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 ADVERTISEMENTS

HOME  NOTES  INFECTIOUS DISEASES
 NOTES
 INFECTIOUS DISEASES

Diphtheria
By
 Marianne Belleza, R.N.
 -
Updated on May 21, 2020
0
 ADVERTISEMENTS

The “strangling angel of children,” as diphtheria was once called, can be traced

to the fourth-to-fifth century BC and was one of the most common causes of
death among children in the prevaccine era. In this study guide, learn more
about diphtheria, its pathophysiology, causes, signs and symptoms, nursing
care management, and interventions.

 What is Diphtheria?
 Pathophysiology
 Statistics and Incidences
 Causes
 Clinical Manifestations
 Assessment and Diagnostic Findings
 Medical Management
o Pharmacologic Management
 Nursing Management
o Nursing Assessment
o Nursing Diagnosis
 o Nursing Care Planning and Goals
o Nursing Interventions
o Evaluation
o Documentation Guidelines
 References

What is Diphtheria?
 Diphtheria is an acute toxin-mediated disease caused by
Corynebacterium diphtheriae.
 Unlike other diphtheroids (eg, coryneform bacteria), which are
ubiquitous in nature,  Corynebacterium diphtheriae is an exclusive
inhabitant of human mucous membranes and skin.
 Diphtheria organisms usually remain in the superficial layers of skin
lesions or respiratory mucosa, inducing local inflammatory reaction.
 Nontoxigenic strains also cause disease, which is mostly cutaneous and
usually mild.

Pathophysiology
Diphtheriae toxin, which is secreted by toxigenic strains of Corynebacterium
diphtheriae, is a single polypeptide of Mr 58,342.

 Within the first few days of respiratory tract infection, a dense necrotic

coagulum of organisms, epithelial cells, fibrin, leukocytes,
and erythrocytes forms, advances, and becomes a gray-brown
adherent pseudomembrane.
 Removal is difficult and reveals a bleeding edematous submucosa.
 Paralysis of the palate and hypopharynx is an early local effect of the
toxin.
 Toxin absorption can lead to necrosis of kidney tubules,
thrombocytopenia, cardiomyopathy, and demyelination of nerves.
 In the classic description of diphtheria, the primary focus of infection is
the tonsils or pharynx in more then 90% of patients; the nose and
larynx are the next most common sites.
Statistics and Incidences
Diphtheria is endemic in many parts of the world, including countries of the
Caribbean and Latin America.

 Death due to mechanical airway obstruction or cardiac involvement

with circulatory collapse occurs in at least 10% of patients with
respiratory tract diphtheria.
 When diphtheria was endemic, it primarily affected children younger
than 15 years; recently, the epidemiology has shifted to adults who
lack natural exposure to toxigenic C diphtheriae in the vaccine era and
those who have low rates of receiving booster injections.
 In the 27 sporadic cases of respiratory tract diphtheria reported in the
United States in the 1980s, 70% occurred in persons older than 25
years.

Causes
Causes of diphtheria may include:

 Non Immunization. Among nonimmunized populations, diphtheria

most often occurs during fall and winter, although summer outbreaks
have occurred.
 Poor socioeconomic conditions. The disease spreads more quickly
and is more prevalent in poor socioeconomic conditions, where
crowding occurs and immunization rates are low.
 Travel history. International travel could pose a risk to persons who
are unvaccinated or inadequately vaccinated.

Clinical Manifestations
Severity of disease due to C diphtheriae depends on the site of infection, the
immunization status of the patient, and the dissemination of toxin.

 Tonsils and pharynx. Tonsillar and pharyngeal diphtheria are most

common; symptoms begin with a sore throat, usually in the absence of
systemic complaints; fever, if it occurs, is usually lower than 102°F,
and malaise, dysphagia, and headache are not prominent features.
  Pseudomembrane. In individuals with diphtheria infection who are
not immune, membrane formation begins after the 2-day to 5-day
incubation period and grows to involve the pharyngeal
walls, tonsils, uvula, and soft palate; the membrane may extend to the
larynx and trachea, causing airway obstruction and eventual
suffocation.

 Edema. Marked edema of the neck may lead to a bull-neck

appearance with a distinct collar of swelling; the patient throws the
head back to relieve pressure on the throat and larynx; erasure edema
associated with pharyngeal diphtheria obliterates the angle of the jaw,
the borders of the sternocleidomastoid muscle, and the medial border
of the clavicles.
 Larynx. In a minority of patients, the larynx is the initial site of
infection, with initial presenting symptoms similar to
laryngotracheobronchitis from other causes; initial hoarseness may
progress to loss of voice and severe respiratory tract obstruction;
initially, nasal diphtheria may present as a common viral upper
respiratory tract infection; a foul odor may develop.
 Skin. Cutaneous diphtheria may occur at one or more sites, usually
localized to areas of previous mild trauma or bruising.

Assessment and Diagnostic Findings

Diagnostic tests used to confirm infection combine isolation of C diphtheriae on
cultures with toxigenicity testing.

