Communicable Disease

1

COMMUNICABLE DISEASES
TERMINOLOGY
1. INFECTION:- When an organism enters in the body of man or animal or when infectious
agent multiplies in the body it is called infection.
2. INFECTIOUS AGENT:- The organisms which causes diseases are called infectious
agent. These organisms are bacteria, virus, protozoa and parasites.
3. INFESTATION:- Presence of parasites on the body are called infestation.
4. INFECTIOUS DISEASES:- Disease due to infection is called infectious disease.
5. IMMUNITY:- It is the capacity of body itself to recognize, destroy and eliminate
antigenic foreign material inside the body.
6. IMMUNOLOGY:- It is the study of physiology defenses of the body.
7. EPIDEMIOLOGIST:- Epidemiologist is collecting the data of particular disease.
MUMPS
Definition Mumps (epidemic parotitis) is a viral disease of the human species, caused by
the mumps virus.
Or
Mumps is an acute viral infection that is characterized by swelling of the parotid glands those
are located just below and front of the ear and at times, the salivary glands located under the
lower jaw.
Incubation period-Two-three weeks
Pathogenesis
The virus enters through the nose or mouth. It proliferates in the parotid glands and the
respiratory mucosa and produce viremia. The virus is localized in the salivary glands (mainly the
parotid) and CNS and brings about the clinical symptoms. The mumps virus can also affect
testes, pancreas, ovaries and prostate.
Causes
1. It is a viral infection and mostly the virus is Paramyxovirus.
2. Mumps is a contagious disease that is spread from person to person through contact with
respiratory secretions such as saliva from an infected person.
3. When an infected person coughs or sneezes, the droplets aerosolize and can enter the
eyes, nose, or mouth of another person.
4. Mumps can also be spread by sharing food and drinks.
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5. The virus can also survive on surfaces and then be spread after contact in a similar
manner.
A person infected with mumps is contagious from approximately 6 days before
the onset of symptoms until about 9 days after symptoms start. The incubation
period (time until symptoms begin) can be from 14–25 days but is more typically 16–18
days.
Signs and symptoms
The more common symptoms of mumps are:
 Parotid inflammation (or parotitis) in 60–70% of infections and 95% of patients with
symptoms.
 Parotitis causes swelling and local pain, particularly when chewing. It can occur on one side
(unilateral) but is more common on both sides (bilateral) in about 90% of cases.
 Fever
 Headache
 Orchitis, referring to painful inflammation of the testicles. Males past puberty who develop
mumps have a 30 percent risk of orchitis.
Other symptoms of mumps can include dry mouth, sore face and/or ears and occasionally in
more serious cases, loss of voice. In addition, up to 20% of persons infected with the mumps
virus do not show symptoms, so it is possible to be infected and spread the virus without
knowing it.
Fever and headache are prodromal symptoms of mumps, together with malaise and anorexia.

Diagnosis
1. A physical examination confirms the presence of the swollen glands.
2. Usually the disease is diagnosed on clinical grounds and no confirmatory laboratory
testing is needed.
3. If there is uncertainty about the diagnosis, a test of saliva, or blood may be carried out; a
newer diagnostic confirmation, using real-time nested polymerase chain reaction (PCR)
technology, has also been developed.
4. An estimated 20%-30% of cases are asymptomatic.
5. As with any inflammation of the salivary glands, serum amylase is often elevated.
Prevention
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1. Prevention is always better than the cure and therefore, one has to prevent the occurrence
of mumps so that further complications are also avoided.
2. The best way to prevent this disease is to get immunized. Mumps vaccine (generally in
the form of MMR – measles, mumps and rubella) is the best way to prevent this
hazardous condition invented by Maurice Hilleman.
3. Two doses of mumps containing vaccine can be given as combination of measles,
mumps and rubella, separated by minimum 28 days, which are routinely recommended
for all children. The first dose can be given on or after the first birthday and another one
at the age of four to six years.
4. It is also advisable for adults who work in healthcare, school/universities etc. to go either
for one or two doses of vaccination against mumps.
5. The precaution is to be taken as pregnant woman and a person with less immunity should
not receive this live attenuated vaccines.
Treatment
1. There is no specific treatment for mumps.
2. Symptoms may be relieved by the application of intermittent ice or heat to the affected
neck/testicular area and by acetaminophen/paracetamol (Tylenol) for pain relief.
3. Aspirin is not used due to a hypothetical link with Reye's syndrome. Warm salt
water gargles, soft foods, and extra fluids may also help relieve symptoms. According to
the Department of Health of Minnesota there is no effective post-exposure
recommendation to prevent secondary transmission, as well as the post-exposure use of
vaccine or immunoglobulin is not effective.
[30]

Patients are advised to avoid acidic foods and beverages, since these stimulate the salivary
glands, which can be painful.

