Diphtheria Nursing Care Management: Study Guide

Diphtheria was once called the "strangling angel of children." Traced to the fourth-to-fifth century BC, it was one of the leading causes of childhood death before the vaccine. Here is the pathophysiology, presentation, and nursing management you need.

What is diphtheria?

Diphtheria is an acute, toxin-mediated disease caused by Corynebacterium diphtheriae. Unlike the ubiquitous diphtheroids, C diphtheriae lives only on human mucous membranes and skin. The organisms stay in the superficial layers of skin lesions or respiratory mucosa and drive a local inflammatory reaction. Nontoxigenic strains can also cause disease, usually mild and cutaneous.

Pathophysiology

Diphtheria toxin, secreted by toxigenic strains, is a single polypeptide of Mr 58,342.

Within the first few days of respiratory infection, a dense necrotic coagulum of organisms, epithelial cells, fibrin, leukocytes, and erythrocytes forms and advances into a gray-brown adherent pseudomembrane. It does not come off easily; removal exposes a bleeding, edematous submucosa. Palate and hypopharynx paralysis is an early local effect of the toxin. Toxin absorption can cause necrosis of kidney tubules, thrombocytopenia, cardiomyopathy, and demyelination of nerves. In the classic picture, the tonsils or pharynx are the primary focus in more than 90% of patients; the nose and larynx are next.

Statistics and incidences

Diphtheria is endemic in many parts of the world, including the Caribbean and Latin America. Death from mechanical airway obstruction or cardiac involvement with circulatory collapse occurs in at least 10% of patients with respiratory tract diphtheria. When the disease was endemic it mainly hit children younger than 15 years; the epidemiology has since shifted to adults who lack natural exposure in the vaccine era and have low booster rates. Of the 27 sporadic respiratory cases reported in the United States in the 1980s, 70% occurred in people older than 25 years.

Causes

• Nonimmunization. Among nonimmunized populations, diphtheria most often occurs in fall and winter, though summer outbreaks happen.
• Poor socioeconomic conditions. Spread is faster where crowding occurs and immunization rates are low.
• Travel history. International travel poses risk to the unvaccinated or inadequately vaccinated.

Clinical manifestations

Severity depends on the site of infection, immunization status, and toxin spread.

• Tonsils and pharynx. The most common form. Starts with sore throat, usually without systemic complaints. Fever, if present, is usually lower than 102°F; malaise, dysphagia, and headache are not prominent.
• Pseudomembrane. In nonimmune patients, membrane forms after a 2-day to 5-day incubation and grows over the pharyngeal walls, tonsils, uvula, and soft palate. It can extend to the larynx and trachea, causing airway obstruction and suffocation.
• Edema. Marked neck edema can produce a bull-neck appearance with a distinct collar of swelling. The patient throws the head back to relieve pressure on the throat and larynx. The edema obliterates the angle of the jaw, the borders of the sternocleidomastoid, and the medial border of the clavicles.
• Larynx. In a minority of patients the larynx is the initial site, resembling laryngotracheobronchitis. Hoarseness can progress to loss of voice and severe airway obstruction. Nasal diphtheria may start like a common viral URI, sometimes with a foul odor.
• Skin. Cutaneous diphtheria appears at one or more sites, usually over areas of prior minor trauma or bruising.

Assessment and diagnostic findings

Confirm infection by combining isolation of C diphtheriae on culture with toxigenicity testing.

• Bacteriologic culture. Essential to confirm the diagnosis.
• Toxigenicity testing. Use the Elek test to determine whether the isolate produces toxin.
• PCR. Polymerase chain reaction can detect nonviable organisms from specimens taken after antibiotics have started.

Medical management

Address critical care needs and complications first.

• Antitoxin. Specific antitoxin is the mainstay and is given on clinical diagnosis, because it neutralizes free toxin only.
• Isolation. Place the patient in strict isolation (respiratory colonization) or contact isolation (cutaneous only) until 2 subsequent cultures taken 24 hours apart, after therapy ends, are negative.

Pharmacologic management

Give antibiotics alongside the antitoxin.

• Antibiotics. Halt toxin production, treat the local infection, and prevent transmission to contacts.
• Antipyretics. Inhibit central synthesis and release of prostaglandins, returning the hypothalamic set-point to normal.
• Vaccines. Diphtheria toxoid is combined with tetanus and acellular pertussis for children younger than 7 years; active immunization raises resistance to infection.

Nursing management

Assessment

• History. Respiratory diphtheria follows an incubation of 2-5 days (range 1-10d). Early symptoms are nonspecific and often look like a viral URI.
• Physical exam. The patient runs a low-grade fever but appears toxic and may have a swollen neck. Cardiac toxicity typically appears after 1-2 weeks of illness, following improvement in the pharyngeal phase; neurologic toxicity tracks with the severity of the pharyngeal infection.

Nursing diagnoses

• Hyperthermia related to exotoxin release.
• Imbalanced nutrition: less than body requirements related to painful swallowing.
• Ineffective airway clearance related to pseudomembrane blocking the airway.

Planning and goals

• Maintain normal body temperature.
• Demonstrate and maintain normal body weight.
• Maintain a clear airway.

Interventions

• Thermoregulation. Keep the room comfortable, dress the patient in thin sweat-absorbing clothes, push oral fluids, and give antipyretics as ordered.
• Caloric intake. Monitor calorie intake and food quality, offer appetite-stimulating foods, and weigh the patient daily.
• Airway clearance. Auscultate breath sounds and note adventitious sounds, position for maximum lung expansion, assist with chest physiotherapy, and suction secretions as needed.

Evaluation

Goals are met when the patient maintains a normal temperature, a normal body weight, and a clear airway.

Documentation

Record individual findings and factors affecting them, social interactions and behavior, cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and progress toward desired outcomes.