Transcript General Medical Emergencies: Part I

General Medical
Emergencies:
Part I
Major Topics
Communicable / Infectious Diseases
 HIV Infection and AIDS
 Diphtheria
 Encephalitis
 Hepatitis
 Herpes: Disseminated
 Measles
 Meningitis
 Mononucleosis
 Mumps
 Pertussis
 Shingles (Herpes Zoster)
 Tuberculosis
 Varicella (Chickenpox)
Major Topics
Skin Infestations
 Lice
 Scabies
 Myiasis
Major Topics
Endocrine Emergencies
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Adrenal Crisis
Diabetic Ketoacidosis
Hyperglycemic Hyperosmolar Nonketotic Coma
Hyperglycemia
Myxedema Coma
Thyroid Storm
HIV Infection and AIDS
Caused by a retrovirus
Viral symptoms start 2-6 weeks
Antibody seroconversion takes
place within 45 days - 6 months
Asymptomatic period for months
to years
 Replication, mutation, and destroying the immune system
HIV Infection and AIDS
Persistent generalized lymphadenopathy
occurs
Constitutional disorders, neurological
disorders, secondary infections, secondary
cancers, and pneumonitis
HIV Infection and AIDS
 All HIV infections will develop into AIDS
Mean between exposure to HIV to
AIDS-10 years
AIDS to death
Sooner the treatment, better long-term
survival
HIV Infection and AIDS Assessment
 Subjective data
 History of present illness
 Generalized lymphadenopathy,
persistent
 Fever for longer than 1 month
 Episodic spiking
 Persistent low-grade fever
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Diarrhea for longer than 1 month
Weight loss
Anorexia
Night Sweats
HIV Infection and AIDS
Assessment
 Malaise or fatigue, arthralgias, myalgias
 Mild opportunistic infections
1. Oral candidiasis
2. Herpes Zoster
3. Tinea
 Skin lesions, rashes
 Cough
 Broad range of neurological complaints, both
focal and global, including dementia
HIV Infection and AIDS Assessment
Current medications
1.Antiretroviral agents: zidovudine (AZT),
zalcitabine (ddC), didanosine (ddI), stavudine
(d4T), lamivudine (3TC), nevirapine,
delavirdine
2. Pneumocystis prophylaxis: trimethoprimsulfamethoxazole, pentamidine, dapsone
3.Protease inhibitors: indinavir, saquinavir
mesylate, nelfinavir, ritonavir
HIV Infection and AIDS
Assessment
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Medical History
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Blood transfusions, especially before 1985
Hemophilia
Occupational needle sticks or blood exposure
Sexually transmitted diseases (STD’s)
Tissue transplantation
Infant with HIV-positive mother
Sexual contact with IV drug user
Sexual contact with HIV-positive partner
Sexual practices including multiple partners, anal sex,
oral-anal sex, or fisting
 Recent TB exposure
HIV infection and AIDS
 Physical examination
 Chronically ill appearance  Wasting syndrome;
signs of volume
 Kaposi’s sarcoma skin
depletion
lesions
 Withdrawn,
 Chest: crackles and
irritable, apathetic,
wheezes
depressed
 Dyspnea
 Slow, unsteady
gait; weakness;
 Abnormal vital signs
poor coordination
 Lymphadenopathy
 Dementia
HIV Infection and AIDS
Diagnostic procedures
CXR
CBC
Anemia
Lymphopenia
Thrombocytopenia
ABG’s
Electrolytes, liver function tests
HIV Infection and AIDS Assessment
Determination of HIV antibodies (e.g., via
enzyme-linked immunosorbent assay
[ELISA] and Western blot analysis)
decreased CD4 cell count
blood cultures
urinalysis
TB skin test (5 mm is positive in HIV infected
person)
Diphtheria
 Alteration in neurological functions
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Lethargy
Withdrawal
Confusion
Cranial nerve neuropathies
 Alteration in cardiac functions
 ST-and T-wave changes
 First-degree heart block
 Dyspnea, heart failure, circulatory collapse
 Anxiety
Diphtheria
Diagnostic procedures
Throat culture: specimen swabbed
from beneath membrane or piece
of membrane
Notify lab that C. diphtheria is
suspected: requires special media
and handling
Diphtheria
Interventions
Provide strict respiratory isolation
Maintain airway, breathing, circulation
Monitor vital signs and pulse ox
Assemble emergency cricothyrotomy
equipment at bedside
Administer O2 for dyspnea or cyanosis
Establish IV catheter for administration
of IV fluids
Diphtheria
Interventions
Diphtheria antitoxin
Equine serum
Test for sensitivity
(intradermal or mucous
membrane) before administration
Often administered before diagnosis is
confirmed because of virulence of
disease
Diphtheria
Antibiotic: EES or PCN G
Antitussive
Antipyretic
Topical anesthetic agent
Minimize environmental stimuli
Instruct patient on importance of
complete bed rest
Diphtheria
Provide immunization
Regular booster Q10years, combined
with TD, after completion of initial series
of 3 doses
Identify close contacts
Culture and prophylactic Booster of TD in
none within 5 years
Antibiotics
Active immunization for nonimmunized
persons (series of 3 doses)
Encephalitis
Viral infection of the brain
Often coexists with meningitis and has
broad range of S&S
Most cases in North America, caused by arboviruses,
herpes simplex I, varicella-zoster, EB, and rabies
Transmission by animal bites, or seasonally form
vectors (mosquitoes, ticks, and midges)
More common human viruses are airborne via droplet
or lesion exudate
All age groups, with mortality from 5-10% from
arboviruses and 100% for rabies
Encephalitis
Assessment
Subjective
History of present illness
Photophobia
Recent viral illness or herpesNausea, vomiting
zoster
Confusion,
Recent animal or tick bite
lethargy, coma
New psychiatric
Travel to endemic area,
symptoms
season of the year
Fever
Headache
Encephalitis
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Assessment
• Subjective
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Medical history