Tuberculosis
Introduction:-
Tuberculosis, one of the oldest and deadliest infectious diseases had a dramatic comeback in the
last quarter of the century.
In developing countries like India, tuberculosis is a common pediatric problem and an important
killer of children. India accounts for nearly one third of global burden of tuberculosis.
Definition:-
Tuberculosis (TB) is an infectious disease caused by bacteria whose scientific name
is Mycobacterium tuberculosis.
Or
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It is a common and in many cases lethal infectious disease caused by various strains
of mycobacteria, usually Mycobacterium tuberculosis.
Epidemiology:-
Agent- All patients of pulmonary tuberculosis and most cases of extra-pulmonary disease are
caused by human type strain mycobacterium tuberculosis. A few cases of extra-pulmonary
illness may be due to the bovine strain.
Reservoir of infection- The infection is spread by the tuberculous patient, who discharges
tubercle bacilli in his sputum or nasopharyngeal secretions during bouts of coughing or sneezing
etc.
Mode of infection- The usual mode of infection is through inhalation of droplets of infected
secretions. The infected sputum spitted carelessly by open cases of tuberculosis dries up and the
tubercle bacilli are suspended in the dust and air. This may be a source of infection through
breathing. Infection through ingestion of infected material is rare. Rarely infection may be
transmitted through skin, mucous membrane or transplacentally.
Host factors-
1. Age. No age is exempt from tuberculosis. Tubercle bacilli are not transferred across the
healthy placenta but the fetus may be infected from the infected placenta. Congenital
tuberculosis, however, is extremely rare. Frequency of infection with tubercle bacilli
increases progressively as the child grows in age.
2. Sex- The adolescent children especially the girls are more prone to develop active
tuberculous disease during puberty. There is little difference in the incidence of
tuberculosis in the two sexes in early childhood.
3. Malnutrition- Undernourished children are more susceptible to develop tuberculosis,
probably due to depressed immunological defenses.
4. Intercurrent infection- A quiescent tuberculous infection may flare up after an attack of
measles or whooping cough. Measles may depress delayed hypersensitivity to tubercular
proteins.
Environment-
There is little difference in the prevalence of disease in the rural or urban communities. Children
living in overcrowded apartments with inadequate ventilation and little sunshine are at high risk.
Damp insanitary and unhygienic living conditions are important predisposing factors.
Incubation period-
Incubation period may be weeks, months and years. It depends upon host parasite relationship,
closeness of contact, extent of disease and sputum positivity of the source cases. Average
incubation period is 3-8 weeks.
Other causes-
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Tuberculosis is a social disease. There are so many social factors which contribute to the
occurrence and spread of this disease. These factors are
1. Poor housing
2. Poor ventilation
3. Overcrowding
4. Air pollution
5. Less sunshine
6. Population explosion
7. Undernutrition
8. Poor quality life style
9. Lack of education and health awareness
Pathophysiology-
Any cause/mode of transmission

Tubercle bacilli reach bronchioles and alveoli and taken up by phagocytes

Multiplication of bacilli

Formation of pathological lesion “tubercle”

Necrosis occur, surrounded by ring of small round of lymphocytes

Tubercle merges to form primary focus

Primary focus found in any portion of lungs but sub-pleurally in the lower part of upper lobe of
right lung

Progressive primary tuberculosis

Primary infection spread through lymphatics and blood stream and carried in meninges,
peritoneum, bone, joints, kidney, spleen, liver lymph glands etc.

