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General Medical Emergencies: Part I. HIV Infection and AIDS Diphtheria Encephalitis Hepatitis Herpes: Disseminated Measles Meningitis. Mononucleosis Mumps Pertussis Shingles (Herpes Zoster) Tuberculosis Varicella (Chickenpox). Major Topics Communicable / Infectious Diseases.

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Presentation Transcript

Major topics communicable infectious diseases

HIV Infection and AIDS

Diphtheria

Encephalitis

Hepatitis

Herpes: Disseminated

Measles

Meningitis

Mononucleosis

Mumps

Pertussis

Shingles (Herpes Zoster)

Tuberculosis

Varicella (Chickenpox)

Major TopicsCommunicable / Infectious Diseases


Major topics skin infestations
Major TopicsSkin Infestations

  • Lice

  • Scabies

  • Myiasis


Major topics endocrine emergencies
Major TopicsEndocrine Emergencies

  • Adrenal Crisis

  • Diabetic Ketoacidosis

  • Hyperglycemic Hyperosmolar Nonketotic Coma

  • Hyperglycemia

  • Myxedema Coma

  • Thyroid Storm


Hiv infection and aids
HIV Infection and AIDS

  • Caused by a retrovirus

  • Viral symptoms start 2-6 weeks

  • Antibody seroconversiontakes

    place within 45 days - 6 months

  • Asymptomatic period for months

    to years

    • Replication, mutation, and destroying the immune system


Hiv infection and aids1
HIV Infection and AIDS

  • Persistent generalized lymphadenopathy occurs

  • Constitutional disorders, neurological disorders, secondary infections, secondary cancers, and pneumonitis


Hiv infection and aids2
HIV Infection and AIDS

  • All HIV infections will develop into AIDS

    • Mean between exposure to HIV to AIDS-10 years

    • AIDS to death

    • Sooner the treatment, better long-term survival


Hiv infection and aids assessment
HIV Infection and AIDS Assessment

  • Subjective data

    • History of present illness

      • Generalized lymphadenopathy, persistent

      • Fever for longer than 1 month

        • Episodic spiking

        • Persistent low-grade fever

      • Diarrhea for longer than 1 month

      • Weight loss

      • Anorexia

      • Night Sweats


Hiv infection and aids assessment1
HIV Infection and AIDS Assessment

  • Malaise or fatigue, arthralgias, myalgias

  • Mild opportunistic infections

    • Oral candidiasis

    • Herpes Zoster

    • Tinea

  • Skin lesions, rashes

  • Cough

  • Broad range of neurological complaints, both focal and global, including dementia


Hiv infection and aids assessment2
HIV Infection and AIDS Assessment

  • Current medications

    • Antiretroviral agents: zidovudine (AZT), zalcitabine (ddC), didanosine (ddI), stavudine (d4T), lamivudine (3TC), nevirapine, delavirdine

    • Pneumocystis prophylaxis: trimethoprim-sulfamethoxazole, pentamidine, dapsone

    • Protease inhibitors: indinavir, saquinavir mesylate, nelfinavir, ritonavir


Hiv infection and aids assessment3
HIV Infection and AIDS Assessment

  • Medical History

    • Blood transfusions, especially before 1985

    • Hemophilia

    • Occupational needle sticks or blood exposure

    • Sexually transmitted diseases (STD’s)

    • Tissue transplantation

    • Infant with HIV-positive mother

    • Sexual contact with IV drug user

    • Sexual contact with HIV-positive partner

    • Sexual practices including multiple partners, anal sex, oral-anal sex, or fisting

    • Recent TB exposure


Hiv infection and aids3

Physical examination

Chronically ill appearance

Kaposi’s sarcoma skin lesions

Chest: crackles and wheezes

Dyspnea

Abnormal vital signs

Lymphadenopathy

Dementia

Wasting syndrome; signs of volume depletion

Withdrawn, irritable, apathetic, depressed

Slow, unsteady gait; weakness; poor coordination

HIV infection and AIDS


Hiv infection and aids4
HIV Infection and AIDS

  • Diagnostic procedures

    • CXR

    • CBC

      • Anemia

      • Lymphopenia

      • Thrombocytopenia

    • ABG’s

    • Electrolytes, liver function tests


Hiv infection and aids assessment4
HIV Infection and AIDS Assessment

  • Determination of HIV antibodies (e.g., via enzyme-linked immunosorbent assay [ELISA] and Western blot analysis)

  • decreased CD4 cell count

  • blood cultures

  • urinalysis

  • TB skin test (5 mm is positive in HIV infected person)


Diphtheria
Diphtheria

  • Alteration in neurological functions

    • Lethargy

    • Withdrawal

    • Confusion

    • Cranial nerve neuropathies

  • Alteration in cardiac functions

    • ST-and T-wave changes

    • First-degree heart block

    • Dyspnea, heart failure, circulatory collapse

  • Anxiety


Diphtheria1
Diphtheria

  • Diagnostic procedures

    • Throat culture: specimen swabbed from beneath membrane or piece of membrane

    • Notify lab that C. diphtheria is suspected: requires special media and handling


Diphtheria2
Diphtheria

  • Interventions

    • Provide strict respiratory isolation

    • Maintain airway, breathing, circulation

      • Monitor vital signs and pulse ox

      • Assemble emergency cricothyrotomy equipment at bedside

      • Administer O2 for dyspnea or cyanosis

    • Establish IV catheter for administration of IV fluids


Diphtheria3
Diphtheria

  • Interventions

    • Diphtheria antitoxin

      • Equine serum

      • Test for sensitivity (intradermal or mucous membrane) before administration

      • Often administered before diagnosis is confirmed because of virulence of disease


Diphtheria4
Diphtheria

  • Antibiotic: EES or PCN G

  • Antitussive

  • Antipyretic

  • Topical anesthetic agent

  • Minimize environmental stimuli

  • Instruct patient on importance of complete bed rest


  • Diphtheria5
    Diphtheria

    • Provide immunization

      • Regular booster Q10years, combined with TD, after completion of initial series of 3 doses

      • Identify close contacts

        • Culture and prophylactic Booster of TD in none within 5 years

        • Antibiotics

        • Active immunization for nonimmunized persons (series of 3 doses)


    Encephalitis
    Encephalitis

    • Viral infection of the brain

    • Often coexists with meningitis and has

      broad range of S&S

    • Most cases in North America, caused by arboviruses, herpes simplex I, varicella-zoster, EB, and rabies

    • Transmission by animal bites, or seasonally form vectors (mosquitoes, ticks, and midges)

    • More common human viruses are airborne via droplet or lesion exudate

    • All age groups, with mortality from 5-10% from arboviruses and 100% for rabies


    Encephalitis1

    Assessment

    Subjective

    History of present illness

    Recent viral illness or herpes zoster

    Recent animal or tick bite

    Travel to endemic area, season of the year

    Fever

    Headache

    Photophobia

    Nausea, vomiting

    Confusion, lethargy, coma

    New psychiatric symptoms

    Encephalitis


    Encephalitis2
    Encephalitis

    • Assessment

      • Subjective

        • Medical history

          • Immune disorders

          • Allergies

          • Medications


    Encephalitis3
    Encephalitis

    • Objective data

      • Physical exam

        • Altered LOC

        • Rash specific to cause

        • Meningism

        • Altered reflexes

        • Focal neurological findings

        • Abnormal movements

        • Seizures


    Encephalitis4
    Encephalitis

    • Diagnostic Procedures

      • Lumbar puncture, CT scan

      • CBC

      • Blood cultures

      • Serology


    Encephalitis5
    Encephalitis

    • Interventions

      • Institute standard precautions and isolation until causative agent identified

      • Monitor airway, breathing, circulation

      • Monitor vital signs and pulse oximeter

      • Administer O2

      • Prepare to assist with intubation

      • Insert large bore IV catheter, and administer isotonic solutions as ordered

      • Administer medications as ordered


    Encephalitis6
    Encephalitis

    • Administer antimicrobial/antiviral agents, steroids

    • Monitor blood sugar and electrolytes

    • Insert urinary catheter PRN

    • Monitor I&O, cerebral edema, keep HOB >30 degrees

    • Institute seizure precautions

    • Elevate HOB 30 degrees


    Encephalitis7
    Encephalitis

    • Restrict IV fluids

    • Keep body temperature normal

    • Administer diuretics as ordered

    • Explain procedures and disease to family/patient

    • Allow patient/significant others to verbalize fears

    • Prepare patient/family for admission to hospital


    Hepatitis
    Hepatitis

    • Viral syndrome involving hepatic triad (bile duct, hepatic venule, and arteriole, and central vein area.

