airborne infection isolation rooms (negative pressure); when possible healthcare workers should not treat if non immune or immunocompromised

what are airborne precautions

varicella (chicken pox), rubeola (measles), tuberculosis, SARS, Covid 19

what are common potential pathogens for airborne illnesses

enteric contact precautions

use soap and water instead of alcohol based hand rub; especially with C diff, rotavirus, norovirus

Covid-19

severe acute respiratory syndrome; different from other viruses due to virulent transmission; produces a hyperactive immune response; presents with mild respiratory infection that can progress to acute respiratory distress syndrome with multi organ failure

virulent transmission

mostly spread via respiratory droplets during close contact; may also spread via airborne transmission (small aerolized particles that linger in the air); to a lesser extent, contact of virus with eyes, nose, mouth

profound systemic inflammation

hyperactive immune response can cause a cytokine storm which leads to

pulmonary invilvement, coagulopathy (increased risk of VTE), neurologic involvement, cardiac involvement, chronotropic incompetence, acute liver injury

what are potential systemic manifestations of COVID 19

chronotropic incompetence

a condition in which the heart rate increases slowly during exercise and never reaches maximum; should use RPE scale

increased inflammatory markers (ESR, C reactive protein), decreased lymphocytes (lowest at day 14), decreased hemoglobin, decreased platelets, increased d dimer and fibrinogen, may see some prolonged clotting times, depending on organ involvement may see increased BUN, creatinine, LFTs, tropinin may be elevated

what are some changes in lab values with COVID-19