Nursing Process: The Patient With an Infectious Disease

Nursing Process: The Patient With an Infectious Disease

Assessment

Symptoms of infectious diseases vary significantly between and within diseases. For some infections, such as chickenpox (vari-cella), widely disseminated rash represents the first suggestion of infection, and it occurs in most newly infected people. In other infections, such as TB and HIV, latency is prolonged, and most of those infected do not have symptoms; instead, infection is determined through diagnostic procedures.

History taking, physical examination, and the use of diag-nostic tests are important for determining the presence of in-fection and infectious diseases. The goals of eliciting the history are to establish the likelihood and probable source of infection and the degree of associated pathology and symptoms. The pa-tient’s previous medical record is reviewed when possible. In obtaining a health history, some of the following questions may be asked:

·      Does the patient have a history of previous or recurrent in-fections? Is the patient aware of infection with an organism associated with prolonged latency, such as HIV, herpesvirus, or TB?

·      Has there been fever? How high has the patient’s tempera-ture been? What is the fever pattern? Is the temperature constant, or does it rise and fall? Has fever been associated with chills? Has the patient taken medication to relieve fever?

·      Is there cough? Is the cough chronic or acute? Is it associ-ated with shortness of breath? Does the cough produce sputum? Is the sputum bloody? Has the patient had a PPD test performed recently? If so, what were the results? Has the patient been given isoniazid (INH) prophylaxis for TB infection? Has the patient been treated for TB in the past?

·      Is there pain? Where is the pain? What is the nature of the pain? Does the patient have sore throat, headache, myalgias, or arthralgias? Is there pain on urination or other activity?

·      Is there swelling? Is there drainage associated with the swelling? Is the swollen area warm to touch?

·       Is there a draining site? Is the drainage associated with trauma or a previous procedure? Is the drainage purulent or clear?

·      Does the patient have diarrhea, vomiting, or abdominal pain?

·      Is there rash? What is the nature of the rash—is it flat, raised, red, crusted, purulent, or lacelike?

·      What is the patient’s vaccination history?

·       Has the patient taken medications that could induce rash?

·      Has there been exposure to another person who has an iden-tified infectious disease or rash?

·      Has there been an insect or animal bite? Has there been an animal scratch or other exposure to pets, farm animals, or experimental animals?

·      What medications are used? Have antibiotics been taken recently or long-term? Is the patient being treated with corticosteroids, immunosuppressing agents, or chemo-therapy?

·      Is there a history of substance abuse?

·      Has the patient been treated in the past for other infectious diseases? Has the patient been hospitalized for infectious diseases?

·      If sexual history is pertinent, has there been sexual exposure to another person with a known STD? Has the patient been treated for STDs in the past? Is the patient pregnant, or has she recently been pregnant? Has the patient been tested for HIV?

·      Has the patient traveled to or from a developing country or abroad? What was the immunization or antimicrobial pro-phylaxis used for protection while traveling?

·      What is the patient’s occupation?

Because infection may occur in any body system, physical examination may reveal signs of infection at any body site. Gen-eralized signs of chronic infection may include significant weight loss or pallor associated with anemia of chronic diseases. Acute infection may manifest with fever, chills, lymphadenopathy, or rash. Localized signs vary significantly according to the source of infection. Purulence, pain, swelling, and redness are strongly as-sociated with localized infection. Cough and shortness of breath may be caused by influenza, pneumonia, or TB, as well as many noninfectious causes.

Diagnosis

NURSING DIAGNOSES

Based on assessment data, the patient’s major nursing diag-noses related specifically to infection may include the following:

·      Risk for infection transmission

·      Deficient knowledge about the disease, cause of infection, treatment, and prevention measures

·      Risk for imbalanced body temperature (fever) related to the presence of infection

Infection may interrupt normal function of any affected body sys-tem.