    • Hep A-fecal-oral route, infectious for 2 weeks before and 1 week after jaundice

    • Hep B-(HBV)blood and sexual contact and consists of 3 antigens

      • Hep B surface


    Hepatitis1
    Hepatitis

    • Hep B-(HBV) blood and sexual contact

    • 3 antigens

      • Hep B e antigens

      • Dane particle- two part antigen: inner core (hep B core antigen) and surface antigen (hep surface antigen)

        • Persistence of core antibody indicates chronic infection

        • Persistence of surface antibody indicates immunity to reinfection

        • Hep B surface antigen in the serum without symptoms is indicative of a carrier state


    Hepatitis2
    Hepatitis

    • Hep C identified by antihepatitis C virus antibody

    • 50% of Hep C become chronic, and no immunity is developed

    • Hep C 90% of hepatitis cases transmitted by blood transfusion


    Hepatitis3
    Hepatitis

    • Hep E is an epidemic, enterically transmitted infection from shellfish and contaminated water

    • Hep D found with acute or chronic HBV infection

    • Chronic infections result in cirrhosis and liver cancer


    Hepatitis4
    Hepatitis

    • Assessment

      • History of present illness

        • Prodrome: preicteric phase, occurs 1 week before jaundice

          • Low-grade fever

          • Malaise: earliest, most common symptom

          • Arthralgias

          • Headache

          • Pharyngitis

          • Nausea, vomiting


    Hepatitis5
    Hepatitis

    History of Illness cont’d

    Rash, with type B usually

    • May or may not progress to icteric phase

    • Incubation:

      • A 15-45 days

      • B 30-180 days

      • C 15-150 days

    • Duration:

      • A 4 weeks;

      • B AND C 8 weeks


    Hepatitis6

    Icteric phase

    Disappearance of other symptoms

    Anorexia

    Abdominal pain

    Dark urine

    Pruritus

    Jaundice

    Hepatitis


    Hepatitis cont d
    Hepatitis cont’d

    • Medical History

      • Immunizations

      • ETOH consumption

      • Allergies

      • Medications: all are significant

      • Blood transfusions, IV drug use, Hemophilia or dialysis

      • Chronic medical problems, travel, living in institution

      • Living in recent floods or natural disasters


    Hepatitis7
    Hepatitis

    • Objective data

      • Physical exam

        • Posterior cervical lymph node enlargement

        • Enlarged, tender liver

        • Splenomegaly in 20%

        • Jaundice

        • Vital signs: may have tachycardia, hypotension

        • Fever


    Hepatitis8
    Hepatitis

    • Diagnostics

      • Liver enzymes: SGOT & SGPT elevated

      • Direct and indirect bilirubin levels: elevated

      • Alkaline phosphatase: elevated

      • Differential leukocyte count: leukopenia with lymphocytosis, atypical lymphocytes

      • CBC, UA: elevated bilirubin, PT: elevated, ABD X-ray

      • Antigen and/or antibody titers


    Hepatitis9
    Hepatitis

    • Interventions

      • Provide increased calories

      • Monitor for signs of dehydration, replacement with isotonic solution

      • Record I&O

      • Assess support systems of patients

      • Hospitalize if unable to care for self or PT >15 seconds


    Hepatitis10
    Hepatitis

    • Initiate prophylaxis

      • Type A

        • Immune serum globulin 80-90% effective if 7-14 days after exposure

        • Vaccine administered in two doses: given to high-risk population: foreign travel, endemic areas (e.g. Alaska), military, immunocompromised or risk for HIV, chronic liver disease, hep C

      • Type B: hepatitis B immune globulin plus vaccination, for exposure to serum, saliva, semen, vaginal secretions, breast milk


    Hepatitis11
    Hepatitis

    • Initiate prophylaxis

      • Type B: vaccination with HBV vaccine inactivated (Recombivax HB)

        • Vaccinate high-risk persons

          • Health care and public safety workers, clients and staff at institutions

          • Hemodialysis patients, recipients of clotting factors

          • Household contacts and sexual partners of HBV carriers

          • Adoptees from countries where HBV in endemic: Pacific Islands and Asia

          • IV Drug users, sexually active homosexual and bisexual men

          • Sexually active men and women with multiple partners

          • Inmates of long-term correctional facilities


    Hepatitis12
    Hepatitis

    • Vaccinate all infants (universally) regardless of hepatitis B surface antigen status of mother (administer first dose in newborn period, preferably before leaving hospital)

  • Report to appropriate health departments

  • Limit exposure of medical personnel to blood, secretions, and feces


  • Hepatitis13
    Hepatitis

    • Instruct patient/significant others

      • Strict hygiene, private bathroom if possible

      • Diet of small, frequent feedings low in fat, high in carbs, patient should avoid handling food to be consumed by others

      • S&S: bleeding, vomiting, increased pain

      • Take meds as prescribed

      • Avoid intake of alcohol

      • Take meds only if necessary

      • Avoid steroids: they delay long-term healing


    Herpes disseminated
    Herpes: Disseminated

    Herpes simplex virus (HSV)

    is a relatively benign disease when cutaneous

    • Can invade all body systems and lead to death

    • Primary viremia occurs from spill-over of the virus at the site of entry

    • During the second stage, HSV disappears from he blood but grows within cells of infected organs, which in turn causes seeding to other organ systems.

    • Dissemination occurs in susceptible persons: newborns, malnourished children, children with measles, people with skin disorders, such as burns, eczema, immunosuppression, and immunodeficiency, especially HIV


    Herpes disseminated1
    Herpes: Disseminated

    • HSV has a predilection for temporal lobe.

    • Encephalitis most common

      • 70% mortality rate without treatment

      • 50% with treatment residual neurological deficits

    • Latency period within sensory nerve resulting in mild or life-threatening infection years later


    Herpes
    Herpes

    • Assessment

      • Subjective data

        • History of present illness

          • Onset: usually acute

            • After other illness

            • After outbreak of cutaneous infection

            • After any stressor


    Herpes1
    Herpes

    • Assessment

      • Subjective data

        • History of present illness

          • Symptoms depend on organ system affected

            • Neurological system: headache, confusion, seizures, coma, olfactory hallucinations

            • Liver: ABD pain, vomiting

            • Lung: cough, fever

            • Esophagus: dysphagia, substantial pain, weight loss


    Herpes2
    Herpes

    • Medical history

      • HSV infection

      • Chronic illness, cancer, HIV

      • Medications: immunosuppressants

      • Allergies


    Herpes3
    Herpes

    • Objective data

      • Physical exam

        • Fever

        • Other vital sign abnormalities depend on organ system involved

        • Focal neurological signs

          • Anosmia (loss of smell)

          • Aphasia

          • Temporal lobe seizures

          • Confusion, somnolence, coma

    • Respiratory

      • crackles


    Herpes4
    Herpes

    • Diagnostic Procedures

      • Viral cultures: blood and skin

      • Lumbar puncture: cerebrospinal fluid for culture

      • Biopsy of target organ, especially brain

      • Clotting studies for DIC

      • Liver Function

      • CBC


    Herpes5

    Interventions

    Prepare to assist intubation

    O2 PRN

    Monitor

    VS with PO

    Neurological status

    Maintain airway, breathing, circulation

    I&O

    Administer Antiviral meds

    FC PRN

    Establish IV of isotonic solution at rate to maintain blood pressure and fluid balance

    Protect from injury from seizures

    Explain procedures and illness to patient or significant others

    Practice standard precautions

    Herpes


    Measles
    Measles

    • Highly acute and contagious virus

    • Caused by rubeola virus, late winter and early spring

    • Airborne droplets, incubation 10-14 days

    • Contagious few days before and after onset of rash

    • Most recover, incidence of OM, diarrhea, pneumonia, and encephalitis


    Measles1
    Measles

    • More serious in infants and in malnourished children, pregnancy with preterm delivery and spontaneous abortion

    • Most born <1957 are permanently immune

    • Vaccine (MMR) 12-15 months, active disease or two immunizations in childhood

    • Booster elementary school, all high school or college revaccinated unless active disease or two immunizations


