Diagnostic Tests for SARS
Test	Purpose	Abnormal Findings
Laboratory Studies
SARS-CoV reverse-transcription–polymerase chain reaction (RT-PCR) test: A signed consent should be completed prior to collection of a sample. The sample should be forwarded to a state or local public health laboratory for processing.	Detects SARS-CoV viral RNA in respiratory samples, stool, and blood. The likelihood of detecting infection is increased if multiple specimens are collected at several times during the course of the illness. Has not been licensed by the U.S. Food and Drug Administration (FDA). Currently approved as an FDA investigational device exemption (test).	A positive SARS-CoV RT-PCR test should be considered presumptive until confirmatory testing by a second reference laboratory is performed. A negative test result for SARs-CoV may not rule out SARS-CoV disease and should not affect patient management or infection control decisions.
SARS-CoV enzyme immunoassay (EIA) test: A signed consent should be completed before collection of the sample. The sample should be forwarded to a state or local public health laboratory for processing.	Detects SARS-CoV antibodies in blood samples. CDC considers detection of SARS-CoV antibody to be the most reliable indicator of infection. Has not been licensed by the FDA. Has been allowed for use by the FDA as a result of the SARS outbreak.	Detectable antibodies
SARS-CoV immunofluorescence assay (IFA) for antibody	Gives results identical to SARS-CoV EIA for antibody	Detectable antibodies
Specimen culture for SARS-CoV	Isolation of SARS-CoV from a clinical specimen to confirm the virus	SARS-CoV identified in specimen
Sputum and blood cultures	Test can aid in ruling out bacterial infection.	Positive for bacterial pathogen
Respiratory viral panels for influenza A and B, respiratory syncytial viruses, and specimens for Legionella and pneumococcal and urinary antigen	These tests aid in ruling out other potential sources of infection.	Positive for pathogen
CBC and clotting profile	Monitoring WBC counts to assist in evaluation of other bacterial infection	Evaluation for lymphopenia, thrombocytopenia, and leucopenia
Radiology
Chest radiograph	Assists in identifying the progression of disease and anatomic involvement	Infiltrates suggestive of pneumonia
Respiratory Tests
Arterial blood gases (ABGs)	Determination of patient oxygen saturation of arterial blood	Alkalosis, acidosis (see Acid-Base Imbalances, p. 1)
Pulse oximetry	Measure patient oxygen saturation of arterial blood	Values of <90%

Sars-cov laboratory studies and interpretation

Laboratory-confirmed SARS-CoV infection requires detection of antibody for SARS-CoV with confirmation in a reference laboratory:

• In a single specimen, OR

• A four-fold or greater increase in SARS-CoV antibiotic titer between active and convalescent-phase serum specimens tested in parallel, OR

• Negative SARS-CoV antibody test result on acute-phase serum and positive SARS-CoV antibody test result on convalescent-phase serum tested in parallel, OR

• Isolation in cell culture of SARS-CoV from a clinical specimen, with confirmation using a test validated by the CDC.

• Detection of SARS-CoV RNA by RT-PCR validated by CDC with confirmation in a reference laboratory from two clinical specimens from different sources or two clinical specimens collected from the same source on 2 different days

A negative serologic test can rule out SARS-CoV infection if the serum specimen is collected more than 28 days after onset of illness. Some patients do not develop an antibody (test positive) until more than 28 days after onset of illness. Patients with a negative antibody test result whose specimens were obtained 28 days before illness onset or earlier should have another serum specimen collected within 28 days after onset of symptoms.

Collaborative management

The Centers for Disease Control and Prevention (CDC) provides guidance on the clinical evaluation and management of patients who present with fever and/or respiratory illness. These guidelines focus on identification of cases and infection control management. At the present time, treatment for SARS is primarily supportive.
Management	Goal
Notify facility infection prevention leadership and the public health department.	Communicate suspected community health threat to comply with public health regulation and facilitate collaboration on the control and diagnosis of SARS-CoV.
At initial suspicion, place a mask on the patient and arrange for isolation. Place patient in an (Airborne Infection Isolation Room. [AIIR]negative pressure room) and wear personal protective equipment (PPE), including gowns, gloves, N-95 respirators, and facial protection upon entry to the room. Removal of protective equipment in a manner that prevents contamination of skin and clothing is a priority.	To prevent the transmission of SARS-CoV to other patients and to yourself.
Oxygen therapy	To support gas exchange and circumvent development of hypoxemia. Maintain pulse oximetry of >90%.
Intubation and mechanical ventilation	To support gas exchange and help maintain acid-base balance
Intravenous fluids	To prevent dehydration and maintain adequate circulatory volume
Antibiotics	To prevent secondary infections. Empirical antibiotic therapy should be prescribed for typical and atypical community-acquired pneumonia. Therapy may include a fluoroquinolone or macrolide.
Antiviral	Ribavirin is the antiviral of choice, but has had mixed results. Adverse side effects include hemolytic anemia and electrolyte imbalances (i.e., hypokalemia and hypomagnesemia). Patients must be monitored closely for significant side effects.
Corticosteroids	May be beneficial in patients with pulmonary infiltrates and hypoxemia. Methylprednisone dosage ranges from 40 mg twice daily to 2 mg/kg daily.

