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Immunization

Immunization

Complete Guide to Immunization

Immunization

Immunization is a process of deliberate inoculation of live attenuated or dead vaccines and toxoids to induce immunity against a specific disease. Immunization against a specific disease provides artificially acquired active immunity. The principle of immunization is to increase specific immunity to infection by administration of either immune serum (passive immunization) or by administration of an antigen (active immunization).

Artificially acquired immunity against some diseases may require periodic booster injections to keep an adequate antibody level (or antibody titer) circulating in the blood. A booster injection is the administration of an additional dose of the vaccine to boost the production of antibodies to a level that will maintain the desired immunity. The booster is given months or years after the initial vaccine and may be needed because the life of some antibodies is short.

Types of Immunization Agents

  • Toxoids: is a toxin that is attenuated (or weakened) but still capable of stimulating the formation of antitoxins.
  • Vaccines: Special preparations of antigenic materials that can be used to stimulate the development of antibodies.
  • Immune Globulins: Preparations containing antibodies against infectious micro-organisms, usually prepared from human plasma or serum.
  • Antisera: Sterile preparations containing immunoglobulins obtained from the serum of immunized animals by purification. They have the power of neutralizing venoms or bacterial toxins.

Active vs. Passive Immunization

The principal goal of immunization is to increase specific immunity to infection. This can be achieved through two main strategies: active immunization and passive immunization.

Passive Immunization

Passive immunization is the administration of already active antibodies to prevent or ameliorate infection. It gives immediate protection but immunity lasts for a short period of time. Passive immunisation is used in post-exposure prophylaxis in immunocompetent hosts when immediate protection is required following exposure to the infection e.g. tetanus.

Infections for which passive immunization is useful are:
  • Hepatitis B
  • Rabies
  • Tetanus
  • Diphtheria
Advantages of passive immunisation:
  • Passive immunisation can be lifesaving if toxin is already circulating.
  • Prompt availability of large amount of antibodies.
Disadvantages of passive immunisation:
  • Protection is short-lived (up to 6 months) as the borrowed antibodies are eventually degraded and cleared.
  • Use of human antisera has dangers of transmitting infections like HIV or Hepatitis.
  • Antisera are expensive compared to vaccines.
  • They need to be kept cool and have limited life span.

Active Immunization

Active immunization is a process of increasing resistance to infection whereby micro-organisms or products of their activity act as antigens and stimulate certain body cells to produce antibodies with a specific productive capacity. It may be a natural process following recovery from an infection, or an artificial process induced by the administration of vaccines.

Active immunization is a process where the individual's own immune system is stimulated to produce antibodies and memory cells against a specific pathogen. This is achieved by administering an antigen, usually in the form of a vaccine. It may be a natural process following recovery from an infection, or an artificial process induced by vaccination.

Aims of Active Immunization:
  • To protect susceptible individuals against specific infections.
  • To reduce the incidence of infection in the community, leading to herd immunity.
  • To eliminate an infection in a particular country or worldwide (e.g., the successful eradication of smallpox and the ongoing effort to eradicate polio).
Booster Injections:

Artificially acquired immunity against some diseases may require periodic booster injections to keep the antibody level (titer) adequate for protection. A booster is an additional dose given months or years after the primary vaccination series to "boost" the immunological memory and production of antibodies.

Advantages of Active immunization:
  • Offers long-term, often lifelong, immunity due to the formation of memory cells.
Disadvantages of Active immunization:
  • Has a slow onset of action, as it takes time (days to weeks) for the body to mount a primary immune response and become fully protected.

Vaccines

Vaccines are special preparations of antigenic materials designed to stimulate the development of antibodies and confer active immunity. Vaccination refers to the administration of a vaccine.

Types of Vaccines:

  • Live Attenuated Vaccines:

    These vaccines use live microorganisms that have been weakened (attenuated) so they can still replicate but do not cause disease in healthy individuals. They typically provide long-lasting immunity with a single dose (with some exceptions like OPV).

    Examples: BCG, Measles, Mumps, Rubella, Oral Polio (OPV), Yellow Fever.

    Advantages of Live Attenuated Vaccines

    • Live vaccines give longer protection than killed vaccines.
    • One dose of the vaccine is usually sufficient with exception of oral polio vaccines.

    Disadvantages of Live Attenuated Vaccines

    • Live vaccines are often unstable e.g. measles and polio need to be stored at -20°C.
    • Live vaccines may not work in the presence of circulating antibodies e.g. measles vaccine has to be given around 9 months of age when maternal antibodies have gone.
    • Live vaccines may cause disease if the host is immuno deficient as in HIV infection.
    • Live vaccines occasionally interfere with each other so that the immune response is not so great if given together.

  • Killed or Inactivated Vaccines:

    These vaccines use whole bacteria or viruses that have been killed and can no longer replicate. They are very safe but usually require a series of injections and booster doses to produce an adequate response.

    Examples: Inactivated Polio Vaccine (IPV), Rabies vaccine, Hepatitis A vaccine, whole-cell Pertussis vaccine.

  • Toxoid Vaccines:

    These vaccines use bacterial toxins that have been chemically inactivated to become harmless toxoids. They stimulate the production of antitoxins.

    Examples: Tetanus toxoid, Diphtheria toxoid.

    Disadvantages: Immunity can be short-lived, requiring booster doses.

    • Indications of Vaccines and Toxoids:

    • Routine immunization of infants and children.
    • Immunization of adults against tetanus.
    • Immunization of adults at high risk for certain diseases (e.g., pneumococcal and influenza vaccines).
    • Immunization of children or adults at risk for exposure to a particular disease (e.g., hepatitis A for those going to endemic areas).
    • Immunization of pre-pubertal girls or non-pregnant women of childbearing age against rubella and cervical cancer.

    Adverse Reactions of Vaccines and Toxoids:

    Adverse reactions from the administration of vaccines or toxoids are usually mild.

    • Chills, Fever, muscular aches and pains, rash, and lethargy may be present.
    • Pain and tenderness at the injection site may also occur.
    • Although rare, a hypersensitivity reaction may occur.

    Contraindications and Precautions of Vaccines and Toxoids:

    • Hypersensitivity: Individuals with known severe allergic reactions to vaccine components or previous doses should not receive the vaccine.
    • Vaccines and toxoids are generally contraindicated during acute febrile illnesses, leukemia, lymphoma, immunosuppressive illness or drug therapy, and non-localized cancer.
    • The measles, mumps, rubella, and varicella vaccines are contraindicated in patients who have had an allergic reaction to gelatin, neomycin, or a previous dose of one of the vaccines.
    • The measles, mumps, rubella, and varicella vaccines are generally contraindicated during pregnancy, especially during the first trimester, because of the theoretical danger of birth defects. Women are instructed to avoid becoming pregnant for at least 3 months after receiving these vaccines.

    Antisera and Immunoglobulins

    • Antisera: Sterile preparations containing immunoglobulins obtained from the serum of immunized animals (e.g., horses). They are used to neutralize venoms or bacterial toxins.
    • Immunoglobulins: Preparations containing specific antibodies, usually prepared from pooled human plasma. They are used for passive immunization.

    Properties of an Ideal Vaccine

    • Should be able to induce an adequate and appropriate immune response without causing active infection.
    • The vaccine should be safe with minimal side effects.
    • The vaccine should be stable and remain potent during storage and transportation.
    • The vaccine should be cheap if it is to be used on a large scale.
    • It should be easy to administer.
    • It should be highly purified so that it consists of one or only a few antigens.

    Autoimmune Diseases

    Autoimmune diseases occur when the immune system loses its ability to distinguish "self" from "non-self" and mistakenly begins to attack the body's own cells and tissues. This failure of self-tolerance can be triggered by a combination of genetic susceptibility, environmental factors, and infections.

    It is thought that female hormones like estrogen may enhance the inflammatory response, which could be one reason why autoimmune diseases are often more common or severe in women than in men.

    Autoimmune Diseases and Parts Affected

    Disease Part of the Body Primarily Affected
    Rheumatoid Arthritis Cartilage and linings of the joints.
    Graves' Disease Thyroid gland (causes hyperthyroidism).
    Insulin-Dependent Diabetes Mellitus (Type 1) Insulin-producing beta cells of the pancreas.
    Multiple Sclerosis (MS) Myelin sheath of nerves in the brain and spinal cord.
    Psoriasis Skin cells.
    Ankylosing Spondylitis Joints of the spine.

    Specific Vaccine Details

    This section provides a detailed breakdown of the key vaccines used in immunization programs, including their type, indications, dose, side effects, contraindications, and special precautions.

    BCG (Bacillus Calmette-Guérin) Vaccine

    Type
    • Live attenuated bacterial vaccine.
    Indications
    • Active immunization against severe forms of tuberculosis (TB) in children, such as TB meningitis and miliary TB.
    • Protection against leprosy (in some contexts where leprosy is endemic and BCG is used for this purpose).
    Dose
    • Infants less than 12 months: 0.05ml administered intradermally in the right upper arm.
    • Adults and children over 12 months: 0.1ml administered intradermally in the right upper arm.
    Side Effects
    • A localized papule, sore, and then ulceration at the injection site is a normal, expected reaction that heals to form a permanent scar.
    • Lymphadenitis (swelling of local lymph nodes).
    • Keloid formation at the scar site.
    • Abscess formation at the injection site (rare, more severe).
    • Osteitis/Osteomyelitis (inflammation of bone, very rare systemic complication).
    • Disseminated BCG infection: A rare but severe complication that can occur in severely immunosuppressed patients.
    Contraindications
    • Severely immunocompromised patients (e.g., advanced HIV/AIDS, congenital immunodeficiency, individuals on immunosuppressive therapy).
    • Generalized skin conditions like eczema or scabies at the intended injection site.
    • Patients undergoing antibacterial treatment for tuberculosis.
    • Known allergy to any component of the vaccine.
    • Infants weighing less than 2 kg.
    • Individuals with a positive tuberculin skin test (PPD) or IGRA (Interferon Gamma Release Assay), as this may indicate latent TB infection.
    • Acute severe febrile illness (generally a temporary contraindication).
    Precautions
    • Pregnancy (though it may be given if the risk of TB exposure is high and benefits outweigh risks, especially in high-endemic areas).
    • Infants born to HIV-positive mothers (careful risk-benefit assessment; may be given if the infant is asymptomatic for HIV and the risk of TB exposure is high, but generally avoided if HIV status is confirmed and symptomatic).
    • Concomitant use with other live vaccines (spacing may be recommended by national guidelines, though many routine schedules allow co-administration).

    Diphtheria, Pertussis, Tetanus (DPT) Vaccine (in Pentavalent)

    Type
    • A combination vaccine containing Diphtheria and Tetanus toxoids and an inactivated (killed) whole-cell Pertussis bacteria component.
    • Note: Modern DPT vaccines often use acellular pertussis (aP) components (DTaP) which have fewer side effects, but the provided text specifies whole-cell. Pentavalent typically contains DPT-HepB-Hib.
    Indications
    • Active immunization against Diphtheria, Tetanus, and Pertussis (whooping cough) in infants and young children.
    • Primary vaccination series for infants as part of routine immunization programs.
    Dose
    • Given as part of the Pentavalent vaccine series: 0.5ml intramuscularly at 6, 10, and 14 weeks of age.
    • Specific schedules may vary by national immunization guidelines.
    Side Effects
    • Common: Pain, redness, and swelling at the injection site; fever; irritability; restlessness; loss of appetite; drowsiness.
    • Less common: Persistent, inconsolable crying (lasting 3 hours or more); high fever (>=40.5°C); febrile seizures (very rare).
    • Rare: Anaphylaxis (severe allergic reaction); hypotonic-hyporesponsive episodes (HHE); peripheral neuropathy; severe neurological reactions (especially associated with the whole-cell pertussis component, e.g., encephalopathy).
    • Injection site nodule/lump which can persist for weeks.
    Contraindications
    • Known hypersensitivity to any of the ingredients of the vaccine or a severe allergic reaction to a previous dose.
    • A history of a severe neurological reaction (e.g., encephalopathy not attributable to another identifiable cause) within 7 days of a previous dose of pertussis-containing vaccine.
    • Progressive neurological disorder, including infantile spasms, uncontrolled epilepsy, or progressive encephalopathy (vaccination should be deferred until the condition has stabilized).
    • Acute severe febrile illness (vaccination should be deferred until recovery).
    Precautions
    • Minor illnesses (e.g., mild upper respiratory infection, low-grade fever) are generally NOT contraindications.
    • Family history of seizures or other neurological disorders (not a contraindication but requires observation after vaccination).
    • History of a reaction following a previous dose that is considered a precaution (e.g., temperature ≥40.5°C within 48 hours not due to another cause, collapse/shock-like state within 48 hours, persistent crying lasting ≥3 hours within 48 hours, seizures with or without fever within 3 days). In such cases, benefits versus risks of subsequent doses should be carefully considered, and acellular pertussis vaccines (DTaP) might be preferred if available.

    Tetanus Toxoid (TT) or Tetanus-Diphtheria (Td) Vaccine

    Type
    • Toxoid vaccine.
    • Td contains tetanus toxoid and a reduced dose of diphtheria toxoid.
    Indications
    • Active immunization against tetanus.
    • Prevention of neonatal tetanus through the immunization of pregnant women and women of childbearing age.
    • Boostering immunity against tetanus and diphtheria in adolescents and adults.
    • Post-exposure prophylaxis for tetanus following wounds (often in combination with Tetanus Immunoglobulin if indicated).
    Dose (for Women of Childbearing Age and General Adult Boosters)
    • Primary Series: Varies, but often 2-3 doses given at intervals (e.g., 0 and 4-8 weeks).
    • TT1 (for Pregnant Women/WOCBA): 0.5ml deep IM or SC at first contact/early in pregnancy.
    • TT2: 0.5ml at least 4 weeks after TT1 (preferably before 36 weeks of pregnancy).
    • TT3: 0.5ml at least 6 months after TT2.
    • TT4: 0.5ml at least 1 year after TT3.
    • TT5: 0.5ml at least 1 year after TT4. (5 doses provide long-lasting protection, often considered lifelong for practical purposes if fully completed).
    • Booster Doses: Recommended every 10 years for adolescents and adults.
    Side Effects
    • Common: Local reactions like pain, tenderness, redness, swelling, and a lump at the injection site. These are usually mild and resolve within a few days.
    • Less common: Low-grade fever, headache, body aches, tiredness.
    • Rare: Anaphylaxis (severe allergic reaction); brachial neuritis (inflammation of nerves in the arm, very rare); peripheral neuropathy.
    • Arthus-type reactions (severe local reaction with swelling and pain) can occur, particularly in adults who receive frequent booster doses.
    Contraindications
    • Known hypersensitivity to any component of the vaccine or a severe allergic reaction to a previous dose.
    • A history of a severe Arthus-type hypersensitivity reaction following a previous dose of tetanus or diphtheria toxoid-containing vaccine (usually not given again for at least 10 years).
    • Acute severe febrile illness (defer vaccination until recovery).
    Precautions
    • Minor illnesses (e.g., mild upper respiratory infection, low-grade fever) are generally NOT contraindications.
    • History of Guillain-Barré Syndrome (GBS) within 6 weeks of a previous dose of tetanus toxoid-containing vaccine (decision to vaccinate should weigh benefits against potential risks).

    Measles, Mumps, and Rubella (MMR) Vaccine

    Type
    • Live attenuated virus vaccine.
    Indications
    • Active immunization against Measles, Mumps, and Rubella.
    • Recommended for all children as part of routine immunization schedules.
    • Prevention of congenital rubella syndrome in women of childbearing age (ensure non-pregnant at vaccination and avoid pregnancy for recommended period).
    • Outbreak control measures in susceptible populations.
    Dose
    • 0.5ml administered by deep subcutaneous or intramuscular injection.
    • First dose: Typically at 12-15 months of age (some regions, like Uganda, may give first measles dose earlier at 9 months, and then MMR later).
    • Second dose: Recommended for sustained immunity, often at 4-6 years of age (e.g., prior to school entry) or later, depending on national schedules.
    Side Effects
    • Common (5-12 days after dose 1): Fever (up to 15%), malaise, and a non-infectious, non-contagious maculopapular rash (measles-like) (5%).
    • Common (3-4 weeks after dose 1): Parotid swelling (mild, mumps-like symptoms, <1%).< /li>
    • Common (2-4 weeks after dose 1, particularly in post-pubertal females): Transient arthralgia or arthritis (joint pain/inflammation) related to the rubella component.
    • Rare: Thrombocytopenia (transient low platelets, 1 in 30,000 to 40,000 doses).
    • Very Rare: Febrile seizures (usually benign, related to the fever, not the vaccine itself causing epilepsy); anaphylaxis (severe allergic reaction, approx. 1 in 1,000,000 doses).
    Contraindications
    • Pregnancy (known or suspected). Women should be advised to avoid pregnancy for at least 1 month after vaccination.
    • Severe immunosuppression (e.g., congenital immunodeficiency, HIV with severe immunosuppression, leukemia, lymphoma, generalized malignancy, high-dose corticosteroids, chemotherapy, radiation therapy).
    • Known hypersensitivity to vaccine components (e.g., neomycin, gelatin).
    • A history of a severe allergic reaction (anaphylaxis) to a previous dose of MMR vaccine.
    • Receipt of blood products (e.g., transfusions, immunoglobulin) containing antibodies within a certain period (typically 3-11 months, depending on the product), as these antibodies can interfere with vaccine efficacy.
    • Acute severe febrile illness (defer vaccination until recovery).
    Precautions
    • History of convulsions or epilepsy in the patient or family (parents should be advised on managing fever and monitoring for seizures, but vaccination is generally safe).
    • Individuals with mild illness (e.g., low-grade fever, upper respiratory infection) can generally be vaccinated.
    • The vaccine should be cautiously administered to individuals with a history of thrombocytopenia or thrombocytopenic purpura, as a recurrence is possible (risk vs. benefit should be assessed).
    • Recent receipt of another live injected vaccine within the last 4 weeks (some guidelines prefer spacing by 4 weeks if not co-administered, but often co-administration is acceptable).

    Hepatitis B Vaccine

    Type
    • Recombinant subunit vaccine (contains inactivated Hepatitis B surface antigen, HBsAg), produced in yeast.
    Indications
    • Active immunization against Hepatitis B infection.
    • Universal vaccination of all infants and children as part of routine immunization programs.
    • Crucial for high-risk groups: infants born to HBsAg-positive mothers (should receive birth dose and Hepatitis B Immunoglobulin - HBIG); healthcare personnel; public safety workers; hemodialysis patients; patients with chronic liver disease; individuals with multiple sexual partners; injecting drug users; close contacts and sexual partners of HBsAg carriers; international travelers to endemic areas.
    Dose
    • Infants: First dose given within 24 hours of birth (birth dose), then typically as part of the Pentavalent vaccine at 6, 10, and 14 weeks (some schedules use a 0, 1, 6 month pattern if given as stand-alone).
    • Children and Adolescents: Typically a 2- or 3-dose series depending on the specific vaccine and age.
    • Adults: Typically a 3-dose series (e.g., 0, 1, and 6 months) or a rapid 4-dose series for specific needs.
    • Administered intramuscularly, usually in the anterolateral thigh for infants/young children and deltoid muscle for older children/adults.
    Side Effects
    • Common: Pain, tenderness, redness, and swelling at the injection site (up to 29%).
    • Less common: Low-grade fever, headache, myalgia (muscle aches), arthralgia (joint pain), fatigue, gastrointestinal disturbances (nausea, diarrhea). These are usually mild and transient.
    • Rare: Anaphylaxis (severe allergic reaction, extremely rare).
    Contraindications
    • Known hypersensitivity to yeast or any other component of the vaccine.
    • A history of a severe allergic reaction (anaphylaxis) to a previous dose of Hepatitis B vaccine.
    • Acute severe febrile illness (defer vaccination until recovery).
    Precautions
    • Immunocompromised patients (e.g., those on dialysis, HIV-infected individuals, transplant recipients) may have a diminished immune response and may require higher doses, additional doses, or post-vaccination serologic testing to ensure adequate protection.
    • Mild illness (e.g., low-grade fever, common cold) is generally not a contraindication.
    • Use with caution in pregnancy and lactation (no evidence of harm, but generally recommended if risk of exposure is high). The benefits of vaccinating pregnant women at high risk for HBV infection outweigh potential risks to the fetus.

    Yellow Fever Vaccine

    Type
    • Live attenuated virus vaccine (17D strain).
    Indications
    • Active immunization against yellow fever, especially for residents of and travelers to endemic areas.
    • Required for entry into certain countries where yellow fever is endemic or where there's a risk of transmission.
    • Mass vaccination campaigns in areas with ongoing outbreaks or high risk.
    Dose
    • A single 0.5ml dose administered by subcutaneous injection (preferred) or intramuscular injection.
    • Typically given at 9 months of age in endemic regions.
    • Provides lifelong immunity for most people after a single dose, according to WHO. Some countries may still require revaccination certificates every 10 years for entry, so checking international health regulations is crucial for travelers.
    Side Effects
    • Mild (common, 5-10 days after vaccination): Headache, myalgia, low-grade fever, flu-like symptoms, injection site reactions (pain, redness, swelling). These usually resolve within a few days.
    • Rare but serious: Anaphylaxis (severe allergic reaction, approx. 1 in 130,000 doses).
    • Very Rare but severe: Yellow Fever Vaccine-Associated Neurologic Disease (YEL-AND), typically neurological symptoms like encephalitis or meningitis (occurs in approx. 0.8 in 100,000 doses).
    • Very Rare and most severe: Yellow Fever Vaccine-Associated Viscerotropic Disease (YEL-AVD), a multi-organ failure resembling severe yellow fever (occurs in approx. 0.3 in 100,000 doses, higher risk in older individuals).
    Contraindications
    • Infants under 6 months of age (and used with caution between 6-8 months due to higher risk of YEL-AND).
    • Severe immunosuppression (e.g., congenital immunodeficiency, HIV with CD4 count <200 cells/mm3, leukemia, lymphoma, generalized malignancy, high-dose corticosteroids, chemotherapy, radiation therapy).
    • Known hypersensitivity to eggs, egg proteins, or any other component of the vaccine (e.g., gelatin, chicken protein).
    • Individuals with a history of thymus disorders (e.g., thymoma, thymectomy, myasthenia gravis, DiGeorge syndrome) due to increased risk of YEL-AVD.
    • Acute severe febrile illness (defer vaccination until recovery).
    Precautions
    • Age 60 years or older: Increased risk of YEL-AND and YEL-AVD. Benefits and risks should be carefully weighed, especially for first-time vaccine recipients.
    • Pregnancy: Generally not recommended unless travel to an endemic area with high risk of exposure cannot be avoided. Risk vs. benefit assessment is crucial.
    • Breastfeeding: Generally not recommended if the infant is under 9 months due to theoretical risk of transmission through breast milk, unless the risk of maternal infection is high.
    • Mild illness is generally not a contraindication.
    • As a live vaccine, it should ideally be given simultaneously with other live vaccines or spaced by at least 4 weeks.

    Other Key Vaccines and Immunoglobulins

    Beyond the primary childhood schedule, several other important vaccines and immunoglobulin preparations are used for specific risk groups, travel, or post-exposure protection.

    Pneumococcal Vaccine

    Type
    • There are two main types, which are not interchangeable:
    • Pneumococcal Conjugate Vaccine (PCV): Such as PCV10 (used in Uganda) or PCV13, PCV15, PCV20. The polysaccharide capsule antigens are "conjugated" (joined) to a protein carrier, which creates a strong and lasting immune response, especially in infants and young children, and induces T-cell dependent memory.
    • Pneumococcal Polysaccharide Vaccine (PPSV23): Contains antigens from 23 different serotypes. It provides broader serotype coverage but elicits a T-cell independent immune response, which is weaker and shorter-lived, and not effective in children under 2 years old. It is primarily used for adults and high-risk older children.
    Indications
    • Active immunization against diseases caused by Streptococcus pneumoniae, including pneumonia, meningitis, bacteremia (invasive pneumococcal disease), and otitis media.
    • Crucial for high-risk populations: all infants and young children (PCV); adults over 65 years (PCV and/or PPSV23); and individuals with underlying medical conditions such as sickle cell disease, functional or anatomic asplenia, chronic heart, lung, or kidney disease, diabetes mellitus, and immunosuppression (PCV and/or PPSV23).
    Dose
    • PCV (Routine for infants): 0.5ml IM at 6, 10, and 14 weeks (Uganda schedule). Other common schedules include 2, 4, 6 months with a booster at 12-15 months, or 2, 4 months with a booster.
    • PPSV23 (for adults/high-risk): 0.5ml IM or deep SC as a single dose. Revaccination with PPSV23 may be considered for those at highest risk after 5 years. Sequential vaccination with PCV followed by PPSV23 is often recommended for certain adult risk groups.
    Side Effects
    • Common: Fever, irritability, drowsiness, and local reactions at the injection site (pain, redness, swelling, tenderness). These are generally mild and resolve within 1-2 days.
    • Less common: Decreased appetite, vomiting, diarrhea.
    • Rare: Anaphylaxis (severe allergic reaction).
    Contraindications
    • A severe allergic reaction (anaphylaxis) to a previous dose of the specific pneumococcal vaccine or to any component of the vaccine.
    • Acute severe febrile illness (defer vaccination until recovery).
    Precautions
    • Mild illness or low-grade fever is generally not a contraindication.
    • In individuals with compromised immune systems (e.g., due to HIV infection, immunosuppressive therapy), the immune response to the vaccine may be diminished.
    • For PPSV23, administer with caution to individuals with a history of severe local reactions to previous doses.

    Meningococcal Vaccine

    Type
    • Can be a polysaccharide vaccine (e.g., MPSV4) or, more effectively, a conjugate vaccine (e.g., MCV4 or MenACWY).
    • They are formulated against the most common disease-causing serogroups of Neisseria meningitidis: A, C, Y, and W-135 (quadrivalent vaccines). Monovalent (e.g., Men C) and bivalent (e.g., Men A+C) preparations are also available.
    • Separate vaccines exist for serogroup B (MenB vaccines).
    Indications
    • Active immunization against meningococcal meningitis and septicemia caused by vaccine-preventable serogroups.
    • Essential for individuals residing in or traveling to the "meningitis belt" of sub-Saharan Africa, particularly during epidemic seasons.
    • Recommended for travelers to high-risk areas, military recruits, university students living in dormitories, and individuals with certain medical conditions (e.g., asplenia, persistent complement component deficiencies, those on eculizumab).
    • Outbreak control in specific populations.
    Dose
    • 0.5ml by deep subcutaneous (polysaccharide) or intramuscular (conjugate) injection as a single dose or multi-dose series depending on the vaccine type, age, and schedule.
    • For conjugate vaccines, routine vaccination for adolescents is common, with a booster dose.
    Side Effects
    • Common: Local pain, redness, and swelling at the injection site; headache; fatigue; malaise; muscle aches; low-grade fever. These are usually mild and transient.
    • Rare: Allergic reactions, including anaphylaxis.
    Contraindications
    • Known severe allergy to any ingredient in the vaccine or a severe allergic reaction to a previous dose.
    • Acute severe febrile condition (postpone vaccination until recovery).
    Precautions
    • Use with caution during pregnancy: Generally recommended only if the benefit of vaccination outweighs the potential risk to the fetus, such as in high-risk travel or outbreak situations.
    • The immune response from polysaccharide vaccines in children under 2 years may be short-lived and does not induce herd immunity or memory, making conjugate vaccines preferred for this age group and for broader public health impact.
    • Individuals with mild illness are generally not a contraindication.

