• HIV Infection and AIDS
• Diphtheria
• Encephalitis
• Hepatitis
• Herpes: Disseminated
• Measles
• Meningitis
• Mononucleosis
• Mumps
• Pertussis
• Shingles (Herpes Zoster)
• Tuberculosis
• Varicella (Chickenpox)

• Lice
• Scabies
• Myiasis
Major Topics

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

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

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

HIV Infection and AIDS

All HIV infections will develop into AIDS
• Mean between exposure to HIV to AIDS-10 years
• AIDS to death
• Sooner the treatment, better long-term survival


HIV Infection and AIDS
Assessment
Subjective data
• History of present illness

Generalized lymphadenopathy, persistent





Fever for longer than 1 month
• Episodic spiking
• Persistent low-grade fever
Diarrhea for longer than 1 month
Weight loss
Anorexia
Night Sweats

HIV Infection and AIDS
Assessment
• Malaise or fatigue, arthralgias, myalgias
• Mild opportunistic infections
1.
Oral candidiasis
2.
Herpes Zoster
3.
Tinea
• Skin lesions, rashes
• Cough
• Broad range of neurological complaints, both focal and global, including dementia

HIV Infection and AIDS
Assessment

1.
Antiretroviral agents : zidovudine (AZT), zalcitabine (ddC), didanosine (ddI), stavudine (d4T), lamivudine (3TC), nevirapine, delavirdine
2.
Pneumocystis prophylaxis : trimethoprimsulfamethoxazole, pentamidine, dapsone
3.
Protease inhibitors: indinavir, saquinavir mesylate, nelfinavir, ritonavir

HIV Infection and AIDS
Assessment

Medical History
 Blood transfusions, especially before 1985
 Hemophilia
 Occupational needle sticks or blood exposure
 Sexually transmitted diseases (STD’s)
 Tissue transplantation
 Infant with HIV-positive mother
 Sexual contact with IV drug user
 Sexual contact with HIV-positive partner
 Sexual practices including multiple partners, anal sex, oral-anal sex, or fisting
 Recent TB exposure

HIV infection and AIDS
• Physical examination




Chronically ill appearance
Kaposi’s sarcoma skin lesions
Chest: crackles and wheezes
Dyspnea



Abnormal vital signs
Lymphadenopathy
Dementia



Wasting syndrome; signs of volume depletion
Withdrawn, irritable, apathetic, depressed
Slow, unsteady gait; weakness; poor coordination

HIV Infection and AIDS
• Diagnostic procedures

CXR

CBC
• Anemia
• Lymphopenia
• Thrombocytopenia

ABG’s

Electrolytes, liver function tests

HIV Infection and AIDS
Assessment

Determination of HIV antibodies (e.g., via enzyme-linked immunosorbent assay
[ELISA] and Western blot analysis)
 decreased CD4 cell count
 blood cultures
 urinalysis

TB skin test (5 mm is positive in HIV infected person)

Diphtheria

Alteration in neurological functions
• Lethargy
• Withdrawal
• Confusion
• Cranial nerve neuropathies

Alteration in cardiac functions
• ST-and T-wave changes
• First-degree heart block
• Dyspnea, heart failure, circulatory collapse

Anxiety

Diphtheria

• Throat culture: specimen swabbed from beneath membrane or piece of membrane
• Notify lab that C. diphtheria is suspected: requires special media and handling

Diphtheria

Interventions
• Provide strict respiratory isolation
• Maintain airway, breathing, circulation

Monitor vital signs and pulse ox

Assemble emergency cricothyrotomy equipment at bedside

Administer O2 for dyspnea or cyanosis
• Establish IV catheter for administration of IV fluids

Diphtheria


Diphtheria antitoxin
• Equine serum
• Test for sensitivity
(intradermal or mucous membrane) before administration
• Often administered before diagnosis is confirmed because of virulence of disease

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

Diphtheria

• Regular booster Q10years, combined with TD, after completion of initial series of 3 doses
• Identify close contacts

Culture and prophylactic Booster of TD in none within 5 years

Antibiotics

Active immunization for nonimmunized persons (series of 3 doses)

Encephalitis






Viral infection of the brain
Often coexists with meningitis and has broad range of S&S
Most cases in North America, caused by arboviruses, herpes simplex I, varicella-zoster, EB, and rabies
Transmission by animal bites, or seasonally form vectors (mosquitoes, ticks, and midges)
More common human viruses are airborne via droplet or lesion exudate
All age groups, with mortality from 5-10% from arboviruses and 100% for rabies

Encephalitis

Assessment
• Subjective

History of present illness
• Recent viral illness or herpes zoster
• Recent animal or tick bite



• Travel to endemic area, season of the year
• Fever
• Headache
Photophobia
Nausea, vomiting
Confusion, lethargy, coma
New psychiatric symptoms

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

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

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

Encephalitis

Interventions
• Institute standard precautions and isolation until causative agent identified
• Monitor airway, breathing, circulation
• Monitor vital signs and pulse oximeter
• Administer O2
• Prepare to assist with intubation
• Insert large bore IV catheter, and administer isotonic solutions as ordered
• Administer medications as ordered

Encephalitis
• Administer antimicrobial/antiviral agents, steroids
• Monitor blood sugar and electrolytes
• Insert urinary catheter PRN
• Monitor I&O, cerebral edema, keep
HOB >30 degrees
• Institute seizure precautions
• Elevate HOB 30 degrees

Encephalitis
• Restrict IV fluids
• Keep body temperature normal
• Administer diuretics as ordered
• Explain procedures and disease to family/patient
• Allow patient/significant others to verbalize fears
• Prepare patient/family for admission to hospital

Hepatitis

Viral syndrome involving hepatic triad
(bile duct, hepatic venule, and arteriole, and central vein area.

