Transcript Document 7298458

Sexually Transmitted
Diseases
Mandy Vichas RN, BSN, NPS
Scabies
Infestation of the skin by an itch mite
(Sarcoptes scabiei)
 Infestation may occur by sexual contact or
hand/finger contact
 It takes approximately 4 weeks from the
time of contact for symptoms to appear
 The most common symptom is severe
pruritis especially at night
 Secondary lesions are common
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Scabies
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Management
After showering medication is applied to the skin
from the neck down and left on for 12-24 hours
– Lindane (Kwell)
– Crotamiton (Eurax)
– Permethrin (Elimite)
Treatment is often repeated after 1 week
All clothing and bedding need to be washed in
hot water and a hot dryer. Dry-cleaning is ok.
 Pruritis may be persistent after treatment and
corticosteroid ointment or antihistamines may be
used
 All family members should be treated!
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Scabies
Gonorrhea
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Bacterial Infection of the reproductive tract
A major cause of PID, tubal infertility, ectopic
pregnancy
The average incubation period is 2-7 days
Often co-exists with chlamydia
Symptoms
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Vaginal or penile discharge
Dysuria
Itching, swelling or pain
Painful intercourse
Dysmenorrhea
50% of women have NO symptoms
Gonorrhea
Diagnosis is done by culture
Female = culture from cervix
Male = culture from penile discharge
CDC recommends the treatment for gonorrhea
and chlamydia at the same time even if only one
is confirmed
 Antibiotics
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– Rocephrine
– Cipro
– Floxin
Gonorrhea of the Eye
Gonorrhea Discharge
Chlamydia
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Bacterial infection of the reproductive tract
Increased risk for ectopic pregnancy and infertility
As many as 40% of untreated women develop PID
Often co-exists with gonorrhea
Often produce no symptoms
– Cervical discharge
– Dysuria
– Bleeding
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CDC recommends the treatment for gonorrhea and
chlamydia at the same time even if only one is confirmed
due to the likelihood of concurrent infections (25%)
– Doxycylcine
– Zithromax
Syphilis
Acute and chronic infections disease caused by
the spirochete Treponema pallidum
 It is acquired through sexual contact or may be
congenital
 Three stages
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– Primary
– Secondary
– Tertiary
Syphilis
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Primary
– 2-3 weeks after inoculation a chancre develops
 A painless round lesion at the site of infections
– Untreated these lesions generally resolve spontaneously in 2
months
– During this time may have headache or locally enlarged nodes
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Secondary
– Spread of organisms from the primary lesion to a generalized
infection
– Skin rash on trunk & extremities (including palms and soles)
occurs 2 - 8 wks after the primary chancre
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hair loss
fever
malaise
sore throat
lymphadenopathy
May feel well
– Serology tests are positive at this stage
Syphilis
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Latency
– No signs or symptoms of active infection
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Tertiary
– 20 – 40% don’t exhibit any symptoms
– Slowly progressive inflammatory disease that affects
multiple organs
– Aorta
– Nervous system
– Stroke
– Generally not infectious at this late stage
– Fatal due to circulatory insufficiency, neurosyphilis,
aortic or joint problems
Syphilis
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Diagnosis is done by direct identification
of the spirochete obtained from the
primary lesion or serology tests
(secondary and tertiary)
– VDRL
– rapid plasma reagin circle card test
– FTA_ABS & MHA-TP
Syphilis
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Treatment is generally with penicillin
– PCN-G IM x 1 (early & early latent)
– PCN-G IM x 3 at 1 week intervals (late latent
& latent of unkown duration)
Doxycycline if allergic to PCN
 Serology tests are repeated every 3
months for 1-2 yrs.