    Cholera Vaccine

    Type
    • An oral vaccine. There are two main types:
      • Live attenuated preparation: (e.g., Vaxchora) - single dose.
      • Inactivated whole-cell preparations: (e.g., Dukoral, Shanchol, Euvichol) - usually multi-dose. These contain killed whole cells of Vibrio cholerae, often combined with B subunit of cholera toxin (Dukoral).
    Indications
    • Prophylactic immunization for travelers over 2 years of age (or younger depending on the specific vaccine) going to areas with high risk of cholera infection, particularly those who will be in areas with poor sanitation and hygiene.
    • Used in outbreak control and humanitarian settings to reduce transmission, but is not a substitute for providing safe water, sanitation, and hygiene (WASH) interventions.
    • Not typically part of a routine national immunization schedule in most non-endemic countries.
    Dose
    • Varies significantly by vaccine type and manufacturer:
      • Inactivated (Dukoral): Requires a multi-dose schedule.
        • Children 2-6 years: 3 doses, with 1-6 weeks between doses.
        • Adults and children >6 years: 2 doses, with 1-6 weeks between doses.
        • A booster dose is typically recommended after 2 years for continued protection.
      • Live attenuated (Vaxchora): Single dose for individuals aged 2 to 64 years.
    • Important Instruction: For most oral cholera vaccines, the patient must avoid food and drink for 1 hour before and 1 hour after taking the oral vaccine. Check specific product instructions.
    Side Effects
    • Common: Abdominal discomfort, mild diarrhea, nausea, vomiting, headache, loss of appetite. These are usually mild and transient.
    • Rare: Hypersensitivity reactions.
    Contraindications
    • History of hypersensitivity or severe allergic reaction to any of the ingredients of the specific vaccine or a previous dose.
    • Should be postponed during an acute moderate to severe gastrointestinal illness (e.g., acute diarrhea, vomiting) or acute moderate to severe febrile illness.
    • For live attenuated vaccines: severe immunocompromise (similar to other live vaccines).
    Precautions
    • Efficacy may be reduced if taken concurrently with certain medications (e.g., antacids, antibiotics). Check specific product information.
    • Not a substitute for practicing safe food and water hygiene.
    • Protection is not 100%, and duration of protection varies by vaccine.
    • Pregnancy and breastfeeding: Consult with a healthcare provider; generally, only given if the risk of exposure is high and benefits outweigh potential risks.

    Rabies Vaccine

    Type
    • An inactivated (killed) virus vaccine. Prepared from purified chick embryo cell culture (PCEC), human diploid cell culture (HDCV), or Vero cell culture.
    Indications
    • Post-Exposure Prophylaxis (PEP): To prevent the development of rabies after a person has been bitten, scratched, or had mucous membrane exposure to a potentially rabid animal. This is a medical emergency, as rabies is nearly 100% fatal once symptoms begin. PEP includes immediate wound cleansing, vaccine administration, and in severe cases, Rabies Immunoglobulin (RIG).
    • Pre-Exposure Prophylaxis (PrEP): For persons at high and continuous risk of exposure, such as veterinarians, animal handlers, laboratory workers handling the rabies virus, speleologists, and travelers to rabies-endemic areas who may not have immediate access to medical care.
    Dose
    • Pre-exposure (PrEP):
      • Standard: 1ml (or 0.5ml for intradermal) IM injection on days 0, 7, and 21 or 28.
      • Newer schedules (e.g., 2 doses for some vaccines) are being explored.
    • Post-exposure (PEP):
      • For unvaccinated individuals: 1ml IM injection on days 0, 3, 7, and 14 (4-dose regimen). In some settings, a 5-dose regimen (days 0, 3, 7, 14, 28) or 2-site intradermal regimens are used.
      • For previously vaccinated individuals (PrEP complete): 1ml IM injection on days 0 and 3 (2-dose regimen), no RIG needed.
      • For severe exposures, especially in unvaccinated individuals, Rabies Immunoglobulin (RIG) should also be infiltrated around the wound and into the wound on day 0, as much as anatomically feasible.
    • Route: Intramuscular (IM) injection, usually in the deltoid muscle for adults and anterolateral thigh for young children. Intradermal (ID) routes are also approved for certain schedules in some regions, which can save vaccine.
    Side Effects
    • Common: Pain, redness, swelling, and itching at the injection site (up to 30-70%).
    • Systemic: Fever, headache, dizziness, myalgia (muscle aches), malaise (general discomfort), nausea, abdominal pain. These are usually mild.
    • Rare: Hypersensitivity reactions (e.g., urticaria, rash, anaphylaxis). Neurological complications are extremely rare.
    Contraindications
    • There are generally no contraindications to PEP once exposure to rabies is suspected or confirmed, given the fatal nature of the disease.
    • For PrEP, contraindications are similar to other inactivated vaccines: severe allergic reaction to a previous dose or component of the vaccine, or acute moderate to severe febrile illness (defer until recovery).
    Precautions
    • Administer with caution to individuals with a history of hypersensitivity reactions to previous doses.
    • Pregnancy and breastfeeding: Not a contraindication for PEP; for PrEP, it should be given if the risk of exposure is substantial.
    • Immunocompromised individuals: May require additional doses or serologic testing to confirm adequate immune response after PrEP, and for PEP, the full recommended series with RIG is crucial.

    Hepatitis A Vaccine

    Type
    • An inactivated (killed) virus vaccine. Whole virus particles are grown in cell culture, purified, and inactivated with formalin.
    Indications
    • Active immunization against Hepatitis A infection, a common cause of acute viral hepatitis transmitted via the fecal-oral route.
    • Recommended for:
      • Travelers to high-risk areas (e.g., regions with high endemicity or poor sanitation).
      • Children as part of routine immunization schedules in many developed countries.
      • Laboratory workers handling hepatitis A virus.
      • Patients with chronic liver disease (of any etiology).
      • Individuals who use parenteral or illicit drugs.
      • Homosexual and bisexual men.
      • Individuals who work with nonhuman primates.
      • People with clotting factor disorders.
      • Close contacts of adoptees from endemic countries.
      • Individuals who change partners frequently or have multiple sexual partners (particularly those engaging in anal-oral sex).
    Dose
    • Typically a two-dose series given by intramuscular injection.
    • An initial dose (e.g., 0.5ml or 1.0ml depending on age and specific vaccine) is followed by a booster dose 6-12 months later (or up to 18 months for some vaccines).
    • For combined Hepatitis A and B vaccine (Twinrix), the schedule is typically 3 doses over 6 months (0, 1, 6 months) or a rapid 4-dose schedule.
    Side Effects
    • Common: Pain, tenderness, redness, and swelling at the injection site.
    • Systemic: Headache, fever (low-grade), fatigue, malaise (general discomfort), myalgia (muscle aches).
    • Less common: Nausea, loss of appetite, irritability, skin rash. These are usually mild and resolve within a few days.
    • Rare: Allergic reactions, including anaphylaxis.
    Contraindications
    • Known hypersensitivity or severe allergic reaction to any component of the vaccine or a previous dose.
    • Acute moderate to severe febrile illness (defer vaccination until recovery).
    Precautions
    • Use with caution in patients with altered immunity; while generally safe, the immune response may be diminished.
    • Pregnancy and lactation: Data on safety are limited, but the vaccine is considered safe, and vaccination should be considered if the risk of exposure to HAV is high (e.g., travel to endemic areas). The benefits of vaccination generally outweigh the theoretical risks.
    • Mild illness is generally not a contraindication.

    Anti-D (Rho) Immunoglobulin

    Type
    • This is a form of passive immunization, not a vaccine. It is a preparation of purified human immunoglobulin G (IgG) antibodies directed against the Rhesus D (RhD) antigen found on the surface of red blood cells. It works by destroying any Rh-positive fetal red blood cells that enter the Rh-negative mother's circulation before her immune system can produce its own antibodies.
    Indications
    • To prevent a Rhesus-negative (Rh-negative) mother from forming her own anti-RhD antibodies when exposed to Rhesus-positive (Rh-positive) fetal red blood cells. This prevents Rh isoimmunization, which can cause severe Hemolytic Disease of the Newborn (HDN) or erythroblastosis fetalis in subsequent Rh-positive pregnancies.
    • It is administered in the following situations to Rh-negative, non-sensitized women:
      • Routine Antenatal Prophylaxis (RAP): Typically given as an intramuscular (IM) injection around 28 weeks of gestation to prevent sensitization from asymptomatic feto-maternal hemorrhage. Some guidelines also recommend an earlier dose around 12-20 weeks.
      • Postnatal Prophylaxis: Given within 72 hours of delivering an Rh-positive infant (or an infant whose Rh status is unknown).
      • Following any potential sensitizing event during pregnancy or within 72 hours of the event:
        • Abortion (spontaneous or induced)
        • Miscarriage
        • Ectopic pregnancy
        • Hydatidiform mole
        • Stillbirth
        • Amniocentesis
        • Chorionic villus sampling (CVS)
        • Cordocentesis (percutaneous umbilical blood sampling)
        • External cephalic version
        • Abdominal trauma (e.g., motor vehicle accident, fall)
        • Antepartum hemorrhage (APH)
        • Any invasive obstetric procedure
      • Transfusion of Rh-positive blood products to an Rh-negative individual.
    Dose
    • The dose of Anti-D immunoglobulin varies based on the specific product, the gestational age, and the extent of feto-maternal hemorrhage (if quantifiable). It is usually administered by intramuscular (IM) injection. Intravenous (IV) preparations are available for specific situations, such as massive hemorrhage.
      • Antenatal Prophylaxis: Typically 300 mcg (1500 IU) IM around 28 weeks of gestation.
      • Postnatal Prophylaxis: Typically 300 mcg (1500 IU) IM within 72 hours of delivering an Rh-positive infant.
      • For sensitizing events earlier in pregnancy or with smaller potential bleeds, a lower dose (e.g., 50-120 mcg) may be used (e.g., for events up to 12 weeks, 12-20 weeks gestation).
      • For suspected or quantified large feto-maternal hemorrhage (determined by Kleihauer-Betke test or flow cytometry), additional doses may be required. One 300 mcg dose typically neutralizes 15 mL of Rh-positive red blood cells.
    Side Effects
    • Common: Local tenderness, pain, swelling, and redness/stiffness at the injection site.
    • Less common systemic effects: Low-grade fever, headache, malaise, nausea, vomiting, myalgia.
    • Rare: Allergic reactions, including urticaria, rash, and very rarely, severe anaphylactic reactions.
    • Extremely rare: Hemolysis (in the recipient), although this is usually mild and transient.
    Contraindications
    • Should NEVER be given to an Rh-positive individual.
    • Should NEVER be given to the Rh-positive newborn infant.
    • Contraindicated in individuals with a known severe allergy or hypersensitivity to human immunoglobulins or any component of the preparation.
    • Contraindicated in individuals with isolated IgA deficiency with known anti-IgA antibodies, due to the risk of anaphylaxis.
    • It is NOT indicated for an Rh-negative woman who has already been sensitized and has produced anti-RhD antibodies. In such cases, the immunoglobulin will not be effective and may cause a reaction.
    Drug Interactions
    • As Anti-D immunoglobulin is a preparation of antibodies, it can interfere with the immune response to live virus vaccines (e.g., Measles, Mumps, Rubella [MMR], Varicella, Oral Polio, Yellow Fever). Live attenuated vaccinations should generally be postponed for at least 3 months (and up to 6 months depending on the dose of immunoglobulin) after receiving Anti-D immunoglobulin to ensure optimal vaccine efficacy.
    • Concomitant administration with other passive antibodies (e.g., other immunoglobulins) should be avoided unless specifically indicated.
    Storage
    • Typically stored refrigerated at 2°C to 8°C (36°F to 46°F). Do not freeze. Protect from light.

    Summary

    Vaccine Details
    Measles–Rubella Vaccine

    Available preparations: Injection powder for solution (live attenuated measles-rubella virus).

    Indications: Active immunization against measles and rubella.

    Dose: 0.5ml SC at 9 months and 18 months (left upper arm).

    Side effects: Fever, Headache and Malaise, Rashes and Thrombocytopenia.

    Contraindications: Hypersensitivity to any antibiotic present in the vaccine, Pregnancy, Immunosuppression.
    Measles, Mumps and Rubella Vaccine (MMR vaccine)

    Available brands: Trimovax®, Priovix®.

    Dose: By deep SC or by intramuscular injection 0.5ml (usually at 12-15 months).

    Indications: Active immunization against measles, mumps and rubella.

    Contraindications: Pregnancy, Hypersensitivity to components like neomycin, Immunosuppressed patients, Children who have received another live vaccine by injection within 4 weeks.

    Side effects: Fever and Malaise, Parotid swelling and Rashes.

    Precautions: History of convulsions.
    BCG Vaccine

    Available preparations: Powder for solution of live bacteria of strain derived from the bacillus of calmette and Guerin.

    Indications: Active immunization against tuberculosis.

    Dose: 0.05ml intradermal in the right upper arm to neonates; 0.1ml intradermal on the upper arm (children > 12 months).

    Side effects: Keloid, Lymphadenitis, Localized necrotic ulceration, Disseminated BCG infection in immunosuppressed patients, Anaphylaxis.

    Contraindications: Generalized oedema, Immunosuppressed patients, Antibacterial treatment.

    Precautions: Pregnancy, Eczema, Scabies. Vaccine site must be lesion free.
    Diphtheria, Pertussis and Tetanus (DPT) Vaccine

    Available brand: Tripacel®, Infantrix®.

    Indications: Active immunization against diphtheria, tetanus and pertussis.

    Dose: Infant: 0.5ml by intramuscular or deep SC injection at 6, 10 and 14 weeks.

    Side effects: Irritability and Limb swelling, Peripheral neuropathy, Urticaria, Fever, Restlessness and Malaise, Myalgia, Headache and Loss of appetite.

    Contraindications: Known hypersensitivity to any of the ingredients.
    Tetanus Toxoid Vaccine

    Available brand: Tetavax®.

    Indications: Active immunization against tetanus and neonatal tetanus.

    Dose: Women 15-49 years of age. 0.5ml deep SC or intramuscular injection. 5 doses (TT1-TT5) are required for lifelong protection.

    Side effects: Peripheral neuropathy.
    Anti-tetanus Immunoglobulin

    Available brand: Tetanea®.

    Indications: Passive immunization against tetanus as part of the management of tetanus prone wounds.

    Dose: Adult and Children: 1ml by IM injection.

    Side effects: Local reactions, Fever, Pain and tenderness at site of injection, Headache.
    Yellow Fever Vaccine

    Available brand: Stamaril®.

    Indications: Active immunization against yellow fever.

    Dose: Infant at 9 months: 0.5ml by SC injection.

    Side effects: Headache, Myalgia, Fever, Influenza like symptoms.

    Contraindications: Immunosuppressed patients, Hypersensitivity to any ingredient (including eggs), Infant under 4 months of age.
    Typhoid Vaccine

    Available brands: Typhim VI®, Typherix PFS®.

    Indications: Active immunization against typhoid.

    Dose: Adult and Children > 2 years: By deep SC or intramuscular 0.5ml with booster doses every 3 years for those at continued risk.

    Side effects: Headache, Nausea, Myalgia, Malaise.

    Contraindications: Immunosuppressed patients, Febrile illness, Hypersensitivity.
    Pneumococcal Vaccine

    Available brand: Pneumo 23® (Polysaccharide version).

    Indications: Immunization against pneumococcal infections in Sickle cell disease Children > 2 years of age, and immunocompromised patients > 5 years.

    Dose: Adults and Children > 2 years: 0.5ml deep SC or IM as a single dose.

    Side effects: Fever, Myalgia.

    Contraindication: Severe allergic reaction to any ingredients.
    Meningococcal Vaccine

    Available brand: Meningo A + C®, Mencevax ACWY®.

    Indications: Active immunization against Neisseria meningitidis infections.

    Dose: Adult and Children > 2 years of age. 0.5ml deep SC or IM injection as a single dose.

    Side effects: Allergic reaction, Anaphylaxis, Erythema.

    Contraindications: Known allergy, Febrile conditions.
    Cholera Vaccine

    Available brand: Dukoral® (Oral).

    Indications: Immunization for travellers > 2 years of age at high risk.

    Dose: Multiple oral doses given at intervals of at least 1-6 weeks.

    Side effects: Abdominal discomfort, Diarrhoea, Headache, Fever, Vomiting, Nausea, Loss of appetite.

    Contraindications: Hypersensitivity, Acute GIT or febrile illness.
    Rabies Vaccine

    Available brand: Verorab®.

    Indications: Pre-exposure prophylaxis and post-exposure treatment to prevent rabies.

    Dose: Pre-exposure: 1ml on days 0, 7 and 28. Post-exposure: 1ml on days 0, 3, 7, 14 and 30.

    Side effects: Pain/erythema at injection site, Nausea, Fever, Headache, Myalgia, Malaise.
    Hepatitis B Vaccine

    Available brand: Euvax B®, Engerix B®.

    Indications: Active immunization against Hepatitis B infection for all infants and high-risk persons (healthcare personnel, lab workers, patients with renal failure, close contacts of carriers).

    Dose: Infants: 0.5ml IM at 6, 10, 14 weeks. Adults: 1ml IM, 3 doses.

    Side effects: Abdominal pain, GIT disturbance, Peripheral neuropathy, Myalgia, Lymphadenopathy.

    Precautions: Immunocompromised patients may need further dose, Pregnancy, Lactation.
    Hepatitis A Vaccine

    Available brand: Avaxim®, Havrix®.

    Indications: Active immunization against Hepatitis A for high-risk groups (lab workers, patients with severe liver disease, travelers).

    Dose: By IM injection, 0.5ml single dose with a booster 6-12 months later.

    Side effects: Headache, Fever, Malaise, Fatigue, Myalgia, Loss of appetite, Nausea.

    Contraindications: Severe febrile infections.
    Anti-D (Rho) Immunoglobulin

    Indications: Prevention of antibody formation to Rh-positive blood cells in Rh-negative mothers. Given following any sensitizing episode (birth of Rh+ infant, abortion, miscarriage).

    Dose: Varies by episode, typically 250-500mcg IM within 72 hours.

    Side effects: Fever, Nausea, Myalgia, Abdominal pain, Local tenderness and stiffness.

    Contraindications: Rhesus positive individuals, Isolated IgA deficiency.

    Immunization Read More »

    Immunity for nurses class notes

    Immunity

    Immunity and Antibodies - Complete Study Guide

    Introduction to Immunity

    Pathogens are foreign disease-causing substances, such as bacteria and viruses, and people are exposed to them every day.

    Antigens are attached to the surface of pathogens and stimulate an immune response in the body.

    An immune response is the body’s defense system to fight against antigens and protect the body.

    Immunity is the body's ability to resist infection and disease. It is a state of having sufficient biological defenses to avoid invasion by pathogens and to destroy foreign substances.

    Immunology is the scientific study of this complex system and how it responds to challenges.

    Terminology in Immunology

    • Pathogen: A foreign, disease-causing microorganism, such as a bacterium, virus, fungus, or parasite.
    • Antigen (Ag): Any substance, usually a protein or polysaccharide on the surface of a pathogen, that is recognized as "foreign" by the immune system and provokes an immune response. Think of antigens as the "uniforms" that identify an invader.
    • Antibody (Ab) or Immunoglobulin (Ig): A highly specific protein produced by plasma cells (a type of B-lymphocyte) in response to a specific antigen. Antibodies bind to antigens to neutralize them or mark them for destruction.
    • Immunogen: Any antigen that is capable of inducing a humoral (antibody) and/or cell-mediated immune response. All immunogens are antigens, but not all antigens are immunogens (some are too small or simple to provoke a response on their own).
    • Hapten: A small molecule that can only provoke an immune response when it is attached to a larger carrier protein. On its own, it is an antigen but not an immunogen.
    • Chemotaxis: The chemical attraction of phagocytic cells (like neutrophils and macrophages) to a site of injury or infection. They follow a chemical trail of substances called chemokines.
    • Chemokines: A family of small proteins that act as chemical messengers, stimulating the movement of leukocytes (white blood cells) towards the source of inflammation.

    Types of immunity

    The immune system is broadly divided into two interconnected branches:

    1. Innate (Non-specific) Immunity: The body's general, inborn protection against all invaders. It acts immediately or within hours and does not have immunological memory. It includes physical barriers and general immune cells.
    2. Adaptive (Acquired/Specific) Immunity: A highly specific defense system that is "acquired" during life after exposure to a pathogen or vaccine. It is characterized by specificity for a particular pathogen and immunological memory, allowing for a much stronger response upon re-exposure.

    1. Innate Immunity: The First and Second Lines of Defense

    Innate immunity is our built-in defense system. It is non-specific, meaning it responds in the same way to all pathogens, and it does not "remember" previous encounters.

    Types of innate immunity

    1. First line of defenses These barriers are designed to prevent pathogens from entering the body in the first place.
    2. Second line of defenses If pathogens breach the first line of defense, they encounter a range of non-specific internal defenses.
    A diagram illustrating the first line defenses of the body, including the skin barrier, mucous membranes with cilia, and acidic environments of the stomach and vagina.

    First Line of Defense: External or Physical and Chemical Barriers

    These barriers are designed to prevent pathogens from entering the body in the first place.

  • Skin: The unbroken epidermis, with its tough outer layer of keratin (stratum corneum), is a formidable physical barrier. Sebum (skin oil) contains fatty acids that create an acidic environment hostile to many bacteria.
  • Mucous Membranes: These line the respiratory, digestive, urinary, and reproductive tracts. They produce mucus, which traps microbes.
    • Ciliary Escalator: The ciliated epithelium of the upper respiratory tract constantly sweeps mucus (with trapped dust and pathogens) up towards the pharynx, where it is swallowed and destroyed in the stomach.
  • Bodily Fluids and Washing Actions:
    • Tears (Lacrimal Apparatus): Constantly wash the surface of the eye to dilute and remove microbes.

      • Blinking spreads tears over the surface of the eyeball, and the continual washing action of tears helps to dilute microbes and keep them from settling on the surface of the eye. Tears also contain lysozyme, an enzyme capable of breaking down the cell walls of certain bacteria.

    • Saliva: Washes microbes from the teeth and mouth.
    • Urine Flow: The one-way flow of urine through the urethra mechanically flushes out microbes, preventing ascending infections.
    • Vaginal Secretions: Move microbes out of the female reproductive tract.
  • Chemical Barriers:
    • Acidity: The low pH of skin (3-5), gastric juice (1.2-3.0), and vaginal secretions discourages the growth of most microbes.
    • Lysozyme: An enzyme found in tears, saliva, nasal secretions, and perspiration that can break down the peptidoglycan cell walls of bacteria.
  • Expulsion Mechanisms: Defecation and vomiting also expel microbes. For example, in response to some microbial toxins, the smooth muscle of the lower gastrointestinal tract contracts vigorously; the resulting diarrhea rapidly expels many of the microbes.
    • A diagram showing the process of inflammation: vasodilation, increased permeability leading to swelling, and the migration of phagocytes (chemotaxis) to the site of injury.

    Second Line of Defense: Internal Defenses

    When pathogens penetrate the physical and chemical barriers of the skin and mucous membranes, they encounter a second line of defense which include the following:

    1. Internal Antimicrobial Substances

  • Interferons (IFNs): Proteins produced by virus-infected cells. They don't save the infected cell, but they signal to neighboring uninfected cells to produce antiviral proteins, helping to limit the spread of the virus.
  • Complement System: A group of over 20 plasma proteins that circulate in an inactive state. When activated (e.g., by an antigen-antibody complex), they "complement" the immune response by:
    • Causing lysis (bursting) of microbial cells.
    • Stimulating inflammation.
    • Enhancing phagocytosis by coating pathogens (a process called opsonization).
  • Iron-Binding Proteins: Proteins like transferrin (in blood), lactoferrin (in milk, saliva), and ferritin (in liver) bind to iron, making it unavailable for bacteria that need it for growth.
  • Antimicrobial Proteins (AMPs): Short peptides that have broad-spectrum antimicrobial activity, directly damaging microbial membranes. Examples include defensins and dermicidin.

    • 2. Defensive Cells

  • Phagocytes ("Eating Cells"): These cells engulf and digest pathogens and cellular debris.
    • Neutrophils: The most abundant type of white blood cell. They are the "first responders" that rapidly move to sites of infection to perform phagocytosis.
    • Macrophages ("Big Eaters"): Develop from monocytes. Fixed macrophages reside in specific tissues (e.g., in the liver, lungs), while wandering macrophages roam through tissues. They are powerful phagocytes and also act as Antigen-Presenting Cells (APCs).
    • Dendritic Cells: Also phagocytes and potent APCs, found in skin and mucous membranes.
  • Natural Killer (NK) Cells: A type of lymphocyte that performs immunological surveillance. They are unique because they can detect and kill abnormal body cells (like tumor cells and virus-infected cells) without needing to be activated by a specific antigen.
  • Basophils and Mast Cells: Release inflammatory chemicals like histamine and heparin. Basophils circulate in the blood, while mast cells are fixed in tissues. They are key players in inflammation and allergic reactions.
  • Eosinophils: Specialize in fighting parasitic worm infections and are also involved in allergic reactions.

    • 3. Inflammation: The Body's Emergency Response

    Inflammation is the physiological response to tissue damage. Its purpose is protective: to isolate the problem, inactivate and remove the causative agent and damaged tissue, and initiate repair.

    The Cardinal Signs of Inflammation:
    1. Redness (Rubor): Caused by vasodilation (widening) of arterioles and capillaries in the damaged area, which increases blood flow. This is triggered by chemical mediators like histamine.
    2. Heat (Calor): Results from the increased blood flow. The localized increase in temperature can inhibit microbial growth and enhance the activity of immune cells.
    3. Swelling (Tumor): Caused by increased capillary permeability. Fluid (exudate) and plasma proteins leak from the blood into the interstitial spaces, leading to edema.
    4. Pain (Dolor): Results from the compression of sensory nerve endings by the swelling and from irritation by chemical mediators like bradykinin and prostaglandins.
    5. Loss of Function (Functio Laesa): The combination of swelling and pain may temporarily limit movement of the affected area, which helps protect it from further injury.