    Measles2
    Measles

    • Assessment

      • Subjective data

        • History of present illness

          • Exposure to measles

          • Prodrome

            • Fever

            • Cough

            • Coryza (nasal mucosal inflammation)

            • Photophobia

            • Anorexia

            • Headache

            • Rarely seizures


    Measles3

    Medical history

    Immunizations

    History of measles

    Current age: born before 1957

    Allergies

    Medications

    Measles

    Subjective


    Measles4
    Measles

    • Objective data

      • Physical exam

        • Fever

        • Koplik’s spots on buccal mucosa (bluish-gray specks on red base)

        • Conjunctivitis

        • Harsh cough


    Measles5
    Measles

    • Red, blotchy rash

      • Appears on third to seventh day

      • Maculopapular, then becomes confluent as progresses

      • Starts on face, then generalized to the extremities

      • Mild desquamation

      • Lasts 4-7 days

    • Vital signs: normal, except fever

    • Neurological system: may have altered LOC, encephalitis

    • Respiratory system: may have OM, pneumonia


    Measles6
    Measles

    • Diagnostic procedures

      • Viral cultures (expensive and difficult, so not usually done)

      • Immunoglobulin M antibodies: measles specific

      • CBC: leukopenia

      • Other studies if seriously ill


    Measles7
    Measles

    • Interventions

      • Provide respiratory isolation

      • Isolate patient/significant others from other people in waiting room

      • Advise patient to avoid school, day care centers, and people outside immediate family until after contagious period

      • Initiate immunization of high-risk contacts

        • Live vaccine if given within 72 hours of exposure (use monovalent vaccine if infants younger than 12 months; need reimmunization at 15 months with MMR)

        • Immune globulin up to 6 days after exposure

        • Immunocompromised persons should receive immune globulin even if previously immunized


    Measles8
    Measles

    • Encourage rest in darkened room

    • Administer acetaminophen for fever

    • Encourage parents to have children immunized at appropriate times

    • Instruct patient/parent about S&S of serious illness or complications

      • Persistent fever or cough

      • Change in mental status or seizures

      • Difficulty in hearing


    Meningitis
    Meningitis

    • Bacterial or viral of the pia and arachnoid meniges

    • Late winter or early spring

    • Viral mild and short lived

    • Bacterial severe and life threatening

    • Streptococcus pneumoniae, Haemophilus influenzae (H. flu), and Neisseria meningitidis subgroups A, B, and C

    • H. Flu incidence decreased because of vaccination

    • Bacteria can enter the blood, basilar skull fracture, infected facial structures, and brain abscesses


    Meningitis1
    Meningitis

    • Bacteria initially colonize in the nasopharynx

    • In bacterial disease, the subarachnoid space is filled with pus, which obstruct CSF, resulting in hydocephalus and increased ICP

    • Infants and elderly often do not exhibit classic signs of meningealirritation and fever

    • Death most common within a few hours after diagnosis

    • Up to 33% of pediatric survivors left with some type of permanent neurological dysfunction

    • Any infant younger that 2 months with a fever, must be evaluated for meningitis


    Meningitis2

    Assessment

    Subjective data

    History of present illness

    Antecedent illness or exposure

    Onset: sudden

    Headache, especially occipital

    Fever and chills

    Anorexia or poor feeding

    Vomiting and diarrhea

    Malaise, weakness

    Neck and back pain

    Restlessness, lethargy, altered mental status

    Disinclination to be held: infants

    Seizures

    Recent basilar skull fracture

    Meningitis


    Meningitis3
    Meningitis

    • Medical history

      • Medications

      • Allergies

      • Immunizations if child

      • Chronic disease: liver or renal, DM, multiple myeloma, alcoholism, malnutrition

      • Asplenic

      • Recurrent sinusitis, pneumonia, OM, mastoiditis


    Meningitis4
    Meningitis

    • Objective data

      • Physical examination

        • High-pitched cry in infants

        • Hyperthermia >101 or hypothermia <96

        • Petechiae that do not blanch: 1-2 mm on trunk and lower portion of body, also mouth, palpebral and ocular conjunctiva

        • Purpura

        • Cyanosis, mottled skin, and pallor


    Meningitis5
    Meningitis

    • Objective data

      • Physical examination

        • Vital signs

          • Tachycardia, hypotension, tachypnea

          • Bradycardia in neonates

        • Meningeal irritation: persons older than 12 months, seen in about 50%

          • Contraction and pain of hamstring muscles occur after flexion and extension of leg: Kernig’s sign

          • Bending of neck produces flexion of knee and hip; passive flexion of lower limb on one side produces similar movement on other side: Brudzinski’s sign

          • Nuccal rigidity


    Meningitis6
    Meningitis

    • Infants with meningeal irritation cry when held and are more quiet when left in crib

    • Photophobia

    • Focal neurological signs, cranial nerve palsies, and generalized hyperreflexia

    • Altered mental status

      • Confusion, delirium, decreased LOC

      • Lethargy and confusion may be only signs in elderly

    • Bulging fontanelle

    • Irritability


    Meningitis7
    Meningitis

    • Diagnostic procedures

      • Blood glucose levels: infants younger than 6 months are prone to hypoglycemia

      • Electrolyte levels: hyponatremia

      • BUN and creatinine levels

      • Serum osmolality

        • Low because of inappropriate vasopressin secretion

        • High because of dehydration


    Meningitis8
    Meningitis

    • Diagnostic procedures

      • CBC

        • Bacterial: high WBC

        • Viral: normal or low WBC

        • Meningococcal: WBC tends to be less that 10,000

      • Blood cultures

      • ABG’s if severely ill

      • Clotting studies

      • UA

      • CXR and skull radiographs


    Meningitis9
    Meningitis

    • Lumbar puncture: CSF

      • Bacterial infection: cloudy appearance; elevated pressure; WBC 200-20,000 with increased polymorphonuclear cells; glucose level decreased; protein level elevated; bacteria present on Gram’s stain

      • Viral infection: clear appearance; WBC <500; normal pressure; glucose level normal; no bacteria present on Gram’s stain


    Meningitis10
    Meningitis

    • Interventions

      • Ensure that health care providers wear masks if infection with meningococcus is suspected

      • Undress patient completely to check for petechiae

      • O2 PRN

      • Monitor VS

      • Prepare to suction and assist with aggressive ventilatory support as needed

      • Prepare to assist with LP

      • Insert NG to prevent aspiration


    Meningitis11
    Meningitis

    • Establish IV catheter, IO in necessary

    • Monitor IV fluids as related to I&O or excessive secretion of antidiuretic hormone

    • KCL replacement PRN, antiemtics PRN

    • Infuse antibiotics (usually ampicillin, aminoglycosides, cephalosporins)

    • Administer benzodiazepines, corticosteroids

    • Control fever

    • Reduce ICP

      • Use hyperventilation with caution to avoid cerebral ischemia

      • Elevate HOB 30 degrees

      • Administer barbiturates and diuretics


    Meningitis12
    Meningitis

    • Insert FC, monitor I&O

    • Monitor for signs of dehydration or fluid excess

    • Monitor mental status and neurological signs every 15 minutes to 1 hour, depending on patient’s stability

      • May need to restrain confuse patient

      • Protect seizing patient form physical harm

    • Explain procedures and need for ICU


    Meningitis13
    Meningitis

    • Administer chemprophylaxis(rifampin, ceftriaxone) within 24 hours of disease identification to household contacts, day care center contacts, and health care providers if bacterial disease

      • Side effects GI, lethargy, ataxia, chills, fever, and red-orange urine, feces, sputum, tears, and sweat

      • Soft contact lenses may be permanently stained with rifampin use

      • Medication may need to be taken with food for GI intolerance, although it is best absorbed on empty stomach

      • Birth control pills may not work

      • Do not give to pregnant women


    Meningitis14
    Meningitis

    • Educate parents to have infants immunized against H. Flu B beginning at 2 months


    Mononucleosis
    Mononucleosis

    • Acute viral illness with broad range of S&S lasting 2-3 weeks, very contagious

    • EBV transmitted in saliva

      • About 50% of the population serovonverts to EBV before 5 years of age with sublclinical infection or mild illness

