Adult Health Nursing IIBlock 7.0

Topic: Infectious Disease & HIV Module: 3.1

Infectious Disease & HIV

Block 7.0 Module 3.1

Selected Topics:

--Chain of Infection & Epidemiological Triangle

--Methods of Infection control

--Types of Infection; viral, bacterial, parasitic, and drug resistant

--HIV – Human Immunodeficiency Virus

Infectious Disease

Block 7.0 Module 3.1

Learning Outcomes:

--Describe the principles of infection control in inpatient and community based settings.

--Differentiate between the four types of transmission precautions

--Identify the different types of infections; viral, bacterial, parasitic, and fungal.

--Identify drug resistance and laboratory monitoring of cultures.

--Assess the common clinical and manifestations of various infections.

--Interpret lab test findings in different types of infections.

--Prioritize and evaluate nursing interventions for the management of the client with an infection.

Infectious Disease• .

Block 7.0 Module 3.1

Outcomes (continued)

--Interpret lab tests for a patient with HIV.

--Identify appropriate nursing and medical interventions for patients with HIV.

--Compare the different classes of HIV drugs with side effects and method of action

Infectious Disease• Chain of Infection

• Pathogen• Reservoir

(i.e. fake fingernails)

• Portal of exit (from the reservoir)

• Mode of transmission• Portal of entry• Susceptible host

Block 7.0 Module 3.1

Agent

Host Environment

The Epidemiological Triangle

Infectious Disease

• Methods of Infection Control – depends on the pathogen’s mode of transmission and it’s virulence

• Inpatient Infection Control:Standard precautionsAirborne precautionsDroplet precautionsBlood and secretion precautionsContact precautions

Block 7.0 Module 3.1

Infectious DiseaseWHO global response video

Block 7.0 Module 3.1

Infectious Disease• Methods of Infection Control• Community based infection control

#1 HandwashingUniversal precautions during procedures

i.e. gloves, splash goggles, masks,etcIsolationDisinfectionSterilization of areas and equipment

Block 7.0 Module 3.1

Infectious Disease

• Important Subjects: (MEMORIZE ALL THE LIST-will help on the NCLEX)

• Standard Precaution is needed for all patients.

• Airborne Precautions• Diseases:

• Measles,• Chickenpox• Disseminated Varicella zoster• TB

• Protection:• Single room under negative pressure and keep door closed• Mask or personal respiratory protection device• Need mask when client leaves the room.

Block 7.0 Module 3.1

Infectious Disease• Droplet Precautions:• Diseases:

• Swine Flu

• Adenovirus• Pharyngeal Diphtheria• Epiglottitis• Influenza• Meningitis• Mumps• Mycoplasmal pneumonia • Meningococcal pneumonia• Parovirus B19• Pertussis• Rubella• Scarlet fever• Sepsis• Streptococcal pharyngitis

Block 7.0 Module 3.1

Infectious Disease

• Droplet precautions• Protection:

• Private room or cohort with similar organ-isms.

• Mask• Mask placed on client leaves the room

Block 7.0 Module 3.1

Infectious Disease• Contact Precautions:• Organisms:

• Clostridium Difficile• Respiratory syncytial virus• Staphylococcus• Varicella zoster• Wound infections• Cutaneous Diphtheria• Herpes simplex• Impetigo• Pediculosis• Scabies

Block 7.0 Module 3.1

Infectious Disease

• Contact Precautions:• Protection:

• Private room or cohort• Gloves and gown

Block 7.0 Module 3.1

Infectious Disease

• Types of Infections:

• Viral• Bacterial• Parasitic• Fungal • Drug resistant

worms or rod bacterium?

Block 7.0 Module 3.1

Infectious Disease• Viral infections – have the ability

to transfer DNA or RNA by enzymes to another cell or host cell, cannot replicate by itself, has a protein coat

• Influenza • Measles

Rubella and Rubeola• Mumps• Polio• Flavoviruses• Hepatitis – all types• HIV

Block 7.0 Module 3.1

Infectious Disease

• Viral infections • Epstein – Barr virus – mononucleosis• Ebola• HIV• Avian Flu• Herpes• West Nile virus• Papillovirus• Hanta virus

Block 7.0 Module 3.1

Infectious Disease

• Viral infections • CMV – cytomegalovirus• RSV• Poliovirus• Coxsackie family• Rabies• Type A and B influenzas• Rhinoviruses – the common cold• Rotavirus & Enteroviruses

Block 7.0 Module 3.1

Infectious Disease• Bacterial Infections – can be

aerobic or anaerobic asexual prokaryotes with a single DNA strand, can replicate by itself as long as it has nutrients available.

