Rocky Mountain spotted fever

Nursing Considerations-Nursing Diagnoses

Activity intolerance Acute pain Anxiety Decreased cardiac output Deficient fluid volume Hyperthermia Imbalanced nutrition: Less than body requirements Impaired skin integrity Risk for decreased cardiac perfusion Risk for infection

Overview

Acute infectious, febrile, rash-producing illness associated with outdoor activities Fatal in about 5% to 10% of patients Reportable to public health authorities

Overview-Pathophysiology

After an incubation period of 3 to 12 days after being bitten by a tick, the infecting organism multiplies in endothelial cells and spreads via the bloodstream and lymphatic system. Focal areas of infiltration lead to thrombosis and leakage of red blood cells into surrounding tissue.

Treatment-Activity

Bed rest until the patient's condition improves

Nursing Considerations-Associated Nursing Procedures

Blood pressure assessment Cardiac monitoring Health history interview and physical assessment Hemodialysis, arteriovenous access Hemodialysis, double-lumen catheter IV bag preparation IV bolus injection IV catheter insertion IV pump use Intake and output assessment Lumbar puncture, assisting Mechanical ventilation, positive pressure Neurologic assessment Nutritional screening Oral drug administration Oxygen administration Pain management Parenteral nutrition administration Parenteral nutrition monitoring Pulse assessment Reportable diseases Seizure management Temperature assessment Tick removal Venipuncture

Treatment-General

Careful tick removal Careful fluid administration Intubation and mechanical ventilation, if needed Hemodialysis, if needed Treatment of hemorrhage and thrombocytopenia, if needed

Treatment-Medications

Doxycycline (the drug of choice), tetracycline, or chloramphenicol (in pregnant women) Topical cycloplegics such as cyclopentolate for uveitis Oxygen therapy I.V. fluids if the patient is critically ill Packed red blood cells for anemia or severe bleeding; platelet transfusion for severe thrombocytopenia

Assessment-Physical Findings

Erythematous macules, 1 to 5 mm in diameter, becoming maculopapules that blanch with pressure Frank hemorrhage at the center of maculopapules, creating petechia that do not blanch with pressure Rash, usually within 3 to 5 days after fever, that begins on the ankles and wrists, spreads to the palms and soles, and spreads centrally to the arms, legs, and trunk Edema on the dorsal aspects of the hands and feet Bronchial cough Tachypnea Altered level of consciousness Periorbital edema Photophobia Ataxia Decreased urine output; dark urine Tachycardia Hypotension Hepatomegaly and splenomegaly Lymphadenopathy Generalized pitting edema Abdominal tenderness Jaundice (in severe cases)

Nursing Considerations-Nursing Interventions

Give prescribed drugs; if the I.V. route is used, ensure patent I.V. access. Avoid giving doxycycline with milk products, iron preparations, or aluminum- or magnesium-containing antacids because of the possible effect on absorption. Administer I.V. fluid therapy, as ordered, if the patient's status is severe. Provide oxygen therapy based on oxygen saturation levels or arterial blood gas results; provide assisted ventilation for pulmonary complications, as ordered. Auscultate heart and lung sounds; note heart rate and rhythm; institute continuous cardiac monitoring, if indicated. Evaluate the patient's neurologic status for changes, including level of consciousness. Institute safety measures to reduce the risk for injury. Offer comfort measures for pain relief and to help suppress itching from the rash, as appropriate. Provide meticulous skin care; change the patient's position frequently. Encourage incentive spirometry and deep breathing. Plan care to promote adequate rest periods; provide small, frequent meals and snacks to minimize energy expenditure; cluster care activities to promote rest. Obtain specimens for laboratory testing such as a complete blood count (CBC), as ordered. Encourage the patient to verbalize feelings and concerns; provide emotional support and clear explanations about the condition and treatments.

