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Study Sample and Design the sample for this descriptive correlational study consisted of 75 participants (53 men and 22 women) who were about to sustain facial disfigurement and dysfunction as an outcome of head and neck surgery. Subjects were requested to complete the State Trait Anxiety Inventory and the Ways of Coping Questionnaire before their surgery and the Coping Behaviors Score and the Disfigurement/Dysfunction Scale afterward. Findings the results of the study revealed no significant correlations between preoperative anxiety and the percentage of problem-focused coping strategies used to handle disfiguring surgery. A high level of anxiety was present, which was equivalent to the anxiety of people admitted to a psychiatric treatment center for an acute anxiety reaction. Although there was low use of problem-focused coping strategies before the surgery, postoperative coping behaviors occurred early in the recovery period. Scores indicated that severe functional impairment was present immediately after surgery. The anxiety scores for these patients decreased over time, but there was no significant correlation between disfigurement/dysfunction and anxiety. The level of anxiety was negatively correlated with self-care after surgery on the fourth and fifth postoperative days. These findings indicate that anxiety is decreased by the performance of selfcare behaviors in the early postoperative period. Nursing Implications For the nurse caring for a postoperative patient who is undergoing head and neck surgery, it is important to recognize that early participation in self-care behaviors is associated with reduced anxiety in these patients. Therefore, nurses need to facilitate self-care activities in this population, because this intervention can help to promote positive postoperative outcomes. Posttraumatic Stress Disorder In medical-surgical settings, especially in emergency departments, burn units, and rehabilitation centers, nurses care for extremely anxious patients who have experienced devastating events that are typically considered to be outside the realm of normal human experience. Every nurse must be vigilant about the patient who worries excessively and demonstrates deterioration in emotional, social, or occupational functioning. If participation in the therapeutic regimen (eg, administration of insulin) becomes a problem because of extreme anxiety, nursing interventions must be immediately initiated. Caring strategies emphasize ways for the patient to verbalize feelings and fears and to identify sources of anxiety. The need to teach and promote effective coping abilities and the use of relaxation techniques are the priorities of care. Chart 7-8 provides a list of basic nursing principles that are useful for assisting patients to manage severe anxiety. Chapter 6 presents additional information about stress and the relaxation response. Patients who have suffered a traumatic event are often frequent users of the health care system by virtue of their extensive injuries, the various treatment modalities that they require, and the overall emotional and physical difficulties experienced. The physiologic responses noted in people who have been severely traumatized include increased activity of the sympathetic nervous system, increased plasma catecholamine levels, and increased urinary epinephrine and norepinephrine levels. The resulting excessive arousal can increase overall body metabolism and trigger emotional reactivity. In this situation, the nurse would observe that the patient has difficulty sleeping, has an exaggerated startle response, and is excessively vigilant. Study Sample and Design A total of 225 consecutive patients going to a local cancer clinic were invited to complete a questionnaire packet. It was further reported by the women that the interpersonal and relational facets of their illnesses were more stressful and were the most difficult aspects of having cancer. Men indicated that their stress was associated with the work role and loss of finances. Nursing Implications Some women find the experience of cancer treatment to be very difficult. Overall, women need support from health care professionals, additional control over their treatment, opportunity to tell their stories and concerns, support groups, and access to complementary therapies. Depression Depression is a common response to health problems and is an often underdiagnosed problem in the patient population. People may become depressed as a result of injury or illness; may be suffering from an earlier loss that is compounded by a new health problem; or they may seek health care for somatic complaints that are bodily manifestations of depression. Clinical depression is distinguished from everyday feelings of sadness by its duration and severity. Most people occasionally feel down or depressed, but these feelings are short-lived and do not result in impaired functioning.

