TETANUS (from DISCUSSION)

● Other name: Lockjaw ○Wound exposure from contaminated soil or from

● Causative agent: Clostridium Tetani animal feces
○ Anaerobic gram-positive, spore-forming bacteria ○ Could also be from firecrackers (some are made up
○ Spores found in soil and intestines and feces of of animal feces - has methane gas)
some animals ○ Motor vehicular accidents → exposes the wound on
○ Produces 2 exotoxins: the ground/dust/soil which may be contaminated
■ Tetanospasmin - causes spasm with the bacteria
■ Tetanolysin - ○ Animal paws can be contaminated too
● Causes hemolysis ● Any wound can be a portal of entry of tetanus
● Affects liver and spleen → ● MANAGEMENT
Hepatomegaly & ○ Pharmacological
hepatosplenomegaly ■ Anticonvulsants
● Decreased RBC → ANEMIA ■ Benzodiazepine
● Types: ■ Anxiolytics
○ (1) Localized
■ Found on specific site ■ Enteral ??? feeding (NGT)
■ Patient may experience numbness & ○Elimination needs
tingling ■ Catheterization
■ Patients have persistent contraction of ■ Laxatives (lactulose) to avoid
muscles in the same anatomic area as the straining/bulk/constipation
injury ○ Airway
■ May precede the onset of generalized ■ Endotracheal tube - keep it patent, no
tetanus but is generally milder secretions
○ (2) Generalized ● Suctioning done in between bolus
■ More severe of diazepam
■ Spasm ● NURSING DIAGNOSIS FOR DIAZEPAM
■ Tonic-clonic seizures may occur ○ RISK FOR FALL AND INJURY
○ (3) Cephalic ● PREVENTION
■ Facial musculature is affected ○ Always use protective gears
■ Site affected is in the head ○ At risk: construction workers, farmers, motorcycle
● Incubation period: 3-21 days riders
○ The shorter the incubation period, more fatal it is ○ Post-exposure prophylaxis: vaccine
● STAGES: ○ Pre-exposure: for pregnant women
○ The stage of severity depends on the incubation ■ Tetanus Neonatorum - neonatal tetanus
period ■ First sign exhibited by the newborn child -
○ The stage also depends on the manifestations poor sucking
○ Stage I - more than 14 days of incubation ■ Route of entry: umbilical cord
○ Stage II - 7-14 dayas ■ Tetanus toxoid protects the mother from
○ Stage III - < 7 days tetanus infection in the process of childbirth
● Signs and symptoms through artificial active immunity
○ HALLMARK SIGN: TRISMUS - spasm of masseter ■ The newborn, on the other hand, develops
(jaw and facial muscle) + muscle of the neck protection after the second dose of
○ RISUS SARDONICUS - Difficulty opening the mouth tetanus through natural passive immunity
○ OPISTHOTONUS - Spasm in the spine → arching ○ PASSIVE IMMUNIZATION
of the back ■ Human Tetanus Immunoglobulin (HTIG)
○ Spasm of abdomen → altered nutrition ● Dose depends on body weight
○ Spasm of the chest → respiratory spasm ● Skin testing if animal serum is used
■ Patients with tetanus are usually on ; no need if human serum
endotracheal tube / artificial airway ○ ACTIVE IMMUNIZATION
■ Prior to placing on ET, give muscle relaxant ■ Tetanus Toxoid
first to relieve spasm ■ Given IM, 0.5mL in deltoid
● Other signs and symptoms: ■ Side effect is mabigat na arm → ask patient
○ Fever which is his/her nondominant hand
○ Difficulty swallowing/chewing ● Do not massage
○ Muscles spasms ● Instruct to take paracetamol (side
○ Tonic-clonic seizures effect: low grade fever)
● STIMULUS - Noxious stimuli TETANUS TOXOID IMMUNIZATION FOR PREGNANT WOMEN
○ Light (From CHN Notes before)
○ Noise
○ Tactile
○ Hunger
○ Smell
○ Pain
○ Proprioception
○ Extreme in temperature
● Confirmatory/Diagnostic Tests:
○ Serology tests, CBC may be done but…. Most of the
time, for cases of tetanus we make use of:
■ CLINICAL DIAGNOSIS: use of pertinent
history taking & through clinical
manifestations
● Common cause: puncture wound
● Other causes:

TUBERCULOSIS

FROM MS LEC TRANS

1
● TB is simply pneumonia but the difference is that specific ○ “Uy may tama ung lungs mo, nagka-TB ka na siguro
ung microorganism that causes TB - mycobacterium bacilli before”
● Infectious disease that primarily affects the lung ○ Dormant stage - you have no symptoms.
parenchyma
○ Pneumonia is lungs lang; TB can infect more than But once your immune system goes down (ex. stressed):
the lungs immunocompromised
○ Tb can infect more than lungs - extrapulmonary TB ● Reinfection and activation of dormant bacteria
■ Ex: TB meningitis, TB of the lymph nodes, ○ Ghon tubercle ulcerates and releases the cheesy
TB of the elbow, of the knee material to the lungs.
■ TB of the vertebral column - Pott’s disease
● Transmitted to other parts of the body ● Clinical Manifestations
○ Meninges ○ Low-grade fever
○ Kidneys ■ Sanay na yung katawan mo with the
○ Bones presence of the microorganism
○ Lymph nodes ○ Night sweats
● Mycobacterium tuberculosis ○ Fatigue
● Mycobacterium bovis and mycobacterium avium (pigs) ○ Weight loss
○ Cough
● Transmission: ■ Nonproductive or (severe) mucopurulent
○ Airborne transmission sputum
■ Talking ○ Present for week-months
■ Coughing
■ Sneezing ● Assessment and Diagnostic Findings:
■ Laughing ○ Complete history
■ Singing ○ Physical examination
○ **Droplet transmission - is only within 3 feet. Pag ○ Tuberculin skin test
airborne, even yung nasa dulo ng room, ○ Chest x-ray
makakukuha ○ Acid fast bacillus smear
○ Sputum culture
● Risk Factors: ○ Bronchoscopy
○ Those with close contact with someone who has ○ Thoracentesis - during the late stages already
active TB ○ Chest CT
○ Immunocompromised status ○ Biopsy (typically lungs, pleura, or lymph nodes)
○ Substance abuse
○ Pre Existing medical conditions or special treatment TUBERCULIN SKIN TESTING
○ Any person without adequate health care ● MANTOUX TEST
○ Immigration from countries with a high prevalence of ● Use of Purified Protein Derivative (PPD)
TB ○ Chinecheck mo if exposed ka na ba
■ Required to do before you go into US, ● You are testing for EXPOSURE to the microorganism
Canada, Australia: magpatest for TB since ● Done annually - sometimes every 6 months
high prevalence dito sa pinas ○ If you tested positive, gagawin pa ba ung mantoux
■ Drink antibiotic as prophylaxis if you’ll be test next year? Not anymore. Once youre positive,
exposed to countries with high prevalence of you already have TB forever
TB ■ No symptoms - dormant lang kasi malakas
○ Institutionalization immune system mo pero forever exposed ka
○ Living in overcrowded, standard housing na
○ Being a healthcare worker performing high-risk ○ If negative mantoux test mo this year, you still need
activities to do the mantoux text next year.
● How to know if active TB mo?
● Pathophysiology: ○ X-ray
○ Susceptible person inhales mycobacterium bacilli, → ○ Gold standard: Gram staining (sputum culture)
infected ● Standardized procedure
○ transmitted through the airways to the alveoli ● Positive: > 10 mm (+)
○ Bacilli are transported ● But if immunocompromised: >5mm
■ Lymph system ○ Immunocompromised: autoimmune disorders,
■ Blood stream - kidneys, bones, cerebral chemotherapy, AIDS
cortex, other parts of the lungs ● You look for induration. Matigas pero di naman gano red.
○ immune system activates the inflammatory response ● Injected intradermal
→ fluid accumulation in alveoli, forms a pulmonary ○ It will create a wheal once injected
granuloma (Ghon tubercle) - Reinfection & activation ○ After Injecting, babalik siya 48-72 hours after
of dormant bacteria Look for induration
○ Lung tissue is inflamed; Pwede mag collapse ang
lungs kasi yung alveoli is full of fluids na ● Medication Management:
1. Chemotherapeutic agents for 6-12 months
2. Several type of drug resistance
○ Primary drug resistance: resistance to one
of the first-line antituberculosis agents in a
person who has not had previous treatment
■ Kaya siya primary If laging ibibigay
nasasanay ka na
○ RIPES (Rifampicin, INH, pyrazinamide,
Ethambutol,)
■ You have to take it because it is
difficult to eradicate the
microorganism.
■ Non-compliance is high for clients
● Granulomas - (encapsulation) accumulation of live and that are with TB
dead bacilli - surrounded by macrophages - creates a wall of ■ You develop drug resistance if you
tissue - fibrous tissue do not comply with the whole
○ If your immune system is good, most likely treatment.
symptoms will not manifest because the immune ● If you constantly expose the
system is working well. But when your body inhales microorganism, they get
the microogranism and enters lung tissues, (lungs used to it.
have macrophages; type 3), the body is going to be ● Multi-drug therapy -
surrounded by macrophages creating a wall of combining drugs
tissues and encapsulate the microorganism ■ Medicine administration
(granulomas) combinations can be RIP, RIPE, or
■ When immune system goes down, later on RIPES
may mangyayari jan ● RIPE lahat to oral
● Center of granuloma is called Ghon Tubercle ● Strepto: IV
● Tubercle becomes necrotic and forms cheesy mass - ■ Gold standard medication in
calcifies and becomes a scar (dormant stage) RIPES: ISONIAZID (INH)

2
 ○ If di parin effective RIPES, nagiiba ka na ng
gamot.
○ Ex: nag RIP/RIPE/RIPES ka pero kasama
mo lagi asawa mo sa bahay, iinom ba sya
ng gamot kasi exposed sya?
■ Ikaw ung may sakit pero exposed
sya so iinom sya ng gamot -
PROPHYLACTIC TREATMENT
● Isang gamot lang: Isoniazid
(INH) (the gold standard)
● Treatment of 1-3 months for
prophylaxis
○ When do you consider a person no longer
communicable / transmissible?
■ 2-3 weeks
■ Once you start anti-TB drugs for
2-3 weeks, you are no longer
communicable
■ Infectious : caused
microorganism
■ Communicable : can
transmitted to another person
■ Contagious : mabilis makahawa
(covid, small pox)
● Nursing management:
1. Standard airborne precautions
○ Should be N95 Mask
○ Di pwedeng yung ordinary masks
2. Diet high in CHO, CHON, B6, C and calories
a. Take B6 supplements with INH since it
blocks it
3. Provide negative pressure room to prevent spread of
infection
a. It’s not just a regular room. Kailangan may
filter
b. Air goes in but it doesn't go out so you won't
infect other people
4. Multi-drug therapy – 6-9 months – to prevent
resistance of microorganisms
5. 2-3 weeks of medications lessens transmission
6. TB Medications
● Rifampicin – reddish orange secretions
○ All secretions, stool, and urine, even
tears are reddish orange.
TETANUS (from RESEARCH)
●
● “Lock jaw” due to tightening of jaw muscles, also called as
trismus
● First produced in animals in 1884
● Tetanus toxoid developed in 1924 and widely used during
world war II
● Organism: clostridium tetani
○ Usually found in soil, dust, and manure
○ Anaerobic gram-positive, spore-forming bacteria
○ Spores found in soil and intestines and feces of
some animals
○ Produces 2 exotoxins:
■ Tetanolysin
■ Tetanospasmin
● A neurotoxin and causes the clinical
manifestations of tetanus
● Usual mode of transmission: puncture wound
○ Bacterial spores through breaks in skin
○ The tetanus toxin Interferes with the release of
neurotransmitters, blocking inhibitor impulse →
unopposed muscle contraction and spasm
● Approximate incubation period: 3-21 days (average of 8
days)
○ The further the injury site from the central nervous
system, the longer the incubation period.
○ The shorter the incubation period, the higher the risk
of death.
● Types of tetanus:
○ Generalized
■ First sign is trismus
■ Neonatal tetanus is a form of generalized
tetanus
● Born without protective passive
immunity because the mother is not
immune
● Usually occurs through infection of
the unhealed umbilical stump,
particularly when the stump is cut
with an unsterile instrument.
● INH (Isoniazid) – blocks vitamin B6 –
peripheral neuritis – paresthesia
○ RIP Both hepatotoxic – avoid
ALCOHOL!
○ Magsupplement ka ng B6
○ B vitamins are important for nerves.
○ Side effect of INH: peripheral
neuritis which can cause
paresthesia in hands (numbness
and tingling sensation)
● PZA (Pyrazinamide)
○ Increase uric acid - hyperuricemia
● RIP/RIPE (Rifampicin, INH, PZA) are
hepatotoxic
○ Avoid drinking alcohol
○ Substance most damaging to the
liver is alcohol
● Ethambutol – optic nerve damage; can
by cause blindness
○ Eyes
be ● Streptomycin – ototoxic and nephrotoxic
○ SON – Streptomycin is Ototoxic and
Nephrotoxic
● Myrin – INH+ Rifampicin+ PZA
● Myrin forte – same + Ethambutol
7. Advocating adherence to treatment regimen - DOTS
program
a. DOTS - Directly Observed Treatment
Strategy
b. Dots program - papupuntahin mo sa ospital
dun mo papainumin ng gamot
c. Ung mga kasama sa bahay sila titingin kung
may compliance sa drugs ung patient
8. Promoting activity and adequate nutrition
9. Promoting airway clearance
● Monitoring and managing potential complications
○ Malnutrition
○ Side effects
○ Side effects of Medication Therapy
○ Multi Drug resistance
○ Spread of TB infection
○ Localized
■ Patients have persistent contraction of
muscles in the same anatomic area as the
injury
■ May precede the onset of generalized
tetanus but is generally milder
○ Cephalic - occur with otitis media; involvement of
cranial nerves
○
● Complications
○ Laryngospasm or spasm of the muscles of
respiration leads to interference with breathing.
○ Fractures of the spine or long bones may result
from sustained contractions and convulsions.
○ Hyperactivity of the autonomic nervous system may
lead to hypertension or an abnormal heart
rhythm.
● Signs & symptoms:
○ Jaw cramping
○ Sudden, involuntary muscle spasms — often in the
stomach
○ Painful muscle stiffness all over the body
○ Trouble swallowing
○ Seizures (jerking or staring)
○ Headache
○ Fever and sweating
○ Changes in blood pressure and heart rate
● Treatment
○ Wound management
■ Necrotic tissue and foreign material should
be removed
○ Tetanus immunoglobulin (TIG) is recommended for
persons with tetanus.
○ Tetanus toxoid vaccine
○ Antimicrobial therapy
■ Metronidazole
● Therapeutic class: antiprotozoals
3
 ● Pharmacologic class: suppresses the spread of seizure
nitroimidazoles activity
● Used for infections caused by ○ Neuromuscular blocking agents
anaerobic microorganisms ○ Magnesium Sulfate
■ Penicillin G ■ Controls muscle spasms
○ Neutralization of unbound toxin ■ Muscle relaxant
■ Intramuscular toxin: Human tetanus immune ■ Watch out for absence of deep tendon
globulin (HTIG) which is administered as reflexes
soon as diagnosis of tetanus is confirmed ■ MgSO4 toxicity antidote: calcium gluconate
○ Active immunization ○ Beta Blockade
○ Benzodiazepines and other sedatives ■ Labetalol
■ Diazepam ○ Other drugs:
● Therapeutic class: anxiolytics ■ Dexmedetomidine
● Pharmacologic class: ■ Atropine
benzodiazepines ■ Clonidine
● Anticonvulsant, muscle relaxant ■ Epidural bupivacaine
● Action: potentiates the effects of Airway management and other supportive measures
GABA, depresses CNS, and

RABIES

● Death always follow (once symptoms show) ○ Incubation period: average of 1 week to 3 months
● Ancient History ■ Some last for years, even up to 21 years
○ Mesopotamia 4,000 years ago ○ Aggravating Conditions:
○ Greece 300 B.C ■ Closeness to brain
■ Aristotle - believed there is no cure in rabies ■ Severity of wound
● Patients, especially in rural areas, used to seek albularyo ■ Amount of virus introduced
and seek medications only when s/sx occur ○ Attaches to a healthy nerve cell → Replicates →
● Dr. Louis Pasteur (1885) leaves cell → attaches to other cells → travels to
○ French Chemist and Microbiologist CNS (movement is 3mm/hr) → peripheral nerves →
○ First step in control of rabies other parts of the body
■ Vaccine for anti-rabies (found out about ■ Spinal Cord -> Brain -> Peripheral →
antibodies) salivary glands
TRANSMISSION ● (2) Prodromal
● Human-human ○ Virus has reached the CNS hence S/Sx develops
○ Possible through saliva (kissing) only when there is ○ Flu like symptom (headache/fever)
a break in his/her mouth (e.g. singaw/mouth ulcer, ○ Pain and numbness at wound site
dental caries) ○ Itchy, depression, anxiety, spontaneous ejaculation
○ Organ Transplant (corneal, kidney) ● (3) Acute Neurologic
■ Transplant of cornea from donor who died of ○ 3 substages:
rabies encephalitis ○ A. Spastic
● Saliva from a rabid animal transferred to humans through ■ Anxiety, made worse by insomnia
bites ■ Difficulty breathing and swallowing
● Scratches from a rabid animal (they tend to lick their paws, ■ Expectoration to improve respiration (bec
and when scratched, the saliva is then transferred) nagsspasm ung larynges)
● Do not get rabies when in contact with feces, urine of the ■ Laryngeal spasm
animal ● Feeling of being strangled
■ Fear of water (hydrophobic)
SIGNS OF RABIES IN ANIMALS: ● Due to alterations in salivary
● Change in behavior production, instead of producing
● Restlessness and aggression saliva, they experience spasm so
● Swallowing problems they also tend to spit their saliva
● Drooling (have a cup ready for whenever
● Paralysis they spit)
○ B. Demential State
IN 1903 ■ Agitation, impulsive
● First definitive diagnosis of rabies ■ Communication with them is possible
○ From the brain of an animal suspected of rabies ○ C. Paralysis
● DFA- Direct Fluorescent Antibody ■ Coma or death
○ Standard, fastest and reliable test ■ Stupor
○ Negri bodies are seen - color apple green ■ Paralysis
■ Round or oval inclusions (reference: CDC) ● Maniacal behavior medications:
○ Rabies virus - rod-shaped ○ Diphenhydramine (benadryl) → sedative
● Dr. Adelchi Negri ○ Haloperidol → antipsychotic drug
MANAGEMENT:
RABIES VIRUS ● Isolate patient
● came from Rhabdoviridae Family ● Encourage family to provide care and company
● rod-shaped ● Darken room and observe silence
● Destroyed in 60C 35 sec ● Give food to patient if hungry (soft diet)
● Stable when frozen under -70C and freeze dried at 0 to -4 C ● Keep water out of sight
STAGES: ● Universal precautions – mask, gloves, gowns, cap
● (1) Incubation ● Wash hands

