Infectious and Inflammatory Disorders (PPT)

INFECTIOUS AND INFLAMMATORY DISORDERS INFECTIOUS DISORDERS OF ADULTS  PNEUMONIA Inflammation of the lung parenchyma caused by a microbial agent CLASSIFICATION Community-Acquired Pneumonia(CAP) Hospital-Acquired (Nosocomial) Pneumonia (HAP)...

INFECTIOUS AND INFLAMMATORY DISORDERS INFECTIOUS DISORDERS OF ADULTS  PNEUMONIA Inflammation of the lung parenchyma caused by a microbial agent CLASSIFICATION Community-Acquired Pneumonia(CAP) Hospital-Acquired (Nosocomial) Pneumonia (HAP) Pneumonia in the Immuno-Compromised Host Aspiration Pneumonia  COMMUNITY-ACQUIRED PNEUMONIA Occurs either in the community setting or within the first 48 hours after hospitalization or institutionalization S. Pneumoniae(pneumococcus) is the most common cause of CAP in people younger than 60 y/o without co-morbidity and in those 60 years and older with co-morbidity H. Influenzae causes a type of CAP that frequently affects elderly people and those with co-morbid illnesses  HOSPITAL-ACQUIRED PNEUMONIA Also known as nosocomial pneumonia Onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission Associated with high mortality rate, in part because of the virulence of the organisms, their resistance to antibiotics, and the patient’s underlying disorder  VENTILATOR- ASSOCIATED PNEUMONIA Considered a type of nosocomial pneumonia that is associated with endotracheal intubation and mechanical ventilation Bacterial pneumonia that develops in patients with acute respiratory failure who have been receiving mechanical ventilation for at least 48 hours  PNEUMONIA IN THE IMMUNOCOMPROMISED HOST cortecosteroids or other Chemotherapy nutritional use of broad spectrum immunosuppressive antimicrobial agents agents depletion acquired immunodeficiency genetic immune long term advanced disorders life support technology syndrome(AIDS)  ASPIRATION PNEUMONIA Refer to the Most common May occur in pulmonary form is bacterial the community consequences infection from or hospital resulting from the aspiration of setting entry of bacteria that endogenous or normally reside in exogenous the upper airways substances into the lower airway RISK FACTORS & PREVENTIVE MEASURES RISK FACTORS AND PREVENTIVE MEASURES RISK FACTORS AND PREVENTIVE MEASURES  CLINICAL MANIFESTATIONS Fever and chills Nonproductive to productive cough Dyspnea, Tachypnea, Orthopnea Tachycardia Pleuritic pain Diaphoresis Rusty, blood-tinged sputum  CLINICAL MANIFESTATIONS Headache Fatigue Bronchial breath sounds over affected area Whispered pectoriloquy Increased tactile fremitus over affected area Dull upon percussion Unequal lung expansion  DIAGNOSTIC TESTS History Blood culture Chest X-ray Sputum examination  Provides specific PREVENTION prevention against pneumococcal pneumonia and other infections caused by S. Pneumococcal vaccine pneumoniae Given to the following: People 65y/o and above Immunocompetent people who are at increased risk for illness and death associated with pneumococcal disease because of chronic illness People with functional or anatomic asplenia People living in environment in which the risk of the disease is high Immunocompromised people at risk for infection  MEDICAL MANAGEMENT Oxygen administration Antipyretics Antitussives Decongestants Antihistamines Antibiotic therapy  NURSING MANAGEMENT Improve airway patency Promote rest and conserve energy Maintain nutrition Promote knowledge Monitor and manage potential complications  PULMONARY TUBERCULOSIS An infectious disease that primarily affects the lung parenchyma May also be transmitted to other parts of the body including the meninges, kidneys, bones, and lymph nodes Primary infectious agent is Mycobacterium tuberculosis Closely associated with poverty, malnutrition, overcrowding, substandard housing, and inadequate health care MODE OF TRANSMISSION Spreads from person to person by airborne transmission  Any person without adequate health care Immigration from countries with a RISK high prevalence of TB (southeastern FACTORS Asia, Africa, Latin America, Caribbean) Institutionalization HIV infected individual/ immunocompromised Underweight/Undernourished persons With pre-existing medical condition Substance abusers Close contact with active TB/ health care workers  CLINICAL MANIFESTATIONS Low grade fever with Hemoptysis night sweats Weight loss Anorexia Dyspnea Fatigability Anemia Body malaise Back pains Amenorrhea Cough Chest pain  DIAGNOSTIC TESTS Chest x-ray Acid-fast bacillus smear Sputum culture QuantiFERON-TB Gold Test Tuberculin skin test (Mantoux method)  Tuberculin skin test (Mantoux method)- standardized intracutaneous injection procedure  MANTOUX TEST INTERPRETATION INDURATION OF > 5mm is INDURATION OF 0-4MM: CONSIDERED POSITIVE IN: Not significant (does not HIV advanced persons exclude TB infection or Recent contacts with TB disease, because patients case patients who are immunosuppressed People with fibrotic changes cannot develop an immune on chest radiograph response that is adequate to consistent with TB produce a positive skin test. Patients with organ transplant and immunosuppressed patient  MANTOUX TEST INTERPRETATION INDURATION OF > 10MM IS CONSIDERED INDURATION OF > 15mm IS CONSIDERED POSITIVE IN: POSITIVE IN: Recent immigrants from countries with Persons with no known risk high prevalence of TB Injection drug users factor to TB Residents and employees of: prisons or jails, long term facilities for elderlies, health care facilities, HIV residential facilities, homeless shelters Persons with the following conditios: silicosis, DM, CRF, some hematologic disorders, soma malignancies, weight loss of 10% of ideal body weight, gastrectomy, jejunoileal bypass Children under 5 years of age Children and adolescents exposed to adults at high risk for developing TB  CLASSIFICATION Class 0- no exposure, no infection Class 1- exposure, no evidence of infection Class 2- latent infection, no disease (positive PPD reaction but no clinical evidence of active TB) Class 3- disease, clinically active Class 4- disease, not clinically active Class 5- suspected disease, diagnosis pending  GERONTOLOGICAL CONSIDERATION Atypical manifestations in elderly patients: Altered mental status Fever Anorexia Weight loss Tuberculin skin test produces no reaction or delayed reactivity for up to 1 week for most patients FIRST-LINE ANTITUBERCULOSIS MEDICATIONS FIRST-LINE ANTITUBERCULOSIS MEDICATIONS FIRST-LINE ANTITUBERCULOSIS MEDICATIONS DRUG REGIMEN FOR TUBERCULOSIS  NURSING Promote airway MANAGEMENT clearance Advocate adherence to treatment regimen Promote activity and adequate nutrition Prevent spread of infection  PREVENTIVE MEASURES Prompt diagnosis and treatment of infectious cases BCG vaccination of newborn, infants and grade 1 or school entrants Educate the public in mode of spread and method of control and the importance of early diagnosis Improve social conditions, which increase the risk of becoming infected, such as overcrowding Maintain good personal and environmental hygiene Adopt a healthy lifestyle  PREVENTIVE MEASURES Keep hands clean and wash hands properly. Cover nose and mouth while sneezing or coughing and dispose of nasal and mouth discharge properly. Seek treatment promptly if symptoms similar to tuberculosis appear, particularly persistently