      • Another wave of seroconversion in med adolescence

      • Peak 15-24-years

    • Incubation 2-5 weeks

    • CMV is the other most frequent causative agent

    • Complications include: glomerulonephritis, autoimmune hemolytic anemia, pericarditis, hepatitis, guillain-Barre syndrome, meningitis, and pneumonia


    Mononucleosis1
    Mononucleosis

    Rarely death may occur from splenic rupture or airway obstruction as a result of tonsillar hypertrophy

    • Assessment

      • Subjective data

      • History of present illness

        • Prodrome lasting 3-5 days: malaise, anorexia, nausea and vomiting, chills/diaphoresis, distaste for cigarettes, headache, myalgias


    Mononucleosis2
    Mononucleosis

    • History of present illness

      • Subsequent development of fever 100.4 to 104 lasting 10-14 days, sore throat,diarrhea, earache

    • Medical history

      • Exposure to mononucleosis, usually not known

      • Allergies

      • Medications


    Mononucleosis3
    Mononucleosis

    • Objective data

      • Physical examination

        • May appear acutely ill

        • Red throat with exudate; tonsils may be hypertrophied

        • Tender lymphadenopathy, particularly posterior cervical

        • Petechiae on palate

        • Fine red macular rash 5% of adults: if given ampicillin, 90-100% of patients will experience rash

        • Abdominal tenderness with heptomegaly

        • Splenomegaly in 50% of patients


    Mononucleosis4
    Mononucleosis

    • Diagnostic procedures

      • Heterophile antibody titer (Monospot): positive by second week of illness; may remain negative in children younger than 5 years

      • Throat culture to rule out group A streptococcus

      • CBC: neutropenia, thrombocytopenia, lymphocytosis with atypical lymphs, leukocytosis

      • Liver functions: may be abnormal

      • CXR if pneumonia suspected


    Mononucleosis5
    Mononucleosis

    • Interventions

      • Isolation not necessary

        • Avoid kissing

        • No sharing eating or drinking utensils

      • Activity as tolerated

        • Extra rest early in illness

        • Avoid heavy lifting and contact sports for at least 4 weeks if splenomegaly present


    Mononucleosis6
    Mononucleosis

    • Interventions

      • Administer antipyretics, analgesics (Avoid ASA)

      • Administer corticosteroids therapy for severe Pharyngitis, evolving airway obstruction, chronic or disabling symptoms, or profound splenomegaly


    Mononucleosis7
    Mononucleosis

    • Warm salt water gargles for sore throat

    • Encourage fluids to avoid dehydration

    • Diet as tolerated

      • Liquids initially

      • Soft foods

    • Do not donate blood for 6 months


    Mononucleosis8
    Mononucleosis

    • Instruct patient about S&S of serious illness or complications

      • Increased fever

      • Cough, chest pain

      • Progression of innless

      • Difficulty breathing

      • Signs of dehydration

      • Increasing abdominal pain


    Mumps
    Mumps

    • Acute, usually benign, viral infection caused by Paramyxoviridae family

    • Swelling and tenderness of salivary glands and one or both parotid glands

    • Direct contact, droplet nuclei, or fomites

    • Incubation averages 16-18 days

    • Peak incidence is January to May

    • Most contagious just before swelling

    • More severe illness in the post pubertal age group; 20-30% of adult men experience epididymoorchitis

    • Complications include viral meningitis, arthritis, arthralgias, and pancreatitis


    Mumps1
    Mumps

    • Assessment

      • Subjective data

        • History of present illness

          • Exposure to mumps

          • Prodrome: fever (<104), anorexia, malaise, headache

          • Earache and tenderness of ipsilateral parotid gland

          • Citrus fruits or juices increase pain

          • Fever, chills, headache, vomiting if meningitis

          • Testicular pain if orchitis

          • Abdominal pain if pancreatitis


    Mumps2
    Mumps

    • Medical history

    • Childhood immunizations

    • Previous mumps

    • Allergies

    • Medications

    Subjective cont’d


    Mumps3
    Mumps

    • Objective data

      • Physical examination

        • Swelling of gland, maximal over 2-3 days, with earlobe lifted up and out and mandible obscured by swelling

        • Trismus with difficulty in pronunciation and chewing

        • Testicle warm, swollen, tender

        • Scrotal redness


    Mumps4
    Mumps

    • Diagnostic procedures

      • CBC: WBC and differential normal or mild leukopenia

      • Serum amylase elevated

        for 2-3 weeks


    Mumps5
    Mumps

    • Interventions

      • Provide respiratory isolation

      • Advise to avoid school/work until swelling gone

      • Administer analgesics

      • Encourage rest until feeling better

      • Encourage fluids, avoid citrus

      • Warm or cold packs

      • For orchitis

        • Bed rest

        • Scrotal elevation

        • Ice packs

        • Pain meds


    Mumps6
    Mumps

    • Administer IV fluids for acutely ill patients

    • Recommend immunization to family and health workers who have no mumps antibodies


    Pertussis
    Pertussis

    • Acute, widespread, highly contagious bacterial disease of the throat and bronchi

    • Gram-negative CoccobacillusBordetellaPertussis

    • Airborne droplets

    • Most common children <4 years

    • Females higher incidence of morbidity and mortality

    • Partially immunized children have less severe illness

    • Adults have only minor respiratory symptoms and persistent cough, majority unrecognized


    Pertussis1
    Pertussis

    • Vaccine immunity is <12 years, most adults are not protected

    • Incubation period 7-10 days but can vary 6-21

    • Peak incidence is during late summer and early fall

    • Pertussis bacteria invade the mucosa of URT

    • Complications include: pneumonia, pneumothorax, seizures, and encephalitis

    • Children also frequently experience laceration of the lingual fremulum and epistaxis


    Pertussis2
    Pertussis

    • Assessment

      • Subjective data

        • History of present illness

          • Exposure to pertussis

          • Three stages: last up to 2 weeks

            • Conjuctivitis and tearing

            • Fever/chills

            • Rhinorrhea, sneezing

            • Irritability

            • Fatigue

            • Dry nonproductive cough, often worse at night


    Pertussis3
    Pertussis

    • Paroxysmal: lasts 2-4 weeks

      • Severe cough with hypoxia, unremitting paroxysms, and clear, tenacious mucous; patient appears well between paroxysims of coughing; cough often triggered by eating and drinking

      • Apnea can occur in rate cases

      • Vomiting follows cough

      • Anorexia

    • Convalescent: residual cough


    Pertussis4
    Pertussis

    • Medical history

      • Recent illness or infection

      • Medications

      • Allergies

      • Immunization status


    Pertussis5
    Pertussis

    • Objective data

      • Physical exam

        • Paroxysmal explosive coughing ending in prolonged high-pitched crowing inspiration

        • Coryza

        • Clear, tenacious mucous in large amounts

        • Temperature >101

        • Restlessness

        • Crepitus from subcutaneous emphysema

        • Periobital/eyelid edema


    Pertussis6
    Pertussis

    • Diagnostic procedures

      • C&S testing of nasopharynx using calcium alginate dacron-tip swab

      • Immunofluorescent antibody staining of nasopharyngeal specimens

      • CBC with differential leukocyte count: lymphocytosis


    Pertussis7
    Pertussis

    • Interventions

      • Maintain respiratory isolation

      • Monitor vital signs and respiratory status

      • Be prepared to assist with intubation

      • O2 PRN

      • Isolate patients with active disease from school or work until they have taken antibiotics for 14 days

      • Monitor for signs of dehydration or nutritional deficiency secondary to vomiting


    Pertussis8
    Pertussis

    • Administer prescribed medication

      • Antibiotic: EES

      • Antitussive

      • Analgesic

      • Antipyretic

    • Position comfortably


    Pertussis9
    Pertussis

    • Admit patients younger than 1 year: prepare for nasotracheal suctioning

    • Initiate immunization

      • Educate parents about importance of complete immunization

      • Household and other contacts <1year: prophylactic EED

      • Household and close contacts ages 1-7 years who had less than four DTP vaccine doses or more that 3 years since:

        • EES for 14 days

        • DTP immunization


    Pertussis10
    Pertussis

    • Review S&S that necessitate return to ER

      • Difficulty in breathing recurs or worsens

      • Blue color of lips or skin

      • Restlessness or sleeplessness develops

      • Medicines are not tolerated

      • Fluid intake decreases


    Shingles herpes zoster
    Shingles (herpes zoster)