Hep A-fecal-oral route, infectious for 2 weeks before and 1 week after jaundice

Hep B-(HBV)blood and sexual contact and consists of 3 antigens
• Hep B surface

Hepatitis

Hep B-(HBV) blood and sexual contact

3 antigens
• Hep B e antigens
• Dane particle- two part antigen: inner core
(hep B core antigen) and surface antigen (hep surface antigen)

Persistence of core antibody indicates chronic infection

Persistence of surface antibody indicates immunity to reinfection

Hep B surface antigen in the serum without symptoms is indicative of a carrier state

Hepatitis

Hep C identified by antihepatitis C virus antibody

50% of Hep C become chronic, and no immunity is developed

Hep C 90% of hepatitis cases transmitted by blood transfusion

Hepatitis

is an epidemic, enterically transmitted infection from shellfish and contaminated water

Hep D found with acute or chronic
HBV infection

Chronic infections result in cirrhosis and liver cancer

Hepatitis

Assessment
• History of present illness

Prodrome: preicteric phase, occurs 1 week before jaundice
• Low-grade fever
• Malaise: earliest, most common symptom
• Arthralgias
• Headache
• Pharyngitis
• Nausea, vomiting

Hepatitis
History of Illness cont’d
Rash, with type B usually
• May or may not progress to icteric phase
• Incubation:

A 15-45 days

B 30-180 days

C 15-150 days
• Duration:

A 4 weeks;

B AND C 8 weeks

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

Hepatitis cont’d
• Medical History

Immunizations

ETOH consumption

Allergies

Medications: all are significant

Blood transfusions, IV drug use, Hemophilia or dialysis

Chronic medical problems, travel, living in institution

Living in recent floods or natural disasters

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

Hepatitis

Diagnostics
• Liver enzymes: SGOT & SGPT elevated
• Direct and indirect bilirubin levels: elevated
• Alkaline phosphatase : elevated
• Differential leukocyte count: leukopenia with lymphocytosis, atypical lymphocytes
• CBC, UA: elevated bilirubin, PT: elevated, ABD X-ray
• Antigen and/or antibody titers

Hepatitis

Interventions
• Provide increased calories
• Monitor for signs of dehydration, replacement with isotonic solution
• Record I&O
• Assess support systems of patients
• Hospitalize if unable to care for self or PT >15 seconds

Hepatitis

Initiate prophylaxis
• Type A

Immune serum globulin 80-90% effective if 7-14 days after exposure

Vaccine administered in two doses: given to high-risk population: foreign travel, endemic areas (e.g.
Alaska), military, immunocompromised or risk for HIV, chronic liver disease, hep C
• Type B: hepatitis B immune globulin plus vaccination, for exposure to serum, saliva, semen, vaginal secretions, breast milk


Hepatitis
Initiate prophylaxis
• Type B: vaccination with HBV vaccine inactivated
(Recombivax HB)

Vaccinate high-risk persons
• Health care and public safety workers, clients and staff at institutions
• Hemodialysis patients, recipients of clotting factors
• Household contacts and sexual partners of HBV carriers
• Adoptees from countries where HBV in endemic:
Pacific Islands and Asia
• IV Drug users, sexually active homosexual and bisexual men
• Sexually active men and women with multiple partners
• Inmates of long-term correctional facilities

Hepatitis

Vaccinate all infants (universally) regardless of hepatitis B surface antigen status of mother (administer first dose in newborn period, preferably before leaving hospital)
• Report to appropriate health departments
• Limit exposure of medical personnel to blood, secretions, and feces

Hepatitis
• Instruct patient/significant others

Strict hygiene, private bathroom if possible

Diet of small, frequent feedings low in fat, high in carbs, patient should avoid handling food to be consumed by others

S&S: bleeding, vomiting, increased pain

Take meds as prescribed

Avoid intake of alcohol

Take meds only if necessary

Avoid steroids: they delay long-term healing

Herpes: Disseminated
Herpes simplex virus (HSV) is a relatively benign disease when cutaneous


Can invade all body systems and lead to death
Primary viremia occurs from spill-over of the virus at the site of entry


During the second stage, HSV disappears from he blood but grows within cells of infected organs, which in turn causes seeding to other organ systems.
Dissemination occurs in susceptible persons: newborns, malnourished children, children with measles, people with skin disorders, such as burns, eczema, immunosuppression, and immunodeficiency, especially HIV

Herpes: Disseminated

HSV has a predilection for temporal lobe.

Encephalitis most common
• 70% mortality rate without treatment
• 50% with treatment residual neurological deficits

Latency period within sensory nerve resulting in mild or life-threatening infection years later

Herpes


History of present illness
• Onset: usually acute

After other illness

After outbreak of cutaneous infection

After any stressor

Herpes

• Subjective data

History of present illness
• Symptoms depend on organ system affected

Neurological system: headache, confusion, seizures, coma, olfactory hallucinations

Liver: ABD pain, vomiting

Lung: cough, fever

Esophagus: dysphagia, substantial pain, weight loss

Herpes

• HSV infection
• Chronic illness, cancer, HIV
• Medications: immunosuppressants
• Allergies

Herpes

• Physical exam

Fever

Other vital sign abnormalities depend on organ system involved

Focal neurological signs
• Anosmia (loss of smell)
• Aphasia
• Temporal lobe seizures
• Confusion, somnolence, coma

Respiratory
• crackles

Herpes
• Diagnostic Procedures

Viral cultures: blood and skin

Lumbar puncture: cerebrospinal fluid for culture

Biopsy of target organ, especially brain

Clotting studies for DIC

Liver Function

CBC

Herpes

Interventions
• Prepare to assist intubation
• O2 PRN
• Monitor

VS with PO

Neurological status
• Maintain airway, breathing, circulation

I&O
• Administer Antiviral meds
• FC PRN
• Establish IV of isotonic solution at rate to maintain blood pressure and fluid balance
• Protect from injury from seizures
• Explain procedures and illness to patient or significant others
• Practice standard precautions

Measles

Highly acute and contagious virus

Caused by rubeola virus, late winter and early spring

Airborne droplets, incubation 10-14 days

Contagious few days before and after onset of rash

Most recover, incidence of OM, diarrhea, pneumonia, and encephalitis

Measles

More serious in infants and in malnourished children, pregnancy with preterm delivery and spontaneous abortion

Most born <1957 are permanently immune

Vaccine (MMR) 12-15 months, active disease or two immunizations in childhood

Booster elementary school, all high school or college revaccinated unless active disease or two immunizations

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

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

Measles

Physical exam
• Fever
• Koplik’s spots on buccal mucosa
(bluish-gray specks on red base)
• Conjunctivitis
• Harsh cough

Measles
• Red, blotchy rash

Appears on third to seventh day

Maculopapular, then becomes confluent as progresses

Starts on face, then generalized to the extremities

Mild desquamation

Lasts 4-7 days
• Vital signs: normal, except fever
• Neurological system: may have altered
LOC, encephalitis
• Respiratory system: may have OM, pneumonia

