0133427269 Module08 Immunity LectureOutline

Module 8 Immunity The Concept of Immunity Human body constantly threatened by foreign substances, infectious agents, abnormal cells Function of immune system ( protect body from invasion by foreign antigens (foreign substances that trigger the immune response) Identify and destroy potentially harmful cells Remove cellular debris Immunity( bodys natural or induced response to infection and conditions associated with its response Immunocompetent clients ( have immune system that identifies antigens ( effectively destroys or removes them Hypersensitivity ( overreaction of immune system to antigen(s) Autoimmune disorders ( immune system loses ability to recognize, begins to attack its own tissues Immunodeficiency ( develops when immune system incompetent, unable to respond effectively Acquired immunodeficiency syndrome (AIDS) ( immune system deficit induced by infection with HIV Characterized by opportunistic infections Understanding of immune system and responses growing ( important for nurse in order to teach clients, families to follow recommended treatment regimens Normal presentation Physiology review Immune system ( complex, intricate network of specialized cells, tissues, organs Performs following functions Defends, protects the body from infection Removes and destroys damaged or dead cells Identifies, destroys malignant cells, preventing further development into tumor Activated by external agents such as microorganisms ( specific, nonspecific responses Inflammation is nonspecific response ( prevent, limit entry of invaders into body Effectiveness of immune system depends on ability to differentiate normal host tissue from abnormal or foreign tissue Components of the immune system Leukocytes (WBCs) ( primary cells involved in nonspecific and specific immune system responses Derived from stem cells (hemocytoblasts) in bone marrow Use circulation to transport themselves to site of inflammatory response Normal number circulating leukocyte 4,50010,000 cells/cubic millimeter (mm3) of blood Bone marrow increases production of leukocytes in presence of attack (infection) ( WBC 10,000/mm3 ( leukocytosis Decrease in number of circulating leukocytes ( leukopenia ( bone marrow activity suppressed, leukocyte destruction increases Divided into major three major groups ( granulocytes, monocytes, lymphocytes Granulocytes ( 6080 of total number of normal blood leukocytes Derived from myeloid stem cells of bone marrow Instrumental in inflammatory response Protect body from harmful microorganisms Three types of granulocytes Neutrophils 5570 of circulating leukocytes Phagocytic Produced in bone marrow Segmented neutrophils (segs) ( mature forms Bands ( immature neutrophils, 5 of leukocytes Circulating half-life of 610 hours Cannot replicate Eosinophils 14 of circulating leukocytes Circulating half-life 30 minutes tissue half-life 12 days Phagocytic ( less efficient than neutrophils Protect body from germs Basophils 0.51 of circulating leukocytes Not phagocytic Contains substances released into bloodstream during hypersensitivity reaction See Figure 81 THE DEVELOPMENT AND DIFFERENTIATION OF LEUKOCYTES FROM HEMOCYTOBLASTS, p. 439 Monocytes ( 2 3 of circulating leukocytes Activate the immune response against chronic infections After settling into the tissues, monocytes mature into macrophages Activate immune response against chronic infections Dendritic cells( serve as sentinels for antigens in most organs Lymphocytes ( from stem cells in bone marrow 2040 of circulating leukocytes Principal effector and regulator cells of specific immune responses to protect body Constantly circulate ( then return to concentrate in lymphoid tissues ( mature into memory cells (acquired immunity) Three types T cells ( mature in thymus gland ( integral to specific immune response B cells ( mature in bone marrow ( integral to specific immune response Natural killer cells ( found in spleen, lymph nodes, bone marrow, blood ( immune surveillance, resistance to infection Antigens Provoke specific immune response when introduced into the body Antigen determinant site ( portion of antigen that incites specific immune response Complete antigens have 2 characteristics Immunogenicity ( ability to stimulate a specific immune response Specific reactivity ( ability to stimulate specific immune system components Antigen encountered in body ( lymphocytes, APCs generate effective immune response ( B cell or humoral branch ( produce antibodies ( primary immune response See Figure 83 THE PRIMARY IMMUNE RESPONSE, p. 442 Classes of antibodies ( called immunoglobulins ( make up antibody-mediated (humoral) immune response Five types of immunoglobulins IgG ( major immunoglobulin ( secondary exposure to foreign antibody antiviral, antibacterial IgA ( found in secretions or respiratory, GI and genitourinary (GU) tracts, tears, saliva ( protect mucous membranes from invading organisms IgM ( responsible for primary immunity ( produces antibody activity against rheumatoid factors, gram-negative organisms, ABO blood group IgD ( unknown IgE ( increases during allergic reactions, anaphylaxis Intracellular pathogens activate T lymphocytes( primary agents of cell-mediated (cellular) immune response Acts at cellular level by attacking antigens directly, activating B cells Helper T cells initiate the immune responsesuppressor T cells limit it Complement is component of blood serum ( 11 protein compounds Activates in response to antigenantibody functions ( generalize inflammatory reaction Immune cells secrete cytokines (proteins) ( carry messages for immune system function Cytotoxic T lymphocytes also attack malignant cells, responsible for rejection of transplanted organs and tissues Lymphoid system Recovers proteins for vascular system, protect bloodstream from invading organisms See Figure 84 THE LYMPHOID SYSTEM, p. 443 Lymph nodes ( small round or bean-shaped encapsulated bodies Filter foreign products or antigens from lymph House and support proliferation of lymphocytes and macrophages Lymph ( enters node through afferent lymphatic vessels( flows through node, which contains macrophages, plasma cells ( foreign antigen stimulates lymphocytes, macrophages to destroy antigen by phagocytosis Spleen ( largest lymphoid organ, only one that filters blood( upper left quadrant of abdomen White pulp ( B cells predominate ( site for lymphocyte proliferation, immune surveillance Red pulp ( blood filtration( phagocytic cells dispose of damaged, aged RBCs, platelets Thymus gland ( superior anterior mediastinal cavity beneath sternum Thymosin stimulates lymphopoiesis Bone marrow ( soft organic tissue found in hollow cavity of long bones ( stores hematopoietic stem cells See Figure 82 THE DEVELOPMENT AND DIFFERENTIATION OF LYMPHOCYTES, p. 441 Lymphoid tissues ( located at key sites of potential invasion of microorganisms Plasma cells in these tissues defend body against bacterial invasion Peyer patches (gut-associated lymphoid tissue GALT) ( processes common intestinal antigens without producing acute inflammation Tonsils and adenoids ( protect body from inhaled or ingested foreign agents Nonspecific inflammatory response Barrier protection is bodys first line of defense ( skin externally, mucus internally Many body fluids contain bactericidal substances Acid in gastric fluid Zinc in prostatic fluid Lysozyme in tears, nasal secretions, saliva, sweat Barrier breached ( nonspecific immune response ( inflammation Inflammation is adaptive response to what the body sees as harmful Nonspecific because same events occur regardless of causes inflammatory process Genetic and lifespan considerations Immune function changes across the life span Pediatric considerations Immune system development complex, multifactorial Infants, children have differing amount of some immunoglobulins IgG only immunoglobulin that crosses placenta ( disappears by 68 months of age Normal values not achieved until 7 8 years Cell-mediated immunity achieves full functioning early in life Thymus, other lymphoid tissues comparatively large in children Newborns most prone to infection due to lower levels of own immune protection Human milk protective against infection Normal changes associated with aging Immune function declines with aging External and internal factors Normal changes demonstrate decrease in immune response, lowered resistance to infections, poor response to immunizations Antibody response to foreign antigens diminished ( autoantibodies more common Alterations to immunity Alterations and manifestations Hyperresponsiveness of the immune system Allergies Autoimmune disorders ( see Table 8-2 SELECTED AUTOIMMUNE DISORDERS, p. 446 Reactions to organ transplantation Impaired immune system response AIDS Other immune deficiency disorders Allergic reactions ( four types Type I, immediate hypersensitivity Type II, cytotoxic hypersensitivity Type III, immune complex reaction Type IV, delayed-type hypersensitivity Autoimmune diseases ( occur when