Infection and Inflammation

INFECTION AND INFLAMMATION

INFECTION

  • Fundamentals of Nursing, Ch. 25

  • Medical-Surgical Nursing, Ch. 31 & 66

  • Porth's Pathophysiology, Ch. 9 & 10

Definition of Infection

  • Infection: Invasion of body tissue by pathogens, which have the potential to cause illness or disease.

  • Microorganisms exist in various environments:

    • Most are harmless or beneficial.

    • If symptoms aren’t produced, the individual is considered asymptomatic.

    • Disease occurs when microorganisms alter normal tissue function.

  • Types of diseases:

    • Communicable disease: Transmissible or infectious.

    • Infectious disease: Disease caused by pathogenic agent.

Infection Cycle

  • The Infection Cycle consists of:

    • Infectious Agent: The pathogen that can cause disease.

    • Reservoir: The natural habitat of the pathogen.

    • Portal of Exit: The path by which the pathogen leaves the reservoir.

    • Means of Transmission: How the pathogen spreads from one host to another.

    • Portals of Entry: The ways through which the pathogen enters a new host.

    • Susceptible Host: An individual who can become infected.

  • The goal is to break the links in this chain to end the infection cycle.

Stages of Infection (Porth's Patho, Ch. 10)

  1. Invasion by Pathogen: Initial entry.

  2. Incubation Period: Pathogen replicates in the host without showing symptoms.

  3. Subclinical Infection: Early asymptomatic stage.

  4. Prodromal Period: Early signs and symptoms, such as fever or fatigue; most infectious stage.

  5. Illness Period: Clinical signs and symptoms are present.

  6. Convalescent Period: Signs and symptoms recede; the person returns to health.

  7. Period of Communicability: Potential for the host to spread the infection; host may become a chronic carrier of the infectious agent.

Types of Infection

  • Localized: Limited to a specific part of the body where microorganisms remain.

  • Systemic: Microorganisms spread and damage different body parts.

  • Bacteremia: Presence of bacteria in blood.

  • Septicemia: Systemic infection that arises from bacteremia.

  • Acute: Appears suddenly and lasts a short time.

  • Chronic: Develops slowly, lasting months or years.

  • Health Care-Associated Infections (HAIs): Also known as nosocomial infections.

    • Preventable; may be Exogenous (originating from outside the patient) or Endogenous (originating from inside the patient).

    • Iatrogenic: Caused by medical treatment.

Defenses Against Infection

  • Intact Skin: Acts as a barrier.

  • Normal Body Flora: Beneficial microorganisms that protect our body.

  • Inflammatory Response: Body's immediate response to pathogens.

  • Immune Response: The body’s ability to protect itself against harmful agents.

    • Antigen: Foreign material that induces an immune response.

    • Antibody: Body’s response to an antigen.

    • Increased production of WBCs to destroy harmful cells.

Risk Factors for Infection

  • Host susceptibility depends on:

    • Integrity of skin.

    • pH levels of GI and GU tracts.

    • Number of WBCs.

    • Age, sex, race, heredity.

    • Immunizations status.

    • Level of stress, general health, nutritional status, pre-existing illnesses.

    • Use of indwelling or invasive medical devices (e.g., urinary catheters, central lines, prosthetics like hip replacements).

Laboratory Data

  • WBC (Leukocyte) Count: Normal range is 5,000-10,000/mm³.

    • Increased in infections; decreased in certain blood cancers or after chemotherapy.

    • Neutrophils: 60-70% of total WBCs; increases in acute infections producing pus.

    • Lymphocytes: 20-40%; increases in chronic bacterial and viral infections.

    • Monocytes: 2-8%; increase during severe infections.

    • Eosinophils: 1-4%; increase primarily in allergic reactions or parasitic infections.

    • Basophils: 0.5-1%; usually unaffected by infections.

  • Erythrocyte Sedimentation Rate (ESR): Measures inflammation; expected values are 0-15 mm/hr (men), 0-20 mm/hr (women), 0-10 mm/hr (pediatrics).

  • Cultures: Absence of pathogens in urine, blood, sputum, or wound cultures indicates no infection.

  • C-Reactive Protein: Normal concentration <0.5 mg/dL; rises in response to inflammation.

Transmission Promotion

  • Modern medicine and public health measures have reduced prevalence of infectious diseases.

  • Challenges include:

    • Pathogen evolution: new strains and diseases.

    • Irresponsible antibiotic prescription practices.

    • Immunosuppressive therapies leading to increased susceptibility.

    • Implants/prosthetic devices serving as colonization sites.

    • Poor hand hygiene exacerbating infection spread.

Nursing Process -- Assessment

  • Subjective Data: Patient-reported symptoms.

