Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for viral and fungal infections
- Describe the diagnostics and laboratory values for viral and fungal infections
- Apply nursing interventions and associated therapies in the care of the patient with viral and fungal infections
- Apply nursing interventions and associated therapies in the care of the patient with viral and fungal infections
Before 2020, you may not have thought much about viruses, except perhaps when it came time to get your annual flu shot. However, that likely all changed with the onset of the COVID-19 pandemic. The pandemic has shed light on the profound impact of viral infections on society and redefined how the world will handle outbreaks in the future.
Infection with the human immunodeficiency virus (HIV), a retrovirus characterized by the destruction of certain WBCs, was nearly 100 percent fatal in the 1980s. Over the past few decades, the development of antiviral drugs has transformed HIV infection into a chronic, manageable disease—provided those with the virus learn about their infection in time to start treatment and avoid passing it to others (HIV.gov, 2023).
The hepatitis viruses are another example of pathogenic viruses. The World Health Organization (2024) estimates that more than 300 million people worldwide are currently living with chronic hepatitis infection that is either undiagnosed or untreated.
Numerous fungi live on and within the human body, but they do not usually cause disease. When they do result in an infection, the areas most often affected are the skin and nails, but it can also spread to the mouth, throat, lungs, and urinary tract.
This section takes a closer look at nursing interventions and medical therapies for various viral and fungal infections. However, we start by examining the pathophysiology of viral infections in general.
Pathophysiology of Viral Infection
A virus consists of a piece of genetic code, such as DNA or RNA, protected by a coating of protein; some viruses also contain an outer envelope of lipids (Kramer, 2023). Regardless of their specific characteristics and how they are classified, viruses can profoundly affect, and even kill, the organisms they infect. Figure 22.7 illustrates one type of virus.
An individual whom a virus infects is called a host. Following the initial infection, the virus invades the host’s cells, injects its genetic material, and uses the host cell’s components to replicate and produce more viruses. The new viruses are then released into the body, creating a cycle of invasion, replication, and release that risks destroying the host’s cells, threatening their health and, in some cases, life.
Viruses are often classified based on whether they contain DNA or RNA. Herpesvirus is an example of a DNA-containing virus, whereas SARS-CoV2 (which causes COVID-19) contains RNA. HIV is another type of virus containing RNA, but it is classified as a retrovirus, meaning that it is able to transcribe itself as permanent DNA inside the host cell. This ability makes retroviruses very difficult to treat. Viruses containing RNA are more likely to mutate, resulting in different strains. Medications and therapies that work on one strain may prove ineffective against a new strain with altered genetic material.
Although most viruses affect the upper airways, they can affect any body system. Humans can become infected by viruses by swallowing or inhaling them (via droplets), being stung or bitten by insects, or having sexual contact or intercourse. A mother can also transfer a virus to her fetus in utero or during birth. Viruses are difficult to treat because they are not responsive to antibiotics. Some antiviral medications are available, but they are not always effective; these are discussed in more detail later in this section.
Clinical Manifestations
Clinical manifestations will vary depending on the specific viral infection. Most viral infections cause vague general symptoms, including fatigue, muscle aches, and headache. Selected viruses and their associated clinical manifestations are listed in Table 22.2 (American Academy of Dermatology Association, n.d.; American Lung Association, 2023).
| Virus | Clinical Manifestations |
|---|---|
| SARS-CoV-2 (COVID-19) |
|
| Influenza |
|
| Respiratory syncytial virus (RSV) |
|
| Viral meningitis |
|
| Herpes simplex virus (HSV) |
|
| Rotavirus |
|
Assessment and Diagnostics
In many cases, viral infections can be diagnosed based on clinical manifestations alone. In other cases, blood tests and cultures may be used to determine the specific virus causing the infection. Laboratory tests are used often when patients present with symptoms that could be indicative of multiple types of viruses. The most common example is when patients present with nonspecific symptoms such as a runny nose and fever. In this case, providers often order rapid influenza and COVID-19 tests to see if either of those infections is the cause of the symptoms, because they both present similarly.
Nursing Care of the Patient with COVID-19
COVID-19 is caused by a coronavirus, a type of virus characterized by a lipid envelope surrounded by proteins that jut out like spikes (Figure 22.7). Coronaviruses are often the cause of the relatively mild cluster of symptoms, including sore throat, congestion, and cough, known as the “common cold.” The coronavirus that causes COVID-19 has proved especially dangerous partly because it is novel (i.e., new): our bodies had never encountered it, so they had not developed any immunity to it.