Care priorities for sars-cov

1. Treating the patient with supportive measures

as outlined earlier is recommended. There are no vaccines or specific management for SARS Co-V.

2. Infection control:

Patients are to be placed in a negative-pressure room under airborne, contact, and standard precautions. Anyone who enters the patient’s room must wear gowns, gloves, an N-95 respirator, and eye protection. Hand hygiene should be performed after contact with a patient on precautions. If there is a lack of negative-pressure rooms and/or there is a need to concentrate infection control efforts and resources, patients may be cohorted on a floor or nursing unit designated for the care of SARs patients only if air-handling systems can be modified to allow these areas to operate under negative pressure relative to surrounding areas.

• Designate “clean” and “dirty” areas for isolation materials. Maintain a stock of clean patient care and PPE supplies outside the patient’s room. Decide where contaminated linen and waste will be placed. Locate receptacles close to the point of use and separate from clean supplies.

• Limit the amount of patient-care equipment brought into the room to that which is medically necessary. Provide each patient with patient-dedicated equipment (e.g., blood pressure cuff, thermometer).

• Limit patient movement and transport out of the negative-pressure room. Whenever possible, use portable equipment to perform radiographs and other procedures in the patient room. Limit visits to patients to persons who are necessary for the patient’s emotional well-being and care.

• Health care workers who perform aerosol-generating procedures should be alert to the fact that there may be an increased risk of SARS-CoV transmission when these procedures are performed. PPE should fit properly and protect all skin surfaces and clothing. Wear a fluid-repellant gown or full-body suit, eye protection, N-95 respirator, and gloves that fit snuggly over the gown cuff. After an aerosol-generating procedure (e.g., intubation, bronchoscopy), clean and disinfect horizontal surfaces around the patient as soon as possible.

Additional nursing diagnoses

See nursing diagnoses for Acute Lung Injury and Acute Respiratory Distress Syndrome (p. 365), Acute Pneumonia (p. 373), Acute Respiratory Failure (p. 383), Mechanical Ventilation (p. 99), Fluid and Electrolyte Disturbances (p. 37), and Emotional and Spiritual Support of the Patient and Significant Others (p. 200).

Creutzfeldt-jakob disease

Pathophysiology

Creutzfeldt-Jakob disease (CJD) is a rare, fatal, neurodegenerative disorder, believed to be caused by an abnormal isoform of a glycoprotein known as a prion, a proteinaceous infectious particle. The most common disorder is bovine spongiform encephalopathy, or “mad cow” disease. A new form of CJD has emerged, called new variant CJD (vCJD or nvCJD). This form of CJD is linked to consumption of cattle with mad cow disease. Clinical and epidemiologic evidence supporting this link between “mad cow” disease and vCJD has become stronger. As of May 2004, a total of 153 cases of vCJD had been reported. vCJD generally affects younger people with a mean age of 29 years, whereas CJD occurs in the age group between 65 and 69 years.

CJD is classified as a transmissible spongiform encephalopathy, a category that includes other diseases (e.g., fatal familial insomnia, Gerstman-Sträussler-Scheinker syndromes). Prion disease occurs in animals, particularly cattle, sheep, and goats. CJD is endemic around the world and its estimated incidence report is 1 case per 1 million population. Three forms of “classic” CJD have been identified. Sporadic CJD affects older adults with rapid-onset dementia and neurologic symptoms of unknown cause. Familial CJD is an inherited disease and generally strikes younger individuals. It has a longer course in comparison to sporadic CJD. Iatrogenic CJD occurs through contact with infected tissue via medical procedures or treatments.

Prion proteins are normal proteins in the body and brain. In CJD, these proteins become abnormally shaped, as a result either of genetics or of contamination from an outside source. This leads to surrounding normal prion proteins taking on the abnormal shape. Central nervous system (CNS) function is disrupted, leading to cognitive impairment and cerebellar dysfunction. As the process continues, the abnormal prions accumulate in the brain, causing neuronal dysfunction, neuron death, gliosis (proliferation of neuroglial tissue in the CNS), and ultimately death.

Transmission

CJD can spread via infectious or hereditary means. Prion infections are transmitted via the peripheral route, either orally or transcutaneously. They may be introduced to lymphatic organs, particularly the spleen and lymph nodes, where initial replication of the infected prions occurs. Either infections enter the circulatory system and are hematogeneously spread to the brain, or infected prions may travel via the vagus nerve to the brain. Genetic mutation of the human prion gene PrP on chromosome 20 leads to the dysfunction of the prion protein. More than 20 reported mutations of this chromosome have been reported. All mutations influence the onset and duration of CJD. vCJD is theorized to be caused by the consumption of meat from cattle that is infected with bovine spongiform encephalopathy or mad cow disease (a prion disease). Once ingested, the infected prions follow the same neuroinvasion route of CJD.