Progressive secondary tuberculosis
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Clinical manifestations-
May be asymptomatic or produce a broad range of symptoms:
1. Fever
2. Malaise
3. Anorexia
4. Weight loss
5. Cough may or may not be present (progresses slowly over weeks to months)
6. Aching pain and tightness in the chest
7. Hemoptysis (rare)
With progression:
1. Respiratory rate increases
2. Poor expansion of lung on the affected side
3. Diminished breath sounds and crackles
4. Dullness to percussion
5. Fever persist
6. Generalized symptoms are manifested
7. Pallor, anemia, weakness, and weight loss
Diagnostic evaluation:-
The diagnosis of tuberculosis is based on clinical features, history of contact with an open
infective case, demonstration of hypersensitivity to tuberculin, evidence of radiological lesions
suggestive of tuberculosis, and certain laboratory investigations.
History of contact with an infective case
1. Contact is defined as any child who lives in a household with an adult taking
antitubercular therapy or has taken such therapy in past 2 years.
2. Contacts can often be traced to maidservant, cook, domestic aid or gardener in case of
tuberculous children from well-to-do families with healthy parents.
Tuberculin test
The tuberculin test is a useful diagnostic aid. Most frequently used test are Mantoux test and
multiple puncture test.
Mantoux reaction: 0.1ml of a suitable dilution of tuberculin (PPD) is injected intradermal on
volar aspect of the forearm. Standard dose is 5 TU (equivalent to 1 TU PPD with RT 23 Tween
80). A weal of 5mm should be raised. The reaction is read after 48 hours to 72 hours. The dosage
of tuberculin is measured in tuberculin units. Five tuberculin units are contained in 0.0001 mg of
purified protein derivative (PPD) in 0.1ml of diluents.
A negative tuberculin reaction does not rule out tuberculosis.
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Tuberculin test in the vaccinated children: Children vaccinated previously with BCG show
positive tuberculin reaction during infancy. In older children the interpretation of tuberculin test
is not altered by the BCG status of the child.
BCG test: During mass BCG vaccination campaign in India, an accelerated response after
injection of the vaccine was observed in individuals suffering from tuberculosis. An induration
of more than 5-6 mm after 3 days of BCG vaccine is considered a positive reaction. Indian
Academy of Pediatric does not recommend BCG test for diagnosis of tuberculosis.
Laboratory investigations:
Erythrocyte sedimentation rate (ESR) and blood counts have no value in diagnosis or follow up
of tuberculosis.
Demonstration of acid-fast bacilli: Most children do not expectorate out the sputum but swallow
it. Therefore the sputum is not available for examination. A laryngeal swab may be obtained for
smear and culture examination for mycobacteria. It is customary to examine the gastric lavage in
children for bacteriological examination on 3 consecutive days. Ryle’s tube is passed in empty
stomach, early in the morning before the child has been given any breakfast. The gastric contents
are aspirated and sent for bacteriological examination. The cerebrospinal fluid, pleural or
bronchial aspirate, urine and discharges from tuberclous sinuses are examined for the tubercle
bacilli.
Histopathology: glands, liver and other tissues may be examined of histological evidence of
tuberculosis by fine needle aspiration cytology (FNAC)
Serology: Antibody detection by ELISA or other methods is of no utility in diagnosis of
childhood tuberculosis.
Radiology: Chest X-ray upright PA view is usually sufficient. CT scan of chest is not routinely
required. Diagnosis of tuberculosis should be strongly considered, if any of the following lesions
is associated with relevant clinical findings:
1. Military mottling
2. Unilateral pleural effusion
3. Fibrocaseous cavitotory lesions;
4. Mediastinal adenopathy with pneumonia.
Ultrasound: It is useful in detection of enlarged lymph node or peritoneal fluid in suspected
abdominal tuberculosis.
Treatment of Tuberculosis:
The treatment of tuberculosis has undergone many changes over the past two decades. The short
course chemotherapy was started in 1972 but only recently accepted by IUATLD, WHO and
American Academy of Pediatrics.
1. The diagnosis should be made early
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2. The treatment should be prompt, adequate, vigorous and prolonged depending on the
severity of illness.
3. More than one antitubercular drug should be used for prevention of delayed development
of resistance of the tubercle bacilli to the drugs.
4. All drugs should be given in a single daily dose on empty stomach.
5. Pyridoxine (vitamin B
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) is not necessary in children taking isoniazid.
6. Nutrition of the child should be improved by an appetizing, nutritionally balanced diet
with adequate calories and protein.
7. Intercurrent infections should be prevented or treated vigorously.
8. Every effort should be made to trace the reservoir of infection or the open infective case
in the family or extra familial contracts and he or she should be treated.
9. The living should be improved by better hygienic measures and improved sanitation. The
child should be exposed to adequate sunshine and the living apartment should be well
ventilated.
Drugs:
Antitubercular drugs are divided into three major categories:
a) First line drugs: Majority of patients can be successfully treated with these drugs.
They are effective with minimal toxicity.

Drug Daily dose Route Adverse reaction
Rifampicin 10mg/kg single dose on
empty stomach (max. 600mg)
Orally Hepatotoxic, dermatitis, flu like
syndrome, thrombocytopenia hemolytic
anemia, acute renal failure
Isoniazid (INH) 5mg/kg (max. 300mg) Orally Peripheral neuritis, toxic
encephalopathy, optic neuritis,
convulsions, psychosis, hepatitis,
aplastic anemia and hypersensitivity
reactions
Streptomycin 20mg/kg (single, max. 1g) IM Auditory or vestibular dysfunction
Ethambutol 20mg/kg divided doses Orally Retrobulbar neuritis (blurred vision),
color blindness, visual field defects
Pyrazinamide 25mg/kg (divided, max. 1g) Orally Hepatotoxicity