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


Measles
Interventions
• Provide respiratory isolation
• Isolate patient/significant others from other people in waiting room
• Advise patient to avoid school, day care centers, and people outside immediate family until after contagious period
• Initiate immunization of high-risk contacts

Live vaccine if given within 72 hours of exposure (use monovalent vaccine if infants younger than 12 months; need reimmunization at 15 months with
MMR)

Immune globulin up to 6 days after exposure

Immunocompromised persons should receive immune globulin even if previously immunized

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

Meningitis

Bacterial or viral of the pia and arachnoid meniges


Late winter or early spring
Viral mild and short lived



Bacterial severe and life threatening
Streptococcus pneumoniae, Haemophilus influenzae (H. flu), and Neisseria meningitidis subgroups A, B, and C
H. Flu incidence decreased because of vaccination

Bacteria can enter the blood, basilar skull fracture, infected facial structures, and brain abscesses

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

Meningitis

Assessment
• Subjective data

History of present illness
• Antecedent illness or exposure
• Onset: sudden
• Headache, especially occipital
• Fever and chills
• Anorexia or poor feeding
• Vomiting and diarrhea






Malaise, weakness
Neck and back pain
Restlessness, lethargy, altered mental status
Disinclination to be held: infants
Seizures
Recent basilar skull fracture

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

Meningitis

Objective data
• Physical examination

High-pitched cry in infants

Hyperthermia >101 or hypothermia <96

Petechiae that do not blanch: 1-2 mm on trunk and lower portion of body, also mouth, palpebral and ocular conjunctiva

Purpura

Cyanosis, mottled skin, and pallor


Meningitis
Objective data
• Physical examination
• Vital signs

Tachycardia, hypotension, tachypnea

Bradycardia in neonates
• Meningeal irritation: persons older than 12 months, seen in about 50%



Contraction and pain of hamstring muscles occur after flexion and extension of leg: Kernig’s sign
Bending of neck produces flexion of knee and hip; passive flexion of lower limb on one side produces similar movement on other side:
Brudzinski’s sign
Nuccal rigidity

Meningitis

Infants with meningeal irritation cry when held and are more quiet when left in crib

Photophobia

Focal neurological signs, cranial nerve palsies, and generalized hyperreflexia

Altered mental status
• Confusion, delirium, decreased LOC
• Lethargy and confusion may be only signs in elderly

Bulging fontanelle

Irritability

Meningitis

Diagnostic procedures
• Blood glucose levels: infants younger than 6 months are prone to hypoglycemia
• Electrolyte levels: hyponatremia
• BUN and creatinine levels
• Serum osmolality

Low because of inappropriate vasopressin secretion

High because of dehydration

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


Meningitis
Lumbar puncture: CSF
• Bacterial infection : cloudy appearance; elevated pressure;
WBC 200-20,000 with increased polymorphonuclear cells; glucose level decreased; protein level elevated; bacteria present on Gram’s stain
• Viral infection : clear appearance; WBC <500; normal pressure; glucose level normal; no bacteria present on Gram’s stain

Meningitis

Interventions
• Ensure that health care providers wear masks if infection with meningococcus is suspected
• Undress patient completely to check for petechiae
• O2 PRN
• Monitor VS
• Prepare to suction and assist with aggressive ventilatory support as needed
• Prepare to assist with LP
• Insert NG to prevent aspiration

Meningitis







Establish IV catheter, IO in necessary
Monitor IV fluids as related to I&O or excessive secretion of antidiuretic hormone
KCL replacement PRN, antiemtics PRN
Infuse antibiotics (usually ampicillin, aminoglycosides, cephalosporins)
Administer benzodiazepines, corticosteroids
Control fever
Reduce ICP
• Use hyperventilation with caution to avoid cerebral ischemia
• Elevate HOB 30 degrees
• Administer barbiturates and diuretics

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

Meningitis

Administer chemprophylaxis(rifampin, ceftriaxone) within 24 hours of disease identification to household contacts, day care center contacts, and health care providers if bacterial disease
• Side effects GI, lethargy, ataxia, chills, fever, and redorange urine, feces, sputum, tears, and sweat
• Soft contact lenses may be permanently stained with rifampin use
• Medication may need to be taken with food for GI intolerance, although it is best absorbed on empty stomach
• Birth control pills may not work
• Do not give to pregnant women

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

Mononucleosis





Acute viral illness with broad range of S&S lasting 2-3 weeks, very contagious
EBV transmitted in saliva
• About 50% of the population serovonverts to EBV before 5 years of age with sublclinical infection or mild illness
• Another wave of seroconversion in med adolescence
• Peak 15-24-years
Incubation 2-5 weeks
CMV is the other most frequent causative agent
Complications include: glomerulonephritis, autoimmune hemolytic anemia, pericarditis, hepatitis, guillain-Barre syndrome, meningitis, and pneumonia

Mononucleosis
Rarely death may occur from splenic rupture or airway obstruction as a result of tonsillar hypertrophy

• Subjective data
• History of present illness

Prodrome lasting 3-5 days: malaise, anorexia, nausea and vomiting, chills/diaphoresis, distaste for cigarettes, headache, myalgias

Mononucleosis
• History of present illness

Subsequent development of fever 100.4 to 104 lasting 10-14 days, sore throat,diarrhea, earache
• Medical history

Exposure to mononucleosis, usually not known

Allergies

Medications

Mononucleosis

Objective data
• Physical examination

May appear acutely ill

Red throat with exudate; tonsils may be hypertrophied

Tender lymphadenopathy, particularly posterior cervical

Petechiae on palate

Fine red macular rash 5% of adults: if given ampicillin,
90-100% of patients will experience rash

Abdominal tenderness with heptomegaly

Splenomegaly in 50% of patients

Mononucleosis

Diagnostic procedures
• Heterophile antibody titer (Monospot): positive by second week of illness; may remain negative in children younger than 5 years
• Throat culture to rule out group A streptococcus
• CBC: neutropenia, thrombocytopenia, lymphocytosis with atypical lymphs, leukocytosis
• Liver functions: may be abnormal
• CXR if pneumonia suspected

Mononucleosis

Interventions
• Isolation not necessary

Avoid kissing

No sharing eating or drinking utensils
• Activity as tolerated

Extra rest early in illness

Avoid heavy lifting and contact sports for at least 4 weeks if splenomegaly present

