Sexually transmitted diseases (STDS) with nursing responsibilty

sexually transmitted diseases (STDS)

1. Sexually Transmitted Diseases Infectious diseases most commonly transmitted through sexual contact Can also be transmitted by Blood Blood products Autoinoculation

2. National Health Picture on STDs As of January 2013, the Department of Health (DOH) AIDS Registry in the Philippines reported 10,514 people living with HIV/AIDS . Most Common in the Philippines - Chlamydia - Gonorrhea - Genital Herpes - HIV / AIDS - Syphillis

3. 3 General Overview Highest incidence: adolescents & young adults Sexual abuse Primary Prevention Advocate for adolescent education re: sex and sexually transmitted disease. (AAP, 2001) Abstinence Condoms

4. 4 Healthy People 2020 Goal: Promote healthy sexual behaviors, strengthen community capacity, and increase access to quality services to prevent sexually transmitted diseases and their complications .

5. 5 Factors contributing to spread Asymptomatic nature of STDs Gender disparities Age disparities Lag time between infection and complications Social, economic and behavioral factors

6. 6 Risk Factors IV drug use Other substance abuse High-risk sexual activity Younger age at beginning of sexual activity Inner city residence Poverty/lower socioeconomic status Poor nutrition Poor hygiene

7. 7 Consequences Sterility Neurologic damage Ophthalmic infection – other congenital problems for newborn Cancer Death

8. 8 Unwanted Pregnancy Negative pregnancy test: a teachable moment Abortion Medical Surgical Post op care

9. Gonorrhea Etiology and Pathophysiology 2 nd most frequently reported STD in US Caused by Neisseria gonorrheae Gram-negative bacteria Direct physical contact with infected host Killed by drying, heating, or washing with antiseptic Incubation: 3-8 days

10. Gonorrhea Etiology and Pathophysiology Elicits inflammatory process that can lead to fibrous tissue and adhesions Can lead to : Tubal pregnancy Chronic pelvic pain Infertility in women

11. Gonorrhea Clinical Manifestations Men Initial site of infection is urethra Symptoms Develop 2 to 5 days after infection Dysuria Profuse, purulent urethral discharge Unusual to be asymptomatic

12. Gonococcal Urethritis Fig. 53-1

13. Gonorrhea Clinical Manifestations Women Mostly asymptomatic or have minor symptoms Vaginal discharge Dysuria Frequency of urination

14. Gonorrhea Clinical Manifestations Women (cont’d) After incubation Redness and swelling occur at site of contact Greenish, yellow purulent exudate often develops May develop abscess Transmission more efficient from men to women

15. Endocervical Gonorrhea Fig. 53-2

16. Gonorrhea Clinical Manifestations Anorectal gonorrhea Usually from anal intercourse Soreness, itching, and anal discharge Orogenital Gonoccocal pharyngitis can develop

17. Gonorrhea Complications Men Include prostatitis, urethral strictures, and sterility Often seek treatment early so less likely to develop complications

18. Gonorrhea Complications Women Include pelvic inflammatory disease (PID), Bartholin’s abscess, ectopic pregnancy, and infertility Usually asymptomatic so seldom seek treatment until complication are present

19. Gonorrhea Diagnostic Studies History and physical examination Laboratory tests Gram-stained smear to identify organism Culture of discharge Nucleic acid amplification test Testing for other STDs

20. Gonorrhea Treatment & Nursing Care Drug therapy Treatment generally instituted without culture results Treatment in early stage is curative Most common IM dose of ceftriaxone (Rocephin)

21. Gonorrhea Treatment & Nursing Care cont’d All sexual contacts of patients must be evaluated and treated Patient should be counseled to abstain from sexual intercourse and alcohol during treatment Reexamine if symptoms persist after treatment

22. Syphilis

23. Syphilis Etiology and Pathophysiology Caused by Treponema pallidum Spirochete bacterium Enters the body through breaks in skin or mucous membranes Destroyed by drying, heating or washing May also spread via contact with lesions and sharing of needles

24. Syphilis Etiology and Pathophysiology Incubation 10 to 90 days Spread in utero after 10th week of pregnancy Infected mother has a greater risk of a stillbirth or having a baby who dies shortly after birth

25. Syphilis Etiology and Pathophysiology Association with HIV Syphilitic lesions on the genitals enhance HIV transmission Evaluation includes testing for HIV with patient’s consent

