Heme and Immune.docx

**Heme** Care of the 
Hematologic Patient Composition of Blood - Ratio of RBC to plasma
 - Males 40-54%
 - Females 37-47%
 - Hgb is O2 carrying capacity of blood
 - Male Hgb: 13-18 g/dL
 - Female Hgb: 12-15 g/dL - RBC (actual \# RBC in 100mL blood): 
 -...

**Heme** Care of the 
Hematologic Patient Composition of Blood - Ratio of RBC to plasma
 - Males 40-54%
 - Females 37-47%
 - Hgb is O2 carrying capacity of blood
 - Male Hgb: 13-18 g/dL
 - Female Hgb: 12-15 g/dL - RBC (actual \# RBC in 100mL blood): 
 - Male RBCs: 4.6-6.2 million/mm3
 - Female RBCs: 4.2-5.4 million/mm3 - Blood Transfusion - Done for RBCs, platelets, plasma - Verification - Order, Type and Screen, Consent, Education, Assess (v/s, lungs) - Type and screen: lab determines blood type and screening makes sure blood is a match to avoid transfusion reaction (rare, but harmful to kidneys and lungs and potentially life threatening) - RBCs contain antigens or protein markers that correspond to blood type so if wrong -\> recipients immune system will detect different proteins and destroy them - Nurse needs to witness consent signature - Educate on when to get nurse attention for potential transfusion reaction (back pain, trouble breathing, high temperature, etc) - Rights of medication administration (medication, patient, dose, route, time, reason, documentation); - Blood must be infused within 4 hours to avoid infection - Do NOT exceed 5mL/min in first 15 min - Transfusion reactions - Febrile non-hemolytic reactions - Acute hemolytic reactions - Allergic reactions - Transfusion-associated circulatory overload (TACO) - Transfusion-related acute lung injury (TRALI) - Bacterial contamination - Signs/symptoms of transfusion reaction - shortness of breath, back pain, dark urine, fever/chills, fainting or dizziness, flank pain, skin flushing, itching - [Transfusion Reactions] Febrile Non-hemolytic Reaction - Most common type of transfusion reaction, not life-threatening - Caused by antibodies to donor leukocytes that remain in the unit of blood or blood component - May be diminished or prevented by depleting the blood component of donor leukocytes or WBCs - Using leukocyte reduction filter - More common in pts who have had past transfusion and have been exposed to multiple antigens from those previous blood products - S/S: - Chills: (minimal to severe) followed by fever (more than 1°C elevation) - Fever: within 2 hours after the transfusion has begun - Fever, chills and muscle stiffness can be frightening to the patient (anxiety) Acute Hemolytic Reaction - Most dangerous, and potentially life-threatening - Occurs when donor blood is incompatible with recipient - Reaction can occur after transfusion of as little as 10 mL of PRBCs - S/S: - Fever, chills, low back pain, nausea, chest tightness, dyspnea, anxiety, hematuria, hypotension, bronchospasm, and vascular collapse may result - Most common causes of acute hemolytic reaction are errors in blood component labeling and patient identification - Rights and scan barcode for safety measures - Attention to detail in labeling blood samples and blood components - Bar coding of blood products

 Allergic Reaction - Cause is thought to be a sensitivity reaction to a plasma protein within the blood component being transfused - S/S: urticaria (hives), pruritis (itching), and flushing - Rarely, the allergic reaction is severe, with bronchospasm, laryngeal edema, and shock - Treated with epinephrine, corticosteroids, and vasopressor support, if necessary. Transfusion-Associated Circulatory Overload (TACO) - Hypervolemia can occur if too much blood is infused too quickly; can be aggravated if a pt already has increased circulatory volume (HF pts, renal function, older, acute MI at risk) - If rate is sufficiently slow, circulatory overload may be prevented - PRBCs are safer to use than whole blood - Remove excess components and infuse just what is needed (just give PRBCs) - S/S: dyspnea, orthopnea, tachycardia, an increase in blood pressure, and sudden anxiety - Jugular vein distention, crackles at the base of the lungs, and hypoxemia will also develop. Pulmonary edema can quickly develop, as manifested by severe dyspnea and coughing of pink, frothy sputum. - Can develop as late as 6 hours after transfusion, monitor patient post transfusion (vital signs, breath sounds, JVD/fluid status) - Stop the transfusion; notify the provider; diuretics, oxygen, morphine to treat dyspnea Transfusion-Related Acute Lung Injury (TRALI) - Fatal, idiosyncratic reaction of pulmonary edema in absence of circulatory overload - Most common cause of transfusion-related death, more likely with plasma and platelets - Development of acute lung injury within 6 hours post blood transfusion - Underlying pathophysiologic mechanism for TRALI is unknown - S/S: - Acute shortness of breath, hypoxia, hypotension, fever, and eventual pulmonary edema - Stop transfusion and notify provider - Aggressive supportive therapy (e.g., oxygen, intubation, fluid support) may prevent death