• Immune disorders
• Allergies
• Medications
Encephalitis
Objective data
Physical exam
 Altered LOC
 Rash specific to cause
 Meningism
 Altered reflexes
 Focal neurological findings
 Abnormal movements
 Seizures
Encephalitis
 Diagnostic Procedures
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Lumbar puncture, CT scan
CBC
Blood cultures
Serology
Encephalitis
Interventions
Institute standard precautions and isolation
until causative agent identified
Monitor airway, breathing, circulation
Monitor vital signs and pulse oximeter
Administer O2
Prepare to assist with intubation
Insert large bore IV catheter, and administer
isotonic solutions as ordered
Administer medications as ordered
Encephalitis
Administer antimicrobial/antiviral
agents, steroids
Monitor blood sugar and electrolytes
Insert urinary catheter PRN
Monitor I&O, cerebral edema, keep
HOB >30 degrees
Institute seizure precautions
Elevate HOB 30 degrees
Encephalitis
Restrict IV fluids
Keep body temperature normal
Administer diuretics as ordered
Explain procedures and disease to
family/patient
Allow patient/significant others to verbalize
fears
Prepare patient/family for admission to
hospital
Hepatitis
 Viral syndrome involving hepatic triad (bile duct, hepatic venule,
and arteriole, and central vein area.
 Hep A-fecal-oral route, infectious for 2 weeks before and 1 week
after jaundice
 Hep B-(HBV)blood and sexual contact and consists of 3 antigens
Hep B surface
Hepatitis
 Hep B-(HBV) blood and sexual contact
 3 antigens
 Hep B antigens
 Persistence of core antibody indicates chronic infection
 Persistence of surface antibody indicates immunity to reinfection
 Hep B surface antigen in the serum without symptoms is indicative of a carrier
state
Hepatitis
 Hep C identified by antihepatitis C virus antibody
 50% of Hep C become chronic, and no immunity is developed
 Hep C 90% of hepatitis cases transmitted by
blood transfusion
Hepatitis
Hep E is an epidemic, enterically
transmitted infection from shellfish and
contaminated water
Hep D found with acute or chronic HBV
infection
Chronic infections result in cirrhosis
and liver cancer
Hepatitis
 Assessment
History of present illness
Prodrome: preicteric phase, occurs 1 week
before jaundice
Low-grade fever
Malaise: earliest,
most common symptom
Arthralgias
Headache
Pharyngitis
Nausea, vomiting
Hepatitis
History of Illness cont’d
Rash, with type B usually
May or may not progress to icteric phase
Incubation:
A 15-45 days
B 30-180 days
C 15-150 days
Duration:
A 4 weeks;
B AND C 8 weeks
Hepatitis
Icteric phase
Disappearance of other symptoms
Anorexia
Abdominal pain
Dark urine
Pruritus
Jaundice
Hepatitis cont’d
Medical History
 Immunizations
 ETOH consumption
 Allergies
 Medications: all are significant
 Blood transfusions, IV drug use, Hemophilia or
dialysis
 Chronic medical problems, travel, living in
institution
 Living in recent floods or natural disasters
Hepatitis
Objective data
Physical exam
Posterior cervical lymph node enlargement
Enlarged, tender liver
Splenomegaly in 20%
Jaundice
Vital signs: may have tachycardia, hypotension
Fever
Hepatitis
Diagnostics
Liver enzymes: SGOT & SGPT elevated
Direct and indirect bilirubin levels: elevated
Alkaline phosphatase : elevated
Differential leukocyte count: leukopenia
with lymphocytosis, atypical lymphocytes
CBC, UA: elevated bilirubin, PT: elevated,
ABD X-ray
Antigen and/or antibody titers
Hepatitis
Interventions
 Provide increased calories
 Monitor for signs of dehydration, replacement with
isotonic solution
 Record I&O
 Assess support systems of patients
 Hospitalize if unable to care for self or PT >15 seconds
Hepatitis
 Initiate prophylaxis
 Type A
 Immune serum globulin 80-90% effective if 7-14 days after exposure
 Vaccine administered in two doses: given to high-risk population: foreign travel,
endemic areas (e.g. Alaska), military, immunocompromised or risk for HIV, chronic
liver disease, hep C
 Type B: hepatitis B immune globulin plus vaccination, for exposure to serum,
saliva, semen, vaginal secretions, breast milk
Hepatitis
Initiate prophylaxis
 Type B: vaccination with HBV vaccine inactivated (Recombivax
HB)
 Vaccinate high-risk persons
 Health care and public safety workers, clients and staff at
institutions
 Hemodialysis patients, recipients of clotting factors
 Household contacts and sexual partners of HBV carriers
 Adoptees from countries where HBV in endemic: Pacific
Islands and Asia
 IV Drug users, sexually active homosexual and bisexual
men
 Sexually active men and women with multiple partners
 Inmates of long-term correctional facilities
Hepatitis
Vaccinate all infants (universally)
regardless of hepatitis B surface antigen
status of mother (administer first dose in
newborn period, preferably before leaving
hospital)
Report to appropriate health
departments
Limit exposure of medical personnel to
blood, secretions, and feces
Hepatitis
Instruct patient/significant others
Strict hygiene, private bathroom if possible
Diet of small, frequent feedings low in fat, high in
carbs, patient should avoid handling food to be
consumed by others
S&S: bleeding, vomiting, increased pain
Take meds as prescribed
Avoid intake of alcohol
Take meds only if necessary
Avoid steroids: they delay long-term healing
Herpes: Disseminated
Herpes simplex virus (HSV)
is a relatively benign disease when cutaneous
 Can invade all body systems and lead to death
 Primary viremia occurs from spill-over of the virus at the
site of entry
 During the second stage, HSV disappears from he blood
but grows within cells of infected organs, which in turn
causes seeding to other organ systems.
