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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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Air-borne infectious micro-organisms, notably Staphylococci, may
be inhaled or transferred to the patient/client via wounds, intravenous cannula, etc. Patients/clients may also infect themselves directly from their
own micro-organisms. Food is a potential source of infection. Generally, if
non-absorbable gut antibiotics are prescribed, pathogen- free food must be
provided. Thoroughly cooked foods, canned foods and foods known to be
pathogen-free, such as cereal, should be served with sterile utensils on
sterile trays. If these facilities are unavailable, the diet should consist only
of food that has been well-cooked and foods known to have high bacterial
counts should be avoided. This means eliminating raw fruit and vegetables
from the diet.
Endogenous infection. The limiting of self-infection, which is the
major cause of infection in immuno-suppressed patients, is difficult. Good
patient hygiene and the restriction of invasive devices and procedures are
all useful, however.
Early detection of signs of infection in the immunosuppressed patient.
A thorough and continuing assessment of the patient is essential in
order to recognize the first signs of infection. The most common areas of
early infection include the lung, pharynx, ano-rectal area, skin and subcutaneous tissue. Unfortunately, signs and symptoms of infection are often
absent.
Investigations to establish the cause of infection include chest X-ray
and bacteriological and viral culture of blood, urine and sputum specimens
and of swabs obtained from any suspicious lesion.
As the progression of infection in the immuno-suppressed patient
may be rapid and widespread, the earliest sign of infection must be looked
for and appropriate anti-microbial therapy started immediately. If an infection is left untreated, fatality rates ranging from 18 % to 40 % can occur
within the first 48 hours.
Clinical nursing procedure guidelines: Protective isolation.
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Guidelines for visitors
Action
Rationale
1. The patient should be asked
to nominate close relatives and friends
who may then, after instruction, visit
freely. The patient or his or her
representative should inform casual
acquaintances or non-essential visitors
that they should avoid visiting during
the period of protective isolation
The incidence of infection increases
in proportion to the number of people
visiting. Large numbers of visitors
are difficult to screen and educate.
Unlimited visiting by close relatives
and friends diminishes the sense
of isolation that the patient may
experience
2. Any visitor with an infection or who
has been in contact with infection should
be excluded
Immuno-suppressed patients
are susceptible to infection
3. Children, unless very close relatives,
should be discouraged from visiting
Children are more likely to have been
in contact with infectious diseases which
can have serious consequences
if transmitted to an immuno-suppressed
patient
Guidelines in relation to food and drinks
Action
Rationale
1. Educate the patient to choose only
cooked food from the hospital menu
and to avoid raw fruit, salads
and uncooked vegetables, whether
on the menu or brought in by visitors
Uncooked foods are often heavily
colonized by micro-organisms,
particularly Gram-negative bacteria
2. Food brought into the hospital by visitors must be:
• Obtained from well-known, reliable
firms.
• In undamaged, sealed tins and packets.
Within expiry date
Correctly processed and packaged foods
are acceptable as they should not
be infected
3. Water should be boiled and allowed
to cool in a covered jug
The safety of available water supplies
needs to be certain. Even where tap water
is safe to drink, it can become colonized
by organisms, particularly Gram-negative
organisms found in the plug hole of sinks
or overflow outlet, when water containers
are being filled
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Action
Rationale
4. Foods and drinks that have been
pasteurized or contain a high sugar
concentrate are usually safe. Once opened
they should be poured into a clean jug
and drunk on the same day
Bottled, concentrated fruit drinks
containing sugar and sealed containers
of fruit juices are usually pathogen-free
until opened. Pathogens do not survive
easily in high sugar concentrates
Exercise. Discharging a patient who is immuno-suppressed
In section 4.1, nursing procedure guidelines were identified for discharging a patient who has been barrier nursed. A person who has been
immuno-suppressed remains immuno-compromised for some time afterwards, even though the white cell count may be considered high enough
for discharge home. As a result, the patient/client needs additional informational and education about the precautions he or she needs to follow.
Using the broad headings given below, try to work out the advice you
would give to a patient who is being discharged from hospital following
protective isolation. Your advice should include an appropriate rationale.