Assessment: creutzfeldt-jakob disease

Risk factors and history

• Family history of CJD

• Exposure to contaminated tissue. People who have received human growth hormone derived from human pituitary glands or who have had dura mater grafts

Sporadic cjd

• Reported as having “come out of the blue”

• Early symptoms are memory loss, loss of interest, and mood changes that progress quickly (within a few weeks) to confusion and memory problems. Complaints of clumsiness, with jerky and stiff limbs, are also seen.

• Median age at death is 68 years old in patients who are initially seen with dementia and neurologic deterioration.

• Course of illness is often 4 months.

• Blurred eyesight and incontinence follow.

• At end stage, patients are unable to move or speak and need 24-hour care.

• Death occurs approximately 6 months after the onset of the disease.

Familial cjd

• Symptoms vary between different people, depending in part on the type of gene mutation responsible.

• In some cases, the illness is similar to sporadic CJD in type, duration, and progression, while in others, it is a more slowly developing dementia that progresses over a few years.

Vcjd

• The incubation period is unknown and may take up to several years before manifesting.

• vCJD affects younger people, with a mean age of 29 years.

• Initial symptoms are more psychiatric than neurologic.

• Patients are anxious and depressed and display withdrawal or other behavioral changes.

• Persistent pain and odd sensations in the face and extremities are common. As disease progresses, the patient develops ataxia, sudden erratic movements, and progressive dementia with marked memory loss.

• Ultimately, the patient will lose the ability to move or speak and will require 24-hour care. Death soon follows.

Diagnostic tests

CJD is diagnosed based on typical signs, symptoms, and progression of disease.

Diagnostic Tests for CID
Test	Purpose	Abnormal Findings
Radiology
Magnetic resonance imaging (MRI): T1-, T2-, and diffusion-weighted and FLAIR sequences should be ordered with MRI.	Identify abnormalities of the brain consistent with CJD	Images will show abnormalities (hyperintensities and cortical ribboning) in specific areas of the brain (e.g., basal ganglia and medial and pons).
Neurophysiology
Electroencephalogram (EEG)	For sporadic CJD cases Identify alteration in brain waves	Consistent slowing of brain waves and/or presence of periodic sharp wave complexes, generally late in the course of the disease
Laboratory Studies
Lumbar puncture: cerebrospinal fluid (CSF) examination	Assess for protein levels consistent with CJD	Elevated CSF protein levels. A 14-3-3 CSF protein test should be highly sensitive and specific to CJD.
Brain biopsy	Assess region of brain that appears abnormal on MRI. Only means of confirming CJD besides autopsy.	Deposits or plaques of abnormal bundles of prion protein, spongiform encephalopathy

Collaborative management

There is no known treatment or cure for CJD. Management of these patients is supportive and palliative in nature. There is no vaccine for CJD.

Care priorities

1. Supportive care:

Ventilatory support, pain management, patient safety, intensive skin care, assessment, nutritional support, care for immobility, and treatment for secondary infections.

2. Infection control:

Standard precautions are used to care for patients with CJD. If a brain biopsy or other procedure is performed on a patient with CJD or suspected CJD, inform the central sterile department so that stringent chemical and autoclave sterilization methods can be used to reprocess instruments.

See nursing diagnoses and interventions in Nutritional Support (p. 117), Mechanical Ventilation (p. 99), Alterations in Consciousness (p. 24), Wound and Skin Care (p. 167), Prolonged Immobility (p. 149), Emotional and Spiritual Support for the Patient and Significant Others (p. 200), and Ethical Considerations in Critical Care (p. 215).

West nile virus

Pathophysiology

West Nile virus (WNV) is a single-stranded positive RNA virus from the Japanese encephalitis virus serogroup of the genus Flavivirus, family Flaviviridae, which is known for Japanese encephalitis and St. Louis encephalitis. In rare cases, WNV may lead to encephalitis or meningitis and death. WNV has an incubation period of 3 to 14 days. It also can be divided into two lineages. Lineage I strains are more widely distributed and linked to human infections.

Transmission

WNV is a disease that has spread worldwide. Initially, WNV was a disease that only occurred in bird species. Approximately 146 different species of birds have been reported to acquire this disease. This disease is spread among the bird population by 29 different species of mosquitoes (vectors). The natural cycle is from bird 1 to mosquito 1 to bird 2 to mosquito 2, and so forth. Due to a complex intensification of this natural cycle, bridge vectors (mosquitoes that bite both birds and humans) became infected with the WNV and spread the disease to humans. Only birds and humans in the United States and Israel have been known to die from WNV.

