Download Severe Acute Respiratory Syndrome: A Health History Examination

Running head: SARS
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Severe Acute Respiratory Syndrome
A Health History Examination
Erica Bailey
Dixie State University
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Severe Acute Respiratory Syndrome: A Health History Examination
Introduction
Severe Acute Respiratory Syndrome (SARS) is a disease cause by a coronavirus (SARSCoV). It is highly contagious disease that killed 20% of the people who contracted the virus
(Fung & Yu, 2003), and it showed the world how unprepared we were to deal with a disease as
contagious as this. Now that the crisis is over, it is important to understand the complexity of
this disease, how it attacks the human body, how the body shows symptoms, the diagnostic tests
that can be run, and most importantly, how nurses can care for and treat those afflicted with this
disease.
History
An outbreak of this virus began in late 2002 and it is now known to have begun in a
western region of China. Chinese officials did not let the World Health Organization (WHO)
know the existence of a highly contagious, deadly, unidentified disease until February 2013, so it
is not clear how many people after patient zero were sick or died in China. Soon, cases of this
mysterious illness began to appear all over the globe; however the outbreak was particularly
significant in Singapore, Hanoi and even Ontario, Canada. The disease spread fast, and travel
restrictions and warning were posted for cities all over the world. Thanks to the wonders of
containment and isolation, on May 18, 2003 the WHO professed “It has been more than three
weeks since the last case was placed into isolation… The WHO is ready to declare that the chain
of human-to-human transmission appears to have been broken” ("WHO China," 2004). No cases
of SARS has been reported globally since; however, in the end, 8,273 were diagnosed with
SARS with over 800 of those people dying.
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Pathophysiology
Many of the exact mechanisms of action with SARS are unknown, but at its most basic
level, SARS is essentially a pneumonia. The SARS-CoV causes damage to lung tissue by
causing a lytic effect on lung cells. In response, the body initiates an immune response; and as a
result fluid begins to fill in the lungs. Secondary to the infection of the lung tissue, the infection
of tracheobronchial and alveolar epithelial cells that sets in motion a chain events that makes
SARS very lethal. When the infection begins, Angiotensin Converting Enzyme II (ACEII)
becomes a receptor for SARS-CoV which results in a down regulation of the enzyme. (Jia et al.,
2005) which in turn causes changes in renal and vascular resistance. Blood pressure control
becomes a problem as the body is not able to regulate systemic changes in the absence of
adequate levels of ACEII. The other pathological consequence is the problems experienced
with the patient’s own immune system. The patient will not have antibodies against this virus,
and this begins a cascade in which the system is sending all kinds of immunity cells in an attempt
to fight the virus. There will be insufficient interferon response, and excessive chemokines and
cytokines and when the immune system realizes it does not have enough cells to fight the illness,
it sends more immature chemokines and cytokines cells to the lungs. This process is called
cytokine storm, and it a struggle between cytokines and white blood cells. This positive
feedback loop, creates a never-ending cycle of unnecessary and damaging cytokines. Excessive
induction of proinflammatory cytokines and chemokines and recruitment of immune cells
together possibly explain the severity of the injury often observed in the lungs of SARS patients
(Gu & Kortwing, 2007).
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Signs and Symptoms
The initial symptoms begin very similarly to the flu, with the first signs developing
within 7-10 days after infection. Fever greater than 38 degrees Celsius, dry cough and shortness
of breath are the usual initial symptoms, but quickly progresses to chills, muscle aches and
diarrhea. Further progression of the disease includes advancing pneumonia, cough, shortness of
breath, hypovolemic shock and possible respiratory collapse.
In the years following the outbreak, an interesting phenomenon occurred. 769 health care
workers in Canada were treated because of suspected or confirmed SARS. These survivors
starting exhibiting unique medical problems. In a study performed by Stainsby, Howitt and Porr
(2011) studied these 769 health care workers and over 60% reported within a year of exposure,
new-onset neuromuscular symptoms such as muscle weakness, tremors, absent Achilles deep
tendon reflex, and neuropathy. There is no physiological or clinical explanation for these
symptoms and the only common exposure is the SARS-CoV.
Diagnosis, Laboratory Studies and Imaging
Because of the nonspecific nature of the symptoms, SARS can be difficult to diagnose.
The most common way to diagnose SARS is based on a combination of criteria. First, the
clinical presentation of signs and symptoms, second, possible exposure such as being in an
infected area, travel or infected person and lastly a positive SARS-CoV antibody test. X-rays are
of little help as initially, the chest x-ray will be negative, and if something does show, it will
appear to be an average looking pneumonia. There are three tests to detect the antibody, and
antibodies can be detected in serum, naso or oropharyngeal secretions or stool (Drehner, Dean, &
Moriarty, 2004). Sometimes it is easier to rule out SARS than diagnose it. Negative antibody
test, suspected contact has had SARS ruled out or another diagnosis can explain the disease
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condition the patient has, so it is especially important that tests for other diseases such as yellow
fever, hanta virus and even standard flu and pneumonia be considered.