• Going out, particularly in crowded areas.
• Pets and animals.
• Diet and foodstuffs.
• Early signs and symptoms of infection.
4.3. GUIDELINES RELATING TO THE CARE OF PEOPLE
WITH HUMAN IMMUNO-DEFICIENCY VIRUS (HIV INFECTION)
AND ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)
This section deals with HIV and AIDS. The information is taken
from the manual HIV prevention and care: teaching modules for nurses
and midwives. WHO Global Programmer on AIDS. It will provide you
with the basic information only and is by no means complete. You are advised to seek further training when dealing with people infected with HIV,
people who have AIDS and their families and friends.
Introduction. HIV infection is a condition which generates fear and
misunderstanding. As members of the community, nurses are likely to
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share the same fears and misconceptions as other members of the public. It
is essential, therefore, to have a clear understanding of your own fears and
concerns about AIDS. Only then will it be possible to separate unfounded
fears from real ones. As a nurse, you should understand the scope of the
AIDS pandemic and how HIV is transmitted. This is the first step in preparing you to be an informed professional with the expertise needed to address the problems of HIV infection.
Exercise
Ask yourself the following questions:
• What have you heard about HIV infection and AIDS?
• Describe the different ways that people in your community say
that HIV infection is spread
• How do you think HIV infection is spread?
• When you think about providing care for a person with AIDS,
what is your reaction?
Background information. Knowing more about the discovery of
AIDS, ways of transmission and measures to prevent it from spreading in
the health care setting, will help you to have a clear idea about it yourself
and to explain to patients and clients.
The disease that we now call AIDS was first recognized in the early
1980 in countries in the developed world (in the United States, Australia,
New Zealand, and Europe) among male homosexuals. In other countries,
AIDS was diagnosed primarily in heterosexual men and women. Because
AIDS was affecting individuals who were sexually active, scientists concluded that the cause was probably a sexually transmitted agent.
As scientists continued to study the disease, it was observed that
many cases also occurred among:
• Injecting drug users.
• Recipients of blood transfusions.
• Children and adults with hemophilia.
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The factor that these people had in common was that all had received
blood or blood products (many injecting drug users share the same injecting equipment).
Babies whose mothers had been infected were also found to have this
disease, indicating perinatal transmission.
Following further scientific studies, the transmission pattern for the
infective agent became evident. Only people who were sexually active, or
who had received injections of someone else’s blood or who were born to
infected mothers, developed the disease.
When these facts became known, scientists concluded that AIDS was
caused by a blood-borne agent, probably a virus, which was transmitted to
sexual partners, or to people who had received blood or blood products, as
well as to the unborn or newly born babies of infected mothers.
We now know that there are at least two different major types of the
virus, one called HIV-1 and the other known as HIV-2. HIV-1 is the principal AIDS virus, while HTV-2 is found mainly in West African countries.
Scientists also studied thousands of people living or working with
people who had developed AIDS. They found that it was only the sexual
partners of infected individuals who became infected and subsequently developed AIDS. From this it became clear that HIV infection is not acquired by casual social contact.
HIV transmission. HIV can be transmitted:
• Sexually, through unprotected intercourse or through unprotected
contact with infected blood, semen, or cervical and vaginal fluids. This is
the most frequent mode of transmission. HIV can be transmitted from any
infected person to his or her sexual partner (man to woman, woman to
man, man to man and, but less likely, woman to woman).
• During transfusion of blood or blood products obtained from donor
blood infected with HIV.
• Using injecting or skin-piercing equipment contaminated with HIV.
• From a mother infected with HTV to her child, during pregnancy,
during labor, or following birth as a result of breast-feeding.
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HIV cannot be transmitted by:
• Coughing or sneezing.
• Handshakes.
• Insect bites.
• Work or school contacts.
• Touching or hugging.
• Using toilets.
• Water or food.
• Using telephones.
• Kissing.
• Swimming pools.
• Public swimming pools.
• Sharing cups, glasses, plates and other eating and drinking utensils.