For example, a person may get an "adrenaline rush" when competing over a decisive point in a ball game, or when excited about attending a party. When the responses to stress are ineffective, they are referred to as maladaptive. Maladaptive responses are chronic, recurrent responses or patterns of response over time that do not promote the goals of adaptation. The goals of adaptation are somatic or physical health (optimal wellness); psychological health or having a sense of well-being (happiness, satisfaction with life, morale); and enhanced social functioning, which includes work, social life, and family (positive relationships). Maladaptive responses that threaten these goals include faulty appraisals and inappropriate coping (Lazarus, 1991a). The frequency, intensity, and duration of stressful situations contribute to the development of negative emotions and subsequent patterns of neurochemical discharge. By appraising situations more adequately and coping more appropriately, it is possible to anticipate and defuse some of these situations. For example, frequent potentially stressful encounters (eg, marital discord) might be avoided with better communication and problem solving, or a pattern of procrastination (eg, delaying work on tasks) could be corrected to reduce stress when deadlines approach. Coping processes that include the use of alcohol or drugs to reduce stress increase the risk of illness. Other inappropriate coping patterns may increase the risk of illness less directly. For example, people who demonstrate "type A" personality behaviors such as impatience, competitiveness, and achievement orientation and have an underlying hostile approach to life are more prone than others to develop stress-related illnesses. Type A behaviors increase the output of catecholamines, the adrenalmedullary hormones, with their attendant effects on the body. Denial may be illustrated by the woman who feels a lump in her breast but downplays its seriousness and delays seeking medical attention. Models of illness frequently cite stress and maladaptation as precursors to disease. If this state is prolonged or the response is excessive, it will increase the susceptibility of the person to illness. This susceptibility, coupled with a predisposition in the person (whether from genetic traits, health, or age), leads to illness. If the sympathetic adrenal-medullary response is prolonged or excessive, a state of chronic arousal develops that may lead to high blood pressure, arteriosclerotic changes, and cardiovascular disease. In addition, the immune response is decreased, and infections and tumors may develop. Selye (1976) proposed a list of disorders that he called diseases of maladaptation: high blood pressure, diseases of the heart and blood vessels, diseases of the kidney, hypertension of pregnancy, rheumatic and rheumatoid arthritis, inflammatory diseases of the skin and eyes, infections, allergic and hypersensitivity diseases, nervous and mental diseases, sexual derangements, digestive diseases, metabolic diseases, and cancer. Chart 6-1 lists signs and symptoms that may be observed directly or reported by the person. They are psychological, physiologic, or behavioral and reflect social behaviors and thought processes. Over time, each person tends to develop a characteristic pattern of behavior during stress that is a warning that the system is out of balance. Among the measures, blood and urine analyses can be used to demonstrate changes in hormonal levels and hormonal breakdown products. The serum creatine/creatinine ratio and elevations of cholesterol and free fatty acids can also be measured. With greater attention to neuroimmunology, improved laboratory measures are likely to follow. In addition to using laboratory tests, researchers have developed questionnaires to identify and assess stressors, stress, and coping strategies. Many of these are discussed in the research monograph developed by Barnfather and Lyon (1993), which was based on a synthesis conference held by nurse scientists on the state of the science in stress and coping nursing research. Some examples of the research instruments that nurses commonly use to measure levels of client distress and client functioning can be found in a variety of research reports (Cronquist, Wredding, Norlander, Langius, & Bjorvell, 2000; Starzonski & Hilton, 2000). Miller and Smith (1993) provided a stress audit and a stress profile measurement tool that is available in the popular lay literature. The point at which compensation subsides and pathophysiology begins is not clearly defined. Early identification of both physiologic and psychological stressors remains a major role of the nurse, and information on the interrelationships between physical and emotional health can be found in research journals.

An X factor requirement is confirmed most readily by the porphyrin test, with a negative result in the presence of H. The incidence of severe invasive infections (meningitis, sepsis, epiglottitis) in children has been reduced drastically-to about one in 10 of the numbers seen previously-since a vaccination program was started, and will continue to fall assuming the vaccinations are continued (see vaccination schedule, p. Immunization is achieved with the conjugate vaccine Hib in which the capsule polysaccharide epitope "b" conferring immunity is conjugated to protein. The immune system does not respond to pure polysaccharide vaccines until about the age of two, since polysaccharides are T-independent antigens against which hardly any antibodies are produced in the first two years of life. A four-day regimen of rifampicin has proved to be an effective chemoprophylactic treatment for nonvaccinated small children who have been exposed to the organism. This bacterium causes ulcus molle (soft chancre) a tropical venereal disease seen rarely in central Europe. The infection locus presents as a painful, readily bleeding ulcer occurring mainly in the genital area. Identification of the pathogen by means of microscopy and culturing are needed to confirm the diagnosis. A raised incidence of Brazilian purpuric fever, a systemic infection with this organism, has been observed in Brazil in recent years. Pasteurella Various different species belonging to the genus Pasteurella occur in the normal mucosal flora of animals and humans; some are pathogenic in animals. Infections by Pasteurella multocida are described here as examples of human pasteurelloses. The bacteria invade the organism through bite or scratch injuries or in droplets during contact with infected animals. Sources of infection include domestic animals (dogs, cats, birds, guinea pigs) and livestock (cattle, sheep, goats, pigs). Gram-Negative Rod Bacteria with Low Pathogenic Potential the bacterial species listed in Table 4. When they are isolated from infective material, their pathological significance is in most cases difficult to interpret. Nonmotile, slender rods; microaerophilic; colonies on blood agar with "starfish" appearance. Abscesses, wound infections, peritonitis, empyemas, septic arthritis, often as part of a mixed flora. Diagnosis involves identification of bacteria in vacuoles of large mononuclear cells using Giemsa staining (Donovan bodies). Antibiotics: aminoglycosides, tetracyclines Pronounced pleomorphism; frequent production of filaments because of defective cell walls. Various opportunistic infections in patients with severe primary illnesses; usually isolated as a component in mixed flora; data difficult to interpret. Donovania granulomatis) Streptobacillus moniliformis 4 Chryseobacterium (formerly Flavobacterium) meningosepticum (and other flavobacteria) Alcaligenes faecalis (and other species of the genus Alcaligenes) Capnocytophaga spp. The pathogens are identified for diagnostic purposes in stool cultures using special selective mediums. Helicobacter pylori contribute to the pathogenesis of type B gastritis and peptic ulcers. Spirillum minus & causes rat bite fever, known as sodoku in Japan where it is frequent. For several years now, Campylobacter bacteria have been classified together with Arcobacter (medically insignificant) in the new family Campylobacteriaceae (fam. Identification is based on growth requirements as well as detection of catalase and oxidase. Direct smear infection transmission among humans is possible, especially in kindergarten or family groups. The pathogenicity factors include pronounced motility for efficient target cell searching, adhesion to the surface epithelial cells of the stomach, urease that releases ammonia from urea to facilitate survival of the cells in a highly acidic environment and a vacuolizing cytotoxin (VacA) that destroys epithelial cells.

