Pamantasan ng Lungsod ng PasigAlkalde Jose St. Kapasigan, Pasig
City
COLLEGE OF NURSING
TuberculosisCusative agent: Mycobacterium tuberculosis.MOT: It
is transmitted from a TB patient to another person through
coughing, sneezing and spitting.*Lungs are commonly affected but it
could also affect other organs such as the kidney, bones, liver and
others.*In 2010, TB was the 6th leading cause of mortality with a
rate of 26.3 deaths for every 100,000 population and accounts for
5.1% of the total deaths.1The National TB Control Program (NTP)*The
NTP is one of the public health programs being managed and
coordinated by the Infectious Disease Office (IDO) of the National
Center for Disease Prevention and Control (NCDPC) of the Department
of Health (DOH).*NTP has the mandate of developing TB control
policies, standards and guidelines, formulating the national
strategic plan, managing program logistics, providing leadership
and technical assistance to the lower health offices / units,
managing data and monitoring and evaluating the program.Vision:
TB-free PhilippinesGoal: By 2016, reduce TB mortality and
prevalence by half compared to 1990 dataRole of the NURSE:a. Manage
the process of detecting TB cases in coordination with other
staffb. Assist the physician in counselling and initiating
treatment of TB patientc. Open the NTP treatment cardd. Agree with
TB patient the mode of DOT including the treatment partnere.
Supervise midwives to ensure proper implementation of DOTSf.
Maintain and update the Presumptive TB Masterlist and TB
registerDirect sputum smear microscopy (DSSM) is fundamental to the
detection of infectious casesg. and is recommended for case finding
among adults and children who can expectorate. It is the primaryh.
diagnostic method adopted by the NTP among such individuals
because:i. 1. It provides a definitive diagnosis of active TB;j. 2.
the procedure is simple;k. 3. it is economical; and,l. 4. a
microscopy center could be put up even in remote areas.m.
Facilitate requisition and distribution of anti-TB drugs,
laboratory supplies and formsn. Maintain records on logistics and
ensure proper storage of drugs.i. Provide continuous health
education to all patientsj. Conduct training of health workers and
community volunteersk. Prepare, analyse and submit the quarterly
reports
\
Case finding is the identification and diagnosis of TB cases
among individuals with signs and symptoms presumptive of
tuberculosis. The current approach to case finding includes passive
and intensified case finding. The available tests utilized by the
program for diagnosing TB are: direct sputum smear microscopy, TB
culture and drug susceptibility test, tuberculin skin test and
rapid molecular diagnostic tests.
Direct sputum smear microscopy (DSSM) is fundamental to the
detection of infectious casesand is recommended for case finding
among adults and children who can expectorate. It is the
primarydiagnostic method adopted by the NTP among such individuals
because:1. It provides a definitive diagnosis of active TB;2. the
procedure is simple;3. it is economical; and,4. a microscopy center
could be put up even in remote areas.
*This is also used to: a) monitor progress of patients with TB
while they are on antiTB treatment; and, b)confirm cure at the end
of treatment.
Chest X-ray is used to complement bacteriologic testing in
making a diagnosis. However, it haslow specificity and does not
differentiate drug-susceptible from drug-resistant disease.
TB Culture and drug susceptibility test (DST) using solid (Ogawa
or Lowenstein Jensen) or liquidmedia (MGIT) is a routine diagnostic
test for drug resistant TB cases under the NTP. It is also used for
TB prevalence surveys, drug resistance surveillance, research and
other special cases.
Tuberculin skin test (TST) is a basic screening tool for TB
infection among children using purifiedprotein derivative (PPD)
tuberculin solution to trigger a delayed hypersensitivity reaction
among those previously infected. Also known as the PPD test or
Mantoux test, it is one of the criteria in determining disease
activity among children.
Rapid molecular diagnostic tests endorsed by the WHO will be
utilized by the NTP. Currently,WHO-endorsed available diagnostic
tests in the country are Xpert MTB/RIF and Line-Probe Assay (LPA)
for first line drugs. Xpert MTB/RIF assay is a rapid test that
detects Mycobacterium tuberculosis and rifampicin resistance.