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b) Second line drugs: these are used in drug resistant cases or in situations where first
line drugs cannot be used either due to toxicity or some other constraint. These
include cycloserine, ethionamide, PAS, capreomycin and kanamycin.
c) Other drugs: These are strictly reserved for drug resistant cases and include
quinolones, rifampicin, amikacin and ampicillin.
Steroids: It is useful to add corticosteroid (predinisolone 1-2 mg/kg/day) for their anti-
inflammatory effect during the first 4-8 weeks of antitubercular therapy in cases of military
tuberculosis, pericarditis or peritonitis. Children with tuberculous meningitis should be given
steroids for 8-12 weeks.
Nursing management:
Nursing Assessment of Tuberculosis Patients
A patient with tuberculosis may show certain signs and symptoms of the disease. During a
nursing assessment, the nurse tries to find out the following:
 if the patient has been exposed to someone who has tuberculosis;
 if the patient has any symptoms of tuberculosis by asking questions and performing a
physical exam. The nurse looks for signs of a productive cough, night sweats,
temperature elevation during the day, unintentional weight loss and chest pain. The nurse
also listens to the patient's lungs for abnormal breath sounds.
 If the patient is on drug therapy for tuberculosis, the nurse assesses for signs of liver
abnormalities such as fatigue, joint pain, fever, tenderness in the liver area, clay colored
stools, dark urine, vision changes, and loss of feeling in the hands and legs. The nurse
also does this by monitoring the patient's liver function lab tests.
Supportive nursing measures should include general nursing care and drug compliance.
1. All drugs should be administered in a single daily dose on an empty stomach.
2. The drugs are safe if used in the recommended dosage schedule.
3. Supervised drug therapy is essential in home based management.
4. Assessment of any adverse effects and complications are very important. Hepatotoxicity
may be found in malnourished children and in disseminated disease.
5. Good diet with balanced intake of protein and vitamins are essential.
6. Fresh air, sun shine, hygienic measures, necessary rest and ambulation should be
promoted.
7. Follow up at regular interval is essential part of management.
Nursing Diagnoses For Tuberculosis
A nursing diagnosis is a statement that describes a patient's response to his medical problem
which in this case is tuberculosis. Nursing diagnoses for tuberculosis are as follows:
 Risk for infection related to pulmonary TB disease
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 Ineffective breathing pattern related to decreased lung volumes and pulmonary infection
 Ineffective therapeutic regimen related to long term treatment and lack of motivation
 Imbalanced nutrition; less than body requirements related to fatigue, poor appetite, and
productive cough.
1. Nursing Interventions for Risk for Infection
The goal of care for this nursing diagnosis is to reduce the risk of spreading tuberculosis and
making sure the patient's tuberculosis is effectively treated. The following nursing activities
address these goals:
 Teach the patient about the infectious nature of tuberculosis and the need to prevent its
spread.
 Place the patient in a negative pressure room and in a private room.
 All nurses and visitors entering the patient's room should wear an N-95 mask.
 Put a mask on the patient during transportation to other departments.
 Keep the door to the patient's room shut and place an isolation sign at a visible location
near the door.
 Use standard precautions when providing direct care to the patient. This includes wearing
gloves, gowns and effective hand washing.
 Teach patient how to avoid spreading the disease by sneezing or coughing into doubly
ply tissue instead of their bare hands, washing their hands after this and disposing of the
tissue into a closed plastic bag.
 Teach the tuberculosis patient to stay in well ventilated areas and limit contact to other
people while he or she is still able to spread the infection.
2. Nursing Interventions for Ineffective Breathing Pattern
Patients with tuberculosis may need to work harder to breathe due to coughing, nervousness or a
high fever. Ineffective breathing pattern involves breathing at a faster or slower rate, use of
accessory muscles to breathe and fast heart rates amongst other things. Nursing interventions for
this problem are as follows:
 Administer oxygen if ordered and as ordered by a physician.
 Give the TB patients fluids to loosen up secretions for easier expulsion from the lungs.
 Position the patient in a high fowlers position to reduce the work needed to breathe.
 Encourage and provide rest periods so the tuberculosis patient can have energy to
breathe.
3. Nursing Interventions to Improve Nutritional Status of TB Patients
Proper nutrition is necessary for the body to heal and fight off infections. Nursing interventions
to improve the nutritional status of TB patients includes explaining the importance of a nutritious
diet, monitoring the patient's weight for improvement or maintenance, administering vitamin
supplements as prescribed and providing small frequent meals.
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4. Nursing Interventions to Improve Compliance with Tuberculosis Drug Regimen
It is important for tuberculosis patients to take their medications as prescribed. Failure to do this
may result in drug resistant forms of tuberculosis. This would make the patient’s tuberculosis
difficult to cure. To increase compliance with the drug regimen for tuberculosis which can be
very long, the nurse does the following:
 Teaches the patient about the importance of taking all prescribed medications because the
bacteria that causes TB grows slowly and requires a long time to be eliminated.
 Provide the TB patient with information about expected side effects of TB drugs so that
they know when to seek a doctors care and when not to be alarmed.
 Refer patients having a hard time sticking to their drug therapy for direct observation
therapy, where someone will watch them take their medication as they should.
If all the goals of care for nursing management of tuberculosis are met, the tuberculosis patient
should be free of fever and able to breathe properly, practice good infection prevention
strategies, maintain his or her body weight and take all medications as prescribed.
Prognosis:
Prognosis of tuberculosis depends upon
1. Age
2. Type of disease
3. Duration of infection
4. Site of infection
5. Nutritional status
6. Living conditions
7. Social economic status
8. Inter-current infection resistance to drugs
9. Early diagnosis
10. Continuation of treatment and facilities available.
Prognosis is worse in military tuberculosis, TB meningitis, chronic pulmonary tuberculosis,
TB with malnutrition and drug resistance cases.
Malaria
Definition:
Malaria is a protozoal disease caused by arthropod borne infection with malarial parasite
(plasmodium), which is transmitted by infected female anopheline mosquito.
Epidemiology:
Agent: Malaria is caused by four distinct species of the malaria parasite (P. vivax, P. falciparum,
P. malariae and P. ovale). In India, P. vivax causes 70% of all infections, 25-30% due to
P.falciparum, about 1% due to P. malariae and P. ovale is rarely found.
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The life cycle of malaria parasite under goes the human cycle (asexual cycle) and mosquito cycle
(sexual cycle). Man is the intermediate host and mosquito the definitive host.
The asexual cycle or schizogany starts when an infected mosquito bites an individual and injects
sporozoites. In the human cycle the parasites passes through hepatic phases and erythrocytes
phase. Sexual forms (i.e. male and female gametocytes) of the parasite develop in human host,
which are infective to mosquito.
The sexual cycle or sporogony starts when gametocytes are ingested by the mosquito during
feeding on an infected person. The gametocyte continues further development in the mosquito to
develop into an oocyst. Sporozoites liberate from mature oocyst and migrate to the salivary
glands of the mosquito. The mosquito becomes infective to man when these sporozoites are
ready to be released in the blood of the human host following the mosquito bite.
Transmission: malaria is spread to humans during the bite of an infected female anopheline
mosquito. Blood meal is required to produce eggs by female mosquitoes. Male mosquitoes do
not suck blood but feed on plant juices. Rarely malaria may be transmitted by blood transfusion,
transplacentlly (congenital malaria) or through contaminated needles.
Vector: There are 400 species of anopheline mosquitoes of which approximately 80 are proven
vectors and about 45 are effective vectors. Important vectors include Anopheles culicifacies, A.
fluviatalis, A. stephensi A. minimus, A. philippensis and A. sundaicus. A. culicifacies is
generally active in rural areas while A. stephensi is more common in urban areas.
Environment: The transmission of malaria is profoundly influenced by climate. The optimum
conditions are environment temperatures between 20 and 30
0
C and relatively humidity of at least
60 percent. Malaria transmission does not occur at temperatures below 16
0
C or above 33
0
C.
Malaria is common during rainy season because stagnant water and high humidity favor
mosquito breeding and survival.
Incubation period:
Incubation period varies depending upon the types of parasite. It is 12 days (9-14 days) for P.
falciparum, 14 days (8-17 days) for P. vivax, 17 days (16-18 days) for P. ovale and 28 days (18-
40 days) for quartan or P. malariae.
Pathophysiology:
Malarial parasites enters human as sporozoites