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

Mononucleosis
• Warm salt water gargles for sore throat
• Encourage fluids to avoid dehydration
• Diet as tolerated

Liquids initially

Soft foods
• Do not donate blood for 6 months

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

Mumps








Acute, usually benign, viral infection caused by
Paramyxoviridae family
Swelling and tenderness of salivary glands and one or both parotid glands
Direct contact, droplet nuclei, or fomites
Incubation averages 16-18 days
Peak incidence is January to May
Most contagious just before swelling
More severe illness in the post pubertal age group; 20-
30% of adult men experience epididymoorchitis
Complications include viral meningitis, arthritis, arthralgias, and pancreatitis

Mumps

Assessment
• Subjective data

History of present illness
• Exposure to mumps
• Prodrome: fever (<104), anorexia, malaise, headache
• Earache and tenderness of ipsilateral parotid gland
• Citrus fruits or juices increase pain
• Fever, chills, headache, vomiting if meningitis
• Testicular pain if orchitis
• Abdominal pain if pancreatitis

Mumps
Subjective cont’d

Medical history

Childhood immunizations

Previous mumps

Allergies

Medications

Mumps

Objective data
• Physical examination

Swelling of gland, maximal over 2-3 days, with earlobe lifted up and out and mandible obscured by swelling

Trismus with difficulty in pronunciation and chewing

Testicle warm, swollen, tender

Scrotal redness

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

Mumps

Interventions
• Provide respiratory isolation
• Advise to avoid school/work until swelling gone
• Administer analgesics
• Encourage rest until feeling better
• Encourage fluids, avoid citrus
• Warm or cold packs
• For orchitis

Bed rest

Scrotal elevation

Ice packs

Pain meds

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

Pertussis

Acute, widespread, highly contagious bacterial disease of the throat and bronchi

Gram-negative Coccobacillus Bordetella Pertussis

Airborne droplets

Most common children <4 years

Females higher incidence of morbidity and mortality

Partially immunized children have less severe illness

Adults have only minor respiratory symptoms and persistent cough, majority unrecognized

Pertussis

Vaccine immunity is <12 years, most adults are not protected

Incubation period 7-10 days but can vary 6-21

Peak incidence is during late summer and early fall

Pertussis bacteria invade the mucosa of URT

Complications include: pneumonia, pneumothorax, seizures, and encephalitis

Children also frequently experience laceration of the lingual fremulum and epistaxis


Pertussis
Assessment
• Subjective data

History of present illness
• Exposure to pertussis
• Three stages: last up to 2 weeks

Conjuctivitis and tearing

Fever/chills

Rhinorrhea, sneezing

Irritability

Fatigue

Dry nonproductive cough, often worse at night

Pertussis

Paroxysmal: lasts 2-4 weeks
• Severe cough with hypoxia, unremitting paroxysms, and clear, tenacious mucous; patient appears well between paroxysims of coughing; cough often triggered by eating and drinking
• Apnea can occur in rate cases
• Vomiting follows cough
• Anorexia

Convalescent: residual cough

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

Pertussis

Objective data
• Physical exam

Paroxysmal explosive coughing ending in prolonged high-pitched crowing inspiration

Coryza

Clear, tenacious mucous in large amounts

Temperature >101

Restlessness

Crepitus from subcutaneous emphysema

Periobital/eyelid edema

Pertussis

• C&S testing of nasopharynx using calcium alginate dacron-tip swab
• Immunofluorescent antibody staining of nasopharyngeal specimens
• CBC with differential leukocyte count: lymphocytosis

Pertussis

Interventions
• Maintain respiratory isolation
• Monitor vital signs and respiratory status
• Be prepared to assist with intubation
• O2 PRN
• Isolate patients with active disease from school or work until they have taken antibiotics for 14 days
• Monitor for signs of dehydration or nutritional deficiency secondary to vomiting

Pertussis

Administer prescribed medication
• Antibiotic: EES
• Antitussive
• Analgesic
• Antipyretic

Position comfortably



Pertussis
Admit patients younger than 1 year: prepare for nasotracheal suctioning
Initiate immunization
• Educate parents about importance of complete immunization
• Household and other contacts <1year: prophylactic EED
• Household and close contacts ages 1-7 years who had less than four DTP vaccine doses or more that 3 years since:

EES for 14 days

DTP immunization

Pertussis

Review S&S that necessitate return to
ER
• Difficulty in breathing recurs or worsens
• Blue color of lips or skin
• Restlessness or sleeplessness develops
• Medicines are not tolerated
• Fluid intake decreases

Shingles (herpes zoster)






Acute localized infection cause by varicella-zoster virus (VZV)
During chickenpox, VZV travels from skin lesions to sensory nerve ganglia sets up latent infection
Postulated that when immunity to VZV wanes, the virus replicates
VZV moves down nerves, causing dermatomal pain and skin lesions
Lasts up to 3 weeks
Exact triggers unknown, old age and immunosuppression are risk factors

Shingles

20% of population

4% second exposure

Fluid from lesion is contagious, but likelihood of transmission is low

Susceptible exposed persons may develop varicella (chickenpox)

Complications: post herpetic neuralgia, debilitation pain syndrome lasts several months, blindness, disseminated disease, and occasionally death

Shingles

Assessment
• Subjective data

History of present illness
• Pain, itching, tingling, burning of involved dermatome precede rash by 3 to 5 days
• Rarely headache, malaise, fever

Medical history
• History of chickenpox, HIV infection, cancer, chronic steroid use
• Allergies
• Medications

Shingles

Objective data
• Physical examination
• Tenderness over involved dermatome
• Rash

Unilateral; does not cross midline

Usually thoracic or lumbar dermatome

Small fluid-filled vesicle on red base

May become hemorrhagic

New lesions occur for about 1 week

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

Shingles

Interventions
• Provide contact isolation
• Advise patient to avoid school/work until all lesions are crusted over
• Recommend immunizations of high-risk contacts
• Varicella-zoster immune globulin (VZIG)

Shingles

Administer medications as prescribed
• Analgesics
• Antihistamines
• Antivirals (acyclovir, famciclovir) will lessen disease severity and incidence of post herpetic neuralgia if administered within 72 hours of onset of rash

