Diphtheria

Key Points

  • Diphtheria is caused by Corynebacterium diphtheriae and spreads through respiratory secretions.
  • A gray pharyngeal pseudomembrane that bleeds with attempted removal is a hallmark finding.
  • Priority risks are airway obstruction, myocarditis, dysrhythmias, and neurologic injury.
  • Diagnosis uses throat culture/PCR with supportive CBC and imaging findings.
  • Treatment requires antibiotics plus diphtheria antitoxin, close airway-cardiac monitoring, and isolation.

Pathophysiology

After inhalation, C. diphtheriae produces toxin-mediated local inflammation in the upper airway. Tissue injury supports formation of a thick pseudomembrane over throat and tonsillar surfaces.

Systemic toxin effects can extend beyond the airway and injure cardiac and neurologic tissues, creating high-acuity complications even after initial throat symptoms.

Classification

  • Respiratory diphtheria: Upper-airway infection with pseudomembrane and potential obstruction.
  • Systemic-toxic complication pattern: Cardiac or neurologic involvement.

Nursing Assessment

NCLEX Focus

Prioritize airway patency and early recognition of toxic cardiac-neurologic complications.

  • Assess sore throat, fever, dysphagia, cervical lymph-node swelling, and malaise.
  • Inspect for pseudomembrane presence and avoid trauma/manipulation that can provoke bleeding.
  • Monitor respiratory effort, stridor, and signs of airway narrowing.
  • Track ECG/cardiac status for myocarditis or dysrhythmia clues.
  • Review diagnostic findings: throat culture, PCR, CBC leukocytosis, and soft-tissue neck/chest imaging.
  • Assess immunization status (DTaP/Tdap history) and exposure risk context.

Nursing Interventions

  • Implement ordered isolation and transmission-control workflows.
  • Administer prescribed antibiotics and diphtheria antitoxin promptly.
  • Maintain continuous airway and cardiac monitoring in unstable presentations.
  • Prepare escalation for intubation and mechanical ventilation if obstruction worsens.
  • Reinforce vaccination counseling for prevention and future risk reduction.
  • Reevaluate frequently and revise care plans with new assessment and diagnostic data.

Airway Obstruction Emergency

Progressive pseudomembrane-related obstruction can rapidly become fatal without immediate escalation.

Pharmacology

Drug ClassExamplesKey Nursing Considerations
antibioticsCulture-directed antibacterial regimensReduce organism burden and transmission risk.
AntitoxinsDiphtheria antitoxin productsNeutralize circulating toxin; monitor for reaction per protocol.

Clinical Judgment Application

Clinical Scenario

A child with fever and severe sore throat develops worsening dysphagia and visible gray membrane over tonsillar tissue.

  • Recognize Cues: Classic diphtheria pattern with airway threat.
  • Analyze Cues: Toxin-mediated disease may progress to airway and cardiac complications.
  • Prioritize Hypotheses: Immediate priorities are airway protection and antitoxin-antibiotic therapy.
  • Take Action: Start isolation workflow, implement ordered therapies, and intensify cardiorespiratory monitoring.
  • Evaluate Outcomes: Airway remains patent, hemodynamics stay stable, and no new systemic complications develop.

Self-Check

  1. Why is pseudomembrane manipulation dangerous in diphtheria?
  2. Which complications require continuous cardiac surveillance?
  3. Why are antitoxin and antibiotics used together?