NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

LESSON 2- AIRBORNE DISEASES

INTRODUCTION OF THE LESSON OF THE LESSON AND PRESENTATION OF OUTCOMES

Airborne diseases are diseases which can be transmitted through droplet nuclei or
small particles which are dispersed into air currents. They are spread when people with
certain infections cough, sneeze or talk, spewing nasal and throat secretions into the air.
Some viruses or bacteria take flight and hang in the air or land on other people or surfaces.
The microorganism can be picked up by you when you touch a surface that harbors them
and then touch your eyes, nose or mouth. Because the causative agents of these diseases
travel in the air, they are hard to control.

At the end of the lesson, you must have:

1. identified the different airborne diseases including the causative agent, mode of
transmission, incubation period, period of communicability and source of infection;
2. described thesigns and symptoms of airborne diseases including the pathognomonic
signs;
3. discussed the various diagnostic examinations and treatment for airborne diseases;
4. used the nursing process as framework for care of patients with airborne diseases;
and
5. enumerated effective ways to prevent and control airborne diseases.

WARM UP ACTIVITY:

THREE WORDS: As quick as you can, think of three words (3) that comes into your mind
about anairborne disease. Write them down and at the end of the lessonin airborne
diseases, get back to them and see if you still think of an airborne diseasethat way.

PRESENTATION OF LEARNING INPUTS:

A.Measles

What is measles?
 It is an acute, highly contagious paramyxovirus infection marked by prodromal
fever, cough, coryza, conjunctivitis, and pathognomonic enanthem such as koplik’sspots),
followed by an erythematous maculopapular rash on the third to seventh day; infection
confers life-long immunity, and despite being considered primarily a childhood illness,
measles can affect people of all ages.

 It is also known as Rubeola, Seven–day measles, morbilli, and red measles.

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

Causative Agent RubeolaVirus– a filtrablevirus

Incubation Period 10 days after exposure; 13–15 days
before appearance of rashes
Mode of Transmission Directly thru droplet infection from
cough or sneeze; indirectly through
articles newly contaminated with
respiratory secretions from sick
patients
Period of Communicability Occurs during prodromal phase
beginning about 9 days after
exposure to the virus and lasting
from 4 days before to 5 days after
appearance of rashes
Sources of Infection Eyes, nose, and throat secretions;
blood; urine of infected person
Immunity One attack confers a lifetime
immunity
Pathognomonic Sign Koplik’s Spots– Small red spots on
the mucous membrane of the cheek,
with a minute bluish–white specks in
the center. Usuallyappears 1-2 days
before rash develops.

Koplik’s spots

Source: https://www.cdc.gov/measles/symptoms/photos.html

What are the risk factors in the development of measles?

1. Being unvaccinated. If the person has not received the measles vaccine, the
person is more likely to develop the disease because of the fact that antibodies
for the said disease are not generated by the body to fight the virus that causes
the infection.

2. Travelling. If the person travels to developing countries where measles is more

common, that person has a higher risk of having the disease.

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3. Malnutrition. When a person is undernourished, important nutrients necessary

in boosting up the immune system is lacking. With this, the person is at risk of
developing measles due to decreased immune system function.

4. Vitamin A deficiency. If the person does not have enough vitamin A in his/her
diet, he/she is more likely to contract measles and to have more severe
symptoms.

5. Environmental Factors. This risk factor includes the exposure to other people
who have the disease. The virus can be easily transmitted thus exposure to other
people would predispose a person, especially those with low immune system to
have the disease.

6. Immunosuppression. Persons with HIV/AIDS, leukemia or other

immunocompromised conditions like those taking alkylating agents or on
corticosteroid therapy are at risks.

What are the manifestations of measles?

a.Pre–eruptive Stage. In this stage, the patient is highly communicable with a high
fever (38-41C). The patient also
experiences catarrhal symptoms
wherein he/she may seem to have
colds, sneezes frequently, and there is
a watering of the eyes, stuffing of the
nose, with increased secretion and
discharge of mucus. The patient also
experiences the following:
 3 C’s: Coryza, Conjunctivitis, and
cough
 Eye signs
Stimson’s sign- puffiness of the
eyelidswith redlinearcongestion
of the lower conjunctiva

Conjunctivitis- inflammation of the

conjunctiva Eyes of a patient with measles
Source: https://www.cdc.gov/measles/symptoms/
photos.html

b. Eruptive/Stage of Skin Rashes

 Characterized by the appearance of rashes (maculopapular) which appear
first on the cheeks or bridge of the nose, forehead, hairline of face and at
temple then spreads to the trunk and other parts of the body like the
entire face, neck, eyelids, arms chest, back, abdomen and thighs.

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 Appearance of the rashes is accompanied by fever which increases as

rashes increase and falls as
rashes disappear
 Appearance of rashes is
fromexposed to unexposedarea
of the body(CENTRIPETAL)
 Otheraccompanying
manifestations:
o Anorexia
o Diarrhea
o Sore throat
o Severe Cough

c. Stage of Convalescence
 Fever gradually subsides as
Maculopapular rash
eruptions disappear
Adopted from:
 Acute symptoms begin to subside https://www.cdc.gov/measles/symptoms/photos.html
 Appetite returns
 Rashes fade in the same manner as they appeared from the face
downwards leaving a dirty brown pigmentation and finally granular which
may be noted for several days.

What are the diagnostic tests done in Measles?

1. Antibody assays. The measles virus sandwich-capture IgM antibody assay, is the
quickest method of confirming acute measles; laboratories can confirm measles
by demonstrating more than a 4-fold rise in IgG antibodies between acute and
convalescent sera, although relying solely on rising IgG titers for the diagnosis
delays treatment considerably.

2. Viral culture. Throat swabs and nasal swabs can be sent on viral transport
medium or a viral culture swab to isolate the measles virus; urine specimens can
be sent in a sterile container for viral culture.

3. Reverse-transcription polymerase chain reaction (PCR). Reverse-transcription

polymerase chain reaction (PCR) evaluation is highly sensitive at visualizing
measles virus RNA in blood, throat, nasopharyngeal, or urine specimens and,
where available, can be used to rapidly confirm the diagnosis of measles.

4. Chest x-ray. If bacterial pneumonia is suspected, perform chest radiography; the

frequent occurrence of measles pneumonia, even in uncomplicated cases, limits
the predictive value of chest radiography for bacterial bronchopneumonia.

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What are the preventive measures in measles?

The following are the measures to prevent the occurrence of measles:

 Measles vaccine at the age of 9 months

 MMR vaccine to be given at 15 months old, and the second dose at 11–12 years old
 Measles vaccine is not given to pregnant women or those with depressed immune
system

What are the possible complications of measles?

Pneumonia may have some complications and these include the following:

1. Pneumonia. Measles infects the respiratory tracts of nearly all affected persons. is
the most common severe complication of measles and accounts for most measles-
associated deaths. Pneumonia maybe caused by measles virus alone, secondary
viral infection with adenovirus or HSV, or secondary bacterial infection.

2. Bronchitis-inflammation of the lining of the bronchial tubes, which carry air to and
from lungs. It is the second most common cause of death in US children
hospitalized with measles, after pneumonia.

3. Otitis Media. inflammation of the epithelial surface of the eustachian tube causes
obstruction and secondary bacterial infection. Lower rates of otitis media are noted
with increasing age, most likely a function of the increasing diameter of the eustachian
tube and the decreasing risk of obstruction.