    4. Immulogical surveillance

    1. Natural killer (NK cells) cells: are leukocytes that attack and destroy tumor cells, or cells that have been infected by viruses

      2. Although they are lymphocytes, they are much less selective about their targets than the other T-cells & B-cells.

    2. Adaptive Immunity: The Specific and Memory-Based Defense

    Adaptive immunity is a highly specific, powerful defense system that develops throughout our lifetime. It is "acquired" after exposure to a pathogen or vaccine. Its two defining characteristics are specificity (it targets one particular antigen) and memory (it "remembers" past encounters, leading to a much faster and stronger response upon re-exposure).

    Lymphocytes

    The Cells of Adaptive Immunity

    B-lymphocytes (B-cells) and T-lymphocytes (T-cells) are the major players. Both originate from stem cells in the bone marrow but mature in different locations.

    T-Cells and Cell-Mediated Immunity

    T-cells are responsible for cell-mediated immunity, which is crucial for fighting intracellular pathogens (like viruses and some bacteria) and eliminating abnormal body cells (like cancer cells). They mature in the Thymus gland.

  • Antigen Recognition: T-cells cannot recognize whole antigens. They can only "see" small fragments of an antigen that have been processed and displayed on the surface of an Antigen-Presenting Cell (APC) like a macrophage or dendritic cell.
  • Clonal Expansion: When a T-cell recognizes its specific antigen presented by an APC, it becomes activated and begins to rapidly divide, creating a large clone of identical cells programmed against that antigen.
  • Types of T-Cells:
    1. Helper T-Cells (TH or CD4+ cells): The "generals" of the immune system. When activated, they produce chemical messengers called cytokines that coordinate the entire immune response. They help activate cytotoxic T-cells, B-cells, and macrophages. HIV specifically targets and destroys these cells, crippling the immune system.
    2. Cytotoxic T-Cells (TC or CD8+ cells): The "soldiers." They directly track down and kill any body cells displaying the specific antigen they recognize (e.g., virus-infected cells, tumor cells) by releasing powerful toxins.
    3. Suppressor (Regulatory) T-Cells (Treg): These cells turn off the immune response after the pathogen has been cleared, preventing excessive and potentially damaging immune activity.
    4. Memory T-Cells: Long-lived cells that persist after the infection is resolved, ready to mount a swift response upon re-exposure to the same antigen.

    • B-Cells and Humoral (Antibody-Mediated) Immunity

    B-cells are responsible for humoral immunity, which involves the production of antibodies that circulate in the body's fluids ("humors" like blood and lymph). This is most effective against extracellular pathogens like bacteria circulating in the blood. B-cells are produced and mature in the Bone marrow.

  • Antigen Recognition: B-cells can recognize and bind to whole, unprocessed antigens.
  • Activation and Clonal Expansion: Once a B-cell binds to its specific antigen, it typically requires a confirmation signal from a helper T-cell to become fully activated. It then enlarges and divides into a clone of two cell types:
    1. Plasma Cells: These are "antibody factories." They dedicate all their energy to producing and secreting thousands of antibody molecules per second into the bloodstream. These antibodies are specific to the antigen that initiated the response.
    2. Memory B-Cells: Long-lived cells that provide immunological memory, enabling a rapid and massive antibody production (the secondary response) if the same antigen is encountered again.

    • Types of Adaptive Immunity

    Acquired (adaptive) immunity develops during an individual's lifetime. It can be classified into two major categories—Active and Passive—each of which can be acquired either naturally or artificially.

    Active Immunity: The Body's Own Production Line

    Active immunity is protection that is induced in the host itself after exposure to an antigen. The individual's own immune system is stimulated to produce memory B-cells and T-cells. This process takes time to develop but results in long-lasting, sometimes lifelong, immunological memory.

    1. Naturally Acquired Active Immunity
    • Mechanism: This is the most natural way to become immune. It occurs when a person is exposed to a live pathogen through an infection (which may be a full-blown illness or a subclinical infection without symptoms).
    • The Process: Upon first exposure, the body mounts a primary immune response. It manufactures specific antibodies and T-cells to fight the invading pathogen. While this initial response takes time (often allowing the person to get sick), it results in the creation of a large pool of memory cells.
    • Outcome: For the rest of that individual's life, any subsequent exposure to the same pathogen will trigger a rapid and powerful secondary immune response. The memory cells will mobilize to produce antibodies and T-cells so quickly that the invading antigen is destroyed before it can cause disease.
    • Clinical Example: A child who gets sick with and recovers from chickenpox develops naturally acquired active immunity. They are protected from getting chickenpox again for the rest of their life.
    2. Artificially Acquired Active Immunity
    • Mechanism: This type of immunity is acquired through the deliberate action of vaccination (immunization). An individual is intentionally given a prepared antigen.
    • The Process: The vaccine contains a safe form of the antigen—it might be a killed pathogen, a live attenuated (weakened) pathogen, a subunit (a piece of the pathogen), or a toxoid (an inactivated toxin). This antigen is enough to stimulate the recipient's immune system to produce its own antibodies and memory cells, but it does not cause the actual disease.
    • Outcome: The individual develops long-term immunity without ever having to suffer through the illness. Sometimes, a person might experience minor symptoms like a low-grade fever or soreness after a vaccine; this is a sign that their immune system is actively learning to fight the antigen.
    • Clinical Example: A baby receiving the Measles, Mumps, and Rubella (MMR) vaccine. The vaccine contains live attenuated viruses, which stimulate the baby's immune system to create memory cells against all three diseases, providing long-term protection.

    Passive Immunity: Borrowed Protection

    Passive immunity is protection that is acquired through the transfer of pre-formed antibodies from an immune individual to a non-immune individual. The recipient's body does not produce the antibodies itself. This provides immediate protection but is always temporary because the "borrowed" antibodies are eventually broken down and eliminated, and no immunological memory is created.

    1. Naturally Acquired Passive Immunity
  • Mechanism: This occurs naturally from mother to child. It is nature's way of protecting a newborn while its own immune system is still immature.
  • The Process:
    • During Pregnancy: IgG antibodies are actively transported across the placenta from the mother's bloodstream to the fetus, especially during the last one to two months of pregnancy. A full-term infant is born with the same set of IgG antibodies as its mother.
    • After Birth: IgA antibodies (secretory IgA) are transferred from the mother to the infant through breast milk (especially the colostrum). This IgA protects the baby's gastrointestinal tract from infections.
  • Outcome: The antibodies protect the infant from specific diseases that the mother is immune to. This protection is crucial but temporary, typically lasting for the first 6-12 months of life, until the maternal antibodies wane and the infant's own immune system begins to produce its own antibodies.
  • Clinical Relevance: This is why the timing of infant vaccinations is so important—they are scheduled to begin as the mother's protective antibodies start to disappear.
    • 2. Artificially Acquired Passive Immunity
  • Mechanism: This involves injecting a person with ready-made antibodies (immunoglobulins or antiserum) that were produced in another human or an animal (like a horse).
  • The Process: This is used when a person needs immediate protection from a fast-acting toxin or pathogen and there is no time to wait for their own active immune response to develop.
    • It can be used prophylactically (to prevent disease) in individuals who have been exposed to an infection they are not immune to.
    • It can be used therapeutically (to treat a disease) after symptoms have already developed, to help neutralize a toxin or pathogen.
  • Outcome: Provides immediate but short-lived protection. There is no memory formation. There is also a potential risk of a hypersensitivity reaction (like serum sickness) if the antibodies come from a non-human source.
  • Clinical Examples:
    • Giving Tetanus Immunoglobulin (TIG) to a person with a deep, contaminated wound who has an uncertain vaccination history.
    • Giving Rabies Immunoglobulin (RIG) infiltrated around a wound from a suspected rabid animal bite.
    • Giving pooled human immunoglobulin (IVIG) to treat immunodeficiency diseases like hypogammaglobulinemia.

    • Summary of Acquired Immunity

    Type of Immunity How It Is Acquired Memory Produced? Duration Example
    Naturally Acquired Active Surviving an infection Yes Long-term / Lifelong Recovering from measles
    Artificially Acquired Active Vaccination Yes Long-term / Lifelong Receiving the polio vaccine
    Naturally Acquired Passive Antibodies from mother to child (placenta/breast milk) No Short-term (months) An infant's temporary immunity to diseases the mother had
    Artificially Acquired Passive Injection of pre-formed antibodies (antiserum) No Short-term (weeks to months) Receiving Rabies Immunoglobulin after a bite

    Antibodies (Immunoglobulins)

    Antibodies are Y-shaped glycoprotein molecules produced by plasma cells in response to a specific antigen. They are found in blood serum and other body fluids. Their primary function is not to kill pathogens directly, but to bind to them and facilitate their destruction.

    A diagram showing the basic Y-shaped structure of an antibody molecule, alongside illustrations of the five different classes (IgG, IgA, IgM, IgD, IgE).

    The Five Classes of Antibodies (Isotypes)

    Class Abundance Key Features and Functions
    IgG (Gamma) ~80% (Most abundant in serum) Provides the majority of long-term antibody-based immunity. It is the only antibody class that can cross the placenta, providing passive immunity to the fetus. It is the main antibody in the secondary response.
    IgA (Alpha) ~15% Known as the secretory antibody. Found in mucosal secretions (saliva, tears, mucus), respiratory, GI, and urogenital tracts. It prevents pathogens from colonizing and attaching to mucous membranes. Also found in breast milk, providing passive immunity to the infant's gut.
    IgM (Mu) ~10% It is a very large molecule (a pentamer). It is the first antibody to be produced during a primary immune response, indicating a recent or current infection. It is a potent activator of the complement system.
    IgD (Delta) <1%< /td> Functions mainly as an antigen receptor on the surface of B-cells. Its exact role is still being researched.
    IgE (Epsilon) ~0.002% (Lowest concentration) Binds to mast cells and basophils. When it encounters its specific antigen (an allergen like pollen), it triggers the release of histamine, causing an allergic reaction. It also plays a role in defending against parasitic worm infections.

    Acquired Immunity

    Acquired immunity develops during an individual's lifetime and can be classified based on how it was obtained: naturally or artificially, and actively or passively.

    The Four Types of Acquired Immunity
    1. Naturally Acquired Active Immunity:
      • How it's acquired: By getting an infection. The body is exposed to a live pathogen, mounts a primary immune response, and develops long-lasting memory cells.
      • Memory: Yes (long-term).
      • Example: Recovering from chickenpox gives you lifelong immunity to that specific virus.
    2. Naturally Acquired Passive Immunity:
      • How it's acquired: Through the transfer of antibodies from mother to child. IgG crosses the placenta to the fetus, and IgA is passed through breast milk to the infant.
      • Memory: No. The immunity is temporary (lasts a few months) because the infant did not make the antibodies themselves.
      • Example: Protection of a newborn from infections during the first few months of life.
    3. Artificially Acquired Active Immunity:
      • How it's acquired: Through vaccination (immunization). The body is deliberately exposed to a harmless form of a pathogen (e.g., killed or weakened) or its antigens, which stimulates a primary immune response and creates memory cells without causing the disease.
      • Memory: Yes (long-term).
      • Example: The measles vaccine provides long-term protection against measles.
    4. Artificially Acquired Passive Immunity:
      • How it's acquired: Through the injection of pre-formed antibodies (immunoglobulins) from an immune human or animal. This provides immediate but temporary protection.
      • Memory: No.
      • Example: Giving someone an injection of tetanus antitoxin (antibodies against the tetanus toxin) after a deep, dirty wound for immediate protection while their own active immunity develops. Another example is giving Rabies Immunoglobulin (RIG) after a suspected rabid animal bite.

    Hypersensitivity: When the Immune System Overreacts

    The term hypersensitivity refers to an exaggerated or inappropriate immune response to an antigen that results in significant inflammation and damage to host tissues. While the immune system's job is to protect us, in hypersensitivity reactions, the protective response itself becomes the cause of the illness.

    These reactions are classified into four types based on the primary immune mediators involved and the time it takes for a reaction to occur.

    Type I: Immediate / Anaphylactic Hypersensitivity

  • Key Immune Mediator: IgE antibodies.
  • Onset Time: Immediate (within minutes to a few hours of exposure).
  • Mechanism: This is a two-step process.
    1. Sensitization Phase (First Exposure): An individual is exposed to an allergen (e.g., pollen, bee venom). Their B-cells are stimulated to produce large amounts of IgE antibodies against this allergen. This IgE then binds to the surface of mast cells and basophils, effectively "priming" them.
    2. Activation Phase (Subsequent Exposure): Upon re-exposure, the allergen binds to the IgE already attached to the mast cells. This triggers the immediate and massive release (degranulation) of inflammatory mediators like histamine, leukotrienes, and prostaglandins.
  • Pathological Effects: The released mediators cause:
    • Vasodilation and Increased Capillary Permeability: Leads to swelling (edema), skin rashes (hives/urticaria), and a dangerous drop in blood pressure.
    • Bronchoconstriction: Contraction of smooth muscles in the airways, leading to wheezing and difficulty breathing (as seen in asthma).
    • Increased Mucus Secretion: Causes a runny nose and watery eyes (as in hay fever).
  • Clinical Examples:
    • Systemic Anaphylaxis: A severe, life-threatening reaction to bee stings, food allergies (e.g., peanuts), or drugs (e.g., penicillin), causing circulatory collapse and airway obstruction.
    • Atopic Diseases (Localized Allergies): Allergic asthma, hay fever (allergic rhinitis), eczema (atopic dermatitis), and hives (urticaria).

    • Type II: Antibody-Dependent Cytotoxic Hypersensitivity

  • Key Immune Mediators: IgG or IgM antibodies.
  • Onset Time: Hours to days.
  • Mechanism: In this type, antibodies (IgG or IgM) bind directly to antigens that are located on the surface of host cells. This "tags" the host cell for destruction through three main pathways:
    1. Complement Activation: The antibody-antigen complex on the cell surface activates the complement system, leading to the formation of the Membrane Attack Complex (MAC), which punches holes in the cell membrane, causing it to lyse (burst).
    2. Phagocytosis: The antibody acts as an opsonin, coating the cell and making it a prime target for phagocytes like macrophages.
    3. Antibody-Dependent Cell-Mediated Cytotoxicity (ADCC): Natural Killer (NK) cells bind to the antibodies attached to the host cell and release cytotoxic granules to kill it.
  • Clinical Examples:
    • Incompatible Blood Transfusion: If a person with Type B blood (with anti-A antibodies) receives Type A blood, their antibodies will attack the transfused red blood cells, causing massive hemolysis.
    • Hemolytic Disease of the Newborn (Rh Incompatibility): An Rh-negative mother carrying an Rh-positive fetus can develop anti-Rh antibodies. In a subsequent Rh-positive pregnancy, these antibodies can cross the placenta and destroy the fetal red blood cells.
    • Some Autoimmune Diseases: For example, in Goodpasture's syndrome, antibodies attack proteins in the kidneys and lungs.

    • Type III: Immune Complex-Mediated Hypersensitivity

  • Key Immune Mediator: Soluble Immune Complexes (clumps of antigen and antibody, usually IgG).
  • Onset Time: Hours to days, or can be chronic.
  • Mechanism: The key difference from Type II is that the antigens are soluble (floating freely) in the blood, not fixed on a cell surface. Large quantities of antigen-antibody complexes are formed. If the body cannot clear these complexes efficiently, they get deposited in the walls of small blood vessels, especially in the kidneys, joints, and skin.
    These deposited complexes activate the complement system, which attracts a large number of neutrophils to the site. The frustrated neutrophils release their powerful lytic enzymes, causing inflammation and damage to the underlying tissue ("innocent bystander" damage).
  • Clinical Examples:
    • Serum Sickness: A classic example where a patient reacts to foreign proteins in injected antisera (e.g., from a horse). It causes fever, rash, joint pain, and kidney damage.
    • Post-Streptococcal Glomerulonephritis: Kidney inflammation following a strep throat infection, caused by the deposition of streptococcal antigen-antibody complexes in the glomeruli.
    • Systemic Lupus Erythematosus (SLE): An autoimmune disease where complexes of self-antigens and autoantibodies deposit in multiple organs.

    • Type IV: Delayed-Type / Cell-Mediated Hypersensitivity

  • Key Immune Mediator: T-Cells (specifically Helper T-cells and Cytotoxic T-cells). No antibodies are involved.
  • Onset Time: Delayed (24-72 hours or more).
  • Mechanism: This reaction is mediated by T-cells, and the delay is because it takes time for the T-cells to migrate to the area and orchestrate a response.
    1. Sensitization Phase: On first contact with the antigen (e.g., chemicals from poison ivy, proteins from M. tuberculosis), an Antigen-Presenting Cell (APC) presents it to Helper T-cells, creating a population of sensitized memory T-cells.
    2. Elicitation Phase: On second exposure, these memory T-cells are activated. They migrate to the site and release cytokines, which recruit and activate a large number of macrophages. It is the prolonged activity and cytokine release from these T-cells and macrophages that causes the inflammation and tissue damage.
  • Clinical Examples:
    • The Mantoux (Tuberculin) Skin Test: A classic example. If a person has been exposed to TB, their memory T-cells will cause a localized, hardened red swelling at the injection site 48-72 hours later.
    • Contact Dermatitis: Skin rash caused by contact with substances like poison ivy, nickel in jewelry, or latex.
    • Granuloma Formation: In chronic infections like tuberculosis and leprosy, the body forms granulomas to wall off the pathogen, which is a classic Type IV reaction causing tissue destruction over time.

    • Summary of Hypersensitivity Reactions

    Type Name Key Mediator Onset Time Mechanism Summary Clinical Examples
    Type I Immediate / Anaphylactic IgE Minutes IgE on mast cells binds to allergen, triggering degranulation and histamine release. Anaphylaxis, Asthma, Hay Fever, Hives
    Type II Cytotoxic IgG, IgM, Complement Hours to Days Antibodies bind to antigens on host cells, leading to cell destruction. Blood Transfusion Reactions, Hemolytic Disease of Newborn
    Type III Immune Complex Antigen-Ab Complexes Hours to Days Soluble immune complexes deposit in tissues, causing inflammation and damage. Serum Sickness, Post-Strep Glomerulonephritis, Lupus (SLE)
    Type IV Delayed-Type / Cell-Mediated T-Cells & Macrophages 24-72 Hours Sensitized T-cells are activated, leading to cytokine release and macrophage-mediated inflammation. TB Skin Test, Contact Dermatitis (Poison Ivy), Granuloma Formation

    Immunity Read More »

    pharmacolgy and mental nursing quiz

    Pharmacology & Mental health Quiz

    Welcome to your Pharmacology & Mental

    This Pharmacology & Mental quiz is marked out of 100%,

    Make sure to input your RIGHT EMAIL because you will receive your RESULTS and ANSWERS to the email you input at the end of this Pharmacology & Mental quiz.

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    immunological agents

    Immunological Agents

    Immunological Agents

    Immunological agents are a broad class of drugs that modify the immune system’s activity, either by enhancing or suppressing its function. 

    They are like tools that help your immune system work better or differently. For example, vaccines help your body fight off specific diseases(enhancing) or autoimmune drugs treat autoimmune diseases, where the immune system attacks the body’s own tissues (suppressing).

    Types of Immunological Agents:

    1. Immunostimulants: These are drugs that boost the immune system’s function, often used when the immune system is weakened or underperforming.
    2. Immunosuppressants: These drugs reduce or suppress the immune system’s activity, essential in preventing transplant rejection and treating autoimmune diseases.
    Examples include;

    IMMUNE STIMULANTS
    Interferons
    interferon alfa-2b
    interferon alfacon-1
    interferon alfa-n3
    interferon beta-1a
    interferon beta-1b
    interferon gamma-1b
    peginterferon alfa-2a
    peginterferon alfa-2b
    Interleukins
    aldesleukin
    oprelvekin

    IMMUNE SUPPRESSANTS
    T- and B-Cell Suppressors
    abatacept
    alefacept
    azathioprine
    Interleukin-Receptor Antagonist
    anakinra
    Monoclonal Antibodies
    adalimumab
    alemtuzumab
    basiliximab
    bevacizumab
    certolizumab

    Immunostimulants

    1. Interferons

    Interferons are proteins produced naturally by cells in response to viral infections and other stimuli. They work by interfering with virus replication within host cells, activating immune cells like natural killer cells and macrophages, and increasing the antigen presentation to lymphocytes.

    Drug

    Indications

    Therapeutic Action

    Adverse Effects

    Interferon alfa-2b

    Chronic hepatitis C, Kaposi’s sarcoma, malignant melanoma

    Inhibits viral replication, enhances immune response, and increases macrophage activity

    Flu-like symptoms, myelosuppression, depression, suicidal ideation

    Interferon alfacon-1

    Hepatitis C

    Inhibits viral replication and boosts immune system

    Headache, dizziness, bone marrow suppression, photosensitivity

    Interferon alfa-n3

    Genital warts, basal cell carcinoma

    Inhibits viral replication and tumor growth

    Fatigue, anorexia, nausea, vomiting

    Interferon beta-1a

    Multiple sclerosis

    Reduces the frequency of clinical exacerbations and slows the progression of disability in multiple sclerosis

    Injection site reactions, flu-like symptoms, liver dysfunction

    Interferon beta-1b

    Multiple sclerosis

    Similar to Interferon beta-1a; modulates the immune system to reduce inflammation

    Fatigue, depression, flu-like symptoms, liver impairment

    Interferon gamma-1b

    Chronic granulomatous disease, severe osteopetrosis

    Enhances the respiratory burst of macrophages, stimulating greater antimicrobial activity

    Fever, rash, diarrhea, myalgia

    Peginterferon alfa-2a

    Chronic hepatitis C and B

    Increases immune response against hepatitis viruses

    Neutropenia, thrombocytopenia, liver enzyme abnormalities, flu-like symptoms

    Peginterferon alfa-2b

    Chronic hepatitis C

    Longer-lasting effects due to its pegylated form, allowing less frequent dosing

    Similar to Peginterferon alfa-2a, including hematologic toxicity and depression

    Therapeutic Action:

    • Interferons prevent viral particles from replicating inside host cells.
    • They stimulate cells to produce antiviral proteins and enhance the cytotoxicity of T-cells and natural killer cells.
    • They inhibit tumor growth by enhancing the host’s immune response.

    Pharmacokinetics:

    • Interferons are well absorbed via subcutaneous or intramuscular injection, reaching peak plasma levels within 3-8 hours.
    • They are metabolized in the liver and kidneys and excreted primarily through the kidneys.

    Contraindications:

    • Allergies to interferons or their components.
    • Pregnancy and lactation (due to teratogenic effects).
    • Cardiac diseases, particularly arrhythmias and hypertension.
    • Myelosuppression.
    2. Interleukins

    Interleukins are cytokines that play an essential role in the immune response by promoting the proliferation of lymphocytes and other immune cells.

    • Cytokines: The general term for any small protein that helps cells communicate with each other. 

    Imagine your immune system as a big army. Interleukins are like the signals that tell different parts of the army what to do.

    • Activate immune cells: Tell certain cells to start fighting off invaders.
    • Control inflammation: Help regulate how much inflammation happens in response to an infection or injury.
    • Promote cell growth: Help immune cells multiply and become stronger.

    Drug

    Indications

    Therapeutic Action

    Adverse Effects

    Aldesleukin

    Metastatic renal cell carcinoma, metastatic melanoma

    Stimulates the proliferation of T-cells and natural killer cells, enhances the immune response against cancer

    Capillary leak syndrome, hypotension, anemia

    Oprelvekin

    Prevention of severe thrombocytopenia in chemotherapy

    Increases platelet production by stimulating megakaryocyte production

    Fluid retention, edema, dyspnea, arrhythmias

    Therapeutic Action:

    • Interleukins boost immune cell activity, enhancing the body’s ability to fight tumors and increase platelet production.

    Pharmacokinetics:

    • Interleukins are absorbed via subcutaneous injection, with peak levels occurring within hours.
    • They are metabolized in the kidneys and excreted in urine.

    Contraindications:

    • Allergies to interleukins or E. coli-produced products.
    • Pregnancy and lactation due to potential teratogenic effects.
    • Patients with renal, liver, or cardiovascular impairments.
    immunological agents interfero interlukin drug doses
    Immunosuppressants

    Immunosuppressants

    Immunosuppressants are used primarily to prevent transplant rejection and treat autoimmune diseases by inhibiting the immune system.

    These are like the “peacekeepers” of the immune system. They dampen down the immune response, preventing it from overreacting. 

    Used to treat autoimmune diseases where the immune system attacks the body’s own tissues. Cyclosporine is the most commonly used immunosuppressant.

    1. T- and B-Cell Suppressors

    T- and B-cell suppressors inhibit the activity of these lymphocytes, reducing the immune system’s ability to mount an attack against transplanted organs or self-tissues in autoimmune diseases.

    Drug

    Indications

    Therapeutic Action

    Adverse Effects

    Abatacept

    Rheumatoid arthritis, juvenile idiopathic arthritis

    Inhibits T-cell activation by binding to CD80 and CD86 on antigen-presenting cells

    Headache, infections, hypertension, nausea

    Alefacept

    Plaque psoriasis

    Inhibits T-cell activation and reduces T-cell numbers

    Lymphopenia, hepatotoxicity, infections

    Azathioprine

    Prevention of kidney transplant rejection, rheumatoid arthritis

    Inhibits purine synthesis, reducing T and B-cell proliferation

    Bone marrow suppression, hepatotoxicity, nausea

    Therapeutic Action:

    • These drugs inhibit the proliferation and activity of T-cells and B-cells, essential for preventing transplant rejection and treating autoimmune conditions.

    Pharmacokinetics:

    • T- and B-cell suppressors are generally well absorbed when administered orally or intravenously.
    • They are metabolized in the liver and excreted primarily via the kidneys.

    Contraindications:

    • Allergies to the drugs or their components.
    • Pregnancy and lactation (due to potential teratogenic effects).
    • Renal or hepatic impairment.
    • Active infections or known neoplasms.
    2. Interleukin-Receptor Antagonist

    This class of drugs blocks interleukin activity, which is critical in the inflammatory and immune response.

    Drug

    Indications

    Therapeutic Action

    Adverse Effects

    Anakinra

    Rheumatoid arthritis

    Blocks the interleukin-1 receptor, reducing inflammation and halting joint damage

    Headache, sinusitis, nausea, infections, injection-site reactions

    Therapeutic Action:

    • Interleukin-receptor antagonists prevent the binding of interleukins to their receptors, reducing inflammation and tissue damage.