The risk of fetal B19 disease is apparently very small for asymptomatic pregnant women in communities where outbreaks of erythema infectiosum occur. However, household contacts with erythema infectiosum place pregnant women at increased risk for acute B19 infection. The estimated risk of B19 infection in a susceptible adult with a household contact is approximately 50%. Considering an estimated risk of 5% for severe fetal disease with acute maternal B19 infection, the risk of hydrops fetalis is approximately 2. For susceptible or acutely infected women, serial fetal ultrasonography to monitor fetal growth and the possible evolution of hydrops. Considering the high prevalence of B19, the low risk of severe fetal disease, and the fact that attempts to avoid potential high-risk settings only reduce but do not eliminate exposure, exclusion of pregnant schoolteachers from the workplace is not recommended. However, in many cases, the typical rash of erythema infectiosum may already be present, at which time infectivity is low. Furthermore, precautions directed at minimizing exposure to respiratory secretions may be taken to decrease the risk of transmission. Particular care should be exercised on pediatric wards where there are immunocompromised patients or patients with hemolytic anemias in whom B19 disease is suspected. These patients may shed virus well beyond the period of initial clinical symptoms, particularly when presenting with aplastic crisis. In this setting, there may be a significant risk for the spread of B19 to susceptible health care workers or other patients at risk for B19-induced aplastic Infectious Diseases 603 crisis. To minimize this risk, patients with aplastic crises from B19 infections should be maintained on contact precautions, masks should be worn for close contact, and pregnant health care providers should not care for these patients. This virus/receptor complex then binds to a coreceptor, and the viral core enters the host cell cytoplasm. The genome consists of the three genes found in all retroviruses (gag, pol, env), along with at least six additional genes, including gp120, which is necessary for the binding of virus to target cells, and p24, which is the major core protein. The host immune response is triggered, viremia is cleared, and 80% of patients become asymptomatic; for 20%, a rapidly progressive course ensues. These data include more than 50,000 cases reported in youth between 13 and 24 years old. The decreased death rate in recent years is in large part attributed to access to more potent antiretroviral therapies since 1996. The vast majority of these infected infants are born to women who were unaware of their diagnosis, either because counseling and testing was not offered or because women did not consent to testing. Breastfeeding has been found to increase the rate of perinatal transmission by approximately 14%; therefore, it is highly discouraged where safe formula-feeding alternatives exist. Trials of continued maternal and/or infant prophylaxis with antiretroviral therapy as well as with early weaning and alternatives to breastfeeding are continuing. Contributions from wealthy foundations and governments in developed countries have helped to put these treatment programs in place. Although there are still many remaining challenges, significant progress is being made. The groups affected have been intravenous drug users and patients receiving transfusions or factor concentrates. Neither infection nor quantity of virus present in the placenta correlates with congenital infection. This may suggest that the placenta in general acts as a protective barrier to transmission or conversely as a focus of potential transmission. After this phase, the patient becomes symptomatic, generally with opportunistic infections, especially tuberculosis, and death occurs within 5 years. Issues of when to initiate antiretroviral therapy must be individualized, and willingness of the care provider to ensure that the infant or child receives every dose every day is a critical component of success. The mother should also have a tuberculin skin test and, when appropriate, be offered hepatitis B, pneumococcal, and influenza vaccines. Currently in the United States, the rate of vertical transmission is 2% in women who are diagnosed and who take antiretroviral therapy before delivery. Data have shown that instituting zidovudine as a component of antiretroviral therapy antenatally, intrapartum, or even neonatally reduces transmission compared with that seen (25%) when no antiretroviral therapy is received by the mother or the infant. Pneumocystis jirovecii and possibly Mycobacterium avium intracellulare prophylaxis also should be considered.