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DIPHTHEDIPHTHE
RIARIA
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An acute, highly
contagious toxin-mediatedinfection caused by
Corynebacteriumdiphtheriae, a gram-
positive, aerobic rod that
usu. infects the respiratorytract; primarily the tonsils,
nasopharynx, & larynx,
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Infected humans
Weakened
Humans
C. diphtheriae
Discharges from mucous
membranes of
nose and nasopharynx,
skin, & other lesions
Airborne droplets,
direct
contact,
contaminated
fomites, & raw milk
Respiratory
Integumentary
CHAIN
OFINFECTIO
N
INCUBATION
PERIOD: Usu.
2-5 days,
possibly longer
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HUMANANATOMYHUMANANATOMY
& PHYSIOLOGY& PHYSIOLOGY
(UpperRespiratory(UpperRespiratory
Tract)Tract)
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RISKRISK
FACTORFACTORSS
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PREDISPOSING RISKFACTORS:
Poor sanitation
Crowded living conditions
Limited access to healthcare
Lack of periodic boosterimmunizations
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PRECIPITATING RISKFACTORS:
Direct contact with infected
person, carrier, orcontaminated articles
Use of contaminated objects
from diphtheria-infected people Ingestion of unpasteurizeed
milk
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PATHOGENPATHOGEN
ESISESIS
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Colonizes in the
mucosal surface &
multiply
Bacteria release a toxin
Diphtheria toxin is
absorbed to themucous membranes
Destruction of
epithelium (tissue
necrosis
RISK FACTORS
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Embedded in exuding
fibrin & red & white cells
Psuedomembrane
formation
DIPHTHERIANASAL:
Resembles common cold;serosanguineous
mucopurulent nasal
discharge w/o constitutional
symptoms
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TONSILLAR/PHARYNGEAL:
Thick, patchy, smooth, adherent white/
grayish memrane over the mucous
Low-grade fever
Malaise
Anorexia
Headache Sore throat
Malodorous breath
Dysphagia
Swollen & tender cervical lymph nodes(lymphadenitis) possibly pronounced w/
warm & swollen neck (bulls neck)
Increased weak pulse
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LARYNGEAL:
Fever
Hoarseness
Rasping cough (and other symptoms similar to
croup)
W/ or w/o other sings listed
(potential airway obstruction)
Restlessness
Apprehensive
Dyspneic (suprasternal) retractions
Tachypnea
Cyanosis
Stridor
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CUTANEOUS:
Skin lesions resemble
impetigo
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CLINICALCLINICAL
MANIFESTATIOMANIFESTATIONSNS
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Headache
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Low-
grade
fever
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Anorexia
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Thick, patchy,smooth,
adherent
white/ grayish
memrane
over themucous
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Swollen & tender cervical lymph nodes
(lymphadenitis) possibly pronounced w/
warm & swollen neck (bulls neck)
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Skin lesions resemble impetigo
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SIMPLE CRITICAL THINKING:
As a nurse caring for a patient
with diphtheria, what should bekept at bedside?
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Suction equipment,Tracheostomy tray andEpinephrine
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DIAGNDIAGN
OSISOSIS
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Examination showing the
characterisic membrane and athroat culture, or culture ofother suspect lesions growing
C. diptheriae in an enzyme-linked immunosorbentasssay( E:LISA) orthe Elek
test (toxigencity test),confirm the diagnosis. Gram-stain or immunofluorescent
antibody stains may also be
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THERAPEUTICTHERAPEUTIC
MANAGEMENTMANAGEMENT
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Diphtheria antitoxin (IM; usu.
IV); preceded by skin orconjunctival test to r/o
sensitivity to horse serum
Antibiotics (penicillin/erythromycin)
CB
R(for prevention ofmyocarditis)
Tracheostomy for airway
obstruction
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COMPLICATICOMPLICATI
ONSONS
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o Thrombocytopenia
oNeurologic involvement(primarily affecting motor fibers
but possibly also sensory
neurons)
o Renal involvement
o Pulmonary involvement(bronchopneumonia)
o Myocarditis (2nd wk.)