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Based on the assessment data, potential complications that may develop include the following:

·      Septicemia, bacteremia, or sepsis

·       Septic shock

·       Dehydration

·       Abscess formation

·       Endocarditis

·       Infectious disease–related cancers

·       Infertility

·       Congenital abnormalities

Planning and Goals

Major goals for the patient may include prevention of spread of infection, increased knowledge about the infection and its treat-ment, control of fever and related discomforts, and absence of complications.

Nursing Interventions

PREVENTING INFECTION TRANSMISSION

Preventing the spread of infection requires an understanding of the usual routes of transmission of the organism. The hospital-ized patient may serve as a risk for transmission to other patients if the patient’s disease was spread by the airborne route or if in-fected by an organism such as C. difficile, which can be spread directly to others by persistence of spores in the environment. In these situations, strict adherence to isolation measures is impor-tant in reducing the opportunity for spread. Preventing trans-mission of organisms from patient to patient usually requires participation of the health care team. Transmission of organisms on the hands and gloves of health care workers remains a common source of cross-infection in the hospital or clinic setting.

Nurses serve an important role in preventing the transfer of organisms in two ways. First, as the health professionals who often spend the most time with patients, nurses have a greater op-portunity for spreading organisms. It is imperative that nurses disinfect their hands before and after contact with patients and after performing a potentially hand-contaminating activity. Hands must be disinfected each time gloves are removed. For example, the nurse who has performed endotracheal suctioning should re-move gloves and wash hands before performing wound care on the same patient.

The second way that nurses reduce hand-to-hand spread is to serve as patient advocates. With the number of health care workers involved in patient care each day, there is a significant opportunity for breaks in hand-hygiene technique. To the degree feasible, the nurse should observe the hand-hygiene activities of other professionals and discuss them when lapses in technique are observed.

TEACHING ABOUT THE INFECTIOUS PROCESS

For infectious diseases, interruption of transmission requires di-agnosis and patient compliance with the treatment regimen. The nurse’s role is to educate and, in some situations, to report the case to public health officials for contact tracing and verification of follow-up.

The nurse must stress the importance of immunization to parents of young children and to others for whom vaccines are recommended, such as patients who are elderly, are immuno-suppressed, or have chronic illnesses. Nurses should recognize their personal responsibility to receive hepatitis B and annual influenza vaccine to reduce potential transmission to self and vulnerable patient groups.

Infectious diseases often seem mysterious and frequently are socially stigmatizing. Patient teaching efforts require empathy and sensitivity. For example, in the past, TB was considered a stigmatized disease. The nurse may need to provide core infor-mation to the patient who needs INH prophylaxis in order to promote understanding and allay guilt that the patient may feel.

CONTROLLING FEVER AND ACCOMPANYING DISCOMFORTS 

Fever must always be investigated to determine whether infection is the source. There is evidence that fever, mediated by the hypo-thalamus, may potentiate beneficial functions in the syndrome of reactions known as acute-phase reaction. These reactions include changes in liver protein synthesis; alterations in serum metals, such as iron; and increased production of certain classes of white blood cells and other immune system cells. Most fevers are phys-iologically controlled to stay below 105.8°F (41°C). However, severe fever, as occurs with meningococcal meningitis, may cause heat stroke and other complications. Even milder fevers accom-panied by fatigue, chills, and diaphoresis are often uncomfortable for the patient. The physician makes decisions regarding fever control. Whether fever is treated or untreated, adequate fluid in-take is important during febrile episodes.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

The patient with a rapidly progressive infectious disease should have vital signs and level of consciousness closely monitored. X-ray findings and microbiologic, immunologic, hematologic, cytologic, and parasitologic laboratory values must be interpreted in the context of other clinical findings to assess the infectious disease course.

Antibiotic therapy is frequently complex, with modifications necessary because of sensitivity test results and disease progres-sion. It is important to initiate antibiotic therapy as soon as it is prescribed, rather than waiting until routine medication sched-uling times. This ensures that therapeutic blood levels can be attained as quickly as possible. The Plan of Nursing Care describes nursing interventions for specific complications of infection.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include the following:

·        Uses appropriate methods to prevent the spread of infection

·        Acquires knowledge about the infectious process

·        Exhibits absence of elevated body temperature