cough for more than one month. Receive BCG immunization according to immunization schedule  MILIARY TB Spread or dissemination of TB infection to nonpulmonary sites of the body Result of invasion of the bloodstream by the tubercle bacillus from late reactivation of a dormant infection in the lung or elsewhere  VIRAL HEPATITIS A systemic, viral infection in which necrosis and inflammation of liver cells produce a characteristic cluster of clinical, biochemical, and cellular changes Five definitive types of viral hepatitis: hepatitis A, B, C, D, and E. HEPATITIS A VIRUS (HAV) Formerly called infectious hepatitis Caused by an RNA virus of the Enterovirus family  HEPATITIS A VIRUS (HAV) Fecal–oral route Mode of transmission Can be transmitted during sexual activity More prevalent in developing countries Incubation period is estimated to be or in areas with overcrowding and poor 15 to 50 days, with an average of 30 sanitation days  HEPATITIS A VIRUS (HAV) Anorexia Jaundice and dark urine CLINICAL Indigestion MANIFESTATIONS Strong aversion to the taste of cigarettes or smell of cigarette smoke and other strong odors Moderately enlarged liver and spleen HEPATITIS A VIRUS (HAV) Conscientious individual hygiene Safe practices for preparing and dispensing food Effective health supervision of schools, dormitories, extended care facilities, barracks, and camps Community health education programs Mandatory reporting of viral hepatitis to local health departments Vaccination (HAV vaccines include Havrix and Vagta)  HEPATITIS A VIRUS (HAV) MANAGEMENT Bed rest Small, frequent meals. Restrict fat intake. Monitor fluid balance If anorexia and nausea and vomiting persist, enteral feedings may be necessary. Instruct patient to abstain from alcohol during acute illness and for 6 months after recovery. Advise patient to avoid substances that may affect liver function  HEPATITIS B VIRUS (HBV) Liver infection caused by the hepatitis B virus Transmitted primarily through blood (percutaneous and permucosal routes) Also transferred from carrier mothers to their babies MODE OF TRANSMISSION Has a long incubation period. It replicates in the liver and remains in the serum for relatively long periods  HEPATITIS B VIRUS (HBV) CLINICAL MANIFESTATIONS Fever Arthralgias Loss of appetite Rashes Dyspepsia Jaundice Abdominal pain Liver may be tender and Generalized aching enlarged Malaise Spleen is enlarged and palpable Posterior cervical lymph nodes may also be enlarged HEPATITIS B VIRUS (HBV) DIAGNOSTIC TESTS HBsAg anti-HBc anti-HBs HBeAg HBV DNA anti-Hbe  HEPATITIS B VIRUS (HBV) Frequent exposure to blood, blood products, or other body fluids Health care workers: hemodialysis staff, oncology and chemotherapy nurses, personnel at risk for needlesticks, operating room staff, respiratory therapists, surgeons, dentists Hemodialysis Male homosexual and bisexual activity IV/injection drug use Close contact with carrier of HBV Travel to or residence in area with uncertain sanitary conditions Multiple sexual partners Recent history of sexually transmitted disease Receipt of blood or blood products  HEPATITIS B VIRUS (HBV) Continued screening of blood donors Use of disposable syringes, needles, and lancets and the introduction of needleless IV administration systems Universal Precaution ACTIVE IMMUNIZATION: HEPATITIS B VACCINE PASSIVE IMMUNITY: HEPATITIS B IMMUNE GLOBULIN  HEPATITIS B VIRUS (HBV) Medical Management NURSING MANAGEMENT Alpha interferon Bed rest Antiviral agents (lamivudine Restrict activities until the hepatic [Epvir] and adefovir [Hepsera]) enlargement and elevated levels of serum bilirubin and liver enzymes Antacids and antiemetics have disappeared Maintain adequate nutrition; proteins are restricted when the liver’s ability to metabolize protein byproducts is impaired  HEPATITIS C VIRUS (HCV) Formerly referred to as non-A, non-B hepatitis, or NANB hepatitis Transmitted through blood transfusions and sexual contact, other parenteral means, such as sharing contaminated needles by IV/injection drug users and unintentional needlesticks and other injuries in health care workers. Incubation period is variable and may range from 15 to 160 days  HEPATITIS C VIRUS (HCV) CLINICAL MANIFESTATIONS Similar to hepatitis B MANAGEMENT Increased risk of chronic liver disease, including Interferon cirrhosis or liver cancer (Intron-A) and Ribavirin (Rebetol)  HEPATITIS D VIRUS (HDV) Hepatitis D (delta agent) occurs in some cases of hepatitis B The incubation period varies between 21 and 140 days The symptoms of hepatitis D are similar to those of hepatitis B, except that patients are more likely to develop fulminant hepatitis and to progress to chronic active hepatitis and cirrhosis.  HEPATITIS E VIRUS (HEV) Believed to be transmitted by the fecal–oral route, principally through contaminated water The incubation period is estimated to range between 15 and 65 days. Has a self-limiting course with an abrupt onset Jaundice is nearly always present. Chronic forms do not develop.  HEPATITIS G (HGV) AND GB VIRUS-C Chronic liver disease which remains cryptogenic They are two different isolates of the same virus Half the patients have previously received transfusions Incubation period for post-transfusion hepatitis is 14 to 145 days Risk factors are similar to those for hepatitis C. There is no clear relationship between GBV-C/HGV infection and progressive liver disease.  AUTOIMMUNE HEPATITIS Results from an abnormal immune system response AUTOIMMUNE HEPATITIS CLINICAL MANIFESTATIONS  AUTOIMMUNE HEPATITIS MANAGEMENT Administration of corticosteroids and immune-modulating agents (azathioprine or 6-mercaptopurine) Liver transplant  TOXIC HEPATITIS Results from exposure to hepatotoxic chemicals Resembles viral hepatitis in onset TOXIC HEPATITIS CLINICAL MANIFESTATIONS Anorexia, nausea, and vomiting Jaundice and hepatomegaly Clotting abnormalities Delirium, coma, and seizures TOXIC HEPATITIS MANAGEMENT Fluid and electrolyte balance Blood replacement Comfort and supportive measures Liver transplantation  DRUG-INDUCED HEPATITIS Although any medication can affect liver function, use of acetaminophen has been identified as the leading cause of acute liver failure Others commonly associated with liver injury include but are not limited to anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and anti-tuberculosis agents. DRUG-INDUCED HEPATITIS CLINICAL MANIFESTATIONS Chills, fever Pruritus Arthralgia Anorexia, and nausea Jaundice and dark urine Enlarged and tender liver DRUG-INDUCED HEPATITIS MANAGEMENT Short course of high-dose corticosteroids Liver transplantation is an option for drug-induced hepatitis, but outcomes may not be as successful as with other causes of liver failure.  