 Dissemination occurs in susceptible persons: newborns,
malnourished children, children with measles, people
with skin disorders, such as burns, eczema,
immunosuppression, and immunodeficiency, especially
HIV
Herpes: Disseminated
 HSV has a predilection for temporal lobe.
 Encephalitis most common
 70% mortality rate without treatment
 50% with treatment residual neurological deficits
 Latency period within sensory nerve resulting in mild or life-threatening
infection years later
Herpes
Assessment
Subjective data
History of present illness
Onset: usually acute
After other illness
After outbreak of cutaneous infection
After any stressor
Herpes
Assessment
Subjective data
History of present illness
Symptoms depend on organ system affected
Neurological system: headache, confusion,
seizures, coma, olfactory hallucinations
Liver: ABD pain, vomiting
Lung: cough, fever
Esophagus: dysphagia, substantial pain,
weight loss
Herpes
Medical history
HSV infection
Chronic illness, cancer, HIV
Medications: immunosuppressants
Allergies
Herpes
 Objective data
• Physical exam
Fever
 Other vital sign
abnormalities depend on
organ system involved
 Focal neurological signs
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• Anosmia (loss of smell)
• Aphasia
• Temporal lobe seizures
• Confusion, somnolence,
coma
Respiratory
crackles
Herpes
Diagnostic Procedures
Viral cultures: blood and skin
Lumbar puncture: cerebrospinal fluid for
culture
Biopsy of target organ, especially brain
Clotting studies for DIC
Liver Function
CBC
Herpes
 Interventions
Prepare to assist
intubation
O2 PRN
Monitor
VS with PO
Neurological status
Maintain airway,
breathing, circulation
I&O
Administer Antiviral
meds
FC PRN
Establish IV of isotonic
solution at rate to maintain
blood pressure and fluid
balance
Protect from injury from
seizures
Explain procedures and
illness to patient or
significant others
Practice standard
precautions
Measles
 Highly acute and contagious virus
 Caused by rubeola virus, late winter and early spring
 Airborne droplets, incubation 10-14 days
 Contagious few days before and after onset of rash
 Most recover, incidence of OM, diarrhea, pneumonia, and encephalitis
Measles
 More serious in infants and in malnourished children, pregnancy
with preterm delivery and spontaneous abortion
 Most born <1957 are permanently immune
 Vaccine (MMR) 12-15 months, active disease or two
immunizations in childhood
 Booster elementary school, all
high school or
college
revaccinated unless active
disease or two immunizations
Measles
 Assessment
 Subjective data
 History of present illness
 Exposure to measles
 Prodrome
 Fever
 Cough
 Coryza (nasal mucosal inflammation)
 Photophobia
 Anorexia
 Headache
 Rarely seizures
Measles
Subjective
Medical history
Immunizations
History of measles
Current age: born before
1957
Allergies
Medications
Measles
Objective data
Physical exam
Fever
Koplik’s spots on buccal mucosa
(bluish-gray specks on red base)
Conjunctivitis
Harsh cough
Measles
Red, blotchy rash
 Appears on third to seventh day
 Maculopapular, then becomes confluent as
progresses
 Starts on face, then generalized to the extremities
 Mild desquamation
 Lasts 4-7 days
Vital signs: normal, except fever
Neurological system: may have altered LOC,
encephalitis
Respiratory system: may have OM,
pneumonia
Measles
Diagnostic procedures
Viral cultures (expensive and difficult, so not
usually done)
Immunoglobulin M antibodies: measles
specific
CBC: leukopenia
Other studies if seriously ill
Measles
Interventions
 Provide respiratory isolation
 Isolate patient/significant others from other people in
waiting room
 Advise patient to avoid school, day care centers, and
people outside immediate family until after contagious
period
 Initiate immunization of high-risk contacts
 Live vaccine if given within 72 hours of exposure (use monovalent vaccine if infants
younger than 12 months; need reimmunization at 15 months with MMR)
 Immune globulin up to 6 days after exposure
 Immunocompromised persons should receive immune globulin even if previously
immunized
Measles
 Encourage rest in darkened room
 Administer acetaminophen for fever
 Encourage parents to have children immunized at appropriate times
 Instruct patient/parent about S&S of serious illness or complications
Persistent fever or cough
Change in mental status
or seizures
Difficulty in hearing
Meningitis
Bacterial or viral of the pia and arachnoid meniges
Late winter or early spring
Viral mild and short lived
Bacterial severe and life threatening
Streptococcus pneumoniae, Haemophilus
influenzae (H. flu), and Neisseria meningitidis
subgroups A, B, and C
H. Flu incidence decreased because of vaccination
Bacteria can enter the blood, basilar skull fracture,
infected facial structures, and brain abscesses
Meningitis
Bacteria initially colonize in the nasopharynx
In bacterial disease, the subarachnoid space is