4. Nephritis-inflammation of the kidney

Uncomplicated measles is rarely dangerous. It is the complication that kills.

What will be the sequela of measles?

1. Pulmonary Tuberculosis-the virus attacks the bronchioles and alveoli of the lungs.
With decreased resistance, tubercle bacillus may also attack, causing PTB.
2. Conjunctivitis-due to severe catarrhal inflammation of the conjunctiva
3. Chronic Bronchitis-due to increased secretions in the bronchial mucosa
4. Sinusitis-inflammation of one or more paranasal sinuses due to colds which is one
of the manifestations of measles.

Medical Management: The treatment for measles is symptomatic and supportive.

1. Antipyretics- we can use Acetaminophen but never Aspirin because this may
result to Reye’s Syndrome which later on leads to liver failure and death.
2. Mild sedatives
3. Cough Medicines such as expectorants, mucolytics
4. Vitamin A-decreases the complications of measles
5. Penicillin for secondary infections

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Nursing Management:

The following are the nursing management for measles:

Monitor respiratory status
Educate the community about immediate isolation of patients with catarrhal symptoms
Avoid exposure of children to known cases or suspected cases
Some reminders about the measles vaccine:
o assess for allergies to eggs
o never administer to clients with fever, with acute illness
o minor illness like diarrhea and URTI are not indicative to defer vaccine
Let the child be immunized at 9 months old
Emphasize proper disposal of nose and throat secretions
Symptomatic and supportive management
oeye care-use warm eye washes to relieve irritation
ohypoallergenic soaps; avoid strongly scented soap for this is irritating to the
rashes
ooral and nasal care
oantipyretics
Nursing Process:

Assessment:

Assessment of the patient with measles include:

Physical exam. Assess the child for symptoms that may indicate the presence of
measles.

Knowledge of the disease. Assess the patient’s or significant other’s knowledge

regarding the disease.

Hygienic practices. Assess the family’s hygienic practices to prevent the spread of
the disease.

Diagnosis:

Based on assessment data, the patient’s major nursing diagnoses may

include thefollowing:

 Impaired social interaction related to isolation from friends

 Risk for impaired skin integrity related to raking pruritus
 High risk for transmission
 Acute pain related to skin lesions and irritated mucous membranes.

Planning and Goals:

The major goals for a patient with measles are:
 Skin will stay clean, dry and intact
 Mucous membranes will stay moist, discomfort will stay within defined
tolerable range by patient.

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 Patient will understand purpose of isolation, cooperate and be free of

distress.

Interventions:

Interventions for a patient with measles are:

Isolation. Patients will need to be on isolation precautions to decrease transmission

within the community; emphasize the need for immediate isolation when early
catarrhal symptoms appear.

Skin care. Measles causes extreme pruritus; nursing interventions include keeping
the patient’s nails short, encourage long pants and sleeves to prevent scratching,
keeping skin moist with health care provider recommended lotions, and avoiding
sunlight and heat.

Eye care. Treat conjunctivitis with warm saline when removing eye secretions and
encourage patient not to rub eyes; protect the eyes from the glare of strong light.

Hydration. Encourage oral hydration; medical literature encourages the use of oral
rehydration solution.

Temperature control. Antipyretics should be administered to the patient as ordered

for a temperature greater than 100.4 Fahrenheit. Never administer Aspirin due to
the risk of Reye’s syndrome.

Evaluation:
Expected patient outcomes may include:

a. Skin becomes clean, dry and intact

b. Mucous membranes stayed moist
c. Discomfort will stay within defined tolerable range by the patient
d. Exhibits absence of elevated body temperature
e. Patient understood the purpose of isolation and cooperate
f. Complications are prevented

ACTIVITY 1:Test your knowledge! Using the table below, supply the
information regarding measles. When finished, kindly take a photo of your
output and post it in the discussion forum for this part of the lesson.

Causative agent:
Incubation Period:
Mode of transmission:
Source of Infection:
Pattern of appearance of rashes:

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B. GERMAN MEASLES
German Measles/Rubella. German measles is also known as the 3-day measles. It
is a mild contagious eruptive disease that is caused by the rubella virus best known
by its distinctive red rash. It is generally mild and self-limiting. It is characterized by
rash, lymphadenopathy and low-grade fever. However, it can be a serious
condition in pregnant women, as it may cause congenital rubella syndrome in the
fetus. Congenital rubella syndrome can disrupt the development of the baby and
cause serious birth defects such as heart abnormalities, deafness and brain
damage.It is not the same as measles (Rubeola), though the two illnesses do share
some characteristics, including the red rash. Rubella is caused by a different virus
and is neither as infectious nor usually as severe as measles.
Causative Agent Rubella Virus– a filtrable virus
Incubation Period Varies from 10–21 days: commonly 18 days
Mode of Transmission Droplet infection; indirectly through articles newly
contaminated with respiratory secretions from sick
patients; trans-placentally especially during the
first trimester of pregnancy causing serious
congenital birth defects
Period of Communicability 4–7 days after onset of catarrhal symptoms
Source of Infection Nasal secretions, contact with soiled articles,
fomites
Pathognomonic Sign Forscheimer’s Spots – a fleeting exanthem
consisting of discrete rose spots on the soft palate

Rashes in German Measles Forscheimer's Spots

Source: https://www.cdc.gov/rubella/about/photos.html Source: https://www.cdc.gov/rubella/about/photos.html

Risk Factors:
1. Lack of immunization against rubella. If the person has not received the vaccine
for German measles, the person is more likely to develop the disease

2. Environmental Factors. Exposure to other people who have the disease would
increase the risk of acquiring the disease

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3. Travelling internationally. If the person travels to developing countries where

German Measles is more common, that individual is at higher risk of having the
disease

4. Malnutrition. When a person is undernourished, the necessary nutrients needed

to boot the immune system are lacking.

Effects to Pregnancy:
 During acute rubella in pregnancy, the rate of congenital infection is:
o over 90% in the 12 first weeks of pregnancy (first trimester)
o approximately 60% in weeks 13 to 17 (4th month)
o 25% in weeks 18 to 24 (5th–6th month)
o increases again during the last month of pregnancy
 Effects of rubella infection to the growing fetus:
Fetal rubella syndrome:
o deafness, mental retardation, congenital cataract, heart defects,
microcephaly, and other structural anomalies

Congenital Defects to Fetus:

Neonatal
Neurologic
congenital Eye defects Ear defects
Manifestations
defects
 patent ductus  cataract  deafness  microcephaly
arteriosus  glaucoma  abnormally–shaped  mental
 atrial septal  retinopathy ears retardation
defect  microphthalmia  psychomotor
 ventricular –unequal eyeballs retardation
septal defect  encephalitis

Signs and Symptoms:

Rash characterized as pinkish and maculopapular which begins on the first day and
rapidly spreads to the trunk and extremities and fades
Usually starts with a low–grade fever
Be familiar with the forscheimer’s spot which is a small red lesion on the soft palate
and mucous membrane
Experiences body malaise
Low– grade fever (37.8 degrees Celsius)
Lymphadenitis at the postauricular, post cervical, and sun occipital lymph nodes
All rashes disappear in 3 days and leaves no pigmentation or desquamation

Other Manifestations:

Other manifestation seen in rubella include headache, mild sore throat,conjunctivitis,

anorexia, runny nose, diaphoresis/profuse perspiration thus skin is moist,
andforscheimer’s spots (seen on first day).