Shingles

To prevent infection of lesions, cut fingernails short

Topical baking soda paste or baths and calamine lotion may help

Ophthalmological consult if facial/eye involvement

Instruct patient about S&S of serious illness or complications
• Increased fever
• Cough
• Becoming more ill
• Signs of skin infection

Skin infestations: Lice

Three types of lice infest humans:
• Pediculus humanus var corporis (human louse)

2-4mm, grayish-white, flattened, wingless, and elongated with pointed heads

Overcrowding and poor sanitation

Skin infestations: Lice

Three types of lice infest humans:
• P. humanus var capitis (human head louse)

Wider and shorter, resemble a crab

Eggs (nits) laid by female

Affects all socioeconomic groups
• Phthirus pubis (pubic or crab louse)

Sexually or close body contact

Can be seen eyebrows, eyelashes, axillary hair, and back and chests

33% with lice have 2 nd STD

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

Lice

Assessment
• Subjective data

History of present illness
• Itching infected areas
• Fever, malaise in severe infection
• Exposure to lice
• Recent sharing of clothing, beds, combs/brushes
• Concurrent STD’s

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

Lice

Physical exam
• Excoriation of scalp
• Secondary bacterial infection, especially of scalp
• Weeping and crusting of skin
• Lymphadenopathy
• Small, red macules, papules on trunk
• Small,gray to bluish macules measuring <1cm on trunk(maculae ceruleae) from anticoagulant injected into skin by biting louse
• Nits on hairs
• Thick, dry skin, brownish pigmentation on neck, shoulder, back form chronic infection
• Signs of concurrent STD’s

Lice

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

Lice

• Use pediculicides

Pyrethrin liquid

Permethrin crème
• Treat sexual contacts

Administer medications for STD’s

Instruct patient/parent that itching may continue after treatment: do not re-treat without physician order

Lice

Instruct patient/parent to
• Remove nits
• Soak hair with equal parts warm vinegar and water
• If eyelashes or eyebrows, apply layer of petroleum jelly
• Soak combs and brushes in pediculicide for 1 hour
• Launder clothing/bedding in hot water; dry in hot drier if possible, discard clothing and linen if practical

Lice

Lice

• Iron seams of clothing
• Put socks over hands of small children at bedtime
• Cut fingernails short
• Put hats, coats, other non-launderable item away for at lest 72 hours
• Avoid hat sharing, combs, brushes

Skin infestations: Scabies

Highly contagious by the itch mite
Sarcoptes scabiei var hominis

Eggs are laid in burrows several millimeter in length

Not a vector for other infections

Transmitted by intimate personal or sexual contact; or by casual contact

Always consider when patient complains of rash with intense itching

Scabies

• Subjective data

History of current illness
• Intense itching, worse at night
• Rash
• Previous treatment for current problem
• Exposure to scabies

Medical history

Previous infestations

Allergies
 medications

Scabies

• Physical exam

Rash
• Red papules, excoriations, and occasionally vesicles
• More common in interdigit web spaces, wrists, anterior axillary folds, periumbilical skin, pelvic girdle, penis, ankles
• For infants and small children, soles, palms, face, neck, and scalp are often involved
• Patient scratching
• Signs of infection of lesions

Scabies

Interventions
• Contact isolation
• Advise patient/parent to avoid school/work until one treatment completed
• Administer analgesics, antihistamines, antibiotics
• Use pediculicides

Pyrethrin liquid

Permethrin crème

Scabies

Instruct patient/parent
• Instruct patient/parent that itching may continue after treatment: do not re-treat without physician order
• Launder clothing/bedding in hot water; dry in hot drier if possible, discard clothing and linen if practical
• Put socks over hands of small children at bedtime
• Cut fingernails short
• Put hats, coats, other non-launderable item away for at least 72 hours

Skin infestations: myiasis

Invasion of living, necrotic, or dead tissue by fly larvae (maggots)

Do not carry infectious agents, but can cause significant disease of the tissues

Skin infestations: myiasis

Assessment
• Subjective data

History of present illness
• Skin lesions or wound

Social History

Living conditions
• Ability to care for self
• Substance abuse
• Previous myiasis
• Medications
• Allergies

Myiasis

Objective data
• Physical examination

Skin wound or lesion

Boil-like lesion

“creeping eruption” of open wounds

Poor hygiene: may see maggots in skin folds or on intact skin surface

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

Myiasis

• Apply petroleum jelly to cutaneous boils
• Instruct patient about prevention

Eradicate flies

Keep open wounds properly dressed

Stay indoors, away from fly-infested areas
• Referrals to Social Services or
Substance Abuse if needed

Tuberculosis






Mycobacterium tuberculosis, acid-fast bacillus (AFB)
Not highly contagious, requires close, frequent exposure for transmission
Droplet nuclei, which can remain in still air for days
Susceptibility of host usually determines whether infection occurs
TB occurs when symptoms occur and is infectious
2-10 weeks after infection, develop immunological response, allows healing and +PPD

Tuberculosis

Greatest risk of disease in the first 2 years after infection

Lung primary site

15% Extrapulmonary
• Kidney, Lymphatic, Pleura, Bones, Joints, and blood
(disseminated or miliary)

Diagnosed by one of two criteria:
• Culture of bacteria
• + PPD or S&S of TB, unsteady CXR

Noncompliance of medication regimen

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

Tuberculosis

History of present illness
• Fever and chills, night sweats
• Easy fatigability and malaise
• Anorexia, weight loss
• Hemoptysis
• Recent +TB skin test
• Foreign born or travel to high-prevalence country: Vietnam, Philippines, Mexico, Haiti,
China, Korea

Tuberculosis

History of present illness
• Resident or staff of nursing home, prison, or homeless shelter
• Alcoholic or other substance abuser
• Racial/ethnic minority:
African-American, Hispanic,
Alaska native,
American Indian

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

Tuberculosis

Objective data
• Physical exam
• Healthy or ill appearance
• Chest: decreased breath sounds
• Fever
• Signs of underlying disease

Tuberculosis

Diagnostic Procedures
• PPD: induration 5mm or
> +if HIV, 10mm + all others
• CXR: infiltrate, especially of upper lobes
• Sputum for AFB: 3 successive earlymorning
• LFT: obtain before starting INH

