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

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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