Sandra Lin, M.D.

• Professor of Otolaryngology - Head and Neck Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0018013/sandra-lin

To meet his early nutritional demands for protein cholesterol levels canada normal buy simvastatin overnight, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much of protein every 24 hours Early indicators of late-stage septic shock include all of the following except: a cholesterol numbers ratio calculator generic simvastatin 10 mg amex. The two age groups that have increased morbidity and mortality from burn injuries are: and cholesterol medication for triglycerides buy discount simvastatin 20 mg. The overall mortality rate (all ages and total body surface area for burn injuries) is: cholesterol levels too low buy simvastatin 40 mg on-line. The severity of burn injury and likelihood of survival is dependent on seven factors cholesterol vegetables best simvastatin 20mg. Name four: cholesterol levels vldl generic 20 mg simvastatin visa, and. Burn injuries are classified according to: and. List two pulmonary complications that occur secondary to inhalation injuries: and. The leading cause of death in thermally injured patients is:. The resuscitation goal of fluid replacement therapy, postburn injury, is a urinary output of:. The three major bacteria responsible for infection in burn centers are:, and. Three commonly used topical antibacterials for skin care are:, and. List four signs of sepsis, postburn:, and. Explain why the survival rate for burn victims has increased significantly over the last 10 years. Explain the pathophysiology of a burn injury specific to the following system alterations: cardiovascular, fluid and electrolyte, pulmonary, renal, and gastrointestinal. Describe general emergency procedures that a nurse should employ at the burn scene. Discuss general nursing actions for six nursing diagnoses for care of a patient during the emergent phase of burn injury. Distinguish between the purposes and nursing implications for biologic dressings (homografts and heterografts) and biosynthetic and synthetic dressings. Describe the appearance of hypertrophic and keloid scars and measures to prevent their formation. Discuss why congestive heart failure is a potential complication of an acute burn. For each nursing diagnosis, list goals, nursing actions, rationale, and expected outcomes. Aimee, a 9-month-old child, climbed onto a stove where an electric range was on high. Her pajamas caught fire, and she was burned over 60% of her body (excluding her face and neck) with second and third-degree burns. Her mother managed to extinguish the flames and immerse her in a sink of cool water before emergency help arrived. Brad, a 12-year-old child, sustained full-thickness burns on his upper chest, face, and neck when he was trying to start a charcoal fire to prepare dinner for his father. His father sprayed him with water from a hose and took him to a hospital emergency department 3 miles away. The muscles of the eyeball are innervated by all of the following cranial nerves except cranial nerve: a. During a routine eye examination, a patient complains that she is unable to read road signs at a distance when driving her car. Increased ocular pressure, resulting from optic nerve damage, is indicated by a reading of: a. When assessing the visual fields in acute glaucoma, the nurse would expect to find a: a. Pharmacotherapy for primary glaucoma that decreases the outflow of aqueous humor would include all of the following except: a. A visual acuity exam result of 20/100 is interpreted to mean:. List four common causes of visual impairment or blindness in those over the age 40:, and. The second leading cause of irreversible blindness in the world is:. Two significant changes in the optic nerve in glaucoma are: and. The most common laser surgeries for glaucoma are: and. According to the World Health Organization, the leading cause of blindness in the world is:. An initial treatment for a splash injury to the eye would be:. Three microorganisms that most commonly cause bacterial conjunctivitis are:, and. A characteristic sign of viral conjunctivitis is. One of the most serious ocular consequences of diabetes mellitus is:. Explain the clinical manifestations of altered vision seen in those with cataracts. Describe the clinical manifestations and surgical management for retinal detachment. Distinguish between the following surgical procedures: enucleation, evisceration, and exenteration. A chronic inflammation of the eyelid margins Formation of scales and granulations on the eyelashes White eyelashes may result from this condition Staphylococcus aureus may be a primary infecting organism 1. Elise lives with her daughter in a three-story house and has rheumatoid arthritis. As part of an oral history, the physician tries to determine whether Marcella has any of the common factors that contribute to cataract development, such as:, and. Marcella, during her history, told the physician that she was experiencing the three common symptoms found with cataracts:, and. On ophthalmic examination, the physician noted the major objective finding seen with cataracts:. The physician decided to perform, the most preferred technique for cataract surgery. Postoperatively, Marcella knows that she will need to avoid lying on the side of the affected eye for a period of. Mechanical vibrations are transformed into neural activity so that sounds can be differentiated by the: a. To straighten the ear canal for examination, the nurse would grasp the auricle and pull it: a. The critical level of loudness that most people (without a hearing loss) are comfortable with is a decibel (dB) reading of: a. The physician ordered an examination of the middle ear to assess muscle reflex to sound. A hearing loss that is a manifestation of an emotional disturbance is known as what kind of hearing loss The minimum noise level known to cause noise-induced hearing loss, regardless of duration, is: a. What is the occurrence of hearing impairment, at birth, which is related to genetic factors 50% of the time It is projected that by 2050 what percentage of people over 55 years of age will have some form of hearing loss Nursing instructions for a patient suffering from external otitis should include the: a. A tympanoplasty, the most common procedure for chronic otitis media, is surgically performed to: a. Postoperative nursing assessment for a patient who has had a mastoidectomy should include observing for facial paralysis, which might indicate damage to which cranial nerve Distinguish between three tests used to evaluate gross auditory acuity: the Rhine test, the Weber Test, and the Whisper Test. Distinguish between three inner ear conditions: vertigo, nystagmus, and motion sickness. Distinguish between three types of hearing aids: behind the ear, in the ear, and in the canal. Preoperatively, the physician reviews the results of the audiogram and assesses for the presence of associ ated ear problems, such as:, and. Identify four major preoperative nursing goals for the patient:, and. Postoperatively, it is common for the patient to experience:. Two important signs of infection are: and. Manipulation of the semicircular canals during surgery may result in the symptom of: a. The patient is advised that it is normal to hear popping and crackling sounds in the affected ear for about: a. The patient is taught to prevent activities that increase intracranial pressure for 2 to 3 weeks after surgery, such as:, and. The basic pathophysiology causing the triad of symptoms listed in the previous question is:. The most common and disrupting clinical symptom of this disease is:. The lobe of the cerebral cortex that is responsible for the understanding of language and music is the: a. Voluntary muscle control is governed by a vertical band of motor cortex located in the: a. The major receiving and communication center for afferent sensory nerves is the: a. The preganglionic fibers of the sympathetic neurons are located in those segments of the spinal cord identified as: a. The parasympathetic division of the autonomic nervous system yields impulses that are mediated by the secretion of: a. To reduce leakage of cerebrospinal fluid after myelography with an oil-based medium, the patient lies down for 12 to 24 hours in what position Patient preparation for electroencephalography includes omitting, for 24 hours before the test, all of the following except: a. For a lumbar puncture, the nurse should assist the patient to flex his or her head and thighs while lying on the side so that the needle can be inserted between the: a. After a lumbar puncture, the nurse knows to assess for the most common (30% occurrence) complication of a(an): a. Demonstrate, on a classmate, how to examine the following reflexes: deep tendon, biceps, triceps, brachioradialis, patellar, and Achilles. The first priority of treatment for a patient with altered level of consciousness is: a. The most severe neurologic impairments are evidenced by abnormal body posturing defined as: a. An indicator of compromised respiratory status significant enough to require mechanical ventilation for an average-weight adult patient with a neurologic dysfunction would be: a. A nurse assessing urinary output as an indicator of diabetes insipidus knows that an hourly output of what volume over 2 hours may be a positive indicator Long-term use of antiseizure medication in women leads to an increased incidence of: a.

The safe handling of needles and other sharp objects is a part of the Standard Precautions created to prevent health care workers from exposure to blood borne pathogens cholesterol lowering foods benecol generic 10mg simvastatin free shipping. Important Facts: Safety devices on needles and other sharps should be used directly after use cholesterol levels in europe purchase cheapest simvastatin and simvastatin. Any used needles cholesterol levels menopause cheap simvastatin 10 mg online, or other contaminated sharps should be discarded in a leak-proof cholesterol levels high during pregnancy best order for simvastatin, puncture-resistant sharps container that is red and has a biohazard label cholesterol diet chart india cheap simvastatin 5 mg on line. Sharps containers should be disposed of after the container is 2/3 full or when contents are at the full line indicated on the containers cholesterol medication lipitor side effects safe 10mg simvastatin. Cleaning and Disinfecting: Patient care areas such as waiting rooms, and additional areas where patients may potentially contaminate surfaces or objects that may be exposed to staff or other patients, i. Unless visibly soiled with blood or body fluids, floors and walls may be routinely cleaned with a detergent or a detergent/disinfectant product. Cleaning surfaces first must happen prior to disinfection since most disinfectants do not adequately clean dirt and organic matter. A wet a cloth should be used with the disinfectant, then wipe away the dirt or organic material. Follow with a clean cloth and apply the disinfectant to the area or item and allow air-drying for the time specified by the product manufacturer. Clostridium Difficile and Norovirus are not in-activated by commercial disinfectants used routinely in local public healthcare settings. When contamination with these pathogens is suspected, a bleach solution (1:10) is recommended for disinfecting contaminated surfaces and items. Subcutaneous tissue: meaning: for "beneath the skin" is the lowest-most layer of the integumentary system in vertebrates. Cardiovascular System: the Heart: the heart is known to beat greater than 100,000 times a day, circulating approximately 6 Liters of blood through the body. The right side of the heart pumps oxygen-deprived blood to the lungs (pulmonary circulation) while the left side pumps oxygen-rich blood to the rest of the body (systemic circulation). The aorta, the largest artery in the body, branches off to all other arteries of the body. As they continue to branch, they become smaller and smaller until they become arterioles. Capillaries: provide the cells with oxygen and nutrients and they transport cellular wastes away for elimination. The superior vena cava is directly connected to the right side of the heart at the right Atria. The Right Atria: After the blood reaches the right atria, it circulates through the right ventricle to the pulmonary artery and then to the lungs for re-oxygenation. After this oxygenation, the blood flows through the pulmonary veins to the left atrium, the right ventricle, and the aorta and the arterial system of the body. The Peripheral Vasculature Layers: Tunica Adventitia: Outer layer of connective tissue Tunica Media: Middle layer of smooth muscle Tunica Intima: Innermost layer of single smooth, flat endothelial cells the arteries carry blood away from the heart first to the lungs, then to the entire body. They are more muscular than veins, dilate and constrict to maintain blood flow, moves blood faster and under more pressure than in veins, carry oxygenated-blood that is bright cherry red in appearance. They carry three times more blood than arteries due to their ability to distend, they contain valves to prevent back-flow due to low pressure of the system, and they carry partially de-oxygenated blood so its appearance is dark red. Without plasma, blood cells would have no medium to travel on as they moved through the body. With this special design, it helps in the transportation of proteins, glucose, hormones and minerals required for the proper functioning of the body. It is plasma that collects the carbon dioxide released by the cells and transports it to the lungs to be breathed out. Plasma is around 90% water, with proteins, minerals, waste products, clotting factors, hormones, and immunoglobins making up the other 10%. Remarkably, the cell is the smallest unit of life that is classified as a living thing, and is often called the building block of life. They fall into three general categories: Red Blood Cells (Erythrocytes), White Blood Cells (Leukocytes), and Platelets known as (Thrombocytes). Red blood cells or Erythrocytes are the most common type of blood cell and the principal means of delivering oxygen (O2) to the body tissues via the blood flow through the circulatory system. Red blood cells are red since they contain protein chemicals called hemoglobin which is bright red. Hemoglobin contains the element Iron, which makes it an excellent means of transportation for oxygen and carbon dioxide. Blood passes through the lungs, at which time oxygen molecules attach to the hemoglobin. The immune system is involved in defending the body against both infectious disease and foreign materials. There are five different types of leukocytes that exist; however, they are all produced and derived from a specific cell in the bone marrow known as a hematopoietic stem cell. Leukocytes are found throughout the body, including within the blood and the lymphatic system. These types of patients required strict asepsis above and beyond normal precautions and usually are placed on reverse isolation to avoid exposure to germs. Platelets circulate in the bloodstream and are involved in hemostasis where they release substances that attract fibrin to the tear which inevitably leads to the formation of a blood clot. Once blood flow is stopped by the clotting activity, the natural healing of an injury can begin. A deficiency in platelets is referred to as thrombocytopenia and can be very serious. There are various medications and some diseases that may contribute to spontaneous bleeding complications. These patients should be monitored closely for any bleeding and must have injections of any type limited. Fluids and Electrolytes: Electrolytes are minerals in the body that have an electric charge. Sodium, Calcium, Potassium, Chlorine, Phosphate and Magnesium are all electrolytes. Electrolytes, especially Sodium, help the body maintain normal fluid levels in these compartments. How much fluid a compartment contains depends on the concentration of the electrolytes in it. Similarly, if the electrolyte concentration is low, fluid moves out of that compartment. To regulate fluid levels, the body can actively move electrolytes in or out of cells. Having electrolytes in the right concentrations is called electrolyte balance and is important in maintaining fluid balance among the compartments. Some causes may include but are not limited to: medications, vomiting, diarrhea, sweating or various kidney problems. The kidneys help maintain electrolyte concentrations by filtering electrolytes from blood, returning some electrolytes, and excreting any excess into the urine. Thus, the kidneys help maintain a balance between daily consumption and excretion. Mechanisms of Action: the kidneys filter the electrolytes in the blood and maintain a balance by excreting the proper amount in the urine. The concentration of electrolytes must be maintained within a narrow range within the blood, otherwise harmful physiological effects may occur. Fluids always move from an area of low solute concentration to an area of high concentration until both sides are equal. Diffusion: is the movement of solutes from an area of greater solute concentration to an area of lower solute concentration. The kidneys purpose is to control the sodium excreted in the urine; this level of sodium in the body is relatively constant on a daily basis. Yet if there is an upset between intake of sodium (through dietary consumption) and output (in urine and sweat), this creates an imbalance affecting the total amount of sodium in the body. Variations in the total amount of sodium are related to the volume of water found in the blood. A reduction in the overall amount of sodium in the body may not necessarily cause the concentration of blood sodium to fall, but it may decrease blood volume. Low blood volume which occurs with a hemorrhage, signals the kidneys to conserve both water and sodium through stimulation of Aldosterone. This helps to return blood volume to normal, by increasing the amount of extracellular fluid sodium. This increase in blood volume initiates a buildup of extracellular fluid, often in the feet, ankles, and lower legs, resulting in a condition known as pedal edema. When sodium concentration -as opposed to too much total sodium is too high, thirst prompts water intake. Common disorders: the electrolytes involved in disorders of salt balance are most often Sodium, Potassium, Calcium, Phosphate, and Magnesium. The concentration of blood chloride is usually similar to the blood sodium concentration, while Bicarbonate is related to the acid-base balance. Hyponatremia is a condition characterized by a low sodium level in the blood; below 136 mEq per liter of blood. In Hyponatremia, the sodium concentration has been over-diluted by an excess of water or a loss of sodium in the body. Lethargy and confusion are typically the first signs, muscle twitching and seizures may occur. As Hyponatremia progresses, there is risk of stupor, coma, and possibly death in the most severe cases. Due to the effects on the central nervous system, mortality risk is considerably greater in acute Hyponatremia than in chronic Hyponatremia. Other factors that may diminish survival include the presence of debilitating illnesses such as alcoholism, hepatic cirrhosis, heart failure, or cancer. Hypernatremia: is a condition characterized by a high concentration of sodium in the blood, above 145 mEq per liter of blood. There is too little water compared to the amount of sodium in the blood, often the result of insufficient water intake. Other causes are profuse sweating, vomiting, fever, diarrhea, or abnormal kidney function. As the body ages, the thirst sensation decreases; consequently, hypernatremia is more prevalent in the elderly. Major causes of high sodium levels include the use of drugs such as lithium, diuretics, demeclocycline (a tetracycline antibiotic), Diabetes Insipidus (a disorder in which there is an abnormal increase in urine output, fluid intake and often thirst), and Sickle cell disease. Severe hypernatremia may result in confusion, muscle twitching, seizures, coma, and death. In comparison to acute Hypernatremia, the gravity of under-lying illness and the outcome on the central nervous system most often ends in a higher incidence of death in chronic hypernatremia. Calcium is essential for proper functioning in nerve conduction, muscle contraction, and enzyme activity. Similar to electrolytes, the body maintains calcium levels both in the blood and cells. To maintain a normal calcium concentration in the body, at least 500-1000 mg of calcium is required daily. When functioning efficiently, the body transfers calcium from the bones to the blood to achieve sufficient levels. Osteoporosis may occur if the intake of calcium levels is insufficient; the bones weaken as a result. The parathyroid hormones and calcitonin hormones aid in regulating the amount of calcium in the blood. If the calcium concentration significantly dips, the parathyroid glands will boost secretion of the parathyroid hormones. Additionally, the parathyroid hormones stimulate the kidneys to release vitamin D which then enhances absorption of calcium from the Gl tract. It is the hormone calcitonin which helps to lower the calcium concentration in blood by improving the concentration of calcium in the bones. Also of consideration is the possibility of a chronic depletion of calcium in the urine. Some other causes of hypocalcemia include the following: acute pancreatitis, magnesium depletion, septic shock, parathyroidism, vitamin D deficiency, renal failure, hypoproteinemia, hyperphosphatemia, and excessive release of calcitonin. However, memory loss, depression, confusion, delirium, and/or hallucinations may result if low calcium levels are left untreated. Fortunately, if calcium levels are replenished, these symptoms can be reversed in due time. The healthcare provider should be aware that severe cases of hypocalcemia could possibly result in: seizures, tetany (prolonged contraction of muscles, mainly of the face and extremities), or muscle spasms in the throat, often affecting the ability to breath. This may result from someone using excessive amounts of calcium or with those who take calcium containing antacids. If hypercalcemia does occur, typical symptoms include: constipation, loss of appetite, nausea and vomiting, and/or abdominal pain. Severe hypercalcemia may induce weakness, confusion, emotional disorders, delirium, hallucinations, or coma. With chronic conditions of hypercalcemia, permanent damage may occur from kidney stones or calcium-containing crystals forming. Potassium: this electrolyte plays a major role in cell metabolism and in nerve and muscle cell performance. Too high or low levels of blood potassium can cause serious effects such as an abnormal heart rhythm or cardiac arrest.

During nursery outbreaks test cholesterol jeun best order simvastatin, cohorting ill and colonized infants is recommended cholesterol medication niacin purchase simvastatin uk, as are good hand hygiene practices oxidized cholesterol in scrambled eggs order genuine simvastatin. Prevention of chlamydia infection during pregnancy includes treatment of infected pregnant women in the third trimester (after 30 weeksgestation) with erythromycin (tetracycline should not be used because it is deposited in the teeth of the developing fetus) home remedies cholesterol lowering foods cheap simvastatin 5 mg on-line. Because antenatal testing is not available in most low-income countries cholesterol risk ratio mmol/l order cheap simvastatin on line, use of eye drops is the only preventive measure usually available cholesterol test validity buy 5mg simvastatin fast delivery. Unfortunately, neither tetracycline nor erythromycin eye drops prevents chlamydial pneumonia. Chlamydial pneumonia is usually mild and treated easily and inexpensively: l Infants with chlamydial conjunctivitis or pneumonia can be treated with erythromycin base or erythromycin ethylsuccinate 50 mg/kg/day in four divided daily doses for 14 days. When caring for patients with chlamydial conjunctivitis or pneumonia and mothers with genital chlamydia, use Standard Precautions. Most severe manifestations of gonorrhea in newborns are ophthalmia neonatorum (a condition of the eye that may result in blindness) and sepsis. Prevention of gonorrhea during pregnancy includes screening, diagnosis, and treatment of infected pregnant women using appropriate antibiotics (tetracycline should not be used because it is deposited in the teeth of the developing fetus). Because antenatal testing is not available in most low-income countries, use of eye drops (tetracycline or erythromycin) is the only preventive measure usually available. When caring for patients with ophthalmia neonatorum and mothers with gonorrhea infection, use Standard Precautions. Infection and Prevention Control: Module 10, Chapter 5 115 Preventing Maternal and Newborn Infections in Health Care Settings Listeriosis Listeriosis is predominantly a foodborne infection caused by Listeria monocytogenes. One in seven pregnant women becomes infected with listeria; pregnant women are 10 times more likely than the general population to get listeria infection. Infection during pregnancy can cause fetal loss, preterm labor, and illness or death in newborn infants. Similar to group B streptococcal