Assessment: west nile virus

Goal of assessment

Evaluate for signs and symptoms of WNV.

History and risk factors

Exposure to mosquitoes where WNV exists increases risk. WNV is common in areas such as Africa, West Asia, and the Middle East. It first appeared in the United States in the summer of 1999 and since then has been found in all 48 contiguous states. Older age is associated with a higher risk for developing more serious CNS disease.

Incubation period

• Two to 14 days, although longer incubation periods have been documented in immunosuppressed persons.

Mild infection/west nile fever

• Symptoms last 3 to 6 days.

• Sudden onset of a fever with malaise, anorexia, nausea, vomiting, eye pain, headache, myalgia, rash, and lymphadenopathy.

Severe infection/wnv meningitis, wnv encephalitis, and wnv poliomyelitis

• When the CNS is affected, clinical syndromes ranging from febrile headache to aseptic meningitis to encephalitis may occur, and these are usually indistinguishable from similar syndromes caused by other viruses.

• WNV encephalitis or meningoencephalitis is characterized by altered mental status or focal neurologic findings.

• WNV meningitis involves fever, headache, and nuchal rigidity (stiff neck). Pleocytosis (abnormal increase in WBC count in cerebrospinal fluid) is present. Changes in consciousness are not usually seen and are mild when present.

• WNV encephalitis also involves fever and headache and more global symptoms. There is typically an alteration of consciousness, which may be mild and result in lethargy but may progress to confusion or coma. Focal neurologic deficits, including limb paralysis and cranial nerve palsies, may be observed. Tremor and movement disorders also have been identified.

• WNV poliomyelitis is characterized by the acute onset of asymmetric limb weakness or paralysis in the absence of sensory loss. Pain sometimes precedes the paralysis. The paralysis can occur in the absence of fever, headache, or other common symptoms associated with WNV infections. Involvement of the respiratory muscles, leading to acute respiratory failure, can occur.

• Clinical features

• Fever

• Gastrointestinal (GI) disturbances

• Change in mental status

• Development of a maculopapular or morbilliform rash (infrequent) involving the neck, trunk, arms, or legs

• Cranial nerve abnormalities

• Severe weakness

• Flaccid paralysis sometimes

• Ataxia/extrapyramidal signs

• Myocarditis, pancreatitis, and fulminant hepatitis have been noted in outbreaks before 1990.

Labwork

Certain findings are seen in patients with severe disease.

• Total leukocyte count is mostly normal but can be elevated with lymphocytopenia and anemia.

• Hyponatremia is sometimes present, particularly among patients with encephalitis.

• CSF examination shows pleocytosis, usually with a predominance of lymphocytes. Protein is universally elevated. Glucose is normal.

Diagnostic Tests for West Nile Virus
Test	Purpose	Abnormal Findings
Laboratory Studies
WNV IgM antibody capture enzyme-linked immunosorbent assay (MAC ELISA) of serum or CSF	To diagnose WNV Most efficient diagnostic test. Best to collect 8 to 21 days after the onset of symptoms.	Positive MAC ELISA Patients who have been vaccinated or infected with other flaviviruses (e.g., Japanese encephalitis) may have positive results.
Complete blood count (CBC)	Identify abnormalities associated with WNV	Elevated leukocyte counts with lymphocytopenia and anemia. CBC can be normal with WNV.
Serum chemistry	To assess for hyponatremia which can be seen in WNV	Hyponatremia
Radiology
Magnetic resonance imaging (MRI)	Identify possible abnormalities associated with WNV	One-third of patients show enhancements of the leptomeninges and the periventricular areas.

Testing for WNV can be obtained through local or state health departments. WNV is on the list of designated nationally notifiable arboviral encephalitides, and the proper authorities should be informed. Check your local or state health department for guidance.

Collaborative management

Treatment of WNV infection is supportive. High-dose ribavirin and interferon alfa-2b have some activity against WNV in vitro. There is no specific antibiotic or antidote for the viral infection. There also is no vaccine.

Care priorities

Supportive care:

Includes intravenous fluids to prevent dehydration, antipyretics for fever management, oxygen therapy and ventilatory support, patient safety, nutritional support, and treatment for secondary infections. Standard precautions should be taken at all times; follow organization’s policy for appropriate personal protection category.

Additional nursing diagnoses

Pandemic flu

An epidemic occurs when there are an unusually high number of people affected by a disease. A pandemic is an international epidemic. An influenza pandemic may occur when a new influenza virus is detected and the human population has no immunity. With the increase in global travel and transportation, and urban development with areas of overcrowding, epidemics that result from a new influenza virus are likely to be disseminated around the world and rapidly become a pandemic. The WHO has defined the phases of a pandemic to create a global framework to aid countries in pandemic preparedness and response planning. Pandemics can be either mild or severe in the illness and death they cause. The severity of a pandemic can change during the time the illness continues to spread.

