Med Surg Lesson 3 Study Guide PDF

1 Med Surg Lesson 3 Study Guide Chapter 5: Physical and Chemical Barriers The first line of defense is intact skin and mucous membranes The second line of defense in...

1 Med Surg Lesson 3 Study Guide Chapter 5: Physical and Chemical Barriers The first line of defense is intact skin and mucous membranes The second line of defense involves phagocytosis and inflammation Phagocytosis is the process of enveloping and destroying foreign matter, helps the body get rid of microorganisms and debris There are five types of leukocytes: ○ Neutrophils ○ Monocytes ○ Eosinophils ○ Basophils ○ Lymphocytes Measuring the number of these cells (leukocytes/WBCs) gives an indication of the severity of the infection Normal WBC count is 5,000-10,000 Immunity Immunity provides the body with resistance to invading organisms and enables it to fight off invaders once they have gained access Factors that can compromise the immune system are: ○ Disease states ○ Aging ○ Stress ○ Interventions like chemo and radiation therapy Any substance that is capable of stimulating a response from the immune system is called an antigen Antigens can be microorganisms, abnormal or mutated body cells, transplanted cells, noninfectious substances like pollen, or foreign molecules from drugs such as PCN Antibodies are proteins that are created in response to specific antigens Innate (Natural) Versus Acquired Immunity Innate (natural) immunity is present in the body at birth, and is not dependent on a specific immune response or previous contact with an infectious agent Nutritional status, stress, and environment can influence natural immunity An individual develops acquired immunity after birth as a response to the body’s natural immune responses to antigens Active acquired immunity is developed after direct contact with an antigen through illness or vaccination Once the body has been exposed to an antigen through illness or vaccination, antibodies develop and retain memory for the antigen, so if the body is exposed to the same antigen later the body can react quickly Flu vaccine should be gotten starting in September and by October, and you can start getting it at 6 months old Pneumonia vaccine is gotten at 2 months old in a series and then again at 65 years old Shingles vaccine is gotten at 50 years and older in a 2 dose series  2 Cells and Organs Involved in Immunity The organs that work to resist and fight off disease are the thymus, bone marrow, lymph nodes, spleen, and the liver The thymus and bone marrow participate in the formation and maturation of immune system cells Lymph nodes attack antigens and debris in the interstitial fluid and produce and circulate lymphocytes The spleen acts as a filter to remove dead blood cells, debris, and foreign molecules from the blood The liver filters the blood and plays a part in the production of specific immunoglobulins and other chemicals involved in the immune response Nonspecific Defenses Against Infection Innate (natural) immunity consists of physical and chemical barriers to invasion of the body as well as processes and substances that protect and repair tissues and stimulate the body to fight off disease Pyrogen is a substance released in inflammation that causes body temperature to increase Fever is thought to inhibit the growth of pathogens and slow reactions that occur in infectious processes Antibody-Mediated (humoral) Immunity Antibody-mediated immunity is immediate and the first line of defense It involved substances found in the humors of body fluid Antibodies are divided into: ○ IgG - most abundant, crosses placenta to provide passive immunity for the newborn ○ IgM - first antibody to appear in response to initial exposure to an antigen ○ IgA - plays a role in the immune function of mucous membranes ○ IgE - is important in allergic reactions and parasitic infections ○ IgD - is co-expressed with IgM in immature B lymphocytes Cell-Mediated (delayed) Immunity A delayed immune response to injury or infection that does not involve antibodies It involves activation of phagocytes, T lymphocytes, and release of substances that enhance the immune response and destruction of antigens T cells include helper cells, suppressor cells, and killer cells Helper T cells enhance humoral immunity Suppressor T cells “turn off” the humoral response Killer T cells directly destroy antigens This process fights most viral or bacterial infections and hinders the growth of malignant cells This process also launches an attack on transplanted tissue or organs in the body Inflammatory Process The inflammatory process is a series of complex cellular changes that signal the body’s response to injury or infection  3 This can be caused by trauma from physical agents, chemical stimuli like insect venom, and biologic agents like bacteria and viruses The five signs that indicate local inflammation are: ○ Redness ○ Heat ○ Swelling ○ Pain ○ Loss of function Actions in the Inflammatory Process Cardiovascular Changes ○ The body initially responds to an injury or infection with dilation of the capillary bed ○ This dilation brings increased blood flow to the area ○ The increased blood flow is responsible for the warmth and redness at the site of inflammation Increased Permeability ○ Chemical mediators cause leukocytes to line the small blood vessel walls near the site of inflammation ○ These cells ingest and carry away bacteria and other foreign substances (phagocytosis) ○ The permeability of these vessels causes protein-rich fluid to flow through the vessel walls and into the interstitial space ○ This collection of fluid is responsible for the swelling that is noted when the inflammation is close to the surface of the skin Chemical Mediators ○ Some of these include prostaglandins, histamine, and leukotrienes ○ These produce pain, a sign of inflammation ○ In some severe allergic reactions there may