Medical Surgical Nursing 4 PDF

Chapter Contents A. Disorders in Immunology B. Oncology Nursing / Cellular...

Chapter Contents A. Disorders in Immunology B. Oncology Nursing / Cellular aberration C. Acute Biologic Crisis D. Emergency Nursing Medical Surgical E. Disaster Nursing Nursing 4 I. Nursing Process for Immune System I. Assessment 1. Health history ❖ Elicit a description of the client’s present illness and chief complaints, including onset, course, duration, location, and precipitating and alleviating factors. Elicit a description of the client’s overall health status, including immunizations status, usual childhood disease, known allergies and a history of past and present medications. Cardinal signs and symptoms indicating altered immunity are subsequently described: o General ▪ Recurrent infections ▪ Seasonal symptoms ▪ Weight loss ▪ Fever o Head ▪ Itching, burning, watering eyes, vision problems, and eye infections ▪ Recurrent ear infections ▪ Rhinitis and sneezing o Respiratory system ▪ Cough ▪ Dyspnea ▪ Recurrent infection o Cardiovascular system ▪ Pain Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 1  ▪ Raynaud’s phenomenon (i.e. extreme pallor and then cyanosis of extremities brought on by cold exposure) o GI system ▪ Nausea and vomiting ▪ Diarrhea o Genitourinary system ▪ Recurrent infections ▪ Dysuria and hemauria o Muscoloskeletal system ▪ Weakness and fatigue ▪ Inability to perform activities of daily living (ADLs) o Neurologic system ▪ Disorientation to name, date, and place ▪ Altered level of consciousness ▪ Paresthesias ❖ Explore the client’s history for risk factors associated with immune disorders, including not keeping up-to-date immunizations, exposure to infectious disease, and exposure to pollens, insects and allergens. 2. Physical Examination ❖ Inspection o Inspect skin and mucous membranes for rashes, lesions, dermatitis, purpura (subcutaneous bleeding), and any type of inflammation or drainage. o Assess the joints for tenderness, edema, and range of motion o Inspect ears for drainage, inflammation, and scarring from ear infections ❖ Palpation o Palpate the anterior and posterior cervical, axillary, and inguinal lymph nodes for enlargement. o Note the location, size, and consistency of lymph nodes. Document complaints of tenderness if the node is palpable. ❖ Auscultation o Auscultate lungs for abnormal lung sounds such as wheezing, crackles, and rhonchi. o Auscultate heart sounds for abnormalities such as palpitations and dysrhythmias. Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 2  3. Laboratory and diagnostic studies ❖ Multi-allergen allergy testing – measures the increase and quantity of allerge- specific immunoglobulin IgE antibodies and is done to identify allergens to which the client has immediate hypersensitivity. ❖ T- and B- lymphocyte assays - evaluate the number of lymphocytes in the immune system. ❖ Ig assays (IgG, IgA, IgM) can detect and monitor immune deficiencies. ❖ Serum complement assays test for C3 and C4 complement when the total complement level is decreased. ❖ Autoantibody tests o Antinuclear antibody (ANA) test measures and differentiates ANAs associated with certain autoimmune disease such as systemic lupus erythmatosus. o Rheumatoid factor test measures for a macroglobulin type of antibody found in rheumatoid arthritis. ❖ Radioallergosorbent test is a radioimmunoassay that measures allergen- specific IgE. ❖ The human immunodeficiency virus (HIV) test determines the presence of HIV antibodies, which is the etiologic factor for acquired immunodeficiency syndrome (AIDS). II. Nursing diagnosis 1. Ineffective airway clearance 2. Risk for infection 3. Acute or chronic pain 4. Impaired skin integrity 5. Deficient fluid volume 6. Deficient knowledge 7. Bathing or hygiene self-care deficit 8. Risk for injury 9. Ineffective coping III. Planning and outcome identification ❖ The goals for a client diagnosed with an immunologic disorder include improved airway clearance, prevention of infection, increased comfort, improvement and maintenance of skin integrity, increased knowledge regarding disease, prevention and self-care, absence of complications and injury, and improved coping. IV. Implementation 1. Assess respiratory status, including assessment of lungs, rate and depth of respirations, effort of breathing, use of accessory muscles, cyanosis, restlessness and anxiety or any change in level of consciousness. 2. Minimize the risk of infection. Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 3  a. Instruct the client on ways to avoid infection, including the importance of personal hygiene and avoidance of people with infections and large crowds. b. Instruct the client to wash the affected area with warm water before applying topical creams. Instruct him to wash his hands before and after administering topical creams. 3. Provide pain relief. Assess the client’s pain, rule out any complications, implement any nonpharmmacologic intervention (e.g. ice, cold, massage) to relieve pan, administer pain medication, and evaluate the effectiveness of interventions. 4. Promote skin integrity a. Assess the skin and mucous membranes for any rashes, color changes, lesions, pallor, purpura, hydration and inflammation. b. Keep skin clean and dry. do not use harsh soaps. 5. Maintain fluid balance. Monitor client’s intake and output, and maintain 30 ml/hour urinary output, use a urometer to ensure accurate output. Assess for hydration. 6. Provide client and family teaching. a. Teach the client about the disease process and possible triggers. b. Teach the client measures to minimize or prevent exposure to the allergens. c. Discuss emergency measures (e.g. use of epinephrine) and medication therapy, including the use of corticosteroids to reduce inflammation. d. Teach the client danger signs and symptoms to report including respiratory distress and infection. 7. Promote self-care. Assist the client with ADLs as needed, but promote independence. Use any energy-saving techniques available. 8. Prevent injury. Instruct the client to wear identification tags or bracelets concerning allergies or disease. 9. Promote client and family coping. a. Teach the client and his family ways to cope with chronic illness, including verbalization of feelings and ways to prevent exacerbations. b. Provide referrals to counselors and support groups. V. Outcome evaluation 1. The client displays no respiratory distress, as evidenced by an absence of chest tightness, wheezing, cyanosis, cough, and exaggerated expiratory effort. 2. The client shows no symptoms of opportunistic infection, such as fatigue, fever, night swats, weight loss, and diarrhea. 3. The client verbalizes relief of joint pain and discomfort 4. The client exhibits clean, dry skin that is free from rash, itching, burning, scaling ulcerations and infection. 5. The client has intact skin and oral mucosa. 6. The client maintains adequate fluid and electrolyte balance and nutritional status. Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 4  7. The client can verbalize an understanding, preventive measures, and treatment of the disease process and the signs and symptoms that should be reported to that health care provider. 8. The client is able to care for himself and perform independent ADLs. 9. The client remains free from injury. 10. The client is able to verbalize appropriate coping mechanisms to control anxiety. A.Disorders in Immunology The immune system is extremely complex, interrelated system that affects the whole body. The nurse must understand immune responses to provide clients with complete and individualized care. Because the care of these clients requires multifaceted interventions, development and implementation of complex care plans are important to meet their needs. CATEGORIES OF IMMUNE DISORDERS A. Hypersensitivity reactions – are immune responses to allergens that result in tissue destruction. a. Type I (anaphylactic) reactions are mediated by the immunoglobulin IgE antibody, which promotes the release of histamine and other reactive mediators. These basophil or mast cells produce the characteristic symptoms of asthma or hay fever. b. Type II (cytotoxic) reactions (e.g. hemolytic anemia) are mediated by IgG and IgM antibodies, which attach to cells (usually circulating blood elements) and cause cell lysis. c. Type III (immune complex) reactions (e.g. rheumatoid arthritis, serum sickness) are mediated by antigen-antibody complexes that deposit in the lining of blood vessels or on tissue surfaces. d. Type IV (delayed hypersensitivity) reactions (e.g. contact dermatitis, transplant rejection) are mediated by lymphokines released from sensitized T lymphocytes. B. Allergic disorders – are hypersensitive responses to an allergen to which an organism has previously been exposed and to which the organism has developed antibodies. a. Interaction between antigen and antibody typically results in one or more manifestations of tissue injury. b. IgE antibodies are formed by persons experiencing allergies who are genetically predisposed. Histamine and other mediators are released on reexposure to the allergen to which the person is sensitized. C. Autoimmune disorders – are conditions in which the body no longer differentiates self from nonself. a. Alteration in T cells or B cells produce autoantibodies and autosensitized T cells that cause tissue injury. These changes may involve one organ or many Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 5  organ systems. b. The cause of autoimmune disorders remains unknown, but many theories exist. D. Immune deficiency – is defined as a congenital or acquired deficit in the immune system that makes the person susceptible to life-threatening opportunistic infection. a. In congenital (primary) immunodeficiency – the body produces inadequate amounts of one or more immune cells. Deficit can be humoral (B cells), cell- mediated (T cell), or combined. b. Acquired (secondary) immunodeficiency is attributed to various etiologies, including: i. Immunosuppressive therapy – such as chemotherapeutic agents, corticosteroids, non-steroidal anti-inflammatory agents, and irradiation. ii. Age-related factors – such as deterioration in the thymus gland and T-cell functioning and a decreased number of suppressor T cells and helper T cells. iii. Disruption of skin integrity, as occurs with burns and trauma. iv. Nutritional deficits v. Malignant processes, such as leukemia and lymphoma vi. Infectious processes, such as sepsis and acquired immunodeficiency syndrome. ALLERGIC RHINITIS I. Definition ❖ Allergic rhinitis is an allergic reaction to inhaled airborne allergens characterized by seasonal occurrences. It is the most common form of respiratory allergy. II. Risk Factors ❖ Airborne pollens ❖ Dusts III. Pathophysiology ❖ Allergic rhinitis occurs when immunoglobulin IgE antibodies in the nasal mucosa combine with inhaled allergens on the mucosal surface. The nasal mucosa reacts by lowering of ciliary action, edema formation, and leukocyte infiltration. Tissue edema is a result of vasodilation and increased capillary permeability. IV. Assessment/Clinical Manifestations/Signs And Symptoms ❖ Itching, burning nasal mucosa ❖ Copious mucous secretions causing runny nose ❖ Red, burning tearing eyes ❖ Sneezing ❖ Pale, boggy nasal mucosa Laboratory and diagnostic study findings Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 6  Skin testing identifies the offending allergens Total serum IgE determination shows an elevated serum level of IgE V. Medical Management The goal of therapy is to provide relief from symptoms. Avoidance therapy o Every attempt is made to remove the allergens that act as precipitating factors. Simple measures and environmental controls are often effective in decreasing symptoms. Pharmacologic therapy o Antihistamines are used in managing mild allergic disorders. The major class of medications prescribed for the symptomatic relief of allergic rhinitis. o Adrenergic agents, vasoconstrictors of mucosal vessels are used topically. The topical route (drops and sprays) causes fewer side effects than oral administration. o Mast cell stabilizers, intranasal cromolyn sodium is a spray that acts by stabilizing the mast cell membranes, thus reducing the release of histamine and other mediators of the allergic response. o Corticosteroids are indicated in more severe cases of allergic rhinitis that cannot be controlled by more conventional medications such as decongestants, antihistamines and intranasal cromolyn. Immunotherapy o Allergen desensitization (allergen immunotherapy, hyposensitization) is primarily used to treat IgE-mediated diseases by injections of allergen extracts. o Goals of immunotherapy include reducing the level of circulating IgE, increasing the level of blocking antibody IgG, and reducing mediator cell sensitivity. VI. Nursing Management Encourage the client to use saline nasal sprays to soothe mucous membranes. Advise the client to blow his nose before administering nasal medications. Prepare the client for immunotherapy, which is prescribed only when IgE hypersensitivity to specific, unavoidable inhalant allergens (house dust and pollens) is demonstrated. Minimize the risk of infection. Promoting understanding of allergy and allergy control Improving breathing pattern Provide client and family teaching. Administer prescribed medications, which may include antihistamines, decongestants, and topical corticosteroids. RHEUMATOID ARTHRITIS I. Definition ❖ Rheumatoid arthritis is a chronic, progressive disease involving inflammation of Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 7  synovial joints. II. Risk Factors ❖ Three times greater than in women than in men ❖ Onset between age 30 and 60 ❖ Autoimmune ❖ Unknown cause ❖ Exacerbations may be associated with increased physical or emotional stress III. Pathophysiology ❖ Pathologic changes begin as inflammation and progress to destruction of joints, producing deformity and loss of motion. The disease may affect only joints or may extend to body organs and blood vessels. IV. Assessment/Clinical Manifestations/Signs And Symptoms ❖ Edematous, warm, tender joints ❖ Limited range of motion in affected joints ❖ Generalized edema or nodules to perform activities of daily living (ADLs) ❖ Fatigue, weakness, and anorexia ❖ In late stages: weight loss, fever, anemia, muscle atrophy Laboratory and diagnostic study findings Radiographic studies reveal abnormalities such as progressive joint damage Rheumatoid factor is present in more than 80% of clients Erythrocyte sedimentation rate is significantly elevated V. Medical Management Treatment begins with education, a balance of rest and exercise, and referral to community agencies for support. Early RA: medication management involves therapeutic doses of salicylates or NSAIDs; includes new COX-2 inhibitors, antimalarials, gold, or sulfasalazine; methotrexate; analgesic agents for periods of extreme pain. Moderate, erosive RA: formal program of occupational and physical therapy; an immunomodulator such as cyclosporine may be added. Persistent, erosive RA: reconstructive surgery and corticosteroids. Advanced unremitting RA: immunosuppressive agents such as methotrexate; cyclophosphamide, and azathioprine (highly toxic, can cause bone marrow suppression) RA patients frequently experience anorexia, weight loss, and anemia, requiring careful dietary history to identify usual eating habits and food preferences. Corticosteroids may stimulate appetite and cause weight gain. Low-dose antidepressant medications (amitriptyline) are used to reestablish adequate sleep pattern and manage pain. VI. Nursing Management Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 8 Care is directed at relieving pain and maintaining function. Provide pain relief. Provide comfort measures, including massage and position changes. Apply hot or cold therapy to affected joints according to the client’s needs. Promote self-care. Promote client and family coping. Promote adequate rest and sleep to prevent fatigue; provide comfort measures, including a foam mattress and supportive pillows; and discuss energy conservation techniques. Encourage proper body alignment to prevent contractures. Collaborate with the physical therapist to design and provide the client with a physical therapy program, which begins after the acute phase resolves. Encourage a muscle activity program for self-care. Recommend a weight reduction program, if appropriate. Collaborate with the occupational therapist and promote the use of braces, splints, and assistive mobility devices, if appropriate. Discuss relaxation techniques, such as imagery, self-hypnosis, biofeedback, diversionary activities, and distraction for pain management. Discuss maintaining optimal nutritional status. Administer prescribed medications, which may include nonsteroidal anti-inflammatory drugs, aspirin, slow-acting antirheumatic medications, and corticosteroids. SYSTEMIC LUPUS ERYTHEMATOSUS I. Definition ❖ Systemic lupus erythematosus (SLE) is a chronic systemic inflammatory disease affecting multiple body systems. II. Risk Factors ❖ Women are more affected than men, women of childbearing age ❖ Autoimmune III. Pathophysiology ❖ SLE involves markedly increased B-cell activity, hypergammaglobulinemia, autoantibody production, and decreased T-cell functions. IV. Assessment/Clinical Manifestations/Signs And Symptoms May be insidious or acute; the client may remain undiagnosed for many years; clinical manifestations involve multiple body systems. ❖ Muscoloskeletal system o Arthralgias and arthritis (synovitis) o Joint edema and tenderness o Pain on movement and morning stiffness ❖ Integumentary system o Subacute cutaneous lupus erythematosus results in a butterfly rash across the bridge of the nose and cheeks. Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 9  o Discoid lupus erythematosus results in skin involvement that may be provoked by sunlight or artificial ultraviolet light. o Oral ulcers of the buccal mucosa and hard palate occur in crops and may accompany skin lesions. ❖ Cardiovascular system o Pericarditis o Popular, erythematosus and purpuric lesions on fingertips, elbows, toes and forearms, and hands ❖ Respiratory system o Pleural effusion o Pleuritis ❖ Neurologic system o Subtle changes in personality and cognitive ability o Commonly, depression and psychosis ❖ Other systems o Lymphadenopathy o With renal involvement, the glomeruli of kidneys are usually affected. Laboratory and diagnostic study findings Antinuclear antibody test result is positive Red and white blood cell counts may be decreased, revealing thrombocytopenia, severe anemia, leukocytosis, and leucopenia Anti-deoxyribonucleic acid cell test reveals a high titer Urine testing reveals proteinuria and cellular casts in urine. V. Medical Management Goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complications from therapy. Monitoring is performed to assess disease activity and therapeutic effectiveness. Pharmacologic therapy o NSAIDs are used with corticosteroids to minimize corticosteroid requirements. o Corticosteroids are used topically for cutaneous manifestations. o Bolus intravenous administration is an alternative to traditional high-dose oral use. o Cutaneous, musculoskeletal, and mild systemic features of SLE are managed with antimalarials drugs. o Immunosuppressive agents are generally reserved for the most serious forms of SLE. VI. Nursing Management Maintain skin integrity, which includes keeping the skin clean and dry, using mild soaps and lotions, and inspecting the skin for vasculitis lesions. Perform a cardiovascular, respiratory, neurologic, and musculoskeletal assessment to Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 10  identify and describe any systemic problems. Provide meticulous mouth care. Arrange a dietary consult, to ensure optimal nutrition while meeting the client’s need for soft, easily tolerated foods. Apply war packs, as needed to relieve joint pain and stiffness Collaborate with the physical therapy department and encourage an appropriate exercise program to help maintain mobility and strength. Provide client and family teaching. o Encourage protection from the sun and ultraviolet light. Advise the client to avoid going out between 10am and 4pm, use sunscreen with a sun-protection factor of at least 30, wear a large hat and tight weave clothing, and refrain from using a tanning bed. o Advise the client to consult a health care provider before receiving immunization or taking birth control pills over-the-counter drugs. o Advise the client to avoid persons with contagious infections. Administer prescribed medications, which may include corticosteroids, nonsteroidal anti-inflammatory drugs, and salicylates to help the joint pain and oral or topical corticosteroids to help with the rash. ACQUIRED IMMUNODEFICIENCY SYNDROME I. Definition ❖ Acquired immunodeficiency syndrome (AIDS) is a severe immunodeficiency caused by the human immunodeficiency virus (HIV), which allows normally benign organisms to flourish and cause disease. The virus causes cell death and a decline in immune function resulting in opportunistic infections, malignancies, and neurologic problems. These opportunistic conditions define the syndrome. II. Risk Factors ❖ Engages in unprotected sexual activity with an infected person ❖ Recipients of transfused blood or blood components ❖ IV drug users ❖ Children (perinatally) of mothers with HIV ❖ Health care workers exposed to HIV by needle stick III. Pathophysiology ❖ HIV is part of a group of viruses known as retroviruses, which carry genetic material in ribonucleic acid rather than deoxyribonucleic acid. HIV infects cells with CD4 lymphocytes (also called T4 or helper T cells). This infection causes cell death and a decrease in the immune function, resulting in opportunistic infections, and neurologic problems. HIV can be isolated from blood, semen, saliva, tears, breast milk, and cerebrospinal fluid. After a variable course of about 10 years from the time of infection, 50% of infected person develops AIDS. The incubation period of HIV varies, ranging from 6 months to 5 years, with an average of 2 years. IV. Assessment/Clinical Manifestations/Signs And Symptoms ❖ Fatigue Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 11  ❖ Fever and night sweats ❖ Weight loss ❖ Generalized lymphadenopathy ❖ Nonproductive cough and shortness of breath ❖ Skin lesions, dry skin, and pallor ❖ GI upset and chronic diarrhea ❖ Edema ❖ Visual impairment ❖ Painful oral lesions ❖ Bruising and bleeding tendencies ❖ Joint pain ❖ Opportunistic infections, such as Pneumocystic carinii pneumonia, mycobacterial infections, cryptococcal infection, toxoplasmosis, histoplasmosis, and cytomegalovirus infection. ❖ Kaposi’s sarcoma and AIDS-related lymphoma ❖ Neurologic deficits, such as AIDS dementia complex ❖ HIV wasting syndrome Laboratory and diagnostic study findings Enzyme-linked immunosorbent assay (ELISA) indicates exposure to or infection with HIV but does not diagnose AIDS. Western blot assay identifies HIV antibodies. AIDS is diagnosed on clinical history, risk factors, physical examination, laboratory evidence of immune dysfunction, and positive ELISA or Western blot assay. V. Medical Management Currently there is no cure for HIV or AIDS. Treatment decisions for an individual patient are based on three factors: HIV RNA (viral load), CD4 T-cell counts, and the clinical condition of the patient. The goals of treatment are maximal and durable suppression of viral load, restoration and/or preservation of immunologic function, improvement of quality of life, and reduction of HIV-related morbidity and mortality. To determine and evaluate the treatment plan, viral load testing is recommended at diagnosis and then every 3 to 4 months thereafter in the untreated person. Combination therapy is defined as regimen containing any combination of two, three or four antiretroviral agents (eg highly active antiretroviral therapy (HAART), two nucleoside reverse transcriptase inhibitors plus a protease inhibitor or a non- nucleoside reverse transcriptase inhibitor, or two protease inhibitors and one other antiretroviral agent) Pharmacologic therapy o Antiretroviral therapy o Medications for HIV-related infections such as PCP, Candidiasis, encephalitis, CMV retinitis, Cryptococcal meningitis) o Anticancer agents Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 12  o Immunomodulators o Antidepressants o Antidiarrhea agents and appetite stimulants Nutrition therapy (individualize and integrate into the overall management plan) o Goal is to maintain ideal weight and when necessary to increase weight. o Appetite stimulants (Megace) have been successful; dronabinol (Marinol) has been effective when used to relieve nausea and vomiting. VI. Nursing Management No cure or vaccine has been found, and treatment focuses on maintaining health and improving survival time. Promote preventive measures related to the transmission of HIV. o Promote public education regarding HIV and AIDS. Teach clients and families to practice safe sex, avoid sharing needles, and avoid touching another’s body fluids without protection. o Inform HIV-infected clients that even though HIV is undetectable, the client may be infectious and should practice safe sex. o Promote standard precautions to protect health care providers from exposure to the client’s blood or body fluids and to protect the client from cross-contamination. Maintain skin integrity. o By instructing the client to avoid scratching, strong perfumed soaps, and adhesive tapes; follow routine oral care, keep anal area as clean as possible, wear white socks to prevent foot problems, keep linen dry and clean; and apply protective barriers to the skin as necessary. Instruct the client about the promotion of normal bowel movement and prevention of diarrhea. o Instruct the client to monitor the quantity and volume of liquid stools and avoid bowel irritants such as raw fruits, vegetables, spicy foods, and hot or cold foods. Promote infection prevention. o Discuss the importance of maintaining personal hygiene, keeping bathrooms and kitchen clean, avoiding exposure to individuals who are sick, avoiding smoking and alcohol, and getting adequate rest, activity, and a well-balanced diet. Teach energy conservation techniques. o Such as sitting while doing morning care, using a shower chair, and arranging the home in a way to save time from walking or standing. In the hospital, put all necessary items within easy reach. Discuss ways the client and family can assist with mental status problems. o These include putting notes on the refrigerator or note boards, using calendars and clocks to orient the client to time and place, and assisting the client with paying bills, shopping and other household activities. Teach methods for airway clearance. o These include turning, coughing, and deep breathing; increasing fluid intake Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 13  to thin secretions, maintain semi-Fowler’s position; and using humidified oxygen if necessary. Help maintain nutritional status. o By controlling nausea and vomiting; encouraging foods that are easy to swallow; encouraging oral hygiene before and after meals; promoting a high- protein, high-calorie diet; monitoring weight, intake and output, monitoring fluid and electrolyte balance and administering appetite stimulants. Monitor and manage complications of opportunistic infections. o Opportunistic infections – protozoan, fungal, bacterial and viral – occur because of immune suppression; they account for most of the clinical manifestations observed in AIDS. Pneumocystic carinii pneumonia is the most common. Teach ways to cope with chronic illness to the client and his family. o Always include the family in teaching and care, and provide family members with grief counseling. Administer prescribed medications, which may include drug therapy for AIDS-related opportunistic infections, antiretroviral therapy, antidiarrheals, and antiemetics. ALLERGIC DERMATOSES I. Definition ❖ Allergic dermatoses is a group of inflammatory conditions caused by skin reaction to irritating or allergenic materials. They include allergic contact dermatitis and atopic dermatitis. II. Risk Factors ❖ Allergic contact dermatitis 1. Topical medications 2. Cosmetics 3. Soaps 4. Industrial chemicals ❖ Atopic dermatitis 1. Irritants 2. Infection 3. Allergens III. Pathophysiology ❖ Allergic contact dermatitis. o Involves delayed hypersensitivity and requires a latent period ranging from several days to years. ❖ Atopic dermatitis. o Is a type I immediate hypersensitivity disorder resulting in large amounts of histamine in the skin, changes in lipid content of the skin, sebaceous gland activity and diaphoresis. It most commonly begins in infancy or early childhood it may subside spontaneously to be followed by unpredictable Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 14  exacerbations throughout life. IV. Assessment/Clinical Manifestations/Signs And Symptoms ❖ Allergic contact dermatitis o Burning itching, edema and erythema of skin o Crusting, weeping lesions o Drying and peeling of the skin o Hemorrhagic bullae, possibly with severe responses ❖ Atopic dermatitis o Pruritus o Hyperirritability of the skin o Excessive dryness of the skin o Redness for 15 to 30 seconds after stroking, followed by pallor lasting for 1 to 3 minutes. Laboratory and diagnostic study findings Allergic contact dermatitis. Patch tests of the skin may clarify diagnosis with offending agents being identified. Atopic dermatitis. o Serum immunoglobulin E levels are frequently elevated. o Skin biopsy shows nonspecific eczematous changes. V. Medical Management Using antihistamines such as diphenhydramine (Benadryl) and avoiding animals, dust, sprays, and perfumes. Topical corticosteroids are used to prevent inflammation and any infection is treated with antibiotics to eliminate Staphylococcus aureus when indicated. Use of a low doses of cyclosporine (Sandimmune) an immunosuppressive agent may be effective. VI. Nursing Management Minimize the risk of infection Provide pain relief Promote skin integrity Promote client and family coping. Provide client and family teaching. o Instruct the client to wear cotton fabrics and wash with a mild detergent o Advise the client to take daily baths to hydrate the skin. o Encourage the client to use topical skin moisturizers. Administer prescribed medications, which may include antihistamines, antipruritics or steroidal creams. SCLERODERMA (Systemic sclerosis) I. Definition ❖ Is a multisystem inflammatory disease characterized by skin thickening (scleroderma) Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 15  and deposition of excessive quantities of connective tissues (particularly collagen) which eventually resultsd in severe fibrosis II. Risk Factors ❖ Environomental factors (working with plastics, coal, or silica dust) ❖ High alcohol intake ❖ Genetic factors ❖ Metabolic disorders ❖ Postinfectious disorders ❖ Neurologic conditions III. Pathophysiology ❖ Lymphocytes accumulate in the lower dermis, which in turn generate lymphokines which in turn stimulate to produce fibroblasts to produce excessive amounts of procollagen. After the procollagen is secreted form the cell, it undergoes cross-linking in the extracellular environment to produce mature, relatively insoluble collagen. The skin undergoes fibrotic changes, leading to loss of elasticity and movement. IV. Assessment/Clinical Manifestations/Signs And Symptoms ❖ Type 1 (diffuse, cutaneous scleroderma) o Symmetrical widespread thickening of the skin in the extremeties, face and trunk o Early stage: Bilateral symmetrical swelling of the fingers, face and feet; tense and wrinkle-free appearance of skin o Disease progression: thickened and shiny skin, changes in pigmentation, mask-like face o Problems in GI tract, heart, lungs and kidneys o Disease progression is rapid ❖ Type 2 (limited cutaneous scleroderma) o Skin changed confined to the fingers, distal portions of the extremities, face o CREST (poor prognosis indicator) ✓ Calcinosis: calcium deposits in the tissues ✓ Raynaud’s phenomenon: intermittent vasospasms of fingertips ✓ Esophageal hardening: sclerosis of the esophagus ✓ Sclerodactyly: scleroderma of the digits ✓ Telangiectasis: capillary dilations that form vascular lesions on the face, lips and fingers Laboratory and diagnostic study findings Mild hypergmmaglobulinemia (IgG) (+) rheumatoid factor Slight elevation of ESR Proteinuria (+) for ANA (+) anticentromere and antricentriole antibodies Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 16 V. Medical Management Pharmacologic management o Vasoactive agents o Anti-inflammatory medications (glucocorticoids) o Immunosuppresive drugs o Immunomodulating agent (Penicillamine) o Minocycline for treatment of diarrhea o Proton pump inbhibitor to reduce acidity of gastric reflux o ACE-inhibitors to reduce renal complications VI. Nursing Management Encourage activity as tolerated Maintain a constant room temperature Provide