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GONORRHEA

Synonyms Clap/Flores Blancas/Gleet Definition Gonorrhea is a sexually-transmitted bacterial disease involving the mucosal lining of the genitourinary tract, the rectum, and pharynx. History The exact time of onset of gonorrhea as prevalent disease or epidemic cannot be accurately determined from the historical record. One of the first reliable notations occur in the Acts of the (English) Parliament. In 1161 this body passed a law to reduce the spread of "...the perilous infirmity of burning." The symptoms described are consistent with, but not diagnostic of, gonorrhea. A similar decree was passed by Louis IX in France in 1256, replacing regulation with banishment. Similar symptoms were noted at the siege of Acre. Coincidental to, or dependent on, the appearance of a gonorrhea epidemic, several changes occurred in European medieval society. Cities hired public health doctors to treat afflicted patients without right of refusal. Pope Boniface

rescinded the requirement that physicians complete studies for the lower orders of the Catholic priesthood. Medieval public health physicians in the employ of their cities were required to treat prostitutes infected with the "burning", as well as lepers and other epidemic victims. After Pope Boniface completely secularized the practice of medicine, physicians were more willing to treat a sexually transmitted disease.

Reference: http://en.wikipedia.org/wiki/Gonorrhea#History

Infectious Agent Neisseria gonorrhea or gonococcus 1. This is a Gram-negative coccus found in pairs. 2. This coccus is non-spore former and non-motile. 3. It is fragile and does not survive long outside the body. 4. It is readily killed by drying, sunlight, and ultraviolet light. 5. It may be killed by ordinary disinfectants. Incubation Period The incubation period is from three to twenty-one days and averages from three to five days. Period of communicability The period of communicability of the disease is varied. The infected person remains communicable as long as the organisms are present in secretions and discharges. Mode of Transmission

1. Bacteria are transmitted by contact with exudates from the mucous membranes of infected persons, usually as a result of a sexually activity. 2. Transmission may occur in utero upon the rupture of membranes, as observed in infants delivered by cesarean section after the membrane ruptures. 3. Bacteria are transmitted through direct contact with contaminated vaginal secretions of the mother as the baby comes out of the birth canal. 4. It may be acquired through sexual contact (orogenital, angogenital) between opposite sexes, as well as of the same sex. 5. Bacteria may also be transmitted through fomites. Pathology 1. After infection, gonococci become adherent to the urethral epithelium. 2. Penetration of the mucosa usually elicits an acute inflammatory response consisting mainly of polymorphonuclear leukocytes in the submucosa. 3. Inflammatory edema of the gland ducts or plugs of debris obstruct drainage to form microabscesses that may coalesce to form large abscesses. 4. Infection tends to spread along mucosal surfaces and may involve the fallopian tubea and the endometrium and evenyually enter the peritoneal cavity of women. 5. Scarring from this abscess formation or tubal involvement may lead to strictures and sterility. 6. A similar mechanism, epididymitis, and therefore, possible sterility may occur in men. Clinical Manifestations 1. In Females a. Burning sensation and frequent urination b. Yellowish purulent vaginal discharge c. Redness and swelling of the genitals

d. Burning sensation ad itching of the vaginal area. e. Urinary frequency and pain on urination f. Urethritis or cervicitis occurs initially a few days after exposure g. Endometritis salpingitis or pelvic peritonitis are symptoms of uterine invasion which may lead to infertility. There is the presence of early signs of pelvic infection like fever, nausea and vomiting, and abdominal pain/ thderness. h. Pregnant women with gonorrhea may infect the eye of her baby during the passage through the birth canal.

2. In Males After a three-to-six day incubation period, the following may be noted: a. Dysuria with purulent discharge (gleet) from the urethra two to seven days after exposure. b. Rectal infection is common in homosexuals. passage of urine. d. Prostatitis e. Urethritis f. Pelvic pain and fever Other Clinical Features Vary According To Site Involved (Longworth, 2004) 1. Urethra a. Dysuria b. Urinary frequency and incontinence c. Purulent discharge d. Itching e. Red and edematous meatus 2. Vulva c. Inflammation of the urethra can cause strictures which can prevent the

a. Ocassional itching b. Burning and pain due to exudates from the adjacent infected area c. Vulva symptoms are more severe before puberty and after menopause 3. Vagina a. Engorgement, redness, and swelling b. Profuse purulent discharge 4. Pelvis a. Severe pelvic and lower abdominal pain b. Muscle rigidity, tenderness and abdominal distention c. Tachycardia may develop in patients with PID and salpingitis 5. Liver a. RUQ pain 6. Other possible symptoms include pharyngitis, tonsilits, rectal burning Complications 1. Sterility and pelvic inflammatory disease in women 2. Epididymitis 3. Arthritis 4. Endocarditis 5. Conjunctivitis 6. Meningitis Diagmostic exam 1. In females- culture of specimen taken from the cervix and anal canal (inoculation of specimen on Thayer-Martin medium. The medium conatins antibiotic that inhibits the growth of microorganisms. 2. In males- Gram stain