4
 ● Remove nasal and oral secretions ● D0, D3, D7 → 2 doses
● Dispose contaminated materials ● D28-30 → 2 doses (If verorab/rabipur is used, 4th
● Terminal disinfection recommended dose is optional. If the animal has rabies, 4th dose is
needed)
LOCAL WOUND TREATMENT ● **Do not press to avoid spillage
● Wash wound thoroughly (for 10 minutes)
○ Before: use soap and warm water B. SERUM or Rabies Immunoglobulins
○ Now: flowing/running water for 15-30 minutes ● (1) Equine Rabies Immunoglobulin (ERIG)
● Irrigate with virucidal agent ○ 1 vial = 10mL
● Rush victim to nearest animal bite center ○ Brand: EQUIRAB - horse serum
● Anti tetanus and antibiotics given ○ Vastus lateralis
● Loose suturing for severe wound ○ Computation for mL : 40IU/KBW (200 IU/mL)
■ 40 / 200 = 0.2
GENERAL CONSIDERATIONS FOR POST-EXPOSURE ■ KBW x 0.2 =
TREATMENT ■ Ex. KBW: 50kg
● Nature & site of the bite ● 50 x 0.2 = 10mL
● Place of incidence ○ Do skin testing first. If positive, human serum is
● Vaccination status of animal given
● Availability of animal ● (2) Human Serum / Human Rabies Immunoglobulin
● Lab exam of dog’s brain (HRIG)
● Start PET ○ 1 vial = 2 mL
● Stop treatment if negative results ○ More expensive
● High risk ○ No need for skin test
○ Bite exposure to … mucus ○ Computation for mL: 20IU/KBW (150IU/mL
● At risk ■ 20 / 150 = 0.133
○ People who slaughter animals or infected carcass ■ KBW x 0.133
○ People who work closely with animals (zookeepers, ■ Ex: KBW: 50kg
veterinarians, etc) ● 50 x 0.133 = 6.5 mL
● No treatment ● Rabies serum - D0 and D7 only because after D7, vaccine
○ Ate well cooked infected meat (eating dog meat is should be given
against the law) ● Serum is given in category 3 bite (these are transdermal
○ Had a casual contact with rabies victim bites with spontaneous bleeding)
○ Were bitten by rats ● If animal is stray, patient is recommended to receive the
serum (D0, D7)

IMMUNIZING AGENTS For serum

● Vaccine (Active Immunity) - different brands can be used ● Infiltrate in and around wound
interchangeably ● Administer IM at a site distant from any vaccine inoculation
● Serum (Passive Immunity) ● Given to category 3 bites
○ Transdermal bites
Post-Exposure Treatment - ○ Spontaneous bleeding
A. VACCINE ○ Biting animal is lost like stray dogs
1. Reduced multisite Intramuscular ■ Recommended to receive the serum
○ Purified Vero Cell Vaccine (PVCV or PVRV) ○ Fruit bat/bat is a wild animal. Category 3 bite as well
■ Brand: Verorab
■ Given in 1 full vial dose: 0.5 mL (can be For vaccine
shared by 2 patients) ● Do not inject in gluteal area
○ Purified Duck Embryo Vaccine (PDEV) now ● For pedia: anterolateral part of the upper thigh
known as Purified Chick Embryo Cell (PCEC) ● For adults: deltoid
■ Brand: Rabipur
■ Given in 1 full vial dose: 1mL (can be PRE-Exposure Prophylaxis
shared by 4 patients) ● 1 dose in D0, D7, & D21
○ Skin test is done first before 1st dose ● IM:
○ SCHEDULE FOR IM: ○ 1 mL PDEV
■ (1) 2-1-1 ○ 0.5 mL PVCV
● D0 (Day of consultation) - 2 doses ● ID - 0.1mL all types
● D7 - 1 dose
● D21 - 1 dose BOOSTER DOSE
■ (2) 1-1-1-1-1 ● Every year - vets, zoo keepers
● D0 ● Every 6 months - lab personnels in animal bite centers,
● D3 those at high risk jb
● D7
● D14 (if WHO-recognized vaccine is “MANIACAL BEHAVIOUR”
used, the dose stops here at 14th ● PHARMACOLOGICAL MANAGEMENT:
day) ○ Primary med: Haloperidol - an antipsychotic drug,
● D28 (other FDA approved vaccines, sometimes combined with Diphenhydramine (
vax must be up to D28) benadryl )
2. 2-site Intradermal Regimen ○ Other drugs:
● PVCV - given in 0.1mL ■ Diazepam
● PDEV/PCEC - given in 0.2 mL (before) ; now 0.1mL ■ Midazolam
is given also since its discovered they have the
same potency

