Which of the following is the first priority in preventing infections while providing care for a client?

Review this study guide to know more about the Middle East respiratory syndrome, its causes, symptoms, treatment, prevention, and nursing management.

MERS or Middle East respiratory syndrome is a zoonotic disease (spreads from animals to people) that can cause severe respiratory illness. It was first identified in Saudi Arabia in 2012 and has infected more than 2,000 individuals worldwide.

• What is Middle East Respiratory Syndrome (MERS)?
• Pathophysiology
• Causes
• Statistics and Incidences
• Clinical Manifestations
• Assessment and Diagnostic Findings
• Medical Management
  • Pharmacologic Management
• Nursing Management
  • Nursing Assessment
  • Nursing Diagnosis
  • Nursing Care Planning and Goals
  • Nursing Interventions
  • Evaluation
  • Documentation Guidelines
• Practice Quiz: Middle East Respiratory Syndrome (MERS)
• References

Middle East respiratory syndrome (MERS) is caused by a novel coronavirus (Middle East respiratory syndrome coronavirus, or MERS‐CoV).

• Through first reported in Saudi Arabia, it was later identified that the first known cases of MERS occurred in Jordan in April 2012.
• Most MERS patients developed severe respiratory illness with symptoms of fever, cough, and shortness of breath.
• A large MERS outbreak occurred in the Republic of South Korea linked to a traveler from the Arabian Peninsula in 2015.
• Travel-associated cases have been identified in Algeria, Austria, China, Egypt, France, Germany, Greece, Italy, Malaysia, Netherlands, Philippines, Republic of Korea, Thailand, Tunisia, Turkey, United Kingdom (UK), and United States (US).
• CDC has published guidance for health departments and healthcare infection-control programs for investigating potential cases of MERS and preventing its spread.

Pathophysiology

MERS is considered an international threat to public health.

• Compared with severe acute respiratory syndrome coronavirus (SARS-Cov), MERS-CoV can establish infection in monocyte-derived macrophages (MDMs) and macrophages.
• The virus induces the release of proinflammatory cytokines, leading to severe inflammation and tissue damage, which may manifest clinically as severe pneumonia and respiratory failure. [
• Vascular endothelial cells located in the pulmonary interstitium may also be infected by MERS-CoV, and, because MERS-CoV receptor DPP4 is expressed in different human cells and tissues, dissemination of the infection may occur. 
• Interestingly, lymphopenia has been noted in most patients infected with MERS-CoV, as was noted in SARS infections.
• This is due to cytokine-induced immune cell sequestration and release and induction of monocyte chemotactic protein-1 (MCP-1) and interferon-gamma-inducible protein-10 (IP-10), which suppresses the proliferation of human myeloid progenitor cells.

Causes

Coronaviruses are the largest of all RNA viruses, with positive-sense single-stranded RNA genomes of 26-32 kb.

• Betacoronavirus. MERS-CoV is a recently discovered betacoronavirus of lineage C that was first reported in Saudi Arabia in 2012; the exact origin of this novel coronavirus is still unknown; MERS-CoV is closely related to two coronaviruses of the same lineage found in bats, which may indeed be its wild reservoir.
• Dromedary camels. Specific mechanisms for transmission from animals are unclear but appear to involve contact with dromedary camels or their urine, as well as the consumption of their undercooked meat or unpasteurized dairy products.

Statistics and Incidences

About 3 or 4 out of every 10 patients reported with MERS have died.

• In May 2014, CDC confirmed two unlinked imported cases of MERS in the United States—one to Indiana, the other to Florida; both cases were among healthcare providers who lived and worked in Saudi Arabia; both traveled to the U.S. from Saudi Arabia, where scientists believe they were infected.
• Since 2012, 2,374 laboratory-confirmed cases of infection with MERS-CoV have been reported to the World Health Organization (WHO), including at least 823 related deaths.
• Twenty-seven countries have reported MERS cases.
• On the Arabian Peninsula, countries include Bahrain, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates (UAE), and Yemen.
• Other countries reporting travel-associated MERS include Algeria, Austria, China, Egypt, France, Germany, Greece, Italy, Malaysia, Netherlands, Philippines, Republic of Korea, Thailand, Tunisia, Turkey, United Kingdom (UK), and the United States.
• The vast majority of these cases have so far occurred in the Kingdom of Saudi Arabia.
• The largest MERS outbreak outside of Saudi Arabia occurred in 2015 in the Republic of Korea; the outbreak involved 186 confirmed cases and caused 36 deaths.
• The outbreak sparked quarantine of more than 5,000 individuals and the closure of 2,000 schools before ending.