Treatment Modalities 1. For uncomplicated gonorrhea in adults- ceftriaxone 125-250 mg IM single dose; doxycycline 100 mg orally BID x seven days. 2. For pregnant women- ceftriaxone, 125- 250 mg IM, single dose, plus erythromycin 500 mg orally for seven days. 3. Aqueous procaine penicillin- 4 million units injected intramuscularly after a negative skin test. 4. Recommended initial regimen for disseminated gonococcal infection in adults and adolescents is 1 gram ceftriaxone IM IV every 24 hours, or for patients allergic to beta-lactam antibiotics, 2 g spectinomycin IM every 12 hours. 5. All regimen should be continued for 24 to 48 hours after improvement begins, then therapy may be switched to the following regimens to complete one full week of antimicrobial therapy. a. 400 mg cefime p.o twice daily or 500 mg ciprofloxacin p.o 2x daily.Ciprofloxacin is contraindicated for children, adolescents, and pregnant lactating women. b. Treatment for gonoccoccal conjunctivits requires 1 g single dose ceftriaxone IM and irrigation of infected eye with normal saline solution. Nursing Management 1. Before treatment, ask the patient whether he/she has drug sensitivities and watch closely for adverse effects during therapy. 2. Explain to the patient that until cultures prove negative, he/she is still infectious and can transmit gonoccoccal infection. 3. Practice standard precautions. 4. All information concerning the patient is considered confidential. There should e no discussion concerning the patient and the laboratory reports. 5. The patient should be isolated until he/she recovers from the disease. 6. For a ptient with gonoccoccal arthririts, apply moist hea to relieve pain on the affected site.

7. Infants born to mothers positive for gonorrhea should e instilled with one percent silver nitrate or any recommended optahlmic prophylaxis onto both eyes at the time of birth. 8. Report all gonorrhoeal cases to health authorities, and for gonorrhea in children to Child Abuse Authorities. 9. Encourage patient to inform sexual contacts so that they can seek treatment. Advice them to refrain from sexual intercourse until treatment is completed. Signs of Gonoccocal Opthalmia Neonatorum Lid edema Bilateral conjunctival edema Abundant purulent discharge 2-3 days after birth Untreated gonoccocal conjunctivits can progress to corneal ulceration and blindness.

If not treated gonococcal ophthalmia neonatorum will develop in 28% of infants born to women with gonorrhea.

Common Nursing Diagnosis Altered sexuality pattern Social isolation Knowledge deficit Altered urinary isolation

Risk for infection

Prevention and Control 1. Sex education, not only in schools, but also in the community, must emphasize the mode of transmission and the source of the inection. 2. Case finding, contact tracing. 3. Incidence of gonorrhea must be reported so that health authorities may be notified and contacts can be treated.

HEPATITIS

Definition Hepatitis is defined as inflammation of the liver, and is classified as either viral or non-viral. I. Hepatitis A ( Infectious hepatitis/ Catarrhal jaundice) Hepatitis A is a liver disease caused by the hepatitis A virus. This inflammation of the liver is not really very severe and runs as acute course. This generally starts within two to six weeks after contact with the virus, and lasts no longer than two months. It is known as infectious hepatitis because it spreads relatively easy to individual who have close contact with the infected. Incubation Period The incubation period for hepatitis A ranges from 15 to 60 days, or three to five weeks, with a mean incubation period of 30 days.