5
 POSSIBLE CASES

HIV

● MOST COMMON METHODS OF TRANSMISSION OF HIV ● ARC is a term used to describe HIV infected persons have
ARE: some symptoms of AIDS but have not yet had a major
○ Transmitted through sharing of body fluids complication of AIDS
○ Unprotected sex with an infected partner ● persistent lymphadenopathy, oral candidiasis, persistent
○ Sharing needles with affected person fever & diarrhea
● Almost eliminated as risk factors for HIV transmission are: > Phase D: AIDS
○ Transmission from infected mother to fetus ● A. Constitutional disease; HIV wasting syndrome;
○ Infection from blood products (blood transfusion) opportunistic infections
● Saliva cannot transfer (ex, kissing/sharing of utensils) not ○ protozoal infections:
unless may break sa skin ■ Pneumocystis Carinii Pneumonia (PCP)
● There is a stigma sa AIDS patients ■ Toxoplasmosis
● #1 cause is sex but that is not always the case ■ Cryptosporidiosis
● Don’t judge the patient ■ isosporiasis
○ Viral infections:
PATHOPHYSIOLOGY OF AIDS ■ herpes simplex virus
● The retrovirus infects helper T4 lymphocytes (attaches itself ■ Cytomegalovirus
to helper T cells) → HIV fuse directly with the cell membrane ■ progressive multifocal encephalopathy
mediating its entry into cell membrane → the enzyme ○ bacterial infections:
reverse transcriptase converts RNA to DNA ( dormant stage ■ TB
) → years or months later → HIV starts to replicate → new ■ salmonellosis
HIV cells bud on outer membrane → new cells are released ○ fungal infections:
and infect other helper T cells ( kills T4 cells ) → resulting in ■ Candidiasis
4, stimulation of macrophages, natural killer cells, killer ■ Histopiasmosis
lymphocytes & B Lymphocytes → depressed immune ● B. Secondary cancers ( neoplasms )
response → allows opportunistic infections & specific ○ Kaposi's Sarcoma
neoplasms to develop in HIV infected persons ○ Non-Hodgkin's Lymphoma
○ CNS lymphoma
RELATIONSHIP BETWEEN HIV ANTIBODIES AND AIDS ○ Burkitt's Lymphoma - retroperitoneal area &
● Everybody who has AIDS is HIV antibody positive, but not mandible
everybody who is HIV antibody positive has got AIDS ● C. Neurological Disease
● After infection with HIV, the mean length of time to the ○ HIV encephalopathy
development of AIDS is 8 years
● After diagnosis of AIDS, the mean length of survival is 18 [from lecture]:
mos. → steadily increasing because of advancement in ● PRIMARY INFECTION
technology ○ Virus lang si HIV. pag nakuha mo ung virus, hindi ka
agad may AIDS.
MODE OF TRANSMISSION ○ FIRST STAGE: From time na nakuha mo ung virus
● The essential criteria for successful transmission in all forms (natusok, nakipagsex) until such time na gumawa
of contact is that there must be an exchange of body fluids ung katawan mo ng antibodies against it.
and/or blood between the infected individual & the recipient ■ Wag ka muna mag test kasi magfafalse
individual. (semen, vaginal secretions, tears, saliva, negative
breastmilk, CSF ) ■ In covid, have the test after 3 - 5 days
● (1) transmission through sexual contact ■ In HIV –have the test in 2-3 weeks, or even
○ penis to vagina, penis to anus, penis to mouth, 6 months
vagina to mouth, mouth to anus, hand intovagina, ○ defined as the period from infection to the
hand to rectum development of antibodies to HIV.
○ mucosa trauma & rupture small bld. Vessels ○ Intense Viral replication and widespread
● (2) transmission through blood & blood products dissemination of HIV throughout the body.
○ blood transfusion - best known recipients are the ○ VIREMIA
hemophiliacs - unsophisticated method of blood ■ Mabilis mag multiply → VIREMIA (virus sa
screening blood)
○ blood transfusion through sharing an equipment - ■ Symptom: “tintrangkaso”, flu-like symptoms
syringes or needles ■ Symptoms: None to Severe flu-like
○ transmission through skin piercing products - ○ Window Period
tattooing, ear piercing, skin graft ■ HIV antibodies – seen in the sera of
○ transmission through other bodily fluids - urine, infected individuals – 2 to 3 weeks post
feces, saliva (few cases) infection (6 months at times)
● (3) mother to child transmission ■ Di ka agad pwede pumunta sa ER after
○ either in the womb or during delivery, when the exposure kasi magnnegative ka sa test
mother's and child's blood become mixed ■ For those sexually active, they test every 6
○ through amniotic fluid months
○ through breast milk ○ Antibodies lack the ability to inhibit the virus.
○ Neutralizing Antibodies are detected – HIV is
RISK FACTORS established already
● homosexual or bisexual men
● hemophiliacs & other recipients of BT ( infected donors ) 1. High Viral Replication and killing of CD4 T cells
● IV drug users4. heterosexual partners of persons with AIDS ■ High HIV in Blood & Low CD4 T cell count
● children of mothers with WV 2. Symptoms: Mononucleosis (Acute Phase)
● health workers - accidental puncture of needles ■ Fever
■ Enlarged Lymph Nodes
STAGES OF HIV DISEASE ■ Rash
[from handout]: ■ Muscle Aches
> Phase A: Acute Seroconversion Illness ■ Headaches
> Phase B: Antibody Positive Phase
● B-1 : asymptomatic HIV infection ○ Viral Set point occurs (6 weeks after symptoms are
● B-2: persistent generalized lymphadenopathy (PGL) Or detected / Steady State)
lymphadenopathy syndrome (LAS) ■ Ex: naexpose sa virus, virus will multiply
> Phase C : AIDS Related Complex (ARC) (virus in blood / viremia), → minsan hindi na
kaya ng katawan so gumagawa ung

6
 katawan mo slowly ng antibodies, and with ○ Category B: 200-499 (not yet aids) but with
that, may viral set point. Sa sobrang dami na symptoms
nya, ung antibodies mo nagagawa na kaya ○ Category C: less than 200 → AIDS
nadetect na sya sa blood mo. Si virus at a ● **Category is based on T cell count
certain point, it will stop multiplying threby
gagana na ung immune system mo → Diagnostic Criteria
masstablize ka na → steady state CDC Clinical and Immune Cell categories of HIV Infection
■ Immune System produces antibody
molecules to contain the virus; bind to free
Classificat Categorie Sample Criteria
HIV particles – removed.
ion s
● CD4 T cells stimulate other immune
cells (CD8 lymphocytes)
CD4+ Category > 500 cells/uL
■ Normal: CD4T cell count:
count 1
800-1200/microliter of blood
categories
● Usually lasts 100 days
Category 200 - 499 cells/uL
● Parameter that we will use
2
● Normally T cells last for 100 days,
but in AIDS it only lasts 2 days
Category < 200 cells/uL
■ T cells in AIDS: lasts 2 days
3
A. HIV ASYMPTOMATIC (CDC CATEGORY A: More than 500
Clinical Category Primarily Asymptomatic
CD4+ T LYMPHOCYTES/MM3)
Categories A
○ Pertains to asymptomatic stage (no symptoms)
pero nasa loob mo ung virus. Category Symptomatic attributed to HIV infection
○ It is defined as a chronic asymptomatic state after B Fungal, Oral hairy leukoplakia,
viral set point. listeriosis, peripheral neuropathy,
■ After bumaba yung virus level, it doesnt persistent fever/diarrhea
mean wala kang virus
■ Nandun pa rin – namamaintain pa yung T Category Diseases that are opportunistic and
cell C define AIDS. Cancers, Kaposi’s
○ Rate of viral replication reach a low but steady levels sarcoma, wasting syndrome, and
(at a set point) pervasive candidiasis.
■ Set Point varies among patients
■ Subsequent rate of the disease
■ Average 8-10 years before major HIV ASSESSMENT AND DIAGNOSTIC FINDINGS
complication ● HISTORY OF PATIENT
● May HIV ka, u still have 10 years na ○ Blood samples are tested for presence of antibodies
wala kang symptoms. But it varies to HIV:
on the immune system of the person ■ After infection with HIV, antibodies to the
○ NOT TRUE na all AIDS virus develop in most persons in 6-12 wks.,
patients die kagad; pero although seroconversion can take 6-12
some do months. These antibodies can be detected
○ Depende yung 8-10 yrs sa by:
immune system ng person; ■ (1) EIA (Enzyme immunoassay) test /
its just the average ELISA (Enzyme- linked
● Kaya walang symptoms kasi more immunosorbentassay)
than 500 pa yung T cells; pag ● Identifies antibodies specifically
narereach pa yung 500, ok pa against HIV
○ Apparent Good Health with few if any symptoms ● (+) for antibodies in blood >
■ CD4 T cells levels remain high – preserve Seropositive
defense mechanism to other pathogens. ● Saliva can be utilized
○ Bakit walang symptoms? Kasi 500 palang nmn. ● a test used to screen a given
Basta may T cell ka pa, may immune system ka pa. population for HIV infection
● indicates presence of HIV but not
B. HIV SYMPTOMATIC (CDC CATEGORY B: 200 to 499 CD4 diagnose AIDS
+ T LYMPHOCYTES/MM3) ● may produce a false positive result
○ Symptomatic na. Bumababa na ung T cells mo ● a positive test result must be
○ “In between” validated by a second ELISA test, if
○ Pwede ba nagchacharge yung status ng px? Yes still positive… → WBA
depende sa T cell count ■ (2) Western Blot Assay
■ Category is based on T cell level. So ● To confirm seropositivity when the
possible na magchange status ng patient EIA is positive
depende sa T cell count ● Immunoblot
○ CD4 T cell levels gradually falls ● more accurate and is used for final
○ Consists of symptomatic conditions in HIV infected confirmation
patients that are not classified in category C. ● CONFIRMATORY TEST
○ Condition is due to HIV infection or a defect in ● Dont just rely sa saliva or swab.
cellular immunity. Even if you do the EIA, the
○ Condition must be considered to have clinical course CONFIRMATORY is Western Blot. if
or require management complicated by HIV infection nagpositive ka sa EIA, may mas
○ Patient developed was treated for category B; has positive pa
not developed category C and symptom free → still ● Parang RTPCR
belong to category B. ■ (3) OraQuick Rapid HIV-1 Antibody Test
● Note: HIV positive lang tawag either asymptomatic or ● A drop of blood used to test for
symptomatic antibodies
● Fast (20 minutes) and reliable
C. AIDS (CDC CATEGORY C: Less than 200 CD4 + T (99.6% accuracy)
LYMPHOCYTES/MM3) ■ ** remember not to test right away; test 2-3
○ Person has AIDS; the time na masasabi mo may months after or 6 months after
AIDS na ■ Always have a confirmatory test
○ T cell Levels – below 200/mm3 → AIDS ■ (4) Lab, Findings
○ T cell Levels – below 100/mm3 > severely ● anemia, leukopenia,
impaired Immune System (SIIS) thrombocytopenia
■ Ang mas malaa sa AIDS is SIIS ● low serum albumin
■ All forms of cancer or infection pwede ● elevated transaminase, alkaline
kumapit sayo phosphatase
● decreased CD4 count
SUMMARY: ● Viral Load Tests
● FIRST STAGE: primary infection (exposure → gumawa ○ Target Amplification – quantify HIV RNA or DNA
antibodies, dito ka magttest) levels
● Normal T cell count: 800-1200 ■ Reverse transcriptase polymerase chain
○ Category A : asymptomatic average 8-10 years reaction(RT-PCR)
more than 500 t cells