    • Acute localized infection cause by varicella-zoster virus (VZV)

    • During chickenpox, VZV travels from skin lesions to sensory nerve ganglia sets up latent infection

    • Postulated that when immunity to VZV wanes, the virus replicates

    • VZV moves down nerves, causing dermatomal pain and skin lesions

    • Lasts up to 3 weeks

    • Exact triggers unknown, old age and immunosuppression are risk factors


    Shingles
    Shingles

    • 20% of population

    • 4% second exposure

    • Fluid from lesion is contagious, but likelihood of transmission is low

    • Susceptible exposed persons may develop varicella (chickenpox)

    • Complications: post herpetic neuralgia, debilitation pain syndrome lasts several months, blindness, disseminated disease, and occasionally death


    Shingles1
    Shingles

    • Assessment

      • Subjective data

        • History of present illness

          • Pain, itching, tingling, burning of involved dermatome precede rash by 3 to 5 days

          • Rarely headache, malaise, fever

        • Medical history

          • History of chickenpox, HIV infection, cancer, chronic steroid use

          • Allergies

          • Medications


    Shingles2
    Shingles

    • Objective data

      • Physical examination

      • Tenderness over involved dermatome

      • Rash

        • Unilateral; does not cross midline

        • Usually thoracic or lumbar dermatome

        • Small fluid-filled vesicle on red base

        • May become hemorrhagic

        • New lesions occur for about 1 week


    Shingles3
    Shingles

    • Fever (low grade if present)

    • Visual acuity, if eye involved

  • Diagnostic procedures

    • Viral culture

    • Other studies if seriously ill


  • Shingles4
    Shingles

    • Interventions

      • Provide contact isolation

      • Advise patient to avoid school/work until all lesions are crusted over

      • Recommend immunizations of high-risk contacts

      • Varicella-zoster immune globulin (VZIG)


    Shingles5
    Shingles

    • Administer medications as prescribed

      • Analgesics

      • Antihistamines

      • Antivirals (acyclovir, famciclovir) will lessen disease severity and incidence of post herpetic neuralgia if administered within 72 hours of onset of rash


    Shingles6
    Shingles

    • To prevent infection of lesions, cut fingernails short

    • Topical baking soda paste or baths and calamine lotion may help

    • Ophthalmological consult if facial/eye involvement

    • Instruct patient about S&S of serious illness or complications

      • Increased fever

      • Cough

      • Becoming more ill

      • Signs of skin infection


    Skin infestations lice
    Skin infestations: Lice

    • Three types of lice infest humans:

      • Pediculus humanus var corporis (human louse)

        • 2-4mm, grayish-white, flattened, wingless, and elongated with pointed heads

        • Overcrowding and poor sanitation


    Skin infestations lice1
    Skin infestations: Lice

    • Three types of lice infest humans:

      • P. humanus var capitis (human head louse)

        • Wider and shorter, resemble a crab

        • Eggs (nits) laid by female

        • Affects all socioeconomic groups

      • Phthirus pubis (pubic or crab louse)

        • Sexually or close body contact

        • Can be seen eyebrows, eyelashes, axillary hair, and back and chests

        • 33% with lice have 2nd STD


    Lice

    • Can cause significant cutaneous disease

    • Lice serve as vectors for typhus, relapsing fever, and trench fever


    Lice

    • Assessment

      • Subjective data

        • History of present illness

          • Itching infected areas

          • Fever, malaise in severe infection

          • Exposure to lice

          • Recent sharing of clothing, beds, combs/brushes

          • Concurrent STD’s


    Lice

    • Medical history

      • Previous infestations

      • Allergies

      • Medications

      • Objective data


    Lice

    • Physical exam

      • Excoriation of scalp

      • Secondary bacterial infection, especially of scalp

      • Weeping and crusting of skin

      • Lymphadenopathy

      • Small, red macules, papules on trunk

      • Small,gray to bluish macules measuring <1cm on trunk(maculae ceruleae) from anticoagulant injected into skin by biting louse

      • Nits on hairs

      • Thick, dry skin, brownish pigmentation on neck, shoulder, back form chronic infection

      • Signs of concurrent STD’s



    Lice

    • Interventions

      • Contact isolation

      • Advise patient/parent to avoid school/work until one treatment completed

      • Administer analgesics, antihistamines, antibiotics


    Lice

    • Interventions

      • Use pediculicides

        • Pyrethrin liquid

        • Permethrin crème

      • Treat sexual contacts

        • Administer medications for STD’s

        • Instruct patient/parent that itching may continue after treatment: do not re-treat without physician order


    Lice

    • Instruct patient/parent to

      • Remove nits

      • Soak hair with equal parts warm vinegar and water

      • If eyelashes or eyebrows, apply layer of petroleum jelly

      • Soak combs and brushes in pediculicide for 1 hour

      • Launder clothing/bedding in hot water; dry in hot drier if possible, discard clothing and linen if practical



    Lice

    • Instruct patient/parent to

      • Iron seams of clothing

      • Put socks over hands of small children at bedtime

      • Cut fingernails short

      • Put hats, coats, other non-launderable item away for at lest 72 hours

      • Avoid hat sharing, combs, brushes


    Skin infestations scabies
    Skin infestations: Scabies

    • Highly contagious by the itch mite Sarcoptes scabiei var hominis

    • Eggs are laid in burrows several millimeter in length

    • Not a vector for other infections

    • Transmitted by intimate personal or sexual contact; or by casual contact

    • Always consider when patient complains of rash with intense itching


    Scabies

    Assessment

    Subjective data

    History of current illness

    Intense itching, worse at night

    Rash

    Previous treatment for current problem

    Exposure to scabies

    Medical history

    Previous infestations

    Allergies

    medications

    Scabies


    Scabies1
    Scabies

    • Objective data

      • Physical exam

        • Rash

          • Red papules, excoriations, and occasionally vesicles

          • More common in interdigit web spaces, wrists, anterior axillary folds, periumbilical skin, pelvic girdle, penis, ankles

          • For infants and small children, soles, palms, face, neck, and scalp are often involved

          • Patient scratching

          • Signs of infection of lesions


    Scabies2
    Scabies

    • Interventions

      • Contact isolation

      • Advise patient/parent to avoid school/work until one treatment completed

      • Administer analgesics, antihistamines, antibiotics

      • Use pediculicides

        • Pyrethrin liquid

        • Permethrin crème


    Scabies3
    Scabies

    • Instruct patient/parent

      • Instruct patient/parent that itching may continue after treatment: do not re-treat without physician order

      • Launder clothing/bedding in hot water; dry in hot drier if possible, discard clothing and linen if practical

      • Put socks over hands of small children at bedtime

      • Cut fingernails short

      • Put hats, coats, other non-launderable item away for at least 72 hours


    Skin infestations myiasis
    Skin infestations: myiasis

    • Invasion of living, necrotic, or dead tissue by fly larvae (maggots)

    • Do not carry infectious agents, but can cause significant disease of the tissues


    Skin infestations myiasis1

    Assessment

    Subjective data

    History of present illness

    Skin lesions or wound

    Social History

    Living conditions

    Skin infestations: myiasis

    • Ability to care for self

    • Substance abuse

    • Previous myiasis

    • Medications

    • Allergies


    Myiasis
    Myiasis

    • Objective data

      • Physical examination

        • Skin wound or lesion

        • Boil-like lesion

        • “creeping eruption” of open wounds

        • Poor hygiene: may see maggots in skin folds or on intact skin surface


    Myiasis1
    Myiasis

    • Interventions

      • Contact isolation

      • Advise patient/parent to avoid school/work until treatment completed

      • Administer analgesics and antibiotics

      • Prepare to assist with surgical debridement


    Myiasis2
    Myiasis

    • Interventions

      • Apply petroleum jelly to cutaneous boils

      • Instruct patient about prevention

        • Eradicate flies

        • Keep open wounds properly dressed

        • Stay indoors, away from fly-infested areas

      • Referrals to Social Services or Substance Abuse if needed


    Tuberculosis
    Tuberculosis

    • Mycobacterium tuberculosis, acid-fast bacillus (AFB)

    • Not highly contagious, requires close, frequent exposure for transmission

    • Droplet nuclei, which can remain in still air for days

    • Susceptibility of host usually determines whether infection occurs

    • TB occurs when symptoms occur and is infectious

    • 2-10 weeks after infection, develop immunological response, allows healing and +PPD