• Genus includes: (Note: Iggy has mycoplasmas and Rickettsiae as separate classes, but are in the same family)

• Bacterium/Spirochetes• Mycobacterium• Mycoplasmas• Rickettsiae• Chlamydiae• Ehrlichieae

Block 7.0 Module 3.1

Infectious Disease• Bacterial Infections • Most common in children are: • Streptococcus• Maxarella• Staphylococcus

There are more bacterial species than any other life form on the planet.

Block 7.0 Module 3.1

Infectious Disease4 bacterial colonies

Block 7.0 Module 3.1

Infectious Diseaseanthrax

Block 7.0 Module 3.1

Infectious DiseaseHeliobacter pylori

Block 7.0 Module 3.1

Infectious DiseaseRadiation resistant coloniesnicknamed the “Conan” bacteria

Block 7.0 Module 3.1

Infectious Disease

• Parasitic Disease – live off the host and require a host to replicate, are animals themselves

• Protozoans – often water-borne• Helminths – worms, includes

nematodes, trematodes, and flukes – they lay eggs

• ArthropodsBlock 7.0 Module 3.1

Infectious Disease• Parasitic Diseases• Tape worms• Pin worms• Roundworms• Entamoeba histolytica• Malaria• Toxoplasma gondii• Trichomonas• Leishmaniasis

Treatments- anti-microbials: Flagyl, Vermox, albendazole, amphotericin- B, pentamidine

Block 7.0 Module 3.1

Infectious Disease• Fungal diseases Racquet

hyphaeon slide

Block 7.0 Module 3.1

Infectious Disease

• Fungi – self-replicating eukaryotes, includes the class of yeasts and molds

• Candida albicans• Aspergillus• Coccidiomycoses• Cryptococcus neoformans• Histoplasmosis

Block 7.0 Module 3.1

Infectious Disease• Nosocomial – from the Greek word

“nosocomia” which means “Nurse”.• This term was coined by

Hippocrates – the Father of Medicine, who determined that nurses were responsible for nosocomial infections.

• Nosocomial infections are infections that are acquired by a patient who is undergoing medical treatment, and who did not present with that particular organism originally but acquired it while receiving care.

Block 7.0 Module 3.1

Infectious Disease• Drug Resistant Organisms – these

organisms are becoming more prevalent with the over-use of antibiotics. They have cellular memory and enzymes which make certain antibiotics ineffective, i.e. penicillinase.

• Examples:• Streptococci• Methicillin Resistant Staph. Aureus

(MRSA)• Vancomycin Resistant Enteroccocci

(VRE)• E. coli• Pseudomonas

Block 7.0 Module 3.1

MRSA – resistant to all drugs except Vancomycin & Linezolid

Block 7.0 Module 3.1

Infectious Disease• Laboratory testing for Viruses:• Enzyme immunoassay = EIA

• ELISA test

• Titers - measures past exposure and present level of exposure

• Direct fluorescent antibody technique

• IgM and IgG antibody levels

• Viral loads

• Viral RNA or DNA count

• Viral cultures – on urine, blood, sputum, secretions, stool, tissue, or semen

• Viral serology

• PAP – High risk HPV profile

• MonotestBlock 7.0 Module 3.1

Infectious Disease

Block 7.0 Module 3.1

Infectious Disease• Laboratory testing for Bacterium• Cultures & Sensitivity – blood

cultures have to be taken from three different sites. Otherwise secretions, pus, sputum, urine, or skin may be used.

• Acid Fast Bacilli culture and smear• Gram stain• CBC with diff• Macroscopic and microscopic

evaluation Block 7.0 Module 3.1

Infectious DiseaseUnknown bacterium

Block 7.0 Module 3.1

Infectious Disease• Laboratory testing for

Bacterium• Cultures and sensitivities• MIC = minimal inhibitory concentration • MIC is the minimal level of a certain drug or antibiotic that it

takes to kill a specific species of bacteria. The lower the MIC number, the faster the bacteria are killed by that drug.

• Treatment – specific antibiotics

Block 7.0 Module 3.1

Infectious Disease• Lab testing for Bacterium• Cultures and Sensitivities

Example• MR FEBRE was treated for a sore throat for

two weeks with Z-packs and did not get better. The culture and sensitivity of an oropharyngeal swab done December 30, 2010, results read on January 2, 2011 = Beta streptococcus at 3,000 colonies/mm3.