GUILLAIN-BARRÉ SYNDROME An autoimmune attack of the peripheral nerve myelin which results in acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia, hyporeflexia, and paresthesias. In 66% of cases, there is a predisposing event, most often a respiratory or gastrointestinal infection, although vaccination, pregnancy, and surgery have also been identified as antecedent events CLINICAL Muscle weakness and diminished reflexes of the lower extremities. MANIFESTATIONS Hyporeflexia and weakness progress and may result in quadriplegia. Paresthesias of the hands and feet Respiratory failure Blindness – due to optic nerve demyelination Inability to swallow or clear secretions – due to demyelination of glossopharyngeal and vagus nerve Instability of the cardiovascular system – due to vagus nerve demyelination  DIAGNOSTIC TESTS Lumbar puncture Evoked potential studies  Medical Management Respiratory therapy or mechanical ventilation Anticoagulant Thigh-high elastic compression stockings or sequential compression boots Plasmapheresis and IVIG  NURSING MANAGEMENT Maintain respiratory function Provide adequate nutrition Enhance physical mobility Improve communication Decrease fear and anxiety Monitor and manage potential complications SEXUALLY TRANSMITTED INFECTION TRICHOMONIASIS A sexually transmitted infection (STI) caused by the protozoan parasite, Trichomonas vaginalis (T. vaginalis)  Vaginal discharge that is thin(sometimes frothy), yellow Vulvitis with vulvovaginal to yellow-green, malodorous, burning or itching and very irritating CLINICAL MANIFESTATIONS Vaginal and cervical erythema pH testing of a trichomonal with multiple small petechae discharge will demonstrate a pH (strawberry spots) greater than 4.5 DIAGNOSTIC TESTS Wet mount microscopy and staining Culture and sensitivity Nucleic acid amplification test (NAAT)  MEDICAL NURSING MANAGEMENT MANAGEMENT Relieve Metronidazole discomfort Reduce anxiety Prevent reinfection or spread of infection  HUMAN PAPILLOMAVIRUS Most common sexually transmitted disease (STD) among young, sexually active persons More than 80 strains exist, some of which are associated with cervical abnormalities, including dysplasia and cancer.  CLINICAL MANIFESTATIONS Strains 6 and 11, usually cause condylomata Strains 16, 18, 31, 33, 35, and 45 may cause cervical changes that may appear as koilocytosis on Pap smear  MEDICAL MANAGEMENT Topical application of trichloroacetic acid, Interferon injections podophyllin, Bleomycin Electrocautery and Laser therapy, Cryotherapy, Regular Pap smears Surgical excision Podofilox (Condylox) Imiquimod (Aldara)  PREVENTION HPV vaccines 9-valent HPV vaccine (Gardasil 9, 9vHPV) Quadrivalent HPV vaccine (Gardasil, 4vHPV) Bivalent HPV vaccine (Cervarix, 2vHPV)  HERPES VIRUS TYPE 2 INFECTION (HERPES GENITALIS, HERPES SIMPLEX VIRUS) Is a recurrent, life-long viral infection that causes herpetic lesions on the cervix, vagina, and external genitalia Recurrences are often associated with stress, sunburn, dental work, or inadequate rest or nutrition  CLINICAL MANIFESTATIONS Itching and pain Blister, which later coalesces, ulcerates, and encrusts Influenza-like symptoms Inguinal lymphadenopathy Dysuria Complications may arise from extragenital spread, such as to the buttocks, upper thighs, or even the eyes DIAGNOSTIC TEST Smears and scrapings from the lesions are examined microscopically using special stains to confirm the clinical impression  Medical Antiviral agents - Acyclovir (Zovirax), Valacyclovir (Valtrex),and Famciclovir Management (Famvir) Relieve pain NURSING Prevent infection and its spread Relieve anxiety MANAGEMENT Increase knowledge about the disease  CHLAMYDIA The most common and fastest-spreading bacterial STI Causative microorganism is bacterium Chlamydia trachomatis Spread by sexual intercourse or genital contact without penetration Chlamydial infections also can be spread to the eyes by autoinoculation Untreated chlamydia can cause sterility in infected women; infected pregnant women can transmit the microorganism to their infants during birth.  CLINICAL MANIFESTATIONS Sparse, clear urethral discharge Redness and irritation of the infected tissue Burning on urination Lower abdominal pain in women, and testicular pain in men  Antimicrobial drugs, such as a single oral dose of azithromycin (Zithromax) or a Medical 7-day regimen of doxycycline Management (Vibramycin) Erythromycin (E-Mycin), Ofloxacin (Floxin), or Levofloxacin (Levaquin) Obtain a sexual history Follow precautions for preventing Nursing infection transmission Management Explain the course of treatment Discuss methods for preventing transmission and reinfection  GONORRHEA The most common causes of endocervicitis Caused by a bacterium, Neisseria gonorrhoeae Microorganism invades the urethra, vagina, rectum, or pharynx, depending on the nature of sexual contact Chlamydial infection and gonorrhea often coexist Highest incidence occurs in the 15- to 24-year-old age group also a major cause of PID, tubal infertility, ectopic pregnancy, and chronic pelvic pain  CLINICAL MANIFESTATIONS White or yellow vaginal discharge, intermenstrual bleeding in women Urethritis with a purulent discharge and pain on urination and epididymitis in men Painful bowel elimination and purulent rectal discharge if with anal infection Sore throat when the pharynx is infected Skin rash, fever, and painful joints If the microorganism disseminates throughout the body Fifty percent of women with gonorrhea have no symptoms, but without treatment 40% may develop PID DIAGNOSTIC TESTS Gram stain Culture  MANAGEMENT Hospitalization Single and treatment Single dose of intramuscular with IV oral azithromycin dose of a (Zithromax) or multiple-drug broad-spectrum oral doxycycline therapy- for Cephalosporin (Vibramycin)for 7 complicated or oral dosing to 10 days. gonococcal with Cefixime infections  SYPHILIS Causative microorganism is Treponema Pallidum Transmitted through sexual contact, direct contact from the lesion, or across the placenta to an unborn infant. Only infectious during the primary and secondary stages  CLINICAL MANIFESTATIONS chancre appears on the genitals, anus, cervix, or other parts of the PRIMARY body fever, malaise, rash, headache, sore throat, and lymph node SECONDARY enlargement tabes dorsalis , ataxia, Charcot’s joints Cardiovascular complications include aortic aneurysm and aortic valve TERTIARY insufficiency DIAGNOSTIC EXAMINATIONS chancre Microscopic examination of scrapings from the chancre Rapid plasma reagin (RPR) on blood serum Venereal Disease Research Laboratory (VDRL) test Fluorescent treponemal antibody absorption test (FTA-ABS).  MEDICAL MANAGEMENT PRIMARY AND TERTIARY SECONDARY Single dose of 3 doses of parenterally penicillin at 1 week administered intervals penicillin G 14-day regimen of tetracycline or doxycycline (if allergic to penicillin)  NURSING MANAGEMENT Gather health information, sexual history and allergic history Prepare the client for diagnostic laboratory tests Support the client emotionally AGENTS USED TO TREAT STI AGENTS USED TO TREAT STI AGENTS USED TO TREAT STI AGENTS USED TO TREAT STI  EBOLA Cause by Ebola viruses Severe and often deadly illness Feared for potential use as biological weapon Incubation period ranges from 2 to 21 days, with an average of 8 to 10 days CLASSIFICATION OF EBOLA VIRUS SPECIES Sudan ebolavirus & Zaire ebolavirus Ivory Coast ebolavirus Reston ebolavirus Bundibugyo ebolavirus MODE OF TRANSMISSION CLINICAL MANIFESTATIONS  DIAGNOSTIC EXAMINATION Real-time polymerase chain reaction (RT-PCR) IgM-capture ELISA IgG-capture ELISA Rapid Ebola antigen tests  MEDICAL MANAGEMENT SYMPTOMATIC AND SUPPORTIVE Isolation Oxygen Fluid substitution Broad spectrum antibiotics Antipyretics and analgesics Ebola Zaire vaccine (Ervebo) - vaccine approved in the United States and Europe