Presumptive TB any person whether adult or child with signs
and/or symptoms suggestive ofTB whether pulmonary or
extra-pulmonary, or those with chest x-ray findings suggestive
ofactive TB. Presumptive Drug Resistant-TB (DRTB) Any person
(whether adult or child) who belongs toany of the DR-TB high-risk
groups, such as: re-treatment cases, new TB cases that are contacts
ofconfirmed DR-TB cases or non-converter of Category 1, and people
living with HIV with signs and symptoms of TB.
Identification of Presumptive TB
1.For patients 15 years old and above, a presumptive TB has any
of the following:
i. Cough of at least 2 weeks duration with or without the
following symptoms: Significant and unintentional weight loss,
Fever, Bloody sputum (hemoptysis), Chest/back pains not referable
to any musculoskeletal disorders, Easy fatigability or malaise,
Night sweats, and Shortness of breath or difficulty of
breathing;
ii. Unexplained Cough of any duration in: 1) a close contact of
a known active TB case; 2) high-risk clinical groups (HIV/AIDS,
diabetes, end-stagerenal disease, cancer, connective tissue
diseases, autoimmune diseases, silicosis, patients who underwent
gastrectomy or solid organ transplantation and patients on
prolonged systemic steroids); and, 3) high risk populations
(elderly, urban poor, inmates and other congregate settings)
2. For patients below 15 years old, a presumptive PTB has any of
the following:
i. at least three (3) of the following clinical criteria:
Coughing/wheezing of 2 weeks or more, especially if unexplained;
Unexplained fever of 2 weeks or more after common causes such as
malaria or pneumonia have been excluded; Loss of weight/ failure to
gain weight/ weight faltering/ loss of appetite; Failure to respond
to 2 weeks of appropriate antibiotic therapy for lower respiratory
tract infection; Failure to regain previous state of health 2 weeks
after a viral infectionor exanthema (e.g., measles); and, Fatigue,
reduced playfulness, or lethargy (child has lost his/her normal
energy)
ii. ANY one of the above signs and symptoms (clinical criteria)
in a child who is a close contact of a known active TB case.
3. Chest x-ray findings suggestive of PTB, with or without
symptoms, regardless of age.
4. Presumptive extra-pulmonary TB may have any of the following:
Gibbus, especially of recent onset (resulting from vertebral TB);
Non-painful enlarged cervical lymphadenopathy with or without
fistula formation; Neck stiffness (or nuchal rigidity) and/or
drowsiness suggestive of meningitis that is not responding to
antibiotic treatment, with a sub-acute onset or raised intracranial
pressure; Pleural effusion; Pericardial effusion; Distended abdomen
(i.e., big liver and spleen) with ascites; Non-painful enlarged
joint; and Signs of tuberculin hypersensitivity (e.g. phlyctenular
conjunctivitis, erythema
nodosum)._______________________________________Sputum Collection.
Demonstrate how to produce quality sputum. Mucus from the nose and
throat, and saliva fromthe mouth are NOT good specimens. Advise the
patient to:a. Clean mouth by thoroughly rinsing with water. Food
particles or other solid particulates may inhibit the test for
Xpert MTB/RIF.b. Breathe deeply, hold breath for a second or two,
and then exhale slowly. Repeat the entire sequence two (2) more
times.c. Cough strongly after inhaling deeply for the third time
and try to bring up sputum from deep within the lungs.d.
Expectorate the sputum into a container with a well fitted cap.e.
Collect at least 1 teaspoonful (5-10ml) for DSSM. For Xpert
MTB/RIF, sputum sample should not be less than one (1) ml.f.
Examine the specimen to see that it is not just saliva. Repeat the
process if necessary.