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*Lymphadenitis- swelling of the lymph glands below the ear at the nape of the neck
which appears before the rash; the hallmark of the disease
*Forscheimer’s spots-bright rose red macules on the throat (soft palate); pathognomonic
sign of the disease

* Rash and fever disappear at the same time

Difference between Rubeola and Rubella:

The evolution of rubeola is very slow, about 3-5 days; It is characterized by the presence of
high-grade fever with accompanying skin rashes and marked catarrhal symptoms
and presence of koplik’s spots which is the pathognomonic sign. The prodromal
period is long and severe. It does not lead to congenital malformations unlike the rubella.
On the other hand, rubella has a rapid evolution which is 24 hours and characterized by low
grade fever which occurs before appearance of skin rashes; catarrhal symptoms which are
usually mild and appearance of forscheimer’s spot in the soft palate. The prodromal period
is mild and shorter. However, rubella leads to serious congenital malformations.
Diagnostic Tests:

The diagnostic tests for rubella are the following:

 Rubella Hemagglutination Inhibition test.It is done to determine the amount of

specific antigen in a blood serum sample.
 Complement fixation test. It is an immunological test for determining the presence
of a particular antibody in which serum is treated in a manner that allows existing
antibodies to accept and bind to known amount of antigen.
 ELISA-Enzymes Linked Immunosorbent Assay
 Hemagglutination Inhibition Antibody Test

Prevention:

In order to prevent the occurrence of rubella live attenuated rubella vaccine and
gamma globulin could be administered. However, pregnancy should be avoided
within 3 months from the administration of the vaccine.

Management:

There is no definite treatment for both German measles and measles and it is generally
self-limiting in nature. Observe isolation precaution to prevent the spread of the
disease. The only form of management for patients suffering from either
rubella/rubeola is supportive management.

Supportive Management:
1. Keep room warm, quiet, and well ventilated
2. Encourage use of dark glasses when exposed to bright lights or sunrays
3. Soft bland diet during febrile stage
4. Daily cleansing bath using hypoallergenic soap
5. Antipyretic for fever

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6. Cough and cold medicines for respiratory manifestations

Nursing process:

Assessment:

 Assess for risk factors like travel history to areas with rubella, malnutrition, lack of
immunization and exposure to people with rubella
 Asses for presence of pinkish maculopapular rashes, low-grade fever and red
macules on the soft palate
 Assess for other manifestations like headache, mild sore throat, conjunctivitis,
body malaise, anorexia, runny nose, diaphoresis.
Diagnosis:

Based on assessment data, the patient’s major nursing diagnoses may include the
following:

 Risk for infection transmission

 Deficient knowledge about the disease, treatment and preventive measures
 Alteration in thermoregulation (low-grade fever) related to infection

Planning and Goals:

Major goals for the patient may include prevention of spread of infection, increased
knowledge about the disease, its treatment and preventive measures, and control of
fever and related discomforts

Interventions:

1. Preventing Transmission
a. Isolate the patient to prevent the spread the microorganism
b. Disinfect hands before and after contact with patients who have measles and after
performing a potentially-contaminating activity.
c. Discuss to the patient and significant others the mode of transmission and measures to
prevent transmission of the disease to other people
d. Emphasize proper disposal of secretions

2. Teaching about the infection (German Measles)

a. Discuss to the patient or significant others about the disease including its mode of
transmission, period of communicability, incubation period, causative agent,
manifestations and possible sequela and complications.
b. Discuss to the patient the diagnostic tests for the disease including its
management.

3. Controlling fever and other accompanying discomforts

a. Administer antipyretics to lower down the body temperature
b. Do tepid sponge bath

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c. Offer patient fruit juices, milk and water

d. Keep room well-ventilated
e. Encourage patient to use dark glasses or darken room to relieve photophobia
f. Encourage patient to have daily cleansing bath but use hypoallergenic soap
g. Encourage patient to do saline gargle for sore throat using a lukewarm water with a pinch
of salt

Evaluation: Expected patient outcomes may include:

a.Use of appropriate methods to prevent infection
b. Acquires knowledge about the infection or disease process
c. Exhibits absence of low-grade fever
d. Exhibits improved comfort
ACTIVITY 2:Using the table below, differentiate rubeola from rubella as to
evolution, characteristic of fever, prodromal, pathognomonic sign and
severity of catarrhal symptoms. When finished, kindly take a photo of your
output and post it in the discussion forum for this part of the lesson.

Rubeola Rubella
Evolution
Fever
Prodromal
Pathognomonic sign
Catarrhal symptoms

C. Chickenpox
Chickenpox is otherwise known as Varicella. It is anacute infectious disease, caused
by the varicella–zoster virus (VZV), which is a DNA virus that is a member of the
herpesvirus group. It ischaracterized by vesicular eruptions, slight fever, and malaise.

Primary infection with VZV

causes varicella. After the
infection. Varicella virus stays in
the bodyin the sensory nerve
gangliaas a latent infection.

Rashes in Chickenpox
(Source: https://www.cdc.gov/chickenpox/about/photos.html)

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Causative Agent Varicella zoster virus: A DNA containing Virus

Incubation Period 14–21 days, but is commonly within 14–16 days
Mode of Transmission Droplet infection; indirectly through articles
newly contaminated with respiratory secretions
from sick patients
Period of Communicability 1 day before lesions erupt until 6 days after
vesicles form. It is most contagious in early
stages of skin lesion eruption

Risk Factors:

The risk factors in chickenpox are the following:1) lack of immunity to the disease; 2)
no past history of the disease; 3) presence of diseases that compromise the
immunesystem (leukemia, lymphoma, and HIV, etc.); 4) taking in
immunosuppressant drugs; 5) Close contact with infected persons; 6)
Age.Newborns, especially those born prematurely, under 1 month old, or whose
mothers had never contracted chickenpox prior to pregnancy are at high risk of
contracting the disease.

Manifestations:

Clients with chickenpox may have the following manifestations:

1. Pre-eruptive manifestationslike low grade fever, body malaise, headache and

anorexia.
2. Eruptive stage
e. Rash starts on the trunk (unexposed areas), then spreads to other body
parts-CENTRIFUGAL
f. Initial lesions are distinctively red papules whose contents become milky and
pus-like within 4 days.
g. There is rapid progression that transition is completed in 6-8 hours.
h. Vesicular lesions are very pruritic
i. All stages are present simultaneously before all areas are covered with scabs
leading to the appearance known as “Celestial Map”
j. All lesions appear in different stages: macule, papule, vesicles, pustule, crust.

Diagnostic Tests:
To diagnose chickenpox, the following procedures can be done:
Polymerase chain reaction (PCR) testing. The most sensitive method for confirming
a diagnosis of varicella is the use of PCR to detect VZV in skin lesions (vesicles, scabs,
maculopapular lesions).

IgM testing. IgM testing is considerably less sensitive than PCR testing of skin lesions;
commercial IgM assay may not be reliable and false negative IgM results are not

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uncommon; a positive IgM ELISA result, although suggestive of a primary infection,

does not exclude re-infection or reactivation of latent VZV.

