Infectious Diseases Transmitted Through AlimentaryTract ... · •Nursing interventions:...

Infectious Diseases Transmitted Through AlimentaryTract and

Nursing Care

Cuneyt MIRZANLI

Istanbul Gelisim University

• Gastrointestinal infections are viral, bacterial or parasitic infections that usually cause gastroenteritis,

• An inflammation of the gastrointestinal tract involving both the stomach and the small intestine.

• Symptoms include diarrhea, vomiting and abdominal pain.

• Dehydration is the main danger of gastrointestinal infections,

• so rehydration is important,

• but most gastrointestinal infections are self-limited and resolve within a few days

Prevention / Treatment

• The best ways to prevent gastrointestinal infection include:

• Proper hand-washing

• Disinfecting of contaminated surfaces

• Washing of soiled articles of clothing

• Identifying infected patients as soon as possible to implement extended infection control

• There are no vaccines for most gastrointestinal infections.

Enteric Precautions

• What are enteric precautions?

• Some germs are easily spread to other patients by direct or indirect touch.

• Enteric precautions are a way of preventing this spread.

• Direct contact means physical contact between people, often with the hands.

• Indirect contact means contact with a contaminated object, such as toys, clothing, or surfaces.

• Often this happens when hands with germs on them touch a surface,

• which is then touched by someone else.

• The gastrointestinal tract is the route for the entry of fluids and nutrients into the body.

• Diseases of this system cause gastro intestinal symptoms, and are likely to effect nutritional status through impairing function.

Gastroenteritis

• Self-limiting inflammation of the stomach and small intestine.

• Intestinal flu, traveler's diarrhea, viral enteritis and food poisoning.

Pathophysiology

• The bowel reacts to the various causes of gastroenteritis with increased fluid that can't be absorbed.

• This results in abdominal pain, vomiting, severe diarrhea and secondary depletion of intracellular fluid.

• Dehydration and electrolyte loss occur.

Causes

• Amebae, most commonly Entamoeba histolytica

• Bacteria, such as Staphylococcus aureus, Salmonella, Shigella, Clostridium botulinum, Clostridium perfringens, and Escherichia coli

• Parasites, such as Ascaris, Enterobius, and Trichinella spiralis

• Viruses, such as adenoviruses, echoviruses, and coxsackieviruses

• Drug reactions from antibiotics

• Enzyme deficiencies

• Food allergens

• Ingestion of toxins, such as poisonous plants

Incidence

• Gastroenteritis occurs at any age.

• This disorder is the major cause of morbidity and mortality in underdeveloped nations.

• The fifth most common cause of death among young children.

• can be life-threatening in elderly patients.

Complications

• Severe dehydration

• Electrolyte imbalance

Physical findings

• Slight abdominal distention

• Poor skin turgor (with dehydration)

• Hyperactive bowel sounds

• Decreased blood pressure

• Nausea

• Vomiting

• Diarrhea

Skin Turgor

• A decrease in skin turgor is indicated when the skin (on the back of the hand for an adult or on the abdomen for a child) is pulled up for a few seconds and does not return to its original state.

• A decrease in skin turgor is a late sign of dehydration.

Treatment

• General:

• Supportive treatment for nausea, vomiting and diarrhea

• Diet:

• Rehydration

• Initially, liquids as tolerated

• Electrolyte solutions

• Avoidance of milk products

• Activity:

• As tolerated (encourage mobilization)

• Medications:

• Antidiarrheal therapy

• Antiemetics

• Antibiotics

• I.V. fluids

Nursing interventions

• Allow uninterrupted rest periods.

• Replace lost fluids and electrolytes through diet or I.V. fluids.

• Give prescribed drugs.

• Monitoring:

• Intake and output of fluid

• Vital signs

• Signs of dehydration

• Electrolytes

Food poisoning

• Foodborne illnesses are caused by ingestion off foods containing microbial and chemical toxins or pathogenic microorganisms.

• The diagnosis of specific food poisoning syndromes is suggested by the clinical presentation,

• the incubation period from exposure to onset of symptoms and the food consumed.