Migrates from peripheral blood into liver and reticulo-endothelial tissues with in 60 min of
mosquito bite.

In liver, exo-erythrocytic multiplication occur
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Sporozoites become hepatic schizonts ruptured to release thousands of merozoites into blood
stream

Merozoites penetrates the RBC and passes through the stages of trophozoites and schizont

Infected erythrocyte rupture and release morozoites into circulation infects freash RBCs
Cycle is repeated for 48-72 hrs

The infected individual become symptomatic with paroxysms of high fever

When RBCs ruptured, symptoms like hemozoin pigment and parts of unused cytoplasm are
released with merozoites

Pathological changes occur like tissue pigmentation, fatty degeneration, hypoplasia of reticulo-
endothelial system.

Clinical manifestations
The typical paroxysmal attack of malarial fever found in three stages i.e. cold stage, hot stage
and sweating stage followed by an afebrile period.
The onset of cold stage is usually found with
1. Headache
2. Nausea
3. Anorexia
4. Pain in the limbs
5. Chilly sensation followed by rigors within an hour.
6. Body temperature rises rapidly to 39-41
0
C with severe headache, vomiting, restlessness,
weakness and rapid pulse.
7. In early stage the skin feels cold and later it becomes hot. Duration of this stage is ¼ to an
one hour.
In the hot stage,
1. Patient feels too much hot and put off clothing
2. Te skin is flashed and dry.
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3. Headache become intense
4. Full pulse and rapid respiration.
5. Nausea usually diminished with presence of excessive thirst.
6. This stage last for 2-6 hours
In the sweating stage,
1. Body temperature rapidly reduces to normal with profuse sweating.
2. Skin feels cool and moist.
3. The pulse rate becomes slower.
4. The patient feels relieved and fall asleep.
5. This stage last for 2-4 hours.
The febrile paroxysms occur every 3
rd
or 4
th
day depending upon the type of parasite
involved. Diarrhea, vomiting, pain abdomen, convulsions and coma may be found in some
children. The relapse of the disease is common and is characterized by enlargement of spleen
and secondary anemia.
Neonatal malaria is not common in endemic areas due to transplacental passage of
maternal antibody (IgG). Congenital malaria may occur due to transmission of malarial
parasite from the mother or due to infected blood transfusion or by acquired infection due to
mosquito bite.
Diagnostic evaluation:
Clinical symptoms associated with travel to countries that have identified malarial risk suggest
malaria as a diagnosis. Unfortunately, many diseases can mimic symptoms of malaria (for
example, yellow fever, dengue fever, typhoid fever, cholera, filariasis, and
even measles and tuberculosis). Consequently, physicians need to order the correct special tests
to diagnose malaria, especially in industrialized countries where malaria is seldom seen.
1. The classic and most used diagnostic test for malaria is the blood smear on a microscope
slide that is stained (Giemsa stain) to show the parasites inside red blood cells. Although
this test is easily done, correct results are dependent on the technical skill of the lab
technician who prepares and examines the slides with a microscope.
2. Routine blood examination for haemoglobin (usually low).
3. WBC count (shows leucopenia).
4. Fluorescent antibody technique to detect species specific antibody (IgG)
5. Bone marrow examination.
Management of malaria
Three main factors determine treatments:
1. The infecting species of Plasmodium parasite
2. The clinical situation of the patient (for example, adult, child, or pregnant female with
either mild or severe malaria)
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3. The drug susceptibility of the infecting parasites.