Paired acute and convalescent sera. Paired acute and convalescent sera showing a four-
fold rise in IgG antibodies have excellent specificity for varicella, but are not as
sensitive as PCR of skin lesions for diagnosing varicella.

Blood testing. Most patients with varicella have leukopenia in the first 3 days,
followed by leukocytosis; marked leukocytosis may indicate a secondary bacterial
infection but is not a dependable sign

Tzanck smear. A Tzanck smear involves scraping the base of the lesions and then
staining the scrapings to demonstrate multinucleated giant cells; the presence of
multinucleated giant cells suggests a herpes virus infection but is not specific for
varicella-zoster virus.

Immunohistochemical staining. Immunohistochemical staining of skin lesion

scrapings can confirm varicella.

Complications:
Possible complications of chickenpox are: 1)Pneumonia. This is the most common
bacterial infection that occurs with chickenpox; 2)Encephalitis. This is the most
dreadful complication. It is characterized by sudden transient delirium, seizures,
neck pain, headache, and sensitivity to light; 3) viral hepatitis. This occurs when the
virus replicate in the liver; and 4) scarring of skin. This is secondary to bacterial
infection which could be related to scratching the lesions with contaminated hands.

Medical Management:
The following are the usual management done to patients with chickenpox.
1. Acyclovir (ZOVIRAX). This is an antiviral drug whichdecreases the severity and
duration of the disease. It also controls the spread of the microorganism and
slows vesicle formation. It also helps the sores heal faster and decreases pain
and itching.
2. Antihistamine like Calamine lotion, Diphenhydramine (Benadryl), Hydroxyzine
(Herax). These drugs may help prevent from scratching the rash and blisters for
antihistamines may ease itchiness. Calamine lotion works by causing a colling
sensation as it evaporates in the skin.
3. Antipyretics can be given for fever.

Nursing Management:

The following are the nursing management for a patient with varicella:
Calamine lotion or cool carbonate bath to relieve itchiness
Have to advise parents to trim fingernails to prevent secondary infection
Include medications (Diphenhydramine, acyclovir)
Children from school should excused for at least 5 days after eruptions first appear
or until vesicles have dried up

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Keep mittens at bedside to avoid scratching lesions to prevent secondary infection

Emphasize good hygiene like handwashing
Never admit patient together with immunocompromised individuals
Strict isolation until all vesicles disappear which is usually 1 week after onset of
rash.

Nursing Process:

Nursing Assessment:
Assessment of a patient with chickenpox includes the following:

 History taking. The history should elicit if a recent outbreak of chickenpox in the
community has occurred and if any exposure to varicella at school, daycare, or
among family members has occurred.
 Immunizations. It should also be noted whether the child has previously received
varicella vaccine or if the child is immunocompromised (including recent systemic
steroid use) to help guide management.
 Immunocompromised Persons. Immunocompromised individuals often have
severe and complicated varicella, and their mortality rate is higher than that in
immunocompetent children.

Nursing Diagnosis:

Based on the assessment data, the major nursing diagnoses are:

1. Hyperthermia related to viral infection

2. Disturbed body image related to lesions on the skin
3. Deficient knowledge about the condition and treatment needs
4. Risk for secondary infection related to damaged skin tissue

Planning and Goals:

Desired outcomes for a person with chicken pox include:

1. Client will be comfortable as evidenced by the ability to rest.

2. Client or caregiver will verbalize needed information regarding the disease,
signs and symptoms, treatment, and possible complications.
3. Client will remain free of secondary infection, as evidenced by intact skin
without redness or lesions.
4. Client will have minimal risk for disease transmission through the use of
universal precautions.
5. Client will verbalize feelings about lesions and continues daily activities.
6. Client will demonstrate positive body image, as evidenced by the ability to
look at, talk about, and care for lesions.

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

Nursing Interventions:
Interventions for a patient with chicken pox include:

 Patient education. Educate parents about the importance and safety of the
Varicella Zoster vaccine.
 Manage pruritus. Manage pruritus in patients with varicella with cool
compresses and regular bathing; warm soaks and oatmeal or cornstarch baths
may reduce itching and provide comfort.
 Trim fingernails. Trimming the child’s fingernails and having the child wear
mittens while sleeping may reduce scratching.
 Dietary measures. Advise parents to provide a full and unrestricted diet to the
child; some children with varicella have reduced appetite and should be
encouraged to take sufficient fluids to maintain hydration

Evaluation:
All goals are met as evidenced by:
1. Client is comfortable as evidenced by the ability to rest.
2. Client or caregiver verbalized needed information regarding the disease,
signs and symptoms, treatment, and possible complications.
3. Client remained free of secondary infection, as evidenced by intact skin
without redness or lesions.
4. Client had minimal risk for disease transmission through the use of universal
precautions.
5. Client verbalized feelings about lesions and continues daily activities.
6. Client demonstrated positive body image, as evidenced by the ability to look
at, talk about, and care for lesions.

ACTIVITY 3: Using the table below, describe/define the different lesions that
occur in chickenpox. When finished, kindly take a photo of your output and post
it in the discussion forum for this part of the lesson.

Lesion Description
macule
papule
vesicles
crust
scabs

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NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

D. Herpes Zoster/Shingles

This disease is otherwise known as shingles/Acute Posterior Ganglionitis. It

isan acute unilateral and segmental viral infection of the nerve structure caused by
the same causative agent that causes chickenpox. After a case of chickenpox run
its course, the virus lies dormant in the ganglia of the spinal nerve tracts. Then the
virus reactivates and travels along the peripheral nerves to the skin, where the
viruses multiply and produce painful vesicular eruptions. It is most common in
older adults and people who have weak immune systems.Although VZV typically
affects the trunk of the body, the virus may also be noted on the buttocks or face.
If an ophthalmic nerve is involved, the client may potentially experience keratitis,
ulceration and possibly blindness. Secondary infection resulting from scratching
the lesions is common.The total course of the disease is 10 days to 5 weeks from
onset to full recovery. Some individuals may develop painful postherpetic
neuralgia long after the lesions heal.Approximately 20% of people who have had
chickenpox will develop herpes zoster.
Causative Agent Varicella zoster virus
Incubation Period 1–2 weeks
Mode of Transmission Direct or indirect contact
Direct contact with infectious vesicular fluid
from an infected person; Indirect contact
with materials soiled with vesicular fluid
Prognosis Good unless the infection spreads to the
brain
Period of Communicability Until the last crust has fallen off
Risk Factors:
The following are the risk factors in the development of varicella: 1) lack of immunity
to varicella virus; 2) past history of chickenpox; 3) presence of health conditions
that weaken the immune system such as HIV infections/AIDS, Cancer especially
lymphoma and leukemia; 4) taking in immunosuppressant drugs or undergoing
radiation or chemotherapy; 5) close contact with persons infected with chickenpox
or shingles; 6) Age.People over 50 years old are at higher risk; and 6) ethnic
background. White people are at higher risk than black people

Manifestations:

Patients with chickenpox may

experience: 1) fever, 2) malaise, 3)
severe deep pain in the affected
area, 4) paresthesia on trunks,
arms and legs, 5) small, red
nodular skin lesions
(pruritic)erupting on painful areas

Source: https://www.bmj.com/content/364/bmj.k509
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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

spreading unilaterally on thorax or vertically over arms and legs.

Diagnostic Procedures:To diagnose chickenpox, the following procedures can be done.