the immune system attacks components of its own body Transplant reactions ( occur when a recipients body has an immune reaction to a newly transplanted organ or tissue ( leading to transplant rejection Hyperacute rejection Acute rejection Chronic rejection See CONCEPTS RELATED TO IMMUNITY, p. 446 See ALTERATIONS AND THERAPIES IMMUNITY, p. 447 Prevalence Allergic disease ( 40 50 of school children worldwide are sensitized to one or more allergens Autoimmune disease ( approximately 8 of U.S. population nearly 80 are female Organ transplantation ( approximately 29,000 are performed each year in the U.S. ( prevalence of rejection is difficult to determine Primary immune deficiencies ( affect about 500,000 people in the U.S. Genetic considerations and nonmodifiable risk factors Genetics ( key component in a number of immune disorders and deficiencies Gender ( important factor Many conditions more prevalent in women Some autoimmune diseases may be triggered by pregnancy others go into remission during pregnancy Age ( secondary immune deficiencies People over age 55 more prone to transplantation problems Ethnicity ( prevalence of specific autoimmune disease varies from race to race African Americans ( more prone to SLE, scleroderma Case Study Part 1 ( Marisol Jimenez is a 7-year-old Hispanic American female who was diagnosed with peanut sensitivity as a toddler Prevention Two types of prevention must be considered Prevention of immune disorders themselves Use of vaccines to prevent infectious diseases Healthy People 2020 Nationwide effort to identify and eliminate most serious preventable threats to health Elimination rubella, congenital rubella syndrome, polio Reduction pertussis, hepatitis A, hepatitis B, hepatitis C, tuberculosis, varicella, Haemophilus influenza type b, measles, mumps, meningococcal diseases, and pneumococcal infections Specific goals for reduction of vaccine-preventable diseases Adequately immunize 80 - 90 of U.S. children by 35 months of age Adequately immunize 95 of children in kindergarten Adequately immunize 80 90 of adolescents Have 95 of children younger than 6 years of age participating in a fully operational population-based immunization registry Modifiable risk factors Nutrition ( related to development of food allergies Weight ( being underweight or overweight can be detrimental to immune system Stress ( chronic stress leads to heightened endocrine response Alcohol, drug, cigarette use ( can increase susceptibility to immune diseases Unprotected sex ( key risk factor for HIV Immunizations Introduce antigen into body ( allowing immunity against a disease to develop natural Active immunity ( immunity in which antibody production is stimulated without causing clinical disease Antigen given in form of vaccine Passive immunity ( antibodies produced in human or animal host ( given to person Not lasting immunity Types of vaccines Killed virus vaccines ( contains microorganism that has been killed, still induces human body to produce antibody (inactivated polio virus) Toxoid ( toxin that has been treated to weaken toxic effects but retain antigenicity (tetanus toxoid) Live virus vaccine ( contains microorganism in live but attenuated (weakened) form (measles, varicella) Recombinant forms ( organism that has been genetically altered for use in vaccines (hepatitis B) Conjugated forms ( altered organism joined with another substance to increase immune response (H. influenzae type b vaccine conjugated with protein carrier such as tetanus toxoid) Responses to vaccines Local reaction ( erythema, swelling, pain, induration at injection site Systemic reaction ( fever, fussiness or irritability, malaise, loss of appetite Provide guidelines for home care Serious reactions rare ( reportable events Local allergic reactions ( minutes to hours after injection Non-life-threatening systemic reactions ( urticaria, transient petechiae ( may occur in minutes Life-threatening allergic reaction ( anaphylaxis Immunization schedule Specific ages and intervals Recommended schedule for immunization updated annually to reflect new vaccines, need for repeat immunization Children should have immunization status assessed during all healthcare visits, hospitalizations, schools Adults should have boosters of childhood vaccines, vaccines for older adults, immunizations for those at high risk for infection Contraindications ( acute illness with high fever, hypersensitivity reaction to specific components, immunoglobulin therapy in past 36 months, cancer treatment, pregnancy Parental rights and informed consent ( choosing not to immunize children Concerns that too many vaccines are dangerous, can be harmful to child Beliefs that vaccines do not work Disagreement with government regulation and monitoring of immunizations Belief that child not at risk because disease threat is low as result of so many other children being immunized Realization that the number of adverse events after vaccinations now exceeds number of cases of vaccine-preventable diseases Belief that they can control their childs susceptibility to disease, and outcome if their child becomes infected Belief that it is better to get disease to develop immunity Healthcare providers need to be consistent in message about value of vaccines Nurse responsible for informing parents, supplying literature, obtaining written consent Discuss risks and benefits with parents Parents have right to refuse immunizations ( if disease outbreak occurs, nonimmunized child must be kept out of child care or school Document informed refusal Assessment Health history Review biographic data Family history Provide privacy Individualize terms used ( clients culture, language, education, intellectual abilities See ASSESSMENT INTERVIEW Immunity, p. 452 Physical examination See IMMUNE SYSTEM ASSESSMENTS, p. 453 Assess general appearance, height, weight, body type Check vital signs Inspect mucous membranes Assess skin color, temperature, moisture Inspect skin for evidence of rashes, lesions Inspect and palpate cervical lymph nodes, axillae, and groin for evidence of lymphadenopathy or tenderness See Figure 86 LYMPH NODES THAT CAN BE ASSESSED BY PALPATION, p. 452 Assess musculoskeletal system for redness, swelling, tenderness, deformity Check joint range of motion Diagnostic tests Enzyme immunoassay and enzyme-linked immunosorbent assay Immunoglobulins Polymerase chain reaction Rapid HIV tests Radioallergosorbent test Skin reactions Western blot test Complete blood count (CBC) Complement Case Study Part 2 ( Marisol recovered from her hypersensitivity reaction quickly Interventions and therapies Independent Nutrition, exercise, sleep, stress reduction ( simple but vital Collaborative Goal to restore immune function Mild manifestations ( supportive treatment Pharmacologic therapy Nonsteroidal anti-inflammatory drugs (NSAIDs) Corticosteroids See MEDICATIONS IMMUNITY, p. 455 Nonpharmacologic therapy Gene transfer appears promising Complementary and alternative therapy Acupuncture alleviates side effects of antiretroviral therapy Dietary supplements, hydrotherapy, acupuncture ( show promise for treating rheumatoid arthritis Alternative therapies to bolster immune system seek to increase antibody production or improve other areas of the immune response Review The Concept of Immunity Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Student Nursing Resources Reflect Case Study Part 3 ( Marisol has been hospitalized for 2 days Exemplar 8.1 HIV and AIDS Overview 1981 ( cases of Pneumocystis carinii pneumonia (PCP) (now Pneumocystis jiroveci), Kaposi sarcoma diagnosed in young, healthy gay men Acquired immunodeficiency syndrome (AIDS) 1983 antibody identified ( human immunodeficiency virus (HIV) isolated AIDS ( final fatal stage of infection with HIV (a retrovirus) Jumped from animal to human ( epidemic Progression of HIV to AIDS has slowed because of effectiveness of HAART ( highly active antiretroviral therapy Pathophysiology and etiology AIDS caused by HIV-1 ( destroys bodys ability to fight infection Virus found in blood, semen, vaginal, cervical secretions, cerebrospinal fluid (CSF), breast milk, and saliva Transmitted primarily through sexual contact Contact with infected blood ( needles, transfusions Virus infects cells that have CD4 antigen Viral DNA integrated into host cell DNA See Figure 87 HOW HIV INFECTS AND DESTROYS CD4 CELLS, p. 458 Virus may remain latent, or become activated to produce new RNA ( form virions May remain inactive in infected cells for years ( antibodies produced to its proteins seroconversion Antibodies detectable 6 weeks to 6 months after initial infection Helper T cells, CD4 cells primary cells infected See Figure 89 THE HIV VIRUS GAINS ENTRY INTO HELPER T CELLS, p. 459 Etiology 1.7 million in U.S. infected with HIV from 1981 - 2008 Mostly men women account for 23 of cases Major transmission categories (see Figure 89 TRANSMISSION CATEGORIES OF ADULTS AND ADOLESCENTS DIAGNOSED WITH HIV/AIDS, p. 460) Nurses should be aware of current