Adult Health Test 1
inflammation
After an injury occurs:
Neutrophils and monocytes move to site of injury (WBC) chemotaxi
6-12 hours neutrophils first to the scene.
As this occurs, the bone marrow produces more neutrophils and monocytes, slightly increasing WBCs.
Phagocytosis-engulf any bacteria, damage cells, and foreign material
Clinical Manifestations
Left shift (increase in WBC) means increased consumption and production of neutrophils.
Increase in body temp, fatigue caused by cytokines (soluble parts from WBC’s acting as messengers)
Pulse and RR increase from temp
All this causes increased killing of microorganisms,
Inflammatory Exudate
Serous draining is clear and watery (often straw colored)
Serosanguineous drainage is a mixture of blood and serum, is yellowish with small amounts of blood
Fibrinous drainage is thick, is an elastic, white protein made of thrombin and fibrinogen
Hemorrhagic drainage is bright red blood
Purulent drainage is thick and yellow, this is PUS
Catarrhal drainage is a mixture of mucous and WBCs.
Pressure Injury Staging
uStage I: Non-blanchable redness of a localized area over a bony prominence. May be painful, firm OR soft, warmer OR cooler than surrounding tissue.
uStage II: Partial thickness loss of dermis. Shallow open ulcer with a red-pink wound bed without slough or bruising. May also present as an intact fluid filled blister. Can be shiny or dry & shallow. BRUISING INDICATES DEEP TISSUE INJURY
uStage III: Full thickness skin loss. SubQ fat may be visible, but bone, tendon or muscle not exposed. Slough may be present. May include undermining and/or tunneling. Depth can vary by anatomical location.
uStage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and/or tunneling. Depth can vary by anatomical location. Can lead to osteomyelitis. Bone and muscle is visible and directly palpable.
Chapter 15
Infection
KEY POINTS
INFECTIONS
• An infection is an invasion of the body by a pathogen (any microorganism that causes disease) and the resulting signs and symptoms that develop in response to the invasion.
• Infections can be divided into localized, disseminated, and systemic disease.
TYPES OF PATHOGENS
• The most common types of pathogens are bacteria, viruses, fungi, and protozoa.
• Agents cause infection in 2 ways: They grow inside human cells, causing damage, or they secrete toxins that damage cells.
EMERGING INFECTIONS
•An emerging infection is an infectious disease whose incidence has increased in the past 20 years or threatens to increase in the immediate future. Examples include Ebola, MERS, H1N1, SARS, West Nile virus, and Zika.
•Emerging infectious diseases can originate from unknown sources, contact with animal or insect vectors, changes in known diseases, or biologic warfare. Global travel, population density, encroachment into new environments, misused antibiotics, and bioterrorism have contributed to the increased risk of emerging infections.
•Drug resistance occurs when pathologic organisms change in ways that decrease the ability of a drug (or a family of drugs) to treat disease.
•Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and penicillin-resistant Streptococcus pneumoniae are 3 of the most troublesome drug resistant bacteria currently causing problems in North America.
HEALTHCARE-ASSOCIATED INFECTIONS
◦CLABSI – central line-associated bloodstream infections
◦CAUTI – catheter-associated UTIs
◦SSI – surgical site infections
◦Clostridium difficile, MRSA bacteremia
GERONTOLOGIC CONSIDERATIONS: INFECTION IN OLDER ADULTS
• The rate of HAIs is 2 to 3 times higher for older adult patients than for younger patients.
• Common infections in older adults include pneumonia, urinary tract infections (UTIs), and skin infections.
INFECTION PREVENTION AND CONTROL
• Healthcare workers should be provided personal protective equipment (PPE) which are items that prevent infection or injury to the wearer. PPE includes gloves, gowns, facial protection, and disposal systems for sharps.
• The Occupational Safety and Health Association (OSHA) mandates that any employer whose employees could be exposed to potentially infectious materials implement standard policies and procedures for protection of those employees.
• The Centers for Disease Control and Prevention (CDC) developed guidelines with 2 levels of precautions: standard precautions (designed for use during the care of all patients in hospitals and health care facilities) and transmission-based precautions (designed for specific diseases).