be a massive release of histamine and other substances that produce vasodilation, vascular permeability, and smooth muscle contraction ○ These cellular changes produce the classic signs of anaphylactic shock: hypotension, swelling, and bronchoconstriction Anti Inflammation ○ Cortisol is a hormone produced by the adrenal cortex, is an anti inflammatory substance that slows the release of histamine, stabilizes lysosomal membranes, and prevents the influx of leukocytes ○ This is to impede the inflammatory process and limit the effects of excessive or prolonged inflammation ○ Drugs that mimic the action of cortisol are often used in the treatment of inflammatory conditions Clinical Manifestations of Inflammation Systemic inflammation produces: ○ Fever ○ Headache  4 ○ Muscle aches ○ Chills ○ And sweating Wound Healing Repair and regeneration of tissue are set in motion from the very beginning of the inflammatory response The speed at which wound healing happens depends on type of tissue injured, severity of the wound, presence of infection, and health of the host Macrophage cells clean up inflammatory debris Fibroblasts begin the repair process by laying down elastin and collagen at the edges of the wound, and eventually form granulation tissue Epithelial cells migrate over the wound and under the scab The age and health of the person affect how rapidly the regeneration and repair processes occur The healing process can be delayed in the older adult as a result of decreased tissue elasticity and decreased blood cells A wound occasionally becomes infected or ulcerated resulting in tissue loss Infection Infection is a process involving the invasion of body tissues by microorganisms, the multiplication of the invading organisms, and the subsequent damage of tissue Infection is different from inflammation, in that inflammation is a nonspecific reaction by the body tissue injury whereas infection refers to a specific process that causes tissue injury Infection nearly always results in inflammation but inflammation may be causes by other processes besides infection Inflammation precedes infection Infectious agents are: ○ Bacteria ○ Viruses ○ Fungi ○ Protozoa ○ Rickettsiae ○ Helminths ○ Prions Transmission of Infection Causative agent ○ The microorganisms that are present in sufficient number and virulence to damage human tissue Reservoir ○ Areas in which organisms can pool and reproduce ○ Reservoirs may be human or animal tissues, soil or animal feces ○ When the reservoir occurs in the tissue of humans that human is called a host Portal of Exit  5 ○ This refers to the route by which infectious agents leave one host and travels to another Mode of Transmission ○ The means by which a microorganism is transported to a hose ○ This can happen via direct or indirect contact Portal of Entry ○ The ways in which the infectious agent enters a host Susceptible Hose ○ The susceptibility of a host depends on genetic or constitutional factors Clinical Manifestations of Infection Once an inflammation becomes infected with a pathogen, symptoms may or may not be apparent In many instances a period of incubation occurs in which few, if any, symptoms are present. During this period the asymptomatic persons may be more contagious that those who are exhibiting symptoms S/S of localized infections are essentially the symptoms of inflammation: ○ Redness ○ Pain ○ Warmth ○ Swelling ○ Pus may form Patients with generalized infections may not show all the signs of infection that are apparent with local infections Pain may be moderate to severe, depending on the location Swelling may produce symptoms from mild to severe depending on location Swelling in a large organ like the liver may produce a dull ache Swelling in a small organ like the appendix may produce severe discomfort Warmth is generally expressed as fever in a generalized infection as pyrogens are part of the inflammatory process Other symptoms that often are present in generalized infection include malaise, anorexia, or prostration Types of Infections Community Acquired Infections ○ Acquired in day-to-day contact with the public ○ Childhood illness are common in September when children go to school and are exposed to viruses ○ Poverty, low immunization rates, unsanitary living conditions, and resistant strains of pathogens are partially responsible for the increase in infectious diseases that were once well controlled ○ The resurgence of TB is attributed to poverty ○ HIV/AIDs epidemic is attributed to an increase in the number of infected immigrants, declining public health resources, and the emergence of strains of bacteria that are resistant to multiple drugs ○ Foodborne illnesses are a common community acquired infection  6 ○ STIs like gonorrhea, syphilis, and HIV are community acquired infections ○ Prevention of these include: Ensuring childhood immunizations are complete Adult immunizations help prevent and control diseases Importance of hand washing and proper food handling decreases spread of foodborne illness Sanitation of water supplies Proper hygiene Use of personal barriers like condoms Staying home when sick Health-Care Associated Infections ○ These infections occur within a healthcare facility and may affect both patient and healthcare worker ○ HAIs are more serious because strains of bacteria in the hospital are usually more virulent and often are resistant to antimicrobials ○ The patient's resistance is already compromised from the disorder that led to hospitalization ○ Medicare and other insurance companies don't reimburse institutions for HAIs ○ VRE and MRSA are examples ○ Prevention includes: Contact precautions Standard precautions Use single patient rooms when available Care of Patients with Infection Medical Asepsis ○ Limiting the spread of microorganisms as much as possible ○ This is often calls the clean technique ○ Refers to things like changing bed