Syphilis is a chronic, infectious, systemic, sexually transmitted vascular infection that is characterized by five stages: incubation, primary, secondary, latency, and late. The incubation stage begins with the penetration of the infecting organism, the spirochete Treponema pallidum, into the skin or mucosa of the body. Within 10 to 90 days after the initial infection, the primary stage begins with the appearance of a firm, painless lesion called a chancre at the site of entry. In women, the chancre often forms in the vagina or on the cervix and therefore goes unnoticed. If it is left untreated, the chancre heals spontaneously in 1 to 5 weeks. As this primary stage resolves, systemic symptoms appear, thus signaling the start of the secondary stage. Secondary stage symptoms include malaise, headache, nausea, fever, loss of appetite, sore throat, stomatitis, alopecia, condylomata lata (reddish-brown lesions that ulcerate and have a foul discharge), local or generalized rash, and silver-gray eroded patches on the mucous membranes. These symptoms subside in 1 week to 6 months, and the infected person enters a latent stage, which may last from 1 to 40 years. During latency, periodic symptoms of secondary syphilis may recur.
Approximately one-third of untreated syphilis patients eventually progress to the late or tertiary stage of syphilis; the complications are often disabling and life-threatening. In this stage,
destructive lesions called gummas develop in either the skin, bone, viscera, central nervous system, or cardiovascular system. Three subtypes of late syphilis are late benign syphilis, cardiovascular syphilis, and neurosyphilis. Late benign syphilis can result in destruction of the bones and body organs, which leads to death. Cardiovascular syphilis develops in approximately 10% of untreated patients and can cause aortitis, aortic regurgitation, aortic valve insufficiency, and aneurysm. Neurosyphilis develops in approximately 8% of untreated patients and can cause
meningitis and paresis.
Syphilis is a communicable disease caused by the organism T. pallidum. Transmission usually occurs through direct contact with open lesions, body fluids, or the secretions of infected persons during sexual contact. Blood transfusions, placental transfer, and in rare cases, contact with contaminated articles are also modes of transmission. Susceptibility to syphilis is universal, but only 10% of exposures lead to active infection.
Nursing care plan assessment and physical examination
Establish a sexual history, including the number of sexual partners and whether the patient was protected by a condom. Determine if any of the patient’s partners were infected with a sexually transmitted infection (STI). Question the patient about intravenous (IV) drug use and previous STIs. With an infant, establish the sexual history of the mother. Elicit a history of chancres. Ask the patient to describe the appearance, location, and duration of any chancres, particularly if they are no longer present. Establish a history of fever, headaches, nausea, anorexia, weight loss, sore throat, mild fever, hair loss, or rashes, symptoms of the primary and secondary stages. Determine if the patient has experienced paresis, seizures, arm and leg weakness, alterations in judgment, or personality changes, all of which are symptoms of late-stage syphilis.
Carefully inspect the patient’s genitalia, anus, mouth, breasts, eyelids, tonsils, or hands for a primary lesion. With female patients, be sure to determine if chancres have developed on internal structures such as the cervix or the vaginal wall. Chancres vary in appearance and location, depending on which stage the disease has entered, so record a detailed description of any lesions If a chancre exists, palpate the surrounding lymph nodes for hard, painless nodules. Also inspect the scalp, skin, and mucous membranes for hair loss, rashes, or mucoid lesions, which are characteristic of the secondary stage. Inspect the fingernails for signs of pitting. If late syphilis is suspected, assess the patient for the characteristic complications. Observe for joint deformities or disfiguring lesions on the palate. Note areas of numbness or paralysis and hyperactive reflexes. Assess the pupils for size and reaction to light. Assess the patient for pulmonary congestion. Auscultate for heart sounds to determine irregularities, which may indicate valvular degeneration.
The patient with syphilis is usually embarrassed by the infection and may be reluctant to seek out and continue treatment. Be nonjudgmental. Assure the patient that her or his privacy and confidentiality will be maintained during examination, diagnosis, and treatment, although all sexual partners need to be notified so that they can be examined and treated as needed.
Nursing care plan intervention and treatment plan
Medical treatment for syphilis infection at any stage consists of antibiotic therapy to destroy the infecting bacteria. After treatment, patients are instructed to refrain from sexual contact for at least 2 weeks or until lesions heal and to return for serology testing in 1 month and then every 3 months for 1 year.
Carefully question patients about penicillin sensitivity before treatment. They should also be warned about the Jarisch-Herxheimer reaction, which is believed to be caused by toxins that are released from dying spirochetes. The reaction develops 6 to 12 hours after the initial penicillin dose and causes fever, headache, nausea, tachycardia, and hypotension. Instruct the patient to rest, drink fluids, and take antipyretics.
Tell the patient that the disease must be reported to the local health authority and that confidentiality will be maintained. Identifying and treating sexual partners of the infected patient is an important intervention. If the patient is treated in the primary or secondary stage, attempt to contact all sexual partners from the past 3 months. If the patient is in the later stages of the disease, contacts from the previous year are screened. Handle the “contact discovery” interview
carefully, and if possible, have a public health professional conduct the interview.
Provide care for the patient’s lesions. Keep them clean and dry. Properly dispose of contaminated materials from draining lesions. Use universal precautions when you come in direct contact with the patient, when collecting specimens, and when caring for the lesions.
Focus on prevention. Educate patients about the course of the disease and the need to return for follow-up treatment or blood tests. Patients need to understand that although their lesions may heal, the infection may not be gone. Approximately 10% of patients do not respond to the first round of antibiotics, so additional treatment may be necessary.
Teach patients how to reduce risk factors to prevent future infections by limiting the number of sexual partners and practicing safer sex. Using condoms with spermicide and inspecting partners for any rashes or lesions may reduce exposure to the disease. Patients need ongoing emotional support to make lifestyle changes. Explain the need for regular laboratory testing (VDRL) every 3 months for 2 years to detect a relapse. Urge patients in the latent or late stages to have blood tests every 6 months for 2 years. Explain the relationship between human immunodeficiency virus (HIV) and syphilis and perform HIV testing if the patient wishes.
Nursing care plan discharge and home health care guidelines
Instruct the patient to avoid sexual contact for at least 2 weeks or as prescribed by the physician. Tell the patient to contact the physician if any new lesions or rashes are noted. Teach the patient how to prevent infection from STIs through safer sex practices.
Teach the patient the purpose, dosage, schedule, precautions, and potential side effects, interactions, and adverse reactions of all prescribed medications. Recommend that patients treated as outpatients wait in the clinic or office for at least 30 minutes after administration of penicillin IM or IV to make sure there is no allergic reaction. Instruct patients given oral tetracycline to take the medication 1 hour before or 2 hours after meals and to avoid dairy products, antacids, iron, and sunlight while taking the drug.
Teach the patient the importance of follow-up care, and make sure the patient knows the dates and times for follow-up appointments. Teach the patient the cause, symptoms, and mode of transmission for syphilis. Emphasize the importance of testing and treating all of the patient’s sexual partners; urge the patient to provide the names of sexual partners.