HUMAN IMMUNODEFICIENCY VIRUS INFECTION
• Human immunodeficiency virus (HIV) infection is a global pandemic.
• HIV can only be transmitted under specific conditions that allow contact with infected body fluids, including blood, semen, vaginal secretions, and breast milk.
• Sexual contact with a person with a detectable HIV viral load is the most common mode of transmission.
Pathophysiology
• HIV is a ribonucleic acid (RNA) virus, which replicates by using its RNA as a template to produce deoxyribonucleic acid (DNA), which is then integrated into the human genome.
• Immune dysfunction in HIV infection is caused by damage and destruction of CD4+ T cells (also known as T helper cells or CD4 cells).
• The major concern related to immune suppression is the development of opportunistic diseases (infections and cancers that occur in immunosuppressed patients that can lead to disability, disease, and death).
Clinical Manifestations and Complications
• HIV infection is divided into different stages, including acute, asymptomatic, symptomatic, and AIDS.
• Acute HIV infection occurs 2 to 4 weeks after the initial infection and is often accompanied by a mononucleosis-like syndrome that may be mistaken for the flu.
• Asymptomatic infection is the interval between untreated HIV infection and a diagnosis of acquired immunodeficiency syndrome (AIDS). Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur.
• Symptomatic infection occurs as the CD4+ T-cell count drops to 200 to 500 cells/μL, and the viral load increases. Symptoms seen in earlier phases tend to become worse and other problems, including infections, lymphadenopathy, and nervous system manifestations, may occur.
• AIDS is characterized by severe immune system suppression and CD4 cell counts of less than 200 cells/μL.
Diagnostic Studies
• The most useful screening tests for HIV are those that detect HIV-specific antibodies and/or antigens.
• Two important laboratory assessments monitor the progression of HIV infection: CD4 cell counts and HIV viral load.
Interprofessional Care
• Interprofessional management of the HIV-infected patient focuses on (1) monitoring HIV disease progression and immune function, (2) initiating and monitoring antiretroviral therapy (ART), (3) preventing the development of opportunistic diseases, (4) detecting and treating opportunistic diseases, (5) managing symptoms, (6) preventing or decreasing the complications of treatment, and (7) preventing further transmission of HIV.
• The goals of drug therapy in HIV infection are to decrease the viral load, maintain or raise CD4 cell counts, prevent the development of HIV-related symptoms and opportunistic diseases, and delay disease progression.
• The major drug classifications for HIV include nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), integrase inhibitors (INSTIs), protease inhibitors (PIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), and entry/fusion inhibitors.
• Treatment regimens can have side effects and often interact with other medications.
• Management of HIV is complicated by the many opportunistic diseases that can develop as the immune system deteriorates.
• Examples of opportunistic diseases include Pneumocystis jiroveci pneumonia (PCP),
Mycobacterium avium complex (MAC), and Kaposi sarcoma.
NURSING MANAGEMENT: HIV INFECTION
• Since HIV infection can be prevented, nursing care for people not known to be infected with HIV should focus on preventing disease transmission.
• The first step is to assess the patient’s individual risk behaviors, knowledge, and skills.
• Based on the assessment, nursing interventions can then encourage the patient to adopt safer, healthier, and less risky behaviors, particularly about sexual intercourse, drug use, perinatal transmission, and work issues.
• The overriding goals of therapy for infected persons are to keep the viral load as low as possible for as long as possible, maintain or restore a functioning immune system, improve the patient’s quality of life, prevent opportunistic disease, reduce HIV-related disability and death, and prevent new infections.
• Nursing interventions are based on and tailored to patient needs at every stage of HIV disease and can be instrumental in improving the quality and quantity of the patient’s life.
• Nursing care can assist the patient to (1) adhere to drug regimens; (2) promote a healthy lifestyle that includes avoiding exposure to other sexual and blood-borne diseases; (3) protect others from HIV; (4) maintain or develop healthy and supportive relationships; (5) maintain activities and productivity; (6) explore spiritual issues; (7) come to terms with issues related to disease, disability, and death; and (8) cope with the frequent symptoms caused by HIV and its treatments.