7
 ● Detects HIV high-risk seronegative
people before development of QUESTION: Can you have sex with an HIV positive person?
antibodies (1) PREP
● Confirms positive EIA ● Preexposure Prophylaxis
● Neonatal Screening ● May gamot tayo na kahit may AIDS pa yan, ung gamot na
■ Nucleic Acid Sequence Based iinumin napapatay or nabblock nya ung virus when you
Amplification(NASBA) become exposed. (recommened by WHO and CDC)
○ • To track the viral load and response to treatment ● 99% nakakatulong daw – as long as you take it correctly and
○ • Better than CD4 count follow the instructions
○ • Low Viral Load = longer time to AIDS diagnosis (2) PEP
and the longer the survival rate ● Post Exposure Prophylaxis
● Involves taking anti-HIV drugs very soon after a possible
NON-SPECIFIC SYMPTOMS: wt. loss, fatigue, diarrhea, fever, exposure to HIV to prevent HIV
pallor, anorexia, & inability to prevent infections ● Kailangan may masunod ka na certain time para inumin mo.
if di mo nasunod ung time, at risk ka to get HIV
PREVENTION ● Truvada
● safe sex guidelines - 1 partner at a time, condom's efficacy is
unknown but it reducestransmission
● personal things should not be shared
● discard used needles or properly autoclaved - don't recap
● regular medical evaluation & follow-up care
● AIDS precaution

MANAGEMENT
● antibacterial agents for opportunistic infection
● AZT (azidothymidine) - do not kill the virus but interrupt and
inhibit the process of virus replication by interfering with the
function of reverse transcriptase- long-term efficacy is
doubtful
● Suramin & Interferon - causes biochemical changes which RESPIRATORY MANIFESTATIONS
interferes with the ability of the virus to infect other cells ● Opportunistic Infections (OIs)
● chemotherapy or radiotherapy for neoplasms ○ Shortness of Breath (SOB)
● strict hand washing ○ Dyspnea
● reverse isolation if leukopenia develop ○ Cough
● emotional & psychological support ○ Chest pain
○ Fever
TREATMENT ○ Very common in imunocompromised people
● There’s no cure for AIDS. ● Pneumocystis carinii pneumonia (jiroveci)
● Our goal for HIV positive: maintain the T cell count. Mas ○ #1 cause of death of patients with AIDS
mataas dapat T cell kesa sa viral level mo. if bumaliktad, ○ Old name: Pneumocystis carinii pneumonia (since it
immunocompromised ka was previously believed to be mycobacterial in
● Maximal suppression of viral load nature)
○ Preserve the immune system of the client and ○ New name: Pneumocystis jiroveci pneumonia
reduce the virus in the person since the virus cannot (fungal)
go away. ■ Fungal type of pneumonia
● Restoration/preservation of immunologic function ● Mycobacterium avium complex (MAC)
● Improved quality of life ● TB
● Reduction of HIV related morbidity ● Diarrhea (50-90% of all patients)
● ANTIRETROVIRAL AGENTS ● Wasting syndrome → lose more than 10% of their body
○ Note: will not focus much on this in the exams. weight
○ Nucleoside analog reverse transcriptase inhibitors ● Kaposi sarcoma – skin cancer (brownish pink to deep
■ Becomes part of the DNA and derail its purple)
building process, the damaged viral DNA ○ A type of skin cancer
can not take control of the host cell’s DNA
● zidovudine (AZT, Retrovir)
● lamivudine (3TC, Epivir)
● d4t (Zerit, stavudine)
● ddi (Videx)
● ddc (Hivid, zalcitabine)
● abacavir (Ziagen)
○ Non-nucleoside reverse transcriptase inhibitors
(NNRTIs)
■ Attach to the reverse transcriptase enzyme, ○
which prevents it from converting HIV RNA ● Peripheral neuropathy
into HIV DNA ○ Bc it affects the nerves
● nevirapine (Viramune) ● HIV encephalopathy – cytomegalovirus (blindness)
● delavirdine (Rescriptor) ○ Problems in the brain
● efavirenz (Sustiva) ● Cryptococcus neoformans
● tenofovir (Viread) ● Herpes simplex
○ Protease Inhibitor ● Candidiasis (oral/esophageal)
■ Prevents the protease enzyme from cutting ●
HIV viral proteins into the viral particles that
infect new CD4 T4 cells. New copies of HIV GI MANIFESTATIONS
are defective and unable to infect new host ● Oral Candidiasis
cells. ○ Fungal Infection – occurs to almost all patients with
● » nelfinavir (Viracept) AIDS
● » ritonavir (Norvir) ○ Characterized by creamy white patches in the oral
● » saquinavir (Invirase) cavity
● » indinavir (Crixivan) ○ Patients complain of difficult and painful swallowing;
● » amprenavir (Agenerase) and retro sternal pain
○ Block viral replication within cells by inhibiting either ○ Untreated > esophagus and stomach
reverse transcriptase or the HIV protease ■ Ulcerating oral lesions
○ Duration of treatment needed to control HIV infection ○ Medical Management
is unknown, but may continue for several years ■ Clotrimazole (Mycelex)
(average of 5-7 years) or for life. ■ Nystatin Suspension
● COMBINATION THERAPY ■ Ketoconazole (Nizoral) or fluconazole
○ contains two antiretroviral agents (Diflucan) – with esophageal involvement
Highly Active Antiretroviral Therapies (HAART)
○ Two nucleoside reverse transcriptase inhibitors plus ● Common lymphoma affecting people with AIDS is
a protease inhibitor Non-Hodgkins Disease since hodgkin disease affects B
○ Non-nucleoside reverse transcriptase inhibitor cells while AIDS affects T cells
○ Two protease inhibitors and one other antiretroviral
agent OPPORTUNISTIC INFECTIONS AND SECONDARY DISEASES