 Bacterial Contamination - Very low incidence - Can occur at any point during procurement or processing, often results from organisms on the donor's skin - Poor hand hygiene when blood is obtained or not efficient asepsis of skin when obtaining the blood - Can occur beyond 4 hour mark - Platelets at greater risk of contamination because stored at room temperature - Prevention: meticulous care in procurement and processing; must transfuse within 4 hours - S/S: fever, chills, and hypotension - Manifestations occur post transfusion, occasionally several hours post transfusion - Treat with IV fluids, broad-spectrum antibiotics - Sepsis -\> IV fluids and antibiotics; corticosteroids and vasopressors (if severe) Nursing Management --Transfusion Reactions - Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, given at a slow rate, monitor vital signs, blood/urine samples as per hospital protocol. - Assess the patient carefully. - Vital signs including O2 saturation now vs. baseline - Respiratory status-adventitious breath sounds, accessory muscles, dyspnea - Change in mental status, anxiety, confusion - Chills, fever, diaphoresis - Jugular vein distention - Back pain (hemolytic reaction) - Urticaria - Notify the primary provider of the assessment findings, and implement any treatments prescribed. Monitor the patient's vital signs and respiratory, cardiovascular, and renal status. - Notify the blood bank that a suspected transfusion reaction has occurred. - Send the blood container and tubing to the blood bank for repeat typing and culture. The patient's identity and blood component identifying tags and numbers are verified. Blood types - \+ = have rh protein - \- = do not have it - Antigens are proteins on surface of blood cells that determine blood type; genetically determined - A = antigen A and so on - O = neither A or B antigens - Antibodies are specialized immune proteins produced based on antigens NOT present - i.e. Have A antigens, then will develop B antibodies - Type B blood has anti A antibodies in plasma - AB has neither AB antibodies in plasma which is what makes AB the universal recipient - O has both A and B antibodies present in plasma -\> universal donor - Rh positive can receive more types of blood (+ and -) - Rh negative can only receive from other negatives - Negatives can donate to more types *Practice* *A patient with A- blood type and a history of colorectal cancer is found to be anemic with a hemoglobin and hematocrit of 7.5 and 22. The patient's provider has ordered a transfusion of one unit of packed RBCs to be transfused over 3-4 hours. Describe the process for transfusion. Indicate the blood groups from which this patient may receive donor blood and the infusion rate of the packed RBCs to ensure transfusion within the ordered timeframe.* - Come back\* Hematologic Disorders - Blood - Anemias (hemolytic, hypoproliferative) - Sickle cell disease - Neutropenia - Polycythemia vera - Bleeding - Thrombocytopenia - Hemophilia - Platelet defects - Coagulation - Disseminated Intravascular Coagulation (DIC) Anemias - Lower than normal hemoglobin and fewer than normal circulating erythrocytes; a sign of an underlying disorder - Most common blood disorder - Hypoproliferative: defect in production of RBCs - Caused by iron, vitamin B12, or folate deficiency, decreased erythropoietin production, cancer - Hemolytic: excess destruction of RBCs - Caused by altered erythropoiesis, or other causes such as hypersplenism, drug-induced or autoimmune processes, mechanical heart valves - May also be caused by blood loss (gi bleed, stabbing, etc) Hypoproliferative vs. Hemolytic Anemias - Hypoproliferative Anemias - Iron deficiency anemia - Anemia in renal disease - Anemia of inflammation - Aplastic anemia - Rare disease caused by decrease or damage to marrow stem cells - Megaloblastic anemia - Bone marrow produces unusually large, abnormal, immature RBCs called megaloblasts - From folic acid deficiency or vitamin B12 deficiency - Folic acid from diet - Vitamin B12 from diet or intrinsic factor - Glycoprotein produced by parietal cells of stomach (bariatric surgery removing parts of stomach, removing intrinsic factors -\> B12 deficiency) - Malabsorption from Crohn's as well - Pernicious anemia from weakened stomach lining or autoimmune condition; present with fatigue, weakness - Bone marrow produces unusually large, abnormal, immature RBCs called megalith blasts - Pts with B12 anemia will have [smooth, sore, red, beefy tongue] and mild diarrhea; extremely pale; confusion, paresthesia, untreated -\> nerve damage and damage to spinal cord - Hemolytic anemias - Sickle cell disease - Thalassemia - Inherited blood disorder where body makes abnormal or inadequate hemoglobin - Mostly in people form Mediterranean, North Africa, Middle East, India, Central Asia, Southeast Asia - Glucose-6-phosphate dehydrogenase deficiency - Immune hemolytic anemia - Hereditary hemochromatosis - Others (refer to Chart 33-1) Anemia-Assessment - Health history and physical exam - Religious restrictions (e.g., Jehovah's witness) - Laboratory data - H&H, B12, iron, etc. - Presence of symptoms and impact of those symptoms on patient's life; fatigue, pallor (skin, mucous membranes), weakness/malaise, pain - Nutritional assessment - Result of diet? - Medications - Cardiac, GI, Neuro assessments - Blood loss - Menses, GI bleed, GYN bleed, internal bleed/large volume hemorrhage - Lab data: - Hemoglobin and hematocrit - RBC indices - Iron studies - Reticulocyte count - Vitamin B12 - Folate - Haptoglobin and erythropoietin levels - Bone marrow aspiration Anemia-Medical Management - Correct or control the cause - Transfusion of packed RBCs - Treatment specific to the type of anemia - Dietary therapy - Iron or vitamin supplementation: iron, folate, B12 - Transfusions for low counts or blood loss Anemia-Implementation - Balance physical activity, exercise, and rest - Maintain adequate nutrition and perfusion - Patient education to promote compliance with medications and nutrition - Monitor VS and pulse oximetry; supplemental oxygen as needed - Monitor for potential complications Anemia-Complications - Heart failure - Angina - Paresthesias - Reduced oxygenation and perfusion to tissues -\> ischemia and death of tissue - Confusion - Reduced perfusion to brain - Injury related to falls - hypotension - Depressed mood Gerontologic Considerations - Anemia is the most common hematologic condition affecting older patients, particularly those admitted to hospitals or in long-term care facilities. - The impact of even mild anemia on function in older adults is significant and may include decreased physical performance, decreased mobility, increased frailty, increased rates of depression, increased risk for falling, and delirium. - Fatigue, dyspnea, and confusion may be seen more readily in the older adult who is anemic. Sickle Cell Disease - Can cause severe hemolytoc anemia - Inherited RBC disorder (HbS) - Hemoglobin molecule is defective -\> round shape is altered so that it is sickle-shaped - RBCs are hard, sticky, resemble a sickle -\> as blood passes through vessels, the sickle cells will stick to each other and cause occlusions in vessels - Sickled RBCs die early causing shortage of RBCs (sickle cell anemia) and shortage of oxygen carrying capacity - When they travel through small blood vessels, they get stuck and clog the blood flow - They also cause pain - The only cure for SCD is bone marrow or stem cell transplant - Reserved for severe cases in children with minimal organ damage from SCD - Very risky, serious side effects including death - Usually best match is sibling - Sickle Cell Disease-Assessment - Health history and physical exam - PAIN assessment - Present in sickle cell crisis - Excruciating pain from anemia and occlusions - Laboratory data: S-shaped hemoglobin (sickle hemoglobin gene) - Presence of symptoms and impact of those symptoms on patient's life; swelling, fever, pain - Sickle cell crisis assessment - Blood loss: menses, potential GI loss, GYN bleed, etc. - Cardiovascular and neurologic assessment - Increased risk for heart attack and stroke from the clumping of RBCs Sickle Cell Disease-Planning & Implementation - Hydration (IV fluids) - Oxygen - Pain management - Manage fatigue - Infection prevention - Increased risk of pnemonia, meningitis, bone infections, bloodstream infections - This is due to damage of the spleen from clogging - Promote coping - Often have shortened lifespans and a lot of pain - Education of disease process - Monitor for complications - Crisis: avoid extreme temperatures, high altitude/low oxygen Sickle Cell Disease-Complications - Hypoxia, ischemia, infection - Dehydration - CVA - Anemia - Acute and chronic kidney disease - Heart failure - Impotence - Poor compliance - Substance abuse Medications to Treat - HOP to treatment: - Hydrate -\> IV fluids - Oxygen - Pain management (IV opioids) Neutropenia - Decreased production or increased destruction of neutrophils (\ - Pts have ruddy and red complexion and splenomegaly - Symptoms from increase in blood volume (HA, dizziness, fatigue, tinnitus, paresthesia, blurred vision) or increased blood viscosity (angina, chest pain, claudication, dyspnea, thrombus phlebitis); increased blood pressure as well if pt has atherosclerotic blood - Death can occur from thrombosis, bleeding or acute myeloid leukemia - Medical management - Treatment not needed if condition is mild - Treat underlying cause (in secondary polycythemia) - i.e. treating COPD - Therapeutic phlebotomy - Nursing management - Focuses on symptom management: fatigue, pruritis - Fatigue: encourage independence and alternate activities with rest - Health history to know baseline, chronic conditions, meds that can also contribute to fatigue - Pruritis: antihistamines, bathing in cooler water, coco butter or oatmeal lotions and bath products Thrombocytopenia - Overall reduction in Platelets (\ further bleeding - Bleedings is characterized by low platelet and fibrinogen levels and prolonged coagulation (increased PTT, thrombin time, PT; elevated fibrin and D-dimer - 2 stages - Early: overactive clotting leads to blood clots throughout blood vessels -\> clots block blood flow and damage organs - Late: as DIC progresses, overactive clotting uses up all platelets and clotting factors -\> bleeds just under skin, nose mouth and deep within tissues - Severity is variable; may be life threatening - Triggers: - Sepsis, trauma, shock, cancer, abruptio placentae, toxins, and allergic reactions - Most are from infection or cancer - Inflammation tissue damage (burns or trauma), clotting factors from cancers or pregnancy complications (placental abruption or amniotic fluid embolism) - Treatment: - Treat underlying cause, correct tissue ischemia, replace fluids and electrolytes, maintain blood pressure, replace coagulation factors, use heparin or LMWH - Heparin to prevent clotting from occurring to prevent bleeding - Transfusion of pack cells, FFP DIC-Assessment - Low platelet count - Increased bleeding time - Fibrinogen is decreased DIC-Complications - Kidney injury - From tissue ischemia - Gangrene - Lack of perfusion - Pulmonary embolism or hemorrhage - Acute respiratory distress syndrome (ARDS) - Stroke Medications to Treat DIC - Want to prevent clotting! - Unfractionated heparin therapy - Low\--molecular-weight heparin therapy (Lovenox, Fragmin) - Warfarin (Coumadin) therapy - Dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa), Aspirin ***Practice*** *MD writes an order for Valium 1 mg via PEG tube daily. Pharmacy dispenses you with 3 mg/mL. How many mL will you administer per dose?* Order: 1 mg Have: 3 mg/mL 3/1 = 1/x -\> 1/3 = *A. 0.3 mL/dose* *B. 0.6 mL/dose* *C. 9 mL/dose* *D. 2 mL/dose* *MD writes an order for Colace 50 mg daily via PEG tube. Pharmacy dispenses you with 100 mg/15 mL. How many mL will you administer per dose?* Order: 50 mg Have: 100 mg/15 mL *A. 50 mL/dose* *B. 7.5mL/dose* *C. 15 mL/dose* *D. 2.5 mL/dose* *A donor has AB- blood. Which patient or patients below can receive this type of blood safely?* *A. A patient with O- blood.* *B. A patient with A- blood* *C. A patient with B- blood* *D. A patient with AB- blood.* *True or False: Patients who are Rh positive can only receive Rh positive blood, while patients who are Rh negative can only receive blood from donors who are Rh negative.* *True* *False- positive can receive from + and -, negative can only receive -* *A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 1200. The patient is scheduled to have IV antibiotics at 1000. As the nurse you will:* A. *Stop the blood transfusion and administer the IV antibiotic, and when the antibiotic is done resume the blood transfusion.* B. *Administer the IV antibiotic via secondary tubing into the blood transfusion's y-tubing.* C. *Hold the antibiotic until the blood transfusion is done.* D. *Administer the IV antibiotic as scheduled in a second IV access site.