Tuberculosis

Interventions
• Decrease transmission of disease

Isolate coughing patient, preferably in negative pressure

Teach to cover nose and mouth

Educate to dispose of tissue and wash hands

Isolate at home first 2 weeks of therapy; considered infectious until
• 14 days of directly observed therapy
• Decrease cough and afebrile
• Three consecutive negative AFB smears

Tuberculosis

Surgical masks are helpful for patient; not effective for health care staff or family

Ventilate living quarters with fresh air: 20 times every day

Unnecessary to dispose of clothes, to wear caps, gowns, gloves
• Encourage patient/significant other for reading of TB skin test, compliance with medication regimen
• Reportable disease

Tuberculosis

Administer and educate about meds
• All patients with active disease should have directly observed therapy
• Preventive therapy for 6 months

HIV with PPD +5> :treat 12 months

Household members and close contacts of newly diagnosed patient

Recent TB converter

IV drug users known to be HIV- with PPD induration of 10mm>

Tuberculosis
• Medications: preventative and therapeutic 4drug regimen

Isoniazid

Pyridoxine: prevents peripheral neuropathy from isoniazid

Rifampin: discolors

Pyrazinamide

Ethambutol

Encourage HIV testing

Provide Social Service in needed

Varicella (chickenpox)

Highly contagious caused by VZV

Direct contact, droplet, or aerosol from skin lesion fluid

Incubation 14-16 days

Contagious period start 1-2 days before rash and ends when all lesions are crusted

90% cases children <3

Varicella (chickenpox)

Adolescents, adults, and immunocompromised at risk for severe disease

<5% of cases >20 years, but 55% of deaths

Complications
• Bacterial infection, pneumonia, DIC, renal failure, and encephalitis
• 31% mortality to neonates born to infected mothers

Chickenpox- Assessment

Subjective data
• History of present illness

Exposure to chickenpox

Prodrome: 48 hours before rash: fever, malaise, headache, rash often with itching
• Medical history

Immunizations

Pregnant or trying to become pregnant

HIV, cancer, or other immunocompromised state

Allergies

Medications

Chickenpox

Objective data
• Physical exam
• Rash, typically 250-500 lesions

Starts on trunk as faint, red macules

Becomes teardrop vesicles on a red base, which dry and crust over

New crops appear over several days

Palms and soles are spared

Vesicles may occur in mucous membranes, rupture, and become shallow ulcers

Chickenpox

Objective data
• Fever, low grade
• Skin excoriations form scratching
• Signs of lesion infection: red, swollen, tender
• Altered mental status
• Dehydration
• Cough

Chickenpox
• Diagnostic procedures

Generally none

Chickenpox

Interventions
• Provided respiratory and contact isolation
• Isolate patient/significant others from waiting room
• Advise to avoid school/work until all lesions are crusted

Chickenpox

Interventions
• Recommend immunization of high-risk contacts

VZIG
• Post exposure prophylaxis
• Immunocompromised (HIV, AIDS, cancer, steroid therapy)
• Effective up to 96 hours after exposure
• Susceptible health care workers should be vaccinated

Chickenpox

Administer medications
• Acetaminophen
• Never use ASA (risk of Reye’s syndrome)
• Antihistamines
• Antivirals to older children will lesson the severity

To prevent infection of lesions
• Suggest putting socks over small children’s hands at bedtime to decrease scratching and excoriation

Chickenpox

• Cut fingernails short
• Topical backing soda paste or baths and calamine lotion
• Encourage parents to have children immunized

Chickenpox

Instruct patient/parent about S&S or serious illness
• Increased fever
• Cough
• Becoming more ill
• Signs of skin infection

Adrenal Crisis

Addison’s Disease (adrenal insufficiency)

Adrenal cortex ceases to produce glucocorticoid and mineralocorticoid hormones

Acute stressors, infection, hemorrhage, trauma, surgery, burns, pregnancy, or abrupt cessation for
Addison’s disease

Life threatening because hormones are necessary for the maintenance of blood volume, BP, and glucose homeostasis

Adrenal Crisis

Suspect with patients who have septicemia with unexplained deterioration, major illness who have abdominal, flank, or chest pain, with dehydration, fever, hypotension, or shock, and adrenal hemorrhage

Death because of circulatory collapse and hyperkalemiainduced dysrhythmia

Adrenal Crisis- Assessment

• History of present illness

Rapid worsening of symptoms of adrenal insufficiency

Fever

Nonspecific abdominal pain; may simulate acute abdomen

N&V

Adrenal Crisis- Assessment

Medical history
• Primary adrenal insufficiency
• Hyperpigmentation of skin
• Weakness, fatigue, lethargy
• Anorexia and weight loss
• Nausea, vomiting, diarrhea
• Salt craving
• Postural hypotension
• Allergies
• Medications

Adrenal Crisis

Physical examination
• Appears acutely ill
• Signs of shock as a result of dehydration

Hypotension, but may have warm extremities

Tachycardia

Tachypnea

Orthostatic hypotension

Adrenal Crisis

• Fever
• Altered mental status, confusion
• Hyperpigmentation of skin
• Very soft heart sounds

Adrenal Crisis

Diagnostic procedures
• CBC: anemia of chronic disease
• Electrolyte levels

Hyponatremia

Hyperkalemia
• Blood glucose level: hypoglycemia
• BUN: elevated (azotemia secondary to dehydration)
• UA

Adrenal Crisis

UA

Blood cultures

Plasma cortisol level

ECG
• Low voltage
• Flat or inverted T wave
• Prolonged QT, QRS, or PR intervals
• CXR
• CT of abdomen: if diagnosis not clear

Adrenal Crisis

Interventions
• O2, IV, monitor
• VS, with Orthostatic VS
• I&O
• Weight
• Monitor signs of adequate tissue perfusion: capillary refill and skin temperature and moisture

Adrenal Crisis
• Medications

Dexamethasone

Hydrocortisone

Corticotropin

Glucose

Vasopressors
• Monitor electrolytes
• Monitor cardiac function
• Prepare for admission
• Instruct about disease process

Diabetic Ketoacidosis

Result of insulin deficiency

Typically Insulin-dependent

Hyperglycemia promotes osmotic diuresis with dehydration, hyperosmolality, and electrolyte depletion

Free fatty acids are converted to ketones bodies, which release hydrogen ions, thereby contributing to metabolic ketoacidosis

Diabetic Ketoacidosis

Infection and stressful events are usual precipitation factors, along with omission of insulin and new-onset diabetes