for the prevention of disease caused by Zaire ebolavirus in patients aged 18 years or older NURSING MANAGEMENT Prevent bleeding Restore normal fluid and electrolyte balance Prevent shock Relieve pain Restore normal fluid volume  Middle East respiratory syndrome coronavirus (MERS-CoV) Viral respiratory disease caused by a novel coronavirus that was first identified in Saudi Arabia The zoonotic virus is transferred to humans from infected dromedary camels  CLINICAL MANIFESTATIONS Fever Cough Rhinorrhea Diarrhea Pulmonary findings, including hypoxemia, rhonchi, and rales (some patients may have a normal auscultation) Tachycardia Shortness of breath Hypotension - may occur with severe illness DIAGNOSTIC EXAMINATION rRT-PCR assay Serologic testing Imaging studies MEDICAL MANAGEMENT Hydration Antipyretic Analgesics Respiratory support Antibiotics  NURSING MANAGEMENT Monitor vital signs Educate the patient and folks Reduce increase in temperature Ensure patent airway Reduce anxiety  H1N1 Also known as swine flu A type of influenza A virus One of several flu virus strains that can cause the seasonal flu  CLINICAL MANIFESTATIONS Cough Headache Fever Chills Sore throat Fatigue Stuffy or runny nose Diarrhea Body aches Nausea and vomiting  COMPLICATIONS Worsening of chronic conditions Pneumonia Respiratory failure  High risk of flu complications People who are in a hospital, nursing home or other long-term care facility Younger than 5 years of age, particularly children younger than 2 years 65 years old or older Pregnant or within two weeks of delivery, including women who have had pregnancy loss. Younger than 19 years of age and are receiving long-term aspirin therapy Have a body mass index above 40 Have certain chronic medical conditions Immunosuppressed American Indian or Alaska Native heritage  DIAGNOSTIC EXAMINATION Polymerase chain reaction (PCR) Chest radiography  MANAGEMENT Oseltamivir (Tamiflu) Peramivir (Rapivab) Zanamivir (Relenza)  PREVENTION Annual flu vaccination for everyone age 6 months or older  PREVENTION Wash hands thoroughly and frequently Cover mouth or nose when coughing and sneezing Avoid touching face Clean surfaces Stay away from crowds if possible INFLAMMATORY DISORDERS OF BODY SYSTEMS GASTROINTESTINAL SYSTEM Appendicitis Peritonitis Crohn’s disease Ulcerative colitis Cholecystitis Pancreatitis  APPENDICITIS Appendix becomes inflamed and edematous as a result of either becoming kinked or occluded by a fecalith. can occur at any age but is most common in adolescents and young adults  Clinical Manifestations Vague epigastric or periumbilical pain which progresses to right lower quadrant and is usually accompanied by a low-grade fever and nausea and sometimes by vomiting Local tenderness elicited at McBurney’s point Rebound tenderness Rovsing’s sign Loss of appetite Constipation If the appendix has ruptured, the pain becomes more diffuse; abdominal distention develops as a result of paralytic ileus Fever of 37.7°C (100°F) or higher, a toxic appearance, and continued abdominal pain or tenderness if perforation occurs  MEDICAL MANAGEMENT NURSING MANAGEMENT Appendectomy Prepare the patient for surgery Nasogastric tube If there is evidence Antibiotics or likelihood of paralytic ileus Intravenous fluids Semi-fowler’s position after surgery Discharge teaching - make an appointment to have the surgeon remove the sutures between the fifth and seventh days after surgery. Incision care and activity guidelines are discussed; normal activity can usually be resumed within 2 to 4 weeks. Potential Complications and Nursing Interventions After Appendectomy Potential Complications and Nursing Interventions After Appendectomy  PERITONITIS Inflammation of the peritoneum  External sources such as injury ortrauma or an inflammation thatextends from an M n - wi ay i o , organ outside the th als t c oli s, ab o b e peritoneal area p l i nf c u i a te as. pe roc dom e as a h ri ric Pro on rit ed in so e t he a, m on ur al cia c ea es sur te Ba Esc siell udo l d an gi d ial d cal l eb se ys K dP is an CAUSES  Clinical Manifestations Diffuse type of pain that tends to become constant, localized, and more intense near the site of the inflammation Distended abdomen Rebound tenderness and paralytic ileus Nausea and vomiting Diminished peristalsis Increase temperature and pulse rate Elevated leukocyte count  ABDOMINAL X-RAY DIAGNOSTIC EXAMINATION CT SCAN Peritoneal aspiration and culture and sensitivity studies of the aspirated fluid  Administration of several liters of isotonic solution Analgesics Antiemetics Intestinal intubation and suction Oxygen therapy Massive antibiotic therapy Surgery  Nursing Management Report the nature of the pain Administer analgesic medication Position the patient for comfort - placed on the side with knees flexed Record intake and output and central venous pressure Observe and record the character of the drainage postoperatively  REGIONAL ENTERITIS (CROHN’S DISEASE) Also called granulomatous colitis, ileitis, and regional enteritis Commonly occurs in adolescents or young adults but can appear at any time of life More common in women, and it occurs frequently in the older population (between the ages of 50 and 80) Can occur anywhere along the GI tract but the most common areas are the distal ileum and colon More prone to this disorder include those with a family history of the disease, those who are white with a European and/or Jewish ancestry Seen two times more often in patients who smoke than in non smokers Characterized by periods of remissions and exacerbations  CLINICAL MANIFESTATIONS Prominent lower right quadrant abdominal pain unrelieved by defecation Chronic diarrhea Crampy abdominal pains after meals Weight loss Nutritional deficiency and secondary anemia Steatorrhea Abscesses, fistulas, and fissures Symptoms extend beyond the GI tract and commonly include joint involvement, skin lesions, ocular disorders , and oral ulcers.  DIAGNOSTIC EXAMINATION Proctosigmoidoscopic examination Stool examination Barium study of the upper GI tract Endoscopy and intestinal biopsy CT scan CBC  Complications Intestinal obstruction or stricture formation Perianal disease Fluid and electrolyte imbalances Malnutrition Fistula and abscess formation. Colon cancer  ULCERATIVE COLITIS Recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum It is a serious disease, accompanied by systemic complications and a high mortality rate Peak incidence is between 30 and 50 years of age. Exact cause is unknown Multiple factors trigger ulcerative colitis, including genetic predisposition, infection, allergy, and abnormal immune response. The clinical course is usually one of exacerbations and remissions CLINICAL MANIFESTATIONS Lower left quadrant abdominal pain Rebound tenderness in the right lower quadrant Intermittent tenesmus Rectal bleeding Feeling of an urgent need to defecate Passage of 10 to 20 liquid stools each day Anorexia Weight loss Fever Vomiting Dehydration Extraintestinal symptoms include skin lesions , eye lesions, joint abnormalities and liver disease.  