trends Most rapid increase in young gay and bisexual men, women, and inner-city injection drug users, especially African American and Hispanic Rapid increase of AIDS in women is of special concern Rates of infection have slowed dramatically for children Number of clients age 50 and older is increasing Research suggests the possibility of a functional cure for HIV Risk factors Behavior Men who have sex with other men ( 60 of reported cases Injection drug use For women ( heterosexual intercourse with injection drug user, exchanging sex for drugs Hemophilia and blood transfusions No risk for donating blood Blood screening methods ( antibody testing ( small risk of HIV transmission from donors in window period Health care as occupation Needlestick, nonintact skin contact Less than 1 risk of becoming HIV positive Poverty Less access to preventive health care Less access to healthcare education Poverty among women increases risk for STI overall Lifespan considerations Infants can acquire HIV by vertical transmission Can be reduced with Maternal treatment with antiretrovirals during pregnancy Delivery by cesarean section Drug therapy for newborn after birth Adults Adults over age 50 account for 24 of cases of HIV/AIDS in U.S Decline in immune system function Failure to use condoms Prevention Includes preventing new cases of HIV infection and preventing and treating opportunistic infections Education Important to education sexually active adolescents and adults about importance of safe sex The only totally safe sex practices are No sex Long-term mutually monogamous sexual relations between two uninfected individuals Mutual masturbation without direct contact Standard precautions Healthcare workers can prevent most exposures to HIV by using standard precautions Postexposure prophylaxis Healthcare workers exposed to HIV or adults who experience high-risk exposure may choose postexposure prophylaxis Clinical manifestations Range ( none to severe immunodeficiency with multiple opportunistic infections, cancers See Box 82 CLINICAL STAGING OF ADULT HIV INFECTION, p. 463 See CLINICAL MANIFESTATIONS AND THERAPIES HIV/AIDS, pp. 465-466 Acute illness ( similar to viral illnesses Long-lasting asymptomatic period Asymptomatic Can be transmitted to others May develop persistent generalized lymphadenopathy Asymptomatic ( to AIDS Not clearly defined Usually 1012 years after initial infection General malaise, weight loss, night sweats, diarrhea, oral lesions Neurologic manifestations, opportunistic infections, significant constitutional disease ( poor prognosis Clinical manifestations ( outcomes vary Antiretroviral therapies ( stop, suppress activity of virus PCP most commonly diagnosed in those undiagnosed, late diagnosis, fail to take prophylactic antibiotics AIDS dementia complex and neurologic effects Neurologic manifestations common ( dementia, delirium, seizures Direct effects of virus Opportunistic infections Aids dementia complex Direct effect of virus on brain Impacts motor, cognitive, behavioral functioning Toxoplasmosis, non-Hodgkin lymphoma Peripheral nervous system manifestations common Sensory neuropathies Guillain-Barr type of inflammatory demyelinating polyneuropathy can occur Opportunistic infections Most common manifestation of AIDS Risk predictable by T4 or CD4 cell count Pneumocystis jiroveci pneumonia ( most common Tends to recur Nonspecific, may progress insidiously Tuberculosis (TB) Reactivation or new primary infection Rapid progression and dissemination common in clients with AIDS Pulmonary TB ( present with cough, fever, fatigue, weight loss, lymphadenopathy Disseminated disease ( bone marrow, bone, joints, multisystem Candidiasis Manifests as oral thrush or esophagitis Vaginal candidiasis frequent in women with AIDS Mycobacterium avium complex Typically occurs late in disease ( CD4 cell counts less than 50/mm3 Organism commonly found in food, water, soil Wasting syndrome that affects nearly every organ ( disseminated disease Other infections Herpes CMV Parasitic infections Women with AIDS have high incidence of pelvic inflammatory disease Secondary cancers Kaposi sarcoma Most common cancer associated with AIDS Indicator of late-stage HIV disease Cause by virus ( KS-associated herpes virus Tumor of endothelial cells lining small blood vessels Initially painless ( more painful as disease progresses Lymphomas Non-Hodgkin lymphoma ( 5 times more frequent in clients with HIV infection Usually CNS Primary lymphoma of brain Cervical cancer 40 of women with HIV have cervical dysplasia Cancer develops frequently, tends to be aggressive Pediatric manifestations Interval from HIV infection to onset of overt AIDS shorter in children than adults Opportunistic diseases, prematurity primary cases of mortality in babies infected with HIV Most children with AIDS have nonspecific findings Bacterial, opportunistic infections See CLINICAL MANIFESTATIONS AND THERAPIES Pediatric HIV, p. 467 Collaboration Goals of care Early identification of infection Prolong asymptomatic period as long as possible with health maintenance activities Prevent of opportunistic infections Treatment of disease complications, such as cancer Provide emotional and psychosocial support Regular consultation with pharmacist Preventive education in high-risk communities Homeless shelters Education of caregivers, teachers to ensure safety of child and center personnel Standard precautions Notification of parents Limit exposure of child with HIV infection to other infectious diseases Diagnostic tests Screening and monitoring Rapid diagnostic tests Widely used ( immediate results Further testing to confirm reactive test Enzyme-linked immunosorbent assay (ELISA) ( most widely used Tests for antibodies Repeat to confirm positive Western blot antibody testing More reliable than ELISA ( more time consuming, more expensive HIV viral load tests ( measure amount of actively replicating HIV More than 5,000 to 10,000 copies/mL indicate need for treatment CBC( detect anemia, leukopenia, thrombocytopenia CD4 cell count ( most widely used to monitor progress and guide therapy Other diagnostic tests Tuberculin skin testing MRI of brain to identify lymphomas Specific cultures, serologic examinations for opportunistic infections Pap smears every 6 months Pediatric testing Early identification essential during newborn period May take up to 18 months for infected infants to form own antibodies HIV DNA polymerase chain reaction (PCR) ( preferred test Results available within 24 hours Most children diagnosed early in life Repeated testing if mother HIV positive Repeat testing to confirm positive results See Box 84 CLINICAL STAGING OF PEDIATRIC HIV INFECTION, p. 469 Pharmacologic therapy See MEDICATIONS ANTIRETROVIRAL NUCLEOSIDE ANALOGS, pp. 470471 Highly active antiretroviral therapy ( HAART approach that uses minimum of three antiretroviral agents Pharmacologic treatment of HIV has four primary foci Suppress the infection itself, decreasing symptoms and prolonging ife Provide prophylaxis of opportunistic infections Stimulate hematopoietic response Treat opportunistic infections and malignancies Effectiveness of treatment Monitored by viral load, CD4 cell counts Symptoms of severe disease treated regardless of CD4 level, viral load Four classes of drugs HAART protocol combines 34 antiretroviral drugs to reduce incidence of drug resistance Does not eradicate HIV infections Medications expensive Scheduled for specific times during the day Major adverse reactions ( less-than-perfect adherence May lead to viral resistance Several methods to promote, ensure adherence Nucleoside reverse transcriptase inhibitors (NRTIs) ( inhibit action of viral reverse transcriptase Enzyme that catalyzes substrates for conversion, copying viral RNA to DNA sequences Necessary for viral integration into cellular DNA and replications Zidovudine ( slows progressions to severe disease, decreases symptoms ( in combination with didanosine, ddC, or 3TC Didanosine ( also inhibits reverse transcriptase and viral replication ( in combination with AZT Stavudine ( increase CD4 count, decrease serum p24 ( clients who are intolerant of AZT Lamivudine ( low CD4 counts, symptomatic disease in combination with AZT Abacavir( potent, serious hypersensitivity reactions Zidovudine plus lamivudine ( combination drug Protease inhibitors (PIs) Viral enzyme necessary for formation of specific viral protein needed for viral assembly, maturation Resistance occurs quickly ( plan use and dose carefully Associated with serious metabolic derangements Body fat compositions changes ( lipodystrophy Saquinavir ( used with nucleoside analogs to treat progression of disease Ritonavir ( used with nucleoside analogs to treat progression of disease Indinavir ( used with nucleoside analogs to treat progression of disease Nelfinavir ( used in clients with failure of or intolerance to other PIs Amprenavir( newest PI Lopinavir/ritonavir ( first combination of PIs Nonnucleoside reverse transcriptase inhibitors (NNRTIs) Used in combination with NRTIs and PIs High incidence of cross-resistance to NRTIs Only one NNRTI should be used at same time Nevirapine Delavirdine Efavirenz Entry inhibitors Prevent HIV from entering target cells ( bind to protein envelop that surrounds virus Improves CD4 counts and lowers viral load Enfuvirtide Agents used in combination with antiretroviral therapy Interferons Other agents to prevent, treat opportunistic infections See Table 84 PHARMACOLOGIC TREATMENT OF COMMON OPPORTUNISTIC INFECTIONS AND MALIGNANCIES IN HIV DISEASE, p. 472 Vaccines Prophylaxis when cell counts fall below specific parameters Lifespan considerations ( pregnancy See LIFESPAN CONSIDERATIONS CARING FOR THE HIV-POSITIVE CLIENT WHO IS PREGNANT, p. 473 Antenatal identification of pregnant women at risk ( Centers for Disease Control and Prevention (CDC) HIV testing guidelines ( all pregnant women Women infected with HIV should be evaluated and treated for other sexually transmitted infections (STIs), other commonly occurring infections Hepatitis B vaccine, pneumococcal vaccine, flu shot CBC with differential at first prenatal visit, each trimester Assessed regularly for serologic changes that indicate disease progressing Monitor for early signs of complications Pregnancy complicated with HIV infection ( high risk Weekly nonstress testing starting at 32 weeks gestation Ultrasounds, biophysical profiles Scheduled cesarean birth At risk for postpartum complications Screening for all pregnant women, especially high risk Prostitutes Women with multiple sex partners Women whose partners have been bisexual, abused injection drugs, had hemophilia, tested positive for HIV Women who are, have been injection drug users Women from countries where heterosexual transmission common Medical management begins with prevention of spread of HIV from mother to newborn All infants of infected mothers should start prophylaxis against PCP Earlier child develops AIDS, poorer prognosis Nonpharmacologic therapy Encourage clients to use a single pharmacy to fill prescriptions to decrease the possibility of taking contraindicated medications Collaborate with homeless shelters, day care directors, schools, to ensure health and safety of those with HIV/AIDS Complementary therapies Shown to decrease side effects of certain medical treatments, increase comfort related to acute exacerbations Client with HIV/AIDs should be encouraged to consult with treating physician prior to any complementary and alternative medicine (CAM) therapy Nursing process Assessment Health history Risk factors Infections Medications Foreign travel Pets Physical assessment Observation and evaluation of potential sites of infection Skin, mucous membranes, breath sounds, level of consciousness (LOC), mental status Pain Psychosocial assessment Developmental age Coping mechanisms Support systems Access to and availability of resources Diagnosis Ineffective Coping Impaired Skin Integrity Imbalanced Nutrition Less Than Body Requirements Risk for Deficient Fluid Volume Risk for Infection Anxiety Fear Deficient Knowledge Diarrhea related to GI infection, malignancy, drug reactions Impaired Gas Exchange related to pulmonary disease Delayed Growth and Development related to chronic infection, poor nutrition Risk for Compromised Family Coping related to life-threatening illness Planning Prevention education Testing, prevent transmission Education to sexually active adolescents Nursing care needs for client with HIV infection change over course of disease Counseling Prophylaxis Psychosocial support Direct care Implementation Prevent secondary infections Preventing infection with HIV No immunization Education of adolescents, adults ( safer sex, ramifications of high-risk sexual behavior Condom use Totally safe sex No sex Long-term mutually monogamous sexual relations between two uninfected people Mutual masturbation without direct contact Injection drug users Autologous transfusion when possible HIV positive( abstain from donating blood, organs, sperm Standard precautions Healthcare workers ( treat all clients alike Newborn exposed to HIV/AIDS ( care for newborn suspected of having blood infection Comfort care Well nourished Protect from opportunistic infections Provide skin care, prevent rashes Facilitate growth, development, attachment Glove use See Table 83 ISSUES FOR CAREGIVERS OF INFANTS AT RISK FOR HIV/AIDS, p. 26 Postexposure prophylaxis High-risk exposure ( needlesticks, cuts, contact with mucous membranes or nonintact skin, splash exposure Initiate immediately HAART 4-week course of treatment Start within 72 hours of exposure, preferably in 23 hours Preventing infections in those with HIV/AIDS Frequent hand hygiene Limit exposure of client to others with upper-respiratory or other infections Immunize child with HIV at recommended age Protect neonate from HIV-infected maternal secretions Promote adherence to medication regimen Complex treatment regimen Nonadherence ( increased morbidity and mortality Assess clients readiness to adhere to treatment regimen ( intervene to overcome identified barriers Education of client regarding purpose of medications Behavior modification with positive reinforcement for children Balance between challenge and support ( impress on client importance of strict adherence to regimen Collaborate with client to help meet prescribed regimen Promote effective coping Diagnosis ( multiple issues Assess social support network and usual methods of coping If possible, assign a primary nurse Plan for consistent, uninterrupted time with client Interact at every opportunity outside of providing specific nursing care treatments Support clients social network Promote interaction between client, significant others, and family Encourage involvement in making care decisions Set and maintain limits on manipulative and other destructive behaviors Assist client to accept responsibility for actions without blaming others Support positive coping behaviors, decisions, actions, and achievements Reassure parents, family members that there are no documented cases of people contracting HIV/AIDS from routine care of infected babies Tactile, auditory stimulation important to infants Maintain skin integrity Monitor skin frequently for lesions and areas of breakdown Monitor lesions for signs of infection or impaired healing Turn the client at least every 2 hours, more frequently if necessary Use pressure-relieving deices Keep skin clean and dry using mild, nondrying soaps or oils for cleansing Massage around, but not over affected pressure sites to increase circulation to surrounding tissue If blisters noted, leave them intact and dress with hydrocolloid dressing Caution against scratching Avoid use of heat or occlusive dressing Prevent skin shearing ( use turn sheet, adequate personnel when repositioning Encourage ambulation if client confined to bed, encourage range-of-motion (ROM) exercises Monitor nutritional intake and albumin levels Manage adequate nutrition Assess nutritional status, including weight, body mass, caloric intake, laboratory studies Identify possible causes of altered nutrition Administer prescribed medication for candidiasis and other manifestations as ordered Administer antidiarrheal medications after stools and antiemetics before meals antipyretics as needed Provide diet high in protein and kilocalories Offer soft foods, serve small portions Involve client in meal planning, encourage significant others to bring favorite foods from home Assist with eating as needed Provide supplementary vitamins and enteral feedings Provide or assist with frequent oral hygiene Administer appetite stimulants such as megestrol and dronabinol as ordered Address ineffective sexuality patterns Examine own feelings about sexuality, role in dealing with a clients sexuality, the clients lifestyle and sexual preferences Establish trusting therapeutic relationship ( use of time, active listening, caring self-disclosure Provide factual information about HIV infection and its effects Discuss safer sex practices, including hugging, cuddling, nonsexual contact, use of latex condoms, and spermicidal lubricant and mutual masturbation Encourage discussion of fears and concerns with the significant other For the client without a significant other, stress the need to continue meeting people and developing social relationships while practicing safer sex Refer client, significant other to local support groups ( people, partners of those with HIV Address knowledge deficits Teaching needs for client, significant other, family extensive Guidelines for safer sex practices Nutrition, rest, exercise, stress reduction, lifestyle changes, maintain positive outlook Infection prevention and transmission, including hand washing and wearing gloves when handling clients secretions or excretions Importance of regular medical follow-up and monitoring of immune status Signs and symptoms of opportunistic infections and malignancies, as well as other symptoms that should be reported