• When gastrointestinal symptoms develop 1 to 16 hours after exposure, the likely agents include Staphylococcus aureus and Clostridium perfringens.

• Vomiting is the dominant feature of S. aureus infection.

• Abdominal cramps and diarrhea are most prominent in C. perfringens food poisoning.

• Diarrhea following a slightly longer incubation period is typical of viral foodborne illness, particularly Norovirus and

• enterotoxin-producing bacteria, including enterotoxigenic E. Coli, Vibrio cholerae and other Vibrio species.

• Bacterial infections of the gastrointestinal tract are due to mostly Salmonella, Shigella, Clostridium jejuni and Yersinia enterocolitica, bacteria.

• These infections follow a longer incubation period and are marked by more prominent signs of colonic inflammation or systemic illness.

• Nausea, vomiting, diarrhea and paralysis results from exposure to one of three distinct botulinum toxins, A, B, and E,

• produced when Clostridium botulinum spores germinate in food in an anaerobic environment.

• Gastrointestinal symptoms occur before the onset of neurologic symptoms in about 50% of patients with acute foodborne botulism.

THERAPY

• Nonspecific therapy:

• Most food poisoning syndromes are self-limited and for the majority the nonspecific supportive therapy is all that is required.

• Exceptions include botulism, some enteric infections in infants and compromised hosts.

• The mainstay of treatment is fluid and electrolyte replacement to prevent and treat dehydration.

• The first step is to assess the degree of volume depletion by examining the skin turgor, mucous membranes, vital signs and mental status.

• Measuring postural changes in pulse and blood pressure is helpful in quantifying the volume loss.

• Slightly dry mucous membranes and thirst indicate mild dehydration (3% to 5% deficit;

• loss of skin turgor, very dry mucous membranes, postural pulse increases, and sunken eyes indicate moderate dehydration (6% to 9%);

• and the additional presence of weak pulse, postural hypotension, cold extremities, or depressed consciousness indicates severe volume depletion, above 10%.

WHO Recommendation

• One liter of the World Health Organization’s currently recommended replacement solution contains 75 mmol of sodium, 13.5 g of glucose, 20 mmol of potassium, 65 mmol of chloride and 10 mmol of citrate (as a bicarbonate source).

• Specific therapy:

• Antitoxin for Botulinum species borne toxins.

Brucellosis

• An acute febrile illness transmitted to humans from animals.

• Also known as undulant fever, Malta fever or Bang's disease.

Pathophysiology

• Transmitted through the consumption of unpasteurized dairy products or uncooked- undercooked contaminated meat and through contact with infected animals or their secretions or excretions.

Causes

• The nonmotile, non–spore-forming, gram-negative coccobacilli of the genus Brucella, notably B. suis (found in swine), B. melitensis (in goats), B. abortus (in cattle), and B. canis (in dogs).

Incidence

• Brucellosis is most common among farmers, butchers and veterinarians.

• Incidence is six times higher in men than in women.

• The disease occurs less commonly in children than in adults.

Complications

• Abscesses in the testes, ovaries, kidneys and brain (meningitis and encephalitis)

• Eczematous rashes, petechiae, purpura

• Orchitis

• Osteomyelitis

• Pleural effusions

• Pneumothorax

• Subacute bacterial endocarditis

Physical findings

• Excessive perspiration

• Chills

• Weakness

• Lymphadenopathy

• Hepatosplenomegaly

Diagnostic tests

• Definitive diagnosis is provided by three to six cultures of blood and bone marrow and biopsies of infected tissue (for example, the spleen).

• Erythrocyte sedimentation rate is increased.

• White blood cell count is normal or reduced.

Treatment

• High-calorie, high-protein diet

• Bed rest during the acute phase

• Antibiotics

• Antipyretics

• Corticosteroids


• Keep suppurative granulomas and abscesses dry.

• Properly dispose of secretions and soiled dressings.

• Reassure the patient that this infection is curable.

Patient teaching

• continuing medication for the prescribed duration

• preventing recurrence by cooking meat thoroughly and avoiding unpasteurized milk

• warning meat packers and other people at risk of occupational exposure to wear rubber gloves and goggles.

Enterobacteriaceae infections

• Variety of infections caused by a family of mostly aerobic, gram-negative bacilli

• Cause local and systemic infections, including invasive diarrhea resembling shigellosis and noninvasive, toxin-mediated diarrhea resembling cholera.

• Escherichia coli: the cause of most enterobacteria infections.

• Enterobacterial infections can be produced by bacteria that normally live in the human digestive tract without causing serious disease or by bacteria that enter from the outside.

• The most troublesome organism in this group is Escherichia coli.

• Other examples of enterobacteria are species of Salmonella, Shigella, Klebsiella, Enterobacter, Serratia, Proteus and Yersinia.

• When a patient becomes infected, incubation takes 12 to 72 hours.

• Noninvasive diarrhea results from two toxins produced by enterotoxigenic or enteropathogenic strains of E. coli.

• Toxins interact with intestinal fluid and promote excessive loss of chloride and water.

• The invasive form directly attacks the intestinal mucosa without producing enterotoxins, causing local irritation, inflammation and diarrhea.

• This form produces sporadic and outbreak-associated bloody diarrhea from hemorrhagic colitis,

• which can be life-threatening in infants and elderly people.

Causes

• Enterotoxigenic E. coli (major cause of diarrhea among those who travel from industrialized to developing regions).

• Ingestion of contaminated food or water

• Most common food source: chopped beef

• Some strains of E. coli that are part of normal GI flora but cause infection in immunocompromised patients and elderly.

• Transmission directly from an infected person.

Complications

• Bacteremia

• Severe dehydration and life-threatening electrolyte disturbances

• Acidosis

• Shock

Assessment

• History:

• Recent travel to another country

• Ingestion of contaminated food or water

• Recent close contact with a person who has diarrhea

• Abrupt onset of watery diarrhea

Physical findings

• Cramping abdominal pain with hyperactive bowel sounds

• Blood and pus in infected stools

• Vomiting and anorexia

• Low-grade fever

• Signs of dehydration, especially in children

• Rapid, speedy pulse

• Orthostatic hypotension

Diagnostic tests

• Laboratory:

• Cultures — growth of E. coli in a normally sterile location, including the bloodstream.

Treatment

• General:

• Enteric precautions

• Diet:

• Correction of fluid and electrolyte imbalances

• Initially, nothing by mouth

• Increased fluid intake (if appropriate)

• Avoidance of foods that cause diarrhea

• Small frequent meals until bowel function returns to normal

• Activity:

• As tolerated

• Medications:

• I.V. antibiotics

Nursing considerations

• Nursing diagnoses:

• Acute pain

• Deficient fluid volume

• Diarrhea

• Imbalanced nutrition: Less than body requirements

• Ineffective tissue perfusion: Cardiopulmonary, GI.

• Nursing interventions: • Institute contact precautions and use proper hand-

washing technique. • Replace fluids and electrolytes as needed. • Clean the perianal area and lubricate it after each

episode of diarrhea. • Give prescribed antibiotics. • During epidemics, screen all facility personnel and

visitors for diarrhea, • and prevent people with the disorder from having

direct patient contact.

Patient teaching

• General:

• the disorder, diagnosis, and treatment

• proper hand-washing technique

• the need to avoid unbottled water, ice, unpeeled fruit, and uncooked vegetables in other countries

• signs of dehydration and seeking prompt medical attention if these occur (if the patient is to be cared for at home).

Shigellosis

• An acute intestinal infection caused by the bacteria Shigella, a short, nonmotile, gram-negative rod.

• Also known as bacillary dysentery.

Pathophysiology

• Highly contagious aerobic, nonmotile, glucose-fermenting, gram-negative rods cause diarrhea after ingestion.

• Rods invade the colonic epithelium and produce enterotoxin, which enhances virulence.

Causes

• Transmission of Shigella bacteria through the fecal-oral route,

• by direct contact with contaminated objects

• or through ingestion of contaminated food or water.

Incidence

• Shigellosis is most common in children ages 1 to 4; many adults acquire the illness from children.