disease, listeriosis can present as an early or late-onset syndrome. An erythematous rash with small pale papules can also occur in early onset with severe newborn infection. Immunocompetent patients with mild infections can be treated with ampicillin alone. Additionally, immunizing mothers with the tetanus vaccine, which is inexpensive and effective, is essential for prevention. Infants become infected during childbirth through use of an unclean instrument to cut the umbilical cord or following childbirth by placement of substances heavily contaminated with tetanus endospores. To be effective, non-immunized pregnant women should receive at least two doses of tetanus toxoid prior to childbirth. If there is sufficient time before childbirth, two doses should be administered at least 4 weeks apart, and the second dose should be given at least 2 weeks before childbirth. When caring for patients with tetanus, use Standard Precautions, as this infection is not transmitted from person to person. It is transmitted through sexual contact with an infected partner and is also transmitted from mother to child during pregnancy. Antenatal testing of pregnant women should be done to identify and treat women who are seropositive for syphilis and to prevent congenital syphilis in their newborns. If the results of serologic tests for syphilis are equivocal or not available, a cord blood or venous sample from the newborn should be tested. Regardless of stage of pregnancy, infected women should be treated with penicillin according to the dosage appropriate for the stage of syphilis as recommended for non-pregnant patients. Standard Precautions apply to all patients (women and their babies) irrespective of their hepatitis B vaccine status or disease status. Care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhea. Breastfeeding is not contraindicated, but if her nipples are cracked and bleeding, the mother may wish to abstain. However, it is often difficult to determine whether or not an infection is recurrent or primary. Duration of Contact Precautions is until infant surface culture is negative after 48 hoursincubation. Mothers can continue to breastfeed their babies, provided there are no lesions in the breast area and all skin lesions are covered. Because the risk is low, delivery of infected women by C-section is not indicated to protect the infant. C-section may be necessary, however, in women whose genital warts are so extensive that soft tissue stretching of the vulva and perineum may not be sufficient to allow vaginal delivery. Consider separation of a mother who is ill with suspected or confirmed influenza from her newborn during her hospital stay. At least, mothers with influenza should wear a surgical mask while breastfeeding and when within 3 feet of the infant. It causes mild disease with fever, rash, and lymphadenopathy that disappears in 3 days. However, developing fetuses of mothers who have not been vaccinated against rubella lack passively acquired maternal antibodies and can develop congenital rubella syndrome if exposed to the virus during pregnancy. Women receiving rubella vaccine should be counseled to avoid pregnancy for 3 months because of the possible small risk that the vaccine could cause a congenital abnormality. Rubella infection during early pregnancy can result in miscarriage and stillbirth. Congenital rubella syndrome can cause cataracts, congenital heart disease, hearing impairment, and developmental delays. The risk is highest during the first 12 weeks of gestation and decreases after the twelfth week; defects are rare after the twentieth week of gestation. Vaccination of all children and non-pregnant women is the most effective method of preventing congenital rubella in infants. The following precautions should be observed for pregnant women with active rubella, newborns with congenital rubella infection, or those born to mothers known to have had rubella during pregnancy: l Initiate Standard and Droplet Precautions for 7 days after onset of the rash. Duration of precautions is until they are at least 1 year of age, because they may shed virus from the throat and urine until they are older than 1 year unless two cultures of clinical specimens obtained 1 month apart after 3 months of age are negative. Pregnant women who are not immune (have not been vaccinated or had rubella) should not care for these patients. Infants are unlikely to transmit infection by coughing, but suctioning may generate infectious aerosols so Airborne Precautions will be needed. The greatest risk is if the baby is born within 2 days before or 5 days after the onset of maternal chicken pox. A post-exposure vaccine should be provided to exposed persons as soon as possible, but within 120 hours of exposure. Clean cord care practices and neonatal mortality: evidence from rural Uttar Pradesh, India. Effectiveness of intrapartum penicillin prophylaxis in preventing early onset group B streptococcal infection: results of a meta-analysis. Clinical management of intra-amniotic infection and chorioamnionitis: a review of the literature. Effect of topical application of chlorhexidine for umbilical cord care in comparison with conventional dry cord care on the risk of neonatal sepsis: a randomized controlled trial. A review of health system infection control measures in developing countries: what can be learned to reduce maternal mortality. Surveillance of post-caesarean surgical site infections in a hospital with limited resources, Cambodia. A Decade of Tracking Progress for Maternal, Newborn and Child Survival: the 2015 Report. Infection and Prevention Control: Module 10, Chapter 5 123 Preventing Maternal and Newborn Infections in Health Care Settings Van Dillen J, Zwart J, Schutte J, van Roosmalen J. Guidelines for the Screening, Care and Treatment of Persons with Hepatitis C Infection. Guidelines for the Prevention, Care and Treatment of Persons with Chronic Hepatitis B Infection. Integrated Management of Pregnancy and Childbirth, Pregnancy, Childbirth, Postpartum and Newborn Care: a guide for essential practice 3rd edition. Infection and Prevention Control: Module 10, Chapter 5 125 Preventing Health Care-Associated Infectious Diarrhea Chapter 6. Preventing Health Care-Associated Infectious Diarrhea Key Topics l Common risk factors and causes of health care-associated infectious diarrhea l Preventing transmission of health care-associated diarrhea l Introduction to management of outbreaks of diarrheal illness Key Terms l Colonization is the establishment of a site of pathogen reproduction in or on a host individual that does not necessarily result in clinical symptoms or findings. A colonized individual may transmit the colonizing pathogens to other individuals. This is the same definition as epidemic, but an outbreak usually refers to disease events occurring in a more limited geographic area (such as a health care facility ward) than that of an epidemic. This may occur after the resolution of symptoms of certain infections such as typhoid. Untreated infectious diarrhea can cause dehydration from loss of body fluids and electrolytes. Dehydration can be treated with oral rehydration salts solution (clean water, salt, and sugar) or intravenous fluids. Health care-associated infectious diarrhea is defined as diarrhea with an infectious origin that begins on or after the third calendar day of hospitalization (the day of hospital admission is calendar Day 1). The term health care-associated diarrhea used in this chapter refers to infectious diarrhea. In addition, the emergence and spread of Clostridium difficile is a growing problem among hospitalized adults worldwide. However, in these settings, the causative agents may not be identified on a routine basis, particularly in facilities where access to reliable laboratory services is limited. For this reason, there are few data describing organisms commonly responsible for health care-associated diarrhea in low and middle income settings. However, in a report from India, where 10% of pediatric patients in the hospital developed health care-associated diarrhea, the most common pathogens were Shigella spp. In Iraq, a hospital where 32% of pediatric patients developed health care-associated diarrhea reported E. Some are normal flora or colonize the gut, but some serotypes of these can cause infections. Outbreaks occur via fecal contamination of hands, from food that is not cooked properly, or from contaminated water. The virus can survive on inanimate surfaces, is easily spread, and may become endemic in health care facilities. Prolonged shedding of the virus in stool may occur in both immunocompetent and immunocompromised children and the elderly. Noroviruses (Norwalk and Caliciviruses) Rapid identification and immediate implementation of interventions are important in preventing serious outbreaks of norovirus. Cohorting of affected patients to separate airspaces and toilet facilities may help interrupt transmission during outbreaks. Clostridium difficile the use of antibiotics is associated with some types of health care-associated diarrhea, especially C. The illness was previously known as antibiotic-resistant diarrhea or pseudomembranous colitis. High levels of antibiotic use disrupt helpful, protective bacteria normally living in the gut, leaving the person at risk for infection with microorganisms that cause some types of diarrhea (see Figure 6-2). Outbreaks in health care facilities can include common, unusual, or opportunistic pathogens. Illnesses and treatments that compromise the immune system put patients at risk of infection from organisms that do not usually bother healthy people (opportunistic). In hospitalized patients, infectious diarrhea may present in unexpected ways, such as by becoming prolonged or more severe, due to decreased immunity or other risk factors. Immunocompromised patients may shed the viruses or bacteria in stool for prolonged periods. Remember that Standard Precautions assume that every patient is potentially infectious. They should return to duties only after they have fully recovered from the symptoms. They should comply fully with hand hygiene as they may continue to shed the bacteria or virus in their stool and thus spread infection even after symptomatic recovery (see Module 4, Chapter 2, Infection Prevention and Control Aspects of Occupational Health in Health Care Settings). Systems for identifying symptomatic foodservice personnel should be in place to prevent ill persons from working in the foodservices area. Management of outbreaks can be expensive because outbreaks require additional resources to stop the spread and treat cases. In many cases, the cause of an outbreak will not be found but the outbreak will be halted by improving infection control measures. Infection and Prevention Control: Module 10, Chapter 6 131 Preventing Health Care-Associated Infectious Diarrhea Managing Outbreaks of Diarrheal Illness the following actions should be taken in an outbreak of diarrheal illness at a health care facility: l Determine if there is an outbreak: l Consider whether the cases appear clinically to have the same illness (or different manifestations of the same disease), if possible. Infection and Prevention Control: Module 10, Chapter 6 133 Preventing Health Care-Associated Infectious Diarrhea Appendix 6-A. Diarrhea Source Survey Form Diarrhea Source Survey Form Please return completed form to: Date form completed: Name of person completing this form: Name of person being surveyed: Age: Sex: Patient: No Yes (If yes, go to patient section below) Health care worker: No Yes (If yes, go to health care worker section below) Health Care Worker Section If health care worker, type of work: Nurse Clerical Physician Housekeeper Student Other: not applicable Shift or work hours: Unit/Area: Do you work in any other places besides this facility

