Unit 1 Immunology Problems PDF

**Unit 1** 1. **Immunology problems**: a. **Hydroxychloroquine**: DMARD/antimalarial i. Tx for rheumatoid arthritis and Lupus ii. May be administered concurrently with NSAIDs. iii. Assess for visual changes, GI upset, skin rash, headaches, photosensiti...

**Unit 1** 1. **Immunology problems**: a. **Hydroxychloroquine**: DMARD/antimalarial i. Tx for rheumatoid arthritis and Lupus ii. May be administered concurrently with NSAIDs. iii. Assess for visual changes, GI upset, skin rash, headaches, photosensitivity, bleaching of hair. b. **Zidovudine** \[an NRTI -- Nucleoside Reverse Transcriptase Inhibitors (NRTIs)\]: iv. used in HIV tx v. Zidovudine given in combination with one or more protease inhibitors such as ritonavir in the management of patients with AIDS (book) c. **NSAIDs** vi. Used in tx of rheumatoid arthritis vii. AE: GI bleeding/ulcers (red vomit or black tarry stools) viii. Do not mix with alcohol or steroids; H2 antagonist to prevent GI bleed d. **Antivirals** ix. **Herpes-zoster:** acyclovir, valacyclovir \[1st line\], famciclovir x. HIV: PrEP 1. **PrEP (pre-exposure prophylaxis):** single pill containing 2 antiviral meds (tenofovir, disoproxil fumarate 300 mg & emtricitabine 200 mg) taken daily to protect from HIV in people 12 and older a. Educate patient to continue using condoms b. Blood should be assessed for HIV every 3 months 2. **HIV/AIDS medications** e. **ART (Antiretroviral Agents)** therapy (table 32-4): xi. **ART is a combination of drugs to suppress viral replication, prevent disease progression, and reduce transmission risk** xii. CDC recommendation: anyone who tests positive should be on these agents, before CD4+ cell count of 350 (we monitor tx by looking at the CD4+ cell count) f. **Medications:** xiii. NRTIs (zidovudine) & NNRTIs (doravirine/efavirenz); blocks phase 3 xiv. **Protease Inhibitors:** end in "navir" (ex: fosamprenavir) 2. Stops replication in phase 5 xv. **Fusion Inhibitors:** enfuvirtide; stops phase 2 xvi. **Integrase Strand Transfer Inhibitors:** raltegravir; blocks phase 5 (blocks enzyme) xvii. **CCR5 Antagonist:** maraviroc; stops HIV entry into cell 3. **Autoimmune disease (Lupus, Rheumatoid Arthritis, and Gout)** g. **Gout**: xviii. Chronic Inflammatory Arthritis due to high levels of uric acid 3. Impacts joints of the great toe, hands, ankles, knees, elbows, and fingers xix. **Risk factor:** male; incidence increases with age, BMI (25+), alcohol consumption, increases risk for HTN/CVD, consumption of fructose rich foods, & diuretic use; **heavy consumption of red meat is a high contributor** xx. **Clinical Manifestations:** severe pain, redness, swelling, & warmth of the affected joint xxi. **Labs**: uric acid level 4. Malignancies and kidney dz will also have elevation in uric acid xxii. **Meds**: **Cholchice** (acute flares) and **allopurinol** (take everyday for chronic gout to suppress s/s) h. **Lupus**: xxiii. Widespread autoimmune disease causing chronic inflammation & tissue damage 5. Affects joints, skin, blood vessels; includes hearts, lungs, & kidneys xxiv. **S/s:** alopecia, raynaud's phenomenon, & **butterfly rash (symmetrical)** xxv. **Labs:** increased ANA (antinuclear antibody), ESR, & BUN/Creatinine, pancytopenia, urinalysis shows protein, CBC to look at anemia, leukocytosis xxvi. **Treatment**: NSAIDs, steroids, immunosuppressants, & antimalarials/DMARDS (**hydroxychloroquine**) xxvii. **Education**: live vaccines are contraindicated for 30 days after initiation of treatment xxviii. **Complications**: lupus nephritis & cardiac inflammation/myocardial ischemia, pericarditis/pericardial friction rub, dysrhythmias 6. **Lupus Nephritis**: HTN, edema, decreased UOP, and F&E imbalances c. Hallmark: foamy urine, hematuria, nocturia, edema