26. Syphilis Clinical Manifestations Variety of signs/symptoms that can mimic other disease Primary stage Painless indurated lesions Occur 10 to 90 days after inoculation Lasting 3 to 6 weeks

27. Primary Syphilitic Chancre Fig. 53-4

28. Syphilis Clinical Manifestations Secondary stage Systemic Begins a few weeks after chancres Blood-borne bacteria spread to all major organ systems Flu-like symptoms Bilateral symmetric rash Mucous patches Condylomata lata

29. Secondary Syphilis Fig. 53-5

30. Syphilis Clinical Manifestations Latent or hidden stage Immune system is suppressing infection No signs/symptoms at this time Diagnosed by positive specific treponema antibody test for syphilis with normal cerebrospinal fluid

31. Syphilis Clinical Manifestations Tertiary or late stage Manifestations rare Significant morbidity/mortality rates Gummas Cardiovascular system Neurosyphilis

32. Syphilis Complications Occur mostly in late syphilis Irreparable damage to bone, liver, or skin from gummas Pain from pressure on structures such as intercostal nerves by aneurysms

33. Syphilis Complications Scarring of aortic valve Neurosyphilis Tabes dorsalis Sudden attacks of pain Loss of vision and sense of position

34. Syphilis Diagnostic Studies History including sexual history PE Examine lesions Note signs/symptoms Dark-field microscopy Serologic testing Testing for other STDs

35. Syphilis Treatment & Nursing Care Drug therapy Benzathine penicillin G (Bicillin) Aqueous procaine penicillin G

36. Syphilis Treatment & Nursing Care cont’d Monitor neurosyphilis Confidential counseling and HIV testing Case finding Surveillance

37. Chlamydial Infections Etiology and Pathophysiology #1 reported STD in US Caused by Chlamydia trachomatis Gram-negative bacteria Transmitted during vaginal, anal, or oral sex Incubation period: 1 to 3 weeks

38. Chlamydial Infections Etiology and Pathophysiology Risk factors Women and adolescents New or multiple sexual partners History of STDs and cervical ectopy Coexisting STDs Inconsistent/incorrect use of condoms

39. Chlamydial Infections Clinical Manifestations “Silent disease” Symptoms may be absent or minor Infection often not diagnosed until complications appear

40. Chlamydial Infections Clinical Manifestations Men Urethritis Dysuria Urethral discharge Proctitis Rectal discharge Pain during defecation

41. Chlamydial Infections Clinical Manifestations Men (cont’d) Epididymitis Unilateral scrotal pain Swelling Tenderness Fever Possible infertility and reactive arthritis

42. Chlamydial Infection Fig. 53-6

43. Chlamydial Infections Clinical Manifestations Women Cervicitis Mucopurulent discharge Hypertrophic ectopy Urethritis Dysuria Frequent urination Pyuria

44. Chlamydial Infections Clinical Manifestations Women (cont’d) Bartholinitis Purulent exudate Perihepatitis Fever, nausea, vomiting, right upper quadrant pain

45. Chlamydial Infections Clinical Manifestations Women (cont’d) PID Abdominal pain, nausea, vomiting, fever, malaise, abnormal vaginal bleeding, menstrual abnormalities Can lead to chronic pain and infertility

46. Chlamydial Infections Diagnostic Studies Laboratory tests Nucleic acid amplification test (NAAT) Direct fluorescent antibody (DFA) Enzyme immunoassay (EIA) Testing for other STDs Culture for chlamydia

47. Chlamydial Infections Treatment & Nursing Care Drug therapy Doxycycline (Vibramycin) 100 mg BID for 7 days Azithromycin (Zithromax) 1 g in single dose Alternatives include erythromycin, ofloxacin (Floxin), or levofloxacin (Levaquin)

48. Chlamydial Infections Treatment & Nursing Care cont’d Abstinence from sexual intercourse for 7 days after treatment Follow-up care for persistent symptoms Treatment of partners Encourage use of condoms

49. Chlamydia Prevention: limit the number of sexual partner & use condoms & spermicides What are the Nursing Implications?