DIAGNOSTIC EXAMINATION Sigmoidoscopy or colonoscopy Barium enema CT scanning, magnetic resonance imaging, ultrasound Leukocyte scanning Stool examination  Complications Toxic megacolon Perforation and bleeding Vascular engorgement Osteoporotic fractures Management of Chronic Inflammatory Bowel Disease PHARMACOLOGIC SURGICAL MANAGEMENT THERAPY Sedatives Total colectomy and ileostomy Antidiarrheal Proctocolectomy with ileostomy Antiperistaltic Strictureplasty Aminosalicylate Intestinal transplant Corticosteroids Immunomodulators  NURSING MANAGEMENT Maintain normal elimination pattern Relieve pain Maintain fluid intake Maintain optimal nutrition Promote rest Reduce anxiety TOPICS TO INCLUDE WHEN TEACHING ABOUT IBD Comply with special dietary modifications Know the name, purpose, dosage, and adverse effects of prescribed drugs Use medications to control symptoms rather than cure the disease. Keep all follow-up physician and laboratory appointments Use proper techniques for rectal hygiene and skin care Know signs to report immediately to the physician Have regular medical checkups, even when symptoms subside DIFFERENCES BETWEEN CROHN’S DISEASE AND ULERATIVE COLITIS DIFFERENCES BETWEEN CROHN’S DISEASE AND ULERATIVE COLITIS  CHOLECYSTITIS Inflammation or infection of the gallbladder Calculous cholecystitis Two major types of gallstones: those -gallbladder stone obstructs composed predominantly of pigment and bile outflow those composed primarily of cholesterol Acalculous cholecystitis - Occurs after major surgical procedures, severe trauma, or gallbladder inflammation burns Other factors : torsion, cystic duct obstruction, primary in the absence of obstruction bacterial infections of the gallbladder, and multiple blood by gallstones transfusions.  CLINICAL MANIFESTATIONS Pain and biliary colic - pain, tenderness, and rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with nausea and vomiting Epigastric distress following a meal rich in fried or fatty foods Jaundice Changes in urine and stool color Vitamin deficiency Empyema of the gallbladder if the gallbladder becomes filled with purulent fluid DIAGNOSTIC EXAMINATION Abdominal Xray Ultrasonography Radionuclide Imaging or Cholescintigraphy Cholecystography Endoscopic Retrograde Cholangiopanceatography Percutaneous Transhepatic Cholangiography  MANAGEMENT NUTRITIONAL AND SUPPORTIVE THERAPY Rest Intravenous fluids Nasogastric suction Low-fat liquids PHARMACOLOGIC THERAPY Ursodeoxycholic acid (UDCA) Chenodeoxycholic acid (chenodiol or CDCA) Analgesic Antibiotic agents  MANAGEMENT NONSURGICAL REMOVAL OF GALLSTONES Dissolving Gallstones Stone Removal by Instrumentation Extracorporeal Shock-Wave Lithotripsy Intracorporeal Lithotripsy SURGICAL REMOVAL OF GALLSTONE Cholecystectomy Mini-cholecystectomy Choledochostomy Surgical Cholecystostomy Percutaneous Cholecystostomy  PANCREATITIS Inflammation of the pancreas May be acute or chronic with a long history of relapse and recurrences  ACUTE PANCREATITIS Self-digestion of the pancreas by its own CAUSE proteolytic enzymes, principally trypsin Attacks of acute pancreatitis may result incomplete recovery, may recur without permanent damage, or may progress to chronic pancreatitis Mild acute pancreatitis - Severe acute characterized by edema and pancreatitis- characterized by inflammation more widespread and complete confined to the pancreas enzymatic digestion of the gland  CLINICAL MANIFESTATIONS Pain that occurs in the mid - epigastrium occurring 24 to 48 hours after a very heavy meal or alcohol ingestion Abdominal distention Poorly defined, palpable abdominal mass Decreased peristalsis Hypotension Bulky, pale, and foul-smelling stool Respiratory distress Ecchymosis in the flank or around the umbilicus - may indicate severe pancreatitis  DIAGNOSTIC EXAMINATION Blood tests - Hematocrit and hemoglobin, WBC, serum amylase and lipase, bilirubin, serum cal cium level, blood glucose X-ray studies of the abdomen and chest Ultrasound and contrast-enhanced computed tomography scans MEDICAL MANAGEMENT NPO Parenteral nutrition Nasogastric suction Histamine-2 (H2) antagonists Antiemetic agents Meperidine Biliary drainage Surgical intervention  POST-ACUTE MANAGEMENT Antacids Oral feedings low in fat and protein Caffeine and alcohol are eliminated from the diet If the episode of pancreatitis occurred during treatment with thiazide diuretics, corticosteroids, or oral contraceptives, these medications are discontinued.  NURSING MANAGEMENT Relieve pain and discomfort Improve breathing pattern Improve nutritional status Improve skin integrity Monitor and manage potential complications  CHRONIC PANCREATITIS An inflammatory disorder characterized by progressive anatomic and functional destruction of the pancreas Alcohol consumption in Western societies and malnutrition worldwide are the major causes of chronic pancreatitis  Clinical Manifestations Recurring attacks of severe upper abdominal and back pain, accompanied by vomiting Weight loss Steatorrhea Calcium stones may form within the ducts  DIAGNOSTIC EXAMINATION ERCP Magnetic resonance imaging, computed tomography, and ultrasound Glucose tolerance test Serum amylase levels and the white blood cell count  Management Endoscopy to remove pancreatic duct stones and stent strictures Pancreaticoduodenectomy Pancreaticojejunostomy (also referred to as Roux-en-Y) Partial or total pancreatectomy Pancreatic autotransplantation URINARY SYSTEM Cystitis Urolithiasis  CYSTITIS Inflammation of the urinary bladder Usually caused by a bacterial infection  CLINICAL MANIFESTATIONS Frequent pain and burning on urination Urgency Low back pain Dysuria Perineal and suprapubic pain Hematuria Fever and chills In patients with complicated UTIs, manifestations can range from asymptomatic bacteriuria to a gram-negative sepsis with shock  DIAGNOSTIC EXAMINATION Culture and sensitivity studies If repeated episodes occur, intravenous pyelogram (IVP) or cystoscopy with or without retrograde pyelograms  MEDICAL MANAGEMENT NURSING MANAGEMENT Antibacterial agent - single-dose Apply heat to the perineum administration, short-course (3 Encourage to drink liberal to 4 days) medication regimens, amounts of fluids or 7- to 10-day therapeutic courses Encourage frequent voiding Periodic monitoring of renal function for patients with repeated UTIs Advise cranberry juice or vit. C  Client and Family Teaching to Prevent Cystitis Increase fluid intake to 2 to 3 L a Void every 2 to 3 hours while day. awake. Avoid coffee, teas, colas, and Empty bladder completely with alcohol. each voiding. Shower rather than bathe in a tub. Void after sexual intercourse. Cleanse perineum after each bowel Notify physician of the following: movement with front to- back urgency, frequency, burning with motion. urination, difficulty urinating, or Avoid irritating substances blood in the urine. Wear cotton underwear Take medication exactly as prescribed  INTERSTITIAL CYSTITIS (IC) Chronic inflammation of the bladder mucosa More common in women than men CLINICAL MANIFESTATIONS Frequent, painful urination and passing a small volume of urine Painful intercourse DIAGNOSTIC EXAMINATION Cystoscopy Poiding cystourethrogram Biopsy of the bladder mucosa  Elmiron (pentosan polysulfate) Antidepressant drugs Advise the client to bladder instillation of avoid spicy and acidic DMSO (dimethyl foods sulfoxide) or silver nitrate. Psychological support Laser Urinary diversion  UROLITIASIS Refers to stones (calculi) in the urinary tract Stones may form