*Among the first group (the oral first-line drugs) high-dose
isoniazid, pyrazinamide, and ethambutol are thought of as an
adjunct for the treatment of MDR and XDR tuberculosis. The second
group is the fluoroquinolones, of which the first choice is
high-dose levofloxacin. The third group are the injectable drugs,
which should be used in the following order: capreomycin,
kanamycin, then amikacin. The fourth group are called the
second-line drugs and should be used in the following order:
thioamides, cycloserine, then aminosalicylic acid. The fifth group
includes drugs that are not very effective or for which there are
sparse clinical data. Drugs in group five should be used in the
following order: clofazimine, amoxicillin with clavulanate,
linezolid, carbapenems, thioacetazone, then clarithromycin.
*Rifampicin: taken before meals, causes red urine urine WOF s/s
hepatitis. Monitor liver and kidney function. *Isoniazide: causes
peripheral neuritis, given with Vit.B6 (pyridoxine). Taken with
food *Pyrazinamide: cause hyperurucemia*Ethambutol: causes optic
neuritis/blurring of vision*Streptomycin: cause tinnitus, loss of
hearingbalance, damage to 8th cranial nerve
Note: After 2-4 weeks of treatment, patient is no longer
contagious
Meningococcemia
Causative agent: Neisseria meningitidis, also called
meningococcus.
MOT: Neisseria meningitidis bacteria are spread through the
exchange of respiratory and throat secretions like spit (e.g., by
living in close quarters, kissing). Fortunately, these bacteria are
not as contagious as germs that cause the common cold or the flu.
The bacteria are not spread by casual contact or by simply
breathing the air where a person with meningococcal disease has
been.
Incubation- 2-10 days
*Bacteria enter the bloodstream and multiply, damaging the walls
of the blood vessels and causing bleeding into the skin and
organs.
Symptoms may include:
FatigueVomitingCold hands and feetCold chillsSevere aches or
pain in the muscles, joints, chest or abdomen (belly)Rapid
breathingDiarrheaIn the later stages, a dark purple rash
Diagnostic Tests: Lumbar puncture, cultures of blood, urine,
nose and throat secretions.
Prophylaxis:Rifampicin Adults: 600 mg twice daily for two days
Children: 10 mg/kg twice daily for two days Neonates: 5 mg/kg twice
daily for two daysFor pregnant women or contraindication to
rifampicinCeftriaxone < 12yo: 125mg IM once only > 12yo: 250
mg IM once only Reconstitute 1 g vial with 3.2 ml lignocaine 1%
(250 mg/ml)ORCiprofloxacin >12yo: 500 mg oral as single
doseTreatment: Penicillin, ceftriaxone, vancomycin,
chloramphenicol.
Nursing Considerations:
1. Give IV antibiotics as ordered.2. Maintain a patent airway.3.
Monitor GCS
Dengue Hemorrhagic fever
Causative agent: DENV-1 to 4 genus flavivirusMOT: Ades aegypti,
Aedes albopictus
Incubation Period: Uncertain. Probably 6 days to 1 week
Manifestations: First 4 days: Febrile/Invasive Stage - starts
abruptly as fever - abdominal pain - headache - vomiting -
conjunctival infection epistaxis, 4th 7th days: Toxic/Hemorrhagic
Stage - decrease in temperature - severe abdominal pain - GIT
bleeding - unstable BP (narrowed pulse pressure) - shock - death
may occur 7th 10th days: Recovery/Convalescent Stage - appetite
regained
Classification (WHO): Grade I: a. flu-like symptoms b. Hermans
sign c. (+) tourniquet signGrade II: a. manifestations of Grade I
plus spontaneous bleeding b. e.g. petechiae, ecchymosis purpura,
gum bleeding, hematemesis, melena Grade III: a. manifestations of
Grade II plus beginning of circulatory failure b. hypotension,
tachycardia, tachypnea Grade IV: a. manifestations of Grade III
plus shock (Dengue Shock Syndome)
Diagnostic Test: Torniquet test (Rumpel Leads Test / capillary
fragility test) PRESUMPTIVE; positive when 20 or more oetechiae per
2.5 cm square or 1 inch square are observed Platelet count
CONFIRMATORY; (Normal is 150 - 400 x 103 / mL)
Treatment: Supportive and symptomatic Paracetamol for fever
Analgesic for pain Rapid replacement of body fluids most important
treatment ORESOL Blood tansfusion Diet: low-fat, low-fiber,
non-irritating, noncarbonated. Noodle soup may be given. ADCF
(Avoid Dark-Colored Foods) ALERT! No Aspirin
Prevention: 4 oclock habit Chemically treated mosquito net Larva
eating fish Environmental sanitation Antimosquito soap Neem tree
(eucalyptus)Eliminate vector Avoid too many hangingclothes inside
the house Residual spraying withinsecticide Daytime fumigation Use
of mosquito repellants Wear long sleeves, pants,and socks For the
control of H-fever,knowledge of the natural history of the disease
is important. Environmental control isthe most appropriate primary
prevention approach and control of Hfever.