linens, sanitizing bed linens, using personal equipment for each patient, and frequent hand hygiene Hand Hygiene ○ Soiled hands are the primary mode of transmission of HAIs ○ The most effective hand hygiene is use of soap and water, waterless antiseptic with at least 60% alcohol, or a surgical scrub ○ The hands should be rubbed together for at least 20 seconds ○ A waterless antiseptic is rubbed in until dry Surgical Asepsis ○ Sterile technique refers to elimination of microorganisms through chemical or physical sterilization ○ Techniques are observed to prevent unsterile surfaces from coming into contact with the patient Standard Precautions ○ Used for all patients in the hospital regardless of their health or medical status ○ Use standard precautions when you perform procedure in which you will have contact with a patient’s blood, body fluids, secretions except sweat, excretions,  7 broken skin, and mucous membranes; when you have contact with materials that have blood or body fluids ○ Respiratory hygiene and cough etiquette emphasizes education of staff, patients, and visitors to cover their mouth and nose when coughing or sneezing Airborne Infection Isolation ○ This is for patients who have diseases that spread through the air ○ Examples of diseases that spread through air: TB Severe acute respiratory syndrome (SARS) Varicella (chickenpox) Rubeola (measles) ○ Patients with these conditions are placed in an airborne infection isolation room, where a negative pressure system is in place ○ Properly fitted N95 masks are worn when entering patient rooms ○ Patients with infections spread via air require a surgical mask when leaving their rooms Droplet Precautions ○ Droplets are spread via coughing, sneezing, or talking, and during procedures like suctioning ○ Because droplets only travel about 3 feet before falling from the air, special air handling and ventilation are not required ○ Examples of these are: Covid-19 Rubella Mumps Diphtheria Influenza ○ Patients should be placed in a private room ○ Staff and visitors must wear a surgical mask when within 3 feet of the patient Contact Precautions ○ Use these when interacting with a patient who is infected with microorganisms that are transmitted by direct or indirect contact ○ The patient is placed in a private room ○ Disposable or dedicated patient care equipment is used ○ Wear gloves when entering the room, and before you leave the room wash your hands and remove gloves ○ Wear a gown if your clothing will come into contact with contaminated surfaces or the patient ○ These are used for: GI infections Respiratory tract infections Skin and wound infections ○ These patients rooms must be cleaned or disinfected daily  8 Nursing Care of the Patient with an Infection Urge the patient to consume adequate fluids, at least 2L per day to replace fluids lost via perspiration and respiration Encourage patients to consume high protein and high vitamin foods If a patient's infection requires isolation remember that effective isolation may also isolate your patient from normal human contact, engage the patient in conversations while giving care Lab tests used to screen patients for infection include: ○ White blood cell count - increased in infection ○ Erythrocyte Sedimentation Rate (ESR) - elevated with inflammation ○ Iron Level - decreased in chronic infection ○ Cultures of urine, blood, and sputum - identifies the organism that grows ○ White blood cell differential count - helps differentiate causes of infection Caution the patients not to stop taking the medication when they start feeling better, they need to take the whole course or until the provider orders them to stop Immunodeficiency When the body’s self-defenses against foreign invaders fail to function normally a state of immunodeficiency exists The body is unable to launch an adequate immune response, increasing the risk for infection Immunodeficiencies can be congenital, or acquired The primary clue to immunodeficiency is the tendency to develop recurrent infections In congenital immunodeficiencies, some part of the immune system fails to develop properly Acquired immunodeficiency results from factors outside the immune system Some causes of acquired immunodeficiency are: ○ Infections ○ Malignancies ○ Autoimmune diseases like SLE and RA ○ Chronic diseases like DM and renal disease ○ Drugs ○ Aging ○ Stress ○ Malnutrition Medications often place patients at risk for infection: ○ Corticosteroids ○ Antineoplastic drugs (used to treat cancer) ○ Immunosuppressive drugs (used for transplant recipients) Congenital immunodeficiencies are usually treated with replacement therapy of the deficient immune component Bone marrow transplants or fetal thymus tissue transplants may be used in some treatments  9 Treating an acquired immunodeficiency entails correcting the underlying condition that is causing the problem, like reducing stress, correcting malnutrition, and discontinuing medications that alter immunity To care for an immunocompromised patient: ○ Use good hand hygiene, for patient, staff, and visitors ○ Encourage adequate nutrition ○ Perform effective skin, mouth, perineal, wound, and IV site care; with continuous assessment for signs of infection ○ Encourage patient to turn, cough, and deep breathe ○ Protective isolation may be necessary ○ Disposable equipment is preferred ○ Patient should be educated on signs and symptoms of infection ○ Provide a supportive listening environment Hypersensitivity and Allergy This describes an atypical immune response that is activated by a foreign substance that is normally inoffensive Hypersensitivity can be harmful and even deadly The tendency to develop an allergy is inherited, though the type may vary Someone who is prone to allergies may be called atopic An antigen that causes a hypersensitive reaction is called an allergen Some common allergens are: ○ House dust ○ Animal dander ○ Pollