Immunology: Epinephrine & HIV Post-Exposure

• Study notes

Immunology

• Epinephrine has a ratio of 1:1000 for intramuscular injection.

• Steps for epinephrine auto-injection:

• Uncap the device while holding the injecting end upright

• Position the device on the middle/side portion of the thigh

• Push the device into the thigh and hold for 10 seconds

• Go to the hospital ASAP after injection.

• If there is no improvement after 15 minutes, inject another dose into the opposite leg.

• Intravenous epinephrine may need to be followed up at the hospital

HIV (Post Exposure)

• Needle sticks or sharps are the most common cause of HIV exposure for healthcare providers.

• One can be infected via non-intact skin or mucous membranes through exposure to body fluids.

• The best prevention method is to use standard precautions for all patients.

• Post-exposure protocol after potential exposure:

• Notify the supervisor

• Initiate an incident report

• Identify the source patient

• Follow institutional/state law

• Report to the emergency room or employee health services

• Baseline testing includes testing for HIV, hepatitis B, and hepatitis C within 72 hours

• Start post-exposure treatment

• Post-exposure prophylaxis (PEP) must be given within 72 hours of exposure

• Schedule follow-up appointments at 1 month, 3 months, 6 months, and 1 year

• Practice safe sex

Hypersensitivity Reactions

• Type 1 (Anaphylactic):

• Reactions are rapid and can range from mild to severe

• Symptoms can include respiratory distress and rash

• Examples: anaphylaxis, hay fever, allergic asthma.

• Type 2 (Cytotoxic):

• Can lead to cell and tissue damage.

• Examples: hemolytic anemia, Goodpasture's syndrome, and Myasthenia Gravis.

• Type 3 (Immune Complex):

• Involves an inflammatory reaction.

• Can destroy joints or organs, causing pain

• Examples: lupus, rheumatoid arthritis.

• Type 4 (Delayed Type):

• Reactions occur 1-3 days after exposure.

• Examples: contact dermatitis, PPD test.

• Penicillin is the most common cause of anaphylaxis.

• Treatment for anaphylaxis includes epinephrine 1:1000 and Benadryl (antihistamine); second-line treatments consist of albuterol and steroids.

Renal

Lithotripsy

• Lithotripsy involves disintegration of gallstones by shockwaves (ultrasound).

• Post-procedure considerations include:

• Discomfort from multiple shocks

• Monitoring for obstruction and infection resulting from blockage of the urinary tract

• Monitor urine for signs of infection, output, and hematuria

• Strain urine and send fragments to the lab

• Several treatments may be needed

• Electrohydraulic lithotripsy may be used.

• A percutaneous nephrostomy tube may be left in place to ensure no obstruction via edema, blood clots, or fragmented calculi.

• Patients are at risk for hemorrhage, infection, and urinary extravasation.

• Use Tylenol for pain management.

• Screen urine.

• Conduct 24-hour urine analysis.

• Conduct blood chemistries.

Renal Transplant

• Post-operative care involves monitoring for rejection
• Symptoms of rejection:
• Can occur within 24 hours to a few weeks
• Increase in creatinine levels
• Fever or warmth over the site
• Tenderness at the site
• Malaise
• Oliguria
• Drainage at the site

Dialysis

• Assess an arteriovenous fistula.

• Vascular access for dialysis must be placed, usually in the forearm.

• Wait 3 months after installation before use.

• Perform hand exercises.

• Assessment includes monitoring for infection, listening for bruit, and feeling vibration over the site.

• A strong pulse distal to the access site indicates no blockage.

• Have the patient raise their arm to assess for collapse.

• Possible complications:

• Infection

• Clots/air embolism

• Give Heparin for Peritoneal Catheter

• Complications of chronic dialysis include:

• Peritonitis

• Leakage

• Bleeding

• Hernias

• Monitor the patient's weight pre- and post-dialysis

Orthopedics

Traction/Pin Care

• Prevent infection as follows:

• Inspect the site every shift

• Use chlorhexidine 2mg/mL solution.

• For optimal traction:

• Allow for longer traction time and heavier weights.

• Have patients engage in isometric exercises 10 times each hour while awake.

• Monitor for complications.

• Potential complications include:

• Atelectasis

• Pneumonia

• Constipation

• Anorexia

• Urinary stasis and infection

• Deep Vein Thrombosis

• Skin breakdown

• Weights should never be on the floor.

• Assess Distal Neurovascular function as follows:

• Pallor

• Paresthesia

• Pain

• Pulse

Cast Care

• Assess Neurovascular function every shift for the first 24 hours.

• Elevate the extremity higher than the heart for the first 24-48 hours to decrease edema and improve perfusion.

• Apply ice for the first 24-86 hours.

• Avoid indentations or wetting of the cast.

• Handle the wet cast with palms, not fingertips.

Fractures

• Open Fracture:

• The bone breaks through the skin

• Risk of infection

• Pathological (Spontaneous) Fracture:

• Occurs with osteoporosis

• Compression Fracture:

• Common in vertebrae.

• Compartment Syndrome:

• Increased pressure within a compartment.

• Assess neurovascular function every shift for the first 24 hours.

• Symptoms:

• Severe pain that worsens with movement

• Pallor

• Cool to the touch

• Decreased Pulses

• Paresthesia

• Poor capillary refill

• The treatment is to remove the cast ASAP and elevate.

• Fasciotomy (if severe)

• Fat Embolism:

• Most common in long bone fractures (femur/hip).

• Fat globules inside bone marrow are released into the bloodstream.

• Occurs 48-72 hours after injury.

• Most commonly affects the lungs.

• Manifestations:

• Hypoxemia, dyspnea, tachypnea, substernal chest pain

• Neurologic compromise: decreased level of consciousness

• Petechiae

• An arterial blood gas (ABG) is the diagnostic procedure

• Prevention with immediate immobilization

• Management includes respiratory support via mechanical ventilation.

• Intravenous Steroids can be used.

• Vasopressors may be needed.

• Use incentive spirometry.

Amputations

• Complications to look out for include:

• Hemorrhage (have a tourniquet at the bedside)

• Infection (wash and gently dry the limb twice a day)

• Skin breakdown

• Phantom limb pain (recognize it as real pain)

• Neuroma (tumor with damaged nerve cells)

• Joint flexion contractures

• Perform range of motion(ROM) exercises.

• Ambulate the patient

• Turn patient and reposition them often.

• Post-operative Care focuses on:

• Tissue perfusion and pain management

• Wound healing (cast dressing / limb shrinker)

• Monitoring for other complications.

Hematology/Oncology

• Complications for immunocompromised patients include infection.

• Neutropenic Precautions:

• Avoid going to work sick

• No flowers

• No raw fruit/vegetables/meat

• Surgical mask and gloves

• Hand hygiene

• Limit visitors

• No rectal temperatures

• Prophylactic antibiotics

• Private room

• No live vaccines

• No live vaccines among members in the same household

Skin Cancer

• A = Asymmetry

• Half of the mole does not match the other half

• B = Border

• Irregular shape

• C = Color

• The color varies throughout the mole

• D = Diameter

• Larger than a pencil eraser

• E = Evolution

• New changes over time

Sickle Cell Crisis

• Prevention

• Avoid extremes, sick contacts, extreme tempos, maintain hydration, avoid extreme altitudes & stress

• Stay up to date with immunizations

• Treatment

• Manage pain

• Hydrate the patient if there is no pregnancy

• Give oxygen

• Pharm = hydroxyurea and blood transfusion

Hodgkin's Lymphoma

• Lymph nodes with Reed-Sternberg cells

• Large but painless, not hard

• Symptoms:

• Can come from tumor compression

• Usually unilateral node, supraclavicular

• Good prognosis with chemotherapy

• Hematopoietic stem cell transplant

Neutropenia

• Neutropenic precautions include:

• Do not go to work sick

• No flowers

• No raw fruit, vegetables, or meat

• Surgical mask and gloves

• Hand hygiene

• Limit visitors

• No rectal temperatures

• Prophylactic abx

• Private room

• No live vaccines

• Members in the same house should not receive live vaccines

• Patient(pt) monitoring is to monitor ANC (Absolute Neutrophil Count) tells amount of immunity a patient has.