Providing nursing care for patients with COVID-19 has presented many challenges in the past few years since the onset of the pandemic (WHO, 2024b). Initially, nurses and other health-care professionals were unsure about how to care for these patients because there was not enough information available about the virus. Once there was more evidence and data collected about the virus, nursing care became more complex. However, this continuously changed as more data, trends, and treatments were discovered. COVID-19 had a significant mortality rate, requiring emotional and mental care to be provided to patients, families, and health-care staff alike (Mayo Clinic, 2023). Nurses remain on the frontlines of treating patients with COVID-19; therefore, it is critically important to be knowledgeable about the latest best practices in caring for these patients.
Recognizing and Analyzing Cues
It is imperative that nurses be able to recognize and analyze subtle changes in patients’ conditions that may be indicative of the onset or progression of a COVID-19 infection. Early intervention for the infection reduces its mortality rate, so early detection is essential. Early signs include vague symptoms, such as the following (CDC, 2024c)
- congestion or runny nose
- fatigue
- fever
- headache
- muscle aches
If any of these symptoms are noted, the nurse should advocate for the patient to be tested for COVID-19 to rule out or confirm the diagnosis so treatment can be initiated quickly. Later signs and symptoms of COVID-19 include a loss of taste or smell, severe shortness of breath, cyanosis, and confusion. Emergent intervention is required once these symptoms are present, and the nurse must recognize the urgency of the situation and intervene appropriately (Administration for Strategic Preparedness & Response, n.d.).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
If the patient presents with symptoms indicative of COVID-19 infection, the nurse will hypothesize that coronavirus is the cause and perform a rapid COVID-19 test. Results from rapid tests are obtained very quickly, thus the nurse can determine the next steps quickly. If the results are negative, the nurse should consider other potential causes of the symptoms and act accordingly. If the results are positive, the nurse begins to generate solutions and take actions, which include the following interventions:
- Monitoring vital signs: These can change quickly in patients with COVID-19, so the nurse should monitor them closely and frequently.
- Respiratory support: COVID-19 can cause severe lung damage, so providing respiratory support is essential. In mild cases, supplemental oxygen via nasal cannula may be sufficient, but many cases will require high-flow oxygen devices or intubation and mechanical ventilation.
- Positioning: Frequent repositioning of patients (ideally every 2 hours) helps facilitate lung expansion, which is crucial for treatment of COVID-19. The use of prone positioning also improves outcomes. Many units have specialized proning beds (Figure 35.11) for this purpose, but proning (placing patient in prone position) can also be done manually with assistance from other health-care staff.
- Infection control: Nurses caring for patients with COVID-19 must be vigilant about always wearing appropriate personal protective equipment (PPE; e.g., gloves, gown, N95 mask). The patient should be placed on isolation precautions and visitors to the room should be limited to prevent the spread. During the pandemic, visitation regulations became stricter during the peak spread of COVID-19 and visitation was eventually not permitted.
- Psychosocial support: Offering emotional support, reassurance, and education to patients and their families is a huge aspect of nursing care for patients with COVID-19 infection. These patients are often isolated, making them anxious and afraid. The nurse should comfort them, address their concerns, and assist them to develop appropriate coping strategies while in the hospital.
Evaluation of Nursing Care for the Patient with COVID-19
Nurses play a vital role in evaluating outcomes to gauge the effectiveness of interventions. The nurse will closely monitor for changes in the patient’s condition that indicate improvement or worsening of the infection.
Evaluating Outcomes
The nurse should evaluate assessment findings to determine if there has been any improvement in the patient’s condition. Findings that would indicate improvement include:
- improved mobility and tolerance of activity
- increase in appetite
- negative COVID-19 test
- resolution of respiratory symptoms, as indicated by a decrease in supplemental oxygen needs and improved oxygen saturation
- stable vital signs
Medical Therapies and Related Care
For mild COVID-19 infections, specific treatment may not be required. Mild infections are usually self-limiting and improve with adequate hydration and rest. More severe cases, however, require pharmacologic intervention. With the onset of the pandemic, there was a rush to develop medications that were effective against COVID-19 infection. To date, three medications are available: nirmatrelvir/ritonavir (brand name: Paxlovid), molnupiravir (Lagevrio), and remdesivir (Veklury). Nirmatrelvir/ritonavir and molnupiravir are taken orally as pills, and remdesivir is given intravenously; remdesivir is used in more severe cases for patients who require hospitalization for symptoms. In hospitalized cases requiring supplemental oxygen, dexamethasone, a steroid, is often prescribed to reduce inflammation and improve breathing. In addition to developing medications, governments and private laboratories collaborated to develop vaccines that will prevent future outbreaks. As of early 2024, the Centers for Disease Control and Prevention (CDC, 2024f) recommends that all people over the age of 5 years get the COVID-19 vaccine and a booster. Experts also expect the COVID-19 vaccines will require annual updates to treat new and emerging strains of the virus, similar to the influenza vaccine that is recommended each year (Yale Medicine, 2023).