• Teach patients and families about treatment options: (1) advantages and disadvantages of new treatments, (2) dangers of nonadherence to therapeutic regimens, (3) how and when to take each drug, (4) drug interactions to avoid, and (5) side effects to report to the HCP.
• While patients living with HIV share problems experienced by all people with chronic diseases, these problems are worsened by negative social attitudes and stigma associated with HIV. Discrimination related to HIV infection can lead to social isolation, dependence, frustration, low self-image, loss of control, and economic pressures.
• Should the nurse be exposed to HIV-infected fluids, postexposure prophylaxis (PEP) with combination ART can significantly decrease the risk of infection.
MULTIPLE SCLEROSIS
• Multiple sclerosis (MS) is a chronic, progressive, degenerative disorder of the central nervous system (CNS) characterized by disseminated demyelination of nerve fibers of the brain and spinal cord.
• The cause of MS is unknown. MS is related to infectious (viral), immunologic, and genetic factors.
• Disease onset is often gradual, with vague symptoms occurring intermittently over months or years. Some patients have chronic, progressive deterioration, while others have remissions and exacerbations.
• Common manifestations of MS include motor, sensory, cerebellar, and emotional problems.
• No definitive diagnostic test exists for MS. Diagnosis is based on history, manifestations, and the presence of multiple lesions over time on MRI.
• To be diagnosed with MS, the patient must have (1) evidence of at least 2 inflammatory demyelinating lesions in at least 2 different locations within the CNS, (2) damage or an attack occurring at different times (usually 1 month or more apart), and (3) all other possible diagnoses ruled out.
• No cure is available for MS. The goal of interprofessional care is treating the disease process and providing symptomatic relief.
• Treatment begins with use of immunomodulator drugs to modify disease progression and prevent relapse. These drugs include interferon β-1a (Rebif, Avonex), interferon β-1b, and glatiramer acetate (Copaxone).
• Many other drugs are used to treat the various symptoms of MS. Spasticity is treated primarily with muscle relaxants.
• Bladder dysfunction and constipation are major problems. Open discussions about their management is essential.
• During an acute exacerbation, the patient may be immobile and confined to bed. The focus of nursing intervention at this phase is to prevent major complications of immobility.
• Patient teaching should focus on building general resistance to illness, including avoiding fatigue, extremes of heat and cold, and exposure to infection. Exercise and nutrition are valuable.
PARKINSON’S DISEASE
• Parkinson’s disease (PD) is a chronic disease of the basal ganglia characterized by increased muscle tone, tremor at rest, gait changes, and slowness in the initiation and execution of movement.
• The exact cause of PD is unknown. Researchers believe it results from the complex interplay between environmental factors and the person’s genetic makeup.
• The classic manifestations of PD include tremor, rigidity, akinesia, and postural instability (TRAP).
• Tremor can involve the hand, diaphragm, tongue, lips, and jaw.
• Rigidity is the increased resistance to passive motion when limbs go through their range of motion.
• Akinesia (bradykinesia) is evident in the loss of automatic movements, such as blinking of the eyelids, swinging of the arms while walking, swallowing saliva, and self-expression with facial and hand movements.
• Patients with postural instability may describe being unable to stop themselves from going forward (propulsion) or backward (retropulsion).
• Many non-motor symptoms are common. They include depression, anxiety, apathy, fatigue, pain, urinary retention and constipation, erectile dysfunction, and memory changes.
• Because no cure is available, interprofessional management is aimed at relieving the symptoms.
• The goal of drug therapy is to correct an imbalance of neurotransmitters within the CNS. Antiparkinson drugs either enhance the release or supply of dopamine (dopaminergic) or block the effects of the overactive cholinergic neurons in the striatum (anticholinergic).
• Surgical procedures may relieve symptoms in patients who are not responsive to drug therapy or have developed severe motor complications.
• Encourage physical exercise and promote a well-balanced diet. Direct your teaching and nursing care toward maintaining good health, encouraging independence, and avoiding complications, such as contractures.