  • Objective Data: Measurable signs observed by healthcare personnel.

  • Focus on recognizing symptoms of infection and inflammation.

Clinical Presentation: Local vs. Systemic Infection

  • Localized Symptoms:

    • Warmth, swelling, erythema (redness), drainage, pain, tenderness, restricted movement.

  • Systemic Symptoms:

    • Changes in vital signs (e.g., increased pulse and respiration rates), anorexia, malaise, fatigue, lymphadenopathy, confusion.

Case Study Example: Cellulitis

  • Cellulitis: Acute inflammation of dermis and subcutaneous tissue.

    • Usually caused by infection through skin damage (e.g., bites or wounds).

    • Symptoms include redness, edema, warmth, and pain in the affected area; can also involve MRSA.

Nursing Process – Diagnosis/Analyze/Hypothesize

  • Diagnoses related to infection:

    • Risk for Infection: Related to factors such as alteration in skin integrity or inadequate vaccinations.

    • Insufficient Knowledge: Patients may need education on practices to avoid pathogen exposure.

    • Malnutrition: Observe for signs of nutritional deficiencies that increase risk for infection.

    • Deficient Fluid Volume: Related to insufficient fluid intake, evidenced by decreased blood pressure, dry mucous membranes, elevated body temperature, and weakness.

    • Readiness for Enhanced Knowledge: Recognizing the patient’s eagerness to learn about infection prevention practices and vaccination guidelines.

Nursing Process -- Planning

  • Patient outcomes include:

    • Demonstrating effective hand hygiene and personal hygiene practices.

    • Identifying signs and symptoms of infection.

    • Maintaining adequate fluid and food intake.

    • Utilizing appropriate cleaning and disinfecting techniques.

    • Understanding the necessity of proper immunizations.

    • Adhering to infection control precautions (isolation practices, equipment handling, and visitor management).

  • Planning outcomes must be measurable with a defined completion date.

Nursing Process – Implementation

  • Hand Hygiene: The cornerstone of infection prevention.

  • Asepsis: Two types:

    • Medical Asepsis: Clean technique used to reduce the number of pathogens.

    • Surgical Asepsis: Sterile technique used to prevent any pathogen introduction.

  • Prevent transmission through strong isolation practices and proper disposal of soiled linens, equipment, and supplies.

Sterile Technique in Operating Room

  • Maintain sterile fields, sterile gloves, and sterile gowns to prevent contamination.

Means of Transmission

  • Common transmission methods include:

    • Excretions and secretions.

    • Personal contacts.

    • Equipment and supplies.

  • Transmission Barriers:

    • Hand hygiene protocols, barrier techniques, sterilization methods, decontamination processes, and proper waste disposal.

    • Use of personal protective equipment (PPE) including gloves, gowns, masks, and protective eye gear.

Disinfecting and Sterilizing

  • Disinfection and sterilization disrupt the first two links in the chain of infection (etiologic agent and reservoir).

  • Disinfectant: Kills some microorganisms, used on surfaces.

  • Antiseptic: Disinfectants safe for skin.

  • Bactericidal agent: Kills bacteria.

  • Bacteriostatic agent: Inhibits bacterial reproduction.

  • Sterilizing techniques: Include moist heat, gas, boiling water, and radiation that destroy all microorganisms.

Health Promotion and Education

  • Promote good hand hygiene, general hygiene, balanced diet, fluid intake, adequate sleep, stress management, and immunizations.

Nursing Process -- Evaluation

  • Patient goals achievement includes:

    • Correct use of medical asepsis techniques.

    • Identification of health habits and lifestyle patterns promoting health.

    • Accurate recognition of infection signs and symptoms.

    • Recognition of unsafe home environments.

DEVELOPMENTAL AND LIFESPAN CONSIDERATIONS

Infection in Newborns/Children/Adolescents

  • Majority of infections caused by viruses; usually transient.

  • Considerations:

    • Underdeveloped immune systems with natural immunity from the placenta.

    • Breastfed infants generally have higher immunity.

    • High risk of febrile seizures between ages 6 months and 5 years; emphasize hand hygiene and immunizations.

    • Adolescents at higher risk for STIs; emphasize prevention education.

Infection in Older Adults

  • Emphasize early recognition and treatment.

  • Factors contributing to infection risk include:

    • Poor nutrition, lack of vitamins and minerals, dehydration.

    • Diabetes increasing risk of infection and impeding healing.

    • Slow immune response and delayed inflammatory response.

    • Atypical inflammatory responses may manifest as confusion instead of typical signs (redness, swelling, fever).

Additional Factors for Increased Infection Susceptibility in Older Adults

  • Cardiovascular, respiratory, urological, gastrointestinal, and skin changes.