Malaria
Causative agent: Plasmodium Parasites: Vivax Falciparum (most
fatal; most common in the Philippines) Ovale Malariae, recent
species: P. knowlesi
MOT: Bite of infected anopheles mosquito Night time biting
High-flying Rural areas Clear running water
Assessment Findings: Cold Stage: severe, recurrent chills (30
minutes to 2 hours) Hot Stage: fever (4-6 hours) Wet Stage: Profuse
sweating Episodes of chills, fevers, and profuse sweating are
associated with rupture of the red blood cells. - intermittent
chills and sweating - anemia / pallor - tea-colored urine - malaise
- hepatomegaly - splenomegaly - abdominal pain and enlargement -
easy fatigability
Treatment and Management: Early diagnosis identification of a
patient with malaria as soon as he is seen through clinical and/or
microscopic methodClinical method based on signs and symptoms of
the patient and the history of his having visited a malaria-endemic
area Microscopic method based on the examination of the blood smear
of patient through microscope (done by the medical technologist)
QBC/quantitative Buffy Coat fastest Malarial Smear best time to get
the specimen is at height of fever because the microorganisms are
very active and easily identified Chemoprophylaxis: Only
chloroquine should be given (taken at weekly intervals starting
from 1-2 weeks before entering the endemic area). In pregnant
women, it is given throughout the duration of pregnancy.
Treatment: Blood Schizonticides - drugs acting on sexual blood
stages of the parasites which are responsible for clinical
manifestations 1. QUININE oldest drug used to treat malaria; from
the bark of Cinchona tree; ALERT: Cinchonism quinine toxicity 2.
CHLOROQUINE 3. PRIMAQUINE sometimes can also be given as
chemoprophylaxis 4. FANSIDAR combination of pyrimethamine and
sulfadoxine
Prevention: *Insecticide treatment of mosquito net *House
Spraying (night time fumigation) *On Stream Seeding construction of
bio-ponds for fish propagation (2-4 fishes/m2 for immediate impact;
200-400/ha. for a delayed effect) *On Stream Clearing cutting of
vegetation overhanging along stream banks *Avoid outdoor night
activities (9pm 3am) *Wearing of clothing that covers arms and legs
in the evening *Use mosquito repellents *Zooprophylaxis typing of
domestic animals like the carabao, cow, etc near human dwellings to
deviate mosquito bites from man to these animals Intensive IEC
campaign
NURSING CARE: 1. TSB (Hot Stage) 2. Keep patent warm (Cold
Stage) 3. Change wet clothing (Wet Stage) 4. Encourage fluid
Lyme Disease
Causative agent: bacterium, Borrelia burgdorferiMOT: spread
through the bite of infected ticks. The blacklegged tick (or deer
tick, Ixodes scapularis) spreads the disease in the northeastern,
mid-Atlantic, and north-central United States, and the western
blacklegged tick (Ixodes pacificus) spreads the disease on the
Pacific Coast.