Some patients who did recover from COVID-19 continue to have symptoms and adverse effects for months after the infection. This is called long COVID or post-COVID syndrome and, in some cases, it has resulted in death (CDC, 2024e). The most common long-term symptoms following COVID-19 infection include fatigue, shortness of breath, and brain fog (Johns Hopkins Medicine, 2022). Interventions for the treatment of long COVID include:
- breathing exercises and respiratory therapy
- physical therapy
- steroid medications to reduce inflammation
- supplemental oxygen
Nursing Care of the Patient with Influenza
Caring for patients with influenza, (more commonly called the “flu”) involves symptom management, infection control, and implementing interventions to alleviate discomfort, prevent complications, and promote recovery. Though the flu has been discussed less in recent years due to overshadowing by the COVID-19 pandemic, it is still a prevalent health concern that has led to death, and will continue to be studied in the coming years.
Recognizing and Analyzing Cues
Early detection and intervention for influenza infection is essential. Thus, the nurse is tasked with being able to recognize cues that indicate the presence of the virus. Early symptoms that may be indicative of influenza include:
- cough
- fatigue
- fever or chills
- headache
- muscle and body aches
- shortness of breath
Early symptoms of influenza are vague, making it difficult to make a definitive diagnosis based on clinical manifestations alone. The nurse must combine assessment findings with a thorough health history to recognize cues that would be consistent with influenza infection.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
If the patient presents with symptoms indicative of influenza, the nurse will first perform a rapid flu test. Likely, the nurse will also perform a rapid COVID-19 test at the same time, because both diseases present similar symptoms, at least initially. If the test is positive, the nurse begins to generate solutions and take actions, which include the following interventions:
- Symptom management: This includes administering antipyretics to decrease fever, analgesics for pain, and cough suppressants as needed.
- Respiratory support: The nurse should position the patient to facilitate breathing, apply supplemental oxygen as needed, and assist with coughing and deep breathing exercises. The nurse will monitor closely for changes such as worsening shortness of breath or dyspnea that would indicate the condition is not improving.
- Infection control: Nurses should perform adequate hand hygiene when caring for all patients, but especially patients with infections that are easily spread. The nurse should also educate all visitors about the importance of hand hygiene in preventing spread of the flu. Patients are placed on droplet precautions, and masks should be worn at all times to limit the spread of infection. Additionally, equipment and surfaces in the patient’s room should be cleaned and disinfected often.
Evaluation of Nursing Care for the Patient with Influenza
Nurses play a vital role in evaluating outcomes to gauge the effectiveness of interventions when caring for patients with influenza. The nurse will closely monitor for changes in the patient’s condition that indicate improvement or worsening of the infection.
Evaluating Outcomes
The nurse should evaluate assessment findings to determine if there has been any improvement in the patient’s condition. Findings that would indicate improvement include:
- adequate hydration (e.g., moist mucous membranes, adequate urine output)
- decreased fatigue
- improvement in body aches and headache
- improvement in respiratory status
- increased appetite
- resolution of fever
Medical Therapies and Related Care
Medical treatment for influenza involves a combination of medications and nonpharmacologic interventions. Most importantly, patients with the flu should be educated about the importance of rest and maintaining adequate hydration. In mild cases, this is usually enough to treat the infection, which will improve on its own over the course of days to weeks. In more severe cases, medications may be required. Oseltamivir (brand name, Tamiflu), zanamivir (Relenza), and peramivir (Rapivab) are the three antiviral medications currently available to treat influenza. It is important to note that these medications should be started within 48 hours of symptom onset for best results (CDC, 2024c). Beyond treatment, it also remains important to receive annual influenza vaccinations to decrease the risk of infection. These vaccines are altered each year to account for mutations in the virus, which is why it is important to educate patients about the need to get a vaccine every year.
Human Immunodeficiency Virus
In June 1981, the CDC, in Atlanta, Georgia, published a report of an unusual cluster of five patients in Los Angeles, California. All five were diagnosed with a rare pneumonia caused by a fungus called Pneumocystis jirovecii (formerly known as P. carinii). Why was this unusual? Although commonly found in the lungs of healthy individuals, this fungus is known to cause disease in individuals with suppressed or underdeveloped immune systems. The very young, whose immune systems have yet to mature, and older adults, whose immune systems have declined with age, are particularly susceptible. The five patients from Los Angeles, though, were between 29 and 36 years of age and should have been in the prime of their lives, immunologically speaking. What could be going on?
