Download Upper respiratory Tract Infection

UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
CLINICAL PROTOCOL
UPPER RESPIRATORY TRACT INFECTION (URTI)- Common cold, influenza, sore throat, tonsillitis,
Practitioner
Scope
Outcomes
Nurse Practitioner
(NP)
Acute nasal, sinus, ears, pharyngeal and upper airway symptoms in adult
and adolescent detainees.
Identify clients suitable for Custodial Health Nurse Practitioner
(CHNP).
Medical Officer
(MO)
Management of clients not suitable for NP scope of practice (as per above).
Underlying complex medical pathology and/or immunocompromised patient
Altered conscious state including effects of drugs/ ETOH
If quinsy is present, consult MO (may need evacuation / hospitalisation for
IV Penicillin and/or surgical drainage of pus)
History consistent with collapse
Non blanching petechial rash or toxic clinical picture
Severe respiratory distress
Recent travel in High Risk Area (SARS/Avian Flu)
Identify client not suitable for NP and refer to Medical Officer or
Emergency Department (ED) of Western Australian Hospital.
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UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
CLIENT ASSESSMENT
Activity
Assessment
Outcome

Primary survey
assessment
• Airway
• Breathing
• Circulation
Abnormal primary survey identified → exit Clinical Protocol
(CP) and commence emergency procedures.
Presenting
History
• Time of onset of symptoms
• Nature of symptoms- Cough Productive/ non productive, fever, nasal
discharge, headache, facial, pharyngeal or ear
• pain, ocular symptoms, rash
• Ability to function/perform ADL’s
• Risk factors
• Smoking and/or illicit drug use
• Allergies / Immunisation status
• Relevant past medical history / medication use particularly asthma,
COPD, rheumatic fever or heart disease
• Pre-hospital care including GP care, complimentary therapies and
pharmacological agents
• Other family members affected/ contacts/cell mate
• Travel History
• Social and work related status.
Identify client not suitable for NP CP exit Clinical Protocol (CP)
and refer to Medical Officer if required
Always be alert to the relationship between group A streptococcal infections and Acute Rheumatic Fever / Acute Post Streptococcal Glomerulonephritis which are
especially common in Aboriginal and Torres Strait Island communities
The vast majority of URTIs are caused by viruses and do not require antibiotics. A viral upper respiratory tract infection can be complicated by secondary bacterial
infection, eg. sinusitis, bronchitis, pneumonia, requiring antibiotics. Other complications include exacerbation of asthma/chronic obstructive pulmonary disease
(COPD)
Influenza is an acute respiratory illness caused by influenza viruses of which there are many different types. Epidemics commonly occur over the winter months
Influenza is probably over-diagnosed. Systemic symptoms such as fever, extreme lethargy, sore muscles and joints and headache differentiate it somewhat from a
‘common cold’
Patients at risk may develop pneumonia secondary to influenza and should be offered influenza and pneumococcal vaccination as per National Immunisation
Guidelines and HDWA recommendations
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May 2010
UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
Activity
Focused Clinical
Assessment
Assessment
• G
 eneral appearance and vital signs – respiratory distress, toxicity
• Oropharyngeal examination – tonsillar exudate, redness, oedema, stridor,
drooling, assess dentition
• Palpate sinuses – tenderness, oedema, bogginess
• Assess for evidence of rash, arthritis
• Palpate for lymphadenopathy, splenomegaly, hepatomegaly
• Assess for signs of meningitis –stiff neck, photo phobia, petechial rash,
altered conscouis level)
• Ear and eye examination
• Chest auscultation- Listen to the chest for air entry and added sounds
(crackles or wheezes)
• Palpate joints for any swelling (if appropriate)
Pain Assessment
• Pain scale
Imaging
Imaging not usually required.
Consider plain CXR if focal signs on chest examination, fever with
productive cough or prolonged symptoms of URTI.
Pathology
Pathology not routinely required unless: • Suspicion of Infectious Mononucleosis then order monospot, FBP and
EBV serology
• Throat swab for MC&S if Streptococcal pharyngitis suspected
• Consider Nasopharyngeal Aspirate for Pertussis PCR/IgA and serology
if Pertussis suspected
Outcome
Clinical examination finding consistent with diagnosis of Upper
Respiratory Tract Infection, ongoing care to be provided by
NP.
Identify clients not suitable for NP and refer to MO or ED of
Western Australian Hospital.
Identify differential diagnosis and if necessary manage using
alternative CP.
Determines need and type of pain relief modalities required.
Can guide the NP in determining alternative differential
diagnosis.
Detect underlying pathology. Identify degree of systemic
involvement.
Detect underlying pathology. Identify degree of systemic
involvement.
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May 2010
UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
INTERPRETATION OF RESULTS AND MANAGEMENT DECISIONS
Interpretation of results (diagnostic features) and management decisions
Pharyngitis
and/or tonsillitis
Rhinosinusitis
Antibiotic therapy recommended in:
• Tonsillitis displaying the 4 diagnostic features suggestive of
Streptococcus pyogenes infection:
o Fever > 38 C,
o tender cervical lymphadenopathy,
o tonsillar exudate, and
o No cough.
• Existing rheumatic fever at any age
• Scarlet fever
• Peritonsillar cellulitis or quinsy (severe infection of the tonsils causing
massive enlargement, evidence of pus on tonsil).
Medications as per formulary
Pt education /health promotion – symptom relief
Follow up appointment with NP if required
Consider antibiotics only in severe cases displaying at
least 3 of the following;
o persistent mucopurulent nasal discharge ( > 7 to 10 days).
o Facial pain
o Poor response to decongestants
o Tenderness over the sinuses, especially unilateral maxillary
tenderness
o Tenderness on percussion of maxillary molar and premolar teeth
that cannot be attributed to a single tooth.
Medications as per formulary
Pt education /health promotion – symptom relief
Follow up appointment with NP if required
Outcomes
Ensure patient understands problem, treatment, follow-up and
when further treatment required.
Ensure patient understands problem, treatment, follow-up and
when further treatment required.
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May 2010
UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
Interpretation of results (diagnostic features) and management decisions
Acute
Most often viral and usually does not require antibiotic therapy.
Bronchitis
• Pertussis should be considered in clients with persistent paroxysmal
cough > 2 weeks. Consult MO. May require pernasal aspiration and
antibiotics as per formulary.
• Pneumonia should be considered in clients with more severe illness
• Client education /health promotion
• Follow up appointment with NP
Outcomes
Ensure client understands problem, treatment, follow-up and
when further treatment required.
Pneumonia
Refer to MO or ED of Western Australian Hospital as
appropriate.
Non specific
infection ( all
symptoms
frequently
present but not
prominent)
moderate/severe pneumonia: if heart rate >120/min, respiratory rate
>30/min, cyanosis, hypotension/shock or confusion
mild pneumonia: if heart rate <120/min, respiratory rate <30/min, not
cyanosed, normal BP and fully orientated
· Pt education /health promotion – symptom relief
· Consider antibiotics only if symptoms have persisted for >7 days and
purulent sputum associated with cough, or nasal discharge
· Follow up appointment with NP if required
Pertussis is a notifiable disease
Pertussis and pneumonia to be referred to MO
Ensure client understands problem, treatment, follow up and is
safe for discharge home
CLIENT SUPPORT
Topic
When to
Return
Follow Up
Client Education
Action
Increasingly febrile
Not tolerating fluids
Symptoms persist for greater than 7 days
Reaction to prescribed medication
As required by NP or MO
Prevention of further recurrences
Encourage Influenza and Pneumococcal vaccination as per National
Immunisation Guidelines and HDWA recommendations.
NP/MO follow up.
Adverse drug effects.
Outcomes
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May 2010
UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
Topic
Referrals
Action
Health Care Practitioners for issues that lie outside NP Scope of Practice.
Outcomes
Issues that lie outside NP Scope of Practice will be referred onto
appropriate Health Care Practitioners.
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May 2010
UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
PHARMACOLOGY INFORMATION
Drug Group
Drug Formulary
General
Information
All medication will be stored, labelled and dispensed in accordance with
DCS policy and relevant legislation
Analgesia Mild
pain
(unscheduled-S2)
Paracetamol Adults and children > 12yrs old:
PO 0.5 to 1.0g 4-6hrly not to exceed 4g in 24 hours.
Analgesia
Moderate Pain
(S2-S4)
If pain not controlled by paracetamol:
Add Ibuprofen Adults: PO 200-400mg TDS or QID up to maximum
dose of 2400mg per 24 hours.
•
If non steroidal anti-inflammatory drugs not suitable or pain poorly controlled
refer back to Medical Officer
Antiemetics
S4
Metoclopramide hydrochloride
Oral/IM 10mg 8 hourly
Outcomes
Client will use the medication in an effective and safe manner.
