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CARE OF CLIENTS WITH INFECTIOUS DISORDERS

OVERVIEW OF THE IMMUNE SYSTEM

IMMUNITY
- ‘resistance”; is the body’s specific protective response to a foreign agent or organism
- Immune function is affected by central nervous system integrity; general physical and emotional status
medications; dietary patterns; and the stress of illness, trauma, or surgery
- basic function of the immune system is to remove foreign antigens such as viruses and bacteria to
maintain homeostasis
- Two general types of immunity: 1.) natural (innate) 2.) acquired (adaptive)
Terms related to Immunity
✓ Immune memory - is a property of the immune system that provides protection against harmful
microbial agents despite the timing of re-exposure to the agent
✓ Susceptibility- refers to a vulnerability or lack of resistance
✓ Antigens- are membrane proteins which are cell markers that identify cells; those antigens recognized
by our body as “non-self” or “foreign” will be destroyed by immune cells

GENERAL TYPES OF IMMUNITY

1. NATURAL / INNATE/ NON-SPECIFIC IMMUNITY
- refers to defenses present at birth
- provides a broad spectrum of defense against and resistance to infection
- considered the first line of host defense following antigen exposure
- does not create memory; its responses are the same regardless of the target
- primarily involves intact skin & mucous membranes, the inflammatory response, a number of chemicals
and defensive cells
- can be divided into two stages: immediate (generally occurring within minutes) and delayed (occurring
within several days after exposure)

Components of Innate Immunity

I. First Line of Defense
- A system of Physical and Chemical Barriers that prevent pathogens from entering the body
- Physical surface barriers include intact skin, mucous membranes, and cilia of the respiratory tract
- Chemical barriers, such as mucus, acidic gastric secretions, enzymes in tears and saliva, and substances
in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi

II. Second Line of Defense

1. Antimicrobial substances
a.) Complement
- A group of plasma proteins produced by the liver that normally circulate in the blood in an inactive, non-
functional form
- Once activated, certain complement proteins promote inflammation and phagocytosis and can directly
lyse (rupture) bacterial cells
b.) Interferons
- Are proteins produced by cells infected with viruses & by T lymphocytes
- Blocks the replication or reproduction of viruses, preventing them from infecting unaffected cells

2. Phagocytosis
- Ingestion of microbes or other particles such as cellular debris
- Phagocytes- are specialized cells, primarily neutrophils & macrophages, that perform phagocytosis:
❖ Neutrophils
➢ Most abundant WBC; Their levels usually increase during acute bacterial infections
➢ Attracted by bacterial products, they are the FIRST to arrive at the site of invasion since they
migrate quickly
➢ often die after phagocytizing a single microorganism.
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➢ Functions: engulf microorganisms, especially bacteria AND Release bacteria-destroying
substances (e.g. lysozymes) into the surrounding extracellular matrix of the infected tissue
➢ Pus- is an accumulation of fluid, dead neutrophils, and other cells at a site of infection.
❖ Macrophages
➢ are monocytes that leave the blood, enter tissues, and enlarge about fivefold; some are
given specific names, such as dust cells in the lungs, Kupffer cells in the liver, and microglia
in the central nervous system.
➢ can ingest more and larger items than can neutrophils. Macrophages usually appear in
infected tissues after neutrophils do
➢ are also found in uninfected tissues. For example, macrophages are located beneath the
skin and mucous membranes, and around blood and lymphatic vessels

3. Other defensive cells

a.) Langerhans cells
- Cells on the skin’s epidermis which also phagocytize foreign material, not merely to destroy it, but take it
to a lymph node where the adaptive immunity defenses are then activated
b.) Natural killer (NK) cells
- type of lymphocyte produced in red bone marrow which circulate in the blood & lymph
- their response is non-specific (unlike the T & B cells) and do not exhibit a memory response
- non-phagocytic & act by making direct contact with foreign substances & kill them by rupturing their
membranes with chemicals
c.) Mast cells
- also derived from red bone marrow; are nonmotile cells in connective tissue, especially near capillaries
- produce histamines & leukotrienes in response to tissue damage
- Histamine= causes vasodilation & makes capillaries more permeable or “leaky”
- Leukotrienes= also increase capillary permeability & attract phagocytes to the area of tissue damage
d.) Basophils
- least abundant and rarest of the WBCs
- their levels increase during allergic reactions & parasitic infections
- secrete histamine and heparin
e.) Eosinophils
- secrete a range of highly toxic proteins and free radicals that kill bacteria and parasites. The use of toxic
proteins and free radicals also causes tissue damage during allergic reactions, so activation and toxin
release by eosinophils is highly regulated to prevent any unnecessary tissue damage
4. Inflammation
- A nonspecific, defensive response of the body to tissue damage
- Main purpose is to try to contain the damage, keep it from spreading, eliminate the cause & permit tissue
repair
- Occurs in 3 basic stages:
- (1) Vasodilation increases blood flow and brings phagocytes and other white blood cells to the area
- (2) phagocytes leave the blood and enter the tissue;
- (3) Tissue repair
- Local inflammation is an inflammatory response confined to a specific area of the body. Symptoms of
local inflammation:
➢ Redness (rubor)
➢ Pain (dolor)
➢ Heat (calor)
➢ Edema/ swelling (tumor)
➢ Loss of function
- Systemic inflammation is an inflammatory response that is generally distributed throughout the body.
three additional features can be present:
1. Red bone marrow produces and releases large numbers of neutrophils, which promote
phagocytosis.
2. Pyrogens -chemicals released by microorganisms, neutrophils, and other cells, stimulate fever
production. Fever promotes the activities of the immune system, such as phagocytosis, and inhibits
the growth of some microorganisms.
3. In severe cases of systemic inflammation, vascular permeability can increase so much that large
amounts of fluid are lost from the blood into the tissues. The decreased blood volume can cause
shock and death
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2. ACQUIRED/ ADAPTIVE IMMUNITY

- usually develops as a result of prior exposure to an antigen through immunization (vaccination) or by
contracting a disease
- this form of immunity relies on the recognition of specific foreign antigens
- may involve antibodies, does create memory & may become more efficient
- broadly divided into two mechanisms:
o the cell-mediated response, involving T-cell activation
o effector mechanisms, involving B-cell maturation and production of antibodies
- The two types of acquired immunity are known as active and passive

Properties of Adaptive Immunity

1. Specificity
- adaptive immunity are antigen-specific
- They only recognize & act against particular pathogens or foreign substances

2. Memory
- Adaptive immunity defenses recognize & mount even stronger attacks on previously encountered
pathogens & foreign substances
- The second encounter with an antigen prompts an even more rapid & vigorous response

Cells involved in Adaptive Immunity

1. Lymphocytes
- Circulated in both blood & lymph and are located in lymphatic tissues (e.g. spleen, lymph nodes)
- Smallest of the WBCs; 2nd most abundant WBC
- Usually increase during acute viral infection
- Are effective in fighting infectious organisms because each lymphocyte recognizes & acts against an
antigen
- 3 types:
- T cells ,B cells, Natural killer (NK) cells
- Reject grafts or donated organs
- 2 types involved in adaptive immunity:
a.) T lymphocytes / T cells
- Released as immature T cells from the red bone marrow; they mature in the thymus
- Only immunocompetent or mature T cells are capable of responding to a specific antigen by binding to it
- Specialized groups: helper T cells, cytotoxic T cells
- Provides cell-mediated immunity in which T-cells, once activated, directly interact with antigen-bearing
cells/agents to destroy them (cells attacking cells)
b.) B lymphocytes/ B cells
- Named such because they both arise & mature in the bone marrow
- Provides antibody-mediated immunity in which B cells, once activated, indirectly interact with antigen-
bearing cells/ agents to destroy them by producing antibodies

2. Macrophages
- Phagocytes which are involved in both innate & adaptive immunity
- are differentiated Monocytes (When they leave the bloodstream, they enlarge and differentiate into
MACROPHAGES)
- Largest of the WBCs; Numbers usually increase during a chronic infection
- like the neutrophils, they phagocytize bacteria, dead cells & any other debris within the tissues; although
they take longer to reach a site of infection than neutrophils, they are more efficient phagocytes
- They not only engulf foreign material, but also present fragments of the foreign materials’ antigens, on
their own surfaces where they can be recognized by immunocompetent T cells
Gen Phases of Adaptive Immunity
1. Recognition of an Antigen as Foreign
2. Activation of cell-Mediated & Antibody-Mediated Immune Responses

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Types of Adaptive Immunity
1. Cell-Mediated Immunity
- Does not result in the production of antibodies
- Effective against intracellular pathogens such as viruses, bacteria & fungi located inside cells; and also
against some cancer cells & foreign tissue transplants
- Primarily involves the t cells
- Commences when activated helper T cells release their cytokines shortly after the invading antigen is
presented by the macrophages
- Predominates during Transplant rejection, Delayed hypersensitivity (tuberculin reaction), Graft-versus-
host disease, Tumor surveillance or destruction, Intracellular infections, Viral, fungal, and parasitic
infections
2. Antibody-mediated immunity
- This mechanism of immunity involves the production of antibodies
- Is effective against extracellular pathogens such as viruses, bacteria, and fungi in blood and body fluid
- Primarily involves the B cells
- Predominates during Bacterial phagocytosis and lysis, Anaphylaxis, Allergic hay fever and asthma &
Immune complex diseases, Bacterial and some viral infections

Types of T-lymphocytes
T cells include effector T cells, suppressor T cells, and memory T cells.
1. Helper T cells
- also referred to as CD4+ cells
- are activated on recognition of antigens and stimulate the rest of the immune system
- When activated, helper T cells secrete cytokines, which attract and activate B cells, cytotoxic T cells, NK
cells, macrophages, and other cells of the immune system
2. Cytotoxic T cells (killer T cells)
- also referred to as CD8+ cells
- attack the antigen directly by altering the cell membrane, causing cell lysis (disintegration), and releasing
cytolytic enzymes and cytokines
3. Suppressor T cells
- have the ability to decrease B-cell production, thereby keeping the immune response at a level that is
compatible with health (e.g., sufficient to fight infection adequately without attacking the body’s healthy
tissues)
4. Memory cells
- are responsible for recognizing antigens from previous exposure and mounting an immune response

Classes of Antibodies
1. IgG (75% of Total Immunoglobulin)
- Location: blood & lympth
- Most abundant of all antibodies in the blood
- The only class of antibody to cross the placenta
- Function:
✓ Provides passive immunity for newborns
✓ Provides long-term immunity following recovery from infection or administration of a vaccine

2. IgA (15% of Total Immunoglobulin)

- Location: secretions of all mucous membranes (sweat, tears, saliva, mucus GI secretions) & breastmilk
- Function:
✓ Provides passive immunity for breast-fed newborns
✓ Provides localized protection of mucous membranes against bacteria & viruses

3. IgM (10% of Total Immunoglobulin)

- Location: blood
- First antibody to be secreted by plasma cells after an initial exposure to any antigen
- Function:
➢ produced first during an infection (IgG follows)
➢ Are the Anti-A & Anti-B antibodies of ABO blood group which bind with antigens to cause
agglutination during transfusion reactions

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4. IgD (0.2% of Total Immunoglobulin)
- location: blood & lymph, particularly on the B lymphocytes
- role is unclear
- Function:
➢ serve as antigen receptors on the surfaces of B cells which are involved in its activation

5. IgE (0.004% of Total Immunoglobulin)

- Appears in serum
- Takes part in allergic and some hypersensitivity reactions
- Location: blood, mast cells & basophils
- Function:
➢ Involved in allergic & hypersensitivity reactions
➢ Provides protection against parasitic worms

Antibody Responses
1. Primary Response
- Occurs during initial exposure to the antigen
- B cells are activated to proliferate & begin producing antibody
- However, on a person’s first exposure to the antigen, antibody production is usually too slow
- In the case of an antigen of a pathogen (e.g. measles virus), antibody production during the primary
response is unable to prevent the disease itself, and therefore disease (e.g. clinical measles) ensues
2. Secondary Response
- Occurs during subsequent exposure to the antigen
- Memory cells formed during the primary response stimulate the production of plasma cells & an almost
immediate rise in antibody levels occur
- In the case of previously-acquired disease (e.g. previous measles), on second exposure to the pathogen,
the large amounts of antibodies are enough to prevent a second case of the disease
- This is the reason why we develop immunity to certain diseases & this is also the basis for the protection
given by vaccines