A few days later, eight similar cases were reported in New York City, also involving young patients, this time exhibiting a rare form of skin cancer known as Kaposi’s sarcoma. This cancer of the cells that line the blood and lymphatic vessels had previously been observed as a relatively innocuous disease of older adults. The disease that doctors saw in 1981 was frighteningly more severe, with multiple, fast-growing lesions that spread to all parts of the body, including the trunk and face. Could the immune systems of these young patients have been compromised in some way? Indeed, when they were tested, they exhibited extremely low numbers of a specific type of WBC in their bloodstreams, indicating that they had somehow lost a major part of the immune system.
A new disease, called acquired immunodeficiency syndrome (AIDS), was identified as caused by the previously unknown human immunodeficiency virus. Although AIDS was nearly 100 percent fatal in those early years, over the past few decades, the development of antiviral drugs has transformed HIV infection into a chronic, manageable disease—provided those with the virus learn about their infection in time to start treatment and avoid passing it to others (HIV.gov, 2023).
Pathophysiology of HIV
The underlying pathophysiology of HIV is complex because it is caused by a retrovirus (CDC, 2022c). A retrovirus is a virus that is composed of a strand of ribonucleic acid (RNA), which can be turned into deoxyribonucleic acid (DNA) and inserted into a healthy cell permanently. HIV is dangerous mainly because it infects and destroys a specific type of WBC known as CD4. As you can see in Figure 22.8, the viral RNA strand inside of a cell infected with HIV carries reverse transcriptase, which is an enzyme used to convert RNA into DNA. When an infected cell attaches to a healthy cell, it injects the enzyme into the cytoplasm of the healthy cell, where it creates strands of viral DNA. These strands are then inserted into the nucleus of the healthy cell, where they become permanently integrated into the cell’s DNA. Once this happens, the newly infected cell produces more cells by using viral mRNA, all of which contain the new viral DNA. Cell replication can occur quickly, leading to an influx of infected immune cells. When this happens, the CD4 cells of the immune system can no longer function effectively, resulting in severe immunosuppression and eventually leading to the development of AIDS, the latest and most severe stage of HIV (HIV.gov, 2023a).
Link to Learning
Watch a detailed animation of the pathophysiology of HIV and AIDS in this video.
Clinical Manifestations and Risk Factors
HIV is transmitted through semen, vaginal fluids, breast milk, and blood, and can be caught by having unprotected sex or sharing needles used to inject intravenous (IV) drugs; it can also be passed from an infected mother during childbirth or by breastfeeding (Justiz Vaillant, 2022). Flu-like symptoms sometimes emerge in the first 1 to 2 weeks after infection. This early period of rapid infection is known as the acute stage of HIV. The amount of virus circulating in the blood then drops to a low level. This is known as the chronic or latent stage of HIV: the person is infected but likely not carrying a large enough number of infected cells to show symptoms. This stage can last from a few months or years to decades, but eventually the immune system is overtaken by infected cells, resulting in end-stage HIV, also known as AIDS. The symptoms of AIDS include:
- diarrhea
- fever
- night sweats
- rashes
- severe weight loss (typically >10% of total body weight)
- swollen lymph nodes
In addition to these somewhat nonspecific clinical manifestations, AIDS is characterized by the development of opportunistic infections (Mayo Clinic, 2024). An opportunistic infection is caused by bacteria or other organisms in the body that would not typically cause an infection in a healthy individual. However, in someone with AIDS, these infections not only develop, they can also become life-threatening because the person’s immune system is unable to eradicate the pathogen effectively. In some cases, patients with AIDS also develop certain cancers. Some of the common infections and cancers seen in patients with AIDS include:
- candidiasis (oral thrush)
- Kaposi’s sarcoma (Figure 22.9)
- non-Hodgkin’s lymphoma
- Pneumocystis carinii pneumonia (PCP)
- tuberculosis
- varicella-zoster virus
Assessment and Diagnostics
HIV can be difficult to detect and diagnose in the early stages because patients may be completely asymptomatic or have vague symptoms that resemble the flu. Although HIV diagnostic tests are usually fairly accurate, they cannot detect the virus immediately after infection. This highlights the need for community education about regular testing, especially for populations in which needle use for drugs or unsafe sexual practices are more common (CDC, 2022b). Table 22.3 lists the three main types of HIV tests.
| Test | Description |
|---|---|
| Antibody tests |
|
| Antigen/antibody tests |
|
| Nucleic acid tests (NATs) |
|
Diagnostics and Laboratory Values
In addition to the diagnostic tests specific for HIV that were described in the previous section, there are several other laboratory values that are affected in patients with HIV. Because HIV is an immune disorder, the patient’s WBC count will be abnormal (HIV.gov, 2023b). A normal WBC count is 5,000–10,000 cells/mm3, whereas in patients with HIV, it is typically less than 3,000 cells/mm3. The overall count is lower because the immune system is using up WBCs trying to fight off the virus. And because HIV specifically infects CD4 cells, their count will be exceptionally low. Consequently, CD4 count is one of the main laboratory tests used both to detect and monitor the progression of HIV. A normal CD4 count is 500–1,200 cells/mm3, whereas in patients with HIV, it is less than 400 cells/mm3. Once the CD4 cell count falls below 200 cells/mm3, the patient is diagnosed with AIDS, the most advanced stage of HIV.