8
● Pneumocystis Carinii Pneumonia (PCP)- most common ○ early manifestation: peripheral neuropathy
cause of death in AIDS ○ later manifestation: alteration in patient's personality
○ shortness of breath, weakness, dry cough, & and lucidity, eventually becoming demented
hypoxemia
○ treatment: pentamidine isethionate I.V. or Prevention for Immunodeficiencies
co-trimoxazole side-effect: nephrotoxicity ● Protection from infection - most important factor in the care
● Herpes Simplex - treated w/ acyclovir of immunodeficient
● Kaposi's' Sarcoma - purple plaques on the skin & mucous ○ medical asepsis
membrane ○ laminar air flow units - rooms that are specially
● Non-Hodgkin's Lymphoma - fever & lymphadenopathy designed with air flow across the unit in layers to
● HIV Encephalopathy decrease the microorganism moving toward the
○ HIV dementia, AIDS dementia, Sub-acute patient
encephalitis ○ life island - consist of plastic tents
○ most common neurologic effect
○ directly affects the brain's subcortical regions and
covering

CUTANEOUS FUNGAL INFECTION

●
● Also known as mycoses ○ Poor hygiene
● Commonly cause by dermatophytes ● Effects
○ Tinea pedis ○ Irritation
○ Tinea corporis ○ Scaly skin
○ Tinea cruris ○ Redness
○ Tinea capitis ○ Itching
○ Tinea ungiuim ○ Swelling
● Most susceptible to fungal skin infection: ○ Blisters
○ Immunodeficient/ Immunosuppressed clients ● Often treated topically unless severe
○ Obese ○ Tinea unguium - responds best to oralmeds
○ Impaired circulation ○ Tinea capitis - treated orally since topical agents
○ Prolonged exposure to moisture cant penetrate the hair shaft.

TOXIC EPIDERMAL NECROLYSIS

●
● A.k.a Stevens-Johnson syndrome (SJS) ■ Shedding of skin within days after blisters
● Increased risk: form
○ Older people ● Complications
○ Immunocompromised ○ Keratoconjunctivitis
● Characterized by widespread erythema and macule ○ Sepsis
formation with blistering, resulting in epidermal detachment ○ Multiple organ dysfunction syndrome (MODS)
or sloughing and erosion formation ● Medical Management
● Triggered by a reaction to medications such as antibiotics ○ Goal: control of fluid & electrolyte balance
(esp sulfonamides), anticonvulsants, NSAIDs, allopurinol, ○ prevention of sepsis
and oxicam NSAIDs ○ prevention of ophthalmic complications
● Symptoms ○ Supportive
○ One to three days before a rash develops, you may ○ IV crystalloid fluids
show early signs of Stevens-Johnson syndrome, ■ To maintain fluid & electrolyte balance
including: ○ Thermoregulation
■ Fever ■ Prevent hypothermia since they are prone to
■ A sore mouth and throat chilling
■ Fatigue ○ Wound care
■ Burning eyes ○ Pain management
○ As the condition develops, other signs and ○ Systemic corticosteroids
symptoms include: ○ IVIG
■ Unexplained widespread skin pain ○ Surgical debridement/hydrotherapy - hubbard tank
■ A red or purple rash that spreads
■ Blisters on your skin and the mucous
membranes of the mouth, nose, eyes and
genitals
●
CAP (community acquired pneumonia)
●
● Refers to an acute infection of the pulmonary parenchyma ○ Viral respiratory tract infection
acquired outside of the hospital. ○ Impaired airway protection
● One of the classifications of Pneumonia, ○ Smoking and alcohol overuse
○ Other classifications: ○ Other lifestyle factors
■ Nosocomial pneumonia ● Common causes: streptococcus pneumoniae
● Hospital-acquired pneumonia (pneumococcus) and respiratory viruses
(acquired >48 hours after hospital ○ Typical bacteria
admission) ■ S. pneumoniae (most common bacterial
● Ventilator associated pneumonia cause)
(acquired >48 hours after ■ Haemophilus influenzae
endotracheal intubation) ■ Moraxella catarrhalis
■ Healthcare associated - referred to ■ Staphylococcus aureus
pneumonia acquired in health care facilities ○ Atypical bacteria
(eg, nursing homes, hemodialysis centers) ■ Mycoplasma pneumoniae
or after recent hospitalization. ■ •Chlamydia pneumoniae
● Occurs <48 hours of hospital admission ○ Respiratory viruses
● Risk factors ■ SARS-CoV-2
○ Older age ■ Coronaviruses
○ Chronic comorbidities ■ Phinoviruses

9
 ■ Adenoviruses ● Tests
■ Influenza a and b ○ ESR, procalcitonin, CRP - inflammatory markers
● Transmission: droplets, or less commonly, via aerosol ○ Blood cultures
inhalation ○ Sputum gram stain and culture
○ Following inhalation, the pathogen colonizes the ○ Urinary antigen testing for S. pneumoniae
nasopharynx and then reaches the lung alveoli via ○ Sars-cov2 testing
microaspiration. ● Diagnosis:
○ When the inoculum size is sufficient and/or host ○ X-ray - Pulmonary infiltrates / pulmonary opacities,
immune defenses are impaired, infection results. lobar consolidations
○ Replication of the pathogen, the production of ● Management
virulence factors, and the host immune response ○ Do C&S Sensitivity test
lead to inflammation and damage of the lung ■ If it's taking too long, u can start antibiotics
parenchyma, resulting in pneumonia but give broad-spectrum (covers both gram
● Signs and symptoms: positive and gram negative)
○ Cough (with or without sputum production) ○ Improve airway patency (DBCE, mucolytics)
○ Dyspnea ○ Increase fluid intake
○ Pleuritic chest pain ○ Conserve energy
○ Tachypnea, increased work of breathing ○ High calorie, high CHON
○ Adventitious breath sounds (rales/crackles and ○ Vaccine given for a lifetime: Prevnar13
rhonchi)
○ Tactile fremitus, egophony, dullness to percussion
○ These signs and symptoms result from the
accumulation of white blood cells (WBCs), fluid, and
proteins in the alveolar space

G1P0 39 WEEKS - POST PARTUM DEPRESSION

●
DKA
● Diabetic ketoacidosis (DKA)
● Patient does not have enough insulin to utilize glucose for energy -> Utilize fat instead which produces ketones (acid) -> too much ketones
● Signs and symptoms
○ Polyuria
○ Polydipsia
○

10