Period of Communicability The infected patient is capable of transmitting the organism from a week before until a week after the appearance of symptoms. Mode of Transmission The virus is transmitted through the fecal-oral pathway: 1. ingestion of contaminated drinking water or ice, uncooked fruits and vegetables, and fruits and vegetables grown in or washed with contaminated water; and 2. contamination of food/drinks by infected food handlers. Groups at Risk for HAV 1. Children in day care centers can transmit the infection through diapers and toys. 2. Troops living in crowded conditions at military camps or in the field are at great risk. 3. Homosexual men are at an increased at risk of HAV infection from oral-anal sexual contact. 4. People who live in areas with a breakdown of sanitary conditions, such as after a flood or other natural disasters. Pathology/ Pathogenesis 1. Following ingestion, HAV enters the bloodstream through the epithelium of the oropharynx or intestines. 2. The blood carries the virus to its target, the liver, where it lives and multiplies within the hepocytes and Kupffer cells (i.e., liver macrophages). 3. Virions are secreted into the bile and released in stools. HAV is excreted in large quantities approximately 11 days prior to the appearance of symptoms or anti-HAV IgM antibodies in the blood.

Clinical Manifestations 1. Flu-like illness with chills and high fever. 2. Diarrhea, fatigue and abdominal pain. 3. Loss of apetite 4. Nausea, diarrhea and fever 5. Jaundice and dark-colored urine 6. The infection in young children is often mild and asymptomatic. 7. Hepatitis A does not have a chronic stage and does not case permanent liver damage. 8. Following infection, the immune system makes antibodies against A virus that confer immunity against future infection. The disease can be prevented by A vaccine. Complications 1. Progressive encephalopathy characterized by drowsiness and cerebral edema. 2. GIT bleeding progressing to stupor and later coma. Bleeding is not responsive to parenteral vitamin K administration. 3. Clonus and hyperflexia are later replaced by loss of deep tendon reflexes. 4. Edema and ascitis. 5. Aplastic anemia 6. In the late blood, respiratory failure, and cerebrovascular collapse may be present. Diagnostic Procedures 1. HAV and HBV- complement fixation rate 2. Liver function test- to determine the presence and extent of liver damage and check the progress of the liver. 3. Bile examination of stool and urine samples 4. SGOT- serum glumatic oxaloacetic transaminase SGT- Serum glutamic pyruvic transaminsae

ALT- serum alanine transaminase 5. IgM level Treatment Modalities 1. There is no specific treatment, although bde rest is essential. 2. Diet must be high in carbohydrates, low in fat and low in protein. 3. Patient must take vitamin supplements, especially the B complex group. 4. Intravenous therapy is occasionally necessary. 5. Isoprinosine (Methisoprenol) may enhance the cell- mediated immunity of the T- lymphocytes. 6. Alkalies, belladonna, and anti-emetics should be administered to control dyspepsia and malaise. Nursing Management 1. The patiet must be isolated (enteric solution). 2. Patient should be encouraged to rest during the acute symptomatic phase. 3. The patients nutritional status must be improved. 4. Appropriates measures to minimize spread of the diseases must be taken. 5. Observe the patient for melena and check for the presence of blood. 6. Provide optimum skin and oral care. 7. Increase the ability to carry out activities. a. Encourage the patient to limit the activity when fatigued. b. Assist the client in planning periods of rest and activity. c. Encourage gradual resumption of activities and mild exercise during recovery. Prevention and Control 1. Hands should be washed thoroughly after using the toilet. 2. Travelers should avoid water and ice if unsure of their purity. 3. Food handlers should be carefully screened. 4. Safe preparation and serving of food must be practiced.

5. The public should be educated on the mode of transmission.

II.

HEPATITIS B (Serum hepatitis) Hepatitis B is the inflammation of the liver caused by hepatitis B virus.

This is considered to be more serious than hepatitis A due to the possibility of severe complications such as massive damage and hepatocarcinoma of the liver. It was once thought to be transmitted only through direct exchange of contaminated blood. Hepa B is now known to be transmitted also by contact with human secretions and stools. Recipient of plasma-derived products and hemodialysis clients are particularly at risk. Etiologic Agent The disease is caused by the Hepatitis B virus. 1. This virus has every limited tissue tropism. 2. HBV infects the liver and possibly the pancreas. 3. HBsAg appears in the blood 30 to 60 days after exposure and persist for variable periods of time. Incubation Period The incubation period is 50 to 189 days or 5 months with a mean equal to 90 days. Period of Communicability The patient is capable of transmitting the virus during the latter part of the incubation period and during the phase. The virus may persist in the blood for many years.