Another important laboratory value used to monitor the treatment and progression of HIV is the viral load test (CDC, 2022b). This blood test directly measures the amount of virus in the blood. A patient with high viral load has more virus in their body, indicating that treatment is not effective or the disease is progressing into more advanced stages. In contrast, an undetectable viral load indicates that treatment is effective and the patient cannot transmit the virus to others. However, it is important to note that an undetectable viral load does not mean the virus is not present in the blood. Rather, it is present in a sufficiently low amount that it cannot be detected or transmitted.
Nursing Care of the Patient with HIV
Nursing care of the patient with HIV requires knowledge of the disease, technical skills, and the ability to provide holistic care that is nonjudgmental. Patients with HIV are often scared and anxious about the diagnosis and disease progression. Nurses not only provide medical care to these patients, they also provide emotional support and resources.
Recognizing and Analyzing Cues
Nurses should have a working knowledge of the signs and symptoms of HIV so cues can be recognized to aid with early diagnosis. This is difficult, however, because the presenting symptoms of HIV are usually vague (e.g., fever, rash, sore throat) and may be so mild that the patient does not even seek care. For patients who do seek care for presenting symptoms, the nurse must collect a thorough medical history, including assessing for risk factors for contracting HIV. If risk factors are noted, the nurse should advocate for the patient to be tested for HIV.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Patients with HIV often require a lot of nursing care, especially in the later stages of the disease. The nurse should conduct a full physical assessment and determine what symptoms are the priority. Per the CDC (2023), common nursing interventions for patients with HIV include
- alternating rest and activity periods for patients with severe fatigue
- checking laboratory values to monitor the progression of the disease and the effectiveness of treatment
- maintaining adequate nutritional status (e.g., offering high-calorie foods, administering enteral nutrition as needed)
- promoting skin integrity to prevent development of opportunistic infections
- providing regular oral care and other hygiene care to prevent infections
- providing the patient resources such as information about counseling or support groups
- relieving pain with pharmacologic and nonpharmacologic interventions
Evaluation of Nursing Care for the Patient with HIV
Patients with HIV are infected for life, so nurses will likely be continuously evaluating their health status. This is especially true in clinic settings where patients are cared for by the same provider for several years. It is important for the nurse to understand how to monitor the patient’s condition and determine whether it is improving or requires a revised plan of care.
Evaluating Outcomes
First and foremost, the nurse should understand that monitoring the patient’s viral load is the most accurate way to determine their health status and the effectiveness of medications. A viral load that begins to trend upward indicates that either the disease is progressing or the patient has not been taking medications as prescribed. This warrants further investigation and intervention by the nurse and care team. Outcomes that would indicate the patient's treatment is effective include a downward trending or undetectable viral load, as well as the absence of opportunistic infections, a healthy body weight, and patient demonstration of adequate coping skills.
Cultural Context
Providing Culturally Sensitive Care to the Patient with HIV
The Joint United Nations Program on HIV/AIDs aims to end the HIV epidemic by 2030. One of the key strategies for achieving this goal is nurse-led clinical programs. Such programs are run by nurses and involve providing home care for patients with HIV to ensure that patients adhere to antiretroviral treatments and receive adequate mental health support. Establishing trust, being nonjudgmental and compassionate, and listening have been pivotal for increasing antiviral compliance within the HIV population. Patients with HIV are at risk due to stigmatization, marginalization and having adequate access to care. Nurses have been an essential bridge connecting an at-risk population to treatment (Rouleau et al., 2019; Wood et al., 2018).
Medical Therapies and Related Care
Medical treatment of HIV focuses on decreasing viral load to slow progression of the disease, prevention and treatment of opportunistic infections, and symptom management. To decrease viral load, antiretroviral (ART) medications are used to block or slow viral replication. There are several different classes of ART medications, and most patients with HIV are prescribed at least two or three, each from a different drug class.
The various medication classes work on different parts of the HIV life cycle, so taking two different types increases the chance of slowing disease progression. It is important to note that many ART medications have unpleasant side effects, such as gastrointestinal upset or fatigue, so patients often skip medication doses or stop taking them altogether. This is dangerous not only to the patient’s health but to others’ because the virus is more likely to spread if it is not being controlled with medication.