filled with pus, which obstruct CSF, resulting in
hydocephalus and increased ICP
Infants and elderly often do not exhibit classic signs
of meningeal irritation and fever
Death most common within a few hours after
diagnosis
Up to 33% of pediatric survivors left with some type
of permanent neurological dysfunction
Any infant younger that 2 months with a fever, must
be evaluated for meningitis
Meningitis
Assessment
Subjective data
 History of present illness
 Antecedent illness or
exposure
 Onset: sudden
 Headache, especially
occipital
 Fever and chills
 Anorexia or poor feeding
 Vomiting and diarrhea
 Malaise, weakness
 Neck and back pain
 Restlessness, lethargy,
altered mental status
 Disinclination to be held:
infants
 Seizures
 Recent basilar skull
fracture
Meningitis
Medical history
Medications
Allergies
Immunizations if child
Chronic disease: liver or renal, DM,
multiple myeloma, alcoholism, malnutrition
Asplenic
Recurrent sinusitis, pneumonia, OM,
mastoiditis
Meningitis
Objective data
Physical examination
 High-pitched cry in infants
 Hyperthermia >101 or hypothermia <96
 Petechiae that do not blanch: 1-2 mm on trunk
and lower portion of body, also mouth,
palpebral and ocular conjunctiva
 Purpura
 Cyanosis, mottled skin, and pallor
Meningitis
 Objective data
 Physical examination
 Vital signs
 Tachycardia, hypotension, tachypnea
 Bradycardia in neonates
 Meningeal irritation: persons older than 12 months, seen
in about 50%
 Contraction and pain of hamstring muscles occur after
flexion and extension of leg: Kernig’s sign
 Bending of neck produces flexion of knee and hip;
passive flexion of lower limb on one side produces
similar movement on other side: Brudzinski’s sign
 Nuccal rigidity
Meningitis
 Infants with meningeal irritation cry when held and are more quiet when left in
crib
 Photophobia
 Focal neurological signs, cranial nerve palsies, and generalized hyperreflexia
 Altered mental status
 Confusion, delirium, decreased LOC
 Lethargy and confusion may be only
signs in elderly
 Bulging fontanelle
 Irritability
Meningitis
Diagnostic procedures
Blood glucose levels: infants younger than
6 months are prone to hypoglycemia
Electrolyte levels: hyponatremia
BUN and creatinine levels
Serum osmolality
Low because of inappropriate vasopressin
secretion
High because of dehydration
Meningitis
Diagnostic procedures
CBC
 Bacterial: high WBC
 Viral: normal or low WBC
 Meningococcal: WBC tends to
Blood cultures
ABG’s if severely ill
Clotting studies
UA
CXR and skull radiographs
be less that 10,000
Meningitis
 Lumbar puncture: CSF
 Bacterial infection: cloudy
appearance; elevated pressure;
WBC 200-20,000 with increased
polymorphonuclear cells; glucose
level decreased; protein level
elevated; bacteria present on
Gram’s stain
 Viral infection: clear
appearance; WBC <500; normal
pressure; glucose level normal; no
bacteria present on Gram’s stain
Meningitis
 Interventions
 Ensure that health care providers wear masks if infection with
meningococcus is suspected
 Undress patient completely to check for petechiae
 O2 PRN
 Monitor VS
 Prepare to suction and assist with aggressive ventilatory support
as needed
 Prepare to assist with LP
 Insert NG to prevent aspiration
Meningitis
 Establish IV catheter, IO in necessary
 Monitor IV fluids as related to I&O or excessive secretion of
antidiuretic hormone
 KCL replacement PRN, antiemtics PRN
 Infuse antibiotics (usually ampicillin, aminoglycosides,
cephalosporins)
 Administer benzodiazepines, corticosteroids
 Control fever
 Reduce ICP
 Use hyperventilation with caution to avoid cerebral
ischemia
 Elevate HOB 30 degrees
 Administer barbiturates and diuretics
Meningitis
Insert FC, monitor I&O
Monitor for signs of dehydration or fluid excess
Monitor mental status and neurological signs every
15 minutes to 1 hour, depending on patient’s
stability
 May need to restrain confuse patient
 Protect seizing patient form physical harm
Explain procedures and need for ICU
Meningitis
Administer chemprophylaxis(rifampin, ceftriaxone)
within 24 hours of disease identification to household
contacts, day care center contacts, and health care
providers if bacterial disease
 Side effects GI, lethargy, ataxia, chills, fever, and red-orange
urine, feces, sputum, tears, and sweat
 Soft contact lenses may be permanently stained with rifampin
use
 Medication may need to be taken with food for GI intolerance,
although it is best absorbed on empty stomach
 Birth control pills may not work
 Do not give to pregnant women
Meningitis
 Educate parents to have infants immunized against H. Flu B
beginning at 2 months
Mononucleosis
Acute viral illness with broad range of S&S lasting 2-3
weeks, very contagious
EBV transmitted in saliva
 About 50% of the population serovonverts to EBV before 5
years of age with sublclinical infection or mild illness
 Another wave of seroconversion in med adolescence