  • Immune system changes affecting disease defense.

  • Decreased activity, chronic diseases, and polypharmacy further raise infection risk.

  • Presence of invasive devices may act as another risk factor.

INFLAMMATION

Inflammatory Process

  • The primary role of inflammation is to protect the body by isolating damaged areas and promoting tissue repair.

  • Acute Inflammation: Occurs rapidly within minutes. Symptoms include redness, swelling, pain, heat, and impaired function; continues until trauma is neutralized.

  • Chronic Inflammation: Persists due to the acute response being ineffective; lasts for months or years, caused by factors like autoimmune diseases or seasonal allergies.

Causes of Inflammation

  • Immune responses triggered by:

    • Infectious microorganisms.

    • Trauma or injury.

    • Surgical procedures.

    • Exposure to caustic chemicals.

    • Extreme temperatures (heat or cold).

    • Ischemic damage to body tissues.

Stages of Inflammation

  1. Stage 1: Vascular and Cellular Responses

    • Blood vessels at the injury site constrict temporarily.

    • Injured tissue releases histamines, kinins, prostaglandins leading to increased vascular permeability and vasodilation (redness, heat).

    • Neutrophils are the first WBCs to arrive; leukocytosis occurs.

  2. Stage 2: Exudate Production

    • Fluid (exudate) escapes from blood vessels, containing dead phagocytic and tissue cells.

    • Can be classified as:

      • Serous: Clear fluid.

      • Purulent: Pus-producing.

      • Hemorrhagic: Bloody.

  3. Stage 3: Repair

    • Regeneration of new cells that are identical or similar to the original.

    • Architectural pattern and function of tissue restored; may involve granulation tissue leading to scar formation (cicatrix).

Manifestations of Inflammation

  • Classic signs of inflammation include:

    • Redness: Due to increased blood flow.

    • Swelling: Result of fluid accumulation.

    • Heat: Due to increased blood flow.

    • Pain/Tenderness: Result of chemical mediators affecting surrounding tissues.

  • Healthy inflammatory response activates and recruits WBCs to affected sites, presenting either localized or generalized symptoms.

  • Chronic inflammation can lead to ongoing symptoms affecting overall health.

Laboratory Diagnostics

  • Similar tests as infection diagnosis including:

    • WBC count to assess inflammation or infection.

    • Neutrophils as primary phagocytes responding to infection.

    • Erythrocyte Sedimentation Rate (ESR): Used to assess the level of inflammation.

    • Exudate Cultures: Used in wound assessments.

Nursing Process -- Assessment

  • Recognizing cues related to inflammation is vital:

    • Assessment guided by the area affected.

    • Observation and patient interviews help gather subjective reports.

    • Need to assess degree of inflammation and any systemic symptoms involved.

Nursing Process -- Diagnosis

  • Possible diagnoses include:

    • Acute Pain related to inflammation.

    • Impaired Skin Integrity.

    • Ineffective Tissue Perfusion.

    • Risk for Infection.

    • Ineffective Coping.

    • Deficient Knowledge.

Nursing Process -- Planning

  • Plan to reduce inflammatory symptoms:

    • Promote comfort and reduced pain levels.

    • Educate patients on the disease process and medications.

    • Maintain adequate tissue perfusion.

    • Aim for no further impairments or deterioration.

Nursing Process – Implementation

  • Treatment may necessitate addressing:

    • Pain, edema, heat, impaired function, infection.

  • If inflammation is severe, surgery may be required.

  • Pharmacologic therapy may assist in reducing inflammatory responses and related pain.

  • Educate patients on:

    • Prevention of further injuries.

    • Importance of adhering to prescribed medications.

    • Nutrition and hydration.

Nursing Process -- Evaluation

  • Evaluate if patient goals are met:

    • Pain at tolerable levels.

    • No signs of tissue damage or impairment.

    • Noticeable reduction or absence of inflammation.

HEALTH CARE ASSOCIATED INFECTIONS (HAIs)

  • Refer to Med-Surg, Ch. 71, Fundamentals, Ch. 25, pg. 610, & Lippincott Advisor.

Vancomycin-Resistant Enterococci (VRE)

  • Transmission: Direct person-to-person contact and indirect contact (e.g., bed rails, tables).

  • Contact Precautions: Require gloves and gown use.

  • Treatment involves Chlorhexidine baths, strict hand hygiene, use of disposable equipment, and private rooms.

  • Risk Factors: Include history of antimicrobials treatment, being older, being immunocompromised, having indwelling catheters, prolonged hospital admissions, changes due to surgery, or having open wounds.

  • Symptoms: Patients may experience chills, fever, malaise, and tachycardia.