When patients enter the later stages of HIV, they typically start developing frequent opportunistic infections. Patients with HIV should be counseled about the importance of maintaining good hygiene and avoiding crowds to limit their exposure to pathogens. Additionally, if they suspect they have an infection of any kind, it is important for them to seek care immediately; because their immune system is not functioning optimally, a “small” infection can quickly become life-threatening (Mayo Clinic, 2024).
Symptom management focuses on treating pain and depression, both of which are commonly seen in patients with HIV. These conditions are usually treated with pharmacologic interventions such as analgesics and antidepressants but may also be treated with nonpharmacologic options like counseling, meditation, and guided imagery. Additionally, patients with HIV often experience malnutrition and weight loss, so medical intervention may include use of appetite stimulants or administration of enteral feedings.
Hepatitis
A condition characterized by inflammation of the liver, hepatitis is often the result of a viral infection (WHO, 2019). There are several types, including hepatitis A, B, C, D, and E. Each of these types varies slightly regarding transmission and symptoms; types A, B, and C are the most common and, therefore, are the focus of this section. The World Health Organization (2024) estimates that more than 300 million people worldwide are currently living with chronic hepatitis that is either undiagnosed or untreated. The condition is a leading cause of liver cirrhosis, resulting in permanent scarring and fibrosis and in a significant number of deaths each year.
Pathophysiology of Hepatitis
Although the five hepatitis viruses differ, they can cause similar signs and symptoms because all have an affinity for a type of cell called a hepatocyte (liver cell) (). Hepatitis A can be contracted through ingestion, whereas types B and C are transmitted by parenteral contact (Table 22.4). It is possible for individuals to become long-term or chronic carriers of hepatitis viruses, which typically spread to the spleen, kidneys, and liver after entering the bloodstream. During viral replication, the virus infects hepatocytes. Inflammation occurs as the hepatocytes replicate and release more hepatitis virus.
| Type | Transmission | Incubation Period | Prevention |
|---|---|---|---|
| Hepatitis A | Ingestion (e.g., fecal-oral route, contaminated food or water) | 2–6 weeks | Vaccine is available and recommended for all children and high-risk groups (e.g., traveling to high risk area, food service workers, gay men, IV-drug users). |
| Hepatitis B | Parenteral, sexual contact | 3–26 weeks | Vaccine is available and recommended for all children as part of standard vaccine schedule and boosters for adults, as needed, to maintain immunity. |
| Hepatitis C | Parenteral | 2–33 weeks | No vaccine available. Prevention strategies include avoidance of using shared needles or razors and avoiding sexual contact with infected individuals. |
Hepatitis A
The hepatitis A virus is generally transmitted through the fecal-oral route, close personal contact, or exposure to contaminated water or food. Hepatitis A can develop after an incubation period of 15 to 50 days (the mean is 30 days) (CDC, 2024a). The infection is normally mild or even asymptomatic and usually self-limiting within weeks to months. A more severe form, fulminant hepatitis, rarely occurs but has a high fatality rate of 70%–80% (CDC, 2024a). Vaccination is available and is recommended especially for children (between the ages of 1 and 2 years), those traveling to countries with higher risk, those with liver disease and certain other conditions, and drug users.
Hepatitis B
Hepatitis B has a mean incubation period of 120 days and is generally associated with exposure to infectious blood or body fluids such as semen or saliva (CDC, 2023a). Exposure to the virus can occur through skin puncture, across the placenta, or through mucosal contact, but it is not spread through casual contact such as hugging, hand holding, sneezing, or coughing, or even through breastfeeding or kissing (Tripathi & Mousa, 2023). Risk of infection is greatest for those who use IV drugs or who have sexual contact with an infected individual. Health-care workers are also at risk from needle sticks and other injuries when treating infected patients. The infection can become chronic and may progress to cirrhosis or liver failure; it is also associated with liver cancer. Vaccination is available and is recommended for children as part of the standard vaccination schedule (one dose at birth and the second by 18 months of age) and for adults at greater risk (e.g., those with certain diseases, IV-drug users, those who have sex with multiple partners). Health-care agencies are required to offer the hepatitis B vaccine to all workers who have occupational exposure to blood or other infectious materials.
Hepatitis C
Hepatitis C is often undiagnosed and, therefore, may be more widespread than is documented. It has a mean incubation period of 45 days and is transmitted through contact with infected blood (CDC, 2024b). Although some cases are asymptomatic or resolve spontaneously, 75% to 85% of infected individuals become chronic carriers (CDC, 2024b). Nearly all cases result from parenteral transmission, often associated with IV drug use or transfusions. The risk is greatest for individuals with a past or current history of IV drug use or who have had sexual contact with infected individuals.
Link to Learning
The CDC provides information about preventing needlestick injuries to limit the spread of hepatitis in health-care settings.