 Peak 15-24-years
Incubation 2-5 weeks
CMV is the other most frequent causative agent
Complications include: glomerulonephritis, autoimmune
hemolytic anemia, pericarditis, hepatitis, guillain-Barre
syndrome, meningitis, and pneumonia
Mononucleosis
Rarely death may occur from splenic
rupture or airway obstruction as a result
of tonsillar hypertrophy
Assessment
Subjective data
History of present illness
Prodrome lasting 3-5 days: malaise, anorexia,
nausea and vomiting, chills/diaphoresis, distaste
for cigarettes, headache, myalgias
Mononucleosis
History of present illness
Subsequent development of fever 100.4 to
104 lasting 10-14 days, sore
throat,diarrhea, earache
Medical history
Exposure to mononucleosis,
usually not known
Allergies
Medications
Mononucleosis
 Objective data
 Physical examination
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May appear acutely ill
Red throat with exudate; tonsils may be hypertrophied
Tender lymphadenopathy, particularly posterior cervical
Petechiae on palate
Fine red macular rash 5% of adults: if given ampicillin, 90-100% of patients will
experience rash
 Abdominal tenderness with heptomegaly
 Splenomegaly in 50% of patients
Mononucleosis
 Diagnostic procedures
 Heterophile antibody titer (Monospot): positive by second week of illness; may
remain negative in children younger than 5 years
 Throat culture to rule out group A streptococcus
 CBC: neutropenia, thrombocytopenia, lymphocytosis with atypical lymphs,
leukocytosis
 Liver functions: may be abnormal
 CXR if pneumonia suspected
Mononucleosis
Interventions
Isolation not necessary
Avoid kissing
No sharing eating or drinking utensils
Activity as tolerated
Extra rest early in illness
Avoid heavy lifting and contact sports for at
least 4 weeks if splenomegaly present
Mononucleosis
Interventions
Administer antipyretics, analgesics
(Avoid ASA)
Administer corticosteroids therapy for
severe Pharyngitis, evolving airway
obstruction, chronic or disabling
symptoms, or profound splenomegaly
Mononucleosis
Warm salt water gargles for sore
throat
Encourage fluids to avoid
dehydration
Diet as tolerated
Liquids initially
Soft foods
Do not donate blood for 6 months
Mononucleosis
Instruct patient about S&S of serious
illness or complications
Increased fever
Cough, chest pain
Progression of innless
Difficulty breathing
Signs of dehydration
Increasing abdominal pain
Mumps
 Acute, usually benign, viral infection caused by
Paramyxoviridae family
 Swelling and tenderness of salivary glands and one or
both parotid glands
 Direct contact, droplet nuclei, or fomites
 Incubation averages 16-18 days
 Peak incidence is January to May
 Most contagious just before swelling
 More severe illness in the post pubertal age group; 2030% of adult men experience epididymoorchitis
 Complications include viral meningitis, arthritis,
arthralgias, and pancreatitis
Mumps
 Assessment
 Subjective data
 History of present illness
 Exposure to mumps
 Prodrome: fever (<104), anorexia, malaise, headache
 Earache and tenderness of ipsilateral parotid gland
 Citrus fruits or juices increase pain
 Fever, chills, headache, vomiting if meningitis
 Testicular pain if orchitis
 Abdominal pain if pancreatitis
Mumps
Subjective cont’d
Medical history
Childhood immunizations
Previous mumps
Allergies
Medications
Mumps
 Objective data
 Physical examination
 Swelling of gland, maximal over 2-3 days, with earlobe lifted up and
out and mandible obscured by swelling
 Trismus with difficulty in pronunciation and chewing
 Testicle warm, swollen, tender
 Scrotal redness
Mumps
Diagnostic procedures
CBC: WBC and differential
normal or mild leukopenia
Serum amylase elevated
for 2-3 weeks
Mumps
Interventions
 Provide respiratory isolation
 Advise to avoid school/work until swelling gone
 Administer analgesics
 Encourage rest until feeling better
 Encourage fluids, avoid citrus
 Warm or cold packs
 For orchitis




Bed rest
Scrotal elevation
Ice packs
Pain meds
Mumps
 Administer IV fluids for acutely ill patients
 Recommend immunization to family and health workers who
have no mumps antibodies
Pertussis
Acute, widespread, highly contagious bacterial
disease of the throat and bronchi
Gram-negative Coccobacillus Bordetella Pertussis
Airborne droplets
Most common children <4 years
Females higher incidence of morbidity and mortality
Partially immunized children have less severe
illness
Adults have only minor respiratory symptoms and
persistent cough, majority unrecognized
Pertussis
 Vaccine immunity is <12 years, most adults are not
protected
 Incubation period 7-10 days but can vary 6-21
 Peak incidence is during late summer and early fall
 Pertussis bacteria invade the mucosa of URT
 Complications include: pneumonia,
pneumothorax, seizures, and encephalitis
 Children also frequently experience laceration of
the lingual fremulum and epistaxis
Pertussis
 Assessment
 Subjective data