WHO has developed a global influenza preparedness plan that outlines the responsibilities of WHO and national authorities in the event of an influenza pandemic. WHO also offers guidance tools and training to assist in the development of national pandemic preparedness plans (http://www.who.int/csr/disease/influenza/A58_13-en.pdf).

Two strains of flu—seasonal flu and the H1N1 (swine) flu—were circulating in North America during 2009. A third, highly lethal H5N1 (Avian) flu is circulating outside the United States. Healthy people generally recover from the flu without difficulty, but there is a subset of people at higher risk for serious complications. Efforts are under way to monitor the spread of all flu viruses.

Avian influenza (“bird flu”)

Pathophysiology

Avian influenza is an infection caused by avian (bird) flu viruses, type A strains. These viruses occur naturally among birds. Wild birds carry the viruses in their intestines but usually do not get sick from them. However, domesticated birds such as poultry can become very ill and die from avian influenza viruses.

Fifteen subtypes of type A strain influenza have been identified based on their surface proteins. Two proteins, hemagglutinin (H) and neuraminidase (N), are used to delineate the subtypes. All subtypes have been recognized in birds; only three subtypes of H (H1, H2, and H3) and two subtypes of N (N1 and N2) have been known to infect humans.

It is theorized that certain subtypes of avian influenza mutated, crossed species, and infected humans. Three subtypes of avian influenza are linked to human infections: H5N1, H7N7, and H9N2. The H5N1 subtype is of particular concern to humans because of its ability to mutate and its tendency to acquire genes from viruses from other animal species. It has demonstrated high pathogenicity and causes severe disease in humans.

Transmission

Avian influenza is most commonly spread from infected birds to humans. The virus is harbored in birds (in the intestine), which shed the virus through their saliva, nasal secretions, and feces. The most common means of transmission among birds is fecal to oral. Humans who come in direct contact with infected poultry are susceptible to infection. Avian influenza survives on inanimate objects. Items contaminated with secretions/excretions of infected birds can be a vector for transmission to humans. The spread of avian influenza from one sick person to another has been reported very rarely, and transmission has not been observed to continue beyond one person.

Assessment

History and risk factors

• Direct or close contact with H5N1-infected poultry or H5N1-contaminated surfaces. In outbreaks, most cases have occurred in previously healthy children and young adults.

• A Health Safety Alert will be sent out by the CDC to all hospitals if there are avian influenza outbreaks that lead this federal organization to recommend heightened surveillance and diagnostic testing of targeted patients. In this situation, the CDC will outline triage guidelines, which will likely include travel to the outbreak location within the past 10 days and hospitalization with a severe respiratory illness.

Signs and symptoms

• In more severe cases of avian influenza, when assessed, the patient may display signs and symptoms of viral pneumonia (see Acute Pneumonia, p. 373) and ARDS (see Acute Lung Injury and Acute Respiratory Distress Syndrome, p. 365).

• These symptoms can be accompanied by nausea, diarrhea, vomiting, and neurologic changes.

Diagnostic tests

Diagnostic Tests For Avian Influenza
Test	Purpose	Abnormal Findings
Laboratory Studies
CBC	Assess for changes suggestive of other bacterial infections	Elevated white blood cell count
Influenza A/H5 (Asian lineage) virus real-time reverse transcription–polymerase chain reaction (RT-PCR) assay: Must consult with and have authorization from local or state health departments. Test is conducted only in designated labs.	To identify causative agent	Positive
Rapid bedside tests: Available but results are not confirmatory	Conduct for rapid screening for virus	Positive Confirmatory tests should be performed.
Viral culture: Must be conducted in biosafety Level 3 laboratory	Identify causative agent	Positive for pathogen
Radiology
Chest radiograph	Identify progression of lung disease, and anatomic involvement	Infiltrates, atalectasis
Respiratory Tests
ABG (if patient is in respiratory distress)	Determination of oxygen saturation and blood gases	Acidosis, alkalosis
Pulse oximetry	Measure oxygen saturation	< 90%

Collaborative management

At present, the primary medication therapy option is oseltamivir (Tamiflu). An alternative is zanmivir (Relenza); however, there is concern that viruses may become resistant to both of these drugs. Treatment is supportive according to the clinical status of the patient.

Care priorities

1. Supportive management:

2. Infection control:

Place patient in a negative-pressure room under airborne, contact, and standard precautions. An N-95 respirator should be worn by everyone who enters the room. Gowns and gloves are to be worn for all patient contact, and eye protection should be worn when within 3 feet of the patient. Good hand hygiene should be practiced. Precautions should be continued for 14 days after onset of symptoms or until either an alternative diagnosis is established or diagnostic test results indicate that the patient is not infected with influenza A virus. Restricted visitation should be implemented and an ongoing log kept of all persons entering the patient’s room. Minimize the number of health care personnel caring for the patient. All equipment and other items should remain in patient’s room and should not be used with other patients or outside the isolation room.

