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Information

  1. LYME DISEASE: a spirochetal illness (syndrome); most common tick-borne infectious disease in United States; prevalent Northeast, upper Midwest, and coastal northern California. Reporting is mandatory. With early treatment, recovery is usually quick and complete.
    1. Stages:
      1. Stage I. Rash (erythema migrans) at site of tick bite; bull's-eye or target pattern; may appear as hives or cellulitis; common in moist areas (groin, armpit, behind knees). Flu-like symptoms may occur (joint pain, chills, fever).
      2. Stage II. If untreated, may progress to cardiac problems (10% of clients) or neurological disturbances—Bell's palsy (10% of clients); occasionally meningitis, encephalitis, and eye damage may result.
      3. Stage III. From 4 weeks to 1 year after the tick bite, "arthritis," primarily large joint, develops in half the clients. If untreated, chronic neurological problems may develop.
    2. Assessment (depends on stage): History is important—where do they live or work? Recent travel? Outdoor activities (gardening, hiking, camping, clearing brush)? Knowledge of tick bite and how removed? Pets?
      1. Subjective data:
        1. Malaise (stage I).
        2. Headache (stage I).
        3. Joint, neck, or back pain (stages I and III).
        4. Weakness (stages II and III).
        5. Chest pain (stage II).
        6. Light-headedness (stage II).
        7. Numbness, pain in arms or legs (stage III).
      2. Objective data:
        1. Rash—erythema migrans (stage I); at least 5 cm/lesion.
        2. Dysrhythmias; heart block (stage II).
        3. Facial paralysis (stage II).
        4. Conjunctivitis, iritis, optic neuritis (stage II).
        5. Laboratory data: Lyme titer—elevated (stages II and III). Often inconclusive.
        6. Diagnostic tests: isolation of Borrelia burgdorferi in tissue or body fluid; diagnostic levels of IgM or IgG antibodies in serum or CSF.
    3. Analysis/nursing diagnosis:
      1. Anxiety related to diagnosis.
      2. Pain related to joint inflammation.
      3. Fatigue related to viral illness.
      4. Impaired physical mobility related to joint pain.
      5. Altered thought processes related to neurological deficit.
      6. Decreased cardiac output related to dysrhythmias.
      7. Knowledge deficit (learning need) related to treatment and course of disease.
    4. Nursing care plan/implementation:
      1. Goal: minimize irreversible tissue damage and complications.
        1. pillImageMedications according to presenting symptoms: stage I—oral antibiotics for 21 days (doxycycline, amoxicillin, cefotaxime); stages II and III—oral (see stage I) or intravenous antibiotics for 21 to 28 days (ceftriaxone).
        2. If hospitalized, monitor vital signs q4h for increased temperature, signs of heart failure; check level of consciousness and cranial nerve functioning.
        3. Note treatment response: worsening of symptoms during first 24 hours: redder rash, higher fever, greater pain (Jarisch-Herxheimer reaction).
      2. Goal: alleviate pain, promote comfort.
        1. pillImageMedications: salicylates, nonsteroidal anti-inflammatory agents, or other analgesic, as ordered; observe for side effects (GI irritation).
        2. Rest: give instructions on relaxation techniques; create a quiet environment.
      3. Goal: maintain physical and psychological well-being.
        1. Activity: ROM at regular intervals; medicate for pain before exercise; encourage proper posture to reduce joint stress; rest periods between activities and treatments.
        2. Referral: occupational or physical therapy as appropriate.
        3. Reassurance: give psychological support; encourage discussion of feelings.
      4. Goal: health teaching.
        1. Information on disease. Transmission from tick not likely if removed before 48 hours of attachment.
        2. Instructions for home IV antibiotics with heparin lock, if ordered.
        3. Side effects of antibiotics (drug specific); importance of completing therapy.
        4. Signs of disease recurrence (later stages of disease: less severe attacks).
        5. Preventing subsequent infections: wear proper clothing and tick repellent on clothing (20% to 30% DEET); conduct "tick checks" of self, children, and pets; proper tick removal (use tweezers, steady, gentle traction).
        6. pillImageStart vaccination series (LYMErix); three injections at 0, 1, and 12 months.
    5. Evaluation/outcome criteria:
      1. Achieves reasonable comfort.
      2. Regains normal physiological and psychological functioning—no irreversible complications; vital signs within normal limits.
      3. Resumes previous activity level; returns to work.
      4. Adheres to follow-up care recommendations.
      5. Knows ways to minimize risk of reinfection.
  2. ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS): the terminal stage of the disease continuum caused by human immunodeficiency virus (HIV), a retrovirus; typically progresses from asymptomatic seronegative status to asymptomatic seropositive status to subclinical immune deficiency to lymphadenopathy (early AIDS) to AIDS-related complex (middle stage with combination of symptoms) to AIDS; hallmarks of HIV infection include opportunistic infections: Pneumocystis jiroveci (carinii) pneumonia (PCP); cytomegalovirus (CMV); Mycobacterium tuberculosis; hepatitis B; herpes simplex or zoster; candidiasis; may take 7 to 10 years before signs and symptoms occur.