• Range is 2500–7000.

• Levels below 500–1000 mean chemotherapy or treatment needs to be held.

Connective Tissue Disorders

• Inflammatory

• Systemic Lupus Erythematosus

• Medications include:

• Analgesics

• Anti-inflammatory drugs (ASA, Steroids)

• Immunosuppressive Drugs (Imuran, Cytoxan)

• Antimalarials

• Health promotion

• Avoid sun exposure, fatigue, and stress

• Take meds as directed & monitor side effects

• Practice regular exercise

• Wear a medical alert bracelet

• Minimize or limit immune response or complications

• Balance rest and activity

• Provide skin care

• Use topical steroids

• Monitor for discoloration or sunburn

• Provide mouth care

• Address ulcerations

• Eat a diet low in sodium and protein (if renal involvement present)

• Complications from SLE include:

• Kidney damage

• Myocarditis

• Arthritis

• Seizures

• Anemia

• Skin ulcers

Skin

Shingles

• Reactivation of dormant varicella-zoster virus.

• Must have had chickenpox in order to have shingles.

• Can come out during periods of stress.

• Manifestations progress through three phases:

• Pre-eruptive phase (1-10 days) that presents with pain and sometimes pruritus or paresthesia.

• Acute eruptive phase (10-15 days) that presents with unilateral patchy erythematous areas.

• Vesicles are initially clear and then become cloudy before rupturing and crusting.

• Causes severe and unrelenting pain.

• Postherpetic neuralgia (PHN) lasts for a variable duration with varying manifestations.

• Treatment includes:

• Antiviral drugs (within 72 hours of the onset of symptoms)

• Analgesics

• Systemic corticosteroids

• • Gabapentin

• Management includes contact precautions.

• People who have not had chickenpox and are not vaccinated are at risk

• Children and unborn fetuses are most at risk

Scratch/Itch Syndrome

• Patients are at risk for infection (cellulitis).

• Management:

• Increase patient comfort and prevent skin injury.

• Use tepid water for baths & Shake off excess water; gently blot body folds

• Apply emollient immediately after bathing

• Avoid situations that cause vasodilation

• Reduce exposure to hot environments

• Avoid ingestion of alcohol/hot foods/liquids

• Avoid activities resulting in perspiration

Cellulitis

• Generalized infection involving the deeper connective tissue.

• Responsible bacteria are Staphylococcus or Streptococcus

• Symptoms

• Localized inflammation

• Lymphadenopathy

• Redness

• Fever

• Warmth

• Sudden Rash that worsens quickly with general systemic symptoms

• Tendernesses/pain

• Treatment involves:

• IV antibiotics (for severe cases) or PO antibiotics (at home)

• Elevate above heart

• Cool moist compress initially, then warm moist compress every 2-4 hours

• Skin/foot care

• Remove any restrictive clothing

• Closely monitor blindness near eye = prompt response TX

Sensory

Retinal Detachment

• Phallimaru symptoms: Curtains Slowly coming down/covering eye" - sudden change in loss of vision
• Emergency, can have permanent blindness
• Treatment:
• Surgical scleral buckling and vitrectomy
• Prone position post-op
• Restrict activity/head movement
• Avoid increase in intraocular pressure
• Most commonly caused by trauma (punched).