Sources of Immunity
1. Genetic immunity
- Is conferred by our DNA
- Does not involve antibodies or the immune defenses but is the result of our genetic makeup
- Results in certain pathogens incapable of causing disease in all human species

2. Acquired Immunity
- Involves antibodies

ACTIVE IMMUNITY
- Means that the individual produces his or her own antibodies; the type of immunity that stays with you
for long periods (usually for life), as the memory cells & long-lasting antibodies remain with you

a.) NATURALLY-ACQUIRED ACTIVE IMMUNITY

- mechanism: exposure to live pathogens with which you are not immune
- examples: getting sick with chicken pox & measles
- result: stimulation of an immune response with symptoms of a disease; there is recovery from the
disease, with production of antibodies & memory cells

b.) ARTIFICIALLY ACQUIRED- ACTIVE IMMUNITY

- mechanism: an antigen is deliberately introduced into an individual to stimulate the immune
system (vaccination). The vaccine contains weakened or killed pathogens (attenuated vaccine),
their components (usually DNA) or their inactivated toxins (toxoid)
- examples: tetanus toxoid (TT), attenuated measles virus (AMV)
- result: stimulation of an immune response without the severe symptoms of the disease

PASSIVE IMMUNITY
- Means that antibodies are from another source (from another person or animal) therefore “pre-made”;
however, the immunity it provides is fleeting; once the antibodies degrade, so does the immunity because
there is no immune cells to produce new antibodies

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a.) ARTIFICIALLY- ACQUIRED PASSIVE IMMUNITY

- mechanism: begins with vaccinating an animal, such as a horse. After the animal’s immune system
responds to the antigen, antibodies are removed from the animal and injected into the human requiring
immunity.
- is therefore the preferred treatment when not enough time is available for the individual to develop his
or her own active immunity. However, the technique provides only temporary immunity because the
antibodies are used or eliminated by the recipient.
- Antibodies that provide passive artificial immunity are referred to by the general term antiserum because
the antibodies are found in serum, which is plasma minus the clotting factors
- examples: Antisera are available against microorganisms that cause disease, such as rabies, hepatitis, and
measles; bacterial toxins, such as those that cause tetanus, diphtheria, and botulism; and venoms from
poisonous snakes and spiders.
- result: short-term immunity without stimulating an immune response

b.) NATURALLY-ACQUIRED PASSIVE IMMUNITY

- mechanism: results when antibodies are transferred from a mother to her child across the placenta
before birth. Following birth, the antibodies protect the baby for the first few months. Eventually,
the antibodies break down, and the baby must rely on its own immune system
- examples: placental transmission of antibodies (IgG) from mother to fetus; transmission of antibodies in
breastmilk (IgA)
- result: short-term immunity for newborn without stimulating an immune response

THE INFECTIOUS PROCESS

Related Terms

o Infectious Disease- is any disease caused by the growth of pathogenic microbes in the body; may or may
not be communicable (contagious)
o Susceptible- not possessing immunity to a particular pathogen
o Immune- not susceptible

Types of Infection
o Viral Infections
- Smaller than bacteria; are parasitic and require a host cell in which to carry out their life cycle
- Examples of viral infections: Influenza, Measles, Rubella, Chickenpox, HPV, HIV, rabies
- Possible treatments: interventions relieving symptoms (until immune system clears the infection),
antivirals
o Bacterial Infections
- Bacteria are single-celled microorganisms and can be found in all sorts of environments
- Examples of bacterial infections: strep throat, E. coli, Salmonella, gonorrhea, chlamydia, TB
- Possible treatments: antibiotic
o Fungal Infections
- Include yeast and molds
- Examples of fungal infections: vaginal yeast infections, athlete’s foot, histoplasmosis
- Possible treatment: antifungals
o Parasitic Infections
- Three types: Protozoa, Helminths, Extoparasites (fleas, ticks, lice)
- Examples of Parasitic Infections: Malaria, Toxoplasmosis, tapeworm infection, Scabies
- Possible treatment: Antiparasitics
o Prions
- Proteins that can affect normal proteins and cause them to fold into abnormal shapes
- Can cause dementia and difficulties in walking or speaking
- Are very rare; some are inherited while some are acquired through consuming contaminated food
- Examples: Creutzfeldt-Jakob disease
- Currently no curative treatment
o Health care-associated infection (HCAI)
- also referred to as "nosocomial" or "hospital" infection
- is an infection occurring in a patient during the process of care in a hospital or other health care facility
which was not present or incubating at the time of admission

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- Example: central line-associated bloodstream infections, catheter-associated urinary tract infections, and
ventilator-associated pneumonia, surgical site infections

The Chain of Infection

- Complete chain of events necessary for infection to occur
- Has six elements: causative organism, reservoir of available organisms, portal of exit from the reservoir,
a mode of transmission from the reservoir to the host and a mode of entry into a susceptible host

CAUSATIVE ORGANISM / AGENT

- The types of microorganisms that cause infections are bacteria, rickettsiae, viruses, protozoa, fungi, and
helminths
- Factors that influence the ability of a microorganism to cause infection include the number of
microorganisms present, the potency of the microorganism, the ability of the agent to enter the body, the
susceptibility of the host, and whether the organism can live in the host's body

RESERVOIR
- Term used for any person, plant, animal, substance or location that provides nourishment for
microorganisms and enables further dispersal of the organisms
- Infections may be prevented by eliminating the causative organisms from the reservoir
- For example, shellfish are reservoirs for hepatitis A and the anopheles mosquito is a carrier of the malaria
parasite
MODE OF EXIT
- The microorganism has to leave the reservoir to establish itself as an infection
- Portals of exit include the gastrointestinal (GI) tract (mouth or anus), respiratory tract (nose or mouth),
genitourinary tract (GU) tract (ureteral meatus or urinary diversion), blood (open wound, needle
puncture site, or any break in the skin or mucous membranes), and tissue (drainage from a wound)
ROUTE OF TRANSMISSION
- Connects the infectious source with its new host
- three methods of transmission:
❖ Direct transmission
- is through direct transfer from one person to another
- can be through biting, touching, kissing, or sexual intercourse
- Sneezing, coughing, spitting, singing, or talking can also transfer microorganisms from one person to
another if the person is close to the host and the organism is transferrable by droplet spray into the
mucous membranes of the mouth, nose, eye, or conjunctiva
- Example: Staphylococcus aureus

❖ Indirect transmission
- can be either vehicle or vector-borne
- A vehicle is anything that serves as a way to transfer a microorganism from the host to the susceptible
person. Example: Inanimate objects (fomites) such as toys, soiled clothes, eating utensils, handkerchiefs,
surgical instruments or dressings, and stethoscopes can serve as vehicles for indirect transmission
- Vector-borne transmission is when an animal or insect transports the infectious agent. Transmission
occurs when the animal or insect either injects saliva through biting or by depositing feces or other
materials through broken skin

❖ Airborne transmission
- can include droplets or dust
- Evaporated droplets and dust particles containing the infectious agent can remain in the air for long
periods
- Example: Clostridium difficile and Mycobacterium tuberculosis

PORTAL OF ENTRY
- Needed for the organism to gain access to the host
- Specific organisms may require specific portals of entry for infection to occur. Example: M. tuberculosis
does not cause disease when it settles on the skin but rather through the respiratory tract

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SUSCEPTIBLE HOST
- For an infection to occur, the host must be susceptible
- Any impairment of the body's natural defenses makes an individual a susceptible host who's at risk for
infection. Risk factors include:

➢ age (very young and very old)

➢ immune suppression treatment for cancer or organ transplant
➢ immune deficiency conditions
➢ chronic disorders, such as COPD and end-stage renal disease, and disorders that require
immunosuppressive therapy, such as rheumatoid arthritis, Crohn disease, and multiple
sclerosis
- Note: expect that any hospitalized patient is at risk for infection because of the physical stress of illness or
surgery and the prevalence of microorganisms, including HAIs

Taking precautions
- include standard precautions and transmission-based precautions

STANDARD PRECAUTIONS
- are guidelines that were established to break the chain of infection and reduce the risk of pathogen
transmission in hospitals
- apply to blood and body fluids, secretions and excretions (except sweat), nonintact skin, and mucous
membranes
- premise: ALL PATIENTS are colonized or infected with microorganisms, whether or not there are signs or
symptoms, and that a uniform level of caution should be used in the care of all patients

❖ Hand hygiene
- is the number one weapon in preventing the spread of microorganisms
- includes alcohol-based hand rubs and hand washing with soap and water
- Alcohol-based hand rubs containing 60% to 95% alcohol are the preferred method for decontaminating
hands, except when hands are visibly soiled or when a patient has infectious diarrhea
- C. difficile and norovirus are not affected by alcohol-based hand rubs
- soap and water should be used in suspected or confirmed cases of infectious diarrhea
- 5 moments of Hand hygiene:
✓ Before touching a patient;
✓ Before clean/aseptic procedure;
✓ After body fluid exposure/risk;
✓ After touching a patient;
✓ After touching patient surroundings.
- The CDC recommends scrubbing hands for at least 20 seconds, using soap, water, and friction, and paying
special attention to the areas between fingers, the backs of hands, underneath fingernails, and the
thumbs. Humming the "Happy Birthday" song twice or the "Alphabet" song or "Twinkle, Twinkle Little
Star" once can help count the time
- Alcohol-based hand rubs should be rubbed into all surfaces of the hands until dry.

❖ PPE (source: [Link]; updated as of Aug 2020)

- includes gloves, gowns, masks, respirators, and eyewear that create barriers to protect skin, clothing,
mucous membranes, and the respiratory tract from infectious organisms
- The item selected depends on the infectious agent, the type of interaction, and the method of
microorganism transmission
- Knowing how to put on and remove PPE can help prevent cross-contamination
❖ Gloves- should be worn when touching blood, body fluids, nonintact skin, mucous membranes, and
contaminated items, and for any activities involving vascular access
❖ face shield or mask and goggles- should be worn if you anticipate a splash or spray of blood or body
fluids that might come in contact with your nose, eyes, or mouth.
❖ Gown- If you expect your skin or clothing might be exposed to body fluids or blood

▪ Donning PPE:
1. Identify and gather the proper PPE to don.
2. Perform hand hygiene using hand sanitizer.
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3. Put on isolation gown
4. Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is
not available)
5. Put on face shield or goggles.
6. Put on gloves.
7. Healthcare personnel may now enter patient room.

▪ Doffing PPE:
1. Remove gloves.
2. Remove gown.
3. Healthcare personnel may now exit patient room.
4. Perform hand hygiene.
5. Remove face shield or goggles.
6. Remove and discard respirator (or facemask if used instead of respirator).
7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your
workplace is practicing reuse
* Facilities implementing reuse or extended use of PPE will need to adjust their donning and doffing procedures
to accommodate those practices.

❖ Promoting injection safety

- gloves should be worn when administering injections
- Puncture-proof disposal systems are recommended to dispose of uncapped needles and sharps
- Never recap needles following administration of medication to reduce your risk of being stuck with an
unclean needle
- engage a needle safety device immediately after performing an injection

❖ Environmental cleaning
- includes medical equipment and environmental surfaces
- Any reusable equipment, including stethoscopes, bandage scissors, and hemostats, used on multiple
patients must be cleaned between each patient contact, following organizational policy, with a broad-
spectrum antimicrobial agent such as chlorhexidine-a commonly used antimicrobial agent for
disinfecting topical and hard surfaces in healthcare agencies, effective against Gram-positive and Gram-
negative bacteria and fungi
- Nursing staff should work closely with environmental services to ensure that rooms are thoroughly
cleaned and disinfected between patients to prevent the spread of infection through inanimate objects

❖ Respiratory hygiene and cough etiquette

- Patients with signs and symptoms of a respiratory infection should be taught to cover their mouth and
nose with a tissue when coughing or sneezing and dispose of the tissue in the nearest trash container as
soon as possible
- These patients should also perform hand hygiene with alcohol-based rubs, soap and water, or an
antiseptic hand wash after being exposed to respiratory secretions or contaminated materials or objects.

TRANSMISSION-BASED PRECAUTIONS
- Use transmission-based precautions in addition to standard precautions
- three types: contact, droplet, and airborne.