• Drug tested MICPenicillin 1000 ug/mlErythromycin 280 ug/mlAzithromycin 87 ug/mlCefuroxime 5 ug/mlVancomycin 0.05 ug/mlAmoxicillin 490

ug/mlAmoxicillin clavunate (Augmentin) 400 ug/mlPresence of + penicillinase noted

Block 7.0 Module 3.1

Infectious DiseasePseudomonas

Block 7.0 Module 3.1

Infectious Disease

• Lab testing for Fungi• Microscopic exam with KOH• Gram stain• Fungal culture• Skin scrapings

• Treatments• PO or IV Diflucan, miconozole,

tetraconazole

Block 7.0 Module 3.1

Infectious Diseases - HIV• Vital Statistics for Human Immune

Deficiency Virus• Worldwide:

• Over 22 million people have died from AIDS.

• Over 42 million people are living with HIV/AIDS, and 74 percent of these infected people live in sub-Saharan Africa.

• Over 19 million women are living with HIV/AIDS.

• By the year 2010, five countries (Ethiopia, Nigeria, China, India, and Russia) with 40 percent of the world's population added 50 to 75 million infected people to the worldwide pool of HIV disease.

Block 7.0 Module 3.1

Infectious Disease - HIV• Vital Statistics for Human

Immune Deficiency Virus• United States:

• An estimated one million people are currently living with HIV in the United States, with approximately 40,000 new infections occurring each year.

• 70 percent of these new infections occur in men and 30 percent occur in women.

Block 7.0 Module 3.1

Infectious Disease - HIV• By race, 54 percent of the new infections in

the United States occur among African Americans, and 64 percent of the new infections in women occur in African American women.

• 75 percent of the new infections in women are heterosexually transmitted.

• Half of all new infections in the United States occur in people 25 years of age

or younger

Source: http://www.until.org Block 7.0 Module 3.1

Infectious Disease• HIV Pathophysiology

• HIV is transmitted as a viral particle in semen, blood, and other bodily fluids in small amounts. This particle must find a way into the host’s bloodstream.

• The HIV virus has a specific target in the blood, and it attacks the CD4 - T- Cells. The T-cells are the primary defense against all pathogens. Like a general in the army, the T-cell either calls in the bodies defenses i.e. B-Cells and macrophages, or acts as the Killer cells themselves.

• The virus uses an enzyme called Protease to attack the Cell

Block 7.0 Module 3.1

Infectious Disease - HIV• HIV Pathophysiology (continued)

• The infected T-cell takes the protease and breaks into the cell’s RNA, changing the function of the cell so that it only produces more HIV virus.

• Then it releases the virus back into the bloodstream.

• In the end, the viral load goes up and the functional T-Cells and CD-4 count goes down.

Block 7.0 Module 3.1

Infectious Disease – HIVA picture of the retrovirus

Block 7.0 Module 3.1

HIVHistory

– 1950s: Blood samples from Africa have HIV antibodies.

– 1976: First known AIDS patient died.

– 1980: First human retrovirus isolated (HTLV-1).

– 1981: First reports of “Acquired Immuno-deficiency Syndrome” in Los Angeles.

– 1983: Virus first isolated in France (LAV).

– 1984: Virus isolated in the U.S. (called HTLV-III and AIDS-Related Virus, ARV).

– 1985: Development and implementation of antibody test to screen blood donors.

Block 7.0 Module 3.1

HIV

History (Continued)– 1986: Consensus name Human

Immunodeficiency Virus (HIV-1). Related virus (HIV-2) identified.

– 1992: AIDS becomes the leading cause of death among adults ages 25-44 in the U.S.

– 1997: Mortality rates of AIDS starts to decline due to the introduction of new drug cocktails.

– 2001: World Health Organization predicts up to 40 million infected individuals. More than 22 million have already died.

Block 7.0 Module 3.1

Infectious Disease• HIV– course of infection • Risks for HIV:

• Unprotected sex – with heterosexual or homosexual encounters

• IV drug usage –

• Needle sticks with unprotected needles

• Exposure to blood – health care workers and Laboratory workers

• Transfusion with non-screened blood products

• Use of contaminated needles or surgical equipment

Block 7.0 Module 3.1

Infectious Disease• HIV– course of infection

• Risks for HIV: (continued)

• Mother to Infant (Perinatal): 25% of children become infected in utero, during delivery, or by breast-feeding (with AZT only 3%).

• AZT should be started in the first trimester to prevent sero-conversion in the infant.