    Tuberculosis1
    Tuberculosis

    • Greatest risk of disease in the first 2 years after infection

    • Lung primary site

    • 15% Extrapulmonary

      • Kidney, Lymphatic, Pleura, Bones, Joints, and blood (disseminated or miliary)

    • Diagnosed by one of two criteria:

      • Culture of bacteria

      • + PPD or S&S of TB, unsteady CXR

    • Noncompliance of medication regimen


    Tuberculosis2
    Tuberculosis

    • Assessment

      • Subjective data

        • History of present illness

          • Exposure to TB

          • Productive prolonged cough

            • Longer than 2 weeks

            • Becoming progressively worse


    Tuberculosis3
    Tuberculosis

    • History of present illness

      • Fever and chills, night sweats

      • Easy fatigability and malaise

      • Anorexia, weight loss

      • Hemoptysis

      • Recent +TB skin test

      • Foreign born or travel to high-prevalence country: Vietnam, Philippines, Mexico, Haiti, China, Korea


    Tuberculosis4
    Tuberculosis

    • History of present illness

      • Resident or staff of nursing home, prison, or homeless shelter

      • Alcoholic or other substance abuser

      • Racial/ethnic minority: African-American, Hispanic, Alaska native, American Indian


    Tuberculosis5
    Tuberculosis

    • Medical History

      • DM

      • Malignancy

      • CRF

      • Immunosuppression

      • HIV and AIDS

      • Medications, especially prolonged steroid therapy

      • Allergies


    Tuberculosis6
    Tuberculosis

    • Objective data

      • Physical exam

      • Healthy or ill appearance

      • Chest: decreased breath

        sounds

      • Fever

      • Signs of underlying disease


    Tuberculosis7
    Tuberculosis

    • Diagnostic Procedures

      • PPD: induration 5mm or > +if HIV, 10mm + all others

      • CXR: infiltrate, especially of upper lobes

      • Sputum for AFB: 3 successive early-morning

      • LFT: obtain before starting INH


    Tuberculosis8
    Tuberculosis

    • Interventions

      • Decrease transmission of disease

        • Isolate coughing patient, preferably in negative pressure

        • Teach to cover nose and mouth

        • Educate to dispose of tissue and wash hands

        • Isolate at home first 2 weeks of therapy; considered infectious until

          • 14 days of directly observed therapy

          • Decrease cough and afebrile

          • Three consecutive negative AFB smears


    Tuberculosis9
    Tuberculosis

    • Surgical masks are helpful for patient; not effective for health care staff or family

    • Ventilate living quarters with fresh air: 20 times every day

    • Unnecessary to dispose of clothes, to wear caps, gowns, gloves

  • Encourage patient/significant other for reading of TB skin test, compliance with medication regimen

  • Reportable disease


  • Tuberculosis10
    Tuberculosis

    • Administer and educate about meds

      • All patients with active disease should have directly observed therapy

      • Preventive therapy for 6 months

        • HIV with PPD +5> :treat 12 months

        • Household members and close contacts of newly diagnosed patient

        • Recent TB converter

        • IV drug users known to be HIV- with PPD induration of 10mm>


    Tuberculosis11
    Tuberculosis

    • Medications: preventative and therapeutic 4-drug regimen

      • Isoniazid

      • Pyridoxine: prevents peripheral neuropathy from isoniazid

      • Rifampin: discolors

      • Pyrazinamide

      • Ethambutol

  • Encourage HIV testing

  • Provide Social Service in needed


  • Varicella chickenpox
    Varicella (chickenpox)

    • Highly contagious caused by VZV

    • Direct contact, droplet, or aerosol from skin lesion fluid

    • Incubation 14-16 days

    • Contagious period start 1-2 days before rash and ends when all lesions are crusted

    • 90% cases children <3


    Varicella chickenpox1
    Varicella (chickenpox)

    • Adolescents, adults, and immunocompromised at risk for severe disease

    • <5% of cases >20 years, but 55% of deaths

    • Complications

      • Bacterial infection, pneumonia, DIC, renal failure, and encephalitis

      • 31% mortality to neonates born to infected mothers


    Chickenpox assessment
    Chickenpox- Assessment

    • Subjective data

      • History of present illness

        • Exposure to chickenpox

        • Prodrome: 48 hours before rash: fever, malaise, headache, rash often with itching

      • Medical history

        • Immunizations

        • Pregnant or trying to become pregnant

        • HIV, cancer, or other immunocompromised state

        • Allergies

        • Medications


    Chickenpox
    Chickenpox

    • Objective data

      • Physical exam

      • Rash, typically 250-500 lesions

        • Starts on trunk as faint, red macules

        • Becomes teardrop vesicles on a red base, which dry and crust over

        • New crops appear over several days

        • Palms and soles are spared

        • Vesicles may occur in mucous membranes, rupture, and become shallow ulcers


    Chickenpox1
    Chickenpox

    • Objective data

      • Fever, low grade

      • Skin excoriations form scratching

      • Signs of lesion infection: red, swollen, tender

      • Altered mental status

      • Dehydration

      • Cough


    Chickenpox2
    Chickenpox

    • Diagnostic procedures

      • Generally none


    Chickenpox3
    Chickenpox

    • Interventions

      • Provided respiratory and contact isolation

      • Isolate patient/significant others from waiting room

      • Advise to avoid school/work until all lesions are crusted


    Chickenpox4
    Chickenpox

    • Interventions

      • Recommend immunization of high-risk contacts

        • VZIG

          • Post exposure prophylaxis

          • Immunocompromised (HIV, AIDS, cancer, steroid therapy)

          • Effective up to 96 hours after exposure

          • Susceptible health care workers should be vaccinated


    Chickenpox5
    Chickenpox

    • Administer medications

      • Acetaminophen

      • Never use ASA (risk of Reye’s syndrome)

      • Antihistamines

      • Antivirals to older children will lesson the severity

    • To prevent infection of lesions

      • Suggest putting socks over small children’s hands at bedtime to decrease scratching and excoriation


    Chickenpox6
    Chickenpox

    • To prevent infection of lesions

      • Cut fingernails short

      • Topical backing soda paste or baths and calamine lotion

      • Encourage parents to have children immunized


    Chickenpox7
    Chickenpox

    • Instruct patient/parent about S&S or serious illness

      • Increased fever

      • Cough

      • Becoming more ill

      • Signs of skin infection


    Adrenal crisis
    Adrenal Crisis

    • Addison’s Disease (adrenal insufficiency)

    • Adrenal cortex ceases to produce glucocorticoid and mineralocorticoid hormones

    • Acute stressors, infection, hemorrhage, trauma, surgery, burns, pregnancy, or abrupt cessation for Addison’s disease

    • Life threatening because hormones are necessary for the maintenance of blood volume, BP, and glucose homeostasis


    Adrenal crisis1
    Adrenal Crisis

    • Suspect with patients who have septicemia with unexplained deterioration, major illness who have abdominal, flank, or chest pain, with dehydration, fever, hypotension, or shock, and adrenal hemorrhage

    • Death because of circulatory collapse and hyperkalemia- induced dysrhythmia


    Adrenal crisis assessment
    Adrenal Crisis- Assessment

    • Subjective data

      • History of present illness

        • Rapid worsening of symptoms of adrenal insufficiency

        • Fever

        • Nonspecific abdominal pain; may simulate acute abdomen

        • N&V


    Adrenal crisis assessment1
    Adrenal Crisis- Assessment

    • Medical history

      • Primary adrenal insufficiency

      • Hyperpigmentation of skin

      • Weakness, fatigue, lethargy

      • Anorexia and weight loss

      • Nausea, vomiting, diarrhea

      • Salt craving

      • Postural hypotension

      • Allergies

      • Medications


    Adrenal crisis2
    Adrenal Crisis

    • Physical examination

      • Appears acutely ill

      • Signs of shock as a result of dehydration

        • Hypotension, but may have warm extremities

        • Tachycardia

        • Tachypnea

        • Orthostatic hypotension


    Adrenal crisis3
    Adrenal Crisis

    • Physical examination

      • Fever

      • Altered mental status, confusion

      • Hyperpigmentation of skin

      • Very soft heart sounds



    Adrenal crisis4
    Adrenal Crisis

    • Diagnostic procedures

      • CBC: anemia of chronic disease

      • Electrolyte levels

        • Hyponatremia

        • Hyperkalemia

      • Blood glucose level: hypoglycemia

      • BUN: elevated (azotemia secondary to dehydration)