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This idiopathic thrombocytopenic purpura and hemophilia with approach is effective only in Rh(+) patients with a func inhibitors high cholesterol foods chart 40mg simvastatin for sale. The risk of with Platelet Alloantibodies (Neonatal overwhelming infection (predominantly with encapsulated Alloimmune Thrombocytopenia) organisms) is increased after splenectomy cholesterol raising foods buy simvastatin 40mg otc, particularly in the young child is there cholesterol in eggs purchase simvastatin 10mg mastercard. Therefore best cholesterol foods cheap simvastatin 10 mg overnight delivery, the procedure should be postponed lowering cholesterol in diet purchase 40mg simvastatin with amex, Platelet alloimmunization occurs in 1 in approximately 350 if possible cholesterol levels low cheap simvastatin 40 mg, until age 5 years. Meningococcal vaccine, gressive over the course of gestation and worse with each although controversial, may be considered. Petechiae or at presentation, insidious onset of bruising, and the presence other bleeding manifestations are usually present shortly of other autoantibodies. Appropriate screening by history and labora If alloimmunization is associated with clinically signifi tory studies (eg, antinuclear antibody) is warranted. If and 75% of neonates with bacterial sepsis are thrombocyto thrombocytopenia is not severe and bleeding is absent, penic. Intrauterine infections such as rubella, syphilis, toxo observation alone is often appropriate. In alloimmune thrombocytopenia is the strongest risk factor addition to specific treatment for the underlying disease, for severe fetal thrombocytopenia and hemorrhage in a platelet transfusions may be indicated in severe cases. If alloimmunization has occurred with a previous preg (Kasabach-Merritt Syndrome) nancy, irrespective of history of intracranial hemorrhage, screening cranial ultrasound for hemorrhage should begin at A rare but important cause of thrombocytopenia in the 20 weeksgestation and be repeated regularly. In addition, newborn is kaposiform hemangioendotheliomas, a benign cordocentesis should be performed at approximately 20 neoplasm with histopathology distinct from that of classic weeksgestation, with prophylactic transfusion of irradiated, infantile hemangiomas. Intense platelet sequestration in the leukoreduced, maternal platelet concentrates. The bone marrow typically shows megakaryocytic section is recommended if the fetal platelet count is less than hyperplasia in response to the thrombocytopenia. Cortico 50,000/ L, to minimize the risk of intracranial hemorrhage steroids, interferon, and vincristine are all useful for associated with birth trauma. Thrombocytopenia Associated with Idiopathic ture, or the lesion is cosmetically unacceptable. If consump Thrombocytopenic Purpura in the Mother tive coagulopathy is present, heparin or aminocaproic acid (Neonatal Autoimmune Thrombocytopenia) may be useful. Disorders of Platelet Function Most neonates with neonatal autoimmune thrombocy Individuals with platelet function defects typically develop topenia do not develop clinically significant bleeding, and skin and mucosal bleeding similar to that occurring in thus treatment for thrombocytopenia is not often required. If petechiae or minor bleeding are evident, a 1 to 2-week this is prolonged, in-vitro platelet aggregation is studied course of oral prednisone, 2 mg/kg/d, may be administered. Platelet transfusions are only platelet aggregometry remains important in selected clinical indicated for life-threatening bleeding, and may only be situations. Many pharmacologic agents decrease plate bleeding episodes is platelet transfusion. The most common offending agents in the has variable efficacy and may be helpful in platelet transfu pediatric population are aspirin and other nonsteroidal anti sion-refractory patients. The hereditary platelet dysfunction generally have a prolonged more common factor deficiencies are discussed in this sec bleeding time with normal platelet number and morphology tion. This condition is characterized by increased platelet size and decreased platelet 1. Glanzmann thrombasthenia is an example of platelet Bruising, soft-tissue bleeding, hemarthrosis. As in Bernard-Soulier syndrome, acute bleeding is treated by platelet transfusion. Disorders involving platelet granule content include stor General Considerations age pool disease and Quebec platelet disorder. One third of cases Hermansky-Pudlak, Chediak-Higashi, and Wiskott-Aldrich are due to a new mutation. Laboratory Findings exhibit considerable variation among individuals depending on comorbid conditions. Subsequent doses are determined according to philia can be detected by determination of the ratio of factor the site and extent of bleeding and the clinical response. Most intracranial intravenous access exists and close contact is maintained hemorrhages in moderate to severe deficiency are spontane with the hemophilia clinician team. Large intramuscular severe hemophiliacs, and this approach is becoming more hematomas can lead to a compartment syndrome with common in pediatric hemophilia care. Although these complica tions are most common in severe hemophilia A, they may be Prognosis experienced by individuals with moderate or mild disease. Through more stringent donor selection, the implementation of sensitive screening assays, the use of heat 2. Management typically consists of perioperative prophylaxis and episodic therapy for acute hemorrhage. Des ited bleeding disorder among Caucasians, with a prevalence mopressin has been used in some cases. The majority (> 80%) of individuals with Other hereditary single clotting factor deficiencies are rare. Homozygous individ mitted as an autosomal dominant trait, but can be autosomal uals with a deficiency or structural abnormality of pro recessive. The diagnosis requires confirmation of laboratory testing and bleeding history is often helpful when present. Topical thrombin and fibrin hematuria, melena, purpura, petechiae, persistent oozing glue may also be of benefit, although antibodies that inhibit from needle punctures or other invasive procedures), and clotting proteins have been described. Estrogen-containing (3) evidence of thrombotic lesions (eg, major vessel throm contraceptive therapy may be helpful for menorrhagia. However, in children, the platelets; however, clinical evidence demonstrating benefit of fibrinogen level may be normal until late in the course. Heparin dosing is provided in the Levels of fibrin-fibrinogen split products are increased, and section on thrombosis treatment. The ratio vitamin K deficiency may occur as a consequence of inade nale for heparin therapy is to maximize the efficacy of, and quate intake, excess loss, inadequate formation of active minimize the need for, replacement of procoagulants and metabolites, or competitive antagonism. Prophylactic administration of erythropoietin before the development of severe anemia appears to decrease 1. Henoch-Schonlein Purpura Although occasionally associated with maternal drug (Anaphylactoid Purpura) usage, it most often occurs in well infants who do not receive vitamin K at birth and are solely