* **Immune** Care of the immunologic Patient The immune system - Immunity: the body's specific protective response to invading foreign agent (antigen) or organism - Immunopathology: the study of diseases that results from dysfunction of the immune system - Components of immune system - Bone marrow: T cells and B cells - WBCs produced here - T cells are involved with cellular/cytotoxic immune response with killer T cells; T cells help the B cells - B cells are involved with humoral immune response in development of antibodies - Lymphoid tissue: spleen, lymphocytes, and lymph nodes Function of the Immune System - To remove foreign antigens such as viruses and bacteria to maintain homeostasis - Phagocytosis: monocytes responsible for engulfing and destroying foreign bodies and toxins - Inflammatory response: - Response to injury or invading organisms - Chemical mediators minimize blood loss, wall off invading organisms, activate phagocytes, promote formation of scar tissue and regeneration of injured tissue Immunity - Natural immunity: nonspecific response to any foreign invader - First line of defense - White blood cell action: release cell mediators such as histamine, bradykinin, and prostaglandins and engulf (phagocytize) foreign substances - Inflammatory response - Physical barriers, such as intact skin, chemical barriers, and acidic gastric secretions or enzymes in tears and saliva - Acquired immunity: specific against a foreign antigen - Result of prior exposure to an antigen (immunization or contracting the disease) - Protective immune response, takes weeks to months after exposure - Active or passive Active and Passive Immunity - Active - Immunologic defenses developed by person's own body - Lasts many years; may last a lifetime - Examples: fighting a cold, allergic response to antigen - from direct exposure - Passive - Temporary - Results from transfer of a source outside of the body that has developed immunity through previous disease or immunization - For example, transfer of antibodies from mother to infant through breast feeding; receiving immune globulin through injections Four Stages in Immune Response - Recognition - Proliferation - Response - Effector - Recognition Stage - Recognition of antigens as foreign -\> triggers immune system to mount defense - Use of lymph nodes and lymphocytes for surveillance - Lymphocytes recirculate from the blood to lymph nodes and from the lymph nodes back into the bloodstream in a continuous circuit - Police officers monitoring the street - Macrophages play an important role in helping the circulating lymphocytes process antigens - Both macrophages and neutrophils have receptors for antibodies and complement; as a result, they coat microorganisms with antibodies, complement, or both, thereby enhancing phagocytosis Proliferation Stage - Circulating lymphocytes containing the antigenic message return to the nearest lymph node - Stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate - Lymphocyte officer has recognized a foreign antigen and asked for backup - T lymphocytes differentiate into cytotoxic (or killer) T cells - B lymphocytes produce and release antibodies Response Stage - Begins with the production of antibodies by the B lymphocytes in response to a specific antigen - Cellular response stimulates the resident lymphocytes to become cells that attack microbes; (killer) T cells - T and B cells mobilize response and prepare for attack - Viral rather than bacterial antigens induce a cellular response - Most immune responses to antigens involve both humoral and cellular responses, although one usually predominates Effector Stage - Humoral Immunity - Interplay of antibodies (B-cells) - B cells develop antibodies -\> we remember invader to prevent future attacks - Cellular Immunity - Action by cytotoxic T-cells - Antigen is killed Immunologic assessment Assessment of the Immune System - Health history - Nutrition, infections, immunizations, allergies, history of autoimmune disorders, cancer, and chronic illness - Physical exam - Skin & mucous membranes - Lesions, dermatitis, purpura, urticaria, inflammation, discharge, any s/s infection - Lymph node assessment - Enlarged: location, size, consistency, tenderness - Tender, fixed, enlarged -\> infection/malignancy - Palpate -\> should be soft, mobile, nontender, pea sized - Other body systems (Chart 34-1) - Respiratory, cardiovascular, genitourinary, gastrointestinal, and neurosensory systems - MSK- joint tenderness, swelling, increased warmth, limited range of motion, pain - Indicate rheumatoid arthritis, septic joint, inflammatory process - Note any functional limitations/disabilities - Lab tests Lab Tests to Evaluate Immune Function - WBC count and differential - Indicate brewing infection - Bone marrow biopsy - Malignancy, diagnos fevers of unknown origin - Humoral and cellular immunity tests - Phagocytic cell function test - Complement component tests - Hypersensitivity tests - Specific antigen--antibody tests - HIV infection tests Allergic reactions - An inappropriate, often harmful response of the immune system to normally harmless substances (e.g., dust, ragweed, pollen) - Allergic