in the bladder or originate in the upper urinary tract and travel to and remain in the bladder  Infection Factors that Increased favor the calcium formation Urinary concentration of stones stasis Immobility CLINICAL MANIFESTATIONS Stones in the Intense, deep ache in the costovertebral region Hematuria renal pelvis Pyuria Acute,excruciating, colicky, wavelike Stones lodged in pain, radiating down the thigh and to the genitalia the ureter Scanty urine Hematuria Stones lodged in Symptoms of irritation and may be associated with UTI and hematuria Urinary retention If the stone the bladder obstructs the bladder neck DIAGNOSTIC EXAMINATIONS KUB Blood chemistries 24-hour urine test Chemical analysis of the stone  MANAGEMENT Opioid analgesics Ureteroscopy ESWL Percutaneous nephrostomy or percutaneous nephrolithotomy Electrohydraulic lithotripsy Chemolysis  MANAGEMENT CALCIUM STONE Restrict calcium in the diet Liberal fluid intake Dietary sodium and protein restriction Cellulose sodium phosphate (Calcibind) Thiazide diuretics URIC ACID STONE Low purine diet  MANAGEMENT OXALATE STONE Limit oxalate intake Increase calcium intake Limit protein intake CYSTINE STONES Low protein diet Administer penicillamine REPRODUCTIVE SYSTEM Pelvic Inflammatory Disease Benign Prostatic Hypertrophy  PELVIC INFLAMMATORY DISEASE An inflammatory condition of the pelvic cavity Usually caused by bacteria but may be attributed to a virus, fungus, or parasite May involve the uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), pelvic peritoneum, or pelvic vascular system  CLINICAL MANIFESTATIONS Infectious malodorous discharge Backache, severe or aching abdominal and pelvic pain Bearing-down feeling Dyspareunia Menorrhagia Dysmenorrhea Fever Nausea and vomiting General malaise  DIAGNOSTIC EXAMINATION Culture and sensitivity test of the vaginal Discharge Ultrasonography Magnetic resonance imaging (MRI) Computed tomography (CT)  MEDICAL MANAGEMENT Broad-spectrum antibiotic therapy Intravenous (IV) fluids Antipyretics Nasogastric intubation and suction if the patient has abdominal distention or ileus Treat sexual partners A ruptured pelvic abscess requires emergency surgery  NURSING MANAGEMENT Position for comfort and limit unnecessary activity Provide diversional activities Wash the perineum well with soap and water every 4 hours Maintain on bed rest Monitor characteristics and amount of vaginal discharge Apply heat to abdomen Observe strict infection control  COMPLICATIONS Pelvic or generalized peritonitis Abscesses Strictures and fallopian tube obstruction Adhesions Bacteremia with septic shock Thrombophlebitis with possible embolization  BENIGN PROSTATIC HYPERPLASIA Enlargement of the prostate gland One of the most common pathologic conditions in older men  CLINICAL MANIFESTATIONS Frequency of urination Nocturia Hesitancy in starting urination Abdominal straining with urination Decrease in the volume and force of the urinary stream Dribbling Acute urinary retention Recurrent urinary tract infection  DIAGNOSTIC EXAMINATION Digital rectal examination (DRE) Cystoscopy Intravenous and retrograde pyelograms Blood chemistry tests Prostate-specific antigen (PSA) test Transrectal ultrasonography Urinalysis and urodynamic studies Renal function tests Complete blood studies  MEDICAL MANAGEMENT Immediate catheterization if patient cannot void Prostatectomy Transurethral incision of the prostate (TUIP) Balloon dilation Transurethral laser resection Transurethral needle ablation Microwave thermotherapy Watchful waiting Alpha-adrenergic receptor blockers Antiandrogen agents Saw palmetto AGENTS FOR BPH INVASIVE PROCEDURE FOR PROSTATIC ENLARGEMENT INVASIVE PROCEDURE FOR PROSTATIC ENLARGEMENT  NURSING MANAGEMENT Instruct the patient to: Void often and assist bladder emptying by leaning forward on toilet and ‘‘bearing down’’ (Valsalva maneuver), or pressing down on the bladder while seated on the toilet (Crede’s maneuver) Drink frequent small volumes of oral fluids Limit alcohol and caffeine Limit the use of cough, cold, or allergy medications containing decongestants Note any signs and symptoms of acute urinary obstruction and urinary infection IMMUNOLOGIC DISORDERS  MULTIPLE SCLEROSIS An Presents in young Geographic immune-mediate adults ages 20 to prevalence is highest in northern Europe, d progressive 40, and it affects southern Australia, demyelinating women the northern United disease of the morefrequently States,and southern CNS than men Canada  CLINICAL MANIFESTATIONS Fatigue Pain Depression Blurring of vision Weakness Diplopia, patchy blindness Numbness (scotoma) and total blindness Difficulty in coordination Spasticity Loss of balance DIAGNOSTIC EXAMINATION MRI Electrophoresis of CSF  MEDICAL MANAGEMENT “ABC (and R) drugs - beta-1a (Avonex), beta-1b (Betaseron), Glatiramer acetate (Copaxone), Rebif Mitoxantrone (Novantrone) Corticosteroids Baclofen Dantrolene Amantadine (Symmetrel), Pemoline (Cylert), or Fluoxetine (Prozac) NSAIDs  NURSING MANAGEMENT Promote physical mobility Prevent injury Enhance bladder and bowel control Manage speech and swallowing difficulties Improve sensory and cognitive function Improve self-care abilities PromotE sexual functioning  DIABETES MELLITUS Metabolic disease that causes high blood sugar Type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus) Classification Type 2 diabetes (previously referred to as non-insulin dependent diabetes mellitus) Gestational diabetes mellitus Diabetes mellitus associated with other conditions or syndromes  DM TYPE 1 Insulin-producing pancreatic Characterized by an acute beta cells are destroyed by onset, usually before age 30 an autoimmune process  CLINICAL MANIFESTATIONS “Three Ps”: polyuria, polydipsia, and polyphagia. Fatigue and weakness Sudden vision changes Tingling or numbness in hands or feet Dry skin Skin lesions or wounds that are slow to heal Recurrent infections. DIAGNOSTIC EXAMINATION Fasting plasma glucose (FPG) Urine Glucose Testing Glycosylated Hemoglobin DIAGNOSTIC TESTS FOR DETECTING GLUCOSE TOLERANCE FIVE COMPONENTS OF DIABETIC MANAGEMENT CATEGORIES OF INSULIN  Alternative Methods of Insulin Delivery INSULIN PENS JET INSULIN IMPLANTABLE INHALANT INJECTORS PUMPS INSULIN INSULIN DELIVERY DELIVERY Complications of Insulin Therapy Local or systemic allergic reactions Insulin lipodystrophy Insulin resistance Morning hyperglycemia TRANSPLANTATION OF PANCREATIC CELLS Transplantation of the whole pancreas or a segment of the pancreas is being performed on a limited population  NURSING MANAGEMENT TEACH PATIENT TO SELF-ADMINISTER INSULIN STORING INSULIN - Whether insulin is the short- or long-acting preparation, the vials not in use should be refrigerated and extremes of temperature should be avoided SELECTING SYRINGES - Syringes must be matched with the insulin concentration PREPARING THE INJECTION: MIXING INSULINS - the longer-acting insulins must be mixed thoroughly before use, regular insulin be drawn up first  NURSING MANAGEMENT SELECTING AND ROTATING THE INJECTION SITE - The four main areas for injection are the abdomen, arms thighs, and hips. Systematic rotation of injection sites within an anatomic area is recommended INSERTING THE NEEDLE - The correct technique is based on the need for the insulin to be injected into the subcutaneous