3. Vaccination of health care workers:

Health care workers caring for patients with documented or suspected avian influenza should be vaccinated with the most recent seasonal influenza vaccine. This allows for protection against the predominant circulating strain and reduces the likelihood of health care workers becoming co-infected with human and avian strains, which could lead to the emergence of a pandemic strain. There is no vaccine for avian influenza at the present time.

Additional nursing diagnoses

See nursing diagnoses for Acute Lung Injury and Acute Respiratory Distress Syndrome (p. 365), Acute Pneumonia (Chapter 4), Acute Respiratory Failure (p. 383), Mechanical Ventilation (p. 99), and Emotional and Spiritual Support of the Patient and Significant Others (p. 200).

The 2009 h1n1 influenza (“swine” flu)

The 2009 H1N1 (“swine flu”) is a new influenza virus causing illness in humans that was first detected in the United States in April 2009. This virus continues to spread between and among humans internationally, in a similar fashion to the spread of seasonal influenza viruses. On June 11, 2009, the WHO raised the influenza alert level to Phase 6, the highest level, indicating a global pandemic of 2009 H1N1 flu was under way.

Transmission

Transmission is the same as for regular flu—via coughing, sneezing, and sometimes touching objects contaminated with the virus.

Assessment: h1n1

History and risk factors

Those at highest risk of contracting H1N1 are pregnant women, people who live with or care for infants younger than 6 months of age, health care and emergency medical services personnel, anyone from 6 months through 24 years of age, and anyone from 25 through 64 years of age with certain chronic medical conditions or a weakened immune system. Those in these groups are given the highest priority for administration of the H1N1 vaccine.

Signs and symptoms

• Fatigue, fever, sore throat, muscle aches, chills, coughing, and sneezing

Collaborative management

At present, the primary medication therapy option is oseltamivir (Tamiflu). Another alternative is zanmivir (Relenza); however, there is concern that viruses may become resistant to both of these drugs. Treatment is supportive according to the clinical status of the patient.

Care priorities

For information on how to provide care for hospitalized patients, see Avian flu care priorities, p. 197.

1. Prevention: administer h1n1 vaccine

• Inactivated vaccine (vaccine containing dead virus) is injected into the muscle, like the annual flu shot.

• A live intranasal vaccine (the nasal spray vaccine) is also available.

Patients who should not receive the 2009 H1N1 flu vaccine include those with a severe (life-threatening) allergy to eggs or to any other substance in the vaccine. Patients who need advice from an expert practitioner on whether to receive the vaccine include those who have had a life-threatening allergic reaction after a dose of seasonal flu vaccine or Guillain-Barré syndrome. Patients who are moderately or severely ill should be advised to wait until recovered before getting the vaccine. Pregnant or breastfeeding women can get inactivated 2009 H1N1 flu vaccine. Inactivated 2009 H1N1 vaccine may be given at the same time as other vaccines, including seasonal influenza vaccine.

2. High-risk populations:

When the vaccine was first available, the CDC Advisory Committee on Immunization Practices (ACIP) recommended the 2009 H1N1 vaccine for the following five target groups:

• Pregnant women

• Household and caregiver contacts of children younger than 6 months of age (e.g., parents, siblings, and daycare providers)

• Health care and emergency medical services personnel

• Persons aged 6 months through 24 years

• Persons aged 25 through 64 years who have medical conditions associated with a higher risk of influenza complications

3. Reactions to vaccination:

Should be reported through the Vaccine Adverse Event Reporting System (VAERS) website at http://www.vaers.hhs.gov,or by calling 1-800-822-7967.

4. Further information:

To learn more about flu and vaccinations, advise patients to call the local or state health department or to contact the CDC:

• Call 1-800-232-4636 (1-800-CDC-INFO).

• Visit the CDC website at http://www.cdc.gov/h1n1flu or http://www.cdc.gov/flu.

• Visit the web at http://www.flu.gov.

Emotional and spiritual support of the patient and significant others

Nurses must be acutely aware of the need to assess objectively and carefully, to avoid imposing personal views on others. Caregivers may feel they are in the best position to assign significance to an event or to decide the most appropriate response to an event. When faced with challenging situations, in order to facilitate therapeutic interactions, the nurse must assess both the patient’s and significant others’ understanding and perception of the situation prior to implementing a plan of care. Assessment requires active listening, being fully present in the interaction, and investing quality time by an interdisciplinary team to assist with problem solving. Given the resource intensity and possible inconsistency of caregiver assignments or coverage by other disciplines, time constraints may prompt dysfunctional situations not to be handled in the best manner to produce a sustainable solution or, in the worst case scenario, not to be noticed at all.