MYASTHENIA GRAVIS
• Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction characterized by fluctuating weakness of certain skeletal muscle groups.
• Antibodies attack acetylcholine receptors (AChRs) in MG, resulting in a decreased number of AChR sites at the neuromuscular junction.
• The muscles most often affected by the fluctuating weakness are those used for moving the eyes and eyelids, chewing, swallowing, speaking, and breathing.
• The course of MG is highly variable. Some patients have short-term remissions, others stabilize, and others have severe, progressive involvement.
• Drug therapy includes anticholinesterase drugs, alternate-day corticosteroids, and immunosuppressants.
• Because the presence of the thymus gland appears to enhance the production of AChR antibodies, removal of the thymus gland results in improvement in most patients.
• Plasmapheresis and IV immunoglobin G can yield short-term improvement in symptoms.
• Myasthenic crisis is an acute exacerbation of muscle weakness triggered by infection, surgery, emotional distress, exposure to certain drugs, or beginning treatment with corticosteroids.
• The major complications of MG result from muscle weakness in areas that affect swallowing and breathing.
• The patient with MG who is admitted to the hospital usually has a respiratory tract infection or is in an acute myasthenic crisis. Nursing care is aimed at maintaining adequate ventilation, continuing drug therapy, and watching for side effects of therapy.
AMYOTROPHIC LATERAL SCLEROSIS
• Amyotrophic lateral sclerosis (ALS) is a rare progressive neurologic disorder of unknown cause. Motor neurons in the brainstem and spinal cord gradually degenerate, often leading to death within 2 to 5 years.
• Progressive muscle weakness and atrophy are the classic signs of ALS. Death often results from compromised respiratory function.
• No cure exists for ALS. Riluzole (Rilutek) and Edaravone (Radicava) may slow the progression.
• The illness trajectory for ALS is devastating because the patient remains cognitively intact while deteriorating physically.
HUNTINGTON’S DISEASE
• Huntington’s disease (HD) is a progressive, degenerative brain disorder. It is a genetically transmitted, autosomal dominant.
• The manifestations include abnormal and excessive involuntary movements (chorea). These writhing, twisting movements of the face, limbs, and body worsen as HD progresses.
• Because no cure exists, interprofessional care is palliative. Antipsychotic, antidepressant, and antichorea drugs are prescribed and have some benefit.
Dementia and Delirium
KEY POINTS
DEMENTIA
• Dementia is a syndrome characterized by dysfunction or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavior problems, such as agitation, delusions, and hallucinations, may result.
• The 2 most common causes are neurodegenerative conditions and vascular disorders. Alzheimer’s disease (AD) is the most common cause of dementia. Vascular dementia, also called multiinfarct dementia, is the loss of cognitive function resulting from brain lesions caused by cardiovascular disease.
• Depending on the cause of the dementia, the onset of symptoms may be more abrupt, or, as in the case of neurologic degeneration, insidious and gradual.
• The initial symptoms are related to changes in cognitive functioning. Patients may have memory loss, mild disorientation, and/or trouble with words and numbers.
• An important first step in the diagnosis of dementia is thorough psychologic, medical, and neurologic evaluations, including mental status testing.
• Depression is often mistaken for dementia in older adults, and, conversely, dementia for depression.
• The management of the patient with dementia is similar to that of the patient with AD.
OTHER NEURODEGENERATIVE DISEASES
• Dementia with Lewy bodies (DLB) is a condition characterized by the presence of Lewy bodies (intraneural cytoplasmic inclusions) in the brainstem and cortex. Since it has some features of Parkinson’s disease, medication therapy may help with symptoms.
• Frontotemporal lobar degeneration (FTLD) is a rare disorder caused by shrinking frontal and temporal lobes of the brain. It is characterized by changes in behavior, sleep, personality, and eventually memory. Care is supportive.
ALZHEIMER’S DISEASE
• Alzheimer’s disease (AD) is a chronic, progressive, neurodegenerative disease of the brain. It is the most common form of dementia.
• The exact cause is unknown. Like other forms of dementia, age is the most important risk factor for developing AD. Multiple genetic factors have been linked to its development.