tissue. Aspiration is generally not recommended with self-injection of insulin. FOOT CARE FOR DIABETICS  Acute Complications of Diabetes HYPOGLYCEMIA MILD MODERATE SEVERE HYPOGLYCEMIA HYPOGYCEMIA HYPOGLYCEMIA Sweating Inability to concentrate Disoriented Light headedness Tremors Confusion behavior Tachycardia Memory lapses Seizures Nervousness Numbness of the lips and tongue Difficulty Hunger Slurred speech arousing from Impaired coordination sleep Emotional changes Double vision Loss of Drowsiness consciousness Management for Hypoglycemia Three or four commercially prepared glucose tablets 4 to 6 oz of fruit juice or regular soda 6 to 10 Life Savers or other hard candies 2 to 3 teaspoons of sugar or honey  Acute Complications of Diabetes DIABETIC KETOACIDOSIS (DKA) DEHYDRATION AND ELECTROLYTE LOSS Caused by an absence or markedly HYPERGLYCEMIA ACIDOSIS inadequate amount of insulin. THREE MAIN CLINICAL FEATURES  Management of DKA Rehydration Restore electrolytes Reverse acidosis  Acute Complications of Diabetes HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNS) Serious condition in which hyperosmolarity and hyperglycemia predominate Occurs most often in older people (ages 50 to 70) with no known history of diabetes or with mild type 2 diabetes  Management of HHNS Fluid replacement Correction of electrolyte imbalances Insulin administration  OTHER COMPLICATIONS MACROVASCULAR COMPLICATIONS Myocardial infarction MICROVASCULAR COMPLICATIONS Coronary artery disease Multiple visual complications Nephropathy  ACUTE GLOMERULONEPHRITIS An inflammation of the glomerular capillaries Primarily a disease of children older than 2 years of age, but it can occur at nearly any age In most cases, group A betahemolytic streptococcal infection of the throat precedes the onset by 2 to 3 weeks May also follow impetigo and acute viral infections In some patients, antigens outside the body initiate the process  CLINICAL MANIFESTATIONS Hematuria Edema Proteinuria Hypertension Decrease BUN and serum Headache creatinine Malaise Anemia Flank pain Tenderness over the CVA  DIAGNOSTIC EXAMINATION Electron microscopy and immunofluorescent analysis Serial determinations of antistreptolysin O or anti-DNase B Titers Percutaneous renal biopsy  MEDICAL MANAGEMENT Penicillin - If residual streptococcal infection is suspected Corticosteroids and immunosuppressant Restriction of dietary protein - when renal insufficiency and nitrogen retention develop Restriction of sodium – when patient has hypertension, edema, and heart failure Loop diuretic medications Antihypertensive agents Oral iron supplements NURSING MANAGEMENT Liberal carbohydrate intake Measure Intake and output Bed rest - when blood pressure is elevated and edema is present  HYPERSENSITIVITY An abnormal, heightened reaction to any type of stimuli  Anaphylactic (Type I) Hypersensitivity Severe form of a hypersensitivity reaction Immediate reaction beginning within minutes of exposure to an antigen. Reaction is mediated by IgE antibodies rather than IgG or IgM antibodies This systemic reaction is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension  Cytotoxic (Type II) Hypersensitivity Occurs when the system mistakenly identifies a normal constituent of the body as foreign May be a result of a cross-reacting antibody, possibly leading to cell and tissue damage Involves the binding of either IgG or IgM antibody to the cellbound Antigen Associated with several disorders. Immune Complex (Type III) Hypersensitivity Involves immune complexes formed when antigens bind to antibodies Increase in vascular permeability and tissue injury Associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and some types of bacterial endocarditis  Cytotoxic (Type II) Hypersensitivity Also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen. Mediated by sensitized T cells and macrophages Symptoms include itching, erythema, and raised lesions MANIFESTATIONS OF ALLERGIC REACTIONS  DIAGNOSTIC EXAMINATION Smears of body secretions Skin tests Radioallergosorbent test (RAST) Complete blood count with differential Eosinophil count Total serum immunoglobulin E levels Provocative testing  Types of Skin Tests scratch or prick test patch test intradermal injection test scratching the skin applies a injects a dilute and applying a concentrated form solution of an small amount of of the substance to antigen the liquid test the skin and covers intradermally antigen to the the area with an scratch occlusive dressing  MANAGEMENT Desensitization A form of immunotherapy in which a person receives weekly or twice-weekly injections of dilute but increasingly higher concentrations of an allergen without interruption AGENTS TO TREAT ALLERGIC DISORDERS AGENTS TO TREAT ALLERGIC DISORDERS AGENTS TO TREAT ALLERGIC DISORDERS AGENTS TO TREAT ALLERGIC DISORDERS  PATIENT EDUCATION Never begin smoking, or quit if you are currently smoking if your allergy causes respiratory symptoms. Understand that treatment for chronic allergic disorders, may extend over several years. Follow the medical regimen as instructed by the physician. Do not overuse nose drops or sprays for nasal congestion. Use only prescribed or recommended drugs and only in the dosage suggested by the physician  PATIENT EDUCATION Keep a record of symptoms or lack of symptoms Keep a record of symptoms or absence of symptoms each time you add a new food to the diet Avoid environmental substances that cause allergic reactions Seek immediate medical attention if symptoms worsen or new symptoms occur.  PATIENT EDUCATION Carry identification, such as a Medic-Alert card or bracelet Do not miss an immunotherapy appointment Check prefilled syringes that contain epinephrine for an expiration date Keep the directions for use with the product  RHEUMATOID ARTHRITIS A systemic inflammatory disorder of connective tissue/joints characterized by chronicity, remissions, and exacerbations Incidence rate is approximately 3%, with a two to three times incidence in women Approximately 70% to 80% of people with RA have a substance called rheumatoid factor (RF)  PROCESS OF RA Increased capillary Vasodilation permeability and increased blood flow Synovial tissue experiences reactive hyperplasia Inflammatory process advances  PROCESS OF RA further inflammation Pannus forms and between joint structural margins changes Pannus destroys adjacent cartilage, joint Pannus capsule, and formation bone.  