Clinical Manifestations

Physical examination findings associated with MERS-CoV infection are similar to those presenting with any flu-like symptoms, including the following:

• Fever
• Rhinorrhea, mostly clear
• Pulmonary findings, including hypoxemia, rhonchi, and rales (some patients may have a normal auscultation)
• Tachycardia
• Hypotension may occur with severe illness, reflecting systemic inflammatory response syndrome

Assessment and Diagnostic Findings

Most state laboratories are approved to test for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) using CDC’s rRT-PCR assay.

• rRT-PCR assay. FDA issued an Emergency Use Authorization (EUA) on June 5, 2013, to authorize use of CDC’s 2012 real-time reverse transcription–PCR assay to test for MERS-CoV in clinical respiratory, serum, and stool specimens.
• Serology. Serologic testing for MERS-CoV is available as a research/surveillance test from the CDC; it is not considered a diagnostic test but may offer valuable epidemiologic data; it must be ordered in consultation and with approval of CDC via the EOC.
• Laboratory studies. Laboratory findings at presentation may include leukopenia, lymphopenia, thrombocytopenia, and elevated lactate dehydrogenase levels; these are most likely with increasing severity of illness. 
• Imaging studies. Chest imaging findings are abnormal in more than 80% of MERS cases; ground-glass opacity (GGO) is found in over 60% of chest radiographs, with about 20% incidence of consolidation; some infiltrates may be nodular.

Medical Management

Management of the Middle East respiratory syndrome (MERS) coronavirus (MERS-CoV) infection is supportive; this includes hydration, antipyretic, analgesics, respiratory support, and antibiotics if needed for bacterial superinfection.

• Consultations. Upon suspicion of MERS, the patient should be placed in an airborne infection isolation room (AIIR) with a minimum of 12 air exchanges per hour, and personnel protection equipment (PEP) appropriate for contact and airborne precautions (gown, gloves, goggles, and N-95 respirator mask or powered air purifier respirator [PAPR]) should be used.
• Medical care. Medical care is supportive and depends on the severity of illness.
• Prevention. No MERS-CoV vaccine is commercially available; prevention of infection in areas where MERS-CoV is being actively transmitted requires avoidance of potentially infectious secretions and careful attention to hand and respiratory hygiene.

Pharmacologic Management

No medications have been approved for the treatment of coronavirus infections. Clinical trials are needed to establish any benefit from ribavirin and/or interferon alfa.

Nursing Management

Nursing care for a patient with MERS-CoV include the following:

Nursing Assessment

Assessment of a patient with MERS-CoV include:

• History. A high index of suspicion is necessary to suspect MERS, and a travel and exposure history is essential to the diagnosis; keys to the case definition of MERS is a history of residence or travel in the Arabian Peninsula, in countries where MERS-CoV is known to be circulating in dromedary camels, or where human infections have recently occurred and exposure within the incubation period of 14 days.
• Physical exam. Clinical manifestation is indistinguishable from other common respiratory viruses and may range from no symptoms to rapidly progressive multiorgan failure and death.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnosis for a patient with MERS-CoV include the following:

• Infection related to failure to avoid pathogen secondary to exposure to MERS-CoV.
• Deficient knowledge related to unfamiliarity with disease transmission information.
• Hyperthermia related to increase in metabolic rate.
• Ineffective airway clearance related to excessive production of pulmonary secretions.
• Anxiety related to unknown etiology of the disease.

Nursing Care Planning and Goals

The major nursing care plan goals for a patient with MERS-CoV are:

• Prevent the spread of infection.
• Learn more about the disease and its management.
• Reduce increase in temperature.
• Provide a patent airway.
• Reduce anxiety.

Nursing Interventions

Nursing interventions for the patient with MERS-CoV include the following:

• Monitor vital signs. Monitor the patient’s temperature; the infection usually begins with a high temperature; monitor the respiratory rate of the patient as shortness of breath is another common symptom.
• Educate the patient and folks. Include the patient and folks in creating the teaching plan, beginning with establishing objectives and goals for learning at the beginning of the session; provide clear, thorough, and understandable explanations and demonstrations; and give information with the use of media. Use visual aids like diagrams, pictures, videotapes, audiotapes, and interactive Internet websites, such as Nurseslabs.
• Reduce increase in temperature. Adjust and monitor environmental factors like room temperature and bed linens as indicated; encourage ample fluid intake by mouth; eliminate excess clothing and covers, and give antipyretic medications as prescribed.
• Ensure patent airway. Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession); position the patient upright if tolerated, and encourage patient to increase fluid intake to 3 liters per day within the limits of cardiac reserve and renal function.
• Reduce anxiety. Use presence, touch (with permission), verbalization, and demeanor to remind patients that they are not alone and to encourage expression or clarification of needs, concerns, unknowns, and questions; accept patient’s defenses; do not dare, argue, or debate; converse using a simple language and brief statements; and allow the patient to talk about anxious feelings and examine anxiety-provoking situations if they are identifiable.