small frequent meals, eliminating foods that stimulate gastric secretions, such as spicy foods, caffeine and alcohol Advise the client to sit up for 1 to 2 hours after meals if the is esophageal involvement Provide supportive therapy as the major organs become affected Administer medications as prescribed Provide emotional support and encourage the use of resources as necessary LYME’S DISEASE I. Definition ❖ Is a multisystem inflammatory process with devastating long-term effects if not treated early or effectively ❖ Infection caused by the spirochete Borrelia burgdorferi, acquired from a deer tick bite (ticks live in wooded areas and survive by attaching to a host) II. Risk Factors ❖ Exposure/contact with tick carrying the spirochete III. Pathophysiology ❖ Infection with the spirochete stimulates inflammatory cytokines and autoimmune mechanisms. IV. Assessment/Clinical Manifestations/Signs And Symptoms ❖ First stage o Symptoms can occur several days to months following the bite o A small red pimple develop that spreads into a ring-shaped rash o Rash may be large or small, or may not occur at all o Flu-like symptoms (headache, stiff neck, muscle aches, fatigue0 ❖ Second stage o Occurs several weeks following the bite o Joint pain o Neurological complications Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 17  o Cardiac complications ❖ Third stage o Large joints become involved o Arthritis progresses Laboratory and diagnostic study findings ELISA test (2-6 weeks after transmission) Western blot to confirm positive ELISA tests V. Medical Management Antibiotic (Doxycycline) Intra-articular steroids and NSAIDs Synovectomy if synovitis occurs as complication VI. Nursing Management Gently remove the tick with tweezers, wash the skin with antiseptic, and dispose of the tick by flushing it down the toilet; the tick may also be placed in a sealed jar so that the health care provider can inspect it and determine its type Obtain a blood test 4-6 weeks after a bite to detect the presence of disease (testing before this time is not reliable) Instruct the client in the administration of antibiotics as prescribed if the disease is confirmed Instruct the client to avoid areas that contain ticks, such as wooded grassy areas, especially summer months Instruct the client to wear long-sleeved tops, long pants, closed shoes and hats while outside Instruct the client to examine the body when returning from wooded areas for the presence of ticks GOODPASTURE’S SYNDROME I. Definition ❖ Is an autoimmune disorder; autoantibodies are made against the glomelular basement membrane (GBM) and alveolar basement membrane II. Risk Factors ❖ Males ❖ Young adults who smoke ❖ Genetics III. Pathophysiology ❖ Immune globins deposited in the basement membranes, causing an inflammatory response, glumeronephritis, and breakdown in the basement membrane with crescent formation. IV. Assessment/Clinical Manifestations/Signs And Symptoms Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 18  ❖ Clinical manifestations indications pulmonary and renal involvement ❖ Shortness of breath ❖ Hemoptysis ❖ Decreased urine output ❖ Edema and weight gain ❖ Hypertension and tachycardia ❖ Complications: pulmonary hemorrhage, respiratory failure, dialysis-dependent ESRD. Laboratory and diagnostic study findings Circulating anti-GBM Proteinuria Chest x-ray shows hemorrhagic infiltrates, atelectasis, pulmonary edema V. Medical Management High dose oral or IV corticosteroid therapy Plasmapheresis to reduce circulating immune complex VI. Nursing Management Administer medications as prescribed Prepare client for plasmapheresis Provide supportive therapy for pulmonary and renal involvement ANAPHYLAXIS I. Definition ❖ Is an immediate, life-threatening hypersensitivity reaction. ❖ Common agents causing anaphylaxis 1. Drugs: penicillins, insulin, tetracycline, cephalosphorin, NSAIDs 2. Insect venoms: wasps, hornets, yellow jackets, ants, bumblebee 3. Foods: eggs, nut, shellfish, chocolate, milk, peanuts, fish or strawberries 4. Animal serums: tetanus antitoxin, diphtheria antitoxin, rabies antitoxin, snake venom antitoxin 5. Treatment: blood products, iodine contrast media or allergenic extracts in hyposensitizing therapy 6. Latex II. Risk Factors ❖ Exposure to allergens ❖ Very young and very old ❖ For latex allergy ▪ Health care workers ▪ Individuals who work in rubber industry ▪ Individuals having multiple surgeries ▪ Individuals with spina bifidas ▪ Individuals who wear gloves frequently (food handlers, hairdressers Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 19  and auto mechanics ▪ Individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts and water chestnuts III. Pathophysiology ❖ IV. Assessment/Clinical Manifestations/Signs And Symptoms ❖ Neurologic o Headache o Dizziness o Paresthesia o Feeling of impending doom ❖ Skin o Pruritus o Angioedema o Erythema o Urticaria ❖ Respiratory o Hoarseness o Coughing o Sensation of narrowed airway o Wheezing o Stridor o Dyspnea, tachypnea o Respiratory arrest ❖ Cardiovascular Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 20  o Hypotension o Dysrhythmuas o Tachycardia o Cardiac arrest ❖ Gastrointestinal o Cramping, abdominal pain o Nausea, vomiting o Diarrhea Laboratory and diagnostic study findings Sensitivity tests V. Medical Management Administer epinephrine (Adrenalin) Removing or discontinuing the causative agent Administer emergency oxygen Maintain open airway Place in Trendelenburg position Give supportive IV fluids (0.9% normal saline