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Primary Syphilis
Secondary Syphilis
Genital Herpes (Type II)
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Considerable overlap between type I & type II
– Clinically indistinguishable
– Can be transmitted asexually from wet surfaces or by self
transmission
– Incubation period is generally 1-2 weeks
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Symptoms
– Blisters
– Flu-like symptoms
– Dysuria
Viral infections are not curable but treatment is aimed at
symptom management
 Condoms for sexual intercourse to prevent transmission
 Antivirals
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– Zovirax
– Valtrex
– Famvir
Oral HSV II
Genital HSV II
HPV
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Human papillomavirus is the most common STD
among young sexually active people
More than 80 strains exist
Infections can be latent, sub-clinical, or clinical
most common strains are 6 & 11 which usually
cause condylomata (genital warts)
Strains 16, 18, 31, 33 increase the risk for
cervical cancer
50% of all cervical cancers are caused by strains
16 & 18
HPV
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Treatment may involve topical agents
– Podofilox (Condylox)
– Imiquimod (Aldara)
– Podophyllin (Podofin)
Chemotherapeutic agents
 Injections of interferon
 Electrocautery
 Laser removal
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Gardisil Vaccine
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Gardisil is a cervical cancer vaccine that helps
protect against 4 types of human papillomavirus
For girls and young women ages 9 to 26.
Is not for women who are pregnant.
Does not treat cervical cancer or genital warts.
It is important to continue routine cervical
cancer screenings.
The side effects include pain, swelling, itching,
and redness at the injection site, fever, nausea,
dizziness, vomiting, and fainting.
Gardisil is given as 3 injections over 6 months.
Genital Wart
Bacterial Vaginosis
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Caused by an overgrowth of anaerobic bacteria
& Gardnerella vaginalis normally found in the
vagina in the absence of lactobacilli
Characterized by a fish-like odor that is
particularly noticeable after intercourse or
menstruation
Usually accompanied by gray to yellowish-white
discharge
50% are asymptomatic
Treatment
– Flagyl
– Cleocin vaginal gel
Candidiasis
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A fungal or yeast infection caused by strains of Candida
Symptoms include
– Watery or thick discharge which has a white cottage-like
appearance
– Pruritis
– Irritation of the skin
– Symptoms are usually more severe before menses
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Infection is less responsive to treatment during
pregnancy
Diagnosis is done by microscopic examination
Treatment
– antifungal agents such as nystatin, Gyne-Lotrimin, used with a
vaginal applicator
– These over the counter RX should be used judiciously and not
unless woman is certain of her diagnosis or if relief not obtained
after using
– Diflucan one pill dose relief within 3 days
Oral Candidiasis
Genital Candidiasis
Facial Candidiasis
Trichomoniasis
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Caused by flagellated protozoan
Second most common STI in the US
Symptoms include
– Vaginal discharge (Thin sometimes frothy, yellow to
yellow green)
 Malodorous & very irritating
Pelvic exam often reveals vaginal & cervical
erythema & multiple small petechiae (strawberry
spots)
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– Flagyl for both partners
– must abstain from alcohol while taking flagyl due to
unwanted side effects
Trichomoniasis
Pelvic Inflammatory Disease (PID)
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Inflammation of pelvic cavity
Can be caused by gonorrhea or chlamydia (most likely)
Can also occur post-partum or post abortion or post
invasive procedures (biopsy or hysteroscopy)
Symptoms: may be acute & severe or low grade & subtle
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discharge
back or abdominal pain
fever
nausea
dysmenorrhea
pain with intercourse or pelvic exam
Pelvic Inflammatory Disease (PID)
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Complications
– Generalized peritonitis
– Abcesses
– Strictures & scar tissue = fallopian tube obstruction = possible ectopic
pregnancy or sterility
– Adhesions,
– Chronic pelvic pain
– Septic shock, bateremia, thrombophlebitis
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Nursing Implications
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Bedrest in semi-fowler’s to promote drainage
Antibiotics IV
Local heat & analgesics for pain management
if abdominal distention or paralytic ileus may require NG with suction
Monitor vital signs
Monitor characteristics and amount of vaginal drainage
Good peri care
Tampons are NEVER used with any presence infection
treatment of partners
HIV/AIDS
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In 1982 CDC issued first definition of AIDS after the first