❖ Contact precautions
- are used when caring for patients with known or suspected diseases that are spread by direct or indirect
contact
- include gloving and gowning when in contact with the patient, objects, and surfaces within the patient's
environment
- All reusable items should be cleaned and disinfected according to organizational policy, and disposable
items should be thrown away immediately after being used
- Sample situations: E-coli, Hep A, Cellulitis, Pressure ulcers, Scabies

❖ Droplet precautions
- require the use of a surgical mask when within 3 ft (6 ft for smallpox) of a patient known to have or
suspected of having a disease spread by droplets

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- observe droplet precautions when examining a patient with respiratory symptoms, especially if the
patient has a fever. These precautions should remain in effect until it is determined that the symptoms
are not caused by an infection that requires droplet precautions
- Sample situations: influenza, pertussis, pneumonia and meningococcal disease

❖ Airborne precautions
- are used when in contact with patients with known or suspected diseases spread by fine particles
transmitted by air currents, such as tuberculosis, measles, and severe acute respiratory syndrome
- must wear a National Institute for Occupational Safety and Health certified, fit-tested N-95 respirator
just before entry into an area shared with a patient suspected or known to have one of these diseases
- If eye protection is needed, wear goggles or a face shield during all contact with the patient, not just if
you predict splashes or sprays
- Sample situations: Measles, Varicella, TB

Stages of Infectious Process

1. Incubation Period
- occurs in an acute disease after the initial entry of the pathogen into the host.
- It is during this time the pathogen begins multiplying in the host. However, there are insufficient
numbers of pathogen particles (cells or viruses) present to cause signs and symptoms of disease
- can vary from a day or two in acute disease to months or years in chronic disease
- Factors involved in determining the length of the incubation period can include strength of the pathogen,
strength of the host immune defenses, site of infection, type of infection, and the size infectious dose
received
2. Prodromal Period
- the pathogen continues to multiply and the host begins to experience general signs and symptoms of
illness, which typically result from activation of the immune system, such as fever, pain, soreness,
swelling, or inflammation
- interval from onset of nonspecific s/sx to more specific symptoms
3. Illness Period/ Acme/ Fastigium
- during which the signs and symptoms of disease are most obvious and severe and more specific to the
type of infection
4. Recovery/ Convalescent Period
- When the acute symptoms of infection disappear & the body tries to replenish resources and return to
state of homeostasis
- some diseases may inflict permanent damage that the body cannot fully repair

INFECTION CONTROL & PREVENTION

A. Organizations Involved in Infection Prevention

✓ The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) are
the principal agencies involved in setting guidelines about infection prevention.
✓ focused more attention on health care–associated infections (HAIs), infections acquired in the health
care setting.
✓ recommendations about many of the situations that a nurse may face when caring for or educating a
patient with an infectious disease.
✓ Morbidity and Mortality Weekly Report (MMWR)- significant cases, outbreaks, environmental hazards,
or other public health problems

❖ Infection Prevention and Control

- is a practical, evidence-based approach which prevents patients and health workers from being harmed
by avoidable infections.
- avoids this unnecessary harm and at times even death, saves money, reduces the spread of antimicrobial
resistance (AMR) and supports high quality, integrated, people-centred health services.
- WORK: HAND HYGIENE, SURGICAL SITE INFECTIONS, CORE COMPONENTS FOR IPC, INJECTION SAFETY,
FOCUS ON AMR, Other health care prevention
❖ Global Infection Prevention and Control Network (GIPC Network)
- to enhance local, national (Member States) and international coordination and collaboration in the field
of infection prevention and control (IPC) and to support WHO’s and Member States’ efforts on IPC; from

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preparedness, to IPC systems and programmes’ strengthening, outbreak prevention and control, as well
as capacity building for surveillance.
- GOAL: reduction of health care-associated infection (HAI) (including in the context of outbreaks) and to
address the global burden of antimicrobial resistance (AMR) in support of all Member States and WHO
priorities.

B. Prevention of Infection in the Community

1. Recommended Adult Immunization Schedule

How to use the adult immunization schedule: (FOR AGES 19 YRS OR OLDER)
1. Determine recommended vaccinations by age (Table 1)
2. Assess need for additional recommended vaccinations by medical condition and other indications (Table 2)
3. Review vaccine types, frequencies, and intervals and considerations for special situations (Notes)

Kindly open the link below:

Source: Adult Immunization Schedule by Vaccine and Age Group. (2020, February 03). Retrieved September
15, 2020, from [Link]

2. Other Non-Communicable Disease Programs

Non-communicable diseases (NCDs)

- include cardiovascular conditions (hypertension, stroke), diabetes mellitus, lung/chronic respiratory
diseases and a range of cancers which are the top causes of deaths globally and locally.
- considered as lifestyle related and is mostly the result of unhealthy habits

NON-COMMUNICABLE DISEASES (LIFESTYLE- RELATED DISEASES)

1. Alzheimer’s Disease 8. Coronary Artery Disease
2. Cancer 9. Heat Stroke
3. Epilepsy 10. High Blood Pressure or Hypertension
4. Osteoarthritis 11. Obesity and Overweight
5. Osteoporosis 12. Diabetes
6. Cerebrovascular Disease (Stroke) 13. Depressive Disorders
7. Chronic Obstructive Pulmonary Disease 14. Substance Abuse: Alcohol
(COPD) 15. Substance Abuse: Ecstasy

❖ Vision :A Philippines free from the avoidable burden of NCDs

❖ Mission
- “Health in All, Health by All, Health for All” whereas Health in All refers to Health in All Policies, Health
by All involves the whole-of-government and the whole-of-society and the Health for All captures the
KP (Kalusugan Pangkalahatan) or the Universal Health Care (UHC).
❖ Objectives
1. To raise the priority accorded to the prevention and control of non-communicable diseases in national,
regional and local health and development plans
2. To strengthen leadership, governance, and multisectoral actions for the prevention and control of non-
communicable diseases
3. To reduce modifiable risk factors for non-communicable diseases and underlying social determinants
through creation of health-promoting environments
4. To strengthen health systems and increase access to quality medicines, products and services, especially at
the primary health care level, towards attainment of universal health coverage
5. To promote and support research and development for the prevention and control of non-communicable
diseases
6. To monitor the trends and determinants of non-communicable diseases and evaluate progress in their
prevention and control
❖ Program Components
1. Cardiovascular Disease
2. Diabetes Mellitus
3. Cancer
4. Chronic Respiratory Disease

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Calendar of Activities
Goiter Awareness Week
National Cancer Consciousness Week World No Tobacco Day
Philippine Heart Month National No Smoking Month
International Childhood Cancer Day Nutrition Month
Hypertension Awareness Month Thyroid Cancer Awareness Week
Cervical Cancer Consciousness Month Obesity Awareness and Prevention Week
International Thyroid Awareness Week Breast Cancer Awareness Month
World Diabetes Day
Partner Institutions
Health Justice Philippines Philippine College of Physicians
WHO Philippines Philippine Thyroid Association
National Nutrition Council Philippine College of Chest Physicians
Philippine Society of Endocrinology, Diabetes Philippine Society of Nuclear Medicine
and Metabolism UP College of Public Health
Philippine Heart Association UP National Institutes of Health
Philippine Academy of Family Physicians UP Philippine General Hospital
Philippine Cancer Society, Inc. Philippine Coalition for the Prevention and Control of Non
Communicable Diseases

C. Role of the Infection Control Nurse

Infection Control Nurse

- Specialize in preventing the spread of infectious agents such as that of viruses and bacteria
- work diligently to prevent dangerous outbreaks from occurring in a hospital setting
- to perform and educate others on how to prevent and contain outbreaks and to prevent further
incidents from occurring.
- Work in:
✓ Hospitals ✓ Hospices
✓ Long-term care facilities ✓ Emergency Preparedness
✓ Home Care ✓ Public Health
✓ Ambulatory Care ✓ Behavioral Health

- Roles and Duties:

o Gathering and analyzing infection data.
o Providing training and education on prevention techniques.
o Develop plans to prevent patients from spreading diseases
o coordinator or leader of an Infection Prevention and Control (IPC) Program.
o Reinforcing the implementation of infection control
o Bringing rates of infection down within a facility.
o Determining the origin of a particular pathogen
o Working side by side with scientists and doctors to develop treatments for other infectious diseases.

STRATEGIES TO POSITIVE PATIENT OUTCOMES

o the practice and promotion of hand hygiene
o consistent use of aseptic technique
o cleaning and disinfection practices
o use of standard precautions
o patient assessment and additional precautions
o patient education
o use of safety devices
o removal of unnecessary invasive devices
o use of bundle strategies for infection prevention
o fit for duty.

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NURSING CARE OF CLIENTS WITH INFECTIOUS DISEASE

A. Health History & Physical Assessment

✓ In general, do not obtain a detailed history until life-threatening injuries have been identified and
therapy has been initiated. The secondary survey is essentially a head-to-toe assessment of progress,
vital signs, etc.
o S: Symptoms
o A: Allergy
o M: Medications
o P: Past Medical History
o L: Last Oral Intake
o E: Events leading up to the illness or injury

❖ Obtaining History
✓ Current symptoms, past medical problems, medications, allergies, social/family history.
✓ Prior hospitalizations, episodes of severe illness, chronic conditions, previous injuries, surgeries
(including dental procedures and blood transfusions
✓ Vaccination history
✓ A medication history should include nonprescription (over-the-counter medications), as well as an
inquiry about use of traditional and/or herbal remedies and therapies

❖ Physical Assessment
✓ Vital signs, including heart rate, respiratory rate, and blood pressure, should be measured and
compared with normal for indication of underlying illness or disease.
✓ Careful respiratory examination should be performed, particularly in individuals with pulmonary signs
or symptoms.
✓ The abdominal examination should include careful assessment for hepatic and splenic enlargement,
conditions that can be associated with a wide variety of conditions.
✓ A full lymph node exam should also be performed through palpation
✓ Nutritional status is also assessed

B. Diagnostic Tests & Nursing Considerations

1. Complete Blood Count with Differential
- is a series of tests used to evaluate the composition and concentration of the cellular components of
blood. It measures the following:
o The number of red blood cells (RBCs) ;
o The number of white blood cells (WBCs) ;
o The total amount of hemoglobin in the blood ;
o The fraction of the blood composed of red blood cells (hematocrit) ;
o The mean corpuscular volume (MCV) — the size of the red blood cells
- CBC also includes information about the red blood cells that is calculated from the other measurements:
o MCH (mean corpuscular hemoglobin) ; MCHC (mean corpuscular hemoglobin concentration)
o The platelet count is also usually included in the CBC
- Purpose:
o as a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis
o to identify persons who may have an infection
o to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as
leukemia
- No preparation needed
- Blood is drawn from a vein: inside of the elbow or back of the hand.
- Puncture site cleaned with antiseptic; elastic band or tourniquet placed around the upper arm to cause
the vein to swell with blood
- Components:
1. White blood cell count (WBC): presence of infection
2. Differential white blood cell count: specific patterns of WBC
3. Red blood cell count (RBC): carries oxygen and carbon dioxide from lungs to tissue and vice versa
4. Hematocrit (Hct): measures RBC mass
5. Hemoglobin (Hgb): main component of RBC
6. Red blood cell indices: calculated values of size and Hgb content of RBCs, important in anemia evaluation
7. Platelet count: necessary for clotting and control of bleeding
8. Red blood cell distribution width (RDW): indicates degree variability and abnormal cell size
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9. Mean platelet volume (MPV): index of platelet production

Red Blood Cells (RBC)

- Red blood cells or erythrocytes, transport oxygen from the lungs to the bodily tissues
- produced in the red bone marrow, can survive in the peripheral blood for 120 days, and are removed
from the blood through the bone marrow, liver, and spleen.
Normal values for red blood cell count:
✓ Male adult: 4.5 – 6.2 million/mm3
✓ Female adult: 4.5 – 5.0 million/mm3
Indications of RBC count:Helps in diagnosing anemia and blood dyscrasia.