reaction: - Manifestation of tissue injury resulting from interaction between an antigen and an antibody - Body encounters allergens that are types of antigens - Body\'s defenses recognize antigens as foreign - Series of events occurs in an attempt to render the invaders harmless, destroy them, and remove them from the body Types of immunoglobulins - Antibodies IgG, IgA, IgM, IgD, IgE that are formed from B cells in plasma cells - Specifically recognizing and binding to antigens and aid in destruction - IgE is in smallest quantity, but plays central role in allergic and hypersensitivity reactions Allergic Reaction - Allergen triggers the B cell to make IgE antibody, which attaches to the mast cell. When that allergen reappears, it binds to the IgE and triggers the mast cell to release its chemicals -\> chemical substances cause reactions in allergic response -\> symptoms - Mediators released: histamine, serotonin, kinase - Role of B Cells and T Cells in Allergic Response - B-lymphocytes - Programmed to produce one specific antibody (IgE from last example) - If a viral/bacterial infection may be IgM produced - Stimulates production of plasma cells (site of antibody production) - Results in outpouring of antibodies - T-lymphocytes - Assist B cells - Secrete substances that destroy target cells and stimulate macrophages - Digest antigens and remove debris (killer T-cells) Assessment of Patients With Allergic Disorders - History and physical assessment of manifestations; comprehensive allergy history - Diagnostic tests - CBC: eosinophil count - Total serum IgE - Skin tests: prick (aka scratch) and intradermal - Checks for immediate allergic reactions Intradermal testing and interpretation - Back is suitable for many tests - Assess for reaction -\> urticarial wheal and localized erythema to identify sensitivities - 0.5 or less is negative - +1 or more is positive Intradermal testing Medications to treat allergic reactions - Oxygen, if respiratory assistance is needed - More severe complications: crash cart and staff to maintain patent airway - Antihistamines (used in conjunction with decongestants for nasal congestion) - Corticosteroids (more severe cases) - Refer to Tables 33-2 (antihistamines) and 33-3 (leukotriene modifiers) for a list of medications Hypersensitivity - Abnormal heightened reaction to a stimulus of any kind - May cause tissue damage - Usually don't occur after first exposure, but after re-exposure after the antibodies have developed - Most are Type 1 or Type 4 - Types of hypersensitivity reactions: - Anaphylactic: type I; most severe - Cytotoxic: type II - Immune complex: type III - Delayed type: type IV Type I: Anaphylactic Reaction - Clinical syndrome that affects multiple organ systems, range from mild-severe - Causes: peanuts, shellfish, meds (sulfa, antibiotics, aspirin, contrast dye) bee stings, wasps, fire ants, latex - Mild - Peripheral tingling and a sensation of warmth, fullness in the mouth & throat - Nasal congestion, periorbital swelling (pruritis), sneezing, tearing of eyes - Onset within 2 hours of exposure - Moderate - Flushing, warmth, anxiety, and itching in addition to any of the milder symptoms - Bronchospasm, edema of airway or larynx, dyspnea, cough, wheezing - Onset within 2 hours of exposure - Severe (aka anaphylactic shock) - Abrupt onset - S/S of above progress rapidly to bronchospasm, laryngeal edema, cyanosis, hypotension. - Dysphagia, abdominal cramping, diarrhea - Emergency - Cardiac arrest and coma may follow Management of Anaphylaxis - Screen and prevent - Treat respiratory problems, oxygen, intubation, and cardiopulmonary resuscitation as needed - May need CPR - Epinephrine 1:1000 subcutaneously for anaphylaxis - Know concentrations - Epi for codes and cardiac arrest is 1:10,000 - Found in code carts - Auto injection system: EpiPen - May follow with IV epinephrine - IV fluids - May have subsequent reactions after this has resolved, so teach them about use of EpiPens *When could a rebound anaphylactic reaction occur after an initial attack even when epinephrine has been given?