    Pharmacokinetics:

    • Anakinra is administered subcutaneously and reaches peak plasma levels within hours.
    • It is metabolized by the liver and excreted primarily in urine.

    Contraindications:

    • Allergies to E. coli–produced products or anakinra itself.
    • Pregnancy and lactation due to the potential transfer of the drug to the fetus or infant.
    • Renal impairment, immunosuppression, or active infections.
    3. Monoclonal Antibodies

    Monoclonal antibodies are laboratory-produced molecules that can mimic the immune system’s ability to fight off harmful pathogens such as viruses.

    These are like highly specific “guided missiles” of the immune system. 

    They’re designed to target and attack specific cells or molecules. They can be used to treat cancer, autoimmune diseases, and even infections. Think of them as a sniper team that only targets the enemy, leaving the rest of the army alone.

    Drug

    Indications

    Therapeutic Action

    Adverse Effects

    Adalimumab

    Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis

    Binds to tumor necrosis factor (TNF) alpha, inhibiting its inflammatory effects

    Infections, malignancies, injection site reactions

    Alemtuzumab

    Chronic lymphocytic leukemia

    Targets CD52 on lymphocytes, leading to cell lysis

    Infusion reactions, infections, cytopenias

    Basiliximab

    Prevention of kidney transplant rejection

    Blocks interleukin-2 receptor on T-cells, preventing their activation

    GI disturbances, infections, hypersensitivity

    Monoclonal antibodies include adalimumab (Humira), alemtuzumab (Campath), basiliximab (Simulect), bevacizumab (Avastin), cetuximab (Erbitux), certolizumab (Cimzia), daclizumab (Zenapax)

    Indications
    • Prevention of renal transplant rejection
    • Treatment of B-cell chronic lymphocytic leukemia
    • Reduction of the signs and symptoms of Crohn disease
    • Treatment of paroxysmal nocturnal hemoglobinuria, to reduce haemolysis.
    • Treatment of B-cell non-Hodgkin lymphoma in conjunction with rituximab.
    • Treatment of asthma with a very strong allergic component and seasonal allergic rhinitis not occasionally controlled by common medicine.
    • Prevention of serious RSV(Respiratory syncytial virus) infection in high-risk children.
    • Treatment of metastatic breast cancer.
    • Treatment of  psoriasis

    Therapeutic Action:

    • Monoclonal antibodies specifically target and neutralize pathogens or inflammatory molecules, providing targeted immune suppression.

    Pharmacokinetics:

    • These drugs are administered via intravenous injection and have variable half-lives depending on the specific antibody.
    • They are metabolized and excreted through the reticuloendothelial system.
    Contraindications
    • Monoclonal antibodies are contraindicated in the presence of any known allergy to the drug or to murine products and in the presence of fluid overload.
    • They should be used cautiously with fever (treat the fever before beginning therapy)
    • They should not be used during pregnancy or lactation unless the benefit clearly outweighs the potential risk to the fetus or neonate. 
    Adverse Effects
    • The most serious adverse effects associated with the use of
      monoclonal antibodies are acute pulmonary edema (dyspnea, chest pain, wheezing), which is associated with severe fluid retention.
    • Fever
    • Chills
    • Malaise
    • Myalgia
    • Nausea
    • Diarrhea
    • Vomiting
    • Increased susceptibility to infection
    • Intravascular hemolysis with resultant fatigue, pain, dark urine, shortness of breath, and blood clots.

    Immunological Agents Read More »

    thyrotoxicosis

    Thyrotoxicosis

    THYROTOXICOSIS.

    Thyrotoxicosis is the condition that occurs due to excessive thyroid hormone of any cause and therefore includes hyperthyroidism.

    Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormone by the thyroid gland.  Some, however, use the terms interchangeably

     

    Overactive thyroid, is called hyperthyreosis/Hyperthyroidism

    thyrotoxicosis-anatomy of the thyroid gland

    Anatomy of the Thyroid gland.

    The thyroid gland is located in the lower portion of the neck in front of the larynx and the trachea at the level of 5th, 6th & 7th cervical and the 1st thoracic vertebrae.

     

    It is a highly vascular gland that weighs about 25 g and resembles a butterfly shape.
    It has two lobes, one on either side.
    The lobes are joined by isthmus in front of the trachea
    Its major function is to produce thyroid hormone (T3 and T4 and calcium).
    These hormones are responsible for growth and regulating metabolic rate

    Common Terms 

    a. Hyperthyroidism: Hyperthyroidism is a medical condition characterized by excessive production of thyroid hormones by the thyroid gland. This overactivity of the thyroid gland leads to an increased metabolic rate in the body, resulting in symptoms such as weight loss, rapid heartbeat, irritability, heat intolerance, and tremors. 

    b. Thyrotoxicosis: Thyrotoxicosis is a condition in which there is an excess of thyroid hormones circulating in the bloodstream. It can be caused by various factors, including hyperthyroidism (excessive thyroid hormone production), inflammation of the thyroid gland, or external sources of thyroid hormone intake. The symptoms of thyrotoxicosis are similar to those of hyperthyroidism. 

    c. Graves’ disease: Graves’ disease is an autoimmune disorder that is the most common cause of hyperthyroidism. It occurs when the immune system mistakenly attacks the thyroid gland, causing it to produce excessive amounts of thyroid hormones. People with Graves’ disease often experience symptoms such as goiter (enlarged thyroid gland), bulging eyes (exophthalmos), weight loss, tremors, and heat intolerance. 

    d. Hypothyroidism: Hypothyroidism is a condition characterized by an underactive thyroid gland, leading to insufficient production of thyroid hormones. This deficiency of thyroid hormones slows down the body’s metabolism, resulting in symptoms such as fatigue, weight gain, cold intolerance, constipation, and depression. 

    e. Cretinism: Cretinism is a condition that occurs when a baby is born with severe hypothyroidism or when the condition is left untreated during early childhood. It leads to stunted growth, intellectual disability, and developmental delays. Cretinism can be caused by iodine deficiency, thyroid gland abnormalities, or genetic factors. 

    f. Myxedema: Myxedema refers to the severe form of hypothyroidism that develops in adults. It is characterized by the accumulation of mucopolysaccharides (a complex sugar) in the connective tissues, leading to swelling and thickening of the skin. Symptoms of myxedema include extreme fatigue, cold intolerance, weight gain, dry skin, hair loss, and mental sluggishness. 

    g. Goiter is a medical condition characterized by the enlargement of the thyroid gland, which is located in the front of the neck. It usually appears as a visible swelling or lump in the throat area. Goiter can develop due to various reasons, including iodine deficiency, inflammation of the thyroid gland, or certain thyroid disorders such as Graves’ disease or Hashimoto’s thyroiditis. 

    h. Hashimoto’s thyroiditis is an autoimmune disorder that affects the thyroid gland which can result in an underactive thyroid or hypothyroidism. In this condition, the immune system mistakenly attacks the thyroid gland, leading to chronic inflammation and damage to the gland. 

    i. Thyroid storm:  Thyroid storm, also known as thyrotoxic crisis, is a life-threatening condition characterized by an extreme and sudden exacerbation of the symptoms of hyperthyroidism. It usually occurs in individuals with untreated or poorly controlled hyperthyroidism, often as a result of Graves’ disease. Symptoms include high fever, severe agitation, delirium, rapid heartbeat, high blood pressure, vomiting, diarrhea, and jaundice.  Thyroid storm requires immediate medical attention and hospitalization. Treatment includes medications to block the production and release of thyroid hormones, as well as supportive care to manage symptoms and stabilize vital signs.

    Why we need the Thyroid Gland & Hormones

    1. Regulation of Metabolism: The thyroid gland plays a central role in regulating metabolism, influencing the rate at which cells convert nutrients into energy. It does so by producing and releasing thyroid hormones (triiodothyronine or T3 and thyroxine or T4), which control the body’s metabolic processes. 

    2. Body Temperature Control: Thyroid hormones help regulate body temperature by influencing heat production and heat loss mechanisms. They help maintain the body’s core temperature within a normal range. 

    3. Growth and Development: Thyroid hormones are important for proper growth and development in children. They are essential for the normal development of the skeletal system, brain, and other organs. Insufficient thyroid hormone production can lead to growth and developmental delays. 

    4. Brain Function: Thyroid hormones are necessary for the normal functioning of the brain. They play a role in cognitive function, mood regulation, memory, and overall mental well-being. 

    5. Energy Levels: Thyroid hormones contribute to energy production in the body. They help convert food into usable energy, ensuring adequate energy levels for daily activities. 

    6. Heart Function: Thyroid hormones have an impact on heart rate, heart rhythm, and cardiac output. They help regulate the overall function of the cardiovascular system. 

    7. Muscle Function: Thyroid hormones are involved in maintaining muscle tone and strength. They contribute to muscle contraction and overall muscle function. 

    8. Digestion: Proper thyroid function is necessary for healthy digestion. Thyroid hormones influence the movement of food through the digestive tract and the secretion of digestive enzymes.

    9. Reproductive Health: Thyroid hormones play a role in reproductive health, including menstrual cycle regulation in women. Thyroid disorders can affect fertility, pregnancy outcomes, and the health of the developing fetus. 

    10. Maintenance of Healthy Skin, Hair, and Nails: Optimal thyroid function is important for maintaining healthy skin, hair, and nails. Thyroid hormones contribute to the growth, maintenance, and integrity of these structures.

    causes of thyrotoxicosis

    Causes of Hyperthyroidism and/or Thyrotoxicosis

    1. Graves’ Disease: An autoimmune disease, Graves’ disease is the most common etiology worldwide, with a prevalence of 50-80%. It is often linked to varying iodine levels in the diet. Graves’ disease is more prevalent in females, occurring eight times more frequently in women than in men, and is commonly diagnosed in young females aged 20-40 years.
    2. Toxic Thyroid Adenoma: Common in Switzerland (53%), this etiology is believed to be atypical due to a low level of dietary iodine in the country. It involves the development of a toxic adenoma in the thyroid.
    3. Toxic Multinodular Goiter: This condition is characterized by the presence of multiple nodules in the thyroid gland, contributing to excessive thyroid hormone production.
    4. Thyroiditis: Inflammation of the thyroid, such as Hashimoto’s thyroiditis (immune-mediated hypothyroidism) and subacute thyroiditis (de Quervain’s), can initially lead to excess thyroid hormone secretion and progress to gland dysfunction, resulting in hypothyroidism.
    5. Medication and Exogenous Thyroid Hormone: Consumption of excess thyroid hormone tablets or ingestion of ground beef contaminated with thyroid tissue can cause hyperthyroidism. Amiodarone, an antiarrhythmic drug, may lead to under- or overactivity of the thyroid.
    6. Postpartum Thyroiditis (PPT): Affecting about 7% of women after childbirth, PPT undergoes several phases, with the initial phase being hyperthyroidism. This usually corrects itself without treatment.
    7. Struma Ovarii: A rare form of monodermal teratoma containing mostly thyroid tissue, leading to hyperthyroidism.
    8. Excess Iodine Consumption: Particularly from algae like kelp, can contribute to hyperthyroidism.
    9. Excessive Thyroid Hormone Supplements: Taking too much thyroid hormone in the form of supplements, such as levothyroxine, can lead to thyrotoxicosis.
    10. Pituitary Adenoma: Hypersecretion of thyroid-stimulating hormone (TSH) due to a pituitary adenoma accounts for less than 1 percent of hyperthyroidism cases.

     

    General Causes of The above conditions(In Common Terms)

    1. Autoimmune Disorders: Autoimmune disorders, such as Hashimoto’s thyroiditis and Graves’ disease, are among the most common causes of thyroid problems. In Hashimoto’s thyroiditis, the immune system attacks and damages the thyroid gland, leading to hypothyroidism. In Graves’ disease, the immune system stimulates the thyroid gland, causing excessive production of thyroid hormones and resulting in hyperthyroidism.
    2. Iodine Deficiency or Excess: Adequate iodine intake is crucial for proper thyroid function, as iodine is a key component in the synthesis of thyroid hormones. An inadequate intake of iodine can lead to hypothyroidism and goiter. Conversely, excessive iodine intake can disrupt thyroid function and potentially cause hyperthyroidism. Governments provide iodized table salts as a way to avoid less iodine intake.
    3. Thyroid Nodules: Thyroid nodules are abnormal growths or lumps that form within the thyroid gland. They can be benign (noncancerous) or malignant (cancerous). Thyroid nodules may cause problems by affecting hormone production or through physical compression of surrounding structures, leading to symptoms or requiring medical intervention.
    4. Medications and Medical Treatments: Certain medications and medical treatments can interfere with thyroid function. For example, certain drugs, such as lithium, can contribute to hypothyroidism or hyperthyroidism. Radiation therapy to the head and neck region, often used in the treatment of certain cancers, can also affect thyroid function.
    5. Congenital Thyroid Disorders: Some individuals may be born with congenital thyroid disorders, such as congenital hypothyroidism. This condition occurs when the thyroid gland does not develop properly or is absent at birth, resulting in inadequate thyroid hormone production. Early detection and treatment are critical to prevent developmental and growth problems.
    6. Genetic Factors: Genetic factors can contribute to an increased risk of developing thyroid problems. Certain gene mutations or a family history of thyroid disorders may predispose individuals to conditions like thyroid cancer or autoimmune thyroid diseases.
    7. Inflammation and Infection: Inflammation of the thyroid gland, known as thyroiditis, can disrupt thyroid function. Viral or bacterial infections can also affect the thyroid gland and potentially lead to thyroid problems.
    Signs and symptoms of thyrotoxicosis

    Signs and symptoms of Thyrotoxicosis

    Thyroid hormone plays a crucial role in normal cellular function. When in excess, it not only over-stimulates metabolism but also increases the effects of the sympathetic nervous system, leading to a “speeding up” of various body systems. This results in symptoms resembling an overdose of epinephrine (adrenaline). Hyperthyroidism may manifest with various symptoms, and while some individuals may be asymptomatic, others may experience significant clinical signs.

    Symptoms

    1. Nervousness: Elevated thyroid hormones stimulate the nervous system, leading to increased sensitivity and heightened feelings of nervousness.
    2. Irritability: The overstimulation of the sympathetic nervous system can result in irritability.
    3. Increased perspiration: Hyperactive metabolism causes an increase in sweat production as the body tries to cool down.
    4. Heart racing: Excess thyroid hormones accelerate heart rate and may cause palpitations.
    5. Hand tremors: Stimulated nervous system and increased metabolic activity contribute to hand tremors.
    6. Anxiety: Elevated thyroid hormone levels can induce a constant state of anxiety.
    7. Difficulty sleeping: Hyperthyroidism disrupts normal sleep patterns, leading to insomnia.
    8. Thinning of the skin: Increased metabolism may affect skin thickness and texture.
    9. Fine brittle hair: Changes in hormone levels can impact hair growth and texture.
    10. Muscular weakness: Thyroid hormones influence muscle function, leading to weakness, especially in the upper arms and thighs.
    11. More frequent bowel movements: Accelerated metabolism speeds up digestive processes, causing more frequent bowel movements and diarrhea.
    12. Weight loss: Increased metabolism burns calories rapidly, resulting in weight loss despite a heightened appetite.
    13. Vomiting: Gastrointestinal disturbances, including increased stomach activity, can lead to vomiting.
    14. Changes in menstrual flow: Altered hormone levels affect the menstrual cycle, leading to lighter periods or longer cycles in women.

    Major Clinical Signs:

    1. Weight loss: Accelerated metabolism and increased calorie consumption contribute to weight loss.
    2. Anxiety: Overstimulation of the nervous system manifests as heightened anxiety.
    3. Heat intolerance: Elevated metabolism generates more internal heat, causing intolerance to warm environments.
    4. Hair loss: Changes in hormone levels impact hair follicles, resulting in hair loss, particularly in the outer third of the eyebrows.
    5. Muscle aches: Thyroid hormones influence muscle function, leading to aches and weakness.
    6. Weakness: Muscular weakness is a common symptom of hyperthyroidism.
    7. Fatigue: Despite increased activity, individuals may experience fatigue due to the strain on the body.
    8. Hyperactivity: Elevated metabolism and increased energy levels contribute to hyperactivity.
    9. Irritability: Overstimulation of the nervous system can lead to irritability.
    10. High blood sugar: Thyroid hormones can impact glucose metabolism, leading to elevated blood sugar levels.
    11. Excessive urination: Altered kidney function due to hormone imbalances can result in increased urination.
    12. Excessive thirst: Increased fluid loss through urine may lead to excessive thirst.
    13. Delirium: Severe cases of hyperthyroidism can cause mental confusion and delirium.
    14. Tremor: Increased nervous system activity may manifest as tremors in various parts of the body.
    15. Pretibial myxedema: Specific to Graves’ disease, it involves skin changes, swelling, and redness on the shins.
    16. Emotional lability: Mood swings and emotional instability can occur due to hormonal fluctuations.
    17. Sweating: Excessive sweating is a common symptom of hyperthyroidism.
    18. Panic attacks: The combination of heightened nervous system activity and anxiety can lead to panic attacks.
    19. Inability to concentrate and memory problems: Cognitive functions may be affected, leading to difficulties in concentration and memory.

    Physical Symptoms:

    1. Palpitations: Increased heart rate and irregular heart rhythms may cause palpitations.
    2. Abnormal heart rhythms: Hyperthyroidism can disrupt normal heart rhythms, notably causing atrial fibrillation.
    3. Shortness of breath: Respiratory and cardiovascular effects may result in shortness of breath (dyspnea).
    4. Loss of libido: Hormonal imbalances can impact sexual desire and lead to a loss of libido.
    5. Gynecomastia and feminization: Altered hormone levels may cause breast enlargement (gynecomastia) and feminine characteristics in males.

    Note:

    • An association between thyroid disease and myasthenia gravis has been recognized, with approximately 5% of patients with myasthenia gravis also having hyperthyroidism.
    • In Graves’ disease, ophthalmopathy may cause enlarged eyes due to swelling eye muscles pushing the eyes forward, often with one or both eyes bulging.
    • Swelling of the front of the neck (goiter) may also occur.

    Minor Ocular Signs:

    • Eyelid retraction (“stare”): Overactive thyroid hormones can affect the muscles that control eyelid movement, leading to a wide-eyed or “staring” appearance.
    • Extraocular muscle weakness: Weakness in the muscles that control eye movement may result in difficulties in moving the eyes.
    • Lid-lag (von Graefe’s sign): A characteristic eye movement sign where the upper eyelid lags behind the downward movement of the eye.
    • Double vision: Weakened eye muscles may cause double vision.

    signs of Proptosis

    Exophthalmos/Proptosis in Graves’ Disease:

    • Exophthalmos or proptosis, the protrusion of the eyeball, is unique to hyperthyroidism caused by Graves’ disease. It results from immune-mediated inflammation in the retro-orbital fat, leading to forward protrusion of the eyes. Exophthalmos, when present with hyperthyroidism, is diagnostic of Graves’ disease.

    Diagnosis and Investigation

    • Physical examination: enlarged, bumpy or tender gland through the neck, Eyes for swelling, redness or bulging, Heart for for a rapid heartbeat and irregular heartbeats, Hands for tremors, Skin if its moist and warm.

    Blood Tests:

    • The Thyroid Stimulating Hormone (TSH) Test measures TSH levels, a hormone from the pituitary gland that stimulates the thyroid. Abnormal levels may indicate hyperthyroidism or hypothyroidism.
    • Thyroid Hormone (T3 and T4) Tests evaluate T3 and T4 hormone levels. Elevated levels may suggest hyperthyroidism, while decreased levels may indicate hypothyroidism.
    • Thyroid Antibody Tests check for antibodies linked to autoimmune thyroid disorders like Hashimoto’s thyroiditis or Graves’ disease.
    • Thyroid Function Panel combines TSH, T3, and T4 tests for a comprehensive thyroid function assessment.

    Imaging Studies:

    • Ultrasound uses sound waves to create thyroid gland images, aiding in identifying nodules, goiter, or structural abnormalities.
    • Thyroid Scan utilizes radioactive tracers to assess overall thyroid structure and function.
    • Radioactive uptake study i.e. For this test,  a small, safe dose of radioactive iodine (also called a radiotracer) is taken by mouth to see how much of it your thyroid gland absorbs. After 6 to 24 hours later, the neck is scanned  with a device called a gamma probe to see how much of the radioactive iodine your thyroid has absorbed. If your it absorbs a lot, it means that your thyroid gland is producing too much thyroxine (T4)

    Fine-Needle Aspiration (FNA) Biopsy:

    • In cases of suspicious thyroid nodules or potential cancer, FNA Biopsy extracts a sample for laboratory analysis.

    Thyroid Imaging:

    • Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) assess the thyroid and adjacent structures when further evaluation is needed.

    ADDITIONAL DIAGNOSTIC MEASURES

    1. TSH Measurement: Initial test for suspected hyperthyroidism, assessing TSH levels produced by the pituitary gland, regulated by the hypothalamus.
    2. Antibody Tests: Checking specific antibodies like anti-TSH-receptor antibodies in Graves’ disease aids in diagnosis, as they indicate autoimmune thyroid disorders.
    3. Confirmation Blood Tests: Confirms hyperthyroidism with blood tests showing low TSH and elevated T4 and T3 levels. Low TSH indicates excess thyroid hormone.
    4. Radioactive Iodine Uptake Test: Measures iodine absorption by the thyroid. Hyperthyroid individuals absorb more iodine, including radioactive iodine used for measurement.
    5. Thyroid Scan: Conducted with the uptake test, it visually examines the over-functioning gland, producing images for characterization.
    6. Thyroid Scintigraphy: Useful in distinguishing causes of hyperthyroidism and thyroiditis. Combines an iodine uptake test and a scan with a gamma camera for comprehensive evaluation.

    Medical Management of Hyperthyroidism: 

     Antithyroid Medications: 

    • – Propylthiouracil (PTU): Adult dose is usually 100-150 mg three times a day. Side effects may include liver toxicity, rash, joint pain, and agranulocytosis (a rare but serious condition characterized by a low white blood cell count). 
    • – Methimazole (Tapazole): Adult dose is 10-30 mg once daily or divided into two doses. Side effects may include rash, itching, nausea, and agranulocytosis. 

    Beta-Blockers: 

    • – Used to alleviate symptoms associated with hyperthyroidism such as rapid heart rate, tremors, and anxiety. Commonly prescribed beta-blockers include propranolol and atenolol. Adult doses may vary, and side effects can include fatigue, dizziness, and low blood pressure. 

    Radioactive Iodine (RAI) Therapy:

    •  Administered orally to destroy or reduce the activity of the overactive thyroid gland. Side effects may include temporary worsening of hyperthyroid symptoms, neck tenderness, and radiation sickness. 

    Management of Thyrotoxicosis

    Aims

    • To reduce the activity of the thyroid gland
    • To reduce heart rate (hypertension)
    • To remove part of thyroid gland

    Pre-operatively

    1. Admission: The patient is admitted 32 days before surgery in surgical ward.
    2. Position: The patient is made to lie in a comfortable position according to her
      choice.
    3. History taking: Patient’s history is taken to details about the patient’s life which includes:
      –  Demographic data
      –  Past history
      –  Medical history for diseases like diabetes, liver cirrhosis e.t.c
      –  Past family history eg hypertension
      –  Actual history to rule out the real cause of the disease
    4. Observation
      –  Vital observation eg TPR/BP to rule out vital abnormalities
      –  General observation i.e head to toe rule out abnormalities (JACCOLD)
      –  Specific observations eg palpation of the enlarged gland to any abnormality
    5. Inform the doctor about patient
    6. On waiting for the doctor the following are done: – orientation of the
      patient, On arrival of the doctor, he will then order for investigations.
      Investigation
      –  Chest x-ray
      –  Thyroid function test. (TFT).
      –  Biopsy of thyroid gland for cytology and histology.
      –  Indirect laryngoscopy
    7. Medical Management: The doctor will then prescribe preoperative medications depending on the results from lab mainly;
    8.  Carbimazole 10-15 mg O.D X 12/52 then reduce to 5 mg 8hrly last
      dose given prior to surgery.
    9.  Lugols iodine 0.3-0.9ml tds in milk 10 times prior to surgery until
      the day of surgery.
    10.  Propranolol 40 – 80 mg 12 hourly incase of increased BP.
    11.  Diazepam 5mg b.d to seduce the patient
    12.  Digoxin 0.25mg o.d if atrial fibrillation is detected
    13.  Nursing care
    14. Explain the procedure, the benefits and outcomes of the operation
      and consent form obtained.
    15. Re-assurance
    16. Give the informed consent form to be signed
    17. Clean the patient and dress the patient in theater gown
    18. Obtain blood sample for Hb estimations & grouping
    19. Inspect and clean operation site if instructed.
    20. Theater is informed about the patient and the patient is then taken to the theater for operation.
    21. In the theater, partial thyroidectomy is done and the patient transferred to the recovery room.
    22. Ward staff are called to go for their patient.
    MANAGEMENT: POST-THYROIDECTOMY (Incase of Surgery)
    1. On receiving information from the theater nurse, two nurses go to receive the patient.
    2. Patients vital observations are taken especially respiratory rate and pulse to confirm whether the patient is alive or dead.
    3. The patient is then transferred back to the ward and laid on a post operative bed after receiving theater instructions about the patient.
    4. Position in recovery position
    5. Observations taken 1/4 hourly, 1/2 hourly, 1 hourly until fully recovered.
    6. Post operative medications. As Doctor will prescribe the following
      > Analgesics like – pethidine 50mg-100mg IM in 3 doses, then continues with
      – IV tramadol 100mg tds X 1/7
      – Sedatives like Diazepam 10-15mg
    7. Specific nursing care: which include the following;
    8. Care of the tube: The drainage tube is removed not later than 48hrs after the operation  according to discharges
    9.  Care of the  wound: Dressing are changed whenever soiled
    10. Stitches removed on the 3rd-4th day, only as instructed by the doctor. Ensuring constant drainage in a drainage bottle or dressing.
    11. Intubation if respiratory edema occurs.
    12. Close observation for hemorrhage.
    13. Creating a calm environment, possibly giving drugs to encourage sleep.
    14. Care of drain and sutures; changing drainage 24 hourly, sutures removed on the third or fourth day.
    15. Minimizing neck movement to reduce pain.
    16. Administering analgesics to reduce pain.
    17. Monitoring vitals every 2 hours to detect complications like thyroid storm or infections.
    18. Giving antibiotics; ceftriaxone 2g 24 hourly.
    19. Diet: High calories diet is ordered to satisfy hunger & to prevent tissue breakdown. Milk is encouraged to be taken then high carbohydrate diet, snacks
      high in proteins, minerals and vitamins A, B6, and C are recommended.
    20.  Daily Nursing care.  Oral care skin care.  Bowel & bladder care
    21. Physiotherapy. Patient is encouraged to do some exercise of the throat and then do some deep breathing and coughing exercise.
    22. Psycho therapy
    23. Fluid monitoring. Fluid intake and output is monitored, maintained and recorded on patient fluid balance charts.
    NURSING INTERVENTIONS 

    1. Assess Thyroid Function: Monitor the patient’s thyroid hormone levels and symptoms to evaluate the effectiveness of treatment and detect any changes in thyroid function. 

