General Medical Emergencies: Part I

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General Medical Emergencies Part I
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Major TopicsCommunicable / Infectious Diseases

• Mononucleosis
• Mumps
• Pertussis
• Shingles (Herpes Zoster)
• Tuberculosis
• Varicella (Chickenpox)

• HIV Infection and AIDS
• Diphtheria
• Encephalitis
• Hepatitis
• Herpes Disseminated
• Measles
• Meningitis

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Major TopicsSkin Infestations

• Lice
• Scabies
• Myiasis

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Major TopicsEndocrine Emergencies

• Adrenal Crisis
• Diabetic Ketoacidosis
• Hyperglycemic Hyperosmolar Nonketotic Coma
• Hyperglycemia
• Myxedema Coma
• Thyroid Storm

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HIV Infection and AIDS

• Caused by a retrovirus
• Viral symptoms start 2-6 weeks
• Antibody seroconversion takes
• place within 45 days - 6 months
• Asymptomatic period for months
• to years
• Replication, mutation, and destroying the immune
  system

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HIV Infection and AIDS

• Persistent generalized lymphadenopathy occurs
• Constitutional disorders, neurological disorders,
  secondary infections, secondary cancers, and
  pneumonitis

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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

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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

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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

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HIV Infection and AIDS Assessment

• Current medications
• Antiretroviral agents zidovudine (AZT),
  zalcitabine (ddC), didanosine (ddI), stavudine
  (d4T), lamivudine (3TC), nevirapine, delavirdine
• Pneumocystis prophylaxis trimethoprim-sulfameth
  oxazole, pentamidine, dapsone
• Protease inhibitors indinavir, saquinavir
  mesylate, nelfinavir, ritonavir

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HIV Infection and AIDS Assessment

• Medical History
• Blood transfusions, especially before 1985
• Hemophilia
• Occupational needle sticks or blood exposure
• Sexually transmitted diseases (STDs)
• 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

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HIV infection and AIDS

• Physical examination
• Chronically ill appearance
• Kaposis 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

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HIV Infection and AIDS

• Diagnostic procedures
• CXR
• CBC
• Anemia
• Lymphopenia
• Thrombocytopenia
• ABGs
• Electrolytes, liver function tests

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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)

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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

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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

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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

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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

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Diphtheria

• Antibiotic EES or PCN G
• Antitussive
• Antipyretic
• Topical anesthetic agent
• Minimize environmental stimuli
• Instruct patient on importance of complete bed
  rest

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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)

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Encephalitis

• Viral infection of the brain
• Often coexists with meningitis and has
• broad range of SS
• 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

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Encephalitis

• 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

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Encephalitis

• Assessment
• Subjective
• Medical history
• Immune disorders
• Allergies
• Medications

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Encephalitis

• Objective data
• Physical exam
• Altered LOC
• Rash specific to cause
• Meningism
• Altered reflexes
• Focal neurological findings
• Abnormal movements
• Seizures

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Encephalitis

• Diagnostic Procedures
• Lumbar puncture, CT scan
• CBC
• Blood cultures
• Serology

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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

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Encephalitis

• Administer antimicrobial/antiviral agents,
  steroids
• Monitor blood sugar and electrolytes
• Insert urinary catheter PRN
• Monitor IO, cerebral edema, keep HOB gt30 degrees
• Institute seizure precautions
• Elevate HOB 30 degrees

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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

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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

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Hepatitis

• Hep B-(HBV) blood and sexual contact
• 3 antigens
• Hep B antigens
• Persistence of core antibody indicates chronic
  infection
• Persistence of surface antibody indicates
  immunity to reinfection
• Hep B surface antigen in the serum without
  symptoms is indicative of a carrier state

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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

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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

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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

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Hepatitis

• History of Illness contd
• 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

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Hepatitis

• Icteric phase
• Disappearance of other symptoms
• Anorexia
• Abdominal pain
• Dark urine
• Pruritus
• Jaundice

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Hepatitis contd

• 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

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Hepatitis

• Objective data
• Physical exam
• Posterior cervical lymph node enlargement
• Enlarged, tender liver
• Splenomegaly in 20
• Jaundice
• Vital signs may have tachycardia, hypotension
• Fever

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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

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Hepatitis

• Interventions
• Provide increased calories
• Monitor for signs of dehydration, replacement
  with isotonic solution
• Record IO
• Assess support systems of patients
• Hospitalize if unable to care for self or PT gt15
  seconds

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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

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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

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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