  • Treatment: May involve a probiotic diet and antimicrobials like Daptomycin or Linezolid; monitoring includes vital signs and fluid balance.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

  • Transmission: Primarily through direct person-to-person contact.

  • Contact Precautions: Include gown and gloves; imperative hand hygiene and disposal protocols.

  • Risk Factors: Occurs more than 48 hours post-admission, recent antibiotic therapy, skin trauma, residing in LTC, exposure to infected patients, and healthcare workers.

  • Symptoms: Fever, malaise, skin symptoms like erythema, painful bullae, and warm, purulent wounds.

  • Treatment: Focus on a high protein diet and antimicrobials such as sulfonamides or doxycycline, with potential need for incision and drainage. It is crucial to monitor vitals, wound culture, wound appearance, and watch for drug reactions.

Clostridium Difficile

  • Risk Factors: Primarily affects hospitalized patients receiving multiple antibiotics, with older patients being particularly vulnerable.

    • Precautions: Enforced contact precautions (gowns and gloves) and strict handwashing with soap and water (no alcohol rubs).

  • Transmission: Direct contact with patients and contaminated items; spores resistant to alcohol are frequently transmitted via surfaces touched by fecal material.

    • Cleaning Protocols: Use bleach cleaning products to eliminate spores effectively.

  • Symptoms: Include watery diarrhea (3+ episodes persisting for 2 or more days), abdominal cramping, smelly stools, fever, and electrolyte imbalances indicative of dehydration.

  • Treatment: Involves IV fluids, electrolyte replacement, ample peri-care, and metronidazole or Vancomycin administration, with careful I&O monitoring; strategies to reduce transmission may include private rooms and educator involvement.

Pharmacology Notes

  • Anti-infective Activity: Anti-infectives vary in their efficacy against invading organisms, categorized as either bactericidal (kill the organism) or bacteriostatic (prevent reproduction).

  • Drug Spectrum:

    • Narrow Spectrum: Effective against fewer microorganisms with specific metabolic pathways.

    • Broad Spectrum: Effective against a wide range of infections.

Prototype Drugs

  • Aminoglycosides: Gentamicin (Gentamycin).

  • Cephalosporins: Cefaclor.

  • Fluoroquinolones: Ciprofloxacin.

  • Penicillins: Amoxicillin.

  • Sulfonamides: Cotrimoxazole.

  • Tetracyclines: Tetracycline.

  • Anti-infectives: Vancomycin.

  • NSAIDs: Ibuprofen.

  • COX-2 Inhibitor: Celecoxib.

  • Related Medications: Acetaminophen.

  • Corticosteroids/Glucocorticoids: Prednisone.

  • Urinary Tract Analgesic: Phenazopyridine.

Acetaminophen (Tylenol)

  • Uses: Antipyretic and analgesic effects; inhibits synthesis of prostaglandins primarily in the CNS.

  • Contraindications: Alcohol consumption may complicate hepatotoxicity; doses above 2 g increase bleeding risk/liver failure.

Cox-2 Inhibitors

  • Use: Anti-inflammatory and pain relief.

  • Cautions: Hypersensitivity to sulfonamides or aspirin; administer with meals to prevent GI distress; monitor liver and renal functions.

Corticosteroids/Glucocorticoids

  • Use: Provide anti-inflammatory effects, suppress immune response, and influence carbohydrate/protein/lipid metabolism.

  • Cautions: Not advisable for patients with certain comorbidities; potential for slow wound healing; tapering off required due to potential withdrawal effects.

Other Drug Types

  • NSAIDs: Provide anti-inflammatory effects; caution with renal/hepatic disease; increased bleeding risk.

  • Fluoroquinolones: Mainly used for severe bacterial infections, not recommended for children <18 due to risk of tendon damage.

  • Penicillins and Cephalosporins: Inhibit bacterial cell wall synthesis; observe for allergies and interactions.

  • Vancomycin: Used for antibiotic-associated infections, requires monitoring of renal function and drug levels to prevent toxicity.

  • Aminoglycosides and Tetracyclines: Administered for specific infections with careful monitoring required for adverse effects, especially in sensitive populations.

Preventing Resistance

  • Limit the usage of antimicrobial agents to target specific pathogen infections, maintain adequate dosing and duration of therapy, and discourage indiscriminate use.

Tips for Studying Drugs

  • Engage with PrepU questions for practice by Karch book chapter.

  • Utilize Kaplan flashcards and maintain a drug sheet for each drug and drug class.

  • Focus on understanding notable side effects or adverse reactions; prepare particularly for recognition of generic names as they are emphasized in exams like NCLEX.

  • Identify distinct characteristics for each drug and its mechanism of action to aid retention and application in clinical contexts.