    2. Medication Administration: Administer prescribed medications, such as thyroid hormone replacement or antithyroid medications, ensuring accurate dosage, timing, and appropriate route of administration. 

    3. Educate Patients: Provide comprehensive education to patients and their families about their specific thyroid problem, including the condition, treatment plan, medication regimen, and potential side effects. 

    4. Monitor Vital Signs: Regularly monitor the patient’s vital signs, including heart rate, blood pressure, and temperature, to assess the impact of thyroid dysfunction and medication therapy. 

    5. Support Emotional Well-being: Offer emotional support and create a therapeutic environment to help patients cope with the emotional and psychological aspects of living with a thyroid problem. 

    6. Promote Comfort: Implement comfort measures to alleviate symptoms such as pain, fatigue, and muscle weakness. Encourage rest and provide pain management techniques as appropriate. 

    7. Nutritional Support: Collaborate with dietitians to develop appropriate dietary plans that support optimal thyroid function and address any specific nutritional needs or restrictions.

    8. Monitor Weight and Fluid Balance: Regularly assess and monitor the patient’s weight and fluid balance to identify any changes or imbalances that may indicate thyroid dysfunction. 

    9. Assist with Thyroid Imaging: Coordinate and assist with thyroid imaging procedures, such as ultrasound or radioactive iodine uptake scans, ensuring patient comfort and safety. 

    10. Collaborate with Healthcare Team: Work collaboratively with physicians, endocrinologists, and other healthcare professionals to ensure coordinated care and effective communication regarding the patient’s thyroid problem and treatment plan. 

    11. Monitor for Side Effects: Monitor patients for any potential side effects or adverse reactions to medications, particularly those related to thyroid hormone replacement or antithyroid medications. 

    12. Educate on Self-Care: Teach patients self-care strategies to manage their condition effectively, including proper medication management, self-monitoring of symptoms, and recognizing signs of worsening thyroid dysfunction. 

    13. Provide Thyroidectomy Care: If the patient undergoes thyroidectomy (surgical removal of the thyroid gland), provide post-operative care, including wound care, pain management, and monitoring for complications. 

    14. Manage Thyroid Storm: In cases of thyroid storm (life-threatening condition with severe hyperthyroidism symptoms), closely monitor vital signs, administer medications as ordered (such as antithyroid medications and beta-blockers), and provide supportive care. 

    16. Advice on Discharge: Collaborate with the healthcare team to plan for the patient’s discharge, ensuring proper medication instructions, follow-up appointments, and education on long-term management and self-care. 

    Complications of Thyroidectomy:

    • Hemorrhage due to hyper-vascularization of the thyroid gland.
    • Thyroid crisis (thyroid storm) characterized by rapid pulse, raised temperature, sweating, and confusion.
    • Tetany due to removal or trauma to parathyroid glands; characterized by tingling and numbness of the face, lips, and hands.
    • Sore throat.
    • Hoarseness due to damage to the recurrent laryngeal nerve.
    • Hypothyroidism due to thyroid removal.
    • Recurrent thyrotoxicosis.
    • Respiratory obstruction due to laryngeal edema.
    • Wound infection.

    Advice on discharge. Advise the patient,

    •  To complete prescribed medications
    •  To do exercise to avoid complication of the neck
    • On personal hygiene to prevent secondary infections.
    • To eat a well balanced diet.
    • To buy a cream like lanolin and rub it on the healed wound.
    • To not take drugs when not prescribed by the physician
    • To avoid high temperatures.
    • To come back for review as indicated.
    • Follow-up Care: Regular monitoring of thyroid function through blood tests. Adjustments in medication dosage as needed.
    • Patient Education: Guidance on dietary restrictions and adherence to medication. Awareness of symptoms requiring prompt medical attention.
    • Long-Term Management: Maintenance therapy based on the chosen treatment modality. Continuous monitoring for potential complications.

    Thyroid Storm Management:

    1. Prompt Recognition: Immediate identification of extreme hyperthyroid symptoms.
    2. Resuscitation Measures: Intravenous beta-blockers like propranolol for rapid symptom control. Thioamide, such as methimazole, to inhibit thyroid hormone production.
    3. Additional Interventions: Administration of iodinated radiocontrast agent or iodine solution. Intravenous steroid, hydrocortisone, to address inflammation.
    4. Intensive Monitoring: Continuous assessment of vital signs and thyroid function. Adjustment of treatment based on response.

    Complications of Hyperthyroidism/Thyrotoxicosis:

    • Heart Problems: Elevated thyroid hormones can lead to increased heart rate (tachycardia) and irregular heart rhythms (arrhythmias), such as atrial fibrillation. Chronic strain on the heart may result in heart failure or other cardiovascular complications.
    • Osteoporosis: Hyperthyroidism can accelerate bone turnover, leading to decreased bone density and an increased risk of osteoporosis. Imbalances in calcium and vitamin D metabolism may further contribute to bone loss.
    • Thyroid Storm: In rare cases, untreated or severe hyperthyroidism can progress to a life-threatening condition known as thyroid storm. This involves a sudden and severe exacerbation of hyperthyroid symptoms, leading to high fever, extreme tachycardia, and organ failure.
    • Eye Complications (Graves’ Ophthalmopathy): Graves’ disease, a common cause of hyperthyroidism, is associated with eye complications. Immune-mediated inflammation in the eye tissues can lead to proptosis (bulging eyes), double vision, and in severe cases, vision impairment.
    • Skin and Hair Issues: Hyperthyroidism may affect skin and hair health. Thinning of the skin and fine, brittle hair are common symptoms. In some cases, individuals may experience skin changes such as redness or swelling.
    • Psychological Complications: Chronic anxiety, emotional lability, and irritability associated with hyperthyroidism can contribute to psychological complications. Severe cases may lead to mental health issues such as depression or exacerbate pre-existing conditions.
    • Menstrual Irregularities: Altered levels of thyroid hormones can impact the menstrual cycle in women. Menstrual flow may lighten, and periods may become irregular, with longer cycles than usual.
    • Muscle Weakness and Wasting: Hyperthyroidism can lead to muscle weakness, especially in the upper arms and thighs. In severe cases, prolonged muscle breakdown may result in muscle wasting.
    • Gastrointestinal Issues: Increased bowel movements and diarrhea are common symptoms of hyperthyroidism. Chronic gastrointestinal issues may lead to nutritional deficiencies and weight loss.
    • Impaired Concentration and Memory: Cognitive function may be affected, causing difficulties in concentration and memory. The combination of anxiety and hormonal imbalances can contribute to cognitive impairment.
    • Thyroid Crisis (Thyroid Storm): In extreme cases, uncontrolled hyperthyroidism can progress to a thyroid crisis or storm. This life-threatening condition involves a sudden surge in symptoms, including hyperthermia, cardiovascular collapse, and neurological dysfunction.
    • Pregnancy Complications: Hyperthyroidism during pregnancy can pose risks to both the mother and the developing fetus. Complications may include preterm birth, low birth weight, and maternal heart issues.
    • Liver and Kidney Dysfunction: Prolonged hyperthyroidism may impact liver and kidney function. Elevated thyroid hormones can affect organ metabolism and contribute to dysfunction over time.

    Thyrotoxicosis Read More »

    wound_dressing

    Wound Dressing

    WOUND DRESSING

    Wound dressing is a method of carrying out surgical dressing and operative treatment with an aim to prevent the entry of Microorganisms into the wound.

    Indications for wound dressing

    • To protect the wound from further injury or infection
    • To absorb exudates such as pus or serum.
    • To immobilize and support the injured part.
    • To apply pressure on the wound to control bleeding or approximate the wound
    • To provide psychological and physical comfort for the patient.

    Wound : A cut or break in the normal continuity of the skin or body structure internally or externally.

     
    Classification of Wounds

    Classification of Wounds

    Wounds can be classified based on manner of production, bacterial content, extent, and time. Below is a detailed breakdown of each classification:

    1. Classification by Manner of Production

    Abraded Wound (Abrasion)

    • Caused by friction that removes the superficial layer of the skin.
    • Commonly occurs due to falls on rough surfaces, such as sand, concrete, or gravel.

    Incised Wound

    • Resulting from a sharp cutting instrument that produces a clean and well-defined separation of tissue.
    • Example: Surgical incisions or cuts made by a sharp knife.

    Contused Wound

    • Caused by a blunt object, leading to significant injury to the soft tissue.
    • Characterized by bruising (hemorrhage) and swelling due to damaged blood vessels.
    • Example: Injuries from a blow, impact from a falling object, or trauma from a blunt force.

    Lacerated Wound

    • Involves tearing of tissue, resulting in irregular and ragged wound edges.
    • Commonly caused by injuries from glass, metal, machinery accidents, or animal bites.

    Penetrating Wound

    • A wound that pierces through deep tissues and may enter a body cavity or organ.
    • Example: Stab wounds caused by knives, long nails, or gunshot injuries.

    Punctured Wound

    • Made by a sharp, narrow, and pointed object.
    • Usually deep with a small entry point, increasing the risk of infection.
    • Example: Injuries caused by nails, splinters, or glass fragments.

    2. Classification by Bacterial Content

    Clean Wound

    • Contains no pathogenic organisms and is made under sterile conditions.
    • Example: Surgical wounds created with aseptic techniques.
    • While surgical wounds are clean, the skin cannot be completely sterilized, making some microbial presence inevitable. However, the body’s immune system prevents infection.

    Contaminated Wound

    • A wound that contains a significant number of microorganisms.
    • All accidental wounds fall into this category since they occur in an uncontrolled environment where aseptic precautions are absent.

    Septic (Infected) Wound

    • A wound infected by pathogenic microorganisms that lead to tissue destruction and pus formation.
    • Even a previously clean or contaminated wound can become septic if unsterile techniques are used during dressing or if the body’s immune response fails.

    3. Classification by Extent

    Open Wound

    • There is a break in the skin or mucous membrane, exposing the underlying tissue to external contaminants.
    • Open wounds pose a higher risk of infection due to potential entry of microorganisms and foreign objects.
    • Example: Incisions, abrasions, lacerations, and puncture wounds.

    Closed Wound

    • The skin remains intact, but underlying tissue is damaged.
    • Internal bleeding, swelling, or bruising (hematoma) may occur.
    • Example: Contusions (bruises) caused by blunt trauma.

    4. Classification by Time

    Acute Wound

    • A wound that heals within four weeks.
    • Includes surgical wounds, minor cuts, and abrasions that heal without complications.

    Chronic Wound

    • A wound that fails to heal within four weeks and remains in the inflammatory phase of healing.
    • Chronic wounds may be associated with conditions such as diabetes, poor circulation, or infection.
    • Example: Pressure ulcers, diabetic foot ulcers, and venous leg ulcers.
    wound dressing Phases-of-the-wound-healing-process

    WOUND HEALING

    Wound healing refers to the body’s natural process of replacing destroyed tissue with new, living tissue. 

    This complex biological process involves multiple phases and can be influenced by various internal and external factors.

    Factors Affecting Wound Healing

    Several factors determine the rate and effectiveness of wound healing:

    1. Age

    • Younger individuals tend to heal faster due to higher cellular activity and collagen production.
    • Elderly individuals may experience delayed healing due to reduced skin elasticity, lower immune response, and slower cell regeneration.

    2. Nutritional Status

    • Proper nutrition is essential for wound healing. Deficiencies in proteins, carbohydrates, lipids, vitamins (especially A, C, and E), and minerals (such as zinc and iron) can delay the process.
    • Proteins are crucial for cell growth and tissue repair.
    • Vitamin C is essential for collagen formation, while Vitamin A aids in immune function and epithelial cell formation.

    3. Type of Wound

    • Clean surgical wounds heal faster than contaminated or infected wounds.
    • Deep wounds with tissue loss take longer to heal than superficial wounds.

    4. Blood Supply to the Affected Area

    • Adequate blood circulation ensures oxygen and nutrient delivery to the wound, promoting faster healing.
    • Conditions like diabetes, peripheral artery disease, and smoking can impair circulation and slow healing.

    5. Presence of Foreign Bodies

    • Dirt, debris, sutures, or other foreign materials in the wound can delay healing and increase infection risk.

    6. Infection and Foreign Bodies in the Wound

    • Infections introduce bacteria into the wound, causing inflammation, pus formation, and delayed healing.
    • The presence of bacteria prevents new tissue from forming properly.

    7. Lack of Rest of the Affected Part

    • Continuous movement or strain on a wound can prevent proper tissue formation and delay healing.
    • Immobilization and rest allow new cells to regenerate effectively.

    8. Hemorrhage (Excessive Bleeding)

    • Uncontrolled bleeding can prevent clot formation, delaying the healing process.
    • Blood loss reduces oxygen supply to the wound, which is crucial for tissue repair.

    9. Presence of Dead Space in the Wound

    • Dead space refers to empty spaces between tissues where fluid can accumulate, increasing infection risk.
    • Proper wound closure techniques (suturing or packing) help eliminate dead spaces.

    10. Malnutrition

    • An inadequate supply of proteins, carbohydrates, lipids, vitamins, and trace elements can slow down all phases of wound healing.

    11. Medications

    Certain medications can impair the healing process, such as:

    • NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): May interfere with inflammation, which is crucial for wound healing.
    • Chemotherapy and Immunosuppressive Drugs: Reduce cell proliferation, slowing tissue repair.
    • Corticosteroids: Suppress the immune response and delay new tissue formation.

    12. Stress, Anxiety, and Depression

    • Emotional and psychological stress can negatively affect immune function and hormone balance, leading to slower wound healing.

    13. Underlying Diseases

    • Conditions such as diabetes, autoimmune disorders, anemia, and cancer can impair wound healing by reducing immune function, circulation, and tissue regeneration.

    14. Infection

    • A wound that becomes infected requires additional time to heal due to the presence of bacteria that compete with new tissue growth.
    • Infections can lead to chronic wounds if left untreated.

    Types of Wound Healing (Wound Closure)

    1. Healing by Primary Intention (First Intention)

    • The wound edges are brought together (approximated) using sutures, staples, or adhesive strips.
    • Occurs in clean, minimal tissue loss wounds such as surgical incisions.
    • Healing is quick with minimal scarring.

    2. Healing by Secondary Intention (Granulation Healing)

    • Happens when there is significant tissue damage or infection, preventing the wound edges from being approximated.
    • The wound heals from the bottom up, filling with granulation tissue (new connective tissue and blood vessels).
    • Requires daily wound dressing as the open wound is at risk of infection.
    • Healing time is longer, and scarring is more prominent.

    Phases of Wound Healing

    The wound healing process consists of four overlapping phases, commonly referred to as the “cascade of healing.”

    1. Hemostasis Phase (Bleeding Control Phase): The immediate response to physical injury, ensuring that bleeding is controlled.

    Includes:

    • Vasoconstriction (narrowing of blood vessels to reduce bleeding).
    • Platelet response (platelets form a clot at the injury site).
    • Biochemical response (release of clotting factors to stabilize the wound).

    2. Inflammatory Phase: Damaged cells release cytokines that attract white blood cells to fight infection.

    Key events:

    • Histamine, serotonin, and kinins cause temporary blood vessel constriction, followed by dilation to allow immune cells to reach the wound.
    • Neutrophils arrive within 24 hours to remove bacteria and dead tissue.

    3. Proliferative Phase: Begins once neutrophils have cleared cellular debris.

    Key processes:

    • Fibroblasts migrate to the wound and produce collagen (Type III initially) to provide structural support.
    • Angiogenesis (formation of new blood vessels) starts within 48 hours.
    • Wound strength increases significantly during this phase.

    This phase lasts up to 3 weeks.

    4. Maturation (Remodeling) Phase: Begins around week 3 and continues for 9 to 12 months.

    • Collagen Type III is replaced with Collagen Type I, increasing tensile strength up to 80% of normal skin.
    • The wound contracts, and scar tissue forms.

    Care of Wounds

    Dressing Methods

    1. Dressing Method – Covers the wound to promote healing.
    2. Non-Dressing Method – Leaves the wound open to air for healing.

    Advantages of Dressing

    • Absorbs wound drainage.
    • Protects from contamination (feces, urine, vomit, etc.).
    • Provides immobilization and prevents mechanical injuries.
    • Helps with hemostasis (prevents bleeding).
    • Provides psychological and physical comfort for the patient.

    Advantages of Non-Dressing Method

    • Prevents bacterial growth by eliminating warmth and moisture.
    • Allows better observation of the wound.
    • Facilitates bathing without disrupting healing.
    • Avoids allergic reactions from adhesive tapes.
    • More economical and comfortable for the patient.

    Disadvantages of Non-Dressing Method

    • Exposure of large wounds may cause anxiety for some patients.
    • Increased risk of contamination in an unclean environment.

    Qualities of a Good Dressing

    • Sterile – Free from microorganisms.
    • Lightweight – Comfortable and non-bulky.
    • Porous – Allows air circulation to prevent moisture buildup.

    Types of Dressings

    Dry Dressing

    • Used for clean wounds.
    • Typically made of 4 to 8 layers of gauze, applied after antiseptic treatment.

    Wet Dressing

    • Used for infected wounds with pus, softening discharge and promoting drainage.
    • Made of moistened antiseptic gauze with multiple layers.

    Pressure Dressing

    • Applied with firm bandages to control bleeding and reduce oozing.
    • Commonly used for trauma or post-surgical wounds.

    General Rules for Wound Dressing

    Wound infections occur when microorganisms contaminate the wound, often originating from the ward environment. The primary sources of contamination include:

    Sources of Wound Infection in the Ward

    1. Airborne Contaminants – Dust particles or infected droplets from the nose and mouth of patients, visitors, and medical staff.
    2. Hands of Healthcare Providers – Bacteria and pathogens from nurses, doctors, and other staff may transfer to wounds if proper hand hygiene is not followed.
    3. Improper Dressing Techniques – Inadequate sterilization and incorrect handling of wounds can introduce infections.
    4. Use of Unsterile Instruments – Dressing materials and instruments that are not properly sterilized can be a source of infection.

    To prevent these risks and minimize wound infections, the following essential rules must be followed:

    General Rules for Wound Dressing

    No.

    Rules

    Rationale

    1.

    All bed making, mopping of the floor and dusting must be finished at least one hour before the dressing round is started.

    To prevent spread of infections.

    2.

    Before the dressing round, wash the trolley with soap and water and dry it.

    		 

    3.

    Before each dressing, wipe the trolley shelves with a disinfectant using a mopper.

    		 

    4.

    Sterile articles are placed on the top shelf, un-sterile articles on the bottom shelf.

    		 

    5.

    Clean wounds are always dressed first

    		 

    6.

    Limit movements in the ward and windows near to the patient  being dressed must be closed.

    To prevent cross infection.

    7.

    Do not carry out dressing when having a focal wound or droplet infection.

    		 

    8.

    If possible 2 nurses should be available to carry out dressing.

    To prevent contamination and save time.

    9.

    Apply universal infection prevention and control before and after each procedure.

    To prevent spread of infections.

    10.

    Nails must be short, watches and rings should be removed.

    		 

    11.

    Masks are worn if required and once in position they must not be handled. 

    • When removing the mask, handle only the tapes and dispose off immediately. 

    • Never put a used mask in the uniform pocket.

    To prevent spread of infections

    12.

    Lotions: The dressing assistant should pour only enough lotion for one dressing. Unused lotion must be disposed off when clearing the trolley.

    To avoid wastage and cross infection.

    13.

    The trolley is reset for each dressing.

    		 

    14.

    All used equipment must be decontaminated, washed with soap water, brushed, dried and sterilisation.

    To be ready for next dressing

    15.

    The trolley is cleaned with disinfectant.

    		 

    Wound Dressing Procedures

    Dressing a Clean Wound

    A clean wound is a superficial wound caused by uncontaminated sharp objects. 

    It may occur electively (e.g., surgical incision) or accidentally (e.g., cuts from broken glass or sharp metal).

    Purpose of Dressing a Clean Wound

    1. To keep the wound clean and free from infection.
    2. To prevent the wound from further injury and contamination.
    3. To hold medications applied locally in place.
    4. To immobilize the wound edges, promoting faster healing.
    5. To apply pressure, minimizing bleeding and swelling.

    Requirements for Clean Wounds

    Top Shelf

    Bottom Shelf

    Bed Side

    Sterile dressing pack containing: 

    – 2 dressing towels 

    – 2 non-toothed dissecting forceps 

    – 2 dressing forceps 

    – 3 gallipots 

    – 1 for swabs 

    – 1 for the lotion 

    – 1 for gauze dressing

    – A pair of stitch scissor or a clip remover if required

    – A dressing mackintosh and towel 

    – Receiver for soiled dressing 

    – Receiver for used instruments 

    – A bottle of antiseptic lotions 

    – A drum for dressing

    – A drum for swabs 

    – A tray with bandages, scissors, safety pins, strapping 

    – A container of Cheatle forceps 

    – A pair of gloves and a pair of clean glove 

    – A bowl

    – Hand washing equipment

    Extra Requirements For Dirty Wound

    – Probe 

    – Sinus forceps

    – Hydrogen peroxide 

    – Pus swab 

    – Laboratory form 

    – Hypotonic saline

    – Pedal bin

    Bed-Side Requirements

    • Hand washing equipment
    • Screen for patient privacy
    • Safety box for disposal of sharps
    • A good source of ligh

    Procedure

    Steps

    Action

    Rationale

    1.

    Refer to general rules.

    –

    2.

    Dressing assistant positions the patient.

    To maintain sterility.

    3.

    Place a mackintosh and towel under the part to be dressed.

    Provides comfort and prevents soiling of bed linen.

    4.

    Dressing assistant puts on clean gloves, removes the bandage, and loosens the strapping.

    For easy removal of the old dressing.

    5.

    Dressing assistant removes gloves, washes hands, opens the dressing pack, and adds any additional sterile equipment using Cheatle forceps.

    To arrange materials for easy use and maintain sterility.

    6.

    Adds sterile cleaning solution required.

    To prevent the spread of infections.

    7.

    Dressing assistant puts on clean gloves, removes the dressing, and discards it in the receiver.

    To prevent the spread of infections.

    8.

    Dressing nurse washes hands thoroughly with soap and water and dries with a sterile towel.

    To reduce the spread of infections.

    9.

    Puts on sterile gloves.

    To maintain surgical asepsis.

    10.

    Drapes the wound with a dressing towel.

    To provide a sterile environment.

    11.

    Using forceps, swabs the wound, discarding each swab after use (first the center, then each side of the wound, working from the middle outwards).

    To minimize the spread of infection.

    12.

    For a dirty wound, perform necessary toileting as prescribed, which may involve the removal of stitches or clips, probing the wound, or packing the wound.

    To promote healing.

    13.

    Applies dressing to cover the wound and puts additional dressing if oozing or discharge is anticipated.

    To protect the wound and prevent soiling of the linen.

    14.

    Places used instruments in a receiver.

    To avoid cross infections.

    15.

    Removes gloves, applies strapping or a bandage on the wound as required.

    –

    16.

    Washes hands, clears away, and leaves the patient comfortable.

    To maintain hygiene and sterility.

    17.

    Documents the procedure and reports accordingly.

    For continuity of care and follow-up.

    Dressing of Septic Wound

    Septic wound is characterized by the presence of pus, dead skin and offensive odour in the wound.

    Purpose of Dressing a Septic Wound

    1. To absorb discharge from the wound.
    2. To apply pressure and prevent excessive fluid buildup.
    3. To apply local medications for infection control.
    4. To reduce pain, swelling, and further tissue injury.

    Need irrigation: As for clean wounds and dirty wounds which may not need irrigation, however with addition of the following, on the top shelf.

    Additional Items (Top Shelf)

    Bowl containing irrigation lotion (e.g., hydrogen peroxide)

    Saline 0.9% solution

    Receiver containing large syringe and fine catheter

    Receiver for used lotion

    Procedure

    Step

    Action

    Rationale 

    1

    Explain procedure to the patient

    To gain patient cooperation and reduce anxiety.

    2

    Clean trolley or tray and assemble sterile equipment on one side and surgically clean items on the other side. Make sure the tray or trolley is covered.

    To maintain asepsis and prevent contamination of sterile supplies.

    3

    Drape patient and position comfortably.

    To provide privacy and comfort for the patient during the procedure.

    4

    Place the rubber sheet and its cover under the affected part.

    To protect the bed linen from becoming soiled.

    5

    First remove the outer layer of the dressing.

    To expose the inner dressing and wound site.

    6

    Wear gloves if necessary. Use forceps to remove the inner layer of the dressing smoothly and discard therefore caps.

    To prevent contamination of the wound and protect healthcare worker from exposure to infectious materials.

    7

    Observe the wound and check if there is drainage rubber or tube.

    To assess the wound’s condition and identify any complications.

    8

    Take specimens for culture or slide if ordered (Do not cleanse wounds with antiseptic before you obtain the specimen.)

    To accurately identify any infectious organisms present in the wound.

    9

    Start cleaning the wound from the cleanest part of the wound to the most contaminated part using antiseptic solution. (Hydrogen peroxide 3%) is commonly used for septic wounds). Discard the cotton ball used for cleaning after each stroke over the wound.

    To prevent the spread of contamination from the dirtier areas to the cleaner areas.

    10

    Cleanse the skin around the wound to remove the plaster gum with benzene or ether.

    To ensure proper adhesion of the new dressing.

    11

    Use cotton balls for drying the skin around the wound properly.

    To create a clean, dry surface for the new dressing.

    12

    Dress the wound and make sure that the wound is covered completely.

    To protect the wound from infection and promote healing.

    13

    Fix dressing in place with adhesive tape or bandages.

    To secure the dressing and prevent it from dislodging.

    14

    Leave the patient comfortable and tidy.

    To promote patient well-being and satisfaction.

    15

    Cleanse and return equipment to its proper places.

    To maintain a clean and organized work environment.

    16

    Discard soiled dressings properly to prevent cross infection in the ward.

    To prevent the spread of infection to other patients and healthcare workers.