Assessment Findings: Early localized stage (3-30 days post-tick
bite) Red, expanding rash called erythema migrans (EM)--- can reach
up to 12 inches (30 cm) across. Parts of the rash may clear as it
enlarges, resulting in a bull's-eye appearance. Rash usually feels
warm to the touch but is rarely itchy or painful. Fatigue, chills,
fever, headache, muscle and joint aches, and swollen lymph nodes
small bump or redness at the site of a tick bite that goes away in
1-2 days, like a mosquito bite.Early disseminated stage (days to
weeks post-tick bite)
Additional EM lesions in other areas of the body Facial or
Bell's palsy (loss of muscle tone on one or both sides of the face)
Severe headaches and neck stiffness due to meningitis (inflammation
of the spinal cord) Pain and swelling in the large joints (such as
knees) Shooting pains that may interfere with sleep Heart
palpitations and dizziness due to changes in heartbeatLate
disseminated stage (months to years post-tick bite)
Arthritis caused by Lyme disease manifests differently than
other causes of arthritis and must be distinguished from
arthralgias (pain, but not swelling, in joints).
These include shooting pains, numbness or tingling in the hands
or feet, and problems with short-term memory.
Lingering symptoms after treatment (post-treatment Lyme disease
syndrome)Lyme disease have symptoms that last months to years after
treatment with antibiotics5. These symptoms can include muscle and
joint pains, cognitive defects, sleep disturbance, or
fatigue.Treatment: doxycycline, amoxicillin, or cefuroxime axetil.
Patients with certain neurological or cardiac forms of illness may
require intravenous treatment with drugs such as ceftriaxone or
penicillin.
Prevention: Tick repellant with N,N-Diethyl-meta-toluamide
(DEET) or permethrin
Parrot FeverPsittacosisCausative agent: gram-negative
intracellular parasite Chlamydia psittaci
MOT: Psittacine birds like parrots, cockatiels, macaws, also
pigeons and turkeys may harbor the parasite in their blood,
feathers, tissue, nasal secretions, liver, spleen, and feces.
Airborne transmission.
Assessment Findings: Incubation- 4 to 15 days. Chills, low grade
fever for 7- 10 daysIn humans, fever, chills, headache, muscle
aches, and a dry cough. Pneumonia is often evident on chest
x-ray.
Complications:Endocarditis, hepatitis, and neurologic
complications may occasionally occur. Severe pneumonia requiring
intensive-care support may also occur. Fatal cases have been
reported.
Diagnostic Tests: Blood culture, ELISA, Complement fixations
Treatment: Tetracycline, doxycycline, erythromycin, and
chloramphenicol can be used
Bubonic Plaque
Causative agent: bacterium, Yersinia pestis.MOT: flea bites,
droplets, contaminated fluid or tissues. Assessment Findings:
Incubation period- 2 to 8 days. Malaise, fever, pain, swelling and
tenderness lymph nodes. Lymph node damaged (axillary and inguinal)
produces painful, inflamed, supporative bubboes. Hemorrhagic areas
become necrotic in the skin and appear dark (black death).
Pneumonic plague:Patients develop fever, headache, weakness, and
a rapidly developing pneumonia with shortness of breath, chest
pain, cough, and sometimes bloody or watery mucous. Pneumonic
plague may develop from inhaling infectious droplets or may develop
from untreated bubonic or septicemic plague after the bacteria
spread to the lungs. The pneumonia may cause respiratory failure
and shock. Pneumonic plague is the most serious form of the disease
andis the only form of plague that can be spread from person to
person (by infectious droplets)
Septicemic plague: Patients develop fever, chills, extreme
weakness, abdominal pain, shock, and possibly bleeding into the
skin and other organs. Skin and other tissues may turn black and
die, especially on fingers, toes, and the nose. Septicemic plague
can occur as the first symptom of plague, or may develop from
untreated bubonic plague. This form results from bites of infected
fleas or from handling an infected animal.
Diagnostic test: Blood culture, CSF, CXR
Treatment: streptomycin. Chloramphenicol for meningeal
type.Prophylaxis: Doxycycline