* A. *1 hour* B. *2 hours* C. *3 hours* D. *4 hours* a. *4-10 hours after initial attack, still go to ER after EpiPen use to prevent complications from rebound* Latex Allergy - Allergic reaction to natural rubber proteins - Rhinitis, conjunctivitis, contact dermatitis, urticaria, asthma, anaphylaxis - Prevalence has been decreasing due to the use of nonlatex gloves - 8% to 17% of healthcare workers affected, also food handlers, hair dressers, mechanics, and the police - Cross reactions with allergies to [kiwis, bananas, avocados, chestnuts] - Ask if previous reactions to these foods when assessing latex allergy Latex allergy-nursing management - Best treatment is avoidance of latex-based products - Wear medical identification - Educate on treatment of irritant contact dermatitis, allergic contact dermatitis that may result from latex exposure - Educate about s/s of type 1 reaction, self-injection of epi pen and return demonstration - Emergency care following use of epi pen, what products contain latex and safe alternatives, importance of preventing future reactions by avoiding latex Rheumatic Diseases - Encompass autoimmune, degenerative, inflammatory, and systemic conditions - Affect the joints, muscles, and soft tissues of the body - More than 100 types of rheumatic diseases - Problems caused by rheumatic diseases include: - Limitations in mobility and activities of daily living - Pain and fatigue - Altered self-image - Sleep disturbances - Systemic effects that can lead to organ failure and death Pathophysiology of Rheumatologic Disorders - Three distinct characteristics: - Inflammation - Complex process resulting in inflamed synovium - Autoimmunity - Hallmark of rheumatologic disease - Body recognizes own tissue as foreign - Degeneration - Secondary process to inflammation - PANNUS formation: proliferation of newly formed synovial tissue infiltrated with inflammatory cells - Destruction of joints, cartilage, erosion of bone follow Common Symptoms of Rheumatic Disease - Pain - Joint swelling - Limited movement - Stiffness - Weakness - Fatigue Assessment of rheumatic disorders - Health history: - Include onset of and evolution of symptoms - Family history - Past health history - Contributing factors - Physical exam - Functional assessment - Combination of history and observation - Gait, posture, general musculoskeletal size and structure - Gross deformities and abnormalities in movement - Symmetry, size, and contour of other connective tissues, such as the skin and adipose tissue - Laboratory studies: (Table 34-1) - Serum creatinine (assess metabolic waste and kidney damage), ESR (inflammation), RBCs (decreased in RA, SLE), Antinuclear antibody (ANA; positive in RA, SLE, scleroderma, etc.), etc. - Lower hematocrit in pts with chronic inflammation - Presence of uric acid for pts with gout - Presence of abnormal antibodies and connective tissue disease -\> rheumatoid factor - CRP indicates active inflammation - ANA: positive in rheumatic disorders (rheumatoid arthritis, lupus, scleroderma, etc) - Imaging studies - X-rays - CT scan - MRI - Arthrography Rheumatic Disorders-Planning Rheumatic disorders-implementation - Pain - Provide comfort measures - Administer anti-inflammatory analgesic - Fatigue - Explain energy conserving techniques - Facilitate development of activity/rest schedule - Impaired physical mobility - Assess for need of PT/OT - Encourage independence in mobility - Self-care deficit - Assist in identifying self-care deficits - Provide assistive devices - Consult with community agencies - Disturbed body image - Assist to identify elements of control over disease - Encourage verbalization of feelings - Ineffective coping - Identify areas of life affected by disease - Develop plan for managing symptoms and enlisting support of family and friends to promote daily function - Complications secondary to medications - Perform periodic clinical assessment and laboratory evaluation - Provide education about correct self-administration, potential side effects, and importance of monitoring - Counsel regarding methods to reduce side effects and manage symptoms - Administer medications in modified doses as prescribed if complications occur Education Plan for Newly Diagnosed Rheumatic Disease - Explain the disease and principles of disease management - Medication teaching and safe self-administration (Table 34-2) - E.g., meds to take with meals, schedule of meds, self-monitor for visual changes, GI upset, tinnitus, or other adverse effects and to notify a provider, etc. - Inflammatory nature may cause retinopathy -\> report visual changes - Pain management techniques - Cope with stress - Verbalization, community resources - Dietary plan - Identify need for health promotion, prevention, and screening - Community resources Autoimmune Diseases-Rheumatoid arthritis (RA)