i. **Rheumatoid arthritis** xxix. **Patho:** Autoimmune disease in which WBCs attack synovial tissue with destruction of cartilage and erosion of bone xxx. **S/s: BILATERAL symmetrical diffuse inflammation of the joints**, hot-swollen painful joints 7. Systemic disease: ASSESS for anemia, pericarditis, arteritis, neuropathies, Raynaud's phenomenon, and Sjögren's syndrome (dry eyes & mucous membranes) xxxi. **Dx**: elevated ESR & CRP, CBC, anti-CCP (hallmark test) xxxii. **Tx:** 8. **NSAIDs**: ibuprofen & naproxen (aleve) sodium d. AE: GI bleeding/ulcers (red vomit or black tarry stools) e. Do not mix with alcohol or steroids; H2 antagonist to prevent GI bleed 9. **Corticosteroids**: typically used for flare-ups f. AE: HTN, hyperglycemia, GI bleeding, & immune suppression 10. **DMARDS**: antimalarials (hydroxychloroquine) i. Methotrexate: NO pregnancy and NO alcohol g. Need eye exams every 6-12 months xxxiii. **Education:** 11. **Heat**: in morning for stiffness 12. **Cold**: for edema, swelling, & pain 4. **Caring for these pts: Pruritus, folliculitis, malignant melanoma, HIV/AIDs, gout, lupus, RA** j. **What is the plan of care? s/s, Tx, Dx, medications to expect?** k. **Pruritus**: xxxiv. **Patho**: Scratching the pruritic area releases histamine & makes the itching worse; pruritus is more severe at night due to less distractions 13. Scratching may result in impaired skin integrity & secondary infection xxxv. **Tx/medical management:** 14. **Antihistamines (diphenhydramine, hydroxyzine, loratadine)**, SSRIs (fluoxetine), Lidocaine or prilocaine 15. Topical: steroid creams 16. Non prescription: oatmeal bathes, calamine lotion, skin moisturizers (emollient) xxxvi. **Nursing care:** 17. **Trim their nails (prevent scratches).** Cold compresses, ice, or cool agents 18. Tepid/warm water for bathing (NOT HOT; this dries skin out) 19. Bath with bath oils (caution in elderly due to risk of falls) 20. Elderly-mild soap, Blot dry. Apply emollient to trap moisture l. **Folliculitis**: xxxvii. Patho: A bacterial (staph) or fungal infection that arises within the hair follicles xxxviii. If a patient is diabetic, could develop boils/furuncles or carbuncles xxxix. **Common areas:** beard area of men, women's legs/pubic area, axillae, trunk, & buttocks xl. **Treatment**: Oral dicloxacillin and cephalosporins are first-line medications. If MRSA is suspected, antibiotic agents selected may include clindamycin, trimethoprim--sulfamethoxazole, doxycycline, or minocycline 21. When pus is localized then do I&D (incision and drainage) xli. **Nursing**: teach to apply dressing (what dressing??), fever reduction, cleanliness (antibacterial soap) m. **Malignant Melanoma:** xlii. A malignant neoplasm in which atypical cells are in both epidermis & dermis exhibiting irregular borders with discolorations xliii. **Cause:** sun exposure, use of tanning beds, & gene identified xliv. **Most common:** hand, foot, or scalp but torso lesions more frequently metastasize xlv. **Risk factors:** 22. Fair-skinned, freckles, blue-eyes, & light hair 23. People who burn easy or do not tan; Sunlight exposure xlvi. **S/s**: A malignant melanoma is typically dark, red or blue colored, or a mix of any of these, and irregular in shape xlvii. **Dx:** Biopsy results confirm the diagnosis of melanoma. An excisional biopsy specimen provides information on the type, level of invasion, and thickness of the lesion xlviii. **Tx:** Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision OR skin grafts and flaps may be necessary xlix. **Plan of care:** 24. Educating patients to recognize its early signs, when it is amenable to treatment and cure. 25. An important risk factor in the development of melanoma is exposure to UV radiation (e.g., sunlight) l. **Meds:** Patients with stage 3 and stage 4 tumors may be managed with intravenous checkpoint inhibitors, such as pembrolizumab, nivolumab, or ipilimumab. 