CLINICAL MANIFESTATIONS Joint pain, swelling, warmth, erythema, and lack of function Rheumatoid nodules Palpation of the joints reveals spongy or boggy tissue Deformities of the hands and feet Extra-articular features - fever, weight loss, fatigue, anemia, lymph node enlargement, and Raynaud’s phenomenon, arteritis, neuropathy, scleritis, pericarditis, splenomegaly, and Sjögren’s syndrome  DIAGNOSTIC EXAMINATION Radiographic films Arthrocentesis Arthroscopic examination C-reactive protein (CRP) test RF test Blood tests for anti-cyclic citrullinated peptide (anti-CCP) antibodies Erythrocyte sedimentation rate (ESR)  MEDICAL MANAGEMENT EARLY-STAGE RA Balance of rest and exercise Relaxation techniques, heat and cold applications Salicylates or NSAIDs, antimalarials, gold, penicillamine, or sulfasalazine, biologic response modifiers Methotrexate MODERATE, EROSIVE RA Occupational and physical therapy Cyclosporine  MEDICAL MANAGEMENT PERSISTENT, EROSIVE RA Reconstructive surgery and corticosteroids Synovectomy, tenorrhaphy, arthrodesis, arthroplasty ADVANCED, UNREMITTING RA Immunosuppressive agents Low-dose antidepressant medications Protein A Immunoadsorption is used in 12 weekly 2-hour apheresis treatments to bind IgG AGENTS OR RHEUMATOID ARTHRITIS AGENTS FOR RHEUMATOID ARTHRITIS AGENTS FOR RHEUMATOID ARTHRITIS AGENTS FOR RHEUMATOID ARTHRITIS  NURSING MANAGEMENT Calorie-restricted diet Encourage intake of foods high in vitamins, protein, and iron Encourage the client to move affected parts even during an acute episode  SYSTEMIC LUPUS ERYTHEMATOSUS A result of disturbed immune regulation that causes an exaggerated production of autoantibodies Brought about by some combination of genetic, hormonal and environmental factors Certain medications, such as hydralazine (Apresoline), procainamide (Pronestyl), isoniazid (INH), chlorpromazine (Thorazine), and some antiseizure medications, have been implicated in chemical or drug-induced SLE.  CLINICAL MANIFESTATIONS MUSKULOSKELTAL INTEGUMENTARY CARDIAC CNS Arthralgias Papulosquamous Atherosclerosis Subtle changes in Arthritis or annular Pericarditis behavior (synovitis polycyclic patterns or lesions, and cognitive ability. discoid lupus Depression erythematosus Psychosis Butterfly-shaped rash across the bridge of the nose and cheeks  DIAGNOSTIC EXAMINATION No single laboratory test confirms SLE Blood testing reveals moderate to severe anemia, thrombocytopenia, leukocytosis, or leukopenia and positive antinuclear antibodies. Other diagnostic immunologic tests support but do not confirm the diagnosis. Hematuria may be found on urinalysis  MEDICAL MANAGEMENT NSAIDs Corticosteroids Antimalarial medications Immunosuppressive agents (alkylating agents and purine analogs)  NURSING MANAGEMENT Teach to avoid exposure to sun and ultraviolet light or to protect themselves with sunscreen and clothing Routine periodic screenings Dietary recommendations  TRANSPLANT REJECTION A process in which a transplant recipient's immune system attacks the transplanted organ or tissue  TYPES OF REJECTION HYPERACUTE REJECTION Occurs a few minutes after the transplant when the antigens are completely unmatched ACUTE REJECTION May occur any time from the first week after the transplant to 3 months afterward CHRONIC REJECTION Can take place over many years  Types of transplant Autograft- transplant of tissue to the same person Allograft- transplant of an organ or tissue between two genetically non-identical members of the same species Isograft(synergic)- a subset of allografts from a donor to a genetically identical recipient Xenograft- a transplant of organ or tissue from one species to another  Finding an eligible donor-recipient match ABO blood group compatibility Tissue typing Cross matching Panel reactive antibody test Serology screening CLINICAL MANIFESTATIONS The organ's function may start to decrease General discomfort, uneasiness, or ill feeling Pain or swelling in the area of the organ (rare) Fever (rare) Flu-like symptoms, including chills, body aches, nausea, cough, and shortness of breath  DIAGNOSTIC EXAMINATION When organ rejection is suspected, one or more of the following tests may be done before the organ biopsy: Abdominal CT scan Chest x-ray Heart echocardiography Kidney arteriography Kidney ultrasound Lab tests of kidney or liver function  Management Cyclosporin Azathioprine Steroids Rapamycin Monoclonal antibodies  COMPLICATIONS Certain cancers Infections Loss of function in the transplanted organ/tissue Side effects of medicines  Subtypes HIV-1 Mutates easily and frequently, producing multiple substrains HIV-2 Less transmittable, and the interval between initial infection with HIV-2 and development of AIDS is longer  INFECTION AND REPLICATION When HIV encounters a helper T-cell lymphocyte, the binding protein gp120 fuses with the T cell’s receptor, called a CD4 receptor. Another binding protein, gp41, connects the HIV virus to either the T-cell’s co-receptors CCR5 or CXCR4. To replicate, HIV becomes a parasite of helper T cells. HIV alters the helper T cell’s genetic code to make more viral particles.  Stages of HIV Disease PRIMARY INFECTION HIV ASYMPTOMATIC (ACUTE HIV INFECTION (CDC CATEGORY A: OR ACUTE HIV MORE THAN 500 CD4+ SYNDROME) T LYMPHOCYTES/MM3) HIV SYMPTOMATIC AIDS (CDC CATEGORY C: (CDC CATEGORY B: 200 LESS THAN 200 CD4+ T TO 499 CD4+ T LYMPHOCYTES/MM3) LYMPHOCYTES/MM3)  Transmission Four known body fluids through which HIV is transmitted: blood, semen, vaginal secretions, breast milk DIAGNOSTIC TESTS  MEDICAL MANAGEMENT Combination therapy, sometimes referred to as a drug cocktail or highly active antiretroviral therapy (HAART) Adjunct drug therapy  Adjunct Drug Therapy Hydroxyurea (Hydrea) Interferons (Roferon-A, Betaseron) Interleukin-2 (IL-2)  Opportunistic Infections Pneumocystis Pneumonia Candidiasis Cytomegalovirus Infection Cryptosporidiosis Tuberculosis Kaposi’s Sarcoma  Nursing Management Explain the action of each antiretroviral drug and develops a schedule for the client’s self-administration Referral of HIV-positive clients to support groups Obtain a thorough history Obtain vital signs and weight Assess the client’s mental status Prevent secondary infection Health teaching and counseling of high-risk populations  Client Teaching Understand that antiviral drugs do not cure AIDS but may slow its progression. Follow the medication schedule religiously; do not omit or increase the dose without physician approval. Comply with the timing of antiviral medications around meals. Eat small, frequent, well-balanced meals; try to maintain or gain weight. Drink plenty of water  Client Teaching Check weight weekly. Report progressive weight loss or loss of appetite to the physician. Avoid exposure to people with infections, including colds, sore throats, upper respiratory tract infections, and childhood diseases (e.g., mumps, chickenpox), and people who have recently been vaccinated. Avoid crowds. Notify the physician if signs of infection, such as fever, sore throat, diarrhea, respiratory distress, and cough occur, or if signs of a skin, rectal, vaginal, or oral infection appear. Wear gloves and a mask when disposing of animal excreta, such as kitty litter, bird cage liners, and hamster shavings; wash hands thoroughly afterward.  Client Teaching Wash all food before cooking; do not eat raw meat, fish, or vegetables or food that has not been completely cooked. Wash bedding and clothes in hot water and separate from the laundry of others, especially if the bedding and clothes are soiled with body secretions. Avoid smoking or exposure to secondhand smoke. Bathe or shower daily, wash hands before and after preparing food, clean the anal and perineal areas well after each bowel movement, and wash the hands after voiding or defecating. Personal cleanliness is a must.  Client Teaching When possible, avoid dry and dusty areas, excessive humidity, and extreme heat or cold. Wear clothing appropriate to the weather and temperature. Take frequent rest periods, and space activities to prevent fatigue. Do not share IV needles, and do not donate blood. Inform healthcare personnel of HIV-positive status.