    NB:

    • If sterile forceps are not available, use sterile gloves. 
    • Immerse used forceps, scissors and other instruments in strong antiseptic solution before cleansing and discard soiled dressing properly. 
    • In a big ward it is best to give priorities to clean wounds and then to septic wounds, when changing dressings, as this might lessen the risk of cross infection.
    • Consideration should be given to provide privacy for the patient while dressing the wound. 
    • Wounds should not be too tightly packed in effort to absorb discharge as this may delay healing.

    Wound Irrigation

    Wound irrigation is the process of removing foreign materials, reducing bacterial contamination, and clearing cellular debris or exudate from the wound surface. 

    It is a critical step in wound management, helping to maintain a clean environment that promotes optimal healing.

    The procedure must be vigorous enough to achieve effective cleansing but gentle enough to prevent additional tissue trauma or the unintentional spread of bacteria and foreign particles deeper into the wound.

    Since wound irrigation involves bodily fluids, splashing and spraying can occur due to the use of pressure. To ensure the safety of healthcare providers, proper personal protective equipment (PPE) such as gloves, masks, eye protection, and gowns must be worn.

    Essential Steps of Wound Irrigation

    1. Assessing the Wound – Evaluate the wound’s size, depth, level of contamination, and presence of infection.
    2. Wound Anesthesia – If necessary, provide local anesthesia to minimize patient discomfort during irrigation.
    3. Wound Periphery Cleansing – Clean the skin around the wound using antiseptic solutions to prevent external contamination.
    4. Irrigation with Solution Under Pressure – Flush the wound using an appropriate solution with controlled pressure to remove debris and bacteria effectively.

    Indications for Wound Irrigation

    Wound irrigation is recommended for both acute and chronic wounds, especially when:

    • The wound is contaminated with debris or foreign materials.
    • The wound will undergo suturing, surgical repair, or debridement.
    • The wound has exudate buildup, which may delay healing.

    Contraindications for Wound Irrigation

    Wound irrigation may not be necessary or should be carefully performed in the following situations:

    Contraindication

    Reason

    Highly vascular areas (e.g., scalp wounds)

    Excessive irrigation may not be required due to the scalp’s rich blood supply, which naturally aids in cleansing.

    Wounds with fistulas or sinuses of unknown depth

    Irrigation could push bacteria and debris deeper into the wound or surrounding body spaces, leading to complications.

    Extensive tissue damage or fragile wounds

    Excessive irrigation pressure can worsen tissue injury.

    Wound Cleansing Agents

    Various wound cleansing agents are available, each with different bactericidal properties:

    Cleansing Agent

    Bactericidal Action

    Effect on Healthy Tissue

    Povidone-Iodine Solution

    Strong against both gram-positive and gram-negative bacteria

    Mildly toxic to healthy cells and granulation tissues

    Chlorhexidine

    Strongly bactericidal against gram-positive bacteria, less effective against gram-negative bacteria

    Generally safe but may cause irritation

    Hydrogen Peroxide

    Strong against gram-positive bacteria, less effective against gram-negative bacteria

    Can damage healthy tissue and delay healing

    Irrigation Solutions for Wound Cleansing

    Different irrigation solutions can be used based on wound type and availability:

    Irrigation Solution

    Properties

    Usage Considerations

    Normal Saline (0.9%)

    Non-toxic, similar in tonicity to body fluids

    Most commonly used due to safety and effectiveness

    Sterile Water

    Non-toxic but hypotonic, may cause cell lysis

    Suitable when saline is unavailable but should be used cautiously

    Potable Water

    Readily available, no significant difference from sterile water in infection rates

    Used when sterile water or saline is unavailable

    Requirements 

    • 2 Receivers
    • Rubber sheet and its cover
    • Solutions (Hydrogen Peroxide or Normal Saline)
    • Adhesive tape or bandage
    • Bandage scissors
    • Sterile Syringe (with desired amount of solution) and Catheter
    • Sterile Forceps (2)

    Procedure

    Step

    Action

    Rationale

    1

    Explain the procedure to the patient and organize the needed items.

    To gain patient cooperation and ensure efficiency.

    2

    Drape and position patient.

    To provide privacy and comfort.

    3

    Put a rubber sheet and its cover under the part to be irrigated.

    To protect the bed linen from becoming soiled.

    4

    Remove the outer layer of the dressing.

    To expose the inner dressing.

    5

    Remove the inner layer of the dressing using the first sterile forceps.

    To maintain sterility during dressing removal.

    6

    Put the receiver under the patient to receive the outflow.

    To collect the irrigation fluid and prevent mess.

    7

    Use a syringe with the desired amount of solution fitted with the catheter.

    To deliver a controlled amount of irrigation fluid.

    8

    Use forceps to direct the catheter into the wound.

    To ensure the catheter reaches the desired area of the wound.

    9

    First inject the solution such as hydrogen peroxide at body temperature gently and wait for the flow. This must be followed by normal saline for rinsing.

    Hydrogen peroxide helps to loosen debris, while normal saline rinses away the debris and remaining peroxide.

    10

    Make sure the wound is cleaned and dried properly.

    To prepare the wound for dressing and prevent maceration.

    11

    Dress the wound and check if it is covered completely.

    To protect the wound from infection.

    12

    Secure dressing in place with adhesive tape or bandage.

    To keep the dressing in place.

    13

    Leave the patient comfortable and tidy.

    To promote patient well-being.

    14

    Record the state of the wound.

    To monitor healing progress.

    15

    Clean and return equipment to its proper place.

    To maintain a clean and organized environment.

    NB:

    Keep patient in a convenient position. According to the need so that solution will flow from wound down to the receiver.


    Complications

    Wound irrigation should be avoided if the wound is actively bleeding, as it can disrupt clot formation and exacerbate hemorrhage. Incomplete or inadequate wound irrigation can lead to several complications:

    • Persistent Debris: Failure to thoroughly remove debris, foreign bodies, or necrotic tissue increases the risk of infection and delayed healing.
    • Sinus Formation: In abscesses, inadequate irrigation can result in the persistence of purulent discharge, potentially leading to chronic sinus tract formation.
    • Infection: Retained bacteria and contaminants can promote local or systemic infection.
    • Cytotoxicity: While povidone-iodine is a common antiseptic, excessive use or direct instillation into deep wounds can be cytotoxic, impairing wound healing. It should be used carefully, primarily on wound edges, and avoided in large quantities within the wound.
    Wound Assessment

    Wound Assessment

    Wound assessment is a critical process in wound management that allows healthcare professionals to determine the appropriate treatment plan and monitor healing progression. 

    It involves evaluating the type, severity, and condition of the wound, along with assessing for signs of infection, complications, or delayed healing.

    Both initial and ongoing wound assessments should be conducted systematically in collaboration with the treating team to ensure optimal patient care.

    Key Factors in Wound Assessment

    The following considerations are essential for a comprehensive wound assessment:

    1. Type of Wound – Categorized as acute or chronic based on duration and healing progression.
    2. Aetiology (Cause of Wound) – Includes surgical wounds, lacerations, ulcers, burns, abrasions, traumatic injuries, pressure injuries, and neoplastic wounds.
    3. Wound Location & Surrounding Skin – Important for understanding healing potential and the impact on mobility or function.
    4. Tissue Loss – Determines whether the wound is superficial, partial-thickness, or full-thickness.
    5. Clinical Appearance of Wound Bed – Indicates the stage of healing and tissue viability.
    6. Measurement & Dimensions – Includes both two-dimensional and three-dimensional wound assessments.
    7. Wound Edges – Assessed for color, contraction, elevation, and rolling, all of which impact healing.
    8. Exudate (Wound Drainage) – Evaluated for quantity, color, consistency, and odor to detect infection or complications.
    9. Presence of Infection – Identified by local or systemic indicators of bacterial overgrowth.
    10. Pain – Helps assess wound progression and potential underlying complications.
    11. Previous Wound Management – Important for evaluating treatment effectiveness and necessary modifications.

    1. Type of Wound

    Wounds can be classified based on terminology related to their cause and general healing characteristics.

    Wound Type

    Description

    Surgical Wound

    Incision made during a medical procedure under sterile conditions.

    Burn

    Caused by heat, chemicals, electricity, or radiation.

    Laceration

    A deep cut or tear in the skin due to trauma.

    Ulcer

    A wound caused by prolonged pressure, infection, or vascular insufficiency.

    Abrasion

    Superficial wound caused by friction removing the skin’s surface.

    Traumatic Wound

    Resulting from external force, such as accidents, falls, or injuries.

    Pressure Injury (Bedsore)

    Skin and tissue damage due to prolonged pressure, especially in bedridden patients.

    Neoplastic Wound

    Caused by malignant tumors breaking down skin tissue.

    2. Tissue Loss

    The depth of a wound determines the level of tissue loss:

    Tissue Loss Classification

    Description

    Superficial Wound

    Involves only the epidermis (outer layer of the skin).

    Partial-Thickness Wound

    Affects both the epidermis and dermis.

    Full-Thickness Wound

    Extends beyond the dermis into subcutaneous tissue, possibly reaching muscles, bones, or tendons.

    3. Clinical Appearance of the Wound Bed

    The wound bed provides insight into the healing process. Different tissue types indicate the stage of healing and whether intervention is required.

    Wound Bed Appearance

    Description

    Granulating

    Healthy red/pink moist tissue, indicating active healing. Contains newly formed collagen, elastin, and capillary networks. Bleeds easily.

    Epithelializing

    Thin, pink or whitish layer forming over the wound. Signifies new skin formation over granulation tissue.

    Sloughy

    Yellow or whitish tissue, made up of dead cells and fibrin. Must not be confused with pus.

    Necrotic

    Black, dry, or grey dead tissue. Prevents healing and may require debridement.

    Hypergranulating

    Excess granulation tissue, extending beyond the wound margins. Often caused by infection, irritants, or bacterial imbalance.

    4. Wound Measurement

    A proper wound assessment requires accurate measurement of its size and depth.

    Measurement Method

    Description

    Two-Dimensional Assessment

    Uses a paper tape measure to record the length and width (in mm). Commonly used for chronic wounds.

    Three-Dimensional Assessment

    Depth is measured using a dampened cotton tip applicator. Helps assess cavity wounds or tracking (tunneling wounds).

    5. Wound Edges

    The edges of the wound give valuable insight into healing progress.

    Wound Edge Feature

    Indication

    Pink edges

    Indicate new tissue growth and healing.

    Dusky edges

    Suggest hypoxia (lack of oxygen) in the wound.

    Erythema (redness)

    May indicate inflammation or cellulitis.

    Contracting wound edges

    Show wound contraction, a normal part of healing.

    Raised wound edges

    Suggest hypergranulation, which may need intervention.

    Rolled edges

    Edges rolling inward may delay healing and require corrective action.

    Changes in sensation

    Increased pain or numbness should be investigated.

    6. Exudate (Wound Drainage)

    Exudate plays a critical role in healing but requires careful monitoring.

    Functions of Exudate in Healing

    • Provides nutrients and growth factors for cell metabolism.
    • Contains white blood cells to fight infection.
    • Cleanses the wound by flushing out bacteria and debris.
    • Maintains moisture balance, preventing wound desiccation.
    • Promotes epithelialization, aiding tissue regeneration.

    Complications Related to Exudate

    • Excess exudate → Causes maceration (breakdown of surrounding skin).
    • Insufficient exudate → Leads to wound dryness, slowing healing.
    • Odorous, thick exudate → Indicates infection or necrosis.

    7. Surrounding Skin Condition

    The surrounding skin should be examined for:

    • Signs of maceration (excess moisture causing soft, broken skin).
    • Erythema (redness indicating inflammation or infection).
    • Dryness or cracking, which may slow healing.
    • Skin integrity changes, requiring protection measures.

    8. Presence of Infection

    A wound infection occurs when bacteria multiply beyond the body’s ability to control them. 

    This can lead to delayed healing, tissue destruction, or systemic illness.

    Local Signs of Infection

    • Redness (Erythema or Cellulitis) – Surrounding skin appears inflamed.
    • Exudate Changes – Purulent (pus-like) or increased drainage.
    • Foul Odor – A strong smell may indicate bacterial growth.
    • Localized Pain – Increased pain in or around the wound.
    • Localized Heat – Warmer than surrounding tissue.
    • Swelling (Oedema) – Fluid accumulation around the wound.

    Systemic Signs of Infection (Indicating worsening condition)

    • Fever or chills
    • Increased heart rate
    • Fatigue or malaise
    • Spreading redness beyond the wound area

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    Self study questions for nurses and midwives

    Self Study Question For Nurses and Midwives

    PREPARATORY QUESTIONS FOR END OF SEMESTER EXAMINATIONS

    SURGERY

    1a) define the term epistaxis

    b) What are the causes of epistaxis?

    c) Write down the management of a patient presenting with epistaxis

    2a) define a sty

    b) What are the causes of a sty?

    c) Outline the signs and symptoms of a sty

    3 An adult has been admitted to a surgical ward with difficulty in breathing, he requires urgent tracheostomy.

    a) List the indications of tracheostomy

    b) Describe the post-operative management of this patient till discharge

    c) Outline the complications that are likely to occur

    d) Formulate five actual nursing diagnoses and four potential diagnoses from this patient with tracheostomy

    4. Mrs Akello 38years old has presented with nasal polyps and she is to undergo polypectomy

    a) List the causes of nasal polyps

    b) Outline the signs and symptoms of nasal polyps

    c) Give the specific pre and post-operative management of this patient

    d) List four complications of nasal polyps

    5. a) Define tonsillitis

    b) List 6 symptoms and signs of a patient with tonsillitis

    c) Give the specific post-operative management for a patient who has undergone tonsillectomy

    6. Mrs Nabukeera was admitted on a surgical with a diagnosis of adenitis .She is to undergo adenoidectomy

    a) Define adenitis

    b) List the signs and symptoms of adenitis

    c) Describe the specific post-operative management you would give to her till discharge

    7. a) Define burns

    b) What are the causes of burns?

    c) How can burns be classified

    d )Mr. KK has sustained burns on the neck and chest

    >calculate the percentage of the area burnt

    >what specific management do you give to Mr. KK in the first 72hrs of admission

    >give five actual nursing diagnoses Mr KK will have due to the burns

    8a) Define the term electrolyte imbalance

    b) Give the causes of electrolyte imbalance

    c) List the signs and symptoms of electrolyte imbalance

    d) Mention the types of electrolyte imbalance in the body

    e) How can you manage patient with electrolyte imbalance

    9a) Define the term gangrene

    b) What are the causes of gangrene?

    c) Write down the types of gangrene

    d) Mention the signs and symptoms of different types of gangrene

    e) Describe the specific management which is given to this patient with gas gangrene

    10a) Define the term shock

    b) Write down the types/classification of shock

    c) State the clinical features of shock

    d) Write down all possible complications of shock

    e) How can a health worker prevent surgical shock?

    11a) Outline the classifications of wounds

    b) Give the factors that delay wound healing

    c) State five complications of wounds

    d) What advice do you give to a patient about wound care at home who is due for discharge?

    e) Explain the process of wound healing

    12a) Define the term a fracture

    b) Mention the different types of fracture

    c) Describe the management of a closed fracture of a femur

    d) List any 6 complications of a fracture

    13a) Define the term inflammation

    b) List the signs and symptoms of inflammation

    c) Describe the process of inflammation

    d) Explain the specific management of a 12yr old patient with inflammation on the lower limb

    13A 28year old male was admitted on a surgical ward with a diagnosis of tetanus

    a) List five cardinal signs and symptoms this patient would present with

    b) Explain the specific nursing management you would give to this from admission to discharge

    c) Formulate four actual and two potential nursing diagnoses from this patient’s condition

    14a) Define the term immunity

    b)Classify immunity

    c) Explain the factors that affect an individual’s immune system

    15a) Define hemorrhage

    b) Explain the different types of hemorrhage

    c) Explain the mechanism of hemostasis

    d) Outline the specific management of a patient with severe bleeding on the left lower leg

    16a)What is blood transfusion?

    b) Describe five complications that may occur due to blood transfusion

    c) What would cause failure of of a blood drip to run during blood transfusion

    d) Explain the nurse’s responsibility before , during, and after blood transfusion

    17a) Define a cataract

    b) outline the cardinal signs of a cataract

    c)Describe the management of Mr Moses a 40yr old presented to your OPD department with a cataract using a nursing process

    d)list the likely complications of a cataract

    MENTAL HEALTH

    18. Define the following terms

    a)suicide

    b) Suicidal ideation

    c) Attempted suicide

    d) par suicide

    e) paradoxical suicide

    19a) outline the common psychiatric conditions associated with suicidal ideation

    b) Explain the common factors contributing to suicide in the community

    c) Mention the impact of suicide to the family and the community

    d) Describe the management of a patient who intends to commit suicide

    e) Explain the assessment you would carry out on a patient with suicidal ideation

    20a) Define PTSD

    b) Outline four signs and symptoms of a patient with PTSD

    c) Manage an 11yr old girl who presented with PTSD after rape

    21a) Define the term delirium tremens

    b) Identify the causes of delirium tremens

    C) How can you manage the patient with delirium tremens?

    d) Formulate 5 potential nursing diagnoses for a patient with delirium tremens

    22. Madam EKEB a 26yr old is very aggressive on the ward that she cares away fellow patients

    a) Differentiate between aggression and violence

    b) What management do you give to madam EKEB who presents with severe aggression on the ward?

    23a) what is a psychiatric emergency?

    b) List 10 common psychiatric emergencies

    c) Which admission procedure would you follow when admitting a patient presenting with any of the psychiatric emergencies

    23a) Explain standards of care in psychiatry

    b) Who is a class B criminal lunatic?

    c) Mention all the orders used to admit mentally ill patient

    d) Write down and explain all the sections used in discharging a mentally ill patient

    e) Outline the rights of a mentally ill patient

    24. A 30yr old patient has presented in a psychiatric ward with status epilepticus

    a) Define status epilepticus

    b) Manage the patient who presents with status epilepticus on a ward

    c) Formulate four potential and 2actual nursing diagnoses for a patient with status epilepticus

    25aDefine mental retardation

    b) Classify mental retardation

    c) Explain 8 causes of mental retardation

    d) What advice do you give to a family with a mentally retarded child?

    26. ADHD is one of the common psychiatric conditions in children

    a) Outline 6 signs and symptoms of ADHD

    b) Manage an 11yr old boy with ADHD

    c) What specific advice do you give to a family with a child having ADHD?

    27a) Define autism

    b) Explain the common features of autism

    c) Describe the management of the above condition

    28. Depression is one of the common psychiatric conditions

    a) Define depression

    b) Outline the specific management of a patient with severe depression on a psychiatric ward

    c) Make 4 priority nursing diagnoses for a patient with severe depression

    COMMUNITY HEALTH

    29. a) Define PHC

    b) Mention the principles of PHC

    c) Outline components /elements of PHC

    d) What strategies are used to achieve PHC activities in a given community?

    30a) What is community assessment?

    b) Explain how you would identify any health problems in a given community

    c) Outline 9 important information you would find out in a given home during assessment

    31a) Define a home visit

    b) Explain how you apply a nursing process during a home visit

    c) Outline the merits and demerits of a home visit

    32a) Define vital statistics in health

    b) Explain the importance of vital statistics in health

    c) Outline 6 key vital statistics used to determine the health status of a community or country

    33a) Explain the relationship between PHC and CBHC

    b) Explain the role of a community nurse/midwife in implementation and achievement of any 4 of the PHC principles

    c) Outline the advantages of PHC over other specialized medical services

    34a) Define community mobilization

    b) Describe how you would mobilize a community towards implementation of a health education program

    35a) Define school health

    b) Explain the importance of a school health program

    c) Explain the role of a nurse in the provision of a school health program

    d) Outline the components of school health services

    36a) Explain the role of a community in PHC services

    b) Give 8 advantages of community participation in PHC services

    c) Explain the obstacles to effective community participation in PHC programs

    37a) Define community diagnosis

    b) Discuss why community diagnosis is important

    c) Explain the steps in conducting community diagnosis

    38Health promotion are actions related to lifestyles and choices that maintain/enhance population health

    a) Outline any 5 health promotion interventions you would implement in a given a community

    b) Explain 5major steps in community mobilization

    39. Describe the different levels of disease prevention

    40. Appropriate technology is one of the elements of PHC

    a) How is appropriate technology expressed in implementation of PHC services?

    b) Explain the advantages and disadvantages of appropriate technology as an element

    41. a) Define the term epidemics

    b) Explain the factors that contribute to the causes of epidemics

    c) What is the role of a nurse in the management of an epidemic in the community?

    42a) Define community health and community based health care

    b) State the characteristics of CBHC

    c) Describe how you would enter a village in Mityana to implement a community health activity

    TROPICAL MEDICINE

    43a) Define schistomiasis

    b) Explain the different types of schistosomiasis

    c )Give the clinical manifestations of schistosoma mansoni

    d) Describe the lifecycle of schistosomiasis haematobium using a well labelled diagram

    e) Outline the preventive measures of all types of schistosomiasis

    44The current disease burden in Uganda is attributed to communicable diseases

    a) Describe the modes of transmission of communicable diseases in general

    b) Describe the methods/approaches used to prevent and control communicable diseases in the community

    c) Explain the types of water diseases and their examples

    45a) Define diarrhoea

    b) Outline the causes of diarrhoea in Uganda

    c) Discuss the drugs used in the management of diarrhoea in children

    d) Formulate 5 priority nursing diagnoses of this patient

    46a) Define measles

    b) Outline the signs and symptoms of measles basing on the stages

    c) Describe the management of a12yr old child presenting with measles from admission to discharge

    d) List the likely complications of measles

    47. Malaria is one of the communicable diseases affecting most communities of Uganda

    a) Classify malaria

    b) Outline the cardinal signs of complicated malaria

    c) Describe the lifecycle of malaria in both man and the mosquito with the aid of diagrams

    d) How can different communities prevent the spread of malaria?

    e) Make 5 actual and 3 potential diagnoses of malaria

    48a) Describe the life cycle of ackylostomiasis with the aid of diagrams

    b) Explain the preventive measures of hook worm infestation

    c) List the likely complications of neglected worms

    49a) Ebola is one of the hemorrhagic fevers devastating some communities and countries due to known and unknown reasons

    a) Define hemorrhagic fevers

    b) List the different hemorrhagic fevers

    c) Outline the different causes and predisposing factors to hemorrhagic fevers

    d) Describe the management of Mr. X presented to your hospital suspected to be an Ebola patient

    50a) Define rabies

    b) Describe the management of rabbis both at home and in the hospital

    c) Explain the complications of rabies

    51a) Define bacilliary dysentery

    b) State the differences between bacilliary dysentery and amoebic dysentery

    c) Describe the specific management of a 3yr old child with bacilliary dysentery from admission to discharge

    52a) Define typhoid fever

    b) Explain the cardinal signs and symptoms of typhoid fever

    c) Describe the important information you would give to the community concerning prevention of typhoid fever

    53a) Define trachoma

    b) Outline the signs and symptoms of trachoma

    c) Explain the management of 23yr female presenting with trachoma

    d) List the complication

    54. Samuel a 30yr old peasant has been presented to the OPD with all the features of tetanus

    a) Outline the clinical features of tetanus

    b) Describe the management from admission to discharge

    c) List the complications of tetanus

    MIDWIFERY 1 AND 2 AND OBSTETRIC ANATOMY

    55. List the 5 medications used in antenatal and discuss them under

    a) Dose

    b) Indication

    c) Side effects

    56a) Outline the obstetrical causes of anemia in pregnancy

    b) List the five causes of hemolytic anemia

    c) Describe the management of Mrs. mucosal who presents at 36weeks with severe anemia

    57a) Define a cervix

    b) With the aid of a diagram, describe the structure of the cervix

    c) Outline the 6 functions of the cervix

    58a) Define the term good antenatal care

    b) Give the indications of referring a mother to a doctor during this period

    c) How would you manage a mother who comes with lower back pain in antenatal at 32weeks?

    59a) Define normal puerperium

    b) Describe the management of a mother who has had normal delivery up to discharge

    c) List the complication that may occur during this period

    60a) Outline the symptoms of pregnancy

    61a) Explain the characteristics of normal uterine action during first stage of Labour

    b) What is the management of a gravid 3 para 2 mother at term who presents to hospital with history of precipitate Labour on the previous pregnancies?

    62a) Describe a vagina

    b) What information is got on vaginal examination during labor?

    c) Mention four contractions of vaginal examination giving reasons for each

    d) List the complications of vaginal examination

    63a) Define intrauterine fetal death

    b) Outline the causes of IUFD

    c) How is the diagnosis of IUFD made?

    d) What is the management of IUFD in the hospital?

    64a) Describe the pelvic floor

    b) Outline injuries that can occur to the pelvic floor during Labour

    c) Explain how the knowledge of fetal skull can help you as a midwife prevent perineal tears

    65a) Describe the fetal skull

    b) How is fetal wellbeing monitored during pregnancy?

    C) List the indications of ultrasound scan in late pregnancy

    66a) Describe a non-pregnant uterus

    b) Describe the changes that take place in this organ during pueperium

    c) List the likely complication in the first stage of labor

    67a) what is the effect of DM on pregnancy?

    68a) how does pregnancy affect DM?

    b) How would you care for a diabetic mother who has had a caesarean section in the first 48hours of the operation

    69a) Describe the umbilical cord

    b) Describe the different abnormalities of the cord

    70. Malaria is of the conditions contributing affecting pregnancy and contributing factor to increased maternal mortality and morbidity

    a) Explain why pregnant women are more susceptible to malaria

    b)Describe the a primigravida who presents to your maternity center at 34 weeks with severe malaria

    c) Outline the likely complications of malaria on pregnancy

    71. Essential hypertension is one of the hypertensive disorders experienced by pregnant women

    a) Define essential hypertension

    b) Classify hypertensive disorders in pregnancy

    c) Describe the management of Mrs Nangobi a G4P2+1 presenting in antenatal clinic at 32weeks with a diagnosis of essential hypertension

    d) How does hypertension affect pregnancy?

    72a) outline the signs and symptoms of first stage of Labour

    b) Describe the management of a young primigravida in first stage of Labour

    c) List the complications likely to occur during this stage of Labour

    73a) Define hyperemesis gravidarum

    b) Outline the causes of hyperemesis gravidarum

    c) Describe the management of G2P1+0 presenting to your maternity center with hyperemesis gravidarum at 28 weeks of gestation

    d) Explain the likely complications of this condition

    74a) what is preeclampsia

    b) Outline the signs and symptoms of preeclampsia

    c) What are the predisposing factors of this condition?

    d) Outline the nursing of a mother with severe preeclampsia

    e) List the complication of severe preeclampsia

    75a) Describe the placenta at term

    b)Explain the functions of the placenta

    c) Outline the abnormalities that may be found on the placenta

    76a) With the aid of a diagram, describe the structure of the female breast

    b) Explain the physiology of lactation

    c) Explain the factors that promote successful lactation

    77a) Define labor

    b) Explain the physiology of the first stage of Labour

    c) Describe the management of a mother in the second stage of Labour admitted in the hospital

    78a) Outline the changes in the cervix during the first stage of labor

    b) What information is found on the partograph?

    c) A G2P1+0 mother came to a health center in normal labor , what may make you refer?