 - Autoimmune disease of unknown origin, autoimmune reaction originates in synovial tissue - Starts in hands, feet, wrist and rpogresses to hips, shoulders, spine, knees - Acute onset: joint pain, swelling, warmth, erythema, limited mobility, lack of function - - 1% of worldwide population, most commonly between 3rd and 6th decade of life - Risk factors - Females 2.5x greater incidence than males - Environmental-pollution, smoking - Family history - Bacterial and viral illnesses - Characterized by chronic, painful, joint inflammation, worse in the AM, exacerbations & remissions - Ulnar deviation , boutonniere, swan-neck: - Rheumatoid Arthritis-assessment - History and physical - Insidious onset - Fatigue - Malaise - Joint pain, warmth, edema, tenderness - Joint pain after inactivity especially in the AM - Joint deformity - Lab and diagnostics: rheumatoid factor (RF), ANA, ESR, CRP, CBC, x-rays, synovial fluid analysis - RF present in 70-80% cases (found from RBCs) Rheumatoid Arthritis-planning & implementation - Administer medications - ASA, NSAIDS, DMARDS (antirheumatics), immunosuppressants, corticosteroids, etc. (Table 34-2) - Encourage frequent rest periods - Encourage ROM activities, cane/crutches/assistive devices - Encourage cold compresses to acutely inflamed joints - Provide emotional support - Education about disease, medication, and self care - Avoid complications Rheumatoid Arthritis-complications - Joint deformity - Impaired self-care and nutrition - Cardiovascular disease (secondary to inflammation from disease) - Medication side effects - E.g., gastric irritation, gastric ulcer, skin rash, headaches, bone marrow depression, hyperglycemia, etc. (see Table 34-2) 
Autoimmune Diseases-Systemic lupus erythematous (SLE) 
 - Chronic, inflammatory, progressive autoimmune disease that can affect multiple organ systems - 1.6-7.8 individuals per 100,000 affected - 6-10x more frequent in females - 3x more frequent in African American than Caucasians - Characterized by remissions and exacerbations - Diagnosed with presence of 4 of 11 symptoms: - Malar rash, discoid rash, photosensitivity, oral ulcers, non-erosive arthritis, pleuritis or pericarditis, kidney disease, neurologic disease, hematologic disorder, immunologic disorder, positive antinuclear antibody - Malar rash: looks like a butterfly rash over nose and cheeks - Discoid rash: raised rash on head, arms, chest, back - Systemic lupus erythematous-Assessment - History and physical - Fever, malaise, weight loss, anorexia - "Butterfly" rash, oral ulcers, alopecia - Joint tenderness, swelling, and pain (early symptoms in 90%) - Photosensitivity - Depression - Labs and diagnostics: ANA, ESR, CBC, LE (lupus erythematosus) cell prep test Systemic lupus erythematous-planning & implementation - Assess/monitor - Skin breakdown - Signs of infection - Lung sounds - Nutritional status - Mobility - Signs of depression - Blood pressure, cardiac function - Visual changes - Avoid complications - Educate - Keep skin lesions clean/dry - Avoid direct sunlight/ultraviolet light - Use sunscreen - Maintain medication schedule - Signs/symptoms of infection - Signs/symptoms of complications (edema, decreased urine output, acute shortness of breath, chest pain, etc.) - Encourage close follow up care Systemic lupus erythematous-complications - Anemia - Nephritis - Pericarditis\* - Substernal chest pain - Cardiovascular disease is primary cause of death in this population - 50% of lupus pts will experience lung involvement - Pleuritis\* - Retinopathy - CNS involvement - Psychosis, cognitive impairment, seizures, peripheral and cranial neuropathies - Stroke and heart attack secondary to atherosclerosis Autoimmune diseases-Sjögren's Syndrome - Systemic, autoimmune disease progressively affects lacrimal and salivary glands - Characterized by dry eyes and dry mouth - \> 90% affected are females between 35-50 years old - 1 of 1000 affected in US = 2-4 million people - Co-occurs with RA or SLE - Manifestations in other systems - Autoimmune diseases-Sjögren's Syndrome Signs/symptoms: - Eyes: dry eyes, redness, feel "gritty", lack of tearing - Mouth: dry mouth, dry and sticky oral mucous membranes, complaints of difficulty swallowing (lack of saliva) - Skin: vasculitis with palpable purpura, skin lesions may ulcerate and cause pain - Other: optic neuritis, trigeminal neuralgia, sensory neuropathy (burning pain in extremities), numbness, vertigo, arthralgia, Reynaud's phenomenon, cough, dyspnea, abdominal pain Nursing management - Administer artificial tears, ocular ointments for dry eyes - Cholinergic drugs for dry mouth, Biotene mouth wash recommended - Recommend small, frequent meals, omitting spicy, salty, and irritating food - Avoiding smoking, excessive alcohol use, and drugs with anticholinergic side effects - Limit dehydration - DMARDS, only for severe cases - Education on disease and self-care, encourage follow up care - Evaluate and document