Clinical Manifestations
The clinical manifestations of each type of hepatitis vary slightly, as presented in Table 22.5. Figure 22.10 illustrates a characteristic symptom, jaundice.
| Type of Hepatitis | Clinical Manifestations |
|---|---|
| Hepatitis A |
|
| Hepatitis B |
|
| Hepatitis C |
|
Assessment and Diagnostics
General laboratory testing for hepatitis begins with blood testing to examine liver function. When the liver is not functioning normally, the blood will contain elevated levels of alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, direct bilirubin, total bilirubin, serum albumin, serum total protein, and calculated globulin; the albumin to globulin (A/G) ratio will also be elevated. Some of these are included in a complete metabolic panel, which may first suggest a possible liver problem and indicate the need for more comprehensive testing. A hepatitis virus serological test panel can be used to detect antibodies for hepatitis viruses A, B, and C.
Nursing Care of the Patient with Hepatitis
Nursing care for patients with hepatitis will vary slightly depending on the specific type present, but care generally focuses on alleviating symptoms, preventing complications, and promoting recovery. Additionally, providing education is a major component of caring for patients with hepatitis to help prevent spread and complications (CDC, 2023a).
Recognizing and Analyzing Cues
Nurses play a vital role in recognizing and analyzing cues in patients with hepatitis to provide timely and effective care. First, nurses conduct thorough assessments, including obtaining a health history and performing a physical examination. The nurse will ascertain whether the patient is exhibiting signs and symptoms indicative of hepatitis, and if so, relay the information to the provider for further investigation. Second, the nurse will inquire about sexual practices and IV drug use to determine if the patient has any risk factors for the development of hepatitis. This should be done in a nonjudgmental manner to ensure truthfulness and allow the patient to feel comfortable talking about these sensitive subjects. Third, the nurse uses information obtained from laboratory tests to further investigate the patient’s situation. Lastly, the nurse will recognize abnormalities in liver panel results and advocate for further testing, if indicated.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
After a diagnosis of hepatitis has been made, the nurse begins to generate solutions based on the type of hepatitis present. Significant nursing interventions are not likely required for hepatitis A, which is usually self-limiting. For patients with hepatitis B and C infections, some actions the nurse might take include
- administering prescribed antiviral medications
- alternating rest and activity periods to improve fatigue
- educating patients and families about hepatitis, including transmission routes, symptom management, and the importance of maintaining medication regimen and follow-up schedule, as well as vaccination education
- encouraging fluids to prevent dehydration
- providing emotional support and refer to counseling, as needed
- using proper hand hygiene, isolation precautions, and sharps (i.e., needle) safety strategies to prevent spread
Evaluation of Nursing Care for the Patient with Hepatitis
Evaluating nursing care provided to patients with hepatitis ensures that their needs are met and optimal health outcomes are being achieved. The nurse will monitor the patient over time to determine whether the current plan of care is effective or if it needs to be changed.
Evaluating Outcomes
To evaluate outcomes, the nurse will assess the patient’s overall health status, monitor vital signs and laboratory values, and observe the patient’s understanding of and compliance with their care plan. Assessment findings that would indicate the patient is improving include
- improved fatigue
- improvement in GI symptoms (e.g., nausea, vomiting)
- increased appetite
- normal skin tone (no jaundice)
- stable vital signs
- statements that demonstrate understanding of the disease and treatment plan
Medical Therapies and Related Care
For all types of hepatitis, supportive therapy including rest and fluids are indicated. Hepatitis A is typically self-limiting and does not require any specific treatment beyond supportive care. Hepatitis B may require specific treatment, especially if it is a chronic infection and/or the patient has a high viral load. If treatment is indicated, there are several antiviral medications that can be used, but it is important to note that there is no complete cure. For chronic cases of hepatitis C, treatment involves antiviral medications, such as sofosbuvir and daclatasvir. The goal of treatment with these medications is to completely rid the body of the virus, which can often be done by taking them for 12 weeks. In severe cases of hepatitis B or C that are refractive to treatment, a liver transplant may be necessary.
Fungal Infections
Fungal infections are caused by organisms that belong to the kingdom Fungi. A fungus is characterized by eukaryotic cells that contain cell walls and vacuoles but not chloroplasts and that typically grow as tubular, thread-like structures called hyphae. Fungi generally are immobile except for the spores they produce in their reproductive stage, and they obtain energy by decomposing and then absorbing dead matter (Constantine et al., 2024). Although mushrooms may be the fungi with which we are most familiar, most fungal infections are caused by yeasts or molds.