    79. Most women find it helpful to get further information and support in their own homes.

    a) Give 5 advantages of following up post-partum mothers

    b) Explain postpartum maternal assessment you would carry out during domiciliary care

    c) List the problems that you would identify during domiciliary care

    80a) Describe 6 factors that influence the length of second stage of labor

    b) Explain 3 phases used in conducting 2nd stage of labor

    c) Give immediate assessment of the baby after 2nd stage of labor

    81a) Mention factors that aid in involution of the uterus

    b) Explain how you assess and document uterine involution immediately after delivery to 10days postpartum

    c) Give five complications of sub involution of the uterus

    82a) Explain the antenatal appointment schedules

    b) Give 6 barriers to adherence to goal oriented antenatal visits

    c) Identify 5 complications a pregnant woman is likely to get if no antenatal is attended

    83a) Describe the structure of the ovary

    b) List the functions of the ovary

    c) Describe the menstrual cycle

    MEDICINE I AND 111

    84. Mr. KIBULA known hypertensive has been brought to hospital with suggestive features of hypertensive crisis.

    a) Mention 8 clinical features of hypertension

    b) List 4 causes of HTN and predisposing factors

    c) Explain the specific Nursing Care you will give to Mr. KIBULA from the time of admission to discharge.

    85. Write short notes on the following (definition, causes, signs and symptoms and complications).

    a) Hydrocele

    b) Hodgkin’s disease

    c) Ankylosing spondylitis

    86 a) Define Paget’s disease/Osteitus, deformans?

    b) Explain the pathophysiology and etiology of Paget’s disease

    c) Describe the specific nursing care you would give to Mr. Muwonge with Paget’s disease

    87. Hepatitis B morbidity and mortality is much higher today than before.

    a) What are the factors, contributing to the high prevalence of hepatitis B in the communities

    b) How does a patient with hep.B present?

    c) Give five priority nursing diagnoses for a patient with Hep B infection.

    d) Describe the specific nursing management you would give to a patient with hep B.

    e) Mention the complications of hep B.

    f) Suggest ways how we can prevent hep B infection in the community

    88. Define myocardial infarction. List the clinical features of myocardial infarction.

    Explain the specific Nursing care given to a patient with myocardial infarction within the first 24Hrs of admission.

    89. An adult male patient has presented to OPD with features of pulmonary tuberculosis

    a) Outline five cardinal signs and symptoms of pulmonary tuberculosis.

    b) List five specific investigations that can be done to confirm pulmonary tuberculosis.

    c) Explain the specific nursing care given to this patient from the time of admission until discharge.

    90. Mrs. A, a female patient has been admitted on a medical ward with suspected bronchial pneumonia,

    a) Outline the clinical features of bronchial pneumonia

    b) Describe the specific nursing management you would give to Mrs. X with in the first 72HRS of admission.

    c) Explain five likely complications Mrs. X is likely to get following this condition.

    91. Mr. Lusoke, a 62 yrs. old male is presented at the OPD with features of congestive cardiac failure

    a) Outline the signs and symptoms of congestive cardiac failure.

    b) Mention the causes of congestive cardiac failure.

    c) Describe the specific nursing care / management you will give to Mr. Lusoke from time of admission to discharge.

    92. Outline the signs and symptoms of Parkinson’s disease.

    b) Mention the causes and predisposing factors to Parkinson’s disease.

    c) Describe the specific Nursing management given to a patient with Parkinson’s disease.

    93. Mr. Okello a 28yrs old male presents at OPD with clinical features of urinary tract infection and was admitted.

    a) List 5 causes and 6 signs and symptoms of urinary tract infection.

    b) Describe the specific nursing care you would give to Mr.Okello within the first 48 hours of admission.

    c) Give the measures that can be taken to prevent urinary tract infections.

    94 Define Addison’s disease?

    b) Outline the causes and risk factions that leads to Addison’s disease.

    c) Using the Nursing process, describe the management of a patient with Addison’s disease.

    PEDIATRICS 1 AND 11

    95. Define the term Apgar score

    a) Outline 10 characteristics of a normal new born baby

    b) Describe the care given to the normal new born baby within 72 hours after delivery of the head.

    96. Differentiate between SAM and MAM

    b) Explain the causes of malnutrition in children under 5 years.

    c) Explain the importance of breastfeeding in babies’ up to 2years of age.

    97. Define the term congenital abnormalities

    a) Classify the congenital abnormalities of the heart

    b) Explain ways of preventing congenital abnormalities.

    98. Mention the factors that predispose to neonatal infections in new born babies.

    b) List 8 clinical features of a child with neonatal tetanus.

    c) Describe the specific management of a 3 month old child with tetanus.

    99. Outline the factors that predispose to birth injuries

    Differentiate between a caput succedaneum and a cephalo hematoma.

    c) Describe the specific management you would give to a new born baby who presents with a caput succedaneum.

    100. Brandon a five weeks old neonate is admitted on ward with a history of fast breathing, chest in drawing and stridor.

    b) Explain the specific nursing care you would offer to Brandon in a hospital within the first eight hours of admission.

    101. A five year old child has been bought to OPD in a painful sickle cell crisis.

    a) Outline 5 possible causes of sick cell crisis.

    b. List 4 diagnostic signs and symptoms of sick cell disease in children.

    c) Explain the specific management of this child from admission to discharge.

    102. A 4 months old baby has been admitted on a pediatric ward and diagnosed with pneumonia.

    a) Outline the clinical presentation of this child.

    b) Explain the specific management given to the child with in the first 72 hours.

    103. Define the following terms.

    1) Fracture

    ii)Osteopenia of prematurity

    osteogenesis imperfecta

    Osteomyelitis

    b) Mention 5 signs and symptom of osteomyelitis in children.

    c) Describe the nursing management of 3 years old child with osteomyelitis.

    104. A 8 month old child has been diagnosed with nephrotic syndrome.

    a) List 6 signs and symptoms of nephrotic syndrome in children.

    b) Describe the specific nursing management you world give to this child within the first 72 hours of admission on a pediatric ward.

    c) Outline five complications of nephrotic syndrome.

    105. What are the advantages of breast feeding?

    Compare human milk and cow’s milk

    Outline problems that are faced by mothers during breastfeeding.

    106. List five congenital abnormalities of the G’T and 5 musculoskeletal system

    Outline the causes of congenital abnormalities.

    How do you cause a mother who has delivered a baby with spinal bifida?

    107. List the factors that promote good nutrition in the under-five.

    List five pieces of advice you would give to a prime para with a two year old baby suffering from protein calorie malnutrition.

    List five problems of birth injuries in Uganda.

    Outline the roles of a nurse in prevention of birth injuries in Uganda.

    PHARMACOLOGY 1 AND 111

    108. Define rational drug use

    Outline the medical classification of drugs giving examples of each

    Mention the legal classes of drugs with examples of each.

    109. Define infertility.

    State the common cause of infertility in women

    c) State the indications, side effects and contraindications of clomiphene and Bromocriptine.

    110. Describe the mechanism of action of non-opioid analgesics.

    b) Write briefly about the handling of the class of drugs in a hospital

    c) Define the following:-

    Chemotherapy

    Anti tussive

    111. Mention 4 Four sources of drugs

    b) Write down all routes which can be used for drug administration giving advantages and disadvantages of each.

    c) Write down the factors that affects drugs absorption.

    d) What factors affect drug dosage and action?

    112. State the clinical uses of oxytocin and mention 6 adverse side effects of the drug.

    b) Outline 5(five) contraindications of oxytocin

    c) Describe 10 (ten) Nursing considerations while administering oxytocin.

    113. Define Narcotic drugs and state the types of narcotics.

    b) List down 7 nursing considerations before during and after administrating narcotics on ward.

    c) What are the legal implications of Narcotics according to the Uganda narcotic drugs and psychotropic substance control ACT?

    114. Define immunity and explain the two major types of immunity.

    State the specific side effects, indication and the dosage following drugs:-

    1. Anti D (RHO) Immunoglobulin
    2. B) Rabies vaccine
    3. Pneumococcal Vaccine.

    115. Describe the physiology of erection in males

    b) State the causes of erectile dysfunction

    b) Mention the class, indication, Dosage and side effects of the following drugs.

    i) Sildenafil.

    ii) Tadalafil

    iii) Finesteride.

    GYNAECOLOGY

    1. a) Outline signs of breast cancer.

    b) Explain post operative care after mastectomy.

    c) List possible complications of mastectomy.

    1. . a) Draw a diagram showing possible sites of vaginal fistula.

    b) Outline the 5 major causes of vaginal fistula.

    c) Explain specific nursing care of a woman after VVF repair.

    118. a) Define the different types of Abortion.

    b) Outline causes of missed Abortion.

    c) Explain different methods used in the management of missed abortion.

    d) Outline the 5 elements of PAC.

    1. a) Define ectopic pregnancy.

    b) Outline signs and symptoms of tubal pregnancy.

    c) A mother presents to the medical facility with a tubal pregnancy, describe her management till discharge.

    119. a) List the disorders of menstruation.

    b) Explain the advice and treatment given to a 17 year old girl with dysmenorrhea.

    120 a) Define Hydatidiform mole.

    b) Outline signs and symptoms of hydatidiform mole.

    c) Describe the methods of managing the above condition and list complications that may follow.

    121. Describe pelvic inflammatory disease.

    b) What are the predisposing factors of this condition?

    c) Describe management of PID in the hospital.

    1. a) What is infertility?

    b) Outline causes of infertility.

    c) Explain the different methods that can be used to manage infertility.

    1. a) Draw a diagram of a uterus indicating sites of fibroids.

    b) Differentiate between benign and malignant tumor.

    c) Give the management of the mother after myomectomy within the first 48 hours.

    d) What specific advice would you give this mother on discharge.

    REPRODUCTIVE HEALTH

    1. a) Define STDs?

    b) Explain ten preventive measures against sexually transmitted infections.

    c) Describe the syndromic management of STDs.

    1. a) List 7 components of reproductive health.

    b) Outline the advantages and disadvantages of intergrating reproductive health.

    c) Outline 10 factors that affect women’s reproductive health.

    1. a) Define sexual abuse?

    b) Explain factors that expose adolescent girls to sexual abuse or vulnerability.

    c) Outline 5 clinical features of sexual abuse in an adolescent.

    1. a) Define i) Post Abortion Care

    ii) Comprehensive abortion care.

    b) Explain the Rational for PAC.

    1. a) Who is an adolescent?

    b) Describe Tanner’s stage of development in an adolescent.

    c) List common health problems faced by adolescents.

    1. a) What is safe motherhood?

    b) Outline the 3 delays that can increase maternal mortality.

    c) What is your role as a midwife in reduction of maternal mortality in your community?

    1. Describe syndromic approach of managing STIs.
    2. a) Define domestic violence.

    b) What are the factors that make you suspect that one is a victim of domestic violence?

    c) How would you prevent domestic violence?

    1. Describe manual vacuum aspiration.

    FOUNDATIONS OF NURSING.

    1. a) Define wounds.

    b) Give 5 types of wounds.

    c) Outline the factors that delay wound healing.

    d) Give the specific management for a patient with specific wound.

    e) What specific advice do you give to a patient with a wound prior to discharge.

    f) Describe the process of wound healing.

    1. a) Outline the indications for oxygen administration.

    b) Give the rules to follow before, during and after administration of oxygen.

    c) Define blood transfusion.

    d) Outline the indications of blood transfusion.

    e) Outline the appropriate care of the patient before, during and after blood transfusion.

    f) Give the complications of blood transfusion.

    1. a) Define drug administration.

    b) Outline the different routes of drug administration.

    c) Mention the principles of drug administration including the dos and don’ts in drug administration.

    1. a) Define infection prevention and control.

    b) Define nosocomial infection.

    c) Outline the steps taken to prevent infections of the wound.

    d) What are the advantages of oral route drug administration over the parental route.

    1. a) Outline the indications of Tracheostomy.

    b) Give the specific pre and post operative nursing care for the patient with tracheostomy.

    c) Mention the complications of tracheostomy.

    d) Formulate 4 actual nursing diagnoses for a patient with colostomy.

    1. a) Define lumber puncture.

    b) Outline the indications of lumber puncture.

    c) Explain the specific nursing care given to the patient prior to after the procedure of lumber puncture.

    d) List the complications of lumber puncture.

    1. a) Define abdominal paracentesis.

    b) Outline the indications of paracentesis.

    c) Give the specific care given to the patient before and after abdominal paracentesis.

    d) Mention the complications of abdominal paracentesis.

    1. a) Define tractions.

    b) Explain the different types of tractions.

    c) Outline the specific nursing care given to a patient with tractions.

    d) Formulate 5 actual nursing diagnoses for a patient with tractions.

    e) Outline the likely complications of the patient on traction.

    1. a) Outline the indications of underwater seal drainage.

    b) Give the specific nursing care for a patient on underwater seal drainage.

    c) Formulate four nursing diagnoses for a patient on underwater seal drainage.

    d) List the complications of underwater seal drainage.

    1. a) Outline 6 indications of gastric lavage.

    b) Define colostomy.

    c) Formulate 4 actual nursing diagnoses and 4 potential nursing diagnoses for a patient with colostomy.

    d) Give the specific nursing care to the patient with colostomy.

    1. a) List the indications of Glasgow coma scale.

    b) Describe the Glasgow coma scale.

    ANATOMY AND PHYSIOLOGY II

    1. a) With illustration, describe the formation of flow of CSF.

    b) List the functions of CSF.

    c) Describe the meninges covering the brain and spinal cord.

    1. a) Describe the position and gross structure of the parathyroid glands. Outline the functions of parathyroid hormone and calcitonin.

    b) Explain the disorders of the thyroid gland.

    1. a) Describe the structure of a nephron.

    b) Explain the processes involved in the formation of urine.

    c) Describe how body water and electrolyte balance is maintained.

    1. a) Describe the structure of the ear.

    b) Explain the physiology of hearing.

    c) Explain the functions of the accessory organs of the eye.

    1. a) Explain the role of lymphatic vessels in the spread of infections and malignant disease.
    2. a) Describe the location of the pharynx and relate it’s structure to it’s function.

    b) List the functions of the trachea in respiration.

    c) Explain the main mechanisms by which respiration is controlled.

    d) Describe the common inflammatory and infectious disorders of the upper respiratory tract.

    1. a) Define a neuron.

    b) Outline the 12 cranial nerves of the nervous system.

    c) Describe the transmission of an impulse across a synapse.

    PALLIATIVE CARE NURSING

    150 a) Define palliative care

    b) Explain the principles of palliative care

    c) Give the challenges faced in implementing in palliative care services in Uganda

    151.a) Define pain according to WHO

    b) Explain different types of pain in palliative care

    c) Describe the principles of pain management in palliative care

    d) Describe the steps of breaking bad news

    152.a) Explain 6 roles of palliative care in Uganda

    b) Outline 6 symptoms commonly experienced by terminary ill patients

    153.a) What is grief?

    b) Explain 5 stages of grief experienced by palliative care patients

    c) Explain the HOPE approach to spiritual pain management

    d) Outline the spiritual problems experienced by palliative care patients

    Self Study Question For Nurses and Midwives Read More »

    Introduction To Community Based Health Care (CBHC)

    Introduction to Community Based Health Care (CBHC)

    CBHC is the program on health care in which community members are actively involved in the identification, prioritization of their own health needs and in mobilization of their own resources to meet those needs.

    Introduction

    Community Based Health Care (CBHC) is part of Primary Health Care (PHC) while more concerned with people. 
    CBHC is viewed in the context that when giving care to patients, you must put in mind that client needs continuous care even when you have left. It shows that community participation is very important and doesn’t
    work in isolation when giving care, involve them in plan so that they take responsibility. Since most of resources come from the community like food and other materials. It will be simple if you can teach them how to make
    use of them in the care.

    The need for PHC and CBHC arises from the following.

    1.  Most illnesses can be prevented: the most common illnesses are preventable or controllable, either by the people themselves or a combined effort between the people and government or other partner
      (NGO) services e.g. malaria.
    2. Morbidity and Mortality rates can be reduced: a reduction in this suffering can only happen if there is more “encouragement” and “enablement” of individuals and communities together to have a positive attitude towards preventive habits and to be willing to take part in improving their local amenities, rather than expecting the people to go to the health services and development projects.
    3.  The encouraging and enabling cannot go on within the walls of the hospitals and health centers; it must go on in the villages and homes.
    4.  Coverage of health services: even if there was full service in the health units, there are still few e.g. dental and mental services and they are mainly located in towns and rural population have little access to essential health care.

    Objectives of CBHC

    The main objective of CBHC is to encourage and enable the community to take care for its own health and welfare, if the community can,

    1.  Identify its own health problems
    2. Find solutions for those problems
    3. Make its own decisions
    4. Find (identify) resources outside the community
    5. Evaluate its actions and replan
    6. Together and individually make healthy behaviors into common practices and habits.

    CBHC activities

    • Provision of information, education and training concerning prevailing health problems in communities and the methods of preventing and controlling them
    •  Promotion of proper nutrition,
    • Maternal and child care;
    • Immunization against the major infectious diseases;
    • Prevention and control of locally endemic diseases such as diarrheal diseases, acute respiratory infection and malaria;
    • Reproductive health services, including family planning and the prevention and control of sexually transmitted infections with particular emphasis on HIV/AIDS;
    • Appropriate treatment for common diseases and injuries; ;
    • Community Mental health;
    • Rehabilitation for people with disabilities and
    • School health activities

    Advantages of CBHC

    1.  Community becomes responsible to care for their own health problems.
    2.  Empowers community to take systematic care of their health using available means at affordable costs.
    3.  Helps the community members in planning, making decision, implementation and evaluation of health care approach in the community
    4.  Gives the communities sense of ownership and belonging in the health care system.
    5. It cuts down costs of health care delivery
    6.  It reduces on dependency the government and donors,
    7.  Helps health workers to have knowledge base in family theory, principle of communication, group dynamic and cultural diversity in care of the patients at community level.
    8.  CBHC forces distance by giving services nearest to the community members, hence become easily accessible.
    9.  Creates awareness with – in the community on various health issues.
    10.  Individual families and communities are actively involved in health activities
    11.  Promotes holistic care that is physical, psychologically, spiritually and culturally.
    12.  Bridges the gap between community and extension worker e.g. from other ministries e.g. Agriculture.
    13.  It promotes unity
    14.  Helps to get appropriate action
    15.  Improves the quality of life
    16.  Community development
    17.  Early identification of the individual
    18.  Mutual interaction
    19.  Uplifts the standards of living

    Disadvantages of CBHC

    •  Diagnosis is made on assumption in most cases no investigations
    •  Increases stigma.


    Source of the CBHC services

    •  TASO (The AIDS Support Organization)
    •  UWESO (Uganda Women’s Effort To Save Orphans)
    •  CGC (Concern for the Girl Child)
    •  Hospice that provides palliative care services

    Village Health Team (Community Based Workers)

    Village Health team / committee; is a non- political health implementing structure responsible for health of the city community members at house hold (HH) level.

    The structure is put in place to facilitate the process of community mobilization, empowerment and participation in delivery, management and implementation of health services at house hold level.
    The overall goal of the village health team/ committee is to achieve an improved quality of life by strengthening service delivery at house hold level.

    Roles or responsibilities of village health team

    •  Facilitate the community to identify an recognize their health problems
    • Mobilize community for health programs e.g. immunization, malaria control etc
    • To collect information and maintenance of record book of house hold members and use it for planning and other programs.
    • Serves as a link between the community and health providers.
    • Follow up patients or clients
    • Conduct home visit
    • Identify individuals who need care at and outside their homes and refer appropriately.
    • Provide basic health message for behavioral change.
    • Distribution of drugs, supplies, information , communication, materials , insect treated nets.
    • Serves as role model in the community, collaborate with other community structures or other ministries.

    Basic health services done by the VHT

    Advice and information will be given on:
    Diseases
    >   Giving treatment and managing simple illness at home
    >   Sexually transmitted diseases (HIV/AIDS, )
    >   Tuberculosis (TB)
    Family
    >   Family Planning (child spacing)
    >   Pregnancy, delivery and care of new born baby
    >   Adolescent sexual and reproductive health
    >   Breast feeding
    >   Food and nutrition
    >   Abuse and violence
    >   Immunization
    >   Mental health
    The home
    >   Water and sanitation
    >   Hygiene
    >   First Aid


    How will the basic health services be done?
    >   Community mapping
    >   Community registers
    >   Home visits
    >   Talking with neighbors about health issues which have been found.


    What should community members do?
    >   Select and support VHT
    >   Attend village health events
    >   Use health services

    >   Improve personal and family health

    What should local leaders do?
    >   Inform communities about VHT
    >   Advocacy for health at home
    >   Mobilize communities for health
    >   Supervision of VHT activities
    >   Give financial support
    >   Planning for VHT in district and village health plans
    >   Attend and support health events

    Selecting and training of village health team

     Selection of a village Health Team (VHT/C) will be done on popular vote after sensitization and conservation, building of all stake holders.
    A = 20 – 30 house holds
     The following will be to guide the voting (selecting) process
    >  Mature 18 years and above
    >  A resident of the village
    >  Able to read and write / a least the local language
    >  A good communication skills).
    >  A dependable & trust worthy person
    >  Interested in health and development issues.
    >  Should be a resource person in the community.

    Composition of village health team / committee
    >   Community own resource persons. (CORPS)
    >   Local leaders
    >   Any similar resource persons in the community.

    Community own resource person [corps]
    A community own resource person (CORP) – is a member of a community residing within the same community selected by the community and trained to help community to improve their own health and facilitate development.

    His / her specific tasks are not to be confined to health care delivery alone but also other aspects of development
    e.g. food production, and income generating activities.
    CORPS includes the following
    >   Community Health Workers
    >   Traditional Birth Attendants (TBA).
    >   Traditional healers
    >   Community Drug Distributors (CDD).
    >   Community HIV/AIDS counselor.
    >   Community reproductive health workers.
    >   Community DOTS. (DOTS – Directly Observed Therapy Short course.)

    >   Peer educators, etc.


    Responsibilities of A CORP

     A CORP has to carry out the following duties/ responsibilities:-
    >   Home Visiting and advising and personal hygiene and environmental sanitation.
    >   Advising and educating communities on matters related to:-
    – Food production and Nutrition
    – Prevention of diseases
    – Use of safe water.
    – Identify health problems (concerns) and prioritize together with community members.
    >   Keeping records and using them for organizing, prioritizing, implementing, monitoring, and evaluation of health services.
    >   Identifying individual and families at risk and refer them for further management.

    TECHNIQUES USED TO ESTABLISH COMMUNITY HEALTH ACTIVITIES

    Below are the steps taken to establish community health activity.

    •  Community approach
    •  Community entry
    •  Community Assessment
    •  Community situation analysis (Diagnosis)
    •  Community mobilization
    •  Community participation
    •  Community organization
    •  Community empowerment
    •  Community based rehabilitative services for disabled and disadvantaged groups

    Introduction to Community Based Health Care (CBHC) Read More »

    Medico-Legal Issues

    Medico-Legal Issues

    Topic: Medico-legal issues

    Learning Outcomes for this Topic/Unit:

    By the end of this topic, you should be able to:

    • Understand the relationship between nursing and the law.
    • Identify common medico-legal issues in nursing practice.
    • Understand the different categories of law relevant to nursing.
    • Explain the importance of the code of conduct and ethics for health workers.
    • Apply legal and ethical principles in your daily nursing practice.
    • Understand the rights of patients in healthcare.
    • Understand some key rights of nurses.

    Nursing and the law

    The law is a system of rules that society creates and maintains. It helps to protect property and keep people safe from harm. For nurses, understanding the law is very important because it affects how they provide care and their responsibilities.

    Importance of Law to Nurses:

    • Protect the public from persons unqualified to practice nursing. This ensures that only trained and competent individuals provide care.
    • To define the scope of the nurse’s practice (i.e. what s/he is expected by law to do and not to do). This helps nurses know their boundaries and responsibilities.
    • To protect patients from legal risks. By following the law, nurses help prevent harm to patients.
    • To deal with legal threats effectively. Knowing the law helps nurses protect themselves and their practice.
    • To issue licenses for practice and revoke or suspend a license in case of gross incompetence or negligence. This helps maintain high standards in the nursing profession.

    Categories of Law:

    Laws that affect nurses fall into different categories:

    • Criminal law: It encompasses conduct considered offensive to the public or society as a whole. Prosecution is brought by the state against an individual for breaking the law known as a crime. Example; a nurse is arrested for stealing drugs, s/he will be charged and brought before the court to handle the case which is prosecuted by the government of Uganda (Uganda vs. the nurse/criminal).
    • Civil law: It deals with the rights and responsibilities of private individuals. The civil law is designed to compensate individuals for the harm caused by the health workers. Example; if the nurse negligently administers treatment to a patient which results in to harm, the patient can sue that nurse for his/her negligence and seek compensation for the harm caused. Or the employer of that nurse meets the consequences of the negligence.
    • Tort Liability/Crimes: These are crimes that are punishable by law. There are two types of tort i.e. intentional and non-intentional. Intentional tort is punishable by law (criminal or civil law.)
      • Intentional Torts: These are harmful acts done intentionally.
        • Assault: Threatening or attempting to touch or treat a person with out his/her consent. Example; Administering an injection to a patient who had refused it. Patients have a right to refuse care or withdraw consent at any time.
        • Sexual assault: where find the health worker harasses the patient/client sexually.
        • False detention: restraining another person with out legal justification or his/her consent. An example; Medical asylums or isolation centers for the presumed mentally ill.
        • Fraud: purposeful misrepresentation that causes harm to another person. Example; Misrepresenting qualifications when applying for licensure.
        • Negligence: deviation from standard of care that results in HARM to the patient. Example; Administering treatment negligently and contrary to the professional standards e.g. wrong medication, wrong route of administration, wrong dosage and concentration. Mistaken identity i.e. preparing a wrong patient for an operation, to exchange babies in the labour room/suit, to exchange dead bodies in the mortuary. Failure to communicate verbally or in written concerning the patient’s condition. Poor or no maintenance of patient’ records. Failure to count sponges and instruments during surgery leading to retaining of some in the patient’s body. Loss or damage to patient’s property and fame. Breach of duty (negligent action/omission that violates the standard of care expected.) Physical or psychological damage of the patient. Failure to report and protect victims e.g. child abuse, sexual assault, patients restrained by law, mentally incompetent and infectious disease exposure.
      • Abandonment: termination of a patient’s care with out assuring the continuation of care at the same level or higher.
      • Euthanasia (mercy killing): taking positive step to kill a person in order to end his/her suffering is murder.
      • Breach of scope of practice: failure to follow the range of activities and limitations of a given medical provider as defined by the state legislation, references national curricula or may be enhanced by medical direction, protocols and standing orders.
      • Breach of confidentiality: failure to keep privileged information i.e. patient’s history, assessment findings, treatment rendered etc.