Cataracts

• Lens opacity/cloudiness that distorts the image projected onto the retina.
• Risk factors
• Age
• Associated ocular conditions
• Trauma
• Toxic agents
• UV light
• Manifestations include:
• Painless blurred vision
• Blurry vision
• Light scattering
• Reduced visual acuity
• Diplopia
• Reduced sensitivity to glare
• The Treatment is Safety and Prevention!
• Smoking cessation
• Weight reduction
• Blood sugar control
• Sunglasses use
• Post-op care
• Antibiotic/steroid eye drop
• Eye patch for 24 hours

Glaucoma

• Optic nerve damage increases intraocular pressure.
• Risk factors include:
• Family history
• Older age
• Thin cornea
• Diabetes
• African American
• Prolong use of steroids
• Wide angle:
• Age related, nonemergency
• Symptoms include gradual peripheral loss and tunnel vision
• Narrow angle:
• Emergency-no aqueous humor being released
• Caused by mechanical issue
• Symptoms include:
• Severe pain
• Colored halos
• headache/brow pain
• Sudden blurred vision
• Reddened sclera/foggy cornea

Macular Degeneration

• Central vision loss.
• Surgery treat.
• Avoid activities that increase intraocular pressure:
• sneezing/coughing
• weight lighting
• inversion (yoga poses)
• holding breath
• playing wind instruments
• Avoid reading
• Eye patch after surgey

Meniere's Disease

• Chronic recurrent disorder of inner ear
• Can eventually cause cranial nerve damage.
• Excess of endolymphatic fluid that distorts inner canal system.

Manifestations:

• Tinnitus

• Fluctuating

• Sensorineural hearing loss vertigo

• Pressure/Fullness in ear

• Severe headaches

• Management

• Restrict head movement

• 2000-3000mL a day

• Limit salty, sugary, processed foods and caffeine.

• Drug therapy

• Mild diuretics thiazide

• Monitor potassium

• Nicotinic acid

##Shock

Stages of shock

First thing: remove and or TX cause oxygen and fluids

###1. Compensatory

• SNS causes vasoconstriction, increases HR and increased heart contractility.

• This maintains BP and CO.

• Body shifts blood from skin kidneys, and GI cool and clammy skin, hypoactive bowel sounds, decreased VO.

• Perfusion in tissues is inadequate

• Acidosis occurs from anaerobic metabolism

• Main concern ↓ 7.35

• Cardiac drugs do not work in acidotic state must give bicarb.

• Prompt Treatment Fluids ABX pressors-

###2. Progressive

• *-**Mechanisms that regulate BP can no longer compensate BP and MAP decrease
• All organs suffer from Hypo-Perfusion
• Hypoxia increases LOC
• Lungs begin to fail
• Inadequate PERFUSION of heart dysrhythmia/ischemia.
• MAP falls below 70, GFR cant be maintained.
• Acute RENAL FAILER may occur.
• LIVER, Gl, and hematological function is affected.
• DIC may occur
• Organ damage os severe Patient doesnt not respond to TX and CANT survive. ( BP remains low. Renal/liver function fail, metabolic acidosis , multiple organ dysfunction
• Vasopressors drugs such as dopamine epinephrine
• Dobutamine

###3.Types of Shock-Cardiac

• Pump faliure

• PE

• Mi

• Dythmias >>TX underlying cause<<

• 02 fluid marker

• O pain control

• Hemodynamic monitor

• Pharm therppy d

• Dobutamine

• Nitro

• Dopamine

• Cantiarrythmic meds.

• Hypovolemic shocu

• Burns

        1-labs =⬇️ Ph ⬇️
  
         ➡️ OPH
  
        2 A Hct⬆️(bleeding= ⬇️
         ✅  Hgb ⬆️(bleeding= ⬇️
    Management
        Position Trendelenburg
       Tx - underlying cause
       ⬆️ Fluids /replacement 
  

##Neurogenic shocks Related to

1. Brain
2. ⬆️Vasodilation Massive

Massive

• Massive
• Hypo-Perfusion tissue and cellular damage!

Nursing assessment include: HVS= Hypotension and Bradycardia Reflexes Autonomic Dyspreflexia

EMERGENCY cause HTN Strokes Sudden onset of severe throbbing headache Nausea and dilated Pupils & Sweating all occur! Severe HTN and Bradycardia

Management

Elevate HBO OVER to support neurologic function monitor bleeding