Overview-Complications

Lobar pneumonia Disseminated intravascular coagulation Renal failure Meningoencephalitis Encephalopathy (usually transient) Seizures Skin necrosis Gangrene Hepatic injury Cardiac or respiratory failure Shock Noncardiogenic pulmonary edema Myocarditis Death

Overview-Causes

Occasionally, inhalation of or contact of abraded skin with tick excreta or tissue juices Rickettsia rickettsii , transmitted by the wood tick (Dermacentor andersoni ) in the western United States and by the dog tick (D. variabilis ) in the eastern United States

Assessment-History

Recent exposure to ticks or tick-infested areas, or a known tick bite, typically within the previous 14 days Abrupt onset of signs and symptoms, including persistent fever (temperature of 102° to 104° F [38.9° to 40° C]); generalized, excruciating headache; and aching in bones, muscles, joints, and back Sensitivity to light Insomnia

Overview-Risk Factors

Recent hiking or outdoor activity Contact with outdoor pets or wild animals

Patient Teaching-Discharge Planning

Refer the patient to an infectious-disease specialist, if needed.

Overview-Incidence

Rocky Mountain spotted fever is endemic throughout the continental United States; more than one-half of the cases occur in the South Atlantic region. More males than females are typically affected by the disease. Whites are more commonly affected than Blacks, but Blacks have a higher fatality rate. Native Americans are at a greater risk than the rest of the population. The incidence is highest in adults older than age 60. The disease occurs with increased frequency in spring and summer.

Diagnostic Test Results-Laboratory

Serologic test results may be negative in initial stages. Indirect immunofluorescence assay has a diagnostic titer of 64 or greater; it is detectable between days 7 and 14 of the illness. Latex agglutination diagnostic titer is 128 or greater 1 week after onset. Platelet counts and fibrinogen levels are decreased. Leukopenia may be present initially, but then mild leukocytosis develops; hemoglobin levels and hematocrit may indicate anemia. Prothrombin time and partial thromboplastin time are prolonged. Serum protein levels (especially albumin) are decreased. Hyponatremia and hypochloremia occur, related to increased aldosterone excretion. Serum creatinine, blood urea nitrogen, and potassium levels are elevated. Hepatic function is abnormal. Cerebrospinal fluid analysis shows mild mononuclear pleocytosis with slightly elevated protein content. Immunohistologic examination of cutaneous biopsy of a rash lesion shows R. rickettsii.

Treatment-Diet

Small, frequent meals Parenteral nutrition, if the patient can't receive oral intake

Nursing Considerations-Monitoring

Vital signs Fluid and electrolyte status Cardiopulmonary status Neurologic status Skin integrity Activity level Anxiety level

Patient Teaching-General

disorder, diagnosis, and treatment, including the need for a full course of antibiotic therapy that the usual prognosis is excellent and that signs and symptoms usually resolve over several days with appropriate treatment prescribed medication therapy, including the drug name, dosage, frequency of administration, and duration of therapy need to complete the entire course of antibiotic therapy, usually 5 to 7 days for doxycycline need to minimize sun exposure, including the use of sunscreen and protective clothing while taking doxycycline to reduce the risk of photosensitivity importance of reporting recurrent signs and symptoms immediately preventive strategies, including avoiding tick-infested areas, performing a whole-body inspection (including the scalp) every 3 to 4 hours for attached ticks, and wearing protective clothing and insect repellent correct tick removal technique using tweezers or forceps and steady traction need to see the practitioner every 2 to 3 days (if not hospitalized) to ensure complete resolution of signs and symptoms and infection importance of adhering to recommended follow-up care, including laboratory testing, such as CBCs and creatinine and electrolyte levels, as indicated.

Nursing Considerations-Expected Outcomes

resume normal activity levels during recovery report increased comfort and decreased pain verbalize feelings and concerns openly maintain adequate cardiac output maintain adequate fluid volume remain afebrile maintain adequate nutritional intake exhibit improved or healed lesions or wounds maintain hemodynamic stability maintain a normal white blood cell count and differential.