Cytomegalovirus (CMV) is a member of the herpes simplex virus group. The virus, transmitted by human contact, results in an infection so mild that it is usually overlooked because no symptoms are present. Approximately 80% of the general population experience a CMV infection by the time they reach middle age. Imunosuppressed patients, however, particularly patients who have received transplanted organs, are highly susceptible to CMV, with estimates as high as 90% of such patients contracting CMV infection. Generally the CMV infection occurs 4 to 6 weeks after the implementation of increased doses of immunosuppressive drugs to treat rejection. CMV infection is also present in at least 80% of patients with acquired immunodeficiency syndrome (AIDS), causing serious problems such as encephalitis, retinitis, pneumonia, and esophagitis in 30% of them.
The virus generally inhabits the salivary glands in a latent infection that is reactivated by pregnancy, blood transfusions, or immunosuppressive medications. Benign in people with normal immune systems, the virus can be devastating to an unborn fetus or a person with immunosuppression. The virus is spread throughout the body by the white blood cells (lymphocytes and mononuclear cells) to organs such as the liver, lungs, gastrointestinal (GI) tract, and central nervous system (CNS), leading to cellular inflammation and possibly organ dysfunction.
CMV is transmitted by contact with the fluids that contain the virus, such as saliva, urine, breast milk, cervical mucus, and semen. It can be transmitted during pregnancy from a primary or reactivated CMV infection. It can be transmitted during delivery from contact with cervical secretions or after delivery in the breast milk. The virus may be present for years after the primary infection.
Nursing care plan assessment and physical examination
Ask about immunosuppressive conditions such as recent traumatic injury that may have required multiple blood transfusions, organ transplantation, or HIV infection. The patient may describe a recent viral infection with symptoms such as sore throat, tiredness, joint and muscle aches, and headache. Some patients will remember an episode that lasted approximately 3 weeks with high fevers as the only symptom. In an immunosuppressed patient, there may be specific organ involvement, such as the lungs (dry cough, difficulty breathing), the GI tract (watery diarrhea, bloody diarrhea, nausea, vomiting, and cramping), and the CNS (blurred vision, headache, neck rigidity, tremors, lethargy, and even seizures and coma).
Infants may show signs of delayed development and may show signs of jaundice, petechial rash, respiratory distress, and hearing loss. With adults, assess all body systems, but the most severe signs and symptoms occur with CNS or liver involvement. Evaluate patients for signs of fever, pallor, changes in the lymph node tissue, and pharyngitis. Auscultate the patient’s lungs to assess for crackles. Note decreased breath sounds, cough, shortness of breath, and symptoms of pneumonia. Patients may also have mental status changes such as irritability, lethargy, and even seizures and coma. Patients may evidence hyperactive bowel sounds, tenderness to palpation of the stomach, and possible distension. Assess for neck rigidity, pupil changes, motor weakness, positive Babinski reflex, and tremors. Perform an eye exam to identify changes in the eye grounds, initially with small, white, cotton-wool spots with irregular borders on the retina that enlarge to fluffy white exudates and visible hemorrhages, causing vision loss progressing to blindness.
Assess the patient’s or his or her parents’ ability to cope. The unborn child’s mother and father will need counseling and support to deal with the possible effects of CMV on their unborn infant.
Nursing care plan primary nursing diagnosis: Risk for infection (spread or reactivation) related to immune suppression.
Nursing care plan intervention and treatment plan
Infants with congenital abnormalities require careful monitoring of growth and developmental patterns throughout infancy. Parents may need referrals for information on special education, physical therapy, and social services. Treatment focuses on preventing complications and relieving symptoms; treatment varies depending on the type and degree of infection. Patients with a generalized infection receive antipyretics for fever and analgesics for aching and sore throat. Such patients need rest, good nutrition, and adequate fluid intake for chronic fatigue. Other, more severe infections, are usually treated with antiviral medications. The amount and duration of medication depend on the severity of the infection. Organ system complications are managed based on the symptoms.
Important priorities are to maintain an adequate level of functioning, prevent complications, support the recuperative process, and provide information about the disease process, prognosis, and treatment. Patients, and caregivers in the case of infants, need to be educated about decreasing the risk of spreading CMV infection. Secretions, particularly in infants, are apt to contain the virus. Families of infants with CMV infection will need emotional support. Answer questions about CMV infection, symptoms, complications, and treatment. Teach adult patients about the CMV infection, the need for adequate rest, exercise, good nutrition, and fluid intake.
Nursing care plan discharge and home health care guidelines
Teach the patient’s caregiver to handle diapers carefully, washing hands to prevent the spread of CMV. In the hospital, universal precautions are needed for women of childbearing potential. Frequent fundascopic examinations are imperative in human immunodeficiency virus (HIV)-positive and AIDS patients. Female healthcare workers who are attempting pregnancy may wish to have CMV titers drawn to identify their risk for the disease. Pregnant women working in daycare centers or hospital nurseries need to avoid caring for infected infants and to use universal precautions.
Teach the patient information about the prescribed dosage, route, action, and follow-up laboratory work needed for all medications. Teach the patient the appropriate use of antipyretics for fever and analgesics for pain and discomfort.
Inform the patient that signs of a relapse or complications may occur after an initial improvement. The patient should be instructed to report visual changes; changes in GI function, such as weight loss, nausea, vomiting, and anorexia; continued fever; and pulmonary symptoms (cough, shortness of breath, chest tightness). If these complications occur, teach the patient to seek medical attention.
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