Complications

• Electrolyte imbalance (especially hypokalemia)

• Metabolic acidosis

• Shock

Physical findings

• Pus in stools

• Signs of dehydration


• Hyperactive bowel sounds

• Abdominal tenderness

• Abdominal distention

• Rapid pulse

Diagnostic test

• Microscopic examination of stools reveals mucus, red blood cells, and polymorphonuclear leukocytes.

• Direct immunofluorescence staining may reveal Shigella .

Treatment

• General: • Enteric precautions • Diet: • Low-residue • Replacement of fluids and electrolytes with I.V.

infusions of normal saline solution (with electrolytes)

• Medications: • Antibiotics ? • I.V. fluids



• Acute pain


• Diarrhea

• Hyperthermia

• Imbalanced nutrition


• Give prescribed I.V. fluids.

• Maintain enteric precautions until microscopic bacteriologic studies confirm that the stool specimen is negative.

• Patient teaching:

• General:

• the disorder, diagnosis, and treatment

• prevention of infecting others.

Salmonella infection

• One of the most common intestinal infections.

• Occurs as enterocolitis, bacteremia, localized infection, typhoid fever or paratyphoid fever.

• Typhoid fever most severe form; usually lasts from 1 to 4 weeks and results lifelong immunity,

• although patient may become a carrier.

Causes

• Gram-negative bacilli of the Salmonella bacteria. (member of the Enterobacteriaceae family)

• Typhoid fever: S. typhi

• Paratyphoid fever: S. paratyphi

• Enterocolitis: S. enteritidis

• Bacteremia: S. choleresis

Risk factors

• Usually, ingestion of contaminated water or food or inadequately processed food, especially eggs, chicken, turkey and duck.

• Contact with infected person or animal.

• Ingestion of contaminated dry milk, chocolate bars or pharmaceuticals of animal origin.

Complications

• Dehydration

• Hypovolemic shock

• Abscess formation

• Sepsis

Physical findings

• Fever

• Abdominal pain

• With enterocolitis, severe diarrhea

• Headache, increasing fever and constipation

• Rash

Treatment

• General: • Usually no treatment • Possible hospitalization for severe diarrhea • Diet: • Fluid and electrolyte replacement • High-calorie fluids • Activity: • As tolerated • Spesific therapy: • Antibiotics usually chloramfenicol, cephalosporins,

ampisillin for salmonella typhi infections.

Nursing diagnoses

• Activity intolerance

• Acute pain


• Diarrhea

• Hyperthermia


• Follow enteric precautions until three consecutive stool cultures are negative.

• Watch closely for signs of bowel perforation.

• Maintain adequate I.V. fluid and electrolyte therapy, as ordered.

• Provide good skin and mouth care.

• Applying mild heat to relieve abdominal cramps.

• Reporting salmonella cases to local public health officials.

Clostridium difficile infection

• A gram-positive anaerobic bacterium often resulting in antibiotic-related diarrhea

• Symptoms ranging from asymptomatic carrier states to severe pseudomembranous colitis caused by exotoxins. Toxin A and B

• Within 14 to 30 days of treatment, recurrence with the same organism possible in 10% to 20% of patients.

Pathophysiology

• Antibiotics may trigger toxin production.

• Both toxins cause electrophysiologic alterations of colonic tissue.

Causes

• Antibiotics that disrupt the bowel flora

• Enemas and intestinal stimulants

• Some antifungal and antiviral agents

• Transmission from infected person

Risk factors

• Contaminated equipment and surfaces

• Antibiotics

• Abdominal surgery

• Antineoplastic agents that have an antibiotic activity

• Immunocompromised state

Incidence

• C. difficile infection is most common in people in nursing homes and daycare facilities.

• This is one of the most common nosocomial infections. (About 20% of hospitalized patients taking antibiotics contract C. difficile infection.)