    Rights of a Patient

    Optimal care of a patient requires harmonious collaboration between the patient and the care provider. Understanding patient rights is important.

    Purpose of Patient Rights:

    • Help the patients feel more confident in the health care setting.
    • To stress the importance of a strong relationship between the patients and their health care givers.
    • To indicate the key roles patients play in staying healthy.

    The following are the rights of a patient:

    • A patient has a right to accurate and clear information relevant to his/ her health care plan except in emergencies.
    • The patient has a right to know the identity of medical personnel involved in their care.
    • Patients have a right to fully participate in decision making related to their health care.
    • A patient has a right to refuse any recommended treatment or care plan.
    • They have a right to be informed of the consequences of any action.
    • Patients who are unable to participate have a right to be represented by parents, guardians or other family members.
    • Patients have a right to respect and non-discrimination from all members of the health care team at all times and under all circumstances.
    • The patients have a right to every consideration of privacy concerned with case discussion and consultation. Examination and treatment should be conducted in a manner that protects the patient’s privacy.
    • All communications and records pertaining the patient’s care must be treated as confidential by the hospital or health care team.
    • Patients have a right to review the records pertaining to their medical care and to have the information explained or interpreted as necessary except when information is restricted by law.
    • The patients have a right to choose health care providers who will ensure access to appropriate high quality of care.
    • The patients have a right to complain about the care or appeal for proper care internally or externally (an independent system).
    • A patient has a right to know the policies of a hospital regarding their care.

    Rights of a Nurse

    While the focus is often on patient rights, nurses also have important rights that protect them and enable them to provide good care. Based on the curriculum's content on ethical standards and the Nurses and Midwives Act, some key rights of a nurse include:

    • The right to a safe working environment: This includes protection from violence, hazards, and infections.
    • The right to fair treatment and compensation: Nurses are entitled to just payment for their work as agreed in their contract.
    • The right to refuse to participate in unethical or illegal practices: Nurses are not obligated to carry out orders that are against their professional code or the law (e.g., participating in an illegal abortion).
    • The right to appropriate resources and support to provide care: This includes having the necessary equipment, supplies, and adequate staffing.
    • The right to continuing education and professional development: To maintain a high standard of competence, nurses have the right to opportunities for learning and improving their skills.
    • The right to be treated with respect by patients, colleagues, and superiors.
    • The right to privacy regarding their personal information.
    • The right to belong to professional associations (like the Uganda Nurses and Midwives Council).
    • The right to acknowledge limitations in their knowledge or skills and decline duties they are not competent to perform safely.

    Code of conduct and ethics for health workers (from the Nurses and Midwives Act, 1996, Part IV)

    This section outlines the expected behavior and responsibilities of health workers in Uganda, as defined by the Nurses and Midwives Act.

    • Article 29. Code of conduct: This part of the Act contains the specific rules of conduct that all health workers in Uganda must follow in their practice.
    • Article 30. Responsibility to patients:
      • A health worker must put the health, safety and interest of the patient first and always treat each patient with due respect.
      • You must ensure that nothing you do or fail to do harms the patient's interest, condition, or safety.
      • A nurse must provide the patient with relevant, clear and accurate information about their health and how it will be managed.
      • If a patient is able to give consent, medical treatment should only be given with their full, free, and informed consent. In emergencies, when immediate action is needed and getting consent might delay care, intervention may be done. For patients who are minors or not able to give consent (incompetent), consent must be obtained from their parent, relative, guardian, or the head of the hospital.
      • Nurses must **respect the confidentiality** of information about the patient and their family. This information should not be shared with anyone without the patient's consent or the consent of an appropriate guardian, unless sharing the information is in the patient's best interest or required by law.
      • A health worker taking care of someone who is detained (like in a prison) must do so in the best interest of the detainee and must maintain **strict confidentiality**.
      • A health worker shall not take, ask for, or accept any bribe from a patient or their relatives.
      • When carrying out an examination or providing a report for an authorized person, maximum care must be taken to protect the **confidentiality and interest** of the patient.
      • A health worker shall **no abandon a patient** under their care.
    • Article 31. Responsibility to the community:
      • The nurse must ensure that their actions do not endanger the safety or condition of the public.
      • Health workers must promote effective health services and inform the health team and other authorities whenever they become aware of a health **hazard to the community** (e.g., an outbreak of cholera or dysentery).
    • Article 32. Responsibility to health unit/institution (place of work): Health workers must follow the rules and regulations of their workplace, meet the expectations of the health unit, and work to fulfill the mission of the institution.
    • Article 33. Responsibility to law, profession and self:
      • A health worker must **observe the law** and uphold the **dignity of their profession** and accepted ethical principles.
      • Health workers shall not take part in activities that **discredit their profession** or the delivery of health services. They must report anyone who engages in illegal or unethical conduct (like stealing or not following the dressing code) without fear.
      • You must **respect the confidentiality** of patient and family information. This information should not be shared with anyone without the patient's written consent or the consent of an appropriate guardian, unless the law requires it.
      • A health worker must maintain a **high standard of professional knowledge and skills** by continuing their medical education.
      • A health worker shall not advertise their professional skills directly or indirectly, or try to take patients away from colleagues. If they notify the public about available services, they must do so appropriately.
      • A health worker shall not perform their duties while under the **influence of alcohol**.
      • A health worker shall not engage in **dangerous lifestyles** such as alcoholism or drug addiction, which can damage the reputation of the profession.
      • Health workers shall not support or be linked with cults or unscientific practices that claim to contribute to health care.
      • A health worker must be **registered** with their relevant professional council and be a member of the national association.
      • Nurses must recognize any **limitations in their knowledge and competence** and should refuse a duty or responsibility if they are not able to perform it safely and skillfully.
    • Article 34. Responsibility to colleagues: A health worker must **co-operate** with their professional colleagues, recognize, and respect each other's expertise to provide the best possible holistic care as a team.

    Introduction to the practice room (PEX 1.1.9) & Hospital economy (Sub-topic 1.1.10)

    These are practical/observational aspects of this topic.

    Introduction to the Practice Room:

    This involves getting familiar with the practice room (sometimes called a skills lab). This is where you will practice nursing procedures in a safe environment before working with real patients. You'll learn where equipment is kept and how to use it correctly.

    Hospital Economy:

    Understanding hospital economy means understanding how resources (like money, supplies, and equipment) are managed efficiently in the hospital. This includes things like managing ward supplies and participating in basic planning related to resources to ensure the hospital runs smoothly.

    Learning-Working Assignments (LWAs) and related Practical Exercises (PEXs) from the curriculum for this topic:

    • Introduction to Ethical Standards (Sub-topic 1.1.1 to 1.1.8 - includes legal and ethical concepts)
    • Introduction to the practice room (PEX 1.1.9)
    • Hospital economy (Sub-topic 1.1.10)

    (Note: The curriculum also lists LWAs/PEXs for other topics in CN-1101 like Infection Prevention and Control and General Nursing Care, which we will cover later.)

    Underpinning knowledge/ theory for Medico-legal issues:

    (This is covered within the sub-topics above.)

    • Nursing and the law (Categories of Law, Importance of Law to Nurses)
    • Code of conduct for Nurses
    • Principles of professional ethics and etiquette
    • Patient’s rights
    • Nurses’ rights
    • Nursing standards and qualities of a nurse
    • General principles and rules of all nursing procedures
    • Hospital economy

    Revision Questions for Medico-legal issues:

    1. Explain why understanding the law is important for nurses.

    2. Describe the difference between criminal law and civil law, and provide an example of each related to nursing.

    3. What is negligence in nursing? Give three examples.

    4. Define 'Assault' and 'False detention' as intentional torts in nursing.

    5. According to the Nurses and Midwives Act, what is the primary consideration for a health worker regarding a patient?

    6. When can a health worker disclose confidential patient information without the patient's consent?

    7. List three responsibilities of a health worker to the community.

    8. What does Article 33 of the Nurses and Midwives Act cover regarding the responsibility to law, profession, and self?

    9. Explain the importance of acknowledging limitations in knowledge and competence for nurses.

    10. What does 'Hospital economy' refer to in the context of nursing training?

    11. List at least five rights that a patient has in healthcare.

    12. Mention three important rights that nurses have.

    References (from Curriculum for CN-1111):

    Below are the core and other references listed in the curriculum for Module CN-1111. Refer to the original document for full details.

    • Uganda Catholic Medical Bureau (2015) Nursing and Midwifery procedure manual 2nd Edition Print Innovations and Publishers Ltd. Uganda
    • Nettina .S,M (2014) Lippincott Manual of Nursing Practice 10th Edition, Wolters Kluwer, Philadelphia, Newyork
    • Gupta, L.C., Sahu,U.C. and Gupta P.(2007):Practical Nursing Procedures. 3rd edition. JAYPEE brothers, New Delhi.
    • Craveni, R. Hirnle, C. and Henshaw, M.C. (2017). Fundamentals of Nursing Human Health and Function. 8th Edition. Wolters Kluwer
    • Hill, R., Hall, H and Glew, P. (2017). Fundamentals of Nursing and Midwifery, A person-Centered Approach to care. Wolters Kluwer
    • Rosdah I, BC and Kowalkski, TM (2017) Text book for Basic Nursing 11th Edition Wolters Kluwer.
    • Samson .R. (2009) Leadership and Management in Nursing Practice and Education 1st Edition Jaypee Brothers Medical Publishers India.
    • Taylor.C.R (2015) Fundamentals of Nursing, The Art and Science of person – centred nursing care, 8th Edition Wolters Kluwer, Health/Lippincott Williams and Wilkins.
    • Timby, K.B (2017) Fundamentals of Nursing Skills and concept 11th Edition Wolters Kluwers, Lippincotts Williams and Wilkins.
    • Lynn, P. (2015) Tyler's Clinical nursing skills, A Nursing Process Approach 4th Edition Wolters Kluwers, China
    • Gupta, D.S. (2005) Nursing Interventions for the critically ill 1st Edition Jaypee Brothers Medical Publishers Ltd. India.
    • Uganda Catholic Medical Buraeu (2010) Nursing and Midwifery Procedure Manual. 1st Ed. Print Innovations and Publishers Ltd., Uganda.
    • Carter, J. P. (2012) Lippincott's Textbook for nursing Assistant. 3rd Edition. Walters Kluwers. Lippingcotts Williams and Wilkins
    • Jensen, S. (2015) Nursing Health Assessment; A host Practice Approach. 2nd Edition. Wlaters Kluwer,
    • UCMB. (2015) Nursing and Midwifery Procedure Manual. 2nd Edition. Print Innovation and Publishers Ltd. Kampala. Uganda.
    • Karesh, P. (2012) First Aid for Nurses. 1st Edition. Jaypee Brothers Medical Publishers Ltd. India.
    • Molley, S. (2007) Nursing Process; A Clinical Guide. 2nd Edition. Jaypee Brothers Medical Publishers Ltd. India.
    • Carter, J.P. (2016) Lippincott's Textbook for Nursing Assistants. 4th Edition. Wolters Kluwer, Lippincotts Williams and Wilkins.
    • Rahim,A. (2017). Principles and practices of community medicine. 2nd Edition. JAYPEE Brothers Medical Publishers Ltd. New Delhi
    • Cherie Rector, (2017) ,Community & Public Health Nursing: Promoting The Public's Health 9e Lippincott Williams and Wilkins
    • Gail A. Harkness, Rosanna Demarco (2016) Community and Public Health Nursing 2nd edition, Lippincott Williams and Wilkins
    • Basavanthapp, B.T and Vasundhra, M.K (2008), Community Health Nursing, 2nd edition. JAYPEE Brothers Medical Publishers Ltd. New Delhi
    • Kamalam, S. (2017), Essentails in Community Health Nursing Practice 3rd edition. JAYPEE Brothers Publishers Ltd. New Delhi
    • James F. McKenzie, PhD, MPH, MCHES, MEd,and Robert R. Pinger, PhD, (2018) An Introduction to Community & Public Health, 9th edition, Jones and Bartlett Publishers. Sandburg, Massachusetts.
    • Maurer, F.A, Smith, C.M (2005), Community /Public health Nursing Practice, 3rd edition ELSEVIER SAUNDERS, USA
    • МОН, (2013) Occupational Safety and Health Training Manual, 1st Edition
    • МОН, (2008), Policy for Mainstreaming Occupational Health & Safety In The Health Service Sector.
    • Wooding, N. Teddy, N. Florence, N. (2012) Primary Health Care in East Africa. 1st Edition. Fountain Publishers. Kampala. Uganda.

    Medico-Legal Issues Read More »

    Ethical standards in nursing

    Ethical Standards in Nursing

    Ethical standards or principles are higher than those standards made by law

     For-example, to steal is wrong by law and it’s punishable by law. To tell lies is not wrong by law but is wrong by the ethical standards of behavior.

    Ethical Standards In Nursing

     The following are the ethical standards or principles;

    • Discipline
    • Intelligent obedience
    • Punctuality
    • Tactiful understanding and patience
    • Respect for persons
    • Respect for autonomy-that individuals are able to act for themselves to the level o their capability
    • Respect for freedom
    • Respect for beneficience
    • Respect for non-maleficience
    • Respect for veracity-truth telling
    • Respect for justice-fair and equal treatment
    • Respect for rights
    • Respect for fidelity-fulfilling promises
    • Confidentiality-protecting privileged information.
    • High sense of responsibility.

    Ethics of nurses

    • Nursing as other professions has its standard of right behaviours that all nurses must adhere Some of the nurses’ ethics are as follows;
    • The fundamental responsibility of a nurse is a three (3) fold:-
    • >       To conserve life
    • >      To alleviate suffering } CAP
    • >      To promote health
    • The nurse must at all times maintain the highest standard of nursing care and of professional
    • A nurse must maintain his/her knowledge and skills at constantly high level
    • Religious beliefs of patient must be respected
    • Nurses must recognize not only their responsibility but also the limitations of their professional
    • Nurses must hold confidence in all personal information entrusted to them.
    • The nurse is under the obligation to carryout physicians’ order intelligently with loyalty and to refuse to participate in unethical procedures g. abortion, mercy killing etc.
    • A nurse is entitled to just remuneration and accepts only such compensation as the contract, actual or implied
    • Nurses should no permit their names to be used in connection with advertisement of products or any other form of self advertisement g. going in public with a uniform.
    • A nurse co-operates with and maintains harmonious relationships with members of other professions and with his/her professional
    • A nurse should participate and share responsibility(ies) with other citizens and other health professions in promoting efforts to meet the health needs of the public, local, district, national, international component.

    ROLES OF A NURSE

    Nurses work as a team which comprises of nurses, doctors, occupation therapists, social workers, physiotherapists, nutritionists and many others. The following are some of the roles of a nurse;

    Care giver: Care giving encompasses the physical psychological, developmental, cultural and spiritual needs

    Patient’s advocate and protector: The nurse must represent the client’s/patient’s needs and wishes to other health professionals e.g. client’s wishes foe information to the physician.

    Communicator: A nurse should identify patient’s problems and then communicate these verbally or in writing to other members of the health team.

    Teacher: As a teacher, the nurse helps patients/clients, their relatives, colleagues and the community to learn about their health and the health care procedures they need to perform to restore or maintain their health.

    Counselor: The nurse counsels health individual with normal adjustments, difficulties and focuses on helping the person to develop new attitudes, feelings and behaviours by encouraging the client to look at alternative behaviours, recognize the choices and developa sense of control.

    Nurse educator:  Some nurses take up teaching of nursing as their profession for- example as tutors, clinical instructors, lecturers and professors. They maintain their clinical skills and facilitate the development of nursing skills in students.

    Manager: Management in nursing is the co-ordination and facilitation of nursing services; nurses are involved in the management of the nursing care by communication i.e.

    • Directly with hospitalized patients
    • Within the nursing team
    • Within the wider health team(including doctors and paramedical staff)

    Decision maker: The nurse observes the patient continuously and makes decision regarding nursing diagnosis of the patients and the steps of the nursing process.

    Rehabilitator:  In the physical medical department, the nurse helps patients in rehabilitation. This is also done in psychiatric department.

    CHARACTERISTICS OF A PROFESSIONAL NURSE

    • Good physical and mental health
    • Truthful and efficient in technical competence
    • Cleanliness, tidy, neat and well groomed
    • Confidence in others and her/himself.
    • Open minded, co-operative, responsible and able to develop good interpersonal relations
    • Leadership quality
    • Positive attitude
    • Self-belief towards human care and cure.
    • Conveys co-operative attitude towards co-workers.

    ACTIVITIES/FUNCTIONS OF A NURSE

    Some of the functions of a nurse include the following;

    • Receiving of patients in out patient department and giving them guidance.
    • Admission of patients on wards, ensuring comfort and reassurance to them
    • Perform duties such as bed making, dump dusting etc.
    • Administer medications to the patients and monitoring the side effects.
    • Taking of vital observations i.e. pulse, respirations, blood pressure, oxygen saturation and level of consciousness and record them to the patient’s charts.
    • Co-ordinates patients with special services such as physiotherapy, radiotherapy psycho-social support etc.
    • It is also the duty of a nurse to co-ordinate patients to the special clinics like diabetic, cardiac, B, skin, cancer institute etc.
    • Provides health education, immunization both in the units and out reaches.
    • Reinforces and repeats doctor’s explanations to the patients in layman’s language (local language or in simple )
    • Knows the number of the patients at her/his unit and their conditions.
    • Keeps the ward/unit inventory on daily basis, weekly, monthly and annually
    • Makes reports about his/her unit per shift.

    QUALITIES/STANDARDS OF A GOOD NURSE

    Punctuality: This is vital for smooth running of the hospital and speedy recovery of the patients, so a nurse is required to be punctual while performing all duties.

    Confidentiality: A nurse is to ensure that the patient’s diagnosis, problems and condition are not discussed with outsiders who are not involved in the patient’s health care. The information should only be released to the relatives and friends with the patients consent.

    Fidelity: Obligation to remain faithful to ones commitments

     

    Empathetic: Awareness of and insight into feelings, emotions and behavior of another person and their meaning and significance

    Resourcefulness and initiative: The nurse should be able to act immediately during emergency by using her/his common sense, knowledge and with ability to use the available resources or equipment for the benefit of the patients. S/he should execute nursing care with in her/his professional level of responsibility.

    Alert and observant: It is the power to see, hear and appreciate what is being done and act accordingly and intelligently.

    Tactfulness (creativeness): A nurse must be careful to say and to do the right thing with greatest consideration for the other person’s feelings.

    Faithfulness: The nurse should remain true or loyal to the patients always while executing her duty. Also to the colleagues and any other thing entrusted to her.

    Loyalty: A nurse must be loyal to her patient colleagues, superiors for the good of the patient.

    Truthfulness and genuineness: A nurse must be honest in word and deed to her patients, fellow workers, with self and the entire community. This is the most important, vital virtue and of special value to nursing profession. She should also be able to admit her mistakes whether discovered by herself or by someone else.

    Speed and gentility: The nurse should always act fast and in a responsible and polite manner while carrying out her/his procedures especially during the emergencies.

    Accuracy (in decision making): The nurse should be correct and precise in whatever she does because the life of the patient is in her hands.

    High sense of responsibility; to promote health, restores health and alleviates suffering.

    Respectful: The nurse should show respect to self, patient, seniors, juniors and all people in authority.

    Courteous: It costs nothing to be polite and considerate to others. S/he should be straight forward in all s/he does.

    Integrity: S/he should adhere to moral principles of the profession and be honest to the patients/clients.

    Justice: All individuals will have equal and fair access to health care, resources available according to an individual’s need.

    Caring: It is the obligation of the nurse to give service of care to the sick person as her calling meeting the patient’s physical, spiritual and psychological needs.

    Co-operative: The nurse should have a sense of working with others, so as to be able to give adequate and quality care to the patients and entire community.

    Accountable: A nurse must be responsible for any action done either to the patients or for the hospital.

    Responsiveness: S/he should be able to react quickly to the situation at hand e.g in emergencies.

    Being considerate: A nurse should be thoughtful or kind to the patients when rendering health services to them.

    Poise: S/he should be composed or show dignity of manner while carrying out her/his duties.

    Intelligent: The nurse should show high sense of knowledge during performance of the procedures to the patients.

    Control of emotions: A nurse should be good tempered and able to control or cope with emotions such as anger, irritation, love or hatred. The nurse needs to develop emotional maturity in order to manage the problems and different behaviours of the patients, caretakers and fellow colleagues.

    Tolerance and understanding:  A nurse must realize that the patients are physically, emotionally, psychologically sick and worried about their health, disease, homes and family. Therefore human understanding, sympathy together with technical knowledge and efficiency are foundation on which a true profession nurse must build her career.

    Cleanliness: Personal and environmental cleanliness and tidiness are essential to quick recovery of the patients and the nurse herself. Apart from other infection control methods, orderliness plays a role in the prevention of disease and infections.

    N.B Nurses learn about professional values both from formal institutions and from informal observation of practicing nursing staff and gradually incorporates professional values into their personal value system. Some of the values are non-moral and others are moral. Example of non-moral values include the following;

    • Hairstyle
    • Uniform
    • Colours
    • Fashions of shoes

    There are two principles under-minding ethical practices in nursing and health care i.e. beneficience-the obligation to do good, non-maleficience-obligation to do no harm. The two are related but distinct and if the distinction is recognized, it helps to guide moral conduct of a nurse.

    AIMS OF A NURSE

    • To help save life
    • To help prevent further suffering
    • To help prevent disease and improve the health of the fellow men.
    • To assist the individual by performing those activities or duties which he would if able to and knowledgeable by himself.

    Liberal Meaning of the word ‘Nurse’

    N-Nobility/Knowledgeable

    U-Usefulness/Understanding

    R-Responsibility

    S-Simplicity/Sympathy

    E-Efficiency/Equanimity

    PROFESSIONAL CODE OF CONDUCT

    Is the way how one must behave towards his/her clients/patients, institution and the entire community which is acceptable professionally and publicly. The code of conduct is as follows;

    Self: 

    • Report any conduct that endangers client/patients.
    • Stay informed of current nursing practices, theory and issues and make judgement based on facts

    Client/patient:

    • Provide clients/patients with accurate information about care and conduct nursing in a manner that ensures clients’ safety and well being.

    Professional:

    • Maintain ethical standards in practice. Encourage other professional peers to follow the same ethical standards
    • Report colleagues with unethical behaviours

    Employment institution

    • Follow practices and procedures defined by the institution.

    Community/society:

    • Maintain ethical conduct in the care of all clients in all settings.
    • Every health worker must conduct him/her self in a manner that is acceptable professionally and publicly at all times.

    Code of conduct and ethics for health workers Part IV.

    Article 29. Code of conduct

    This part of the act shall constitute a code of conduct and shall be observed by all health workers.

    Article 30. Responsibility to patients

    • A health worker shall hold the health, safety and interest of the patient to be first consideration and shall render due respect to each patient at all times and in all circumstances.
    • Ensure that no action or omission on your part or sphere of responsibility is detrimental to the interest or condition or safety of the patient.
    • A nurse shall provide a patient with relevant, clear and accurate information about his/her health and the management for her/his condition.
    • Treatment and other forms of medical intervention to a patient who has capacity to consent shall not be undertaken without the patient’s full free and informed consent except in emergencies when such intervention may be done in the best of the patient. Incase of minor or other incompetent patients, consent shall be obtained from apparent/relative/guardian or the head of the hospital.
    • The nurse shall respect the confidentiality information relating to the patient and his family; such information shall not be disclosed to anyone without the patient’s consent or appropriate guardian, except where it is the best interest of the patient
    • A health worker who attends to a person held in detention shall do so in the interest of the detainee and strict confidentiality must be observed just as with other patients
    • A health worker shall no take, ask or accept any bribe from the patient or relatives.
    • Maximum care shall be taken not to compromise the confidentiality and interest of the patient when carrying out an examination or supplying a report at the request of an authorized person.
    • A health worker shall no abandon a patient under his/her care.

    Article 31. Responsibility to the community

    • The nurse should ensure that no action or omission on her/his part or sphere of responsibility is detrimental (endangers) the interest or condition or safety of the public.
    • A health worker shall promote the provision of effective health services and shall notify the health team and other authorities whenever he/she becomes aware of the hazard to the community e.g. out break of cholera, dysentery, Ebola etc.

    Article 32. Responsibility to health unit/institution (place of work)

    • The health worker shall abide by the rules and regulations governing the place of work and shall confirm to the expectations of the health unit, and strive to fulfill the mission of the institution.

    Article 33. Responsibility to law, profession and self

    • A health worker shall observe law; uphold the dignity of his/her profession and accepted ethical principles.
    • A health worker shall not engage in activities that discredit his/her profession or delivery of health services and shall expose without fear or favour all those who engage in illegal or unethical conduct and practice e.g. stealing, poor dressing code etc.
    • The health worker shall respect the confidentiality of information relating to the patient and his/her family, such information shall not be disclosed to anyone without the patient’s or appropriate guardian’s written consent except where it is required by law.
    • A health worker shall keep a high standard of professional knowledge and skills in order to maintain a high standard of professional competence through continuing medical education program.
    • A health worker shall not directly or indirectly advertise his/her professional skills or allow him/her to be advertised directly or indirectly and shall not entice patients from his/her colleagues except h/she shall notify the public of the services available in the health facilities.
    • A health worker shall not perform his/her duties under the influence of alcohol.
    • A health worker shall not indulge in dangerous life styles such as alcoholism, drug addiction, that discredit the profession
    • The health worker shall not support or become associated with cults or unscientific practices professing to contribute to heath care.
    • A health worker shall be registered with his/ her relevant professional council to be a member of the national association.
    • Nurses shall acknowledge any limitation in their knowledge and competence and decline any duty or responsibility unless able to perform them in a safe and skilled manner.

    Article 34. Responsibility to colleagues:

    • A health worker shall co-operate with his/her professional colleagues, recognize and respect each others expertise in the interest of providing the best possible holistic care as a health team.

    Ethical Standards in Nursing Read More »

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