It is of paramount importance that nurses are familiar with how to provide both emotional and spiritual support to patients and families, to help guide them through the challenges posed by critical illness and hospitalization. Complex support system issues may include identification of high-risk dependent relationships between older adults, family members, domestic partners, children, or religious leaders. Actions required may include steps to prevent further infliction of physical, emotional, or sexual harm, including neglect of the basic necessities of life or exploitation.

Communication must be valued by all caregivers. Time must be invested to develop skills, enhance cognition, and learn to control emotions. Effective exchange of information is foundational for collaboration between the health care team and the patient. Accurate and timely information should be shared throughout the hospitalization to ensure the delivery of holistic patient care. Successful communication results from the development and implementation of strong relationships. In today’s fast-paced, dynamic health care environment, relationships among health care professionals vary and change over time. With less opportunity to establish relationships, trusting the clinical knowledge, decisions, and judgment of unknown colleagues may be difficult. In large metropolitan teaching hospitals, the problem is compounded as the monthly rotation of multiple levels of physician house staff ensues.

Nursing care is often delivered in various time frames on a dynamic schedule and includes increasing numbers of contract and per diem clinical staff. Stabilizing the team and taking the time needed to provide effective communication can be challenging. The larger the number of either health care team members involved or family/significant others involved, the greater is the challenge. Emotionally charged events are common in the critical care environment, and to provide care of the whole patient and family system, emotional support is necessary to assist with coping. Occasionally, the caregivers are also in need of emotional support to cope with difficult situations.

Emotional support is defined as support for emotions the patient feels that will help provide the best outcomes for that patient. Key elements of holistic care include providing encouragement, reassurance, and acceptance during the times of stress. Mental, emotional, and spiritual interventions are needed to help with coping and decision making during critical illness. Emotional responses may be closely associated with mental processes. Thoughts or perceptions drive feelings about life events. Knowledge affects perception, so keeping patients and families informed and up-to-date is of paramount importance to their emotional well-being, as knowledge will promote them having more perceived control of the situation. Frequent, repetitive, simple explanations are often needed, because during emotional upset, ability to remember the information given is often impaired.

Nurses provide assistance to patients to facilitate adaptation to perceived stressors, changes, or threats that interfere with meeting the demands present in their lives, including the role they play when interacting with others. Coping techniques that are used vary with individuals, including the care providers, and are affected by culture. Counseling or family-centered care team conferences may be provided, using an interactive, helping approach, to focus on the needs, problems, or feelings of the patient, significant others, and health care team members. Actions are designed to enhance or support coping, crisis management, problem solving, and interpersonal relationships.

Emotionally charged ethical issues, particularly end-of-life decision making, frequently arise in the critical care environment, prompting care providers to address do-not-resuscitate issues, withdrawal of care, and whether the family desires to be present if resuscitation is needed. Despite countless benefits having been noted, sociology studies have concluded family presence during resuscitation will not be an acceptable practice until all care providers shift to a more holistic perspective. Involvement of the interdisciplinary team, including pastoral care, mental health professionals including the psychologist and/or social worker, palliative medicine or palliative care, and the ethicist, may be warranted on admission to the critical care unit, and throughout the stay if complex end-of-life issues arise.

2-1 RESEARCH BRIEF

A large percentage of the U.S. general public has stated they would like to remain with a loved one during resuscitation. Despite the countless benefits reported, family presence during resuscitation is a controversial, highly debated issue among health professionals in adult critical care units. The authors designed an exploratory, descriptive, and correlational study to determine the relationship between spirituality of health care professionals and support for family presence during invasive procedures and resuscitation. A holistic Spirituality Assessment Scale (SAS) developed by Howden was used to glean information regarding a more comprehensive meaning of spirituality—not focused exclusively on religious beliefs and feelings of patients, but rather, inclusive of feelings of health care providers. Data were collected from 73 nurses, 31 physicians, and 4 physician assistants. Results suggested a link between a holistic perspective and support for family presence. The higher the scores of spirituality for health care providers, the greater was the likelihood that they supported family presence as patient’s right and part of holistic care. The study helps to fill the gap in current literature regarding certain demographic characteristics affecting whether health care providers are willing to allow families to be present during invasive procedures and resuscitation. Further analysis of extraneous variables is needed before the results of this study can be generalized.

From Baumhover N, Hughes L: Spirituality and support for family presence during invasive procedures and resuscitations in adults. Am J Crit Care 18(4):357–367, 2009.

Promoting psychological peace in the final phase of life is of paramount importance to the patient and involves exploration of the spiritual beliefs of all those involved in decisions. Disagreement on the appropriate course of action among health care team members stems from many factors, including their spirituality. Confusion among significant others regarding the wishes of the patient, their own views on death and dying, or vacillating patient views may create a dysfunctional care environment. The problem is compounded when various subgroups of decision makers share perspectives in isolation, rather than discussing them openly in a group composed of all key decision makers.