Medication and Treatment
Because SARS-CoV is a virus, antibiotics are ineffective against this disease, and no
antiviral medication or vaccine has been developed. The best treatment for SARS is to treat the
symptoms. Medications such as anti-pyretics, pain killers, cough syrups, breathing treatments,
and high-dose steroids (to promote lung healing). In addition, oxygen therapy will be essential,
and the use of a BiPap machine or even mechanical ventilation may be needed to maintain
respiratory status.
Nursing Diagnoses
There are several nursing diagnoses that can, and should be utilized by nurses for the
SARS patient.
1. Ineffective breathing pattern related to SARS-CoV lung involvement as evidenced by
shortness of breath and decreased oxygen saturations.
2. Anxiety related to breathing difficulty as evidenced by patient disposition.
3. Risk of fluid volume deficit related to hypovolemic nature of SARS disease process.
4. Risk of impaired skin integrity related to prolonged treatment in bed.
Plan of Care
It should be noted that SARS patients should be place in negative pressure hospital
rooms, with the staff utilizing N95 masks and other standard airborne precautions. Such
isolation and/or the sight of hospital staff wearing PPE might frighten the patient. The nurse
should be explaining to the patient what to expect and why PPE is necessary.
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Any standard of care with regards to a SARS patient will center on respiratory care.
Oxygen delivered via cannula, BiPap, or ventilator with accompanying breathing treatments with
be essential. Nurses should watch for signs and symptoms of worsening respiratory status.
Signs such as, higher oxygen demand (jumps from 2L to 5L) or need to change to a different
delivery method (from cannula to high flow, etc.) as these significant changes are concerning. It
would be good practice for the nurse to place the patient on continuous pulse oximetry so that
saturations will be constantly observed. Regular blood pressure and other vital sign monitoring
is necessary as well.
With any disease process that involves difficulty breathing, anxiety is usually a problem
that warrants treatment. Careful administration of medications such as Ativan or Xanax can be
utilized, but the nurse should be mindful of the respiratory depression of these medication (and
narcotic pain medications) as this side effect could make the situation worse. Try treating
anxiety with other methods such as distraction, meditation or even therapeutic communication
should always be employed.
SARS can cause a hypovolemic state so fluid resuscitation may be needed; in addition, a
patient who is wearing a BiPap mask or ventilator is a patient who is not taking in much oral
fluids. Orders for cautious fluids should be obtained, with the nurse watching for signs and
symptoms of fluid overload.
This patient will be sick for a while, and when patients are sick, they may not reposition
themselves as much as they should. Bed pumps, mattress turning systems, positioning and
elevating are all great ways to prevent pressure ulcers. Nurse should be watching for signs that
the patient is repositioning themselves, if it does not appear that the patient is able to turn
themselves the nurse should begin Q2 turns alternating left, right and supine positioning.
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Mepilex (Pressure Ulcer Prevention or PUP) stickers can be used on bony prominences, such as
the sacrum, as yet another barrier to prevent a pressure ulcer.
Conclusion
While there has not been a case of SARS in over a decade, the lessons learned serve as a
cautionary tale of how quickly one disease process can morph into another condition, more lethal
and contagious than previously thought. SARS should have been seen as a warning shot...so the
question is, are we prepared? Scientifically, the answer is a qualified yes, in terms of public
health, the answer is no (Clarke, 2003). It is hard to believe that SARS-CoV is in the same
category of virus, the Coronavirus, as the one that causes the common cold; however what we
have learned from SARS regarding its pathophysiology symptoms, testing and most importantly
the lessons learned from the health care professionals about isolation and nursing diagnoses and
care can be applied to a whole host of similar respiratory illness.
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References
China’s latest SARS outbreak has been contained, but biosafety concerns remain. (2004).
Retrieved from http://www.who.int/csr/don/2004_05_18a/en/
Clarke, T. (2003). SARS: What have we learned. Retrieved from http://www.nature.com/
nature/journal/v424/n6945/full/424121a.html
Drehner, M. H., Dean, J. L., & Moriarty, D. M. (2004, January). What you need to know about
SARS now. Nursing, 34(1), 58-63. http://dx.doi.org/http://search.proquest.com.libproxy.
dixie.edu/nursing/docview/204621894/67F9E693CBEC4ED5PQ/10?accountid=27045
Fung, W. K., & Yu, P. (2003, August 19). SARS case-fatality rates. CMAJ: Canadian medical
association journal, 169(4), 277-278. Retrieved from http://www.ncbi.nlm.nih.
gov/pmc/articles/PMC180638/
Gu, J., & Kortwing, C. (2007, April). Pathology and pathogenesis of SARS. The American
Journal of Pathology, 170(4). http://dx.doi.org/ 10.2353/ajpath.2007.061088
Jia, H. P., Cook, D. C., Shei, L., Hickley, M., Pewe, L., & et al. (2005, December). ACE2
receptor expression and SARS. Journal of Virology, 79. http://dx.doi.org/
10.1128/JVI.79.23.14614-14621.2005
Stainsby, B., Howitt, S., & Porr, J. (2011, March). Neuromusculoskeletal disorders following
SARS: A case series. Journal of the Canadian Chiropractic Association, 55(1). Retrieved
from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3044805/