50. Genital Herpes Not a reportable disease in most states True incidence difficult to determine Caused by herpes simplex virus (HSV)

51. Genital Herpes Etiology and Pathophysiology Enters through mucous membranes or breaks in the skin during contact with infected persons HSV reproduces inside cell and spreads to surrounding cells

52. Genital Herpes Etiology and Pathophysiology Two different strains HSV-1 Causes infection above the waist HSV-2 Frequently infects genital tract and perineum Either strain can cause disease on mouth or genitals

53. Genital Herpes Clinical Manifestations Primary (initial) episode Burning or tingling at site Small vesicular lesion appear on penis, scrotum, vulva, perineum, perianal areas, vagina, or cervix

54. Genital Herpes Clinical Manifestations Primary (initial) episode (cont’d) Primary lesions present for 17 to 20 days New lesions sometimes continue to develop for 6 weeks Lesions heal spontaneously

55. Genital Herpes Clinical Manifestations Recurrent genital herpes Occurs in 50% to 80% in following year Triggers Stress Fatigue Sunburn Menses

56. Genital Herpes Clinical Manifestations Recurrent genital herpes (cont’d) Prodromal symptoms of tingling, burning, itching at lesion site Lesions heal within 8 to 12 days With time, lesions will occur less frequently

57. Genital Herpes Complications Aseptic meningitis Lower neuron damage Autoinoculation to extragenital sites High risk of transmission in pregnancy with episode near delivery Herpes simplex virus keratitis

58. Autoinoculation of Herpes Simplex Virus Fig. 53-8

59. Genital Herpes Diagnostic Studies History and physical examination Viral isolation by tissue culture Antibody assay for specific HSV viral type

60. Genital Herpes Treatment & Nursing Care Drug therapy Inhibit viral replication Suppress frequent recurrences Acyclovir (Zovirax) Valacyclovir (Valtrex) Famciclovir (Famvir) Not a cure but shorten duration, healing time and reduce outbreaks

61. Genital Herpes Treatment & Nursing Care cont’d Symptomatic care Genital hygiene Loose-fitting cotton underwear Lesions clean and dry Sitz baths Barrier methods during sexual activity Drying agents Pain: dilute urine with water, local anesthetic

62. Genital Herpes Treatment : use Betadine on lesions to dry & prevent secondary infections, however, Acyclovir (Zovirax) eases symptoms & lessens reoccurrence but is not a cure If Untreated: in fetus/newborns there is a risk of spontaneous abortion; neonatal herpes; mental retardation, death Prevention: limit number of sexual partners and using condoms & spermicidal foam may reduce transmission Nursing Implications?

63. Genital Warts Most common STD in the US Often asymtomatic so patient maybe unaware of infection Caused by human papillomavirus (HPV) Usually types 6 and 11 Highly contagious Frequently seen in young, sexually active adults

64. Genital Warts Etiology and Pathophysiology Minor trauma causes abrasions for HPV to enter and proliferate into warts Epithelial cells infected undergo transformation and proliferation to form a warty growth Incubation period 3 to 4 months

65. Genital Warts Clinical Manifestations Discrete single or multiple growths White to gray and pink-fleshed colored May form large cauliflower-like masses

66. Genital Warts Clinical Manifestations Warts in men: penis, scrotum, around anus, in urethra Warts in women: vulva, vagina, cervix Can have itching with anogenital warts & bleeding on defecation with anal warts

67. Genital Warts Diagnostic Studies Serologic and cytologic tests HPV DNA test to determine if women with abnormal Pap test results need follow-up Identify women who are infected with high-risk HPV strains

68. Genital Warts Diagnostic Studies Primary goal: Removal of symptomatic warts Removal may or may not decrease infectivity Difficult to treat Often require multiple office visits and variety of treatment modalities

69. Genital Warts Treatment & Nursing Care Chemical Trichloroacetic acid (TCA) Bichloroacetic acid (BCA) Podophyllin resin For small external genital warts Patient managed Podofilox (Condylox.Condylox gel0 Imiquimod (Aldara) Immune response modifier

70. Genital Warts Treatment & Nursing cont’d If warts do not regress with previously mentioned therapies Cryotherapy with liquid nitrogen Electrocautery Laser therapy Use of α -interferon Surgical excision

71. Genital Warts Treatment & Nursing Care cont’d Recurrences and reinfection possible Careful long-term follow-up advised Vaccine to prevent cervical cancer, precancerous genital lesion, and genital warts due to HPV

72. CMV - Cytomegalovirus Found is saliva, urine, semen, and vaginal secretions symptoms include pharyngitis, malaise, fever and lymphadenopathy, heterophil antibody negative, blood smears may show atypical lymphocytes may be fatal to those patients with AIDS

73. CMV Treatment: most resolve spontaneoulsy therapy is often required for immunosuppressed patients Ganciclovir

74. Trichomoniasis Symptoms: Most men with trichomoniasis do not have signs or symptoms; some men may temporarily have an irritation inside the penis, mild discharge, or slight burning after urination or ejaculation.