1. Tsanck Smear. This is helpful for diagnosing acute infection with a herpes virus
but does not distinguish herpes zoster virus and varicella zoster virus.

2. Skin Scrapings. A procedure in which the skin is gently scraped to determine if

the virus herpes zoster virus or another virus.

3. Real time PCR (Polymerase Chain Reaction) and Viral Culture. PCR is done to
detect VZV DNA rapidly and sensitively in properly collected skin lesion
specimens. Viral culture is done to detect varicella zoster virus in blisters of
fluids from skin lesions.

4. Compliment Fixation Test. This diagnostic test aims to identify antibodies

specific to the virus.

Medical Management:
The medical management for shingles includes the following:
1. Administration of antibiotic:Acyclovir (Zovirax). This drug shortens the duration and
decreases the spread of microorganism and slows vesicle formation.
2. Administration of calamine lotion-to ease the discomfort felt by the patient
secondary to the pruritic lesions.
3. Antihistamines are given such as Diphenhydramine (Benadryl) to symptomatic
pruritus.
4. Analgesics to relieve the pain
5. Antipyretics to manage fever
6. Tranquilizers or sedatives

Nursing Management:
Supportive management:
o Cool, wet compress on lesions using normal saline solution
o Symptomatic treatment with antipyretics and analgesics
o Proper disposal of secretions to reduce possibility of recurrence
o Rest and nutrition

Complications:

1. Ophthalmic herpes- or ocular herpes is eye infection caused by the herpes simplex
virus characterized by pain, inflammation, redness, and tearing of the cornea
surface.

2. Geniculate herpes-(Ramsay Hunt Syndrome)- infection of the geniculate ganglion

(an L-shaped collection of fibers and sensoryneurons) of the facial nerve
characterized by a red painful rash associated with blisters in the ears or mouth and

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

facial paralysis (for example, eyelid or mouth) on one side of the face or hearing
loss

3. Intractable neuralgia- pain in the area where the shingles occurred which may last
for months or years.

Nursing Process:

1. Nursing Assessment:
Assessment of a patient with shingles includes the following:

 History taking. The history should elicit of any past history of chicken pox or
exposure to varicella
 Immunizations. It should also be noted whether the patient has previously
received varicella vaccine
 Immunocompromised Persons. Immunocompromised individuals often have
higher risk of developing the disease.

2. Nursing Diagnosis:
1. Acute/chronic painrelated to nerve pain (most commonly cervical, lumbar, sacral,
thoracic, or ophthalmic division of trigeminal nerve) as possibly evidenced by
alteration in muscle tone, facial mask of pain, reports of burning, dull or sharp
pain and localized pain to affected nerve.
2. Deficient knowledge related to new condition and procedures as evidenced by
inadequate follow-up of instructions and verbalizing inaccurate information.
3. Risk for secondary infection related to presence of skin lesions
4. Risk for disturbed body image related to presence of visible skin lesions
5. Risk for disease transmission

3. Planning and Goals:

Major goals for the patient may include the following:
1. Client will be comfortable as evidenced by the ability to rest.
2. Client will verbalize understanding of the disease condition as to signs and
symptoms, mode of transmission, treatment and possible complications.
3. Client will remain free of secondary infection, as evidenced by intact skin without
redness or lesions.
4. Client will have minimal risk for disease transmission through the use of universal
precautions
5. Client will demonstrate positive body image, as evidenced by the ability to look at,
talk about, and care for lesions.

4. Nursing Interventions:

A. Pain

1. Encourage patient to wear loose, nonrestrictive clothing made of cotton.

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

Rationale: Constrictive, nonbreathing garments may rub lesions and aggravate skin
irritation. Cotton clothing allows evaporation of moisture.
2. Apply cool, moist dressings to pruritic lesions with or without Burrow’s solution
several times a day. Discontinue once the lesions have dried.
Rationale: This provides relief and reduces the risk for secondary infection.

3. Avoid temperature extremes, in both the air and bathwater.

Rationale: Tepid water causes the least itching and burning

4. Avoid rubbing or scratching the skin or lesion.

Rationale: Scratching stimulates the skin, which in turn increases itchiness. It can also
increase the possibility of secondary infection.

5. Use topical steroids (anti-inflammatory effect), anti-histamines (anti-itching effect

particularly useful at bedtime)and analgesics.
Rationale: It may be required to provide relief.

D. Deficient Knowledge
1. Provide necessary information to the client and caregiver, including written
information.
Rationale: Client may confuse terminology and confuse herpes zoster with genital
herpes. Because the client may be reluctant to ask, clarify this point for the client.
Clients must have a comprehensive understanding of their disease to actively
participate in their own care.
o Explanation of the need for isolation. Clients should isolate their clothing
and linen, including towels.
o Description of herpes zoster, including how the disease is spread. Fluids
from lesions contain viruses, which are spread by direct contact.
o Need to notify health care professionals of the signs of central nervous
system (CNS) inflammation (changes in the level of consciousness)-Early
assessment facilitates prompt treatment of complications.

2. Encourage herpes zoster vaccination (Zostavax). This vaccination is recommended

for individuals 60 years or older. It is not recommended for pregnant women or
those with primary or acquired immunodeficiencies or any allergy to its
components. A 50% decrease in future outbreaks and greater than 60% reduction
in postherpetic neuralgia have been reported.

E. Risk for Secondary Infection

1. Encourage patient to do proper handwashing using soap and water- to prevent

the transfer of microorganisms
2. Discourage the scratching of lesions. Encourage the client to trim fingernails.
These measures prevent the inadvertent opening of lesions, cross-contamination,
and bacterial infection.

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3. Assess for lesions around the eye or ear.Particular attention needs to be given to
assessing lesions near the eyes and ears because the virus may cause serious
damage to the eyes and ears. This can cause blindness or hearing difficulties.
4. Obtain a culture and sensitivity test of the suspected infected lesions, as indicated.
A culture and sensitivity test provides an indication for
appropriate antibiotic therapy.

F. Risk for disease Transmission

1. Assess the client’s and family’s immunization status and past history of
chickenpox.
2. Clients with shingles are contagious to others who have not had chickenpox.
Those who have had varicella vaccine are considered immune but should have
varicella titers to confirm immunity.
3. Teach contact isolation. VZV is spread by contact with fluid from lesions
containing viruses.
4. Instruct the client to avoid contact with pregnant women and
immunocompromised individuals. Active lesions can be infectious, and
immunosuppressed individuals are more susceptible.
5. Use universal precautions in caring for the client to prevent transmission of
disease to self or other clients. VZV can be transmitted to others and cause
chickenpox in the person who has not previously had the disease.
6. Administer antiviral medications, as prescribed. Antiviral agents are most
effective during the first 72 hours of an outbreak when viruses are proliferating.
Drugs of choice are acyclovir, famciclovir, or valacyclovir.

G. Disturbed Body Image

1. Note client’s perception of his or her changed appearance- Client typically needs
to work or carry out his/her usual routine; he/she may require assistance coping
with changes in appearance.
2. Note verbal references to skin lesions- Scarring may occur if lesions are infected.
This may cause a preoccupation with appearance.
3. Discuss reasons for infectious isolation and procedures when indicated-Taking
time to sit down and talk/listen to the client in the room decreases the feeling of
isolation and loneliness.
4. Assist the client in articulating responses to questions from others regarding
lesions and infectious risk- Clients may need some guidance in determining what
to say to people who comment on the appearance of their skin. The rehearsal of
set responses to anticipated questions may provide some reassurance.
5. Suggest the use of concealing clothing when lesions can be easily covered. This
approach may help the client who is having problems adjusting to body image
changes.

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Evaluation:
All goals are met as evidenced by:
1. Client is comfortable as evidenced by the ability to rest.
2. Client verbalized understanding of the disease condition as to signs and
symptoms, mode of transmission, treatment and possible complications.
3. Client remained free of secondary infectionas evidenced by intact skin without
redness or lesions.
4. Client have minimal risk for disease transmission
5. Client demonstrated positive body image as evidenced by the ability to look at,
talk about, and care for lesions.

ACTIVITY 3:Answer thequestions/statement below and write your answer in a

piece of paper then take a photo of your answer sheet and post it in the
discussion forum for this part of the lesson.

1. Discuss how a person with a past history of chickenpox develops shingles.

2. What is the antibiotic commonly prescribed to patients with shingles?
What is the specific purpose in administering it to patients with shingles?

E.Mumps/Infectious Parotitis/Epidemic Parotitis

Mumps is an acute viral disease manifested by
the swelling of one or both parotid
glands., with occasional
involvement of other glandular
structures, particularly the testes in
male. The etiologic agent is
paramyxovirus usually found in the
saliva of an infected person. Man is the
only natural reservoir.

Source:https://www.immune.org.nz/diseases/mumps

Causative Agent Mumps virus from the family Paramixoviridae

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Incubation Period 2–4 weeks

Mode of Transmission Droplet infection
Period ofCommunicability 1–6 days before swelling to 9 days after or
untilswelling subsides

The virus gains entry into the system thru droplet infection and multiplies in the
upper respiratory tract and localizes in the salivary glands. The glands become
edematous and the ducts are obstructed by the swelling of the epithelial lining. On
some occasions, necrosis may occur in the acinar cells.

Manifestations:
The first symptom of mumps may begin with a sudden headache, earache, loss of
appetite, fever, and swelling of the parotid gland which is located in front and
below the ear. These manifestations are followed by: a) slight malaise with low–
grade fever; b) pain upon chewing and swallowing; and c) dysphagia.

Diagnostic Tests:
 Blood exam-shows a presumptive evidence of infection
 Viral culture or isolation of the virus from the pharynx a few days before and at
least 5 days after parotid swelling is done.
 Viral serology

Complications:
1. The most notorious complication of mumps is orchitis. Testicular
involvement usually occurs several days after the onset of parotid swelling.
Orchitis is often accompanied by elevation of body temperature and
excruciating pain which is aggravated by movement. The testes are swollen
and are tender to palpation.
2. Meningoencephalitis- also a common complication
3. Pericarditis
4. Deafness
5. Nephritis
6. Arthritis
7. congenital malformations, low birth weights, and fetal demise (mumps
during pregnancy)
8. Juvenile DM

Management:
1. Administration of analgesics for pain and antipyretic for fever
2. Application of hot or cold whichever is preferred by the patient to relieve
pain
3. Administration of steroids for orchitis

ACTIVITY 4:Do what is asked below and write your answer in a piece of paper

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

then take a photo of your answer sheet and post it in the discussion forum for this
part of the lesson.

Discuss briefly what is mumps.

Identify its most common complicationand describe this complication
including its manifestations.

F. Pneumonia/Bronchopneumonia

Pneumonia is an acute infectious disease caused by pneumococcus, associated by

general toxemia and consolidation of one or more lobes of one or both lungs.It is an
abnormal condition of the lungs characterized by inflammation of the parenchyma and
abnormal alveolar filling with fluid. The air sacs are filled with pus or exudate so that air
is excluded and the lungs become solid.

The causative agent passes through the tracheobronchial tree to the parenchyma of the
lungs. When the bacteria established themselves in the alveoli, they multiply and spread
to the adjacent alveoli by enzymatic destruction of tissues. Inflammation may spread to
the pleural surface and stimulate effusion. Organisms may enter the lymphatic system,
empty into the bloodstream, and establish bacteremic infection such as such as
meningitis, endocarditis and arthritis.

Causative agent Streptococcus Pneumoniae

Mode of transmission Droplet spread, direct oral contact
Incubation period 1–3 days
Period of communicability Until discharges of mouth and nose no longer
content virulent pneumococci in significant

Manifestations: The manifestation of pneumonia are:

1. Sudden onset of shaking chills with rising fever
2. Paroxysmal cough or choking cough (productive)
3. Stabbing chest pain aggravated by respirations and coughing
4. Sputum production-little bright red/rusty/prune–juice colored
sputum(pathognomonic sign)
5. s/s of respiratory distress (tachypnea, grunting, flaring of nares)
6. Labored respiration
7. Pain on the abdomen mistaken as appendicitis
8. Herpes may appear on the lips
9. Body malaise
10. Pulse is rapid and bounding

Risk Factors:
1. Cigarette smoking or air pollution. This disrupts mucocilliary and macrophages
activities.

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2. Immunosuppressive therapy such chemotherapy and corticosteroid therapy

3. Prolonged immobility. There will be retention of secretions which will later on lead
to multiplication of microorganisms.
4. Depressed cough reflex. Microorganism will accumulate due to inability to
expectorate secretions.
5. Alcohol. It depresses the immune system.

The pathology of the disease may be divided into 4 stages:

1. Lung engorgement stage. The lung is heavy, dark red in color and pits upon
pressure with finger exuding a bubbly, blood-tinged froth.
2. Red Hepatization Stage. The lung is still heavy, sinks in water and looks like a
piece of granite.
3. Gray Hepatization Stage. The red color of the lungs changed to gray. It now looks
like an ordinary granite. It is softer and tears more easily. When pressed, it
exudes a purulent fluid.
4. Resolution Stage. The inflammatory exudate is either absorbed by the blood
stream or expectorated.

Diagnostic Procedures:
1. Chest x-ray. It confirms the diagnosis. It shows area of consolidation, often lobar.
2. History taking. Ask for recent respiratory tract infection.
3. Blood or serologic exam. There is an elevated level of WBC because of infection.
4. Sputum analysis, sputum smear, and culture.

Management:
1. Bed rest
2. Increase oral fluid intake to liquefy secretions
3. Oxygen administration for dyspnea or signs respiratory distress
4. Administration of medications such as expectorant, bronchodilators and
antibiotics (Pen-G is the DOC)
5. High caloric diet
6. Cooling measures for fever
7. Pain relievers for pleuritic pain

Nursing Care:

1. Maintain the patient’s airway and adequate oxygenation.

2. Teach the patient how to cough and perform deep breathing exercises to clear
secretions
3. Obtain sputum specimen as needed and teach the correct collection of
specimens.
4. Maintain adequate nutrition to off-set high calorie utilization.
5. Provide a clam environment as the patient needs rest.
6. Control the spread of infection by disposing secretions properly.
7. Control temperature by doing cooling measures.
8. Monitor vital signs closely and watch for danger signs like marked dyspnea,
thready, small irregular pulse, cold moist skin and cyanosis and exhaustion

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Complications:
1. Pleurisy (pleuritis)
2. Pleural effusion
3. Pneumococcal meningitis
4. Lung collapse

ACTIVITY 5: List down the 5 cardinal signs of pneumonia. Write your answer in a
piece of paper then take a photo of your answer sheet and post it in the

5 Cardinal signs of Pneumonia

1.
2.
3.
4.
5.
on forum for this part of the lesson.