Hemoglobin (Hgb)
- is the protein component of red blood cells that serves as a vehicle for oxygen and carbon dioxide
transport.
- It is composed of a pigment (heme) which carries iron, and a protein (globin).
- The hemoglobin test is a measure of the total amount of hemoglobin in the blood.
Normal values chart for hemoglobin count:
✓ Male adult: 14 – 16.5 g/dL
✓ Female adult: 12 – 16 g/dL
Indications of Hemoglobin count:
✓ Hemoglobin count is indicated to help measure the severity of anemia (low hemoglobin) or
polycythemia (high hemoglobin).
✓ Monitor the effectiveness of a therapeutic regimen.
Increased Hemoglobin Levels Decreased Hemoglobin Levels
• •
Chronic obstructive pulmonary disease Anemia
• Congenital heart disease • Cancer
• Congestive heart disease • Chronic hemorrhage
• Dehydration • Hemolysis
• Hemoconcentration of the blood • Kidney disease
• High altitudes • Lymphoma
• Polycythemia vera • Neoplasia
• Severe burns • Nutritional deficiency
• Sarcoidosis
• Severe hemorrhage
• Sickle cell anemia
• Splenomegaly
• Systemic lupus erythematosus
Hematocrit (Hct)
- Hematocrit or packed cell volume (Hct, PCV, or crit) represents the percentage of the total blood volume
that is made up of the red blood cell (RBC)
Normal values for hematocrit count:
✓ Male adult: 42 – 52%
✓ Female adult: 35 – 47%

Increased Hematocrit Levels Decreased Hematocrit Levels

• Burns • Anemia
• •
Chronic obstructive pulmonary disease Bone marrow failure
• Congenital heart disease • Hemoglobinopathy
• Dehydration • Hemolytic reaction
• Eclampsia • Hemorrhage
• Erythrocytosis • Hyperthyroidism
• Polycythemia Vera • Leukemia
• Severe dehydration • Liver cirrhosis
• Malnutrition
• Multiple myelomas
• Normal pregnancy
• Nutritional deficiency
• Rheumatoid arthritis

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Red Blood Cell Indices

- Red blood cell indicates (RBC Indices) determine the characteristics of an RBC. It is useful in diagnosing
pernicious and iron deficiency anemias and other liver diseases.
✓ Mean corpuscular volume (MCV): The average size of the individual RBC.
✓ Mean corpuscular hemoglobin (MCH): The amount of Hgb present in one cell.
✓ Mean corpuscular hemoglobin concentration (MCHC): The proportion of each cell occupied by the
Hgb.
Normal Lab Values for RBC Indices are:
✓ Mean corpuscular volume (MCV): Male: 78 – 100 μm3; Female: 78 – 102 μm3
✓ Mean corpuscular hemoglobin (MCH): 25 – 35pg
✓ Mean corpuscular hemoglobin concentration (MCHC): 31 – 37%

Serum Iron (Fe)

- Iron is essential for the production of blood helps transport oxygen from the lungs to the tissues and
carbon dioxide from the tissues to the lungs.
Normal lab values for serum iron:
✓ Male adult: 65 – 175 mcg/dL
✓ Female adult: 50 – 170 mcg/dL
Indication of serum iron:
- Helps in diagnosing anemia and hemolytic disorder.

Increased Serum Iron Levels Decreased Serum Iron Levels

• Hemochromatosis • Chronic blood loss
• Hemosiderosis • Chronic gastrointestinal blood loss
• Hemolytic anemia • Chronic hematuria
• Hepatic necrosis • Chronic pathologic menstruation
• Hepatitis • Inadequate absorption of iron
• Iron poisoning • Iron deficiency anemia
• Lead toxicity • Lack of iron in the diet
• Massive transfusion • Neoplasia
• Pregnancy (late stages)

Nursing considerations for serum iron:

✓ Recent intake of a meal containing high iron content may affect the results.
✓ Drugs that may cause decreased iron levels include adrenocorticotropic hormone, cholestyramine,
colchicine, deferoxamine, and testosterone.
✓ Drugs that may cause increased iron levels include dextrans, ethanol, estrogens, iron preparations,
methyldopa, and oral contraceptives.

White Blood Cells (WBC)

- The normal laboratory value for WBC count has two components: the total number of white blood cells
and differential count.
- WBC count assesses the total number of WBC in a cubic millimeter of blood. White blood cell differential
provides specific information on white blood cell types
Normal lab values for white blood cell count and WBC differential:
✓ WBC Count: 4,500 to 11,000 cells/mm³
✓ Neutrophils: 55 – 70% or 1,800 to 7,800 cells/mm³
✓ Lymphocytes: 20 – 40% or 1,000 to 4,800 cells/mm³
✓ Monocytes: 2 – 8% or 0.0 to 800 cells/mm³
✓ Eosinophils: 1 – 4% or 0.0 to 450 cells/mm³
✓ Basophils: 0–2% or 0.0 to 200 cells/mm³
✓ Bands: 0–2 % or 0.0 to 700 cells/mm³

Increased WBC Count (Leukocytosis) Decreased WBC Count (Leukopenia)

• Inflammation • Autoimmune disease
• Infection • Bone marrow failure
• Leukemic neoplasia • Bone marrow infiltration (e.g., myelofibrosis)
• Stress • Congenital marrow aplasia
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• Tissue necrosis • Drug toxicity (e.g., chloramphenicol)
• Trauma • Nutritional deficiency
• Severe infection
Nursing consideration for WBC count:
✓ A high total WBC count with a left shift means that the bone marrow will release an increased amount
of neutrophils in response to inflammation or infection.
✓ A “shift to the right” which is usually seen in liver disease, megaloblastic and pernicious anemia,
and Down syndrome, indicates that cells have more than the usual number of nuclear segments.
✓ A “shift to the left” indicates an increased number of immature neutrophils is found in the blood.
✓ A low total WBC count with a left shift means a recovery from bone marrow depression or an infection
of such intensity that the demand for neutrophils in the tissue is greater than the capacity of the bone
marrow to release them into the circulation.

Platelets (PLT)
- are produced in the bone marrow and play a role in hemostasis. Platelets function in hemostatic plug
formation, clot retraction, and coagulation factor activation.
- Normal values for platelet count: 150,000 to 400,000 cells/mm³

Increased platelet count Decreased platelet count (thrombocytopenia)

(thrombocytosis)
• Iron deficiency anemia • Cancer
• Malignant disorder • Chemotherapy
• Polycythemia vera • Disseminated intravascular coagulation
• Postsplenectomy syndrome • Hemolytic anemia
• Rheumatoid arthritis • Hemorrhage
• Hypersplenism
• Immune thrombocytopenia
• Infection
• Inherited thrombocytopenia disorders such as Bernard-Soulier, Wiskott-
Aldrich, or Zieve syndromes
• Leukemia and other myelofibrosis disorders
• Pernicious anemia
• Systemic lupus erythematosus
• Thrombotic thrombocytopenia

[Link] Sedimentation Rate (ESR)

- is a measurement of the rate at which erythrocytes settle in a blood sample within one hour.
- Normal lab values for erythrocyte sedimentation rate: 0 – 30 mm/hour (value may vary depending on
age)
- Indication for Erythrocyte Sedimentation Rate:
✓ Assist in the diagnosis of conditions related to acute and chronic infection, inflammation, and tissue necrosis
or infarction.
Increased ESR Levels Decreased ESR Levels
• Bacterial infection • Hypofibrinogenemia
• Chronic renal failure • Polycythemia vera
• Hyperfibrinogenemia • Sickle cell anemia
• Inflammatory disease • Spherocytosis
• Macroglobulinemia
• Malignant diseases
• Severe anemias such as vitamin B12 deficiency or iron deficiency

Nursing Considerations
1. Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured.
2. Encourage to avoid stress if possible because altered physiologic status influences and changes normal
hematologic values.
3. Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of
lipidemia.
4. Apply manual pressure and dressings over puncture site on removal of dinner.
5. Monitor the puncture site for oozing or hematoma formation.
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6. Instruct to resume normal activities and diet.

3. Culture & Sensitivity/Antibiotic Susceptibility Testing

- To determine the likelihood that a particular antibiotic or antifungal drug will be effective in stopping
the growth of the bacteria or fungi causing your infection.
- Sample: eg. Wound, urine, blood, sputum
- No preparation
- Susceptibility testing is performed on bacteria or fungi causing an individual's infection after they have
been recovered in a culture of the specimen; determine potential effectiveness of specific antibiotics or
if bacteria developed resistance to certain antibiotics.
- Helps select drug/s that is most effective for treatment.
- Performed when:
✓ when the culture is positive for one or more pathogens.
✓ when an infection does not respond to treatment
- A sample for culture and susceptibility testing should be collected before the start of any treatment with
an antimicrobial drug, unless the test is used to monitor the effectiveness of treatment.
- When to get the results: 24-48 hours for bacterial cultures; 6-8 weeks for fungal culture and TB

Results
✓ Susceptible — likely, but not guaranteed to inhibit the pathogenic microbe; may be an appropriate
choice for treatment
✓ Intermediate — may be effective at a higher dosage, or more frequent dosage, or effective only in
specific body sites where the antibiotic penetrates to provide adequate concentrations
✓ Resistant — not effective at inhibiting the growth of the organism in a laboratory test; may not be an
appropriate choice for treatment

Microbes and resistance to antimicrobial drugs

- the most susceptible microbes are the ones that are killed first. If treatment is stopped before all of
the pathogens are killed, the survivors may develop a resistance to that particular antimicrobial drug
- Resistance can spread when resistant microbes share their genetic material with susceptible ones. This
may occur more frequently in a healthcare setting, where many patients are treated with antimicrobial
drugs. For instance, resistant strains of bacteria, such as methicillin resistant Staphylococcus
aureus (MRSA), have been a problem in hospitals for decades and are increasingly common in the
community.

Principles in Specimen Collection

1. Contaminated and improperly collected specimens will produce false results which will adversely affect
in the diagnosis and treatment of clients.
2. Specimens allowed to stand at the room temperature for a long time will give a false result
Blood chemistry is not uniform throughout the day, it varies with the food intake.
3. The accuracy and reliability of findings depend upon the correct method of collection, transportation of
the specimens to the laboratory and recording of reports. Inaccurate results may mislead the physician
in the diagnosis and treatment of clients
4. Specimens serve as a media for transmission of disease producing organisms to the personnel who
handle them carelessly.

C. Analysis/Nursing Diagnoses
1. Risk for infection related to impaired immunity.
2. Risk for infection related to tissue damage.
3. Risk for injury related to impaired immunity.
4. Impaired skin integrity related to interruption of circulation
5. Imbalanced nutrition less than body requirements related to poor dietary habits
6. Imbalanced nutrition less than body requirements related to GI dysfunction.

D. Planning for Health Promotion, Restoration & Maintenance

General objective for interventions:

-Prevention of exposure to infectious organisms.
-Monitor and reduce the spread of infection.

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-Maintain resistance to infection.
-Clients and families learn about infection control.

E. Implementation
1. Pharmacologic Agents (including Nursing Considerations)
✓ Anti-infective agents are drugs utilized to exert effect on invading foreign organisms on the body,
especially those which can cause infection
✓ Drug resistance remains to be the major challenge in the use of anti-infectives against infections.
Emergent strains are rapidly adapting to repel the effects of anti-infectives.

Therapeutic Action
✓ Anti-infective agents act on invading organisms in several different ways as mentioned above.
✓ The goal of therapy is interference with the normal function of the invading organisms to prevent
them from reproducing and thereby causing cell death.
✓ Narrow-spectrum anti-infectives are agents that are so selective in their action that they are
effective against only a few microorganisms.
✓ Broad-spectrum anti-infectives are agents that interfere with biochemical reactions in many
different kinds of microorganisms.
✓ Anti-infectives that can cause cell death are said to have bactericidal effects.
✓ Anti-infectives that can interfere with the ability of the cells to reproduce or divide are said to
have bacteriostatic effects.

RESISTANCE
 Ways that microorganisms can develop resistance:
✓ Enzyme production. Strains of bacteria that were once susceptible to penicillin can now produce an
enzyme called penicillinase which inactivates penicillins before they can exert their effect to the
bacteria.
✓ Cell membrane permeability alteration. This prevents the drug from entering the cell. Some bacteria
alter transport systems to prevent the drug from being transported actively into the cell.
✓ Binding site alteration. Prevents the drug from being accepted into the cell.
✓ Chemical production. Acts as antagonist to the drug.

• Vancomycin (Vancocin, Vancoled) is an antibiotic that interferes with cell wall synthesis in susceptible
bacteria; used for patients who are allergic to penicillin and cephalosporins; staphylococcal infections
resistant to penicillins and/or cephalosporins. It is highly-toxic that it is reserved only for certain
situations as it can cause renal failure, ototoxicity, superinfections, and red man syndrome (sudden
and severe hypotension, fever, chills, paresthesia, and erythema or redness of the neck and back).