      • UA


    Adrenal crisis5
    Adrenal Crisis

    • UA

    • Blood cultures

    • Plasma cortisol level

    • ECG

      • Low voltage

      • Flat or inverted T wave

      • Prolonged QT, QRS, or PR intervals

      • CXR

      • CT of abdomen: if diagnosis not clear


    Adrenal crisis6
    Adrenal Crisis

    • Interventions

      • O2, IV, monitor

      • VS, with Orthostatic VS

      • I&O

      • Weight

      • Monitor signs of adequate tissue perfusion: capillary refill and skin temperature and moisture


    Adrenal crisis7
    Adrenal Crisis

    • Medications

      • Dexamethasone

      • Hydrocortisone

      • Corticotropin

      • Glucose

      • Vasopressors

    • Monitor electrolytes

    • Monitor cardiac function

    • Prepare for admission

    • Instruct about disease process


    Diabetic ketoacidosis
    Diabetic Ketoacidosis

    • Result of insulin deficiency

    • Typically Insulin-dependent

    • Hyperglycemia promotes osmotic diuresis with dehydration, hyperosmolality, and electrolyte depletion

    • Free fatty acids are converted to ketones bodies, which release hydrogen ions, thereby contributing to metabolic ketoacidosis


    Diabetic ketoacidosis1
    Diabetic Ketoacidosis

    • Infection and stressful events are usual precipitation factors, along with omission of insulin and new-onset diabetes

    • Goal is a gradual return to normal metabolic balance

    • Complications of therapy: cerebral edema, hypoglycemia, and electrolyte imbalance may contribute to death


    Diabetic ketoacidosis assessment

    Subjective data

    History of present illness

    Onset: gradual, 24 hours to 2 weeks

    Preceding bacterial or viral illness, current infectious process, or significant stress

    N&V

    Abdominal pain, usually generalized

    Fever

    Polyuria, polydipsia, polyphagia

    Lethargy, weakness, and fatigue

    Decreasing LOC and altered mental status

    Weight loss

    Diabetic Ketoacidosis- Assessment


    Diabetic ketoacidosis2
    Diabetic Ketoacidosis

    • Medical history

      • Administration of insulin or oral hypoglycemic agents

      • Discontinuance or decreased dose

      • Other medications

      • Allergies

      • Previous similar episodes


    Diabetic ketoacidosis3
    Diabetic Ketoacidosis

    • Objective data

      • Physical examination

        • Tachycardia

        • Orthostatic or frank hypotension

        • Kussmaul’s respirations if pH <7.2

        • Dry, hyperthermic, flushed skin, poor turgor, dry mucous membranes

        • Acetone breath odor

        • Confusion, coma, and decreased mental status


    Diabetic ketoacidosis4
    Diabetic Ketoacidosis

    • Diagnostic procedures

      • Serum glucose level: >300

      • Electrolyte levels

        • NA, CL, and HCO3: decreased

        • K: normal or elevated initially; falls rapidly during treatment

        • Serum phosphate: elevated 6-7 as a result of insulin deficiency and prerenal azotemia; total body phosphate depletion as a result of osmotic diuresis


    Diabetic ketoacidosis5
    Diabetic Ketoacidosis

    • Diagnostic procedures

      • Serum osmolality: >310

      • Serum acetone level: elevated

      • BUN and creatinine levels: normal unless advanced renal disease or severe dehydration is present

      • ABG

        • Normal PaO2

        • Metabolic acidosis and anion gap acidosis: pH<7.3; HCO3<15

        • Respiratory alkalosis


    Diabetic ketoacidosis6
    Diabetic Ketoacidosis

    • UA: increase glucose and ketone levels

    • CXR

    • ECG

    • CBC: WBC >25,000 if

      infection present

    • Cultures as indicated


    Diabetic ketoacidosis7
    Diabetic Ketoacidosis

    • Interventions

      • Establish two IV’s, one for NS

      • O2, airway, breathing, circulation

      • Administer regular insulin as prescribed

        • Glucostabilizer Program


    Diabetic ketoacidosis8
    Diabetic Ketoacidosis

    • Interventions

      • Administer HCO3 as prescribed: if pH <7.0

      • K: added to IV if < 5.5

      • Add Dextrose when blood glucose <250

      • Administer phosphate (usually several hours into treatment)


    Diabetic ketoacidosis9
    Diabetic Ketoacidosis

    • Administer antibiotic or antiemetics as ordered

    • Insert urinary catheter; NG if decrease LOC

    • VS every 15 to 60 until stable

    • Monitor glucose every hour and K every 2 hours

    • I&O

    • Cardiac monitor until stable, Neuro checks (cerebral edema from too-rapid resolution of acidosis and hypoglycemia)


    Diabetic ketoacidosis10
    Diabetic Ketoacidosis

    • May need to restrain if confused

    • Review preventive fluid therapy

      • Must keep self hydrated, during any illness, no matter how minor

      • If unable to retain fluids, contact physician immediately

    • Teach to identify and manage symptoms of hypoglycemia or hyperglycemia


    Hyperglycemic hyperosmolar nonketotic coma
    Hyperglycemic Hyperosmolar Nonketotic coma

    • Type II, non-insulin-dependent

    • Profound dehydration because of hyperglycemia and resultant osmotic diuresis

    • Unable to drink

    • Ketoacidosis does not develop because there is enough endogenous insulin present to inhibit ketogenisis

    • Precipitated by infection, stroke, or sepsis


    Hyperglycemic hyperosmolar nonketotic coma1
    Hyperglycemic Hyperosmolar Nonketotic coma

    • Initial presentation with new-onset type II DM

    • Dehydration predisposes to widespread thrombosis and DIC

    • Mortality rate is high despite aggressive therapy, probably because patient is usually elderly with impaired renal, cerebral, or cardiac function

    • Illness rarely occurs in infants and children


    Dka vs hhnk

    Serum Glucose:

    HIGH

    pH: <7.3

    HCO3: <15 mEq/L

    Serum Ketones: +

    Ketonuria: +

    Osmolarity: varies

    Serum Insulin: decreased

    Serum Glucose: VERY HIGH

    pH: >7.3

    HCO3: >20 mEq/L

    Serum Ketones: -

    Ketonuria: -

    Osmolarity: High

    Serum Insulin: can be normal

    DKA vs. HHNK


    Nkh assessment
    NKH- Assessment

    • Subjective data

      • History of present illness

        • Insidious onset from days to weeks

        • Recent illness or infection

        • Thirst

        • Reduced fluid intake

        • Polyuria or oliguria

      • Medical history

        • Non-insulin-dependent diabetes

        • Elderly patient with undiagnosed diabetes

        • Medications: oral hypoglycemic agents, diuretics

        • Allergies


    Nkh assessment1
    NKH- Assessment

    • Objective data

      • Physical examination

        • Hypotension and Tachycardia

        • Normal respirations

        • Confusion and altered mental status are most prominent physical findings; may be comatose

        • Dry skin and mucous membranes: dehydration

        • May have fever

        • Seizures

        • Hemiparesis/hemisensory deficits


    HHNK

    • Diagnostic procedures

      • Serum glucose level: >800mg/dl, often >1000

      • Serum osmolality:: >350mOsm/kg

      • Hypernatremia resulting from dehydration

      • K: normal to high initially; hypokalemia develops with insulin therapy

      • BUN and creatinine: elevated as a result of prerenal azotemia


    HHNK

    • Diagnostic procedures

      • ABG’s

        • Normal PaO2

        • Mild metabolic acidosis

        • Serum ketone level: normal or slightly elevated

        • UA: elevated glucose level

        • CXR

        • ECG

        • Cultures of blood, urine, sputum if infection source not obvious

        • Creatine kinase (CK) elevated as a result of rhabdomyolysis


    HHNK

    • Interventions

      • O2, airway, breathing, circulation

      • Assist with intubation if PaO2 .70

      • IV for hydration

        • Adults: NS at 500-1000ml/hr until blood pressure stabilizes

        • Child: NS (20 ml/kg bolus if hypotensive) to prevent cerebral edema from too-rapid correction of hyperosmolality