 Bacteriologic culturing. Bacteriologic culturing is essential to confirm

the diagnosis of diphtheria.
 Toxigenicity testing. Perform toxigenicity testing using the Elek test
to determine if the C diphtheriae isolate produces toxin.
 Polymerase chain reaction (PCR) test. The PCR test can detect
nonviable C diphtheriae organisms from specimens taken
after antibiotic therapy has been initiated.

Medical Management
Critical care needs and complications must be addressed.
  Specific antitoxin. Specific antitoxin is the mainstay of therapy and
should be administered on the basis of clinical diagnosis because it
neutralizes free toxin only.
 Isolation. Individuals are placed in strict isolation (respiratory tract
colonization) or contact isolation (cutaneous colonization only) until at
least 2 subsequent cultures taken 24 hours apart after cessation of
therapy demonstrate negative results.

Pharmacologic Management
Appropriate antibiotic therapy should be administered simultaneously with the
antitoxin.

 Antibiotic agents. Antimicrobial therapy is indicated to halt toxin

production, treat localized infection, and prevent transmission of the
organism to patient contacts.
 Antipyretic agents. These agents inhibit central synthesis and release
of prostaglandins that mediate the effect of endogenous pyrogens in
the hypothalamus; thus, they promote the return of the set-point
temperature to normal.
 Vaccines. Diphtheria toxoid is typically combined with tetanus and
acellular pertussis for children younger than 7 years; active
immunization increases resistance to infection.

Nursing Management
Nursing management of a client with diphtheria include the following:

Nursing Assessment
Assessment of a client with diphtheria include:

 History. Onset of symptoms of respiratory diphtheria typically follows

an incubation period of 2-5 days (range, 1-10d); symptoms initially are
general and nonspecific, often resembling a typical viral upper
respiratory infection (URI).
 Physical examination. The patient has a low-grade fever but is toxic
in appearance, and also may have a swollen neck; cardiac toxicity
typically occurs after 1-2 weeks of illness following improvement in the
 pharyngeal phase of the disease, and neurologic toxicity is proportional
to the severity of the pharyngeal infection.

Nursing Diagnosis
Based on the assessment data, the major nursing diagnosis are:

 Hyperthermia related to the release of an exotoxin.

 Imbalanced nutrition: less than body requirements related to
painful swallowing.
 Ineffective airway clearance related to pseudomembrane blocking
the airway.

Nursing Care Planning and Goals

The nursing care planning goals for Diptheria includes:

 The client will be able to maintain a normal body temperature.

 The client will be able to demonstrate and maintain a normal body
weight.
 The client will be able to maintain a clear airway.

Nursing Interventions
The nursing interventions for Diptheria are the following:

 Improve thermoregulation. Maintain room temperature; advise the

client to wear thin clothes that absorb sweat easily; encourage to
increase oral fluid intake, and administer antipyretics as ordered.
 Improve caloric intake. Monitor calorie intake and quality of food
consumption; provide foods that stimulate the appetite, and measure
the bodyweight daily.
 Improve airway clearance. Auscultate breath sounds, note the
presence of an additional breath sounds; place the client in a
comfortable position that can aid maximum lung expansion; help
performs chest physiotherapy; and suction secretions as needed.
Evaluation
Nursing goals are met as evidenced by:

 The client was able to maintain a normal body temperature.

 The client was able to demonstrate and maintain a normal body
weight.
 The client was able to maintain a clear airway.

Documentation Guidelines
Documentation in a client with diphtheria include:

 Individual findings, including factors affecting, interactions, nature of

social exchanges, specifics of individual behavior.
 Cultural and religious beliefs, and expectations.
 Plan of care.
 Teaching plan.
 Responses to interventions, teaching, and actions performed.
 Attainment or progress toward the desired outcome.

Practice Quiz: Diptheria

Nursing practice questions for Diptheria. For more practice questions, visit
our NCLEX practice questions page.

 EXAM MODE
 PRACTICE MODE
 TEXT MODE
In Exam Mode:  All questions are shown but the results, answers, and
rationales (if any) will only be given after you’ve finished the quiz.

Practice Quiz: Diptheria

 Start

References
Sources and references for this Diptheria study guide:

 Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier

Saunders,. [Link]
 Kimberlin, D. W. (2018). Red Book: 2018-2021 report of the
committee on infectious diseases (No. Ed. 31). American academy of
pediatrics.
 Oshinsky, D. M. (2005). Polio: an American story. Oxford University
Press. [Link]
 Willis, L. (2019). Professional guide to diseases. Lippincott Williams &
Wilkins. [Link]

 TAGS

 BULL NECK

 CORYNEBACTERIUM DIPHTHERIAE

 CUTANEOUS DIPTHERIA

 DIPHTHERIA TOXOID

 DIPTHERIA

 IMMUNIZATION

 PHARYNGEAL DIPHTHERIA

 PSEUDOMEMBRANE

 TONSILLAR DIPHTHERIA

 VACCINE
 Marianne Belleza, R.N.
Marianne is a staff nurse during the day and a Nurseslabs writer at night. She is a registered nurse
since 2015 and is currently working in a regional tertiary hospital and is finishing her Master's in
Nursing this June. As an outpatient department nurse, she is a seasoned nurse in providing health
teachings to her patients making her also an excellent study guide writer for student nurses. Marianne
is also a mom of a toddler going through the terrible twos and her free time is spent on reading
books!

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