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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
• SS bleeding, vomiting, increased pain
• Take meds as prescribed
• Avoid intake of alcohol
• Take meds only if necessary
• Avoid steroids they delay long-term healing

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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

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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

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Herpes

• Assessment
• Subjective data
• History of present illness
• Onset usually acute
• After other illness
• After outbreak of cutaneous infection
• After any stressor

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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

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Herpes

• Medical history
• HSV infection
• Chronic illness, cancer, HIV
• Medications immunosuppressants
• Allergies

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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

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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

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Herpes

• Interventions
• Prepare to assist intubation
• O2 PRN
• Monitor
• VS with PO
• Neurological status
• Maintain airway, breathing, circulation
• IO
• 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

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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

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Measles

• More serious in infants and in malnourished
  children, pregnancy with preterm delivery and
  spontaneous abortion
• Most born lt1957 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

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Measles

• Assessment
• Subjective data
• History of present illness
• Exposure to measles
• Prodrome
• Fever
• Cough
• Coryza (nasal mucosal inflammation)
• Photophobia
• Anorexia
• Headache
• Rarely seizures

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Measles
Subjective

• Medical history
• Immunizations
• History of measles
• Current age born before 1957
• Allergies
• Medications

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Measles

• Objective data
• Physical exam
• Fever
• Kopliks spots on buccal mucosa (bluish-gray
  specks on red base)
• Conjunctivitis
• Harsh cough

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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

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Measles

• Diagnostic procedures
• Viral cultures (expensive and difficult, so not
  usually done)
• Immunoglobulin M antibodies measles specific
• CBC leukopenia
• Other studies if seriously ill

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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

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Measles

• Encourage rest in darkened room
• Administer acetaminophen for fever
• Encourage parents to have children immunized at
  appropriate times
• Instruct patient/parent about SS of serious
  illness or complications
• Persistent fever or cough
• Change in mental status
  or seizures
• Difficulty in hearing

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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

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Meningitis

• Bacteria initially colonize in the nasopharynx
• In bacterial disease, the subarachnoid space is
  filled with pus, which obstruct CSF, resulting in
  hydocephalus and increased ICP
• Infants and elderly often do not exhibit classic
  signs of meningeal irritation and fever
• Death most common within a few hours after
  diagnosis
• Up to 33 of pediatric survivors left with some
  type of permanent neurological dysfunction
• Any infant younger that 2 months with a fever,
  must be evaluated for meningitis

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Meningitis

• Assessment
• Subjective data
• History of present illness
• Antecedent illness or exposure
• Onset sudden
• Headache, especially occipital
• Fever and chills
• Anorexia or poor feeding
• Vomiting and diarrhea

• Malaise, weakness
• Neck and back pain
• Restlessness, lethargy, altered mental status
• Disinclination to be held infants
• Seizures
• Recent basilar skull fracture

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Meningitis

• Medical history
• Medications
• Allergies
• Immunizations if child
• Chronic disease liver or renal, DM, multiple
  myeloma, alcoholism, malnutrition
• Asplenic
• Recurrent sinusitis, pneumonia, OM, mastoiditis

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Meningitis

• Objective data
• Physical examination
• High-pitched cry in infants
• Hyperthermia gt101 or hypothermia lt96
• 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

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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 Kernigs
  sign
• Bending of neck produces flexion of knee and hip
  passive flexion of lower limb on one side
  produces similar movement on other side
  Brudzinskis sign
• Nuccal rigidity

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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

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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

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Meningitis

• Diagnostic procedures
• CBC
• Bacterial high WBC
• Viral normal or low WBC
• Meningococcal WBC tends to
  be less that 10,000
• Blood cultures
• ABGs if severely ill
• Clotting studies
• UA
• CXR and skull radiographs

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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
  Grams stain
• Viral infection clear appearance WBC lt500
  normal pressure glucose level normal no
  bacteria present on Grams stain

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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

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Meningitis

• Establish IV catheter, IO in necessary
• Monitor IV fluids as related to IO 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

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Meningitis

• Insert FC, monitor IO
• Monitor for signs of dehydration or fluid excess
• Monitor mental status and neurological signs
  every 15 minutes to 1 hour, depending on
  patients stability
• May need to restrain confuse patient
• Protect seizing patient form physical harm
• Explain procedures and need for ICU

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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

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Meningitis

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

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Mononucleosis

• Acute viral illness with broad range of SS
  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

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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

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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

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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

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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

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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