 History of present illness
 Exposure to pertussis
 Three stages: last up to 2 weeks
 Conjuctivitis and tearing
 Fever/chills
 Rhinorrhea, sneezing
 Irritability
 Fatigue
 Dry nonproductive cough, often worse at night
Pertussis
 Paroxysmal: lasts 2-4 weeks
 Severe cough with hypoxia, unremitting paroxysms, and clear, tenacious
mucous; patient appears well between paroxysims of coughing; cough
often triggered by eating and drinking
 Apnea can occur in rate cases
 Vomiting follows cough
 Anorexia
 Convalescent: residual cough
Pertussis
Medical history
Recent illness or infection
Medications
Allergies
Immunization status
Pertussis
Objective data
Physical exam
Paroxysmal explosive coughing ending in prolonged
high-pitched crowing inspiration
Coryza
Clear, tenacious mucous in large amounts
Temperature >101
Restlessness
Crepitus from subcutaneous emphysema
Periobital/eyelid edema
Pertussis
Diagnostic procedures
C&S testing of nasopharynx using
calcium alginate dacron-tip swab
Immunofluorescent antibody staining
of nasopharyngeal specimens
CBC with differential leukocyte
count: lymphocytosis
Pertussis
 Interventions





Maintain respiratory isolation
Monitor vital signs and respiratory status
Be prepared to assist with intubation
O2 PRN
Isolate patients with active disease from school or work until they
have taken antibiotics for 14 days
 Monitor for signs of dehydration or nutritional deficiency
secondary to vomiting
Pertussis
Administer prescribed medication
Antibiotic: EES
Antitussive
Analgesic
Antipyretic
Position comfortably
Pertussis
Admit patients younger than 1 year: prepare for
nasotracheal suctioning
Initiate immunization
 Educate parents about importance of complete immunization
 Household and other contacts <1year: prophylactic EED
 Household and close contacts ages 1-7 years who had less than four DTP
vaccine doses or more that 3 years since:
 EES for 14 days
 DTP immunization
Pertussis
Review S&S that necessitate return to
ER
Difficulty in breathing recurs or worsens
Blue color of lips or skin
Restlessness or sleeplessness develops
Medicines are not tolerated
Fluid intake decreases
Shingles (herpes zoster)
Acute localized infection cause by varicella-zoster
virus (VZV)
During chickenpox, VZV travels from skin lesions to
sensory nerve ganglia sets up latent infection
Postulated that when immunity to VZV wanes, the
virus replicates
VZV moves down nerves, causing dermatomal pain
and skin lesions
Lasts up to 3 weeks
Exact triggers unknown, old age and
immunosuppression are risk factors
Shingles
 20% of population
 4% second exposure
 Fluid from lesion is contagious, but likelihood of
transmission is low
 Susceptible exposed persons may develop
varicella (chickenpox)
 Complications: post herpetic neuralgia, debilitation
pain syndrome lasts several months, blindness,
disseminated disease, and occasionally death
Shingles
Assessment
Subjective data
History of present illness
 Pain, itching, tingling, burning of involved dermatome
precede rash by 3 to 5 days
 Rarely headache, malaise, fever
Medical history
 History of chickenpox, HIV infection, cancer, chronic steroid
use
 Allergies
 Medications
Shingles
Objective data
Physical examination
Tenderness over involved dermatome
Rash
Unilateral; does not cross midline
Usually thoracic or lumbar dermatome
Small fluid-filled vesicle on red base
May become hemorrhagic
New lesions occur for about 1 week
Shingles
Fever (low grade if present)
Visual acuity, if eye involved
Diagnostic procedures
Viral culture
Other studies if seriously ill
Shingles
Interventions
 Provide contact isolation
 Advise patient to avoid school/work until all
lesions are crusted over
 Recommend immunizations of high-risk contacts
 Varicella-zoster immune globulin (VZIG)
Shingles
Administer medications as prescribed
Analgesics
Antihistamines
Antivirals (acyclovir, famciclovir) will lessen
disease severity and incidence of post
herpetic neuralgia if administered within 72
hours of onset of rash
Shingles
To prevent infection of lesions, cut fingernails short
Topical baking soda paste or baths and calamine
lotion may help
Ophthalmological consult if facial/eye involvement
Instruct patient about S&S of serious illness or
complications
 Increased fever
 Cough
 Becoming more ill
 Signs of skin infection
Skin infestations: Lice
Three types of lice infest humans:
Pediculus humanus var corporis
(human louse)
2-4mm, grayish-white, flattened, wingless,
and elongated with pointed heads
Overcrowding and poor sanitation
Skin infestations: Lice
 Three types of lice infest humans:
 P. humanus var capitis (human head louse)
 Wider and shorter, resemble a crab
 Eggs (nits) laid by female
 Affects all socioeconomic groups
 Phthirus pubis (pubic or crab louse)
 Sexually or close body contact
 Can be seen eyebrows, eyelashes, axillary hair, and back and chests
 33% with lice have 2nd STD
Lice