Goal is a gradual return to normal metabolic balance

Complications of therapy: cerebral edema, hypoglycemia, and electrolyte imbalance may contribute to death

Diabetic Ketoacidosis-
Assessment

Subjective data
• History of present illness

Onset: gradual, 24 hours to 2 weeks

Preceding bacterial or viral illness, current infectious process, or significant stress

N&V

Abdominal pain, usually generalized





Fever
Polyuria, polydipsia, polyphagia
Lethargy, weakness, and fatigue
Decreasing LOC and altered mental status
Weight loss

Diabetic Ketoacidosis

Medical history
• Administration of insulin or oral hypoglycemic agents
• Discontinuance or decreased dose
• Other medications
• Allergies
• Previous similar episodes

Diabetic Ketoacidosis

Objective data
• Physical examination

Tachycardia

Orthostatic or frank hypotension

Kussmaul’s respirations if pH <7.2

Dry, hyperthermic, flushed skin, poor turgor, dry mucous membranes

Acetone breath odor

Confusion, coma, and decreased mental status

Diabetic Ketoacidosis

Diagnostic procedures
• Serum glucose level: >300
• Electrolyte levels

NA, CL, and HCO3: decreased

K: normal or elevated initially; falls rapidly during treatment

Serum phosphate: elevated 6-7 as a result of insulin deficiency and prerenal azotemia; total body phosphate depletion as a result of osmotic diuresis

Diabetic Ketoacidosis

Diagnostic procedures
• Serum osmolality: >310
• Serum acetone level: elevated
• BUN and creatinine levels: normal unless advanced renal disease or severe dehydration is present
• ABG

Normal PaO2

Metabolic acidosis and anion gap acidosis: pH<7.3;
HCO3<15

Respiratory alkalosis

Diabetic Ketoacidosis

UA: increase glucose and ketone levels

CXR

ECG

CBC: WBC >25,000 if infection present

Cultures as indicated

Diabetic Ketoacidosis

Interventions
• Establish two IV’s, one for NS
• O2, airway, breathing, circulation
• Administer regular insulin as prescribed

Glucostabilizer Program

Diabetic Ketoacidosis

Interventions
• Administer HCO3 as prescribed: if pH
<7.0
• K: added to IV if < 5.5
• Add Dextrose when blood glucose <250
• Administer phosphate (usually several hours into treatment)

Diabetic Ketoacidosis

Administer antibiotic or antiemetics as ordered

Insert urinary catheter; NG if decrease LOC

VS every 15 to 60 until stable

Monitor glucose every hour and K every 2 hours

I&O

Cardiac monitor until stable, Neuro checks
(cerebral edema from too-rapid resolution of acidosis and hypoglycemia)

Diabetic Ketoacidosis

May need to restrain if confused

Review preventive fluid therapy
• Must keep self hydrated, during any illness, no matter how minor
• If unable to retain fluids, contact physician immediately

Teach to identify and manage symptoms of hypoglycemia or hyperglycemia

Hyperglycemic Hyperosmolar
Nonketotic coma

Type II, non-insulin-dependent

Profound dehydration because of hyperglycemia and resultant osmotic diuresis

Unable to drink

Ketoacidosis does not develop because there is enough endogenous insulin present to inhibit ketogenisis

Precipitated by infection, stroke, or sepsis

Hyperglycemic Hyperosmolar
Nonketotic coma

Initial presentation with new-onset type II DM

Dehydration predisposes to widespread thrombosis and DIC

Mortality rate is high despite aggressive therapy, probably because patient is usually elderly with impaired renal, cerebral, or cardiac function

Illness rarely occurs in infants and children

DKA

Serum Glucose:
HIGH
 pH: <7.3





HCO3: <15 mEq/L
Serum Ketones: +
Ketonuria: +
Osmolarity: varies
Serum Insulin: decreased vs. HHNK







Serum Glucose:
VERY HIGH pH: >7.3
HCO3: >20 mEq/L
Serum Ketones: -
Ketonuria: -
Osmolarity: High
Serum Insulin: can be normal

NKH- Assessment

Subjective data
• History of present illness

Insidious onset from days to weeks

Recent illness or infection

Thirst

Reduced fluid intake

Polyuria or oliguria
• Medical history

Non-insulin-dependent diabetes

Elderly patient with undiagnosed diabetes

Medications: oral hypoglycemic agents, diuretics

Allergies


Objective data
• Physical examination

Hypotension and Tachycardia

Normal respirations

Confusion and altered mental status are most prominent physical findings; may be comatose

Dry skin and mucous membranes: dehydration

May have fever

Seizures

Hemiparesis/hemisensory deficits

HHNK

• Serum glucose level: >800mg/dl, often
>1000
• Serum osmolality:: >350mOsm/kg
• Hypernatremia resulting from dehydration
• K: normal to high initially; hypokalemia develops with insulin therapy
• BUN and creatinine: elevated as a result of prerenal azotemia

HHNK

Diagnostic procedures
• ABG’s

Normal PaO2

Mild metabolic acidosis

Serum ketone level: normal or slightly elevated

UA: elevated glucose level

CXR

ECG

Cultures of blood, urine, sputum if infection source not obvious

Creatine kinase (CK) elevated as a result of rhabdomyolysis

HHNK

• O2, airway, breathing, circulation
• Assist with intubation if PaO2 .70
• IV for hydration

Adults: NS at 500-1000ml/hr until blood pressure stabilizes

Child: NS (20 ml/kg bolus if hypotensive) to prevent cerebral edema from too-rapid correction of hyperosmolality

NKH
• K+ as needed
• Low dose heparin
• Add dextrose when glucose <300
• May need to restrain confused patient
• Continually reassess neurological status, and monitor for signs of cerebral edema and seizures
• I&O, FC
• Monitor for signs of fluid overload (major problem in elderly) or dehydration; assess breath sounds as indicated for pulmonary edema
• Discuss disease process

Hypoglycemia

Glucose <50
• most common endocrine emergency

<35 mg/dL, the brain in unable to extract O2 adequately, resulting in hypoxia and coma

Very young and very old are more susceptible

Mainly diabetes and alcohol ingestion, lack of glucose causes permanent brain dysfunction, any person with an altered LOC should be considered to have hypoglycemia until proven otherwise