From the above list you can see that the most common method of being infected with HTV is from sexual intercourse, and today most individuals who have become infected have done so as a result of sexual exposure
to the virus.
It is important to stress at this point that in the great majority of work
activities, nurses are not at risk of becoming infected by people with whom
you work.
Important facts:
• AIDS is caused by a virus called the human immuno-deficiency vi-
rus (HIV).
• People who are infected with HTV often have no symptoms of dis-
ease for many years and can therefore, infect others without realizing that
they themselves are infected.
• AIDS refers to specific clinical manifestations seen during the later
part of HIV infection, when people are ill as a result of this infection.
• By mid-2015, 4,5 million are estimated by WHO to have reached
the later stages of HIV infection known as AIDS. In addition to the people
who have AIDS, WHO estimates that 14 to 15 million men, women and
children have been infected with HIV.
• Most, if not all, individuals infected with HIV will eventually de-
velop AIDS. The average time between HIV infection and the onset of
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AIDS is approximately 10 years for HIV-1. In both cases, this period may
be significantly shorter in developing countries where nutritional status
may be low and access to effective treatment limited. It is much shorter in
children with HIV infection.
• Although many of the opportunistic diseases seen in AIDS can be
managed, there is presently no cure for AIDS. According to our present
knowledge, most people with AIDS will eventually die of the disease.
• Although scientists all over the world are working on developing
a vaccine to prevent HIV infection, it may be many years before one is
available. Prevention is only possible at present, therefore, through education resulting in non-risky behavior. Nurses, midwives and other health
workers have a critical role to play in teaching their patients, clients and
fellow citizens how HIV is and is not transmitted, and how people can protect themselves against infection.
HIV infection and related illness.
The immune system. The immune system is the body's defense
against infections by microorganisms that have been able to get past the
skin or the mucous membranes and which can cause disease. The immune
system produces antibodies to neutralize micro-organisms and activates
special blood cells which work to kill and remove these organisms from
the body. When the immune system is not functioning as it should, the
person is described as having an immuno-deficiency. HIV infects special
cells in the immune system called lymphocytes (T4 helper cells) and monocytes, eventually destroying these cells. This slowly leads to a persistent,
progressive and profound impairment of the immune system, making an
individual susceptible to infections and conditions such as cancer.
There are other causes of either temporary or permanent immunodeficiency. These include:
• Congenital defects in the immune system — primary immune dys-
function.
• Immune dysfunction secondary to drugs (for example, those used
in immuno-suppressant therapy or anti-cancer drugs), cancers, malnutrition, irradiation (both accidental and therapeutic), and other infections, especially with other viruses.
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The nervous system. HTV infects both the central and peripheral
nervous system early in the course of infection, causing a variety of neurological and neuropsychiatric conditions. The impairment of the immune
system also leaves the nervous system vulnerable to opportunistic infections and cancers.
Opportunistic disease. An opportunistic disease is one which normally would not be a problem because of the body's ability to control it
with the immune system, but which can become a major problem when
immuno-deficiency occurs. Consequently, opportunistic diseases occur only in individuals whose immune system is depressed.
There are many micro-organisms that commonly inhabit the body
without causing any illness. When the immune system is depressed, however, they can cause serious problems. One example is Candida, a fungus
found in the mouth of most people but only causing “thrush” when the
immune system is depressed and not able to control the growth of the oral
candida. Pneumocystis carinii, found in the lungs without causing any illness, causes pneumonia in people with immune-deficiency. The tubercle
bacillus (Mycobacterium tuberculosis'), also commonly found in the lungs,
can reactivate when the immune system is depressed, causing pulmonary
tuberculosis, a common opportunistic infection seen in people with HTV
infection. Another common example in Africa is Cryptococcus neofor-
mans (also known as Filobasidiella neoformans) which can cause meningitis in an immuno-deficient person.
HIV infection. HIV infection progresses through several stages. It
begins when an individual becomes infected with the virus. As said before,
HIV infection causes a progressive impairment of both the immune and
nervous systems. Over time, as this impairment worsens, it begins to show
itself as symptoms and the early, middle and late manifestations of HIV infection can therefore be classified. Once infected, the person is infectious —
that is, able to transmit the virus to other people — for life.