100 cases were reported
Since then definition has been revised a number of times
African Americans: 50% of all cases of both 2003
Males 72% of cases
worldwide AIDS kills 8,000 people/day; 1 person/10 secs
(UNAIDS, 2006)
2005 newly infected HIV adults 50/50 men/women
unsafe sex predominant mode
earliest confirmed case was in 1959 in blood drawn from
African man
HIV mutates quickly @ a relatively constant rate with
1% of the virus’s genetic material changing annually
HIV
People with AIDS-indicator conditions (clinical
category C) and those in categories A3 or B3 are
considered to have AIDS
 Period from infection with HIV to the
development of antibodies to HIV is known as
primary infection
 Symptoms of viremia range from none to severe
flu-like symptoms
 Balance between amount of HIV in body &
immune response is viral set point
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HIV/AIDS
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Transmission
Body fluid containing HIV or infected CD4+ lymphocytes
Fluids include blood, seminal fluid, vaginal secretions, amniotic fluid
& breast milk
Mother to child transmission of HIV-1 may occur in utero at the time
of delivery, or through breast feeding although most perinatal
infection thought to occur after exposure during delivery
Because HIV is harbored within lymphocytes, any exposure to
infected blood cells results in a significant risk of infection
Donated blood is tested for antibodies to HIV-1, HIV-2
Blood donated during window period (period of time between initial
infection with HIV & development of a + test for HIV) after
infections is infectious even though it tests negative window can last
up to 1 year
HIV/AIDS
There are more than 20 approved
antiretroviral agents belonging to 4 classes
used to design combination regimens
containing at least 3 medications
 Patients may be given drug holidays (7
days) if their CD4 count is 500800cells/m3
 Medications are resumed if the CD4 count
falls below 350-400cells/m3
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The HIV Antibody Test
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The most common and most accurate test to determine if someone
is infected with HIV is the HIV antibody test. The test actually
consists of two tests: a screening test and a confirmatory test. The
screening test procedure is called an ELISA -- Enzyme Linked
Immuno-Sorbent Assay or an EIA (Enzyme Immunosorbent Assay).
The confirmatory test procedure used is either a Western Blot Assay
(WB) or an Indirect Immunofluorescense Assay (IFA). The screening
and confirmatory tests are usually done using small samples of
blood. If a sample of blood tests positive repeatedly in the screening
test, it will be confirmed through the Western Blot test. Except
when rapid testing is done, test counselors inform people they are
infected with HIV only after both the screening and confirmatory
tests have shown a positive (reactive) result.
Positive HIV antibody tests results are over 99% accurate when
confirmed. Negative HIV antibody tests are over 99% accurate if it
has been at least three months after a contact with a potentially
HIV-infected partner. False negatives or false positives occur rarely.
The window period
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The time period between a person's actual infection with HIV and
until HIV antibodies become detectable in blood or other fluids is
called the "window period". Most people will develop antibodies
detectable with the latest blood tests within 4-6 weeks after
infection with HIV. Some people may take longer; but nearly all
(99%) will have antibodies by 3 months following infection.
Therefore, we recommend that people wait 3 months from
the time of the possible infection with HIV (the date of
latest exposure) before being tested for HIV antibodies. The
test may not give an accurate negative result if a person
gets tested too soon after a potential exposure.
People waiting three months from the time of the exposure before
testing will have a 99% accurate test result. Very rarely, cases have
been reported of people taking longer than three months to develop
antibodies to HIV.
Rapid testing for HIV
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The FDA approved a rapid test for detecting HIV
antibodies in 1996. The technology used to perform this
test is called the Single Use Diagnostic System (SUDS)
for HIV. This system is a screening test using a small
sample of blood, comparable to the ELISA/EIA. It is
more than 99% accurate when used 3 months after
possible exposure; however, positive results on a SUDS
test need to be confirmed by the usual Western Blot or
the Immunoflourescence Assay confirmation tests
performed on blood. The results of the SUDS test for
HIV are available after 15-30 minutes, but only negative
results can be reported at that time. Positive results are
provided tentatively, based on the prevalence of HIV
infection in the subject’s risk group.