Numerous fungi live on and within the human body, but they do not usually cause disease. When they do result in an infection, the areas most often affected are the skin and nails, but fungal infections can also spread to the mouth, throat, lungs, and urinary tract. One of the most common fungal infections is oral thrush (oral candidiasis), which the remainder of this section focuses on. It important to know that in patients who are immunocompromised, such as those with HIV or who are undergoing cancer treatment, fungal infections are more likely to be severe because the immune system is not functioning optimally (CDC, 2021).
Pathophysiology of Oral Thrush
Oral thrush most commonly affects young children, but it can affect all ages, especially in the presence of immunocompromise. It is caused by a fungus called Candida albicans, which is one of the fungi normally found in the mouth. Overgrowth of C. albicans leads to the clinical manifestations discussed in the next section.
Clinical Manifestations
The hallmark symptom of oral thrush is white, raised lesions in the mouth—most often on the tongue and cheeks (Figure 22.11). Other symptoms include (Cleveland Clinic, 2023a):
- difficulty or pain with swallowing
- dry mouth
- fever (if infection spreads)
- loss of taste
- mouth redness
- sore mouth and tongue
Assessment and Diagnostics for Oral Thrush
Oral thrush can typically be diagnosed based on clinical manifestations alone. If the provider is unsure after visual inspection, a swab of the lesions can be done and sent to the laboratory for analysis. A swab is also recommended if medications have been started and are not working after several days. This might mean that the fungus is resistant to the medication, so a specific culture should be obtained to better tailor the medication regimen.
Diagnostics and Laboratory Values
For patients with oral thrush from an unknown cause, it is important to perform diagnostic tests for underlying conditions such as HIV or lupus. Because oral thrush most often occurs with immunocompromise, the patient may have another underlying disorder. Additionally, blood samples can be taken to check for the presence of Candida in the bloodstream to aid in the diagnosis.
Nursing Care of the Patient with Oral Thrush
Oral thrush is mild and easily resolved in most cases, so it is most often treated in outpatient settings. However, some patients who are hospitalized for other problems may develop oral thrush secondary to an underlying issue, such as HIV or receiving cancer treatment, both of which suppress the immune system. Nursing care for the patient with oral thrush involves treatment of symptoms, promotion of good hygiene, and patient education. Appropriate hygiene includes brushing teeth at least twice a day, flossing at least once a day, and rinsing with warm saltwater.
Recognizing and Analyzing Cues
The nurse must be able to recognize the hallmark white lesions that occur with oral thrush and relay that information to the provider so timely intervention can be initiated. Additionally, the nurse should assess the patient for any significant symptoms or medical history that may indicate the cause of the fungal infection, such as a history of HIV or of corticosteroid use, both of which suppress the immune system, more easily allowing infection to occur.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
After determining that the patient is likely dealing with oral thrush, the nurse will begin planning care, which may include the following interventions:
- administer antifungal medications as ordered
- educate patient about importance of finishing antifungal medications as prescribed
- educate patient about oral hygiene
- encourage fluid intake to maintain hydration
- perform oral swab, if ordered by provider
Evaluation of Nursing Care for the Patient with Oral Thrush
The nurse evaluates the care provided to a patient with oral thrush through a combination of subjective and objective measures, including assessing symptoms, ensuring the patient adheres to prescribed medications, and monitoring for adverse effects.
Evaluating Outcomes
To evaluate the effectiveness of interventions, the nurse will first assess the patient’s symptoms. Improvement in the oral lesions would indicate that medications and other interventions have been successful. If the lesions have not improved, a different medication may be required. The nurse should inquire about the patient's adherence to the medication regimen as well. Stopping antifungal medications too early can result in resistance of the fungus to medications, similar to what causes antibiotic resistance, as discussed in 22.3 Antibiotic Resistance. Lastly, the nurse should evaluate whether the patient is experiencing any adverse effects related to the medication or other interventions.
Life-Stage Context
Dentures and Oral Thrush
Patients with dentures require extra attention to oral hygiene to prevent development of fungal infections. Management for these patients may include:
- Disinfecting dentures daily
- Removing dentures for at least 6 hours every night
- Soaking dentures in chlorhexidine and allowing to air dry
- Taking out dentures every time a topical antifungal medication is used
Medical Therapies and Related Care for Oral Thrush
The first-line therapy for mild, uncomplicated cases of oral thrush is topical antifungal medications such as nystatin, clotrimazole, or ketoconazole (Taylor, 2023). These are typically administered as a mouthwash, rinse, or lozenge. For more severe cases, oral or IV antifungal medications may be required. In addition to pharmacologic intervention, the patient may also require dietary counseling. The patient should be educated about the importance of limiting sugar intake, because fungi tend to thrive in high-sugar environments, which may worsen the infection. It is also important to initiate treatment for the underlying cause of immunosuppression, which will decrease the risk of developing fungal infections in the future.