pathopharmacology + care of adults - exam 1 (infection/inflammation)

five cardinal signs of inflammation

• rubor (redness)

• calor (heat)

• dolor (pain)

• tumor (swelling)

• functio laesa (loss of function)

acute inflammation

• caused by bacterial infections and trauma

• start with physical assessment!

• rice - rest, ice, compress, elevation

• heat 24-48 hrs post-injury

three phases of acute inflammation

• vascular

• cellular

• opsonization

stage 1 - vascular phase

• small moment of vasoconstriction

• rapid vasodilation of arterioles and venules = redness + pain

• fluid into tissues = swelling, pain, and tissue damage

  • increasing blood viscosity → increases clotting = stops bleeding

neutrophils

• first responders

• phagocytosis

• treats bacterial infections

eosinophils

• treats allergic and parasitic infections

• weak phagocyte

• controls inflammatory response

basophils and mast cells

• responds to allergic reactions where IgE antibody is present

• releases histamine

monocytes/macrophages

• helps with chronic inflammation → longer lasting than neutrophils

• phagocytosis

• regeneration of tissues through vasoactive mediators (ex. prostaglandins, cytokines, gf)

stage 2 - cellular phase

• wbc moves from tissues to site of injury

• margination: tumbling of wbc

• adhesion: sticking of wbc to wall of injury site

• transmigration: movement of wbc to isf

stage 3 - opsonization

inflammation + phagocytosis

chronic inflammation

• caused by: viral infections and autoimmune disorders

• symptoms: tissue destruction, scarring, diminished mobility, loss of function

local inflammation

• cardinal signs and exudate

• types of exudate

  • serous (watery)

  • hemorrhagic (bloody)

  • purulent (pus)

  • fibrinous and membranous (sticky meshwork)

systemic inflammation

• fever or hypothermia

• tachycardia/pnea

• leukocytosis

• malaise + nausea

• anorexia

• left shift = high release of immature wbc from bone marrow

pus

• wbcs

• tissue debris

• proteins

abscess

localized area of inflammation with pus contained within neutrophil

ulceration

epithelial layer becomes necrotic

cox-1

• physiologic prostaglandins

• protects stomach lining = decreases gastric acid + increases mucus

• platelet aggregation

• renal perfusion

• relaxes smooth muscle = vasodilation and bronchodilation

cox-2

• physiological prostaglandins

• vasodilation and inflammation

• edema and pain

• leukocytosis → releases inflammatory cytokines

non-selectives nsaids

• inhibit cox-1 and cox-2

• decreases inflammatory prostaglandins = lowers pain and inflammation

• stops stomach lining protection

• lowers renal perfusion (kidney issues)

selective nsaids

• inhibits cox-2

• lowers inflammation

viruses

• smallest pathogen

• cannot replicate outside the host

• some remain latent until triggered by stress/hormone changes (ex. herpes and cold sores)

fungal infections

• found everywhere

• opportunistic: causes illness when host is compromised

antibiotic resistance

• genetic mutation

• modification of target molecule

• high efflux of antibiotic

antibiotic resistance caused by

• treat the bug with the right drug

• maintain adequate blood levels

  • trough: lowest concentration of antibiotic in blood

    • check before next dose

  • peak: highest concentration of antibiotic in blood

    • check after dosage

antibiotic resistance tips

• finish antibiotics

• draw blood culture before antibiotics

• assess for suprainfection, toxicity, hypersensitivity reactions

• take oral antibiotics on empty stomach and do not co-administer with other meds

adverse reactions of antibiotics

• superinfection: new infection caused by resistant organism which can kill good bacteria

• steven johnson syndrome: life threatening skin reaction thru blisters and sloughed skin

• red man syndrome: antibiotic given too quickly → flushing, pain, redness at insertion site (slow down infusion!)

antimicrobial stewardship

• using antibiotics correctly and only when needed

• ex. pt asks for antibiotics for viral cold

  • you do not give bc antibiotics are only for bacterial infections

sirs

• systemic inflammatory response syndrome

• temp can be too high or too low

• wbc can be too high or too low

• high hr + rr

sepsis

• sirs and infection

• two or more sirs symptoms

• confirmed or suspected infection

severe sepsis

end organ damage and high serum lactate levels

septic shock

• end organ damage and high serum lactate levels

• main one - hypotension

why is urine output important in sepsis?

decreased urine output can indicate poor renal perfusion

first priorities when a patient is severely deteriorating from sepsis

• abc’s

  • a - hi-flow supplement

  • b - ventilation

  • c - 30 ml/kg of crystalloids

• but if patient is unresponsive cab

what should happen before starting broad-spectrum antimicrobial therapy when possible?