Complications

• Electrolyte abnormalities


• Toxic megacolon

• Colonic perforation

• Peritonitis

• Sepsis

• Hemorrhage

• Pseudomembranous colitis

Assessment

• History:

• Recent antibiotic therapy

• Abdominal pain

• Cramping

Physical findings

• Soft, unformed, or watery diarrhea (more than three stools in a 24-hour period) that may be foul smelling or grossly bloody

• Abdominal tenderness

• Fever

Diagnostic test results

• Laboratory:

• Stool culture may identify C. difficile .

Treatment

• General:

• Withdrawal of causative antibiotic

• Avoidance of antimotility agents

• Good skin care

• Diet:

• Well-balanced

• Increased fluid intake, if appropriate

• Activity:

• Rest periods, if fatigued

• Medications:

• Metronidazole

• Vancomycin

• If relapse and previous treatment was metronidazole, low-dose vancomycin may be effective

• Combination of vancomycin and rifampin




• Acute pain

• Fatigue

• Hyperthermia

• Imbalanced nutrition

• Impaired skin integrity

• Risk for deficient fluid volume


• Give prescribed drugs.

• Institute enteric precautions for those with active diarrhea.

• Wash your hands with an antiseptic soap after direct contact with the patient or his immediate environment.

• Make sure reusable equipment is disinfected before it's used on another patient.

Patient teaching

• General: • the disorder, diagnosis, and treatment • proper hand-washing technique • proper disinfection of contaminated clothing or

household items • adequate fluid intake • signs and symptoms of dehydration • medications and potential adverse reactions • complications and when to notify the practitioner • perirectal skin care.

Cholera

• Acute enterotoxin-mediated GI infection

• Transmitted through food and water contaminated with fecal material from carriers or people with active infections.

• Also known as Asiatic cholera or epidemic cholera.

Pathophysiology

• Humans are the only hosts and victims of V. cholerae, a motile, aerobic organism.

Causes

• The gram-negative bacillus Vibrio Cholerae.

Incidence

• The disease occurs during the warmer months and is most prevalent among lower socioeconomic groups.

• Cholera is common among children ages 1 to 5 in India but it's equally distributed among all age-groups in other endemic areas.

Complications

• Dehydration


• Metabolic acidosis

• Uremia

• Coma and death

Assessment

• History:

• Watery diarrhea

• Vomiting

• Intense thirst

• Weaknes

• Muscle cramps (especially in the extremities)

Physical findings

• Stools containing white mucus (rice-water stools)

• Loss of skin turgor, wrinkled skin, sunken eyes

• Cyanosis

• Tachycardia, tachypnea

• Absent peripheral pulses


• Fever

• Inaudible, hypoactive bowel sounds

Diagnostic test

• A culture of V. cholerae from feces or vomitus indicates cholera.

Treatment

• General:

• Enteric precautions

• Supportive care

• Diet:

• Increased fluid intake

• Medications:

• Rapid I.V. infusion of large amounts (50 to 100 ml/minute) of isotonic saline solution, alternating with isotonic sodium bicarbonate or sodium lactate

• Tetracycline




• Diarrhea

• Fatigue

• Ineffective tissue perfusion: Cardiopulmonary, renal.


• Wear a gown and gloves when handling feces-contaminated articles.

• Carefully observe jugular veins.

• Auscultate the lungs frequently.

• Monitoring:

• Vital signs

• Intake and output

• Laboratory values

• I.V. infusion

• Jugular veins

• Patient teaching: • administration of cholera vaccine to travelers in

endemic areas • proper hand-washing technique • need for increased fluid intake • Explain the use of oral tetracycline to family

members • If the practitioner orders a cholera vaccine, tell

the patient that he'll need a booster 3 to 6 months later for continuing protection.

Rotavirus Infections

• Self-limiting intestinal illness that causes mild to severe diarrhea in children.

• Rotavirus invades and damages the cells of the intestinal mucosa.

• Damage decreases viable absorptive surface, causing an imbalance of secretion and absorption that results in diarrhea.

Causes

• Infection with rotavirus, a member of the Reoviridae family

• Transmitted primarily by the fecal-oral route through ingestion of contaminated water or food or through contact with contaminated surfaces.

• The incidence of rotavirus is highest among infants and young children.