Prescribing NP will be informed of significant adverse effects of
medication.
Adequate analgesia provided.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Analgesia requirements determined by ongoing assessment of
pain.
Adequate analgesia provided.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Use ibuprofen with caution in clients with evidence of renal
impairment and in the elderly and asthma
Analgesia requirements determined by ongoing assessment of
pain.
Patients with excessive pain or pain unrelieved by analgesia
need review by MO
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Referral to MO for poorly controlled nausea and vomiting.
Joint management by MO and NP may be deemed to be
appropriate.
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May 2010
UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
ANTIBIOTIC DRUG FORMULARY
Antibiotics
S4
Antibiotics
Pharyngitis /
Tonsillitis
Bacterial
Sinusitis
Non
prescription
Antibiotic therapy as per drug formulary following.
Phenoxymethylpenicillin: 500 mg orally (child: 10 mg/kg up to 500 mg), 12 hourly
for 10 days. Should be taken on an empty stomach, ½ to 1hr before meals
Hypersensitive to Penicillin use:
Roxithromycin: 300 mg orally, daily (child: 4 mg/kg up to 150mg orally, 12 hourly)
for 10 days. Should be taken on an empty stomach, ½ to 1hr before meals.
Amoxicillin: 500 mg orally (child: 15 mg/kg up to 500 mg), 8 hourly for 5 to 7 days.
If hypersensitive to Penicillin use:
Cefaclor: 375 mg orally, 12 hourly ( child: 10 mg/kg up to 250mg orally, 8 hourly)
for 5 to 7 days
OR
Doxycycline: 100mg orally (child > 8 yrs: 7.5 mg/kg up to 100mg), daily for 5 to 7
days.
Steam Inhalation
Antihistamines
Gargles- aspirin or warm salt water
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May 2010
UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
Drug Group
Drug Formulary
Outcomes
Adrenaline
S3
•
•
Indicated for use in patients experiencing anaphylaxis.
Dosage-for adults and children >12yrs old with spontaneous circulation:
300micrograms (epipen) or 500 micrograms (adrenaline 1:1000) IMlateral thigh repeated every 5 minutes if inadequate resolution of
symptoms.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Cetirizine
S2
•
Indicated for use in patients experiencing cutaneous changes only
associated with drug hypersensitivity reaction.
Dosage for adults and children> 12 years old: 10mg daily.
Route: Oral.
Client prescribed medication appropriate to known adverse drug
reactions, current medications and medical history.
Oxygen therapy will be guided by measured oxygen saturation levels
(SaO2).
Patients with no history/evidence of chronic lung disease aim for SaO2
> 94%.
Oxygen delivery device will be either nasal prongs or face mask.
Patients with history of chronic lung disease aim for Sao2 via oxygen
delivery device equivalent to baseline SaO2 (if known) otherwise aim for
SaO2 >90%.
Authorization for use of oxygen therapy to seek to maintain
SaO2 > 90%.
Transferral of care to MO or ED of WA public hospital.
Joint management by MO and NP may be deemed to be
appropriate.
•
•
Oxygen Therapy
•
•
•
•
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May 2010
UPPER RESPIRATORY TRACT INFECTION (URTI)
CUSTODIAL HEALTH NURSE PRACTITIONER
Clinical
Protocol
Endorsement
Name: Fraser Moss
Position: Director of Health Services
Professional Qualification:
Organisation:
Signature:
Name: Geak Chin Ng
Position: Chief Pharmacist
Professional Qualification:
Organisation:
Signature:
Name: Julia Chin
Position: Nurse Practitioner (Designate)
Professional Qualifications:
Organisation:
Signature:
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May 2010
Clinical Protocol Name –
PRISON HEALTH NURSE PRACTITIONER
REFERENCES
The Royal College of Pathologists Australia, RCPA Manual, 2004, www.rcpamanual.edu.au.
eTG complete Oct 2006. Respiratory Tract Infections [cited 2007 Jan 29];
MIMS. MIMS Online: MIMS, 2005.
th
Queensland Health and the Royal Flying Doctor Service 2009. Primary Clinical Care Manual (6 Ed.)
(Available on-line.)
Brown, A.F.T. and Cadogan, M.D. 2006. Emergency Medicine Emergency and Acute
Medicine: Diagnosis and Management Medicine (5th Ed), Hodder Arnold, London;
DCS would like to thank the Health Department of Western Australia, Joondalup ED and Silver Chain for
their assistance in this Clinical Protocol
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