obtain cultures first

major nursing priority in sepsis

maintain oxygenation and adequate tissue perfusion

older adult considerations for sepsis

• uti is more common

• check for cognitive and behavioral changes

• do not rely on the presence of fever to indicate infection in older adults

what medications may be needed if hypotension persists despite fluid resuscitation?

vasopressin - norepinephrine or dopamine

disseminated infection

infection that spreads beyond the original site

hai

• health associated infection

• clabsi - central line-associated bloodstream infection

• cauti - catheter associated urinary infection

• surgical site infections

• ventilator-associated events

common pathogens associated with hais

mrsa and c. diff

sources of infection

• endogenous - from self

• exogenous - from outside

• latrogenic - from procedure

• nosocomial - from hospital post leaving (24-48 hrs)

what is the most important basic intervention for preventing infection transmission?

hand hygiene

three transmission-based precautions

• airborne

• contact

• droplet

airborne precautions

• for small droplets in the air

• ex. tb, rubeola (measles) and varicella (chicken pox)

• ppe, mask, gloves

contact precautions

• through direct and indirect contact

• ex. hep-A, herpes, mrsa, and vre

droplet precautions

• no gloves needed

• ex. influenza, pertussis, bacterial, meningitis, mumps, pneumonia

what virus causes covid-19?

• sars-cov-2: single stranded rna corona

• comes from nasal, bronchial epithelial cells, pneumocytes

• droplets and close face-to-face transmission

can covid be transmitted before symptoms appear?

yes

what test is used to detect sars-cov-2 rna?

pcr

what is a major priority when caring for a patient with severe covid?

supporting oxygenation and respiratory function

what respiratory support may be needed for severe covid?

oxygen through a nasal cannula and, if necessary, invasive mechanical ventilation

lower uti

• bacterial infection of the lower urinary tract

• bacteria colonize the urethra into the bladder

• symptoms - nocturia, suprapubic pain, and bladder spasms

cystitis

inflammation/infection of the bladder

urethritis

• inflammation/infection of the urethra

• can be associated with stis

most common cause of uti

• e. coli

• gram-negative enteric bacteria

major risk factor for a catheter-associated uti

indwelling urinary catheter

what urine findings can occur with a uti?

cloudy or foul-smelling urine and hematuria

what can flank or lower back pain suggest?

urinary tract involvement beyond simple bladder irritation, especially if infection is progressing upward

what diagnostic test is commonly used to evaluate a uti?

urinalysis

what should patients generally be encouraged to do during a uti?

drink more and pee more

what should patients avoid while experiencing uti symptoms?

• caffeine

• coffee, tea

• alcohol

• citrus

what is phenazopyridine used for?

• temporary burning relief

• used for 1-2 days

how often should a patient empty the bladder?

• every 4 hours while awake

• before and after intercourse

what intervention first?

• physical assessment

• culture and sensitivity

• broad spectrum antibiotics until results showing specific antibiotics

what happens as the cd4 count decreases?

immune function becomes impaired and the risk of opportunistic infections increases

hiv stages

• acute infection

• asymptomatic infection

• symptomatic infection/aids progression (200 cells/µl)

what can acute hiv infection look like?

flu-like symptoms occurring about 2–4 weeks after infection

what are examples of manifestations associated with hiv/aids?

oral candidiasis and kaposi sarcoma lesions

what is art?

• antiretroviral therapy

• decrease viral load, maintain/increase cd4 count, prevent hiv-related symptoms

what does viral load tell you?

amount of hiv circulating in the blood

older adult considerations for hiv

adults are more likely to be infected and die at age 65

intention healings

• primary intention - wound healing through sutures

• secondary intention - wound left open bc edges cannot be brought tg

• tertiary - wound is intentionally left open for a few days to clear out any infection or dirt, and is then surgically closed later

wound healing stages

• inflammatory phase

  • immediate

  • hemostasis + scab forms

• proliferative phase

  • 2-3 days post-injury lasts 3 weeks

  • fibroblasts = making new tissue

• remodeling

  • 3 weeks - 6 months post-injury

  • remodels scar

development of immune response

• develops for fetuses at 5-6 weeks

• secondary lymphoid organs developed at birth

• IgA and IgM reach adult levels at age 1

elderly immune system

• slow ability to adapt to environmental stress

• decrease of thymus gland

• t cells

transmission of aids

• sex

• blood to blood contact

• perinatally - mother to infant

innate vs adaptive

• innate - phagocytes

• adaptive - lymphocytes

  • cells that recognize and respond to foreign antigens (ex. disease)

humoral immunity

• medicated by molecules in blood

• b lymphocytes (bone marrow)

• defense against extracellular microbes

cell-mediated immunity

• mediate by specific t lymphocytes

• made in thymus

• defense against intracellular microbes ex. viruses