Mode of Transmission 1. Hepatitis B can be directly transmitted by person-to-person contact via infected body fluids. 2. It can be transmitted by through contaminated needles and syringes. 3. Transmission can occur through infected blood or body fluids introduced at birth. 4. It can also be transmitted through sexual contact. HBV transmission does not occur via: 1. the fecal-oral route 2. foodborne or waterborne transmission 3. arthropod (mosquito) transmission Pathogenesis 1. Hepatitis B virus primarily interferes with the functions of the liver by replicating in liver cells, known as hepatocytes. 2. During HBV infection, the host immune response causes both hepatocellular damage and viral clearance. 3. The virus replicates and large amounts of HBsAg are released into the blood, in addition to virons. 4. Initiation of virus replication may be soon as 3 days from acquisition,but symptoms may not be observed until after 45 days or much longer. 5. Replication of the virus is not cytopathic and proceeds for relatively long periods without causing liver damage. 6. During the acute phase of infection, the liver parenchyma shows degenerative changes consisting of cellular swelling and necrosis, especially in hepatocytes. Clinical Manifestations 1. Prodromal period

a. fever, malaise, and anorexia b. Nausea, vomiting, abdominal discomfort, fever, chills c. Jaundice, dark urine and pale stools d. Recovery is indicated by a decline of fever and improved appetite. 2. Fulminant hepatitis may be fatal and manifested by severe symptoms like ascites and bleeding. Diagnostic Procedures 1. Compliment fixation test 2. Radio-immunoassay-hamaglutinin test 3. Liver function test 4. Bile examination in blood and urine 5. Blood count 6. Serum count 7. Serum transaminase- SGOT, SGPT, ALT 8. HBsAg Prevention 1. Blood donors must be screened to exclude carriers. 2. Caution must be observed in giving care to patient infected with HBV. 3. Hands and other skin areas must be washed immediately and thotougly after contact with body fluids. 4. Avoid injury with sharp objects or instruments. 5. Use disposable needles and syringes only once and discard properly. 6. Avoid sharing toothbrushes, razors and other instruments that may be contaminated with blood. 7. Practice safe sex. 8. Get adequate rest, sleep, and exercise, and eat nutritious food. 9. Hepatitis B vaccine is recommended for pre-exposure. 10. Hepatitis immune globulin (HBIg) should be administered within 72 hours to those exposed directly to hepatitis B virus ingestion, prick or inoculation.

III. scarring). carcinoma). IV.

HEPATITIS C Is a blood-borne infectious diseased caused by the hepatitis The infection is often asymptomatic, but once established,

C virus (HCV), originally known as non-A, non-B hepatitis can cause scarring of the liver (fibrosis) and eventually, cirrhosis (advance The hepa C virus is associated with a rate of chronic liver

disease (chronic hepatitis, cirrhosis, and an increased risk for hepatocellular Clients with chronic hepatitis C are considered infectious. NO vaccine is available for hepatitis. HEPATITIS D

Hepatitis D virus (also called delta virus) is a small, circular RNA virus. Hepatitis D virus is replication-defective and therefore cannot propagate in the absence of another virus. In humans, hepatitis D virus infection occurs only in the presence of hepatitis B infection.

Hepatitis D virus infection is transmitted by blood and blood products. The risk factors for infection are similar to those in hepatitis B virus infection. A patient can acquire hepatitis D virus infection at the same time that he/she is infected with the hepatitis B virus. This is called co-infection. A patient can also be infected with hepatitis D virus at nay time during acute hepatitis B virus infection. This is called superinfection.

Found only in patients with an acute episode of or chronic hepatitis B and requires the presence of HbsAg. This virus depends on the double-shelled type B to replicate. For this season, type D infection does not outlast type B infection. Type D is rare in the United States, except among drug users. V. HEPATITIS E

Transmitted enterically (fecal-oral and waterborne routes), like hepatitis A. Hepatitis E virus is inconsistently shed in stools; therefore, direction The hepatitis E virus (HEV) is a common cause of hepatitis that is is difficult. transmitted via the intestinal tract. Spread is most often by drinking contaminated water. Hepatitis E never becomes a chronic (long-lasting) illness, but on rare occasions the acute illness damages and destroys so many liver cells that the liver can no longer function. This is called fulminant liver failure and may cause death. Pregnant women are at a much higher risk of dying from fulminant The great majority of patients who recover from acute infection do not liver failure. continue to carry HEV and cannot pass the infection to others.

Signs and Symptoms Assessment findings are similar for the different types of hepatitis. Signs and symptoms progress in three stages. Prodromal stage Patient complains of easy fatigue, anorexia, body malaise, headache, arthralgia, myalgia, photophobia and nausea with vomiting. There are changes in the patients senses of smell and taste. There is moderate grade fever ranging from 37.8-38.9 C As the prodromal stage draws to a close, urine may become dark-colored and stools are clay-colored. Clinical jaundice stage Patient manifest with pruritus, abdominal pain or tenderness and indigestion. There is yellowish discoloration of the sclerae, mucous membrane and the skin, which can last for one to two weeks.