    1. High-risk populations:
      1. Men, homosexual or bisexual (71%).
      2. Injection drug users (IDU)/heterosexual (10%).
      3. IDU/homosexual (9%).
      4. People who have hemophilia and are recipients of multiple transfusion (1%).
      5. Heterosexual (5%).
      6. Undetermined/other (4%).
    2. Pathophysiology: abnormal response to foreign antigen stimulation (acquired immunity) → deficiency in cell-mediated immunity—T lymphocytes, specifically helper T cells (CD4 cells) and hyperactivity of the humoral system (B cells).
    3. Assessment:
      1. Subjective data:
        1. Fatigue: prolonged; associated with headache or light-headedness.
        2. Unexplained weight loss: greater than 10%.
      2. Objective data:
        1. Fever: prolonged or night sweats longer than 2 weeks.
        2. Lymphadenopathy.
        3. Skin or mucous membrane lesions: purplish-red, nodules (Kaposi's sarcoma).
        4. Cough: persistent, heavy, dry.
        5. Diarrhea: persistent.
        6. Tongue/mouth "thrush"; oral hairy leukoplakia.
        7. Diagnostic tests (with permission of client): enzyme-linked immunosorbent assay (ELISA); Western blot test.
        8. Laboratory data: decreased—CD4 T lymphocytes, hematocrit, WBCs, platelets. Seropositive—syphilis, hepatitis B; ELISA—positive; Western blot test—positive (mean time for seroconversion is 6 weeks after infection).
    4. Analysis/nursing diagnosis:
      1. Risk for infection related to immunocompromised state.
      2. Fatigue related to anemia.
      3. Altered nutrition, less than body requirements, related to anorexia.
      4. Impaired skin integrity related to nonhealing viral lesions, Kaposi's sarcoma.
      5. Diarrhea related to infection or parasites.
      6. Risk for activity intolerance related to shortness of breath.
      7. Ineffective airway clearance related to pneumonia.
      8. Visual sensory/perception alteration related to retinitis.
      9. Risk for altered body temperature (fever) related to opportunistic infections.
      10. Social isolation related to stigma attached to AIDS.
      11. Powerlessness related to inability to control disease progression.
      12. Altered thought processes related to dementia.
      13. Ineffective individual coping related to poor prognosis.
      14. Risk for violence, self-directed, related to anger, panic, or depression.
    5. Nursing care plan/implementation:
      1. Goal: reduce risk of infection; slow disease progression.
        1. Observe signs of opportunistic infections: weight loss, diarrhea, skin lesions, sore throat.
        2. Monitor vital signs (including temperature).
        3. Note secretions and excretions: changes in color, consistency, or odor indicating infection.
        4. foodImageDiet: monitor fluid and electrolytes; strict measurement; encourage adequate dietary intake ( high calorie, high protein, low bulk); 5 to 10 times recommended dietary allowance (RDA) for water-soluble vitamins (B complex, C); favorite foods from home; enteral feedings. Six small meals/day.
        5. Protective isolation, if indicated, for severe immunocompromise.
        6. pillImageAntiviral medications, as ordered: nucleoside reverse transcriptase inhibitors (e.g., zidovudine [Retrovir]); nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine [Viramune]); protease inhibitors (e.g., indinavir sulfate [Crixivan]); drug toxicity and numerous side effects likely (rash, GI upset); large number of pills and tight administration schedule; costly; potential for drug resistance.
      2. Goal: prevent the spread of disease.
        1. Frequent hand washing, even after wearing gloves.
        2. Avoid exposure to blood, body fluids of client; wear gloves, gowns; proper disposal of needles, IV catheters (see Chapter 3. Safe, Effective Care Environment, Table 3.4. Standard Precautions—Summary, Standard Precautions—Summary).
      3. Goal: provide physical and psychological support.
        1. Oral care: frequent.
        2. Cooling bath: 1:10 concentration of isopropyl alcohol with tepid water; avoid plastic-backed pads if client has night sweats.
        3. Encourage verbalization of fears, concerns without condemnation; may suffer loss of job, lifestyle, significant other.
        4. Determine status of support network: arrange contact with support group.
        5. Observe for severe emotional symptoms (suicidal tendencies).
        6. Address issues surrounding death to ensure quality of life: advance directive prepared and on file; "code blue" status; reassurance of comfort and pain control.
      4. Goal: health teaching.
        1. Avoidance of environmental sources of infection (kitty litter, bird cages, tub bathing).
        2. Precautions following discharge: risk-reducing behaviors; condoms (latex), limit number of sexual partners, avoid exposure to blood or semen during intercourse.
        3. Family counseling; availability of community resources.
        4. Information on disease progression and life span.
        5. Stress-reduction techniques: visualization, guided imagery, meditation.
        6. Expected side effects with drug therapy; importance of compliance.
    6. Evaluation/outcome criteria:
      1. Relief of symptoms (e.g., afebrile, gains weight).
      2. Resumes self-care activities; returns to work; improved quality of life.
      3. Accepts diagnosis; participates in support group.
      4. Progression of disease slows; improved survival probability.
      5. Retains autonomy, self-worth.
      6. Permitted to die with dignity.
  3. ANIMAL-BORNE DISEASES (Table 6.29. Infectious Diseases: Animal-Borne).
  4. BIOTERRORISM (Table 6.30. Recognizing Bioterrorism Agents and Associated Syndromes).