Medications and adverse effects Use and care of implanted venous access devices, total parenteral nutrition (TPN), intravenous pumps and continuous medication delivery systems, intravenous or aerosolized medications Cessation of smoking, alcohol, recreational and illicit drug use Home health services Hospice and respite care services Community resources such as support groups, social agencies and counselors Evaluation Client remains free from secondary infections Client will have adequate respiratory function and perfusion Nutritional intake will support normal nutritional patterns and prevent malnutrition Client will demonstrate adequate coping with the stress of chronic disease Child with HIV will be attend school, receive other supports in educational process Review HIV/AIDS Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 8.2 Hypersensitivity Overview Hypersensitivity ( altered immune response to an antigen that results in harm to a client Antigen environmental, exogenous ( allergy, antigen allergen Response may be bothersome or life-threatening Classified by type of response, immediate or delayed, organ system, or allergen involved Pathophysiology and etiology Type I (IgE-mediated) hypersensitivity Common hypersensitivity ( allergic asthma, rhinitis, anaphylactic shock Triggered when allergen interacts with free IgE ( causes IgE to bind to mast cells and basophils See Figure 812 TYPE 1 (IgE-MEDIATED) HYPERSENSITIVITY RESPONSE, p. 482 Allergens can be ingested in food, injected as drugs, inhaled through the air, absorbed through contact with unbroken skin Widespread antibodyantigen reaction and response ( systemic response, such as anaphylaxis, urticaria, angioedema Anaphylaxis ( acute systemic type I response that may result in shock and death Reaction begins within minutes of exposure to allergens Client may experience a sense of foreboding, uneasiness, light-headedness, itching palms and scalp Progresses ( air hunger, hives, angioedema, bronchial constriction ( wheezing, barking cough Vasodilation, fluid loss from vascular system can lead to impaired tissue perfusion, hypotension( anaphylactic shock Localized response ( more common Typically atopic responses ( strong genetic predisposition Localized response to allergen Prompted by contact of allergen with IgE to tissue ( chemical mediators released locally ( producing symptoms Typical allergens Pollens, fungal spores, house dust mites Food allergens ( vomiting, diarrhea Type II (cytotoxic) hypersensitivity IgG- or IgM-type antibodies formed to a cell-bound antigen ( such as ABO or Rh antigen Antibodies bind with antigen ( complement cascade activated ( destruction of target cell See Figure 813 TYPE II (CYTOTOXIC) HYPERSENSITIVITY RESPONSE, p. 484 May be stimulated by an exogenous antigen ( foreign tissue or cells, drug reaction ( withdrawal of antigen stops hemolysis Type III (immune complexmediated) hypersensitivity Results from formation of IgG or IgM antibodyantigen immune complexes in circulatory system ( deposited in vessel walls, extravascular tissues ( complement activated ( chemical mediators of inflammation released ( neutrophils attracted to site of inflammation neutrophils attempt to phagocytize immune complexes ( enzymes released that increase tissue damage See Figure 814 TYPE III (IMMUNE COMPLEX-MEDIATED) HYPERSENSITIVITY RESPONSE, p. 485 Local or systemic Systemic ( fever, urticaria, rash, arthralgias ( serum sickness Localized ( immune complex accumulate in glomerular basement membrane ( glomerulonephritis develops Type IV (delayed) hypersensitivity Cell-mediated immune responses ( involve T cells of immune system and type IV reactions delayed, 2448 hours after exposure Results from exaggerated interaction between antigen, normal cell-mediated mechanisms Contact dermatitis ( example of type IV Redness, itching, edema, thickening affect the skin Vesicles often present Poison ivy Latex allergy Cornstarch used to powder gloves ( aerosolized with latex particles when removed ( respiratory and dermal exposure to latex Can progress to type I reaction 813 of healthcare workers are allergic to latex Common in clients with certain health conditions Spina bifida ( 50 Children with three or more surgeries ( 34 See Box 86 MEASURES TO PROTECT AGAINST LATEX ALLERGY, p. 486 See Box 87 LATEX IN THE HOSPITAL AND HOME ENVIRONMENT, p. 487 Etiology Estimated 50 million people in the United States are diagnosed with some form of hypersensitivity Secondary immune response may decrease as people age ( decrease in allergic, or hypersensitivity, reactions Risk factors Increases with previous exposure ( antigens must be formed with first exposure before hypersensitivity likely to occur Reactions likely to increase in intensity with repeated exposure Family member with allergy increases chance child will be affected Clinical manifestations Range from mild ( severe ( life threatening Mild hypersensitivity ( causes discomfort, fatigue, embarrassment Few hours to a day or two Allergic rhinitis Moderate hypersensitive responses of skin ( urticaria, atopic and contact dermatitis Moderate responses from food allergies ( urticaria, GI symptoms Severe reactions ( may lead to respiratory distress or death See CLINICAL MANIFESTATIONS AND THERAPIES, p. 488 Lifespan and cultural considerations People can outgrow certain allergies particularly food allergies However, it is uncommon to outgrow peanut allergy Those who develop allergies in adulthood will have them for the remainder of their lives Collaboration Diagnostic tests Laboratory testing WBC with differential ( detect high levels of circulating eosinophils Radioallergosorbent test (RAST) ( measures IgE directed toward specific allergens Blood type and crossmatch Indirect Coombs test ( detects presence of circulating antibodies against RBCs Direct Coombs test ( detects antibodies on clients RBCs that damage, destroy cells Immune complex assays ( performed to detect presence of circulating immune complexes in suspected type III hypersensitivity responses Complement assay ( useful in detecting immune complex disorders Skin testing Used to determine causes of hypersensitivity reactions Allergens selected according clients history Epicutaneous testing done first ( intradermal( Prick test ( drop of diluted allergenic extract placed on skin or punctured through drop Intradermal test ( small amount of allergen extract injected on the forearm or intrascapular area Patch test( 1-inch patch impregnated with allergen applied to skin for 48 hours Food allergy test ( food diary with allergic reactions ( elimination diet ( as symptoms relieved ( foods reintroduced Pharmacologic therapy Based on severity of hypersensitivity reaction, impact on clients lifestyle Antihistamines( major drugs used to treat symptoms of hypersensitivity responses Block H1 receptors but do not affect production or release of histamine Diphenhydramine (Benadryl) ( alleviates systemic effects of histamine Not effective in relieving asthmatic responses to allergens ( may worsen symptoms Cause drowsiness, dry mouth Available in prescription and nonprescription Mast cell stabilizer Cromolyn sodium ( used to treat allergic rhinitis and asthma Stabilizes mast cell membrane ( prevents chemical mediator release Leukotriene modifiers Block action of inflammatory chemicals Available for asthma Corticosteroids ( systemic, topical Anti-inflammatory effects Short course used for severe asthma, allergic contact dermatitis, some immune-complex disorders Topical or inhalers can be used for longer periods of time Immunotherapy ( hyposensitization, desensitization, allergy shots ( inject extract of allergen in gradually increasing doses Used primarily for allergic rhinitis, asthma related to inhaled allergens Shown to be effective with insect venom allergy Weekly, biweekly shots ( client develops IgG antibodies to allergen that appear to effectively block allergic IgE response Epinephrine Immediate treatment for anaphylaxis ( parenteral epinephrine Adrenergic agonist ( vasoconstricting, bronchodilating Subcutaneous injection of 0.30.5 mL of 11,000 epinephrine generally sufficient Clients with history of anaphylactic reaction to insect venom ( should carry kit Prefilled syringe of epinephrine Epinephrine nebulizer Omalizumab (Xolair) ( inhibits type I hypersensitivity reactions by binding to free-floating IgE ( preventing IgE from binding to mast cell RAST testing and approval from physician, insurance company, manufacturer required Subcutaneous injection in physicians office, clinic, infusion center Expensive Not immediate ( improvement may take up to a year Nonpharmacologic therapy Airway management Endotracheal tube, emergency tracheostomy IV line, initiate fluid resuscitation with isotonic solution Plasmapheresis ( used to treat immune complex responses such as glomerulonephritis, Goodpasture syndrome Plasma and glomerular damaging antibodyantigen complexes removed ( RBCs returned to client with equal amount of albumin, human