Advantages
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The obvious advantage of rapid HIV testing is that people who are
negative for HIV can get results right away.
Research has shown that these tests are more acceptable to people
at high-risk than the standard HIV test, because it eliminates the
week of anxiety that people experience while waiting for results.
People involved in high risk behavior can also learn that they are
probably HIV-infected when their SUDS is positive. They are more
likely to come back to receive their final test results and get help
with partner notification, than those who test with the standard
method.
In certain situations such as occupational exposure, rape or prenatal
care and delivery, rapid identification of HIV infection can result in
timely initiation of antiviral treatment, which may prevent HIV
infection.
Disadvantages
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Positive results from the rapid HIV test need to be confirmed by
another test, which takes up to one week.
There can be a fairly high level of false positives when the rapid
tests are used in lower-risk populations. The level of anxiety in
those initially testing positive by the rapid test may be higher than
those awaiting results of the regular test..
The rapid tests also cost more than the regular antibody test.
However, since so many more people receive test results with rapid
testing, it has been shown to be cost-effective in high-risk
populations.
Rapid testing is currently being used in publicly funded out-reach
testing, and its use will likely continue to expand as less expensive
and more simple rapid tests become available (several are currently
going through clinical trials).
Stages of HIV/AIDS
Based on clinical history, physical examination, lab
evidence of immune dysfunction, signs & symptoms,
infections & malignancies
 Includes rating of CD4+ T-Cell category (AIDS indicator
T-cell count)*
 Stages
 A: asymptomatic, acute (primary) HIV or PGL
(persistent generalized lymphadenopathy)
 B: symptomatic, (not A or C conditions)
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– 1. Condition is due to HIV infection or defect in cellular immunity
– 2. Is considered to have a course that is complicated by HIV
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C: AIDS
– 1. When CD4+ T-cell level is <200cells/m3
– 2. CD4+ T-cells <14% of total lymphocytes
Pneumocystis Carinii Pneumonia
(PCP)
Respiratory infection: pneumocystis
jiroveci is the causative organism
 Most common opportunistic infection
 Symptoms may include SOB, dyspnea,
cough, chest pain & fever
 Diagnosis is done by biopsy, sputum
induction & bronchial-alveolar lavage
 In some cases dramatic onset can lead to
respiratory failure in 2 – 3 days but often
takes weeks-months
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Tuberculosis
Tends to occur in IV/injection drug users
 TB occurs late in HIV infection
 Absence of an immune response to TB
skin test (anergy)
 Immune reconstitution (paradoxical
reactions) may occur
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– Includes high fever, worsening symptoms of
active TB infection or appearance of new
symptoms weeks after Rx. therapy
Chest X-Ray of Tuberculosis
Mycobacterium Avium Complex
(MAC)
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Usually causes respiratory infection caused
by a group of acid-fast bacilli
– M. avium
– M. intracellulare
– M. scrofulaceum
Also often found in GI tract, lymph nodes
& bone marrow
 Associated with rising mortality rates in
HIV patients
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GI Complications
Symptoms include anorexia, N & V,
chronic diarrhea in 50 – 90% of pts.
 Candidiasis
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– Can affect oral & whole GI tract
– Dysphagia & stomatitis (creamy white
patches)
– Generally treated with antifungals
Wasting Syndrome
Profound involuntary weight loss >10% of
baseline body weight OR:
 Chronic diarrhea >30 days OR:
 Chronic weakness
 Caused by intermittent or constant fever
in the absence of concurrent illness
 Cytokine induced fever accelerates the
metabolism 14% for every 1 degree F
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Wasting Syndrome
Kaposi’s Sarcoma (KS)
AIDS patients have higher incidences of cancer
 Kaposi’s Sarcoma (KS)
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Most common HIV-related malignancy
Associated with herpes virus (HIHV-8) transmission
May be first sx. of HIV infection
Cutaneous lesions can appear anywhere on body and
are usually brownish pink to deep purple
Can lead to venous stasis, lymphedema & pain
based on location & size
 Diagnosis is confirmed by biopsy
 May be treated with radiation therapy
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Kaposi’s Sarcoma
B-Cell Lymphomas
Second most common malignancy in AIDS
 Tends to develop outside lymph nodes,
most commonly in the brain, bone
marrow, & GI tract
 Requires aggressive chemotherapy
treatment.