Mild malaria can be treated with oral medication.
Severe malaria (one or more symptoms of either impaired consciousness/coma, severe anemia,
renal failure, pulmonary edema, acute respiratory distress syndrome, shock, disseminated
intravascular coagulation, spontaneous bleeding, acidosis, hemoglobinuria [hemoglobin in the
urine], jaundice, repeated generalized convulsions, and/or parasitemia [parasites in the blood] of
> 5%) requires intravenous (IV) drug treatment and fluids in the hospital.
1. Chloroquine phosphate (Aralen) is the drug of choice for all malarial parasites except for
chloroquine-resistant Plasmodium strains.
2. Although almost all strains of P. malariae are susceptible to chloroquine, P.
falciparum, P. vivax, and even some P. ovale strains have been reported as resistant to
chloroquine. Unfortunately, resistance is usually noted by drug-treatment failure in the
individual patient. There are, however, multiple drug-treatment protocols for treatment of
drug-resistant Plasmodium strains (for example, quinine sulfate
plus doxycycline [Vibramycin, Oracea, Adoxa, Atridox] or tetracycline[Achromycin],
or clindamycin [Cleocin], or atovaquone-proguanil [Malarone]).
3. New drug treatments of malaria are currently under study because Plasmodium species
continue to produce resistant strains that frequently spread to other areas. One promising
drug class under investigation is the spiroindolones, which have been effective in
stopping P. falciparum experimental infections.
4. Symptomatic management should be done with antipyretics and adequate fluid therapy,
orally or with IV fluid.
5. Anticonvulsive drugs and steroids may be needed.
6. Blood transfusion may be required in severe anemia
7. Other complications should be detect and to be managed accordingly.
Prevention:
If people must travel to an area known to have malaria, they need to find out which medications
to take, and take them as prescribed. Current CDC recommendations suggest individuals begin
taking antimalarial drugs about one to two weeks before traveling to a malaria infested area and
for four weeks after leaving the area (prophylactic or preventative therapy).
Doctors, travel clinics, or the health department can advise individuals as to what medicines to
take to keep from getting malaria. Currently, there is no vaccine available for malaria, but
researchers are trying to develop one.
 Avoid outbreaks: To the extent possible, travelers should avoid traveling in areas of known
malaria outbreaks.
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 Be aware of peak exposure times and places: Exposure to arthropod bites may be reduced if
travelers modify their patterns of activity or behavior. Although mosquitoes may bite at any
time of day, peak biting activity for vectors of some diseases (for example, dengue,
chikungunya) is during daylight hours. Vectors of other diseases (for example, malaria) are
most active in twilight periods (for example, dawn and dusk) or in the evening after dark.
Avoiding the outdoors or focusing preventive actions during peak hours may reduce risk.
 Wear appropriate clothing: Travelers can minimize areas of exposed skin by wearing long-
sleeved shirts, long pants, boots, and hats. Tucking in shirts and wearing socks and closed
shoes instead of sandals may reduce risk. Repellents or insecticides such as permethrin can be
applied to clothing and gear for added protection
 Bed nets: When accommodations are not adequately screened or air conditioned, bed nets are
essential to provide protection and to reduce discomfort caused by biting insects. If bed nets
do not reach the floor, they should be tucked under mattresses. Bed nets are most effective
when they are treated with an insecticide or repellent such as permethrin.
 Insecticides: Aerosol insecticides, vaporizing mats, and mosquito coils can help to clear
rooms or areas of mosquitoes
Nursing management
Nursing assessment
1. Activity / rest
Symptoms: Fatigue, weakness, general malaise
Signs: Tachycardia, muscle weakness and decreased strength.
2. Circulation
Signs: Blood pressure normal or slightly decreased. Peripheral pulse strong and rapid
(phase of fever) warm skin, diuresis (diaphoresis) due to vasodilation. Pale and moist
(vasoconstriction), hypovolemia, decreased blood flow.
3. Elimination
Symptoms: Diarrhea or constipation, decreased urine output
Signs: abdominal distension
4. Food and fluid
Symptoms: Anorexia, nausea and vomiting
Signs: Weight loss, reduced subcutaneous fat, and decrease in muscle mass. Decrease in
urine output, urine concentration.
5. Neuro Sensory
Symptoms: Headache, dizziness and fainting.
Signs: Nervousness, fear, mental chaos, disorients delirium or coma.
6. Counseling / learning
Symptoms: chronic health problems, such as liver, kidney, alcohol poisoning, history of
splenectomy, had just had surgery / invasive procedures, traumatic injury.
Supportive management
17