• Characteristic findings relate to changes in the brain’s structure and function: amyloid plaques, neurofibrillary tangles, and loss of connections between cells and cell death.
Clinical Manifestations
• The stages of AD can be categorized as mild, moderate, and severe.
• An initial sign is a subtle deterioration in memory. With progression of AD, more cognitive impairments are noted, including aphasia, apraxia, visual agnosia, and dysgraphia.
Mild Cognitive Impairment
• Mild cognitive impairment (MCI) is a state of cognitive functioning that is below defined norms yet does not meet the criteria for dementia.
• The nurse caring for the patient with MCI must recognize the importance of monitoring the patient for changes in memory and thinking skills that would indicate a worsening of symptoms or a progression to dementia.
Diagnostic Studies and Interprofessional Care
• No single test can be used to diagnose AD; the diagnosis is one of exclusion.
• At this time there is no cure for AD. Interprofessional management is aimed at improving or controlling decline in cognition and controlling the undesirable behavior manifestations that the patient may have.
• Medication therapy may slow the worsening of symptoms but does not cure AD.
Nursing Management
• The diagnosis of AD is traumatic for both the patient and family. It is not unusual for the patient to have depression, denial, worry, fear, and feelings of loss and dread. The nurse is in a key position to assess for depression and suicidal ideation.
• Currently, family members and friends care for most people with AD in their homes. Others reside in various facilities, including long-term care and assisted living facilities.
• The severity of the problems and the amount of nursing care intensify over time. As AD progresses to the late stages (severe impairment), there is increased difficulty with the most basic functions, including walking and talking. Total care is needed.
• Behavior problems occur in most patients with AD. These problems include repetitiveness, delusions, hoarding, hallucinations, agitation, aggression, altered sleeping patterns, wandering, and resisting care. Nursing strategies that address difficult behavior include redirection, distraction, and reassurance.
• A specific type of agitation is termed sundowning, in which the patient becomes more confused and agitated in the late afternoon or evening. Managing sundowning is a critical nursing role and can be challenging for you, the patient with AD, and the family.
• The patient with AD is at risk for problems related to personal safety. These risks include injury from falls, injury from ingesting dangerous substances, wandering, injury to others and self with sharp objects, being burned, and being unable to respond to crisis situations.
• Wandering is a major concern for caregivers. As with other behaviors, the nurse should observe for factors or events that may precipitate wandering.
• Loss of interest in food and decreased ability to feed self, as well as co-morbid conditions, can result in significant nutritional deficiencies that must be addressed.
• During the moderate and severe stages of AD, incontinence can lead to an increased risk of urinary tract infection and the need for increased nursing care.
• AD disrupts all aspects of personal and family life. Caregivers have adverse consequences relating to their employment and to their emotional and physical health, which then results in family conflict and caregiver strain. The nurse should work with the caregiver to assess stressors and to identify coping strategies to reduce the burden of caregiving.
DELIRIUM
• Delirium is a state of confusion that develops over days to hours.
• Delirium is rarely caused by a single factor. It is often the result of the interaction of the patient’s underlying condition with a precipitating event.
• Acute delirium occurs most often in hospitalized older adults.
• Manifestations include disorganized thinking, difficulty in concentrating, and sensory misperceptions. It typically lasts from 1 to 7 days.
• Delirium can be confused with dementia. A key distinction between delirium and dementia is that the patient who has sudden cognitive impairment, disorientation, or clouded sensorium is more likely to have delirium rather than dementia.
• In caring for the patient with delirium, the roles of the nurse include prevention, early recognition, and treatment. Prevention of delirium involves recognition of high-risk patients.
• Care of the patient with delirium is focused on eliminating precipitating factors. If it is drug induced, medications are discontinued. It is important to keep in mind that delirium can accompany drug and alcohol withdrawal.
• Care of the patient with delirium includes protecting the patient from harm. Priority is given to creating a calm and safe environment.
• Comprehensive, multicomponent interventions to prevent delirium are the most effective and should be implemented through interprofessional programs.