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NURSINGNURSING
CONSIDERATICONSIDERATIONSONS
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Preventing Spread of
Infection
Maintain and stress the need
for strict isolation in hospital
Teach proper disposal ofnasopharyngeal secretions
Maintain infection precautions
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SIMPLE CRITICAL
THINKING: When can
we say a patient is
free from C.
diphtheriae?
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Maintain infection precautionsuntil after three consecutive
negative cultures at least 24hours apart, with the firstculture being at least 24 hours
after the completion ofantimicrobial therapy.
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SIMPLE CRITICAL
THINKING:How about
those whom the patient
had close contact with?
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Nasopharyngeal and throat cultures are alsoobtained from all close contacts.
Symptomatic clients are isolated andtreated until two negative throat culturesare obtained.
Asymptomatic disease carriers areconfined to home until at least 3 days ofantibiotic therapy have been completed.
Booster shots are given to people who
were immunized 5 or more yearspreviously. Unimmunized contacts aretreated with immunization andantibiotics.
All contacts, including hospital personnel,
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Monitoring and Preventing
Complications
Administer complete care tomaintain bed rest
Observe respiration for signsof obstruction (esp. inlaryngeal diphtheria) and beready to give immediate lifesupport, including intubation &tracheostomy
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Be alert for signs ofmyocarditis, such as
development of heart murmursorECG changes. Ventricularfibrillation is a common causeof sudden death in diphtheriapatients
Watch for signs of shock, w/ccan develop suddenly
If neuritis develops, tell thepatient its usually transient. Beaware that peripheral neuritis
may not develop until 2 to 3
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Patient Comfort
Limit the diet to liquids and soft
foods
Throat irrigation and fluids
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Collaborative Nursing
Considerations Have patient participated insensitivity testing; haveepinephrine (1:1,000) readilyavailable
Give drugs as ordered. Aftergiving antitoxin or penicillin, be
alert for anaphylaxis; keepepinephrine 1: 1,000 andresuscitation handy. In patients
who receive erythromycin,
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Use suctioning as neededAdminister humidified 02 if
prescribed
Serial ECGs should beperformed twice weekly for4to 6 weeks to watch for
myocarditis Obtain cultures as ordered
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Stress the need for childhood
immunizations to all parents.
Report all cases of diphtheriato local public health
authorities.
Prevention
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SIMP
LE
RECALL:What is the
schedulingofdiphtheria
immunization basedfrom EPI?
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At 6 weeks, infants are given 0.5mL ofDPT vaccine IM at upper
outer portion of the thigh.T
hisimmunization has 3 doses with4 weeks interval..
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Diphtheria infection doesntconfer immunity, therefore
diphtheria immunization shouldbe given duringconvalescence.
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RELATEDRELATED
JOURNALJOURNALSS
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Effect of a single tetanusEffect of a single tetanus--diphtheriadiphtheria
vaccine dose on the immunity of elderlyvaccine dose on the immunity of elderly
people in SoP
aulo, Brazilpeople in SoP
aulo, BrazilAbstractEpidemiological data regarding tetanus and diphtheriaimmunity in elderly people in Brazil are scarce. During the FirstNational Immunization Campaign for the Elderly in Brazil inApril 1999, 98 individuals (median age: 84 years) received onetetanus-dyphtheria (Td) vaccine dose (Butantan Institute, lotnumber 9808079/G). Inclusion criteria were elderly individualswithout a history of severe immunosuppressive disease, acuteinfectious disease or use of immunomodulators. Bloodsamples were collected immediately before the vaccine and 30days later. Serum was separated and stored at -20oC untilanalysis. Tetanus and diphtheria antibodies were measured bythe double-antigen ELISA test. Tetanus and diphtheriaantibody concentrations lower than 0.01 IU/mL wereconsidered to indicate the absence of protection, between 0.01and 0.09 IU/mL were considered to indicate basic immunity,and values of 0.1 IU/mL or higher were considered to indicatefull protection. Before vaccination, 18% of the individuals weresusceptible to diphtheria and 94% were susceptible to tetanus.
After oneT
d dose, 78% became fully immune to diphtheria,13% attained basic immunity, and 9% were still susceptible to
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Although one Td dose increases immunity to diphtheria
in many elderly people who live in Brazil, a complete
vaccination series appears to be necessary for the
prevention of tetanus.
Key words:E
lderly,T
etanus,D
iphtheria, Immunization
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Fin.Fin.
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