G. Pulmonary Tuberculosis/Koch’s Disease/Phthisis/Consumption Disease

Pulmonary tuberculosis is a chronic sub-acute or acute respiratory disease commonly

affecting the lungs characterized by the formation of tubercles in the tissues which
tend to undergo caseation, necrosis and calcification. It mainly involves the lungs, but
may spread to other parts of the body like the meninges of the brain, kidneys, bones and
lymph nodes. It is caused by Mycobacterium tubercle, an acid- fast bacilli which could live for
2 weeks without exposure to sunlight. It can be killed by heat, sunshine, drying and
ultraviolet light.

Causative Agent Mycobacterium tubercle– a gram positive, acid-fast

aerobic bacillus; resides in sputum of humans
Incubation Period 2–10 weeks
Mode of Transmission Droplet infection thru coughing, sneezing and talking;
person to person; adult to child
Portal of exit from Mouth and nose
humans

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

Portal of entry to the Respiratory tract

host
Most definitive Persistent cough for 2 weeks with blood-streak sputum
characteristic accompanied by low-grade afternoon fever, night
sweats and unintentional weight loss.
Source of Infection Sputum, blood from hemoptysis, nasal discharge and
saliva

People at risk of PTB:

The following are the people at risk of PTB:
1. Previously infected adults years back-bacteria remain dormant for years and may
be reactivated with low immune system
2. Close contact with one who has PTB because the causative agent can beeasily
transmitted.
3. (+) tuberculin test
4. Lowered resistance secondary to alcoholism and malnutrition
5. Elderly with healed dormant lesions
6. Immunosuppressed individuals like those undergoing chemotherapy and
corticosteroid therapy.
7. People who are institutionalized like the prisoners
8. Persons without adequate health care like the homeless, those living in
overcrowded areas and substandard housing.

Factors that contribute to high incidence of PTB:

1. Poverty/overcrowded homes. Overcrowding increases concentration of bacilli in
the air and easy spread of microorganisms.
2. Undernutrition. The body does not have enough nutrients to support the
functions of the systems in the body including the immune system which is
responsible for the body’s protection against invading microorganisms.
3. Deficient in vitamins A, D & C.
4. Children below 5 years old& elderly. Elderly are at risk of acquiring PTB due to
a decrease in the capability of the immune system to get rid of unwanted
materials in the body secondary to degenerative changes. Children under 5 years
old are also at risk because they have underdeveloped immune system.
5. Vices such as smoking, alcohol -use and drug use depress the body’s defenses
against invading microorganisms and alter the normal metabolism of t body
increasing the person’s risk.

Quantitative Classifications of PTB:

PTB can be quantitatively classified as:
1. Minimal.This is characterized byslight lesion without demonstrable excavation,
confined to a small part of one lobe or both.

2. Moderately advanced. One or both lungs may be involved; the volume affected
should not extend to one lobe; total diameter of the cavity should not exceed
four centimeters.

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

3. Far advanced. Lesions are more extensive than moderate.

Clinical Classification:
PTB can also be classified as:
1. Inactive TB. Symptoms of tuberculosisare absent; Sputum is absent for tubercle
bacilli after repeated examination; no evidence of cavity on chest x-ray.

2. Active TB.Tuberculin test is positive; x-ray of the chest is generally progressive;

symptoms due to lesions are usually present; sputum and gastric content are
positive for tubercle bacilli.

3. Activity not determined. When activity has not been determined from a
suitable period of observation or adequate laboratory and x-ray studies.

Other classification: PTB can also be classified as

1. Class 0. There is no exposure and no infection
2. Class 1. There is exposure but no infection
3. Class 2. (+) infection, (+) PPD but no manifestations of PTB
4. Class 3.(+) disease and are clinically active; (+) s/s of PTB, sputum exam and
chest x-ray)
5. Class 4. (+) disease but not clinically active (with previous history of PTB)
6. Class 5. Still a suspected case of PTB.

Types of PTB:

1. Primary PTB. First time the client is infected with PTB. Infection is located at the
apices of the lungs or near the pleura of the lower lobe. There is initial
infection but no symptoms

2. Secondary or reactivated PTB. Primary PTB remain latent for years and
reactivated with low resistance.

Manifestations:
The weight is decreased
Body malaise
Blood in the sputum
Amorphic breath sounds
Cavitation and hemoptysis
Indigestion
Low grade afternoon fever
Loss of appetite
Irritability

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a. Primary infection
o Change in behavior from normal to listlessness
o Easy fatigability
o Alertness to apathy
o Normal activity to irritability
o Crepitant rales

b. Post Primary/Progressive Primary TB

o Appears visibly ill
o Cough gradually becomes distressing
o Increased breath sounds with audible fine crepitant rales
o Dyspnea
o hemoptysis in those with cavitary disease

c. Chronic PTB
Generalized systemic signs and symptoms
o general malaise, anorexia, easy fatigability, apathy, irritability,
indigestion, general influenza–like symptoms
o physical signs – tachycardia, low BP, dyspnea, cyanosis
o fever
o night sweats – occurs in cases with acute exudate involvement
o loss of weight

Pulmonary S/S:
o cough with mucoid or mucopurulent sputum
o fine crepitant rales at apical area during deep breathing
o hemoptysis and chest pain
o pleural pain – associated with sero-fibrous pleurisy
o dyspnea

Diagnostic Tests:
1. History. Pervious history of exposure to PTB.
2. Sputum Analysis for AFB-confirmatory test
3. Chest X–ray. Done to detect extent and location of disease.
4. Tuberculin Test
a. Mantoux Test/PPD test. This is an intradermal injection of purified protein
derivative (PPD) into the inner aspect of the forearm. Results is read after
48–72 hours. Result is positive if the induration is 10 mm/ greater or 5mm
in immunocompromised individuals. Positive result is a presumptive
evidence of current or prior TB infection.

b. Patch Test (Von Proquet). A patch is placed in the skin and removed after
24-28 hours. It is positive if there is swelling or redness in the area.

c. Multiple Puncture Test. It is the introduction of tuberculin into the skin by

either puncture of the skin with a device with points coated with dried
tubercle. Result is positive if there is swelling.

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Management:

DOTS or Directly Observed Treatment Short Course

Short course therapy may be given through a six-month treatment with
isoniazid, (INH) Rifampicin, Pyrazinamide (PZA) and Ethambutol.

TB Drugs
Category Cases Intensive Maintenance
phase phase
I • Sputum + new patient RIPE (2 months) RI (4 months)
• TB with extensive lung
damage: (–) AFB
• Extrapulmonary TB
II • TB relapses RIPES(2 months) RIE (5months)
• and failures RIPE (1 month)
III • TB with sputum RIP (2 months) RI (2 months)
negative but with +
CXR-ray
• Extrapulmonary TB
(not serious)
TB Drugs (Dosage and Side Effects)
Rifampicin 450 mg Hepatitis; Red/orange secretions
Isoniazid 300 mg Hepatitis; peripheral neuropathy
Pyrazinamide 500 mg Hepatitis, hyperuricemia
Ethambutol 400 mg Optic neuritis. Do not use in
children too young for visual
examination (children below 8
years of age)
Streptomycin 1g Ototoxicity (irreversible damage to
CN 8); nephrotoxicity (reversible).
ugs

Nursing Management:

1. Maintain respiratory isolation until patient responds to treatment or until

the patient is no longer contagious. Take note that a patient is no longer
infectious after 2-3 weeks of continuous therapy.
2. Administer medicines as ordered.
3. Always check sputum for blood or purulent expectoration.
4. Teach/educate the patient about PTB.
5. Teach the patient to cough or sneeze into tissue paper and dispose
secretions properly.
6. Advise patient to have plenty of rest and eat balanced meals.
7. Be alert for signs of drug reaction.
8. Emphasize the importance of regular follow up examinations.

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

ACTIVITY 6: Using the table below, identify the three quantitative classifications of PTB and describe
each. Write your answer in a piece of paper then take a photo of your answer

Classification Description
1.
2.
3.
and post it in the discussion forum for this part of the lesson.

H.Bacterial Meningitis/Cerebrospinal Fluid

Meningitis is a condition characterized by inflammation of the protective

membranes covering the brain and spinal cord, known collectively as the meninges. The
disease can be caused by several organisms which include the pneumococcus,
staphylococcus, streptococcus and tubercle bacillus.

Causative Agent Neisseria meningitides (meningococcus) -most common

in adolescents
Haemophilus influenzae- most common in children
Streptococcus pneumoniae-most common in elderly
Occurrence Primarily a disease of children
Reservoir Man
Mode of Transmission Respiratory droplets thru nasopharyngeal mucosa;
Direst invasion through otitis media
May result after a skull fracture, a penetrating head
wound, lumbar puncture or ventricular shunting
procedures.
Incubation Period 2-10 days
Period of Until the causative agent is no longer present in nasal
Communicability and mouth discharges.

Diagnosis:

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

1. History and physical exam

2. CT Scan
3. Blood culture/gram staining
4. Lumbar tap/puncture- it is done to obtain a CSF and identify the presence of the
microorganism.

Classifications:
There are 2 classifications of meningitis. These are the acute meningococcemia
and aseptic meningitis.
1. Acute meningococcemia
a. Meningococci invade the bloodstream without involving the meninges.
b. Usually starts as an upper respiratory tract infection followed by sudden onset
of high-grade fever, chills, nausea, vomiting and headache.
c. petechial and purpuric rashes scattered over the entire body
d. The adrenal lesions start to bleed into the medulla which extends into the
cortex.
e. The combination of meningococcemia and adrenal medullary hemorrhage is
known as Waterhouse-Friderichsen syndrome
f. Waterhouse-Friderichsen syndrome is the rapid development of petechiae to
purpuric and echymotic spots in association with shock.

2. Aseptic meningitis
a. It is a benign syndrome characterized by headache, fever, vomiting and
meningeal symptoms.
b. It begins suddenly with a fever of up to 40 degrees Celsius, alterations in
consciousness (drowsiness, confusion, stupor), neck and spine stiffness, which
is slight at first.
c. Characteristic signs of meningeal irritation:
• stiff neck or nuchal rigidity
• Opisthotonus
• (+) Brudzinski’s sign
• (+) Kernig’s sign
• Exaggerated and symmetrical deep tendon reflexes
d. Sinus arrythmia, irritability, photophobia, diplopia and other visual problems.
e. Delirium, deep stupor, and coma
f. Signs of intracranial pressure:
• Bulging fontanel in infants
• Nausea and vomiting (projectile)
• Severe frontal headache
• Blurring of vision
• Alteration sensorium
Manifestations:
The manifestations of meningitis are as follows:
1. Fever, usually high, preceded by a chill

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NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

2. Rapid pulse, respiratory arrythmias-shallow and irregular respirations

3. Generalized hyperesthesia of the skin
4. Soreness of the skin and muscles.
5. Convulsions/seizures-occurs in approximately 10-80% of patients affected
6. s/s of increased intracranial pressure:
a. Nausea and vomiting (projectile) and usually not related to food intake
b. sudden severe frontal headache; irritability or incessant crying-results from
inflammation of the meningeal vessels and from increasing ICP and is usually
accompanied by photophobia and hyperesthesia
c. bulging anterior fontanel
d. Cushing’s triad-widening pulse pressure, irregular respiration, bradycardia
e. If progressive:
• blurring of vision
• alteration in sensorium which usually relates to either toxic and
metabolic encephalopathy and postictal stages.
• Disturbance in vision
7. s/s of meningeal irritation:
a. Nuchal and spinal rigidity in both prone and supine positions.
b. Neck, shoulder and back stiffness from spasms of extensor muscles
c. Opisthotonos or arching of the back.
d. resistance to neck flexion.
• (+) kernig’s sign- when lying with the legtightly flexed on the abdomen,
patient cannot completely extend his leg.
• (+) brudzinski’s sign when the patient’s neck is flexed on the chest, flexion of
the knees and hipare produced. When passive flexion of the lower extremity
of one side is made, a similar movement will be seen on the contralateral
(opposite) extremity

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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

Management:

Meningitis can be managed with the following:

1. Administration of medications
• Corticosteroids
• Broad-spectrum antibiotics for bacterial (Pen-G is the DOC)
• Mannitol to decrease cerebral edema
• Digoxin to control arrythmias
• Acetaminophen to relieve headache and fever
• Anticonvulsant to reduce the severity of convulsive seizures

2. Instituting measures to decrease ICP or prevent increase in ICP such as

putting the patient in high fowler’s position, avoiding sneezing,
administration of diuretics and stool softeners.

Nursing Care:

Maintain fluid and electrolyte imbalance

Source: https://www.google.com/search?q=nuchal+rigidity&tbm
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 NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

Educate regarding personal hygienic measures

Nutrition
Isolate in calm, dim-lighted room
Never provoke any stress
Give adequate rest
Emphasize the importance of medications
Safety measures during seizure episodes

ACTIVITY 7: Using the table below, list down the signs of meningeal
irritation and increased intracranial pressure. Write your answer in a piece
of paper then take a photo of your answer sheet and post it in the
discussion forum for this part of the lesson.

Signs of Meningeal Irritation Signs of Increased Intracranial

Pressure

WRAP UP ACTIVITY:

Write the causative agent, other terms used to refer to the infectious disease,
incubation period and pathognomonic sign. Use the table below. After
completing the table, take a photo of your answer and placed it in the discussion
forum.

Disease Other term Causative Incubation Pathognomonic

agent period sign
Measles
German
Measles
Mumps
Shingles
Chickenpox
PTB
Meningitis

ASSESSMENT (POST ASSESSMENT)

A 30-item quiz will be administered to you via MVLE. You are required to
get 60% of the items to pass the exam.

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NCM 112a CHAPTER IV: CARE OF CLIENTS AT RISK OR WITH INFECTIOUS DISEASES

REFERENCES:

Kennamer, M. (2007). Basic Infection Control for Health Care Providers (2nd ed.)
Delmar Learning

Navales, D. (2008). Handbook of Common Communicable and Infectious

Diseases (Revised edition) C & E Publishing, Inc.

Yuan, S. (2003). Handbook of Diseases (3rd ed.) Lippincott Williams & Wilkins.

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