1. Rapid clinical assessment with respect to level of consciousness (use Blantyre coma
scale), blood pressure, rate and depth of respiration, anemia, state of hydration and
temperature.
2. Thick and thin blood films should be made. Minimal investigation should include PCV
(hematocrit), blood glucose and lumbar puncture specially in cerebral malaria. If lumbar
puncture is delayed proper antibiotic cover for meningitis must be given. Antibiotics may
also be considered if any secondary infection is suspected, which is common in severe
malaria. Start intravenous antimalarial after drawing blood.
3. Good nursing care with proper positioning, meticulous attention to airways, eyes, mucosa
and skin should be done. Appropriate fluid therapy is to be given.
4. For unconscious child nasogastric tube is to be inserted to reduce the risk of aspiration.
5. Oxygen therapy and respiratory support should be given if necessary.
6. In case of shock resuscitate with Normal saline or Ringer lactate by bolus infusion. Avoid
under or over hydration.
7. Convulsion should be treated with Midazolam /diazepam. Rectal Diazepam or Buccal
Midazolam can be used.
8. Hyperpyrexia should be treated with paracetamol, tepid sponging, and fanning.
9. Close monitoring of the vital signs preferably every 4 hours to be done till the patient is
out of danger. Also maintain intake output chart and watch for hemoglobinuria.
10. Monitoring of the response to treatment is essential. Detail clinical examination with
particular emphasis on hydration status, temperature, pulse, respiratory rate, blood
pressure and level of consciousness is to be given. Blood smear examination every 6 to
12 hours for parasitemia for first 48 hours is needed.
11. In case of quinine parasite count may remain unchanged or even rise in first 18-24 hours
which should not be taken as an indicator of quinine resistance. However, parasite count
should fall after 24 hours of quinine therapy and should disappear within 5 days
12. (xiv) In follow up cases add iron and folic acid.
Nursing Diagnosis for Malaria

1. Changes in nutrition less than body requirements related to inadequate food intake,
anorexia, nausea / vomiting
2. High risk of infection related to decreased immune system; invasive procedure
3. Hyperthermia related to increased metabolism, dehydration, direct effects on the
hypothalamic circulation of germs.
4. Lack of knowledge, about illness, prognosis and treatment needs related to lack of
exposure, the interpretation of information, cognitive limitations


Nursing Diagnosis and Nursing Interventions for Malaria
1. Changes in nutrition less than body requirements related to inadequate food intake, anorexia,
nausea / vomiting

Nursing Intervention :
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o Assess history of nutrition, including foods that are preferred. Observation and record the client's
food input.
Rational: watching caloric intake or lack of quality of food consumption.
o Give extra food to eat little and small.
Rational: gastric dilatation may occur when feeding too fast after a period of anorexia.
o Maintain a schedule of regular body weight.
Rational: Monitors the effectiveness of weight loss or nutrition intervention.
o Discuss the preferred client and input in a pure diet.
Rational: It can increase input, increase the sense of participation / control.
o Observation and record the events of nausea / vomiting, and other related symptoms.
Rational: to show the effect of GI symptoms of anemia (hypoxia) on organ.
o Collaboration with a dietitian.
Rational: Need help in planning a diet that meets nutritional needs.

2. High risk of infection related to a decrease in body systems (main defense is inadequate),
invasive procedures.

Nursing Intervention:
o Monitor body temperature increases.
Rational: Fever caused by the effects of endotoxin on the hypothalamus and hypothermia are
important signs that reflect the development status of shock / decrease in tissue perfusion.
o Observe the chills and diaphoresis.
Rational: Shivering often precedes the height of the temperature on a common infection.
o Monitor the sign deviation condition / failure to improve during therapy.
Rational: It can show Inaccurate antibiotic therapy or growth of organisms.
o Provide anti-infective medication as directed.
Rational: It can kill / give temporary immunity to common infections.
o Get specimen blood.
Rational: The identification of the causes of malaria infections.

3. Hyperthermia is related to increased metabolism of circulating germ dehydration direct effect on
the hypothalamus.

Nursing Intervention:
o Monitor patient's temperature (degree and pattern), note the chills.
Rational: Hyperthermia showed an acute infectious disease process. The pattern of fever
indicates a diagnosis.
o Monitor the temperature of the environment.
Rational: The temperature of the room / the number of sheets should be changed to maintain the
temperature close to normal.
o Give a warm compress bath, avoid using alcohol.
Rational: It can help reduce a fever, use of ice / alcohol may cause cold. In addition, alcohol can
dry the skin.
o Give antipyretics.
Rational: Used to reduce fever with its central action on the hypothalamus.
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o Give a cooling blanket.
Rational: Used to reduce fever with hyperthermia.