 Can cause significant cutaneous disease
 Lice serve as vectors for typhus, relapsing fever, and trench
fever
Lice
Assessment
Subjective data
History of present illness
 Itching infected areas
 Fever, malaise in severe infection
 Exposure to lice
 Recent sharing of clothing, beds, combs/brushes
 Concurrent STD’s
Lice
Medical history
Previous infestations
Allergies
Medications
Objective data
Lice
Physical exam
 Excoriation of scalp
 Secondary bacterial infection, especially of scalp
 Weeping and crusting of skin
 Lymphadenopathy
 Small, red macules, papules on trunk
 Small,gray to bluish macules measuring <1cm on
trunk(maculae ceruleae) from anticoagulant injected into
skin by biting louse
 Nits on hairs
 Thick, dry skin, brownish pigmentation on neck, shoulder,
back form chronic infection
 Signs of concurrent STD’s
Lice
Lice
Interventions
Contact isolation
Advise patient/parent to avoid
school/work until one treatment
completed
Administer analgesics,
antihistamines, antibiotics
Lice
Interventions
Use pediculicides
Pyrethrin liquid
Permethrin crème
Treat sexual contacts
Administer medications for STD’s
Instruct patient/parent that itching may
continue after treatment: do not re-treat
without physician order
Lice
Instruct patient/parent to
 Remove nits
 Soak hair with equal parts warm vinegar and water
 If eyelashes or eyebrows, apply layer of petroleum
jelly
 Soak combs and brushes in pediculicide for 1 hour
 Launder clothing/bedding in hot water; dry in hot drier
if possible, discard clothing and linen if practical
Lice
Lice
Instruct patient/parent to
Iron seams of clothing
Put socks over hands of small children at
bedtime
Cut fingernails short
Put hats, coats, other non-launderable
item away for at lest 72 hours
Avoid hat sharing, combs, brushes
Skin infestations: Scabies
 Highly contagious by the itch mite Sarcoptes scabiei var
hominis
 Eggs are laid in burrows several millimeter in length
 Not a vector for other infections
 Transmitted by intimate personal or sexual contact; or by
casual contact
 Always consider when patient complains of rash with intense
itching
Scabies
Assessment
Subjective data
History of current
illness
 Intense itching,
worse at night
 Rash
 Previous treatment
for current problem
 Exposure to scabies
Medical history
Previous
infestations
Allergies
medications
Scabies
Objective data
Physical exam
 Rash
 Red papules, excoriations, and occasionally vesicles
 More common in interdigit web spaces, wrists, anterior
axillary folds, periumbilical skin, pelvic girdle, penis,
ankles
 For infants and small children, soles, palms, face,
neck, and scalp are often involved
 Patient scratching
 Signs of infection of lesions
Scabies
 Interventions




Contact isolation
Advise patient/parent to avoid school/work until one treatment completed
Administer analgesics, antihistamines, antibiotics
Use pediculicides
 Pyrethrin liquid
 Permethrin crème
Scabies
 Instruct patient/parent
 Instruct patient/parent that itching may continue after treatment: do not retreat without physician order
 Launder clothing/bedding in hot water; dry in hot drier if possible, discard
clothing and linen if practical
 Put socks over hands of small children at bedtime
 Cut fingernails short
 Put hats, coats, other non-launderable item away for at least 72 hours
Skin infestations: myiasis
Invasion of living, necrotic, or
dead tissue by fly larvae
(maggots)
Do not carry infectious agents,
but can cause significant disease
of the tissues
Skin infestations: myiasis
Assessment
Subjective data
History of present
illness
Skin lesions or wound
 Social History
 Living conditions
Ability to care for
self
Substance abuse
 Previous myiasis
Medications
Allergies
Myiasis
 Objective data
Physical examination
Skin wound or lesion
Boil-like lesion
“creeping eruption” of open wounds
Poor hygiene: may see maggots in skin folds or
on intact skin surface
Myiasis
Interventions
Contact isolation
Advise patient/parent to avoid
school/work until treatment completed
Administer analgesics and antibiotics
Prepare to assist with surgical
debridement
Myiasis
Interventions
Apply petroleum jelly to cutaneous boils
Instruct patient about prevention
 Eradicate flies
 Keep open wounds properly dressed
 Stay indoors, away from fly-infested areas
Referrals to Social Services or Substance
Abuse if needed
Tuberculosis
 Mycobacterium tuberculosis, acid-fast bacillus (AFB)
 Not highly contagious, requires close, frequent exposure for
transmission
 Droplet nuclei, which can remain in still air for days
 Susceptibility of host usually determines whether infection
occurs
 TB occurs when symptoms occur and is infectious
 2-10 weeks after infection, develop immunological response,
allows healing and +PPD
Tuberculosis
Greatest risk of disease in the first 2 years after
infection
Lung primary site
15% Extrapulmonary
 Kidney, Lymphatic, Pleura, Bones, Joints, and blood