breast fed. The diagnosis of vitamin K deficiency is suspected based on the history, physical examination, and laboratory results. Occurrence is highest in the spring and fall, but with normal fibrinogen level and absence of hepatic and upper respiratory infection precedes the diagnosis in transaminase elevation. The or subcutaneous treatment with vitamin K should be given most common and earliest symptom is palpable purpura, immediately and not withheld while awaiting test results. In which results from extravasation of erythrocytes into the the setting of severe bleeding, additional acute treatment tissue surrounding the involved venules. Bleeding occurs in approximately 50% of patients Clinical Findings with chronic renal failure. Individuals with Ehlers-Danlos syn renal involvement in the second or third week of illness with drome types 4 and 6 are at risk for aortic dissection and either a nephritic or, less commonly, nephrotic picture. In avoided for patients with Ehlers-Danlos syndrome, as should males, testicular torsion may also occur, and neurologic symp medications that induce platelet dysfunction. The platelet count is normal or elevated, and other screening tests of hemostasis and platelet function are typically normal. Although uncommon in children, thrombotic disorders are being recognized with increasing frequency, particularly Differential Diagnosis with heightened physician awareness and improved survival in pediatric intensive care settings. The possibility of trauma should be considered in any child presenting with purpura. Initial evaluation of the child who has thrombosis includes an assessment for potential triggering factors, as well as a Treatment family history of thrombosis and early cardiovascular or cerebrovascular disease. Clinical Risk Factors relief for severe gastrointestinal or joint manifestations but does not alter skin or renal manifestations. Two phenotypes of hereditary protein C defi Ronkainen J: Early prednisone therapy in Henoch-Schonlein pur ciency exist. Heterozygous individuals with autosomal dom pura: A randomized, double-blind, placebo-controlled trial. Homozy Mild to life-threatening bleeding occurs with some types of gous or compound heterozygous protein C deficiency is rare Ehlers-Danlos syndrome, the most common inherited col but phenotypically severe. Ehlers-Danlos syndrome is characterized byent within the first 12 hours of life with purpura fulminans joint hypermobility, skin extensibility, and easy bruising. However, bleeding and easy bruising, in with therapeutic heparin administration is recommended. In children, it may also agulation or in the presence of conditions associated with serve as a risk factor for ischemic arterial stroke. Furthermore, methylene tetrahydrofolate a course similar to those with homozygous or compound reductase receptor mutations do not appear to constitute a heterozygous protein C deficiency. Efforts must be Lipoprotein(a) is a lipoprotein with homology to plas made to distinguish from these conditions from acquired minogen. Antiphospholipid anti bodies, which include the lupus anticoagulant, anticardio d. The lupus antico Leiden, a factor V polymorphism that is resistant to inactiva agulant is demonstrated in vitro by its inhibition of phos tion by activated protein C. In the such as systemic lupus erythematosus, antiphospholipid former case, thrombosis is typically triggered by a clinical antibodies may also develop following certain drug expo risk factor (or else develops in association with additional sures, infection, acute inflammation, and lymphoprolifera thrombophilia traits), whereas in the latter case, it is often tive diseases. Viral illness is a common precipitant in children, and V Leiden, 35-fold among heterozygous individuals taking in many cases, the inciting infection may be asymptomatic. Some patients experi row transplant sinusoidal obstruction syndrome (formerly ence bleeding, while others develop venous or arterial termed hepatic veno-occlusive disease). The diagnosis is suggested by a prolonged dren have suggested a possible therapeutic role for anti thrombin time with a normal fibrinogen concentration. War ing, while that for pulmonary embolism commonly involves farin pharmacokinetics are affected by acute illness, numerous dyspnea and pleuritic chest pain, and in cerebral sinovenous medications, and changes in diet, and require frequent moni thrombosis often includes severe or persistent headache, toring. At least 30% of or regulators of fibrinolysis (eg, D-dimer, plasminogen activa children with deep venous thrombosis involving the extremi tor inhibitor-1, and lipoprotein[a]) should be completed. The presence of homozygous anticoagulant deficien cysteine and lipoprotein(a) have also been well-demonstrated cies, multiple thrombophilia traits, or persistent antiphospho as risk factors for arterial thrombotic and ischemic events. Children who lack normal splenic function are at risk for sepsis, meningitis, and pneumonia due to encapsulated bacte ria such as pneumococci and H influenzae. The prognosis depends on the underlying Splenomegaly due to any cause may be associated with cardiac lesions, and many children die during the first few hypersplenism and the excessive destruction of circulating red months. Prophylactic antibiotics, usually penicillin, and cells, white cells, and platelets. The degree of cytopenia is pneumococcal conjugate and polysaccharide vaccines are variable and, when mild, requires no specific therapy. Because the risk is highest when the procedure is consequence of a storage disease. In such cases, treatment with performed earlier in life, splenectomy is usually postponed surgical splenectomy or with splenic embolization may be until after age 5 years. Although more commonly associated with acute also greater in children with malignancies, thalassemias, and enlargement, rupture of an enlarged spleen can be seen in reticuloendothelioses than in children whose splenectomy is more chronic conditions such as Gaucher disease. Prophylactic Before blood components can be released for transfusion, penicillin reduces the incidence of sepsis by 84%. Many of the screening tests used are very sensitive and donor questions that will protect the recipient from trans have a high rate of false-positive results.

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