Evaluation

Nursing evaluation of goals for a patient with MERS-COV are met as evidenced by:

• Prevention of the spread of infection.
• Acquired knowledge about the disease and its management.
• Reduction in levels of temperature.
• Patent airway achieved.
• Reduction in anxiety.

Documentation Guidelines

Documentation guidelines for a patient with MERS-CoV include the following:

• Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

Practice Quiz: Middle East Respiratory Syndrome (MERS)

Nursing practice questions for Middle East Respiratory Syndrome (MERS). For more practice questions, visit our NCLEX practice questions page.

1. In which order will the nurse perform the following actions as she prepares to leave the room of a client with airborne precautions after performing oral suctioning?

1. Take off goggles
2. Take off gown
3. Remove gloves
4. Remove N95 respirator
5. Perform hand hygiene

A. 1, 2, 3, 4, 5
B. 2, 1, 4, 3, 5
C. 3, 4, 1, 2, 5
D. 4, 3, 2, 1, 5

1. Answer: B. 2, 1, 4, 3, 5

• Option B: Prioritization. This order will prevent contact of the contaminated gloves and gown with areas like the hair that cannot be readily cleaned after client contact and stop transmission of microorganisms to the nurse and the client. The correct order for donning and removal of PPE has been standardized by agencies such as the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration.

2. The nurse assessed the client and noted shortness of breath and recent trip to China. The client is strongly suspected of having Middle East Respiratory Syndrome (MERS-CoV). Which of these prescribed actions will the nurse take first?

A. Place the client on airborne and contact precautions
B. Introduce normal saline at 75 mL/hr
C. Give methylprednisolone (SOLU-Medrol) 1 g intravenously (IV)
D. Take blood, urine, sputum cultures

2. Answer: A. Place the client on airborne and contact precautions

• Option A: Prioritization. MERS-CoV is considered deadly so the initial action is to protect other clients and healthcare workers by securing the client in isolation. If an airborne-agent isolation (negative-pressure) room is not yet available, droplet precautions should be initiated until the client can be moved to a negative-pressure room.
• Options B, C, and D: The other actions should also be taken immediately but are not as important as preventing transmission of the disease.

3. The school nurse is asked which action will take to have the most impact on the incidence of infectious diseases in school. The correct response is:

A. Grant written information about infection control to all parents
B. Ensure that students are immunized according to national guidelines
C. Make soap and water easily accessible in the classrooms
D. Educate students on how to cover their mouths when coughing

3. Answer: B. Ensure that students are immunized according to national guidelines.

• Option B: Prioritization. The incidence of once-common infectious diseases like measles, chickenpox, and mumps has been most effectively reduced by immunization of all school-aged children.
• Options A, C, and D: The other options are also important but will not have much impact as immunization.

4. Which of the following is the FIRST priority in preventing infections when providing care for a client?

A. Handwashing
B. Wearing gloves
C. Using a barrier between client’s furniture and nurse’s bag
D. Wearing gowns and goggles

4. Answer: A. Handwashing

• Option A: Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag.

5. A 10-year-old client contracted Middle East Respiratory Syndrome (MERS-CoV) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of MERS-CoV transmission, which personal protective should the nurse wear?

A. Gloves
B. Gown and gloves
C. Gown, gloves, and mask
D. Gown, gloves, mask, and eye goggles or eye shield

5. Answer D. Gown, gloves, mask, and eye goggles or eye shield

• Option D: The transmission of MERS-CoV isn’t fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting MERS-CoV, any health care worker providing care for a client with MERS should wear a gown, gloves, mask, and eye goggles or an eye shield.

References

Sources and references for this study guide for MERS-COV:

• de Groot, R. J., Baker, S. C., Baric, R. S., Brown, C. S., Drosten, C., Enjuanes, L., … & Perlman, S. (2013). Commentary: Middle East respiratory syndrome coronavirus (MERS-CoV): announcement of the Coronavirus Study Group. Journal of virology, 87(14), 7790-7792. [Link]
• Kimberlin, D. W. (2018). Red Book: 2018-2021 report of the committee on infectious diseases (No. Ed. 31). American academy of pediatrics.
• Oshinsky, D. M. (2005). Polio: an American story. Oxford University Press. [Link]
• Willis, L. (2019). Professional guide to diseases. Lippincott Williams & Wilkins. [Link]