    NKH

    • K+ as needed

    • Low dose heparin

    • Add dextrose when glucose <300

    • May need to restrain confused patient

    • Continually reassess neurological status, and monitor for signs of cerebral edema and seizures

    • I&O, FC

    • Monitor for signs of fluid overload (major problem in elderly) or dehydration; assess breath sounds as indicated for pulmonary edema

    • Discuss disease process


    Hypoglycemia
    Hypoglycemia

    • Glucose <50

      • most common endocrine emergency

    • <35 mg/dL, the brain in unable to extract O2 adequately, resulting in hypoxia and coma

    • Very young and very old are more susceptible

    • Mainly diabetes and alcohol ingestion, lack of glucose causes permanent brain dysfunction, any person with an altered LOC should be considered to have hypoglycemia until proven otherwise


    Hypoglycemia assessment
    Hypoglycemia- Assessment

    • History of present illness

      • Rapid onset

      • No recent food intake

      • Alcohol ingestion within 36 hours followed by fasting

      • Hunger, nausea

      • Weakness, dizziness

      • Lethargy

      • Shakiness

      • Anxiety

      • Headache

      • Altered mental status


    Hypoglycemia1
    Hypoglycemia

    • Medical history

      • Diabetes

      • Insulin: increased dosage (easily reversed)

      • Oral hypoglycemic agents: long half-life (difficult to reverse)

      • Adrenal insufficiency

      • Liver disease

      • Propranolol, salicylates, sedatives

      • Increase in physical exercise


    Hypoglycemia2
    Hypoglycemia

    • Physical exam

      • Cool, diaphoretic skin, pale, dilated pupils

      • Confusion, hypothermia

      • Shallow respirations but normal rate

      • Normal BP and pulse

      • Combative behavior or coma, seizures

      • Hemiplegia or other signs of stroke


    Hypoglycemia3
    Hypoglycemia

    • Diagnostic procedures

      • Blood glucose level: <50

      • Electrolyte levels: normal

      • UA: normal

      • ABG’s: normal pH

      • Serum ETOH


    Hypoglycemia4
    Hypoglycemia

    • Interventions

      • O2, VS, maintain airway, breathing, circulation

      • Assist with intubation if PaO2 <70

      • determine blood glucose level

      • Administer thiamine IM or IV if malnourished

      • Oral glucose if gag present

      • D5w if unresponsive

      • Give IV D50; if no response repeat; D25 if <2yrs

      • Give Glucagon IM or SC


    Hypoglycemia5
    Hypoglycemia

    • Interventions

      • Monitor mental status continually

      • May need to restrain combative patient

      • Educate patient and significant others

        • Reinforce need to eat regularly

        • Carry quick glucose foods

        • Decrease insulin dosage if exercising

        • Avoid alcohol consumption while fasting, alcoholic need to eat when bingeing


    Myxedema coma
    Myxedema coma

    • Severe form of hypothyroidism

    • Marked impairment of CNS and cardiovascular decompensation

    • Recognition of this illness is hampered by its insidious onset and rarity

    • Winter, elderly women with HX of hypothyroidism

    • Precipitating factors include: serious infection (pneumonia and UTI), sedative or tranquilizer use, stroke, exposure to cold environment, and termination or thyroid hormone replacement

    • Death is common, but can survive if prompt adequate care


    Myxedema coma1
    Myxedema coma

    • History of present illness

      • Recent illness

      • Progressive decline in intellectual status

      • Apathy, self-neglect

      • Emotional labiality

      • Anorexia

      • Recent weight gain

    • Medical history

      • Hypothyroidism or thyroid surgery

      • Allergies

      • Medications: thyroid replacement hormone, recent use of tranquilizers and sedatives


    Myxedema coma2
    Myxedema coma

    • Objective data

      • Physical exam

        • Decreased mental status

        • Depressed mental acuteness

        • Confusion or psychosis

        • Pale, waxy, edematous face with periorbitaledema

        • Dry, cold, pale skin


    Myxedema coma3
    Myxedema coma

    • Objective data

      • Physical exam

        • Non-pitting extremity edema

        • Thin eyebrows

        • Deep, coarse voice

        • Scar form prior thyroidectomy

        • Vital Signs

          • Hypothermia, usually above 95 F

          • Bradycardia with distant heart sounds

          • Hypoventilation, Hypotension


    Myxedema coma4
    Myxedema coma

    • Diagnostic procedures

      • Electrolytes: hyponatremia

      • ABG’s: hypoxia and hypercarbia

      • Thyroid studies: low thyroxine (T4), elevated thyrotropin (thyroid stimulating hormone [TSH])


    Myxedema coma5
    Myxedema coma

    • ECG

      • Low voltage

      • Sinus bradycardia

      • Prolonged QT interval

      • CBC: anemia and decreased WBC

      • BUN and creatinine: elevated

      • Blood sugar: variable hypoglycemia

      • CXR

      • UA

      • Obtain pretreatment plasma cortisol level


    Myxedema coma6
    Myxedema coma

    • Interventions

      • Monitor airway, breathing, circulation, and other vital signs

      • O2 as ordered

      • IV, IV fluids

        • Hypertonic saline

        • Crystalloids

        • Whole blood


    Myxedema coma7
    Myxedema coma

    • Interventions

      • Meds as ordered

        • IV thyroid hormone

        • Glucocorticoid

        • Vasoconstrictors

      • Rewarm patient

        • Use passive rewarming with blankets and increased room temperature

        • Avoid rapid rewarming

        • Be prepared for seizures


    Thyroid storm
    Thyroid storm

    • Extreme and rare form of thyrotoxicosis

    • High mortality

    • Untreated or inadequately treated hyperthyroidism, who experiences surgery, infection, trauma, or emotional upset; thyroid surgery; radioactive iodine administration

    • Cardiac decompensation with CHF (terminal event), CNS dysfunction, GI disorders

    • Life-threatening emergency


    Thyroid storm assessment
    Thyroid Storm- Assessment

    • History of present illness

      • Fever

      • N&V&D

      • Abdominal pain

      • Worsening of thyrotoxicosis symptoms

      • Anxiety

      • Restlessness, nervousness, irritability

      • Generalized weakness

      • Possible coma

      • Precipitation event or intercurrent illness


    Thyroid storm1
    Thyroid storm

    • Medical history

      • Thyrotoxicosis

      • Thyroid disease

      • Easy fatigability

      • Weight loss

      • Sweating

      • Body heat loss and heat intolerance


    Thyroid storm2
    Thyroid storm

    • Objective data

      • Physical exam

        • Fever: temp may exceed 104

        • Tachycardia (120-200), systolic hypertension

        • Chest: crackles


    Thyroid storm3
    Thyroid storm

    • Warm, moist, velvety skin; becomes dry as dehydration develops

    • Spider angiomas

    • Tremulousness

    • Delirium, agitation, confusion, coma

    • Thin silky hair

    • Enlarged thyroid gland with thrill or bruit


    Thyroid storm4
    Thyroid storm

    • Eye signs

      • Lid lag

      • Stare

      • Exophthalmos

      • Periorbital edema

    • Hepatic tenderness or jaundice


    Thyroid storm5
    Thyroid storm

    • Diagnostic procedures

      • Cardiac monitoring/ECG: sinus tachycardia wand atrial fibrillation/flutter

      • Thyroid function studies

        • T4: elevated

        • Triiodothyronine (T3): elevated resin uptake

        • TSH: decreased

      • Serum cholesterol level: decreased


    Thyroid storm6
    Thyroid storm

    • Diagnostic procedures

      • Electrolyte levels

      • Serum glucose increased

      • CBC: increased WBC with left shift

      • BUN or creatinine level

      • Hepatic studies: increased liver enzymes

      • UA

      • Cultures and radiographs and indicated


    Thyroid storm7

    Interventions

    O2, airway, breathing, circulation, VS

    IV of D5 and isotonic solution

    Cardiac monitoring

    Meds as ordered

    Vasopressors

    Antipyretic

    D50

    Propylthiouracil every 8 hours

    Glucocorticoids, hydrocortisone

    Iodine: lugol’s solution, potassium iodide

    Digitalis, propranolol

    Antibiotics

    Vitamins and thiamine

    Sedatives

    Thyroid storm


    Thyroid storm8
    Thyroid storm

    • Use cooling blanket, cold packs

    • Prepare patient/significant others for patient’s admission

    • Explain procedures to patient/significant others


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