plasma Done in a series Special considerations for children Parent and child education Action plan for school Support groups Complementary and alternative therapy Clients with type I hypersensitivity ( contact physician before using herbal remedies, teas, aromatherapy Cultural therapies ( Asian Americans, Native Americans Nursing process Assessment Health history Risk factors Hypersensitivities Reaction Type of treatment for reactions Allergy skin testing History of asthma, hay fever, dermatitis Physical assessment Mucous membranes Respiratory rate, breath sounds Diagnosis Ineffective Airway Clearance Decreased Cardiac Output Risk for Injury Impaired Spontaneous Ventilation Risk for Shock Planning Client will avoid known substances that provoke hypersensitivity response Client will describe self-care to reduce symptoms of seasonal allergies Client will describe proper self-administration of medications prescribed by physician Client participates in determining substances that cause hypersensitivity by keeping accurate food journal Implementation Maintain patent airway Maintain patent airway Fowler, high Fowler position Assess respiratory rate and pattern, LOC, anxiety Breath sounds, accessory muscle use Anxiety, air hunger, possible airway obstruction Administer oxygen per nasal cannula at rate of 24 L/min Insert nasopharyngeal or oropharyngeal airway Administer subcutaneous epinephrine as prescribed May be repeated 2030 minutes later Provide calm reassurance Monitor cardiac status Monitor vital signs frequently noting fall in blood pressure, decreasing pulse pressure, tachycardia, tachypnea Assess skin color, temperature, capillary refill, edema, indicators of peripheral perfusion Monitor level of consciousness Insert one or more large-bore ((18 gauge) IV catheters Administer warmed IV solutions of lactated Ringers or normal saline as prescribed Insert an indwelling catheter, monitor urinary output frequently Place a tourniquet above the site of an injected venom (bee sting) and infiltrate site with epinephrine as prescribed Once breathing established, place client flat with legs elevated Reduce risk for injury Obtain and record a thorough history of previous blood transfusions and any reactions experienced, no matter how mild Check for signed informed consent to administer blood or blood products Using two licensed healthcare professionals, double-check client identity, blood type, Rh factor, crossmatch, expiration date for all blood and blood components received from the blood bank with the clients data Take and record vital signs within 15 minutes before initiating blood infusion Acetaminophen and diphenhydramine are prescribed and administered prior to beginning blood transfusion to decrease inflammation and increase client comfort. Infuse blood into site separate from that of any other IV infusion Use catheter of at least 20 gauge for infusion to promote flow, reduce risk of damage to blood cells Administer with normal saline to prime IV tubing Administer 50 mL of blood during first 15 minutes of the transfusion During transfusion monitor for complaints of back or chest pain, increase in temperature of more than 1.8( F, chills, tachycardia, tachypnea, wheezing, hypotension, hives, rashes, cyanosis Stop blood transfusion immediately if a reaction occurs, no matter how mild ( remove blood bag and tubing with blood in it flush new tubing with normal saline, keeping intravenous line open ( notify physician and blood bank If reaction suspected ( send blood and administration set to laboratory with freshly drawn blood sample and urine specimen from the client If no adverse reaction occurs, administer transfusion over 24 hours ( time frame is important to limit the risk of bacterial growth Community-based care Teaching vital component of care When and how to use an anaphylaxis kit containing epinephrine and antihistamines in injectable, inhaler, and oral forms When to seek medical attention Use, adverse reactions of prescription, nonprescription antihistamines, decongestants Advantages of autologous blood transfusion if future surgery scheduled Prevention of immune complex reaction Skin care to prevent contact dermatitis, including Expose affected areas to air and sun as much as possible Avoid direct contact with people who have an infection Wear cool light, nonrestrictive clothing of natural fibers to avoid irritating affected areas Avoid exposure to extremes of heat or cold Use bath oils or plain water instead of soaps and detergents Take tub baths in cool to lukewarm water rather than showers To decrease pruritus, maintain a cool environment and avoid exercising Trim fingernails to reduce risk of skin damage Provide emotional support ( clients often misunderstood by families, community Evaluation Client exhibits decreased symptoms, frequency of hypersensitivity responses Client demonstrates proper technique when administering medication using an EpiPen Client provides accurate, thorough information in food activity and symptom journal Review Hypersensitivity Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 8.3 Rheumatoid Arthritis Overview Rheumatoid arthritis (RA) is a chronic systemic autoimmune disorder Autoimmune disorder ( disease caused by abnormal overactive functioning of the immune system that produces a response against the bodys own cells and tissue Causes inflammation of connective tissues, primarily in the joints Course and severity variable Minimal to multiple inflamed joints and marked deformity Contributes to disability Pattern of symmetric involvement of multiple peripheral joints Periods of remission, exacerbation Most prevalent inflammatory arthritis of any age group Chronic pain, alterations in body image Pathophysiology and etiology Long-term exposure to an unidentified antigen causes aberrant immune response in a genetically susceptible host Normal antibodies (immunoglobulins) ( become autoantibodies and attack host tissues Transformed antibodies ( rheumatoid factors Leukocytes attracted to synovial membrane ( ingest immune complexes, release enzymes that degrade synovial tissue, articular cartilage Synovial membrane damaged by inflammatory, immune processes ( swells from infiltration of leukocytes, thickens as cells proliferate and abnormally enlarge Damage to cartilage Neutrophils, T cells, other cells activated and degrade surface layer of articular cartilage Cytokines, especially interleukin-1 (IL-1) and tumor necrosis factor alpha (TNF-(), cause chondrocytes to attack the cartilage Synovium digests nearby cartilage ( releasing inflammatory molecules containing IL-1 and TNF-(( Inflammation causes hemorrhage, coagulation, deposits of fibrin on synovial membrane ( fibrin develops into granulation tissue over denuded area of synovial membrane ( leads to scar tissue formation that immobilizes joint See Figure 817 JOINT INFLAMMATION AND DESTRUCTION IN RA, p.496 Etiology RA is found worldwide ( 12 of total population and all races 3 times more women than men Onset occurs most frequently between 40 and 60 years Cause unknown Combination of genetic, environmental, hormonal, reproductive factors Incidence has decreased during past 40 years ( environmental factors may change Less common than osteoarthritis ( chronic degenerative changes in cartilage, synovial membranes See Table 87 COMPARISON OF MANIFESTATIONS OF RA AND OSTEOARTHRITIS, p. 496 Risk factors Women between 40 and 60 years Family history Smokers Clinical manifestations Chronic condition manifests clinically by symmetric inflammation of peripheral joints ( marked pain, swelling, significant and often disabling morning stiffness, fatigue and malaise Causes tenderness and limitation of movement ( joints swollen, red, warm Becomes symmetric, additive disease of joints More than 10 of clients with RA will develop deformities of the hands within 2 years Remission likely within first year Women with RA may experience remission during pregnancy, relapse after birth Older clients ( same management as for younger clients Prolonged rest, inactivity not prescribed Medications used with greater caution Maintaining functional status See MULTISYSTEM EFFECTS OF RHEUMATOID ARTHRITIS, p. 498 Joint manifestations Onset Insidious ( preceded by systemic manifestations of inflammation, including fatigue, loss of appetite, weight loss, nonspecific aching and stiffness Polyarticular, symmetric Joints of fingers, wrists, knees, ankles, toes most frequently involved Morning stiffness, lasting more than 1 hour Persistent inflammation causes deformities of joint and supporting structure Hands and fingers ( ulnar deviation of fingers and subluxation at metacarpophalangeal (MCP) joints Swan-neck deformity Flexion deformity of proximal interphalangeal (PIP) joints with extension of distal interphalangeal (DIP) joints See Figure 818 TYPICAL HAND DEFORMITIES ASSOCIATED WITH RA, p. 497 Wrists and elbows ( wrist involvement nearly universal ( limited movement, deformity, carpal tunnel syndrome Knees ( frequently affected with