Hypoglycemia- Assessment

History of present illness
• Rapid onset
• No recent food intake
• Alcohol ingestion within 36 hours followed by fasting
• Hunger, nausea
• Weakness, dizziness
• Lethargy
• Shakiness
• Anxiety
• Headache
• Altered mental status

Hypoglycemia

Medical history
• Diabetes
• Insulin: increased dosage (easily reversed)
• Oral hypoglycemic agents: long half-life
(difficult to reverse)
• Adrenal insufficiency
• Liver disease
• Propranolol, salicylates, sedatives
• Increase in physical exercise

Hypoglycemia

Physical exam
• Cool, diaphoretic skin, pale, dilated pupils
• Confusion, hypothermia
• Shallow respirations but normal rate
• Normal BP and pulse
• Combative behavior or coma, seizures
• Hemiplegia or other signs of stroke

Hypoglycemia

Diagnostic procedures
• Blood glucose level: <50
• Electrolyte levels: normal
• UA: normal
• ABG’s: normal pH
• Serum ETOH

Hypoglycemia

Interventions
• O2, VS, maintain airway, breathing, circulation
• Assist with intubation if PaO2 <70
• determine blood glucose level
• Administer thiamine IM or IV if malnourished
• Oral glucose if gag present
• D5w if unresponsive
• Give IV D50; if no response repeat; D25 if
<2yrs
• Give Glucagon IM or SC

Hypoglycemia

Interventions
• Monitor mental status continually
• May need to restrain combative patient
• Educate patient and significant others

Reinforce need to eat regularly

Carry quick glucose foods

Decrease insulin dosage if exercising

Avoid alcohol consumption while fasting, alcoholic need to eat when bingeing

Myxedema coma






Severe form of hypothyroidism
Marked impairment of CNS and cardiovascular decompensation
Recognition of this illness is hampered by its insidious onset and rarity
Winter, elderly women with HX of hypothyroidism
Precipitating factors include: serious infection
(pneumonia and UTI), sedative or tranquilizer use, stroke, exposure to cold environment, and termination or thyroid hormone replacement
Death is common, but can survive if prompt adequate care

Myxedema coma


History of present illness
• Recent illness
• Progressive decline in intellectual status
• Apathy, self-neglect
• Emotional labiality
• Anorexia
• Recent weight gain
Medical history
• Hypothyroidism or thyroid surgery
• Allergies
• Medications: thyroid replacement hormone, recent use of tranquilizers and sedatives

Myxedema coma

Objective data
• Physical exam

Decreased mental status

Depressed mental acuteness

Confusion or psychosis

Pale, waxy, edematous face with periorbital edema

Dry, cold, pale skin

Myxedema coma

Objective data
• Physical exam

Non-pitting extremity edema

Thin eyebrows

Deep, coarse voice

Scar form prior thyroidectomy

Vital Signs
• Hypothermia, usually above 95 F
• Bradycardia with distant heart sounds
• Hypoventilation, Hypotension

Myxedema coma

Diagnostic procedures
• Electrolytes: hyponatremia
• ABG’s: hypoxia and hypercarbia
• Thyroid studies: low thyroxine (T4), elevated thyrotropin (thyroid stimulating hormone [TSH])

Myxedema coma

ECG
• Low voltage
• Sinus bradycardia
• Prolonged QT interval
• CBC: anemia and decreased WBC
• BUN and creatinine: elevated
• Blood sugar: variable hypoglycemia
• CXR
• UA
• Obtain pretreatment plasma cortisol level

Myxedema coma

• Monitor airway, breathing, circulation, and other vital signs
• O2 as ordered
• IV, IV fluids

Hypertonic saline

Crystalloids

Whole blood

Myxedema coma

Interventions
• Meds as ordered

IV thyroid hormone

Glucocorticoid

Vasoconstrictors
• Rewarm patient

Use passive rewarming with blankets and increased room temperature

Avoid rapid rewarming

Be prepared for seizures

Thyroid storm

Extreme and rare form of thyrotoxicosis

High mortality

Untreated or inadequately treated hyperthyroidism, who experiences surgery, infection, trauma, or emotional upset; thyroid surgery; radioactive iodine administration

Cardiac decompensation with CHF (terminal event), CNS dysfunction, GI disorders

Life-threatening emergency

Thyroid Storm- Assessment

History of present illness
• Fever
• N&V&D
• Abdominal pain
• Worsening of thyrotoxicosis symptoms
• Anxiety
• Restlessness, nervousness, irritability
• Generalized weakness
• Possible coma
• Precipitation event or intercurrent illness

Thyroid storm

Medical history
• Thyrotoxicosis
• Thyroid disease
• Easy fatigability
• Weight loss
• Sweating
• Body heat loss and heat intolerance

Thyroid storm

Objective data
• Physical exam

Fever: temp may exceed 104

Tachycardia (120-200), systolic hypertension

Chest: crackles

Thyroid storm
• Warm, moist, velvety skin; becomes dry as dehydration develops
• Spider angiomas
• Tremulousness
• Delirium, agitation, confusion, coma
• Thin silky hair
• Enlarged thyroid gland with thrill or bruit

Thyroid storm
• Eye signs

Lid lag

Stare

Exophthalmos

Periorbital edema
• Hepatic tenderness or jaundice

Thyroid storm

Diagnostic procedures
• Cardiac monitoring/ECG: sinus tachycardia wand atrial fibrillation/flutter
• Thyroid function studies

T4: elevated

Triiodothyronine (T3): elevated resin uptake

TSH: decreased
• Serum cholesterol level: decreased

Thyroid storm

Diagnostic procedures
• Electrolyte levels
• Serum glucose increased
• CBC: increased WBC with left shift
• BUN or creatinine level
• Hepatic studies: increased liver enzymes
• UA
• Cultures and radiographs and indicated

Thyroid storm

Interventions
• O2, airway, breathing, circulation, VS
• IV of D5 and isotonic solution
• Cardiac monitoring

Meds as ordered
• Vasopressors
• Antipyretic
• D50
• Propylthiouracil every 8 hours
• Glucocorticoids, hydrocortisone
• Iodine: lugol’s solution, potassium iodide
• Digitalis, propranolol
• Antibiotics
• Vitamins and thiamine
• Sedatives

Thyroid storm
• Use cooling blanket, cold packs
• Prepare patient/significant others for patient’s admission
• Explain procedures to patient/significant others