O inspection of the skin, rashes, erythematous patches and urticaria may be seen, especially if the client is suffering from hepatitis B or C. Pain, tenderness of the RUQ, an enlarged and tender liver, splenomegaly and cervical adenopathy are pesent.

Recovery stage During this stage, most of the patients symptoms decrease or subside. Recovery stage commonly last for 2-12 weeks.

Diagnosis Hepatitis A: Detection of antibodies to hepatitis A confirms the diagnosis. Hepatitis B: The presence of HbsAg and hepatitis B antibodies confirms the diagnosis. Hepatitis C: The diagnosis depends on serologic testing for the specific antibody one or more months after the onset of acute hepatitis. Hepatitis D: Detection of intrahepatic delta or immunoglobulin M (IgM) establishes the diagnosis. Hepatitis E: Detection oh hepatitis E antigen supports the diagnosis.

Following are additional findings from liver function test that support the diagnosis: 1. Serum aspirate aminotransferase levels and serum alanine aminotransferase are increased in the prodromal stage of acute viral hepatitis. 2. Serum alkaline phosphotase levels are slightly increased. 3. Serum bilirubin levels are elevated and may continue to rise in severe liver damage. 4. WBC reveals transient neutropenia and lymphopenemia followed by lymphocytosis. 5. Liver biopsy is performed only if diagnosis is questionable.

General Nursing Management 1. Suggest that a large meal be eaten in the morning because nausea tends to intensify as the day progresses. 2. Provide diversional patients to relieve boredom and anxiety. 3. Encouraged anorexic patients to take juices with occasional ice chips to maintain hydration without indusing vomiting. 4. Monitor the patients weight daily. Record intake and output. 5. Observe stools for color, consistency and amount. Record the frequency of bowel movement. 6. Before the patient is discharge, discuss restrictions and how to prevent recurrence of hepatitis. B. NON VIRAL HEPATITIS Non viral hepatitis is classified as either toxic or drug-induced (idiocyncratic) hepatitis. Most of the patients recover from this type of hepatitis, although a few develop fulminant hepatitis or cirrhosis. Causes 1. Alcohol overuse- follows heavy alcohol consumption 2. Diect hepatoxicity- hepatocellular damage and necrosis usually caused by toxins; it is a dose- dependent and occurs primarily in acetaminophen overdose. 3. Idiosyncratic hepatoxicity- follows a sensitization period of several weeks caused by the hosts hypersentivity to medication, such as, INH, methyldopa, lovastatin and halothane. 4. Cholestatic reactions- caused by a lack of bile excretion; direct hepatoxicity from hormaonal contraceptives or anabolic steroids; hypersensitivity to antibiotics, thyroid medications, anti-diabetics and cytotoxic drugs. 5. Metabolic and autoimmune disorders- acute exacerbations of sub-clinical liver disease.

Common Nursing Diagnoses Knowledge deficit Low self-esteem Body image disturbance Risk for infection Impaired skin integrity Altered nutrition: Les than body requirement Social Isolation

Comparison of Types of Viral Hepatitis

VIRUS

HEPATIS A

HEAPATIS B (HBV)

HEAPTITIS HEPATITIS HEPATITIS C (HCV) Blood and bloody fluids 5-12 Slow Yes Chronic hepatitis; Cirrhosis Liver cancer; Anti-HCV; Antibodies present D (HDV) Blood and bodu fluids; perinatal 3-13 Abrupt Yes Chronic hepatitis; Cirrhosis Fulminant hepatitis positive HDVAg (delta antigen) early, antiHDV antibodies later
Reference: Principles of Medical-Surgical Nursing 4th Edition Volume 1 Page 705

E (HEV) Fecal-oral

Mode of transmission Incubation (in weeks) Onset Carrier state Possible Complication s Laboratory findings

(HAV) Fecal-oral Blood and body 2-6 Abrupt No Rare fluids;perinatal 6-24 Slow Yes Chronic hepatitis; Cirrhosis; Anti-HAV present Liver cancer Positive surface antigen); anti-HBV antibodies present

3-6 Abrupt Yes May be seen in pregnant women Anti-HEV antibodies present

antibodies HBsAg (HBV