75. Trichomoniasis Symptoms frothy, yellow-green vaginal discharge with a strong odor discomfort during intercourse and urination, irritation and itching of the female genital area. lower abdominal pain Incubation: 4 to 10 days

76. Trichomoniasis Organism: Trichomoniasis is caused by the single-celled protozoan parasite, Trichomonas vaginalis .

77. Trichomoniasis Infectivity: The vagina is the most common site of infection in women, and the urethra (urine canal) is the most common site of infection in men. The parasite is sexually transmitted through penis-to-vagina intercourse or vulva-to-vulva (the genital area outside the vagina) contact with an infected partner. Women can acquire the disease from infected men or women, but men usually contract it only from infected women.

78. Trichomoniasis Treatment : Trichomoniasis can usually be cured with the prescription drug, metronidazole, given by mouth in a single dose. If Untreated: increases a woman's susceptibility to HIV infection if she is exposed to the virus. Pregnant women with trichomoniasis may have babies who are born early or with low birth weight (less than five pounds). Prevention: limit number of sexual partners and using condoms & spermicidal foam may reduce transmission Nursing Implications?

79. Nursing Care : STD Nursing Diagnoses Risk for infection RT ? Anxiety RT ? Ineffective health maintenance RT ?

80. Ethical/Legal Implications In your opinion, what is the best way to balance the needs of an individual patient with STD with those of the general public?

81. ACQUIRED IMMUNODEFICIENCY SYNDROME

82. Means of transmission Of the 10,514 HIV positive cases reported from 1984 to 2013, 92% (9,637) were infected through sexual contact , 4% (420) through needle sharing among injecting drug users , 1% (59) through mother-to-child transmission , <1% (20) through blood transfusion and needle prick injury <1% (3). No data is available for 4% (375) of the cases.

83. Cumulative data shows 33% (3,147) were infected through heterosexual contact , 41% (3,956) through homosexual contact , and 26% (2,534) through bisexual contact . From 2007 there has been a shift in the predominant trend of sexual transmission from heterosexual contact (20%) to males having sex with other males (80%)

84. Overseas workers from the Philippines (e.g., seafarers, domestic helpers, etc.) account for about 20 percent of all HIV/AIDS cases in the country.

85. HIV (Human Immunodeficiency Virus) AIDS (Acquired Immunity Deficiency Syndrome) HIV is NOT the same as having AIDS, it is only the virus that causes AIDS. Currently there is NO cure but drug therapies "show great promise in managing HIV infection". "HIV infected people are healthy and do not realize they have been infected. HIV primarily infects certain white blood cells that manage the operation of the immune system.

86. HIV (Human Immunodeficiency Virus) AIDS (Acquired Immunity Deficiency Syndrome) Eventually, the virus can disable the immune system, leaving the person with HIV infection vulnerable to a number of life-threatening illnesses. People who have HIV infection may not have symptoms for many years, especially if they receive good medical care and effective therapies" (American College Health Association [ACHA] , 2001).

87. HIV (Human Immunodeficiency Virus) AIDS (Acquired Immunity Deficiency Syndrome) "When symptoms do develop, they are usually similar at first to those of common minor illnesses, such as the "flu", except that they last longer and are more severe. Persistent tiredness, unexplained fevers, recurring night sweats, prolonged enlargement of the lymph nodes, and weight loss are all common.

88. HIV (Human Immunodeficiency Virus) AIDS (Acquired Immunity Deficiency Syndrome) People with HIV infection can transmit the virus to others - even if they have no symptoms and even if they do not know they have been infected. HIV can be transmitted (1) by sexual contact (anal, vaginal, & oral); (2) by direct exposure to infected blood; and (3) from an HIV-infected woman to her fetus during pregnancy or childbirth, or to her infant during breastfeeding" (ACHA, 2001).

89. HIV (Human Immunodeficiency Virus) AIDS (Acquired Immunity Deficiency Syndrome) Prevention: "make careful choices about sexual activity, communicate assertively with your sexual partner and negotiate for safer sexual practices, remove alcohol and drugs from sexual activity," and "use latex condoms for intercourse" (ACHA, 2001).

90. He who gets wisdom has love for his soul: he who keeps good sense will get what is truly good. Proverbs 19:8