or lactated Ringer’s solution as necessary) Other medications: diphenhydramide hydroclhloride (Benadryl) or corticosteroids VI. Nursing Management Establish a patent airway Prepare administration of epinephrine (Adrenalin) diphenhydramide hydroclhloride (Benadryl) or corticosteroids Provide measures to control shock Provide emotional support Provide emotional support Instruct the client to wear a Medic-Alert bracelet prior to discharge from emergent care Instruct the client EpiPen or Ana-Kit for self-injection in case anaphylaxis Management for latex allergy o Ask the client about a known allergy to latex when performing initial assessment o Use latex-free gloves and supplies o Apply a cloth barrier to the client’s arm under a blood pressure cuff o Use latex-free syringes, medication containers and latex-safe IV equipment o Instruct client to wear Meic-Alert bracelet Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 21  B. Oncology Nursing I. Oncologic Disorders Cancer therapy is progressing rapidly at the beginning of the 21 st century. Many cancers once incurable are now controlled with a variety of combination therapies. Even when cancer is not cured, length of life may be extended and the quality of this life has greatly improved. Professionals have greater knowledge of and skills in complications from chemotherapy. New treatment modalities are showing promise in clinical trials, with some already becoming standard care. The nurse for the 21st century needs to stay abreast of new developments in this rapidly expanding field. ONCOLOGY I. Definition ❖ Cancer is the general name given to a large group of diseases characterized by: o Uncontrolled growth and spread of abnormal cells o Proliferation (i.e. rapid reproduction by cell division) o Metastasis (i.e. spread or transfer of cancer cells from one organ or part to another not directly connected) ❖ Cure is considered to be achieved when the client exhibits no evidence of disease, reference points of 5- and 10-year survival rates are used. After cure, the client would have the same expected life span as age- and sex-matched persons without cancer. II. Risk Factors Healthy cells are transformed by unknown mechanisms or exposure to certain etiologic agents, including: ❖ Viruses (e.g. Epstein-Barr, herpes simplex type II, cytomegalovirus, papillomavirus, hepatitis B) ❖ Chemical carcinogens (e.g. chromium, cobalt, tar, soot, asphalt, nitrogen mustards, certain plastics, hydrocarbons in cigarette smoke, air pollutants from industry, crude paraffin oil, fuel oils, nickel, asbestos, arsenicals) ❖ Physical stressors (e.g. excessive exposure to sunlight or radiation, chronic irritation) ❖ Hormonal factors (e.g. imbalance of endogenous or exogenous hormones, such as estrogen or diethylstilbestrol) ❖ Genetic factors (e.g. abnormal chromosome patterns, such as in Burkitt’s lymphoma, chronic myelogenous or acute leukemia, and skin cancers; familial predisposition such as in breast, endometrial, colorectal, stomach, lung, colon and kidney cancers. III. Pathophysiology ❖ Cancer development is closely linked to immune-system failure, as evidenced by: o Increased incidence of malignancy in organ-transplant recipients who receive immunosuppressive therapy Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 22  o Increased risk for developing secondary cancers in clients receiving long-term chemotherapy to treat a primary malignancy o Increased incidence of lymphoma in clients diagnosed with acquired immunodeficiency syndrome o Increased incidence of cancers early in life in clients with an immature immune system or later in life in clients with a failing immune patterns ❖ Proliferation o Neoplasms have several proliferative patterns ▪ Benign (i.e. usually harmless, does not infiltrate other tissues) ▪ malignant (i.e. always harmful; may spread or metastasize to tissues far from the original site) cells display different characteristics of cellular growth; the degree of differentiation (i.e. anaplasia) determines the potential for malignancy. ❖ Hyperplasia o Involves an increase in the number of cells in a tissue, it may be a normal or an abnormal cellular response. ❖ Metastasis o The metastatic process may be divided into three stages: ▪ Invasion. Neoplastic cells from primary tumor invade into surrounding tissue with penetration of blood or lymph; this occurs because cells are not encapsulated. ▪ Spread. Tumor cells spread through lymph or circulation or by direct expansion. ▪ Establishment and growth. Tumor cells are established and grow at secondary site: in lymph filter (lymph nodes) or in organs from venous circulation. IV. Assessment/Clinical Manifestations/Signs And Symptoms CANCER TYPES: Characteristics and Treatments Copyright © 2025 Professional Review Network, Inc. (PRN) This document may not be used, reproduced or disseminated to any third party without written permission from PRN. 23  ETIOLOGY and RISK TYPES CLINICAL MANIFESTATIONS TREATMENT FACTORS Bladder o Carcinogens in the o Gross, painless hematuria o Intravesical into bladder) Cancer workplace, such as o Urinary frequency chemotherapy dyes, rubber, leather, o Urgency o Radiation therapy ink or paint o Dysuria o Uretoroentero- o Recurrent bacterial o Pelvic or back pain with cutaenous diversions infection of urinary metastasis (intestines used) or tract cutaenous (opening o Smoking onto abdominal walls) Bone tumors o Unclear o Bone pain (mild to severe) o Surgery (amputation) o Osteogenic sarcoma: o Movement limitation o chemotherapy