26. Checkpoint inhibitors enhance the action of T cells by inhibiting a specific "off" switch on their cellular surfaces, making them more effective in targeting and attacking cancer cells n. **HIV/AIDS**: li. Retrovirus targets CD4+ T cell (helper T cells) by replicating inside the helper T cells and destroying it lii. **Stages** 27. Example: Pt shares a needle w/ someone. develops flu-like s/s. What stage is he in? Asymptomatic h. After this stage, nothing happens for a while. 28. **Stage 0/acute infection/seroconversion:** primary infection; early HIV infection; determined from lab testing (pg 2771) i. s/s: vague nonspecific flu-like s/s, very contagious j. 2-4 weeks after exposure: fever, profound fatigue, & night sweats (flu-like symptoms) ii. Early s/s: fever, malaise, fatigue, sore throat, rash, lymphadenopathy, rigor \[chills\] (outline) iii. Late s/s: weight loss, night sweats, diarrhea, opportunistic infections (outline) iv. A chronic asymptomatic stage may occur & can last 10 years 29. **Stage 1/clinical latency**: **Asymptomatic period** k. CD4 + T-cell count \> or equal to 500 30. **Stage 2/symptomatic:** CD4 +T-cell count 200-499 31. **Stage 3 (AIDS): CD4 +T Cell count less than 200 cells/mm3 OR presence of opportunistic infections or BOTH (outline)** l. Everyone with AIDS has HIV, but not everyone with HIV has AIDS 32. **Stage unknown:** labs confirm HIV infection & no info on CD4 + T Cell count liii. **Standard precautions** came about due to HIV and AIDS liv. **Labs:** CD4 \[most important lab to monitor\] lv. **Dx:** 33. **Dx as AIDS when CD4 \< 200 and secondary infection (opportunistic infections; Pneumocytitis PNA)** 34. **HIV Antibody tests:** detect the antibodies, not HIV itself (outline) m. Good to use if it has been more than 4 weeks since exposure 35. **CD4+ T cell count** 36. **Viral Load Tests:** HIV RNA quantification; used before treatment begins & to monitor disease progression 5. **Burns** o. How much of my body is burned: Rule of Nines lvi. **Rule of Nines** 37. Face = 9% 38. Each Arm = 9% 39. Anterior Chest = 18% 40. Posterior Chest = 18% 41. Each Leg = 18% 42. Groin = 1% p. **Types of burns:** lvii. **Superficial**/First Degree Burn: 43. Patho: affects the epidermis 44. **S/S:** painful, tingling sensation, minimal or no edema, red, dry, may be blistered, & peeling of the skin lviii. **Partial Thickness**/Second Degree Burn: 45. Patho: partial thickness affecting epidermis & portions of the dermis 46. **S/S**: causes pain, blistered and mottled red skin, and edema lix. **Full-Thickness**/Third or Fourth Degree Burn: 47. Patho: affecting epidermis, dermis, sometimes subcutaneous tissue, may involve connective tissue & muscle and bone 48. If patient has large % of burn affecting the face, main concern is ABCs 49. **S/S:** painless, nerve fibers destroyed, pale white, leathery, charred broken skin, & edema (impossible for skin to regenerate) q. **Medications:** lx. **LR** if fluid of choice lxi. **Silver sulfadiazine** 1% (Silvadene) 50. Apply with glove 1-3 times/day; Cannot use if sulfa allergy lxii. **Mafenide acetate** 5% to 10% (Sulfamylon) 51. It can diffuse through the eschar and avascular tissue \[like cartilage\] & kill the bacteria underneath lxiii. **Silver nitrate** 0.5% 52. Apply to gauze & place on wound; keep dressing wet, but covered 53. Monitor sodium & potassium; keep covered to prevent stains r. **Inhalation injury** lxiv. **S/s:** singed facial/nasal hairs, stridor, cough, wheezing lxv. **Management:** 100% O2, 100% nonrebreather (cover the valve in mask until rebreather bag fills up; O2 should be @ 15 L) 54. If no rebreather bag = suffocation