visible swelling often obliterating contours ( instability of knee joint, quadriceps atrophy Ankles and feet ( ambulation may be limited by pain, deformities when ankles and feet involved subluxation, hallux valgus, lateral deviation of toes, cock-up toes Spine ( usually limited to cervical vertebrae Extra-articular manifestations Systemic disease ( particularly in clients with high levels of circulating rheumatoid factor Anemia resistant to iron therapy Skeletal muscle atrophy Rheumatoid nodules ( subcutaneous tissue of areas subject to pressure Granulomatous lesions See Figure 819 RHEUMATOID NODULES, p.499 Other manifestations Subcutaneous nodules Pleural effusions Vasculitis Pericarditis Splenomegaly Increased risk of coronary heart disease Direct effects on the blood vessels with measures of C-reactive proteins being more predictive of future cardiovascular disease than levels of low-density lipoprotein Increased risk for having low high-density lipoprotein level, high cholesterol and triglycerides, high blood pressure, high homocysteine levels Damaging side effects that many medications often have on coronary vessels Juvenile idiopathic arthritis (JIA) JIA ( chronic inflammatory autoimmune disorder diagnosed in children characterized by joint inflammation resulting in decreased mobility, swelling, and pain Treatment similar to that of adults Remission may last for months, years, lifetime Affects joints and surrounding tissues, possibly other organs 70 of children with JIA experience permanent remission by adulthood Three types of JIA Pauciarticular arthritis ( primarily affects knees, ankles, elbows More frequently in female clients Systemic arthritis ( high fever, polyarthritis, rheumatoid rash Male and female clients equally Internal organs and joints Polyarticular arthritis ( involves many joints (five or more) particularly small joints of hands, fingers May affect hips, knees, feet, ankles, neck Cause unknown ( thought to have autoimmune basis Inflammation begins in joint ( pain, swelling ( scar tissue ( limited ROM Symptoms can include fever, rash, lymphadenopathy, splenomegaly, hepatomegaly Diagnosis made on basis of history and assessment findings Onset before 17 years of age, persisting for at least 6 weeks Monophasic, polycyclic, persistent No specific laboratory tests Rheumatoid factor, human leukocyte antigen B27, antinuclear antibody tests may be positive Complications Chronic eye uveitis ( secondary chronic inflammation Interference with normal growth Bone growth disturbances ( contractures, effusions Corticosteroids Collaboration Goals ( relieve pain, reduce inflammation, slow or stop joint damage, improve well-being and ability to function No cure Relieve manifestations Interdisciplinary approach ( balance of rest, exercise, physical therapy (PT), suppression of inflammatory processes Pharmacist Diagnostic tests Rheumatoid factors Erythrocyte sedimentation rate CBC Antibodies to cyclic citrullinated peptide ( highly effective in accurately detecting early RA Examination of synovial fluid will demonstrate changes associated with inflammation, turbidity, decreased viscosity, increased protein and WBC levels X-rays of affected joints Surgery Synovectomy ( provides temporary relief of inflammation, relieves pain, slows destructive process Arthrodesis ( used to stabilize joints ( cervical vertebrae, wrists, ankles Arthroplasty ( may be necessary in cases of gross deformity, joint destruction Pharmacologic therapies Four general approaches Aspirin and other NSAIDs, mild analgesics used to reduce inflammatory process, manage manifestation of the disease Low-dose oral corticosteroids used to reduce pain and inflammation Diverse group of drugs classified as disease-modifying (slow acting) antirheumatic drugs (DMARDs) Intra-articular corticosteroids may be used to provide temporary relief in clients in whom other therapies have failed to control inflammation NSAIDS ( often first drug prescribed Inexpensive, effective anti-inflammatory and analgesic Multiple doses per day GI side effects, interference with platelet function greatest hazards of aspirin therapy Other nonsteroidal anti-inflammatory drugs Used if aspirin not effective or tolerated Inhibit prostaglandin synthesis Clients respond differently to medications ( trial of several NSAIDs may be necessary Cost may be a factor Common side effects ( GI distress, can be toxic to kidneys See MEDICATIONS NSAIDS COMMONLY USED TO TREAT RHEUMATOID ARTHRITIS, p. 502 Corticosteroids Can dramatically relieve the symptoms, appear to slow progression of joint destruction Long-term use associated with multiple side effects Disease-modifying drugs antirheumatic drugs (DMARDs) Diverse group of medications ( modify immune and inflammatory responses, gold salts, antimalarial agents, sulfasalazine, d-penicillamine See MEDICATIONS DMARDS USED TO TREAT RA, p. 503 May take several weeks or months to see beneficial effects Clinical improvement and decreased disease activity Immune and inflammatory agents Immunosuppression helps reduce bodys autoimmune response ( controlling effects of disease process Methotrexate with NSAIDs often in initial treatment plan Taken with folic acid to control side effects Modify autoimmune response and inflammatory responses Leflunomide (Arava), etanercept (Enbrel) ( injections Infliximab (Remicade) ( infusion Adalimumab (Humira)( injections ( caution with active infection Gold salts PO or IM (more effective) Mode of action unknown ( may produce clinical remission, decrease new bony erosions CBC, urinalysis monitored to assess for toxic results Antimalarial agents Hydroxychloroquine (Plaquenil) ( 36 months until desired response Sulfasalazine ( often prescribed for chronic inflammatory bowel disease Nonpharmacologic therapy Primary objectives ( reduce pain, inflammation, preserve function, prevent deformity Rest and exercise Balanced program of rest, exercise Rest periods during day Splinting inflamed joints reduces unwanted motion, provides local joint rest Physical therapy, exercise ( maintain muscle strength, joint mobility ROM Isometrics exercises Low-impact aerobic exercises Physical and occupational therapy PT ( improving mobility, preventing complications of inactivity OT ( creating modifications to practices and tools needed to perform ADLs, promoting as normal a lifestyle as possible Heat and cold Used for analgesic, muscle-relaxing effects Orthotic and assistive devices Orthotic devices ( reduce strain on a joint Splints, braces ( shortest time possible, lightweight, easily removed Assistive devices ( cane, walker, raised toilet seat Nutrition Ordinary, well-balanced diet Fish oils Adapt calorie intake to meet activity levels Plasmapheresis and irradiation Plasmapheresis used to remove circulating antibodies, moderate autoimmune response Total lymphoid irradiation ( decreases total lymphocyte levels ( serious adverse effects Complementary and alternative therapy Acupuncture, hydrotherapy ( may cause improvement in pain Nutritional supplements ( fish oils, if not contraindicated for the client No cure ( client may be vulnerable to quackery Nursing process Assessment Health history Pain, stiffness, fatigue ( location, duration, onset, effect on function Past illnesses, surgery ADLs Physical assessment Gait, joints including symmetry, size, shape, color, nodules, ROM Flexion contractures PIP joints DIP joints Boutonnire deformities Growth delays Skin Respiratory Cardiovascular Diagnosis Chronic Pain Fatigue Ineffective Role Performance Disturbed Body Image Impaired Physical Mobility Anxiety Activity Intolerance Diagnostic criteria for RA ( four of the following Morning stiffness lasting for at least 1 hour persisting for at least 6 weeks Arthritis with swelling or effusion of three or more joints persisting for at least 6 weeks Arthritis of wrist, MCP, PIP joints persisting for at least 6 weeks Symmetric arthritis with simultaneous involvement of corresponding joints on both sides of the body Rheumatoid nodules Positive serum rheumatoid factor Characteristic radiologic changes of RA noted in hands and wrists Planning Client reports effectiveness of pain management techniques, maintaining pain at tolerable levels by specific date Client performs ADLs independently (or with minimal assistance, depending on degree of impairment) using tools modified by occupational therapy Client expresses feelings about diagnosis of chronic disease and displays progression through grieving process Implementation Monitor and treat chronic pain Monitor level of pain and duration of morning stiffness Encourage client to relate pain to activity level and adjust activities accordingly Teach use of heat and cold applications to provide pain relief Teach use of prescribed anti-inflammatory medications and relationship of pain and inflammation Encourage use of other nonpharmacologic pain relief measures, such as visualization, distraction, meditation, and progressive relaxation techniques Prevent fatigue Encourage a balance