Block 7.0 Module 3.1

Infectious Disease• HIV – Course of Infection

Block 7.0 Module 3.1

Infectious Disease - HIV• HIV – Course of Infection

• Infection - the virus enters the body – initial symptoms are a cold, flu like syndrome, body aches, etc…which pass within a few days. The ELISA test is negative at this time.

• Incubation – 3 months to one year, where the virus enters other cells, but no symptoms are present. This is when sero-conversion occurs.

• Reproduction – For a period of 2 to 6 years, the virus replicates and replaces functional T-cells, reducing the immunity of the patient. The time for symptoms to occur can go from months to years. The patient is still infectious through these 3 phases.

Block 7.0 Module 3.1

Infectious Disease• HIV versus AIDS – Autoimmune

Deficiency Syndrome

• All clients who have HIV are HIV positive, but not all HIV clients have AIDS.

• Definition of AIDS

– Client must have a CD4 count of less than 200cells/mm3– Client will have an opportunistic infection (an infection that normally

would not grow in a healthy immune patient– OR the client will have persistent lymphadenopathy with a low CD4

count

Block 7.0 Module 3.1

Infectious Disease - HIV• AIDS – Complications

• Most of the complications from AIDS is due to the opportunistic infections that the patient gets.

• Examples: • Tuberculosis• Respiratory Candidiasis• Respiratory Pneumocyctis Carinii (PCP)• Out of control cervical cancer• Widespread Karposi’s sarcoma• Cytomegalovirus retinitis (blindness)• Encephalopathy• Lymphoma• Toxoplasmosis

Block 7.0 Module 3.1

Infectious DiseaseAIDS – Complications1. Gastrointestinal: Cause most of illness

and death of late AIDS.

Symptoms:

– Diarrhea

– Wasting (extreme weight loss)

– Abdominal pain

– Infections of the mouth and esophagus.

Pathogens: Candida albicans, cytomegalovirus, Microsporidia, and Cryptosporidia.

Block 7.0 Module 3.1

Infectious Disease - AIDS• African AIDS patient • with slim disease• Source: • Tropical Medicine • and Parasitology, • 1997

Block 7.0 Module 3.1

Infectious Disease - AIDS• Oral candidiasis• Source: Atlas of Clinical Oral

Pathology, 1999

Block 7.0 Module 3.1

Infectious Disease -AIDS -TBHIV

Block 7.0 Module 3.1

Infectious Disease -AIDS2. Respiratory: 70% of AIDS patients

develop serious respiratory problems.Partial list of respiratory problems

associated with AIDS:

• Bronchitis

• Pneumonia – PCP – Pneumocytis Carinii Pneumonia

• Tuberculosis

• Lung cancer

• Sinusitis

• PneumonitisBlock 7.0 Module 3.1

Infectious Disease - AIDS

3. Neurological: Opportunistic diseases i.e. cryptococcus, toxoplasmosis, and tumors of central nervous system.

Symptoms many include: Headaches, peripheral nerve problems, and AIDS dementia complex .

Symptoms:

Memory loss, confusion, motor problems, difficulty with concentration, pain, paralysis, seizures, hyperthermia

Block 7.0 Module 3.1

Infectious Disease - AIDS4. Skin Disorders: 90% of AIDS

patients develop skin or mucous membrane disorders.• Kaposi’s sarcoma

– 1/3 male AIDS patients develop KS– Most common type of cancer in AIDS

patients• Herpes zoster (shingles)• Herpes simplex• Thrush• Invasive cervical carcinoma

5. Eye Infections: 50-75% patients develop eye conditions.• CMV retinitis• Conjunctivitis• Dry eye syndromeBlock 7.0 Module 3.1

Infectious Disease – AIDSPatient with Kaposi’s Sarcoma

Block 7.0 Module 3.1

Extensive tumor lesions of Kaposis’s sarcoma in AIDS patient.Source: AIDS, 1997

Infectious Disease – AIDS• Perinatal Transmission – 25% will be

positive HIV• – Easy to prevent - AZT donations cost =

$3.00 per month while pregnant

Block 7.0 Module 3.1

Infectious Disease – AIDS• Diagnostics for HIV and AIDS

patients• ELISA – screen – can be false positive

• Western Blot – to confirm the ELISA (detects HIV antibodies)

• HIV viral load – Quantitative viral RNA

• CD4 – cell count

• CD8 – cell count and ratios CD4:CD8 AIDS CD4:CD8 ratio is < 2

• CBC with Diff – anemia is common, WBC’s may be low or non-existent

• Cultures• Biopsies

Block 7.0 Module 3.1

Infectious Disease – AIDS– Drugs – Viral Suppressing

Treatments

– Reverse Transcriptase Inhibitors (NARTI’s): Competitive enzyme inhibitors. Example: lamivudine, emtricitabine,and zidovadine.