(disseminated or miliary)
Diagnosed by one of two criteria:
 Culture of bacteria
 + PPD or S&S of TB, unsteady CXR
Noncompliance of medication regimen
Tuberculosis
Assessment
Subjective data
History of present illness
Exposure to TB
Productive prolonged cough
Longer than 2 weeks
Becoming progressively worse
Tuberculosis
 History of present illness
 Fever and chills, night sweats
 Easy fatigability and malaise
 Anorexia, weight loss
 Hemoptysis
 Recent +TB skin test
 Foreign born or travel to high-prevalence country: Vietnam,
Philippines, Mexico, Haiti, China, Korea
Tuberculosis
History of present illness
Resident or staff of nursing home, prison, or
homeless shelter
Alcoholic or other substance
abuser
Racial/ethnic minority:
African-American, Hispanic,
Alaska
native,
American
Indian
Tuberculosis
 Medical History







DM
Malignancy
CRF
Immunosuppression
HIV and AIDS
Medications, especially prolonged steroid therapy
Allergies
Tuberculosis
Objective data
Physical exam
Healthy or ill appearance
Chest: decreased breath
sounds
Fever
Signs of underlying disease
Tuberculosis
 Diagnostic Procedures
 PPD: induration 5mm or
all others
 CXR: infiltrate, especially of
 Sputum for AFB: 3 successive early-morning
 LFT: obtain before starting INH
> +if HIV, 10mm +
upper lobes
Tuberculosis
Interventions
Decrease transmission of disease
Isolate coughing patient, preferably in negative
pressure
Teach to cover nose and mouth
Educate to dispose of tissue and wash hands
Isolate at home first 2 weeks of therapy; considered
infectious until
 14 days of directly observed therapy
 Decrease cough and afebrile
 Three consecutive negative AFB smears
Tuberculosis
 Surgical masks are helpful for patient; not
effective for health care staff or family
 Ventilate living quarters with fresh air: 20 times
every day
 Unnecessary to dispose of clothes, to wear
caps, gowns, gloves
Encourage patient/significant other for
reading of TB skin test, compliance with
medication regimen
Reportable disease
Tuberculosis
Administer and educate about meds
All patients with active disease should
have directly observed therapy
Preventive therapy for 6 months
HIV with PPD +5> :treat 12 months
Household members and close contacts of
newly diagnosed patient
Recent TB converter
IV drug users known to be HIV- with PPD
induration of 10mm>
Tuberculosis
 Medications: preventative and therapeutic 4-drug regimen





Isoniazid
Pyridoxine:
Rifampin:
Pyrazinamide
Ethambutol
 Encourage HIV testing
 Provide Social Service in needed
Varicella (chickenpox)
 Highly contagious caused by VZV
 Direct contact, droplet, or aerosol from skin lesion fluid
 Incubation 14-16 days
 Contagious period start 1-2 days before rash and ends when
all lesions are crusted
 90% cases children <3
Varicella (chickenpox)
 Adolescents, adults, and immunocompromised at risk for severe disease
 <5% of cases >20 years, but 55% of deaths
 Complications
Bacterial infection, pneumonia, DIC, renal
failure, and encephalitis
31% mortality to neonates born to infected
mothers
Chickenpox- Assessment
Subjective data
 History of present illness
 Exposure to chickenpox
 Prodrome: 48 hours before rash: fever, malaise, headache, rash often
with itching
 Medical history





Immunizations
Pregnant or trying to become pregnant
HIV, cancer, or other immunocompromised state
Allergies
Medications
Chickenpox
Objective data
Physical exam
Rash, typically 250-500 lesions
 Starts on trunk as faint, red macules
 Becomes teardrop vesicles on a red base,
which dry and crust over
 New crops appear over several days
 Palms and soles are spared
 Vesicles may occur in mucous membranes,
rupture, and become shallow ulcers
Chickenpox
Objective data
Fever, low grade
Skin excoriations form scratching
Signs of lesion infection: red, swollen,
tender
Altered mental status
Dehydration
Cough
Chickenpox
Diagnostic procedures
Generally none
Chickenpox
Interventions
Provided respiratory and contact
isolation
Isolate patient/significant others from
waiting room
Advise to avoid school/work until all
lesions are crusted
Chickenpox
Interventions
Recommend immunization
of high-risk contacts
VZIG
Post exposure prophylaxis
Immunocompromised (HIV, AIDS, cancer,
steroid therapy)
Effective up to 96 hours after exposure
Susceptible health care workers should be
vaccinated
Chickenpox
 Administer medications
Acetaminophen
Never use ASA (risk of Reye’s syndrome)
Antihistamines
Antivirals to older children will lesson the
severity
 To prevent infection of lesions
Suggest putting socks over small children’s
hands at bedtime to decrease scratching and
excoriation
Chickenpox
To prevent infection of lesions
Cut fingernails short
Topical backing soda paste or
baths and calamine lotion
Encourage parents to have
children immunized
Chickenpox
 Instruct patient/parent about S&S or serious illness




Increased fever
Cough
Becoming more ill
Signs of skin infection