In extreme cases, anger and confusion may result in violent behavior, and the lines of communication may deteriorate if appropriate avenues are not initiated to repair damages. The American College of Critical Care Medicine has developed patient and family guidelines that help widen perspectives, open new options, and suggest different ideas for health care providers to help abate situations escalating to the point of physical violence.

Spiritual support is a part of providing holistic care. Several authors describe spirituality as a variable of holism. Spirituality is not to be confused with religion. Although the vast majority of nurses believe spiritual care is a part of providing patient-centered, holistic care, over half feel inadequate to perform spiritual care interventions. Spirituality has been described as values, beliefs, and behaviors of an individual related to purpose and meaning in life; connectedness to self, others, and life and universal dimensions; and innerness or inner resources and capacity for transcendence. Using these characteristics, Howden developed the Spirituality Assessment Scale (SAS) (Box 2-1). The 28 items on the SAS provide a strong operational framework for evaluating the ability of all involved with patient care and decision making to connect or to be sensitive to the spiritual dimensions of others and possibly frame how to approach the emotional needs of others. If a care provider has not developed the capacity to connect with others, providing care that requires embracing a viewpoint outside of his or her personal sphere of perception is extremely difficult. Behavior modification of the patient, significant others, or health care team members may be necessary as part of facilitating compliance with life changes for the patient and significant others resulting from the hospitalization. Values may collide, based on the past experiences of all involved. Staying focused on the present can assist all involved in remaining objective when approaching the situation.

Box 2-1 ELEMENTS OF THE HOWDEN SPIRITUAL ASSESSMENT SCALE (SAS)

Has a Sense of Belongingness	Feels Part of the Community Lived In
Has Capacity to Forgive	Feels Reconciling Relationships Is Important
Can Rise Above or Go Beyond Mental and Physical Problems	Can Rise Above or Go Beyond Body Changes or Body Losses
Is Concerned about Environmental Destruction	Feels Responsible for Preserving the Planet
Can Find Peace during a Devastating Event	Has Inner Resources for Dealing with Uncertainty
Has a Sense of Kinship to Others	Has Found Inner Strength during Past Struggles
Has a Connection to All of Life	Possesses Life Goals and Aims
Relies on Inner Strength When Struggling	Possesses Inner Strength
Enjoys Serving Others	Feels a Sense of Fulfillment in Life
Has a Sense of Inner Spiritual Guidance	Trusts Life Is Good Despite Discouraging Events
Perceives Ability for Self-Healing	Feels Good About Themselves
Perceives Meaning of Life Provides Peace	Has the Sense Life Has Meaning and Purpose
Feels a Sense of Balance Within Life	Feels Inner Harmony and Peace
Boundaries of Personal Universe Extend Beyond Space and Time	Inner Strength Is Related to Belief in a Higher Power or Supreme Being

Items are rated 1 (Strongly disagree) through 6 (Strongly agree) on a Likert scale after reading statements about the elements listed here.

Howden JW: Development and psychometric characteristics of the Spirituality Assessment Scale. Dissert Abstr Int 54(1):166B, 1992. Abstract reproduced with permission from ProQuest LLC. © 2007 ProQuest LLC; all rights reserved. Further reproduction is prohibited without permission.

Assessment of need for emotional and spiritual support

Goal of assessment

To determine the ability of the patient and significant others to maintain a healthy response to changes brought forth by critical illness, so appropriate emotional and spiritual support can be provided to facilitate appropriate decision making as part of patient and family-centered care. Providing family-centered care requires the creation of mutually beneficial partnerships among patients, families, and health care providers. The patient is a part of a larger support system, and each caregiver is a part of a larger care system. Intense effort may be needed to create one voice for the right course of action in every situation that arises.

History and risk factors

Innumerable variables affect coping and decision making. The factors listed in Box 2-1 have been demonstrated by various studies to affect how decisions are made and may adversely affect coping because of a difference in beliefs related to spirituality. Difficulty coping may be more likely if the patient or any member of the decision-making team has a poor self-image, is unfulfilled in life, has significant financial problems, has developed unhealthy dependent relationships with others, is extremely resistant to change, has no sense of meaning or purpose in their life, has difficulty learning, has unrepaired significant relationships, has a poor sense of belongingness, does not feel inner peace or inner strength, is unable to forgive others for past offenses, has difficulty relating to others, cannot feel a sense of connectedness to others, or is unclear about life goals.

CARE PLANS: EMOTIONAL AND SPIRITUAL SUPPORT OF THE PATIENT, FAMILY, AND SIGNIFICANT OTHERS

Anxiety

Goals/outcomes:

Within 12 hours of intervention, anxiety is absent or reduced as evidenced by patient’s verbalization of same, heart rate (HR) less than or equal to 100 beats/min, RR less than or equal to 20 breaths/min, and an absence of or decrease in irritability and restlessness. Family members are calmer.

Anxiety Level, Anxiety: Self-Control, Concentration, Coping