Prevention of Resistance
✓ Drug dosing. The nurse may collaborate with the physician for around-the-clock dosing to eliminate the
peaks and valleys in drug concentration. This also helps maintain a constant therapeutic level to prevent
the emergence of resistant microbes during times of low concentration.
✓ Drug duration. The nurse should emphasized the importance of finishing the prescribed duration
(correct number of times each day for the full number of days) of anti-infective therapy to ensure that
microbes are completely eliminated and are not given the chance to grow and develop resistant strains.

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Nursing Considerations
✓ Assess for the mentioned cautions and contraindications (e.g. drug allergies, CNS depression, CV
disorders, etc.) to prevent any untoward complications.
✓ Perform a thorough physical assessment (other medications taken, CNS, skin, respirations, and
laboratory tests like renal functions tests and complete blood count or CBC) to establish baseline data
before drug therapy begins, to determine effectiveness of therapy, and to evaluate for occurrence of
any adverse effects associated with drug therapy.
✓ Perform culture and sensitivity tests at the site of infection to ensure appropriate use of the drug.
✓ Conduct orientation and reflex assessment, as well as auditory testing to evaluate any CNS effects of the
drug (aminoglycosides).

1. Nutrition & Diet Therapy

➢ Vitamin C- is an important physiological antioxidant and may even help regenerate other antioxidants
in your body.
E.g. Guavas, citrus fruits. Red bell pepper, strawberries, papaya, kale
➢ Vitamin E – has antioxidant properties can protect your cells from oxidation and thereby contribute to
preventing problems from infection. This nutrient may also have an effect on respiratory tract
infections.
E.g. Sunflower seeds and almonds, spinach, avocados, squash, olive oil
➢ Carotenoids- include beta-carotene and lycopene, are also important for maintaining your immune
system.
E.g. Sweet potatoes, carrots, dark leafy greens, squash, cantaloupe, red bell peppers
➢ Zinc- is a cofactor for many enzymes required for cell membrane repair, the production of collagen,
protein synthesis and cell proliferation, all of which are essential for tissue regeneration
E.g. Oysters, red meat poultry, seafood, beans, nuts
➢ Antibacterial Herbs and Spices- contain antimicrobial and antibacterial compounds that help fight
infection.
E.g. Ginger, Oregano, thyme, cinnamon

2. Client Education
1. Be aware of healthcare-associated infections (HAIs).
2. Feel empowered to speak up for their care.
3. Know to clean their hands often.
4. Understand the basics of safe injection practices.
5. Know to monitor the cleanliness of their area.
6. . Be prepared to ask questions about their medications.
7. 7. Know how to practice good post-surgical care.
8. [Link] how to care for their devices.
9. [Link] a plan to stay up to date with their vaccinations.
10. 10. Know that they can always ask to speak with an infection preventionist (IP).

INFECTIOUS DISORDERS OF ADULTS

EBOLA

- Deadly disease which most commonly affects people and nonhuman primates (such as monkeys,
gorillas, and chimpanzees)
- caused by an infection with a group of viruses within the genus Ebolavirus (e.g.: Ebola, Sudan, Taï Forest,
and Bundibugyo viruses)
- was first discovered in 1976 near the Ebola River in what is now the Democratic Republic of Congo
- Mode of transmission: direct contact (such as through broken skin or mucous membranes in the eyes,
nose, or mouth) with:
o Blood or body fluids (urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who
is sick with or has died from Ebola virus disease (EVD).
o Objects (such as clothes, bedding, needles, and medical equipment) contaminated with body
fluids from a person who is sick with or has died from EVD.
o Infected fruit bats or nonhuman primates (such as apes and monkeys).
o Semen from a man who recovered from EVD (through oral, vaginal, or anal sex)
- incubation period from exposure to first symptoms ranges from 2 to 21 days

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Pathophysiology
- Ebola virus enters the patient and infects many cell types, including monocytes, macrophages, dendritic
cells, endothelial cells, fibroblasts, hepatocytes, adrenal cortical cells, and epithelial cells.
- Ebola virus migrates from the initial infection site to regional lymph nodes and subsequently to the liver,
spleen, and adrenal gland
- Hepatocellular necrosis occurs and is associated with dysregulation of clotting factors and subsequent
coagulopathy
- Adrenocortical necrosis also can be found and is associated with hypotension and impaired steroid
synthesis
- Ebola virus appears to trigger a release of pro-inflammatory cytokines with subsequent vascular leak and
impairment of clotting ultimately resulting in multiorgan failure and shock

Clinical Manifestations
- The initial clinical manifestations include high fever, muscle aches, and fatigue
- Between the third and fifth symptomatic day:
o the patient often develops severe diarrhea, abdominal pain, and vomiting
o great risk of severe dehydration (over 5 L of liquid stool per day)
o This stage can persist for a week or more, and many patients develop hemodynamic shock
o may also show increasing neurologic symptoms such as confusion, agitation, delirium, or
encephalitis
o 5% will develop bleeding or hemorrhage, a very poor prognostic indicator
- Patients who do not die during the first 2 weeks of the disease are likely to survive

Assessment and Diagnostic Findings

- course of the illness typically progresses from “dry” symptoms initially (such as fever, aches and pains,
and fatigue), and then progresses to “wet” symptoms (such as diarrhea and vomiting) as the person
becomes sicker
- To determine whether EVD is a possible diagnosis, there must be a combination of symptoms suggestive
of EVD AND a possible exposure to EVD within 21 days before the onset of symptoms
- Blood samples from the patient should be collected and tested to confirm infection- may take up to
after symptoms start for the Ebola virus to reach detectable levels
- Polymerase chain reaction (PCR)
➢ is one of the most commonly used diagnostic methods because of its ability to detect low levels
of Ebola virus.
➢ can detect the presence of a few virus particles in small amounts of blood
➢ the ability to detect the virus increases as the amount of virus increases during an active infection
➢ When the virus is no longer present in great enough numbers in a patient’s blood, PCR methods
will no longer be effective

Medical Management
✓ is largely supportive maintenance of the circulatory system and respiratory systems
✓ Providing fluids and electrolytes through infusion intravenously
✓ Offering oxygen therapy to maintain oxygen status
✓ Using medication to support blood pressure, reduce vomiting and diarrhea and to manage fever and
pain
✓ Antiviral drugs regeneron (REGN-EB3) and mAb114 currently remain in use for patients with confirmed
Ebola
✓ December 19,2019- The U.S. Food and Drug Administration (FDA) approved the Ebola vaccine rVSV-
ZEBOV (tradename “Ervebo”). This is a single dose vaccine regimen that has been found to be safe and
protective against only the Zaire ebolavirus species of ebolavirus. This is the first FDA approval of a
vaccine for Ebola.
✓ Another investigational vaccine was developed and introduced under a research protocol in 2019 to
combat an Ebola outbreak in the Democratic Republic of the Congo. This vaccine requires two doses
with an initial dose followed by a second “booster” dose 56 days later. The second vaccine is also
designed to protect against only the Zaire ebolavirus species of Ebola.

Nursing Management
✓ Supportive care for a patient with such a devastating disease requires psychological support for the
patient and family

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✓ the patient should be promptly isolated in a private room
✓ observe standard and transmission-based protocols
✓ health care workers should correctly wear complete PPE
✓ Equipment used for the patient with Ebola virus should be used solely for that patient and should be
disposed after use. If equipment must be reused, it should be sterilized or scrupulously cleaned with a
bleach-based solution before reuse
✓ Visitors should be restricted. Exceptions may be considered on an individual basis, and then visitors
should be trained and a logbook kept of all who enter the room

CORONAVIRUSES

- Numerous coronaviruses, first discovered in domestic poultry in the 1930s, cause respiratory,
gastrointestinal, liver, and neurologic diseases in animals. Only 7 coronaviruses are known to cause
disease in humans.
- Four of the 7 coronaviruses most frequently cause symptoms of the common cold.
- Three of the 7 coronaviruses cause much more severe, and sometimes fatal, respiratory infections in
humans than other coronaviruses and have caused major outbreaks of deadly pneumonia in the 21st
century:
❖ SARS-CoV was identified in 2003 as the cause of an outbreak of severe acute respiratory syndrome
(SARS) that began in China near the end of 2002.
❖ MERS-CoV was identified in 2012 as the cause of Middle East respiratory syndrome (MERS).
❖ SARS-CoV-2 is a novel coronavirus identified as the cause of coronavirus disease 2019 (COVID-19) that
began in Wuhan, China in late 2019 and spread worldwide.
- These coronaviruses that cause severe respiratory infections are zoonotic pathogens, which begin in
infected animals and are transmitted from animals to people. SARS-CoV-2 has significant person-to-
person transmission.

Mers-Cov
- Middle East Respiratory Syndrome (MERS) is an illness caused by a virus (a coronavirus) called Middle
East Respiratory Syndrome Coronavirus (MERS-CoV)
- Most MERS patients developed severe respiratory illness with symptoms of fever, cough and shortness
of breath. About 3 or 4 out of every 10 patients reported with MERS have died
- Through first reported in Saudi Arabia, it was later identified that the first known cases of MERS occurred
in Jordan in April 2012.
- A large MERS outbreak occurred in the Republic of South Korea linked to a traveler from the Arabian
Peninsula in 2015
- Transmission: like other coronaviruses, likely spreads from an infected person’s respiratory secretions,
such as through coughing. However, the precise ways that it spreads is not fully understood. MERS-CoV
has spread from ill people to others through close contact, such as caring for or living with an infected
person
- The symptoms of MERS start to appear about 5 or 6 days after a person is exposed, but can range from
2 to 14 days

Pathophysiology
- Compared with severe acute respiratory syndrome coronavirus (SARS-Cov), MERS-CoV can establish
infection in monocyte-derived macrophages (MDMs) and macrophages
- The virus induces the release of proinflammatory cytokines, leading to severe inflammation and tissue
damage, which may manifest clinically as severe pneumonia and respiratory failure.
- Vascular endothelial cells located in the pulmonary interstitium may also be infected by MERS-CoV, and,
because MERS-CoV receptor is expressed in different human cells and tissues, dissemination of the
infection may occur.
- lymphopenia has been noted in most patients infected with MERS-CoV, as was noted in SARS infections

Clinical Manifestations
- flu-like symptoms, including fever, Rhinorrhea, mostly clear Pulmonary findings, including hypoxemia,
rhonchi, and rales (some patients may have a normal auscultation), Tachycardia
- cough, shortness of breath
- Hypotension may occur with severe illness, reflecting systemic inflammatory response syndrome

- diarrhea and nausea/vomiting

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- more severe complications followed, such as pneumonia and kidney failure
- Most of the people who died had a pre-existing medical condition that weakened their immune system
- Some infected people had mild symptoms (such as cold-like symptoms) or no symptoms at all

Assessment and Diagnostic Findings

- rRT-PCR assay- FDA issued an Emergency Use Authorization (EUA) on June 5, 2013, to authorize use of
CDC’s 2012 real-time reverse transcription–PCR assay to test for MERS-CoV in clinical respiratory, serum,
and stool specimens.
- Serology- Serologic testing for MERS-CoV is available as a research/surveillance test from the CDC; it is
not considered a diagnostic test but may offer valuable epidemiologic data;
- Laboratory studies- Laboratory findings at presentation may include leukopenia, lymphopenia,
thrombocytopenia, and elevated lactate dehydrogenase levels; these are most likely with increasing
severity of illness.
- Imaging studies- Chest imaging findings are abnormal in more than 80% of MERS cases