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– Less successful than in general population r/t
hematologic toxicity
HIV Encephalopathy
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80% of all pts with AIDS have some form of neurologic
involvement during HIV infection
HIV Encephalopathy
– Clinical syndrome resulting in progressive decline in cognitive,
behavioral & motor functions
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HIV triggers the release of toxic lymphokines that result
in cellular dysfunction or interference with
neurotransmitter function
– Early symptoms may include memory deficits, progressive
confusion, psychomotor slowing, apathy & ataxia
– later symptoms may include global cognitive impairments
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Difficult to diagnose but can be done by CT, MRI, CSF,
brain biopsy
Cryptococcus Neoformans
(cryptococcal meningitis)
Fungal infection
 Symptoms include fever, headache,
malaise, stiff neck, N & V, mental status
changes & seizures
 Confirmed by CSF analysis
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Progressive Multifocal
Leukoencephalopathy (PML)
Demyelinating disorder that affects the
oligodendroglia
 Occurs in about 3% AIDS pts.
 Causes mental confusion & rapidly
progresses to include multiple CNS
symptoms including blindness, aphasia,
muscle weakness, paresis, & death
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HIV/AIDS NURSING CARE
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Assessment
ID persons at risk r/t
Accurate sexual history including behaviors & other risk
factors
Substance abuse
Tattoos
Acupuncture
Blood products
Encourage testing in patients that are high risk or have
not been tested
Diagnosis & Outcomes is r/t stage of illness & individual
Implementation
Prevent Infections
 Constant observation of universal
precautions
 Meticulous hygiene
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Implementation
Basic Care
TCDB
 Good skin care
 elevate edematous limbs
 emollients to prevent drying of skin
 skin lesions washed with separate cloth, wear gloves
 Monitor alterations in body temperature caused by
dehydration or infection
 Monitor for temp. elevation every 4 hr.
 Provide adequate fluid
 Patients may have persistent fevers without known
cause
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Implementation
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Promote optimal nutrition
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Dysphagia
N&V
Diarrhea
Depression
Food preferences
Daily weights + I & O
Good oral hygiene
Provide socialization with eating
May need parenteral nutrition
May need help with shopping & food preparation
Implementation
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Assist with coping (begin early) r/t anxiety,
uncertainty anger, denial, hopeful/hopelessness
Assist with education & reality
Realistic goal setting
Encourage patient participate in self care &
direction of care
Minimize isolation
Be a good listener
Help the patient find support resources
Mandatory Reporting
Public health surveillance is the collection, investigation and distribution
of data about illness and death. This surveillance helps prevent and control
disease in Washington State.
 Surveillance is used to protect and improve the health of the public by:
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describing disease trends
identifying and controlling the sources of infection;
educating the public
preventing disease.
In Washington State, legal requirements for disease reporting form the
foundation for disease surveillance and require health care providers, health
care facilities, laboratories, veterinarians, food service establishments, child
day care facilities, and schools to notify public health authorities of
suspected or confirmed cases of selected diseases or conditions. These are
referred to as notifiable conditions.
Local health jurisdictions are required to report information regarding those
illnesses or deaths to DOH, which in turn sends disease reports to the
Centers for Disease Control and Prevention (CDC). This system is necessary
to provide local, statewide and national disease incidence and trends in
order to guide public health activities.
http://www.doh.wa.gov/notify/
Notifiable Conditions
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AIDS
Chancroid
Chlamydia
Gonorrhea
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis, unspecified
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Herpes
HIV Infection
Meningococcal
disease
Rare diseases
Syphilis
Trichinosis
Tuberculosis