Acute seroconversion illness. Within three to eight weeks after infection, some (but not all) people develop an acute illness lasting two to three
weeks, with symptoms such as fevers; rash, joint and muscle pain; swollen
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lymph glands; diarrhea and sore throat. Symptoms may be mild and will
eventually disappear completely. This self-limiting condition is known as
an acute seroconversion illness. During this period, the virus continues to
reproduce itself inside the body and the person's immune system responds
by developing antibodies to the virus. Six to 12 weeks after infection, it is
usually possible to detect HIV antibodies in the blood. Unlike antibodies to
most other organisms, these antibodies do not destroy the virus effectively.
In some infected people, antibodies cannot be detected for six months or
longer, yet they are still infected and infectious.
Asymptomatic infection. The person may remain asymptomatic and
feel and appear healthy for years, even though he or she is infected with
HTV. During this asymptomatic period, the person remains infectious
(able to transmit the virus to others via sexual, blood-borne and perinatal
transmission). As the virus continues to replicate, progressive damage to
both the immune and nervous systems results over time. If the person’s
blood is tested during this stage, it will test positive for HTV antibodies.
Some individuals will have persistently enlarged lymph nodes, known as
persistent generalized lymphadenopathy (PLG) during the asymptomatic
stage of HIV infection.
Early symptomatic illness. Many individuals eventually develop
a variety of indicators of ill health due to HIV infection. This is without
developing AIDS-defining opportunistic infections or secondary cancers.
These constitutional symptoms and signs are sometimes referred to as the
AIDS-related Complex (ARC). These symptoms include oral thrush, diarrhea, weight loss, low-grade intermittent fevers and night sweats, a variety
of skin rashes and loss of energy. Various fungal diseases (for example,
tinea infections) or viral diseases (for example, shingles) may be seen and
individuals feel chronically ill during this stage of HTV infection.
Late symptomatic illness: AIDS. Eventually, individuals will have episodes of AIDS-specific opportunistic diseases, such as Pneumocystis ca-
rinii pneumonia, encephalitis caused by Toxoplasma gondii, and severe
and chronic diarrhea caused by Cryptosporidia and Microsporidia.
Pulmonary tuberculosis is increasingly recognized as one of the most
common opportunistic diseases associated with HIV infection, especially
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in the developing world. Opportunistic cancers, such as Kaposi’s sarcoma
and undifferentiated В-cell lymphomas, may also be seen. In addition to
the above, there will be significant weight loss and both neurological and
neuropsychiatric syndromes may be present. This end-stage of HIV infection is referred to as AIDS. Patients in this stage will eventually become
terminally ill and die.
Serological testing for HIV infection. Any blood test used to detect
HIV infection must have a high degree of sensitivity (the probability that
the test will be positive if the person is infected) and specificity (the probability that the test will be negative if the person in uninfected). No antibody test is ever 100 % sensitive and specific, therefore all positive test results should be confirmed by retesting, preferably by a different method, if
available. HIV antibody tests usually show as positive within three months
of the individual being infected with the virus. In some individuals, however, the test may not be positive until six months or longer after infection,
although this would be considered unusual.
HIV tests have been developed to be especially sensitive, consequently, a positive result will sometimes be obtained, even when there are
no HIV antibodies in the blood. This is known as a false positive, and because of this, all positive results must be confirmed by another test method. A confirmed positive result means that the individual is infected
with HIV.
A false negative result occurs when the blood tested gives a negative
result for HIV antibodies when it should have shown a positive result, as
the person is infected. The likelihood of a false negative test result must be
discussed with an individual if his or her history suggests behavior likely
to put the person at risk of HIV infection. In this situation, repeated testing
over time may be necessary before they can be reassured that they are not
infected with HIV. The most frequent reason that a false negative test result has been obtained is that the individual is newly infected and is not yet
producing HIV antibodies. It is important, however, to remember that
someone who has tested negative because they are not infected with HIV,
can become infected immediately afterwards.
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