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Mononucleosis

• Interventions
• Administer antipyretics, analgesics (Avoid ASA)
• Administer corticosteroids therapy for severe
  Pharyngitis, evolving airway obstruction, chronic
  or disabling symptoms, or profound splenomegaly

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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

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Mononucleosis

• Instruct patient about SS of serious illness or
  complications
• Increased fever
• Cough, chest pain
• Progression of innless
• Difficulty breathing
• Signs of dehydration
• Increasing abdominal pain

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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

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Mumps

• Assessment
• Subjective data
• History of present illness
• Exposure to mumps
• Prodrome fever (lt104), 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

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Mumps
Subjective contd

• Medical history
• Childhood immunizations
• Previous mumps
• Allergies
• Medications

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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

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Mumps

• Diagnostic procedures
• CBC WBC and differential normal or mild
  leukopenia
• Serum amylase elevated
• for 2-3 weeks

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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

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Mumps

• Administer IV fluids for acutely ill patients
• Recommend immunization to family and health
  workers who have no mumps antibodies

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Pertussis

• Acute, widespread, highly contagious bacterial
  disease of the throat and bronchi
• Gram-negative Coccobacillus Bordetella Pertussis
• Airborne droplets
• Most common children lt4 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

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Pertussis

• Vaccine immunity is lt12 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

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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

106
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

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Pertussis

• Medical history
• Recent illness or infection
• Medications
• Allergies
• Immunization status

108
Pertussis

• Objective data
• Physical exam
• Paroxysmal explosive coughing ending in prolonged
  high-pitched crowing inspiration
• Coryza
• Clear, tenacious mucous in large amounts
• Temperature gt101
• Restlessness
• Crepitus from subcutaneous emphysema
• Periobital/eyelid edema

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Pertussis

• Diagnostic procedures
• CS testing of nasopharynx using calcium alginate
  dacron-tip swab
• Immunofluorescent antibody staining of
  nasopharyngeal specimens
• CBC with differential leukocyte count
  lymphocytosis

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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

111
Pertussis

• Administer prescribed medication
• Antibiotic EES
• Antitussive
• Analgesic
• Antipyretic
• Position comfortably

112
Pertussis

• Admit patients younger than 1 year prepare for
  nasotracheal suctioning
• Initiate immunization
• Educate parents about importance of complete
  immunization
• Household and other contacts lt1year
  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

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Pertussis

• Review SS 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

114
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

115
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

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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

118
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

119
Shingles

• Fever (low grade if present)
• Visual acuity, if eye involved
• Diagnostic procedures
• Viral culture
• Other studies if seriously ill

120
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)

121
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

122
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 SS of serious illness or
  complications
• Increased fever
• Cough
• Becoming more ill
• Signs of skin infection

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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

124
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

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Lice

• Can cause significant cutaneous disease
• Lice serve as vectors for typhus, relapsing
  fever, and trench fever

127
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 STDs

128
Lice

• Medical history
• Previous infestations
• Allergies
• Medications
• Objective data

129
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 lt1cm 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 STDs

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Lice
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Lice

• Interventions
• Contact isolation
• Advise patient/parent to avoid school/work until
  one treatment completed
• Administer analgesics, antihistamines, antibiotics

133
Lice

• Interventions
• Use pediculicides
• Pyrethrin liquid
• Permethrin crème
• Treat sexual contacts
• Administer medications for STDs
• Instruct patient/parent that itching may continue
  after treatment do not re-treat without
  physician order

134
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

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Lice
136
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

137
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

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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

140
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

141
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

142
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

143
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

144
Skin infestations myiasis

• Ability to care for self
• Substance abuse
• Previous myiasis
• Medications
• Allergies

• Assessment
• Subjective data
• History of present illness
• Skin lesions or wound
• Social History
• Living conditions

145
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

146
Myiasis

• Interventions
• Contact isolation
• Advise patient/parent to avoid school/work until
  treatment completed
• Administer analgesics and antibiotics
• Prepare to assist with surgical debridement

147
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

148
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

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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 SS of TB, unsteady CXR
• Noncompliance of medication regimen

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Tuberculosis

• Assessment
• Subjective data
• History of present illness
• Exposure to TB
• Productive prolonged cough
• Longer than 2 weeks
• Becoming progressively worse

153
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

154
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

155
Tuberculosis

• Medical History
• DM
• Malignancy
• CRF
• Immunosuppression
• HIV and AIDS
• Medications, especially prolonged steroid therapy
• Allergies

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Tuberculosis

• Objective data
• Physical exam
• Healthy or ill appearance
• Chest decreased breath
• sounds
• Fever