SARS (Severe Acute Respiratory Syndrome)

Definition:

It is a respiratory disease in humans which is caused by the SARS coronavirus (SARS-CoV).

Incubation period:

The incubation period for SARS is typically two to seven days, although in some cases it may be
as long as 10 days.

Causes of SARS:
1. A virus called coronavirus is the cause of SARS. There are many kinds ofcoronavirus,
some of which cause the common cold. The SARS coronavirus (SARS-CoV) was a new
variant that may have been transmitted to humans from animals.
2. How SARS spreads is not completely understood, but experts believe that the main way
it spreads is through close contact with an infected person (someone who has cared for or
lived with the person, or has had direct contact with their respiratory secretions and body
fluids).
3. The virus seems to be spread through aerosolized (exhaled) droplets and body secretions.
4. Patient come into contact with these materials when an infected person coughs or
sneezes.
Sign and symptoms of SARS:

Initial symptoms are flu-like include

1. Fever
2. Myalgia
3. Lethargy
4. Gastrointestinal symptoms
5. Cough
6. Sore throat and other non-specific symptoms.
7. The only symptom that is common to all patients appears to be a fever above
38 °C (100.4 °F).
8. Shortness of breath may occur later.

Less common symptoms include (also in order):

* Dizziness
20

* Productive cough (sputum)
* Sore throat
* Runny nose
* Nausea and vomiting
* Diarrhea
Diagnostic evaluation:
1. Any of the symptoms, including a fever of 38 °C (100.4 °F) or higher
2. Either a history of:
a) Contact (sexual or casual, including tattooes) with someone with a diagnosis of
SARS within the last 10 days
b) Travel to any of the regions identified by the WHO as areas with recent local
transmission of SARS

1. The chest X-ray (CXR) appearance of SARS is variable. There is
no pathognomonic appearance of SARS but is commonly felt to be abnormal with patchy
infiltrates in any part of the lungs. The initial CXR may be clear.
2. White blood cell and platelet counts are often low.
3. Other laboratory tests suggest raised lactate dehydrogenase and slightly raised creatine
kinase and C-Reactive protein levels.
4. Three possible diagnostic tests have emerged, each with drawbacks. The first,
an ELISA (enzyme-linked immunosorbent assay) test detects antibodies to SARS reliably
but only 21 days after the onset of symptoms. The second, an immunofluorescence assay,
can detect antibodies 10 days after the onset of the disease but is a labour and time
intensive test, requiring an immunofluorescence microscope and an experienced operator.
5. The last test is a polymerase chain reaction (PCR) test that can detect genetic material of
the SARS virus in specimens ranging from blood, sputum, tissue samples and stools. The
PCR tests so far have proven to be very specific but not very sensitive. This means that
while a positive PCR test result is strongly indicative that the patient is infected with
SARS, a negative test result does not mean that the patient does not have SARS.
Management of SARS:
Treatment –
1. People suspected of having SARS should be evaluated immediately by a physician and
hospitalized under isolation if they meet the definition of a suspected or probable case.
21

2. Antibiotics are sometimes given in an attempt to treat bacterial causes of atypical
pneumonia.
3. Antiviral medications have also been used. High doses of steroids have been employed to
reduce lung inflammation. In some serious cases, serum from people who have already
gotten well from SARS (convalescent serum) has been given. Evidence of general benefit
of these treatments has been inconclusive.
4. Other supportive care such as supplemental oxygen, chest physiotherapy, or mechanical
ventilation is sometimes needed.
Preventive Measures:

1. Consult a doctor promptly if there are respiratory symptoms such as fever, malaise, chills,
headache, joint pain, dizziness, rigors, cough, sore throat and runny nose.
2. Build up good body immunity. This means taking proper diet, having regular exercise
and adequate rest, reducing stress, and avoiding smoking.
3. Maintain good personal hygiene. Cover nose and mouth when sneezing or coughing.
4. Wear mask if you develop runny nose, sore throat and cough.
5. Wear protective mask in public areas, classrooms, computer rooms, public transports, and
communal areas in hostels.
6. Wash hands properly and keep them clean. Use liquid soap for hand washing and
disposable towels for drying hands.
Bibliography:-
1. Dorothy R. Marlow, “Textbook of Pediatric nursing”, 5
th
edition, Elsevier publishers,
2010, Pp 1174-1176.
2. Marilyn J. Hockenberry, “Essential of Pediatric Nursing”, 7
th
edition, Elsevier Publishers,
2007, Pp 231-237.
3. Ghai O.P, “Essential pediatrics” 6
th
edition, 2005, CBS publishers, Pp 807-810, 240-246.
4. Data Parul, “Pediatric Nursing”, 1
st
edition, 2007, Jaypee Publishers, Pp 255-258, 246-
249.
5. Samant Kusum, “Communicable Disease” 1
st
edition, 2006, Vora Publications, Pp- 10,
38
6. www.wikipedia.com
7. nursing crib.com…severe respiratory syndrome