• Complications:

• Severe dehydration and shock

• Skin breakdown

• Worsening of other conditions such as cystic fibrosis

Assessment

• History:

• Fever, nausea and vomiting followed by diarrhea.

Physical findings • Diarrhea • Signs of dehydration, such as: – Tachycardia – Hypotension – Dry mucous membranes – Concentrated urine – Poor tear production – Poor skin turgor – Oliguria – Sunken eyeballs – Sunken anterior fontanel

Diagnostic test

• Laboratory:

• Antigen detection shows rotavirus in stool.

Spreading rotavirus infection

• Rotavirus infection is contagious.

• Rotavirus particles pass in the stool of infected persons before and after they have symptoms of the illness.

• A child can catch a rotavirus infection if he puts his fingers in his mouth after touching something that has been contaminated by the stool of an infected person.

• Usually this happens when the child forgets to wash his hands often enough, especially before eating and after using the toilet.

• Because of the widespread nature of rotavirus and the fact that almost 100% of children get rotavirus illness, total prevention of the spread of rotavirus is nearly impossible.

Treatment

• General: • Skin care • Symptomatic treatment • Diet: • Small, frequent meals • Increased fluid intake • Activity: • Rest periods when fatigued • Medications: • None (antibiotics and antimotility drugs

contraindicated)




• Acute pain

• Fatigue

• Hyperthermia

• Imbalanced nutrition: Less than body requirements

• Impaired skin integrity

• Risk for deficient fluid volume


• Institute enteric precautions.

• Enforce strict hand washing and careful cleaning of all equipment, including toys.

• Implement measures to ensure adequate hydration.

• Clean the patient's perineum thoroughly to prevent skin breakdown.

• Be aware that breast-fed infants can continue to breast-feed without restrictions.

• Bottle-fed infants can use lactose-free soybean formulas.

Patient teaching

• The disorder, diagnosis, and treatment

• Proper hand-washing technique

• Instructions on diaper changing and thorough cleaning of the perineum and all affected surfaces

• The importance of notifying the practitioner of increased diarrhea or signs of dehydration.

Poliomyelitis

• Description:

• Acute communicable disease caused by the polio virus.

• Ranges in severity from inapparent infection to fatal paralytic illness (mortality 5% to 10%).

• Excellent prognosis if central nervous system (CNS) is spared.

• Also called polio or infantile paralysis.

• Pathophysiology:

• The poliovirus has three antigenically distinct serotypes (types I, II, and III) that cause poliomyelitis.

• The incubation period ranges from 5 to 35 days (7 to 14 days on average).

• The virus usually enters the body through the alimentary tract, multiplies in the oropharynx and lower intestinal tract, and then spreads to regional lymph nodes and the blood.

• Factors that increase the risk of paralysis:

• include pregnancy,

• old age

• localized trauma, such as a recent tonsillectomy,

• tooth extraction.

• Causes:

• Contraction of the virus from direct contact with infected oropharyngeal secretions or feces.

• Incidence:

• Minor polio outbreaks, usually among nonimmunized groups.

• Onset during the summer and fall

• Mostly occurs in people over age 15

• Adults and girls at greater risk for infection

• Boys, for paralysis.

• Common characteristics:

• Fever

• Muscle weakness

ASSESSMENT

• History:

• Exposure to polio virus

• Fever

• Physical findings:

• Muscle weakness

• Resistance to neck flexion (nonparalytic and paralytic poliomyelitis).

TREATMENT • General: • Supportive • Moist heat applications • Diet: • Well-balanced diet • Activity: • As tolerated • Physical therapy • Assistive devices • Medication: • Analgesics • Antipyretics

NURSING CONSIDERATIONS



• Delayed growth and development

• Fatigue

• Impaired physical mobility

• Ineffective breathing pattern

• Nursing interventions:

• Provide emotional support.

• Provide good skin care, reposition the patient often, and keep the bed dry.

• Maintain contact isolation.

PATIENT TEACHING

• Disorder, diagnostic tests, and treatment

• Physical therapy

• Avoiding complications of limited mobility

• Proper hand-washing and contact isolation techniques.

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