– Protease Inhibitors: Inhibit the viral protease. Prevent sviral maturation.

– Problem with individual drug treatments: Resistance. Example: lopinavir, ritonavir, atazanavir

– Non -Nucleoside Analog Reverse Transcriptase Inhibitors (NNRTI’s) – inhibit the action of reverse transcriptase

Example – Rescriptor, Etravirine, EfavarenzBlock 7.0 Module 3.1

Infectious Disease – AIDS– Drug Cocktails: A combination of:

• One or two reverse transcriptase inhibitors

• One or two protease inhibitors.• NNRTI – Efavirenz or a smiliar NNRTI

and one or two of the above (depends on the level of the viral load)

• Anti-fungals – used a lot in AIDS patients orally or IV, i.e. Diflucan (fluconazole) Side effects include nausea and vomiting – use antiemetics prophylactically

Block 7.0 Module 3.1

Infectious Disease – AIDS• AIDS Nursing Diagnoses

– Risk for Infection (opportunistic…)– Impaired Gas Exchange– Acute or Chronic Pain– Imbalanced Nutrition– Diarrhea – Alteration in elimination– Impaired Skin Integrity– Low Self Esteem with Social Isolation– Disturbed Thought Processes– Activity Intolerance– Deficit in coping; individual or family

Block 7.0 Module 3.1

Infectious Disease – AIDS• Side Effects of retroviral drugs:• Anemia• High cholesterol and lipid levels• Nausea & Vomiting• Some have to be taken with food,

and some have to be taken without.• Because of the side effects, some

patients will be on antiemetics, appetite stimulants, and cholesterol meds.

Block 7.0 Module 3.1

Infectious Disease – AIDS• Nursing Interventions:• #1 Education

– Don’t have unprotected sex, even oral. – Don’t share razors or toothbrushes– Use bleach mixture for cleaning bathroom– Take drugs as prescribed and on time– Do not dig in the garden – soil pathogens– Avoid litter boxes – cats carry toxoplasmosis– Avoid turtles and reptiles (carry salmonella)– Eat only well cooked vegies and meats

Block 7.0 Module 3.1

Infectious Disease – AIDS• Nursing Interventions:• #1 Education – the most important

prevention for HIV

– Infection control – daily bathing and hand washing – before and after B.M., pet handling

– Avoid large crowds and people who are ill

– Clean toothbrush daily in the dishwasher or with bleach

– Report any non-healing sores, temperature greater than 100°F, dry cough, urine that is cloudy, or any abnormal drainage to the physician

Block 7.0 Module 3.1

Infectious Disease – AIDS• Education

• Do not handle raw meats• Educate on how to use incentive spirometer

at home• May need to teach the patient when and

how to take their drugs• May need to teach the use of the SVN

nebulizer with Pentam daily at home• Drink filtered or bottled water – Have a lab

check for Cryptosporidium if they have city water

Block 7.0 Module 3.1

Infectious Disease – AIDS• Nursing Interventions:• Most physical interventions can

be linked to the nursing diagnosis

• Reverse Isolation - very important even if their WBC’s are normal

• Strict aseptic techniques for IV’s and central lines

• Respiratory therapy – incentive spirometer and good pulmonary toilet

Block 7.0 Module 3.1

Infectious Disease - HIV• Nursing Interventions

• Assess Respiratory function frequently, Pulse Ox, lung sounds, depth and rate of resp.

• Vital signs, especially temperature

• Pain medications and monitor effects

• Education for home maintenance

• Monitor BM’s give Immodium or Lomitil routinely for Diarrhea

• Skin care with lotions and moisturizers

Block 7.0 Module 3.1

Infectious Disease - HIV

• Nursing Interventions• Monitor labs

– CBC and WBC– CD4 cell counts– Albumin – for protein nutritional status– Daily weights– Cultures, blood, respiratory, urine, stool– Electrolytes – monitor for deficiencies

• Note- low sodium levels can make dementia worse

Block 7.0 Module 3.1

Infectious Disease - HIV• Nursing Interventions

• Nutritional Education – high caloric and protein intake

• Psycho-social support– Time one-on one with the patient so they do not

feel that the staff is avoiding them.– Non-judgmental attitude towards significant

others and patient– Hook them up with social services for home

health care– Re-orient the patient if they are confused– If demented, safety may be a big issueBlock 7.0 Module 3.1

Infectious Disease

• End of Presentation

Block 7.0 Module 3.1