Medical management
✓ There is no specific antiviral treatment recommended for MERS-CoV infection
✓ supportive; this includes hydration, antipyretic, analgesics, respiratory support, and antibiotics if
needed for bacterial superinfection
✓ Acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen are given to relieve
fever and muscle aches
✓ the patient should be placed in an airborne infection isolation room
✓ For severe cases, current treatment includes care to support vital organ functions.
✓ Prevention:
- Handwashing
- Covering nose and mouth with a tissue when coughing or sneezing, with proper disposal of tissue
- Avoid touching eyes, nose, and mouth with unwashed hands
- Avoid personal contact, such as kissing, or sharing cups or eating utensils, with sick people
- Clean and disinfect frequently touched surfaces and objects, such as doorknobs
- Avoid touching animals when travelling
✓ Treatment
- no specific antiviral treatment recommended for MERS-CoV infection. Individuals with MERS often
receive medical care to help relieve symptoms
- No MERS-CoV vaccine is commercially available
- Clinical trials are needed to establish any benefit from ribavirin and/or interferon alfa
-
Nursing Management
✓ History- keys to the case definition of MERS is a history of residence or travel in the Arabian Peninsula,
in countries where MERS-CoV is known to be circulating in dromedary camels, or where human
infections have recently occurred and exposure within the incubation period of 14 days
✓ Monitor the patient’s temperature and respiratory rate
✓ Include the patient and family in creating the teaching plan, beginning with establishing objectives and
goals for learning at the beginning of the session
✓ Ensure patent airway. Teach the patient the proper ways of coughing and breathing. (e.g., take a deep
breath, hold for 2 seconds, and cough two or three times in succession); position the patient upright if
tolerated
✓ Patients may require nebulized medications and sometimes intubation- both of which increase the risk
for the virus to become airborne for some time in the environment. To avoid further transmission,
patients should be in negative pressure environments during nebulization and intubation.
✓ For nausea and diarrhea- Infectious waste and laundry must be handled in a way to avoid further
infections
✓ Dehydration, diarrhea, the need for isolation and immobility due to general weakness all contribute to
the patients’ increased risk of developing wounds. Nurses increased their vigilance for wound
prevention and care during the epidemic
✓ Reduce increase in temperature. Adjust and monitor environmental factors like room temperature and
bed linens as indicated; encourage ample fluid intake by mouth; eliminate excess clothing and covers,
and give antipyretic medications as prescribed.
✓ encourage patient to increase fluid intake to 3 liters per day within the limits of cardiac reserve and renal
function
✓ Reduce patient anxiety

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CoVid-19
- is a disease caused by a new strain of coronavirus called severe acute respiratory syndrome coronavirus
2 (SARS-CoV-2)
- was first reported in late 2019 in Wuhan, China and has since spread extensively worldwide
- has an incubation period that ranges from 2-14 days, with symptoms appearing on average around day
5 following exposure
- SARS-CoV-2 virus primarily affects the respiratory system, although other organ systems are also
involved
- The risk of serious disease and death in people with COVID-19 increases with age and in people with
other serious medical disorders, such as heart, lung, kidney, or liver disease, diabetes, obesity, or
immunocompromising disorders

Transmission
- spread mainly from person to person, mainly through respiratory droplets produced when an infected
person coughs, sneezes, or talks. These droplets can land in the mouths or noses of people who are
nearby or possibly be inhaled into the lungs. Spread is more likely when people are in close contact with
one another (within about 6 feet).
- it may be possible to get COVID-19 by touching a surface or object that has the virus on it and then
touching one’s own mouth, nose, or eyes
- There are procedures that can aerosolize the virus resulting in airborne transmission of the virus. These
procedures include, but are not limited to positive pressure ventilation, endotracheal intubation or
extubation, bronchoscopy, airway suction, ventilator care, tracheostomy care, Chest PT, nebulizer
treatment, and sputum induction
- can be transmitted by people before they exhibit symptoms and even by people who are infected but
never develop symptoms

Epidemiology
- Following the outbreak in China, SARS-CoV-2 has spread worldwide. As of early April 2020, the reported
number of COVID-19 patients is highest in the U.S., followed by Spain, Italy, Germany, France and China.
- more men than women suffered from severe disease and died
- The situation in the Philippines has also rapidly evolved, with a single case identified last January 30,
2020, to over 200 cases by March 16, [Link] community transmission led to the implementation
of intensified quarantine measures in March 2020. Cases plateaued in May which led to the relaxation
of quarantine measures. However, by mid-June, there has been a resurgence of cases within the National
Capital Region and in Cebu. As of July 2020, the country has more than 60,000 reported cases with more
than 1,000 deaths

Clinical Manifestations
- respiratory symptoms of COVID-19 are extremely heterogeneous, ranging from minimal symptoms to
significant hypoxia with ARDS
- The most common are fever, dry cough, and fatigue
- Other symptoms:
o Shortness of breath or difficulty breathing
o Muscle or body aches
o Headache
o New loss of taste or smell
o Sore throat
o Congestion or runny nose
o Nausea or vomiting
o Diarrhea
o Discoloration of fingers or toes
- Emergency warning signs:
o Difficulty breathing
o Persistent pain or pressure in the chest
o New confusion
o Inability to wake or stay awake
o Bluish lips or face
- other serious complication include:
o Heart disorders including arrhythmias, heart muscle disorders, and acute heart injury

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o Coagulation disorders including blood clots in small and large blood vessels as well as bleeding

Assessment and Diagnostic Findings

✓ Travel history. Health care providers should obtain a detailed travel history for patients being evaluated
with fever and acute respiratory illness
There are two different types of tests – diagnostic tests and antibody tests. (source: FDA)

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Ancillary Tests
The following diagnostics are recommended when COVID-19 is suspected to guide management:
✓ Complete Blood Count (CBC)
✓ Metabolic panel: creatinine, LFTs, sodium, potassium, magnesium, calcium, albumin
✓ Inflammatory markers: lactate dehydrogenase (LDH), Ferritin, C-reactive protein (CRP), and procalcitonin
✓ Prothrombin and D-Dimer
✓ Arterial blood gas (ABG) measurement
✓ Blood cultures if concomitant bacterial infection is suspected
✓ Respiratory tract specimen for influenza testing
✓ Sputum, endotracheal aspirate (ETA), or bronchoalveolar lavage fluid culture and sensitivity
✓ Chest x-ray
✓ High resolution chest CT scan plain
✓ ECG

Medical management

1. Supportive Care
✓ These include antipyretics for fever, oral fluids for hydration, isolation at home or in temporary
treatment and monitoring facilities [Strong recommendation, low quality of evidence]
✓ Routine empiric antibiotics and routine anti-influenza drugs are NOT recommended for mild COVID-19
disease [Strong recommendation, low quality of evidence]

2. Drugs with anti-SARS CoV-2 activity

A. REMDESIVIR
✓ binds to the viral RNA-dependent RNA polymerase, inhibiting viral replication through premature
termination of RNA transcription
✓ Remdesivir may be given to hospitalized adult patients with severe COVID-19 in the setting of a clinical
trial or under compassionate use, pending the results of ongoing randomized clinical trials and full
analysis of completed trials
✓ There is insufficient evidence to recommend the routine use of remdesivir among hospitalized patients
with mild to moderate COVID disease except in the context of a clinical trial.

B. CHLOROQUINE OR HYDROXYCHLOROQUINE
✓ CQ is used mainly as an anti-malarial agent, while HCQ is used for autoimmune diseases such as SLE and
rheumatoid arthritis
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✓ CQ and HCQ appear to block viral entry into cells
✓ the clinical safety profile of hydroxychloroquine is better than that of chloroquine during long-term use,
allows higher daily dose and has fewer side effects
✓ Chloroquine (CQ) or hydroxychloroquine (HCQ) as monotherapy or in combination with a macrolide (e.g.
azithromycin) or an antiviral agent (lopinavir-ritonavir, favipiravir) is NOT recommended for hospitalized
patients with probable or confirmed COVID-19 pneumonia
✓ Chloroquine or hydroxychloroquine is not recommended for outpatients with early or mild COVID-19
disease except in the context of a clinical trial.
✓ Chloroquine or hydroxychloroquine is not recommended for prophylaxis or prevention of COVID-19
except in the context of a clinical trial. [Strong recommendation, low quality of evidence]

C. LOPINAVIR-RITONAVIR
✓ Lopinavir is a human immunodeficiency virus 1 (HIV-1) protease inhibitor administered in fixed-dose
combination with ritonavir (LPV/r), which increases lopinavir concentration
✓ prevent viral replication
✓ Lopinavir-ritonavir (LPV/r) as monotherapy or in combination with hydroxychloroquine or other
immunomodulators is NOT recommended among hospitalized patients with probable or confirmed
COVID-19 pneumonia. [Strong recommendation, moderate quality of evidence]

D. FAVIPIRAVIR
✓ selectively inhibits the RNA-dependent RNA polymerase, halting viral replication
✓ There is insufficient evidence to recommend the routine use of favipiravir in the treatment of COVID-19
except in the context of a clinical trial or for compassionate use among patients with moderate COVID-
19 disease

3. Immunomodulating Agents

A. CORTICOSTEROID THERAPY (DEXAMETHATSONE)

✓ Corticosteroids inhibit multiple inflammatory cytokines resulting in decreased edema, capillary leakage,
and migration of inflammatory cells, thereby globally suppressing the inflammatory response
✓ is recommended as adjunctive treatment for COVID-19 patients requiring oxygen support and for
patients on mechanical ventilation
✓ Corticosteroid therapy (dexamethasone) is not recommended for COVID-19 patients who do not require
oxygen support (mild to moderate disease severity). [Strong recommendation, moderate quality of
evidence]
✓ Inhaled steroids are NOT recommended for the treatment of COVID-19 pending the results of ongoing
studies.
✓ Oral, inhaled or IV steroids are NOT recommended for prophylaxis or prevention of COVID-19.

B. CONVALESCENT PLASMA (CP)

✓ refers to the administration of antibodies against SARS-CoV-2 with the use of plasma from recovered
COVID-19 patients
✓ It is a means of antibody transfer to provide passive immunity until the individual can develop an active
immune response, with the hope that clinical outcomes can be improved in the recipient
✓ This mode of passive antibody therapy had been previously used to provide immediate immunity to
susceptible individuals against pandemic viruses such as SARS, MERS, A(H1N1) influenza and Ebola
✓ There is insufficient evidence to support the routine use of convalescent plasma for critically ill COVID-
19 patients except in the context of a clinical trial or for compassionate use

C. INTRAVENOUS IMMUNOGLOBULIN G
✓ is a mixture of polyclonal immunoglobulin and proteins pooled from healthy donors
✓ Its mechanism of action is twofold – one, as a neutralizing antibody and second as an anti-inflammatory
or immunomodulator of the cytokine response
✓ There is insufficient evidence to support the use of intravenous immunoglobulin (IVIg) for the
management of COVID-19 among severe hospitalized patients except in the context of a clinical trial

D. HEMOPERFUSION
✓ Cytokine release syndrome is prevalent in severe cases of COVID-19. Hemoperfusion devices or
extracorporeal blood purification has been proven to effectively remove the released inflammatory
cytokines

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✓ There is insufficient evidence to support the routine use of hemoperfusion as adjunctive management
for severe COVID-19 patients suspected to have cytokine storm except for compassionate use.

4. Adjunctive Therapy

A. VITAMIN C AND ZINC

✓ Vitamin C is a water-soluble vitamin with antioxidant properties. In in –animal studies, it is thought to
attenuate organ induced injury. Zinc is an essential mineral used to boost the immune system
✓ There is insufficient evidence to support the use of vitamin C and zinc as adjunctive treatment for COVID-
19.

5. Vaccination
✓ Development of a vaccine is currently underway, however given the length of time for clinical trials, the
vaccine will not be available to the general public for at the least 12-18 months.

Nursing Management

✓ Follow established occupational safety and health procedures, avoid exposing others to health and
safety risks and participate in employer-provided occupational safety and health training
✓ Use provided protocols to assess, triage and treat patients
✓ Treat patients with respect, compassion, and dignity
✓ Maintain patient confidentiality
✓ Swiftly follow established public health reporting procedures of suspected and confirmed cases
✓ Self-monitor for signs of illness and self-isolate or report the illness to managers, if it occurs
✓ Advise management if you are experiencing signs of undue stress or mental health challenges that
require support interventions
✓ Monitor the patient’s temperature; and monitor the respiratory rate of the patient as shortness of
breath is another common symptom.
✓ Monitor the patient’s O2 saturation because respiratory compromise results in hypoxia.
✓ Maintain respiratory isolation. Keep tissues at the patient’s bedside; dispose secretions properly;
intsruct the patient to cover mouth when coughing or sneezing; use masks, and advise those entering
the room to wear masks as well; place respiratory stickers on chart, linens, and so on.
✓ Enforce strict hand hygiene. Teach the patient and folks to wash hands after coughing to reduce or
prevent the transmission of the virus.
✓ Manage hyperthermia. Use appropriate therapy for elevated temperature to maintain normothermia
and reduce metabolic needs.
✓ Educate the patient and family. Provide information on disease transmission, diagnostic testing, disease
process, complications, and protection from the virus
✓ Adhere to the standards for donning and doffing PPE when caring for COVID-19 patients.
✓ Avoid touching N95 respirator, facemask, eye goggles, and face shield if wearing during extended use.
✓ Wash hands before donning all PPE. When doffing PPE, wash hands before doffing your goggles, N95
respirator, and face shield, and again after all PPE is doffed
✓ Doff PPE before breaking for meals and taking trips to the rest room.
✓ Eat meals in non-clinical areas.
✓ Disinfect cell phone frequently, and place cellphone in a clear sealable bag that serves as a barrier,
discard the bag before going home, disinfect the cell phone before entering home
✓ Change scrubs and shoes if possible before returning home

HEPATITIS
- Refers to an inflammatory condition of the liver
- commonly caused by a viral infection, but there are other possible causes of hepatitis. These include
nonviral hepatitis that occurs as a secondary result of medications, drugs, toxins, and alcohol.