of periods of activity with periods of rest Stress importance of planned rest periods during the day Help client to prioritize activities, encouraging client to perform most important ones early in the day Encourage regular physical activity in addition to prescribed ROM exercises Refer client to counseling or support groups Address ineffective role performance Discuss effects of the disease on the clients career and other life roles Encourage client, family to discuss feelings ( role changes, grieve over lost roles, abilities Listen actively to concerns expressed by the client and family members Help client and family to identify strengths they can use to cope with role changes Encourage the client to make decisions, assume responsibility for management of RA Promote a healthy body image Demonstrate caring, accepting attitude toward the client Encourage client to talk about effects of disease, both physical effects and effects on life roles Encourage client to maintain self-care and usual roles to the extent possible Provide positive feedback for self-care activities, adaptive strategies Refer client to self-help groups, support groups, and other agencies that provide assistive devices and literature Encourage child to maintain contact with peers and to attend school when possible Provide support related to impaired mobility Promote general health by encouraging well-balanced diet For children with JRA, plot growth carefully and watch for changes in growth percentiles Teach client, family about condition, prognosis, importance of optimizing activity levels Refer to occupational therapy that can help client to continue performing ADLs Evaluation Client maintains joint mobility Client expresses comfort and freedom from pain Client develops or maintains positive body image Client is free from infection Client, family display adequate understanding, support, management of therapeutic regimen Review Rheumatoid Arthritis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 8.4 Systemic Lupus Erythematosus Overview SLE is a chronic, inflammatory, connective-tissue disease that affects almost all body systems Manifestations widely variable ( caused by deposition of antigenantibody complexes in connective tissues Pathophysiology and etiology Production of varieties of autoantibodies against normal body components ( nucleic acids, erythrocytes, coagulation proteins, lymphocytes, platelets Autoantibody productions results from hyperreactivity of B cells (humoral immune response) ( because of disordered T-cell function (cellular immune response) SLE antibodies react with corresponding antigen ( form immune complexes ( then deposited into connective tissue ( deposits trigger inflammatory response ( local tissue damage Kidneys frequent site of complex deposition and damage Other affected tissues Musculoskeletal system Brain Heart Spleen Lung GI tract Skin Peritoneum Etiology Exact etiology unknown ( genetic, environmental, hormonal factors Human leukocyte antigen genes seen more frequently in client with SLE Outside environmental factors ( virus, bacterial antigens, chemicals, drugs, UV light may play role in activating pathologic mechanisms of disease Women with SLE have reduced levels of several active androgens ( known to inhibit antibody responses Risk factors Women comprise 90 of the affected population Usually women of childbearing age Drug-induced lupus ( procainamide, hydralazine, isoniazid ( resolves when medication discontinued Clinical manifestations Classifications Systemic lupus ( involves one or more of cardiovascular, CNS, hematological, kidneys, lungs, musculoskeletal Drug-induced lupus Discoid lupus ( limited to skin Course ( mild in most clients ( remission ( exacerbation Active disease ( increased risk for infections Typical early manifestations mimic those of RA ( fever, loss of appetite, malaise, weight loss, multiple sclerosis (MS) manifestations Multiple arthralgias, symmetric polyarthritis Rarely deforming Most clients with SLE have skin manifestations at some point ( butterfly rash See Figure 820 THE BUTTERFLY RASH OF SYSTEMIC LUPUS ERYTHEMATOSUS, p. 510 Discoid lesions, hives, erythematous fingertip lesions, splinter hemorrhages See MULTISYSTEM EFFECTS OF SLE, p. 511 See Box 8-8 COMMON MANIFESTATIONS OF SLE, p. 512 See CLINICAL MANIFESTATIONS AND THERAPIES SLE, p. 513 50 Collaboration No cure ( 10-year survival rate greater than 70 Diagnostic tests Anti-DNA antibody testing Erythrocyte sedimentation rate Serum complement levels Complete blood count Urinalysis Kidney biopsy Surgery Damage caused by SLE can lead to conditions that require surgery Clients with lupus nephritis who progress to ESRD may be treated with Hemodialysis Peritoneal dialysis Kidney transplantation Pharmacologic therapy Mild or remittent ( little or no therapy other than supportive care Skin, arthritic manifestations ( antimalarial drugs Severe and life-threatening manifestations ( corticosteroid therapy in high doses 4060 mg of prednisone daily ( tapered as rapidly as clients disease allows Cytoxic or antineoplastic drugs (effective as immunosuppressive agents May be used alone or in combination with corticosteroids Nursing care for clients on immunosuppressive drugs Monitor blood count Monitor renal and liver function studies Administer oral preparations with food Increase fluids Monitor for signs of abnormal bleeding Use meticulous hand hygiene Monitor results of pulmonary function tests Educate clients about threat of infection Nonpharmacologic therapy Clients with SLE should Avoid smoking Avoid sun exposure Consume a healthy diet that includes oily fish Consult healthcare provider before using any supplements, herbs, or vitamins Nursing process Assessment Nutritional status Skin Respiratory Cardiovascular Musculoskeletal Neurologic GI Psychosocial assessment Diagnosis Risk for Infection Risk for Imbalanced Fluid Volume Risk for Imbalanced Nutrition Less Than Body Requirements Risk for Ineffective Management of Therapeutic Regimen Risk or Ineffective Tissue Perfusion Risk for Impaired Skin Integrity Chronic Pain Risk for Activity Intolerance Risk for Disturbed Body Image Compromised Family Coping Planning Client able to verbalize skin care needs to reduce risk of altered skin integrity Client demonstrates proper hand hygiene techniques Client verbalizes impact of diagnosis Client verbalizes methods for preventing infection Implementation Promote skin integrity Assess clients knowledge of SLE and possible effects on skin Discuss relationship between sun exposure and disease activity (dermatologic, systemic) Suggest strategies to limit sun exposure Keep skin clean and dry Encourage use of good hygienic measures and mild soap Recommend limited use of cosmetics Recommend client avoid fluorescent lighting Provide instructions on oral care to maintain intact oral mucosa Provide instructions on care of the head if alopecia occurs Prevent infection Prophylactic antibiotics for dental work, surgical procedures Instruct client and family to inform healthcare providers of disease Educate client on importance of obtaining yearly influenza vaccine Instruct client on hand hygiene and infection control measures in the home Warn adolescents about risks of infection from tattooing, body piercing Maintain fluid balance Monitor intake and output Evaluate fluid and electrolyte status Promote adequate nutrition Diet may be restricted ( renal involvement, weight gain, weight loss, complications Well-balanced nutritious diet as well as appropriate fluid intake should be encouraged Promote rest and comfort Encourage frequent rest periods and nutritious diet to maximize energy stores Manage side effects of medications Observe for side effects of medications Teach client and family about these effects Provide emotional support Adolescents may have altered body image as result of rash, alopecia Refer to lupus support group Teach avoidance of triggers of disease flares Client, partner, family to implement measures to avoid triggers ( alcohol, smoking, drugs, sun exposure, stressors Promote health maintenance Assess clients ability to maintain optimal health, identifying physical and psychosocial factors that may affect health maintenance Provide care and teaching in a nonjudgmental manner Encourage client and family members to discuss the effect of the disease on their lives Initiate an interdisciplinary care conference with the client and family Refer the client and family to counseling as needed Refer the client, family to community and social service agencies, local support groups Evaluation Client maintains normal intake and output levels Client maintains healthy intact skin Client maintains a balance of rest and activity to promote health Client maintains medication regimen to promote health and prevent side effects Client develops or maintains a positive body image Review Systemic Lupus Erythematosus Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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