Functions of the liver:

• bile production, which is essential to digestion
• filtering of toxins from your body
• excretion of bilirubin (a product of broken-down red blood cells), cholesterol, hormones, and drugs
• breakdown of carbohydrates, fats, and proteins
• activation of enzymes, which are specialized proteins essential to body functions

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• storage of glycogen (a form of sugar), minerals, and vitamins (A, D, E, and K)
• synthesis of blood proteins, such as albumin
• synthesis of clotting factors

Assessment and Diagnostics

- HISTORY AND PHYSICAL EXAM- Determine risk factors (infectious or noninfectious hepatitis);
palpation of abdomen for pain and tenderness (enlarged liver), eyes and skin are yellow
- LIVER FUNCTION TESTS and Other blood tests- blood samples; presence of high liver enzymes; check
for virus that cause hepatitis
- HEPATITIS TESTING- for specific hepatitis virus markers to determine type of hepatitis such as
Radioimmunoassay, enzyme linked immunosorbent assay (ELISA), and microparticle enzyme
immunoassay
- ABDOMINAL ULTRASOUND-allows to view liver and nearby organs that may reveal fluid in abdomen,
liver damage/enlargement; liver tumors or abnormalities of gallbladder
- LIVER BIOPSY-invasive procedure; sample tissue of liver through needle; determine infection and
inflammation; areas of liver that appear abnormal

Viral Hepatitis
✓ 5 types: Hepatitis A, B, C, D, and E
✓ Hep. A and E (fecal- oral route)
✓ Hep. B,C and D- share many other characteristics

HEPATITIS A
- Former name: Infectious hepatitis
- Caused by RNA virus of the enterovirus family
- Fecal-oral route- ingestion of foods or liquids infected by virus
- Overcrowding and poor sanitation
- Found in stool of infected pxs; poor hygiene, hand to mouth contact, sewage contaminated waters
- Can be transmitted during sexual activity (oral-anal contact)
- Not transmitted by blood transfusions
- INCUBATION PERIOD: between 2 and 6 weeks (approx. 4 weeks)
- Illness: 4 to 8 weeks
- More severe >40 years old
- Mortality rate of hepatitis A is approximately 0.5% for those younger than 40 years and 1% to 2% for
older adults.
- Morbidity and mortality increases with underlying chronic liver disease

Clinical Manifestations
- Anicteric (without jaundice) & symptomless
- Mild flu-like URTI, with low grade fever
- Anorexia- early symptom (often severe)
- Jaundice and dark urine (later signs)
- Indigestion- vague epigastric distress, nausea, heartburn and flatulence
- Jaundice- perhaps 10 days after its initial appearance

Assessment and Diagnostics

- Enlarged liver and spleen few days after onset
- HAV antigen – present in stool 7-10 days before illness and 2 -3 weeks after symptoms appear
- Analysis of subclasses of immunoglobulins - antibody is acute or past infection.

Prevention
- Scrupulous hand hygiene, safe water supplies, and proper control of sewage disposal are just a few of
these prevention strategies.
- Recommended two-dose vaccine: > 18 years old, 2nd dose given 6 to 12 months after the first.
(Protection against HAV develops within several weeks after the first dose of the vaccine)
- Three doses: children and adolescents (1- 18 yrs old), 2nd dose given 1 month after the 1st dose, and
3rd dose after 6-12 months.
- Recommended for people travelling ( unsatisfactory sanitation and hygiene places); high risk groups:
men to men sex
- Vaccine for community- wide outbreaks

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- Combined HAV and HBV vaccine (Twinrix) for >18 yrs old with indications ( 3 doses, same schedule)
- IM Hepatitis immune globulin: For people who have not been previously vaccinated; given during
incubation period, within 2 weeks of exposure.(6-8 weeks passive immunity; suppress overt symptoms
of disease)
o Susceptible: same household with patient, sex contacts of people w/ HAV
- Pre-exposure prophylaxis of Hepatitis A vaccine: people travelling to developing countries/ poor
sanitation (insufficient time to acquire protection)

Medical Management
- Bed rest – acute stage
- Nutritious diet (important aspect of treatment)
- Small frequent feedings; IV fluids with glucose
- Optimal food and fluid levels are necessary to counteract weight loss and to speed recovery.
- Gradual but progressive ambulation – hastens recovery with periods of rest after activity; not
participate in activities to the point of fatigue

Nursing Management
✓ Assist px and family in coping with temporary disability and fatigue that are common w/ HAV; Educate
them to seek additional healthcare if symptoms persist or worsen.
✓ Diet, rest, follow up blood work, no alcohol as well as sanitation and hygiene measures (particularly
hand hygiene) -> to prevent spread of disease to family members.
✓ Good personal hygiene, stressing careful hand hygiene(after bowel movements and before eating)
✓ Environmental sanitation- safe food and water supply, effective seweage disposal

Health Promotion
✓ Safe practices for preparing and dispensing food
✓ Conscientious individual hygiene.
✓ Proper community and home sanitation.
✓ Community health education programs: vaccination to interrupt community-wide outbreaks.
✓ Recommend pre-exposure vaccination for all children 12– 23 months of age. Continue existing
immunization programs for children 1–18 years of age.
✓ Recommend vaccination for travelers to developing countries, illegal drug users (injection
and noninjection drug users), men who have sex with men, people with chronic liver disease,
people who work with HAV-infected animals or work with HAV in research facilities and recipients
(e.g., hemophiliacs) of pooled plasma products for clotting factor disorders.
✓ Support effective health supervision of schools, dormitories, extended care facilities, barracks, and
camps.

HEPATITIS B
- Transmitted primarily through blood (percutaneous and permucosal routes)
- found in blood, saliva, semen, and vaginal secretions and can be transmitted through mucous
membranes and breaks in the skin.
- carrier mothers to their infants, especially in areas with a high incidence (e.g., Southeast Asia). The
infection usually is not transmitted via the umbilical vein but from the mother at the time of birth and
during close contact afterward.
- has a long incubation period. It replicates in the liver and remains in the serum for relatively long
periods, allowing transmission of the virus.
- Screening of blood donors has greatly reduced the occurrence of HBV after blood transfusion.
- Most people (more than 90%) who contract HBV infection develop antibodies and recover
spontaneously in 6 months.
- Mortality rate: 1 % for acute HBV, 10% Carrier state or chronic hepatitis w/ persistent HBV infection,
hepatocellular injury and inflammation.

Clinical Manifestations
- Incubation period: 1 to 6 months
- s/s: insidious and variable
- Loss of appetite, dyspepsia, abdominal pain, generalized aching, malaise and weakness.
- Jaundice (may or may not be evident); presence of light-colored stools and dark urine (if with jaundice)
- Tender and enlarged liver (12 to 14 cms vertically)
- Palpable and enlarged spleen (few patients)- causes increased vascular pressure from liver disease

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- Posterior cervical lymph nodes may be enlarged (inflammatory/immunological response to host)

Risk Factors
- Close contact with carrier of hepatitis B virus
- Frequent exposure to blood, blood products, or other body fluids
- Health care workers: hemodialysis staff, oncology and chemotherapy nurses, personnel at risk for
needlesticks, operating room staff, respiratory therapists, surgeons, dentists
- Hemodialysis
- IV/injection drug use
- Male homosexual and bisexual activity
- Mother-to-child transmission Multiple sexual partners Receipt of blood or blood products (e.g., clotting
factor concentrate)
- Recent history of sexually transmitted infection
- Tattooing
- Travel to or residence in area with uncertain sanitary conditions

Assessment and Diagnostic Findings

- Presence of HBsAg 1-10 weeks after exposure : 80%-90% infected individuals;
o 2-8 weeks before onset of symptoms or ↑ in transferase (enzyme in liver) levels.
o 6 months or longer after acute infection: HbsAg carriers
- HBeAg: usually appears in serum within 1 week of the appearance of HBsAg, before changes in
aminotransferase levels; disappears from serum within 2 weeks
- HBV DNA: detected by PCR testing (+) serum; same time with HBeAg
- HBcAg: not always detected in serum (does not circulate in significant quantity of blood)

HBV is a deoxyribonucleic acid (DNA) virus composed of the following antigenic particles:
➢ HBcAg—hepatitis B core antigen (antigenic material in an inner core)
➢ HBsAg—hepatitis B surface antigen (antigenic material on the viral surface, a marker of active
replication and infection)
➢ HBeAg—an independent protein circulating in the blood
➢ HBxAg—gene product of X gene of HBV DNA

Each antigen elicits its specific antibody and is a marker for different stages of the disease process:
➢ anti-HBc—antibody to core antigen of HBV; persists during the acute phase of illness; may indicate
continuing HBV in the liver
➢ anti-HBs—antibody to surface determinants on HBV; detected during late convalescence; usually
indicates recovery and development of immunity
➢ anti-HBe—antibody to hepatitis B e-antigen; usually signifies reduced infectivity
➢ anti-HBxAg—antibody to the hepatitis B x-antigen; may indicate ongoing replication of HBV

Medical Management
✓ Alpha-interferon
➢ : single modality of therapy; a regimen of 5 million U daily or 10 million U, 3x weekly for 16 to 24
weeks (remission of disease in approx. 1/3 of pxs); given via injection
➢ S/E: Fever, chills, anorexia, nausea, myalgias, and fatigue
➢ bone marrow suppression, thyroid dysfunction, alopecia and bacterial infections (delayed S/E)
➢ Pegylated interferon or peginterferon (peginterferon alfa-2a [Pegasys]): once-weekly dosing

✓ Entecavir (ETV) and Tenovir (TDF)

➢ oral nucleoside analogs; for chronic Hep B in US.; for HBV-related decompensated cirrhosis &
decompensated liver cirrhosis awaiting liver transplantation (recommended); either can be used
in combination with peginterferon.
➢ loss of detectable virus, improved liver function and reduced progression to cirrhosis
✓ Bed rest until symptoms subside
✓ Restrict activities until hepatic enlargement, level of serum bilirubin & liver enzymes decreased
✓ Maintain adequate nutrition: Protein intake 1.2 to 1.5g/kg/day (no restriction of CHON)
✓ Antacids and antiemetic agents for dyspeptic symptoms and general malaise
✓ All meds are avoided if vomiting occurs
✓ Hospitalization and fluid therapy → if vomiting persists
✓ Is also evaluated for HIV infection (due to mode of transmission)

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Nursing Management
✓ 3 to 4 months or longer : Convalescent period w/ complete symptomatic recovery
✓ Gradual resumption of physical activity after jaundice has resolved
✓ Psychosocial issues: separation from family and friends during acute and infective stages.
✓ Plan: includes family to reduce their fears and anxieties about spread of disease
✓ Promoting home, Community-Based and Transitional Care, Educating patients about self-care.
o provision of adequate rest and nutrition
o educating about risks of contracting HBV, early signs and modes of transmission; avoidance of
drinking alcohol.
✓ Continuance and Transitional Care
o Follow-up visits for px progess and assessment; emphasizes its importance, health promotion
activities and recommended screenings
✓ Avoid substances (medications, herbs, illicit drugs and toxins) that may affect liver function
✓ Enteral feedings: anorexia, nausea and vomiting persist
✓ Monitoring of fluid balance
✓ Abstinence of alcohol during acute illness (6 months after recovery)
✓ Provide intake of 25-30kcal/day: CHON intake of 1.2-1.5g/kg/day
✓ Small frequent meals; minimize periods without food intake

Prevention
✓ Immunization
✓ Avoidance of risk behaviors (sharing of needles, multiple sex partners)
✓ Screening of blood donors (presence of HBAg): lowers risk by blood transfusion
✓ Use of disposable syringe, needles, lancets and NEEDELESS IV sets
✓ Disinfection of work areas (clinical laboratory and hemodialysis unit)
✓ Use of gloves in handling blood or body fluids/secretions
✓ No eating in the laboratory or other areas exposed to secretions and blood.
✓ Patient education
✓ STANDARD PRECAUTION in clinical care
✓ Avoid multidose vials in patient settings
✓ Clean, disinfect and sterilization of reusable devices in px care settings
✓ Active immunization
➢ for high risk people exposed (e.g., health care personnel, patients undergoing hemodialysis, hx
of STI, multiple sex partners, sexually active (men to men), drug users); people with hepatitis C
virus and other chronic liver diseases.
✓ Recombivax HB (yeast- recombinant vaccine)
➢ active immunity; >90% in healthy people
➢ Booster doses of Hep. B vaccine: immunocompromised
➢ Both forms of Hep. B vaccine: given in 3 doses; 2nd and 3rd dose given 1 month and 6 months
after the 1st dose.
➢ (3rd dose: important; prolonged immunity)
➢ given IM deltoid
➢ however, does not provide protection to people exposed with HBV nor types of viral hepatitis
➢ Universal vaccination of all infants; catch-up vaccination for children, prepubertal adolescents up
to age 19 (not been previously immunized)
✓ Passive Immunity: Hepatitis B Immune Globulin (HBIG);
➢ exposed to HBV, never had Hep B, and never received Hep B vaccine. (post exposure vaccine)
➢ Specific indications: (1) percutaneous (needlestick) or transmucosal (splashes in contact with
mucous membrane) routes, (2) sexual contact with people positive for HBAg, and (3) perinatal
exposure. HBIG is prepared from plasma selected for high titers of antiHBs.

HEPATITIS C
- transmitted through direct contact with infected body fluids, typically through injection drug use and
sexual contact.
- Clinical course: similar to HCV; symptoms are mild or absent
- Incubation period: variable and may range 15 to 160 days
- ↑ risk for chronic liver disease, cirrhosis after HCV, High prevalence rates (eg born in certain countries
or regions)
- Alcohol and medications that affect liver

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Risk Factors
- Children born to women infected with hepatitis C virus
- Health care and public safety workers after needlestick injuries or mucosal exposure to blood
- Multiple contacts with a hepatitis C virus–infected person
- Multiple sex partners, history of sexually transmitted infection, unprotected sex
- Past/current illicit IV/injection drug use
- Recipient of blood products or organ transplant before 1992 or clotting factor concentrates before
1987

Medical Management
✓ Peginterferon and Ribavirin (Rebetol): used in combination; produces improvement in Hep C and
treating relapses (2001) (this treatment is no longer employed because of the new recommened
antiviral agents)
✓ Simeprevir (Olysio) plus sofosbuvir (Sovaldi), ledipasvirsofosbuvir (Harvoni) and ombitasvir-
paritaprevir-ritonavir packaged with dasabuvir (Viekira Pak) : few side effects: short treatment
durations and higher cure rates

HEPATITIS D
- Also called delta hepatitis , is a serious liver disease caused by the hepatitis D virus (HDV). HDV is
contracted through direct contact with infected blood.
- Hepatitis D is a rare form of hepatitis that only occurs in conjunction with hepatitis B infection. The
hepatitis D virus cannot multiply without the presence of hepatitis B.
- Common among those who use IV or injection drugs, patients undergoing hemodialysis, and recipients
of multiple blood transfusions. Sexual contact with those who have hepatitis B is considered to be an
important mode of transmission of hepatitis B and D.
- Incubation period: varies between 30 and 150 days
- Symptoms: similar with Hepatitis B; except that patients are more likely to develop fulminant hepatic
failure and to progress to chronic active hepatitis and cirrhosis

Medical Management
✓ similar to other forms of hepatitis
✓ Interferon alfa: only licensed drug available for treatment (High-dose, long-duration therapy for at
least a year is recommended)

HEPATITIS E
- is a waterborne disease caused by the hepatitis E virus (HEV). Hepatitis E is mainly found in areas with
poor sanitation and typically results from ingesting fecal matter that contaminates the water supply.
- Fecal- oral route; resembles Hepatitis A
- Incubation period: variable, ranges between 15 and 65 days
- Presence of Jaundice
- Same management with Hep A: importance of good hygiene

NONVIRAL HEPATITS:

TOXIC HEPATITIS
- resembles viral hepatitis
- hx of exposure to hepatotoxic chemicals (Carbon tetrachloride and phosphorus), medications
(Isoniazid, halothane, acetaminophen, methyldopa) or certain antibiotics, antimetabolites and
anesthetic agents; botanical agents.
- Symptoms:
- fever ,anorexia, nausea and vomiting; jaundice and hepatomegaly
- Vomitting (if persistent) with emesis containing blood; clotting abnormalities (severe),
hemorrhages under the skin
- Severe GI symptoms may lead to vascular collapse, delirium, coma, and seizures
- TREATMENT: Liver transplantation, restoring and maintaining fluid and electrolyte imbalance,
blood replacement; comfort and supportive measures.

DRUG- INDUCED HEPATITIS

- MOST COMMON CAUSE OF ACUTE LIVER FAILURE

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- Manifestations of sensitivity to a medication may occur on the first day of its use or not until
several months later.
- Onset is abrupt: chills, fever, rash pruritus, arthralgia, anorexia and nausea
- Later: may be jaundice, dark urine; enlarged and tender liver
- STOP IMMEDIATELY: if fever, rash or pruritus occurs from any medication
- Use of Acetaminophen: leading cause of acute liver failure
- Causes associated w/ liver injury: anesthetic agents, meds for rheumatic and musculoskeletal dse,
antidepressants, psychotropic meds, anticonvulsants and antiTB agents
- TREATMENT: Short course of high dose corticosteroids; Liver transplantation (optional)

AUTOIMMUNE HEPATITIS
- occurs when your body makes antibodies against your liver tissue.
- Treatment: Azothioprine (Imuran), a drug that suppresses the immune system, is often included in
treatment. It can be used with or without steroids.
- Other immune suppressing drugs like mycophenolate (CellCept), tacrolimus (Prograf) and cyclosporine
(Neoral) can also be used as alternatives to azathioprine for treatment.

GUILLAN-BARRE SYNDROME

- Known as Acute idiopathic polyneuritis, autoimmune attack on the peripheral nerve myelin→ acute,
rapid segmental demyelination of peripheral nerves and some cranial nerves
- Ascending weakness with dyskinesia( inability to execute voluntary movements)
- Hyporeflexia and paresthesia
- Most common infectious agents: Campylobacter jejuni (24% to 50% cases); Cytomegalovirus, Epstein-
barr virus, Mycoplasma pneumoniae, H. influenzae, and HIV

Pathophysiology
➢ result of a cell-mediated and humoral immune attack on peripheral nerve myelin proteins that causes
inflammatory demyelination.
➢ Molecular mimicry: infectious organism contains an amino acid that mimics the peripheral nerve
myelin protein.
➢ Immune system: unable to distinguish between 2 proteins and destroys peripheral nerve myelin.
➢ influx of macrophages and other immune-mediated agents attack myelin and cause inflammation and
destruction, interruption of nerve conduction, and axonal loss

Clinical Manifestations
- Muscle weakness; diminished reflexes of lower extremities
- Hyporeflexia → tetraplegia (known as quadriplegia)
- Neuromuscular and respiratory failure
- Paresthesia of hands and feet
- 1 to 3 weeks before symptoms begin
- Weakness usually begins in legs and may progress UPWARD
- Progresses to peak severity within 2 weeks and no longer than 4 weeks
- Chronic Inflammatory demyelinating polyneuropathy: if progression is longer
- Cranial nerve demyelination: Optic nerve= blindness; Glossopharyngeal and vagus nerves= bulbar
muscle weakness (difficulty swallowing or clear secretions), autonomic dysfunction in CV system=
tachycardia, bradycardia, hypertension or orthostatic hypotension.
- CLASSIC CLINICAL FEATURES: areflexia (muscles don’t respond to stimuli) and Ascending weakness
- Miller- Fisher variant: atypical axonal destruction (sensory progressive symptoms)

Assessment and Diagnostics

- symmetric weakness, diminished reflexes, and upward progression of motor weakness.
- A history of a viral illness in the previous few weeks
- Changes in vital capacity and negative inspiratory force
- elevated protein levels are detected in CSF evaluation, without an increase in other cells
- Evoked potential studies demonstrate a progressive loss of nerve conduction velocity.
 DIAGNOSIS
o Ineffective breathing pattern
o Impaired gas exchange
o Impaired bed and physical mobility

CARE OF CLIENTS WITH INFECTIOUS DISORDERS COMPILED BY: [Link] & EK VILLARANTE
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o Imbalanced nutrition: less than body requirements
o Impaired verbal communication
o Fear and anxiety

Medical Management
✓ may require management in an intensive care unit
✓ Respiratory therapy or mechanical ventilation may be necessary to support pulmonary function and
adequate oxygenation.
✓ Elective intubation before the onset of extreme respiratory muscle fatigue; mechanical intubation for
an extensive period
✓ Anticoagulant agents and sequential compression boots- prevent venous embolism, DVT and
Pulmonary embolism.
✓ Therapeutic Plasma Exchange (TPE) and Intravenous immunoglobulin (IVIG)
✓ -directly affect the peripheral nerve myelin antibody level.
✓ -decrease circulating antibody levels and reduce the amount of time the patient is immobilized and
dependent on mechanical ventilation.
✓ Continuous ECG monitoring- cardiovascular risk by autonomic dysfunction
✓ Alpha- adrenergic blocking agents- tachycardia and hypertension
✓ IV fluid- for hypotension
✓ monitored for life-threatening complications (respiratory failure, cardiac dysrhythmias, VTE [including
DVT or PE])
✓ Patient and family’s ability to cope

Nursing Management
❖ MAINTAINING RESPIRATORY FUNCTION
✓ incentive spirometry and chest physiotherapy;.
✓ Mechanical ventilation is required if the vital capacity falls, making spontaneous breathing
impossible and tissue oxygenation inadequate. (May require for a long period)
✓ Suctioning: to maintain a clear airway because of impaired ability to swallow and clear secretions.
✓ BP and heart rate are assessed (to identify autonomic dysfunction)

❖ ENHANCING PHYSICAL MOBILITY

✓ key to the function and survival
✓ paralyzed extremities are supported in functional positions, and passive range-of-motion exercises
are performed at least twice daily.
✓ ROM exercises, position changes, anticoagulation, use of embolic stockings, sequential
compression boots, and adequate hydration
✓ padding over bony prominences (elbow and heels): to reduce risk of pressure ulcers

❖ PROVIDE ADEQUATE NUTRITION

✓ Paralytic ileus: insufficient parasympathetic activity
✓ IV fluids and parenteral nutrition
✓ Gastrostomy may be placed (due to bulbar paralysis)
✓ Monitor return of gag reflex and bowel sounds

❖ DECREASING FEAR AND ANXIETY

o -provide information about the condition; relaxation exercises and distraction techniques
o -Diversional activities to decrease loneliness and isolation
o -Encouraging visitors to alleviate px’s sense of isolation.

❖ MONITORING AND MANAGING POTENTIAL COMPLICATIONS

✓ respiratory insufficiency and subsequent failure due to weakness or paralysis of the intercostal
muscles and diaphragm may develop quickly.
✓ Other complications include cardiac dysrhythmias (which necessitate ECG monitoring), transient
hypertension, orthostatic hypotension, DVT, PE, urinary retention, and other threats to any patient
who is immobilized and paralyzed.

❖ PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE

✓ family members and other home care providers are educated about care of the patient and their
role in the rehabilitation process. Preparation for discharge is an interdisciplinary effort requiring

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family or caregiver education by all team members, including the nurse, physician, occupational
and physical therapists, speech therapist, and respiratory therapist.

Evaluation
1. Maintains effective respirations and airway clearance
2. Shows increasing mobility
3. Receives adequate nutrition and hydration
4. Demonstrates recovery of speech
5. Shows lessening fear and anxiety
6. Has absence of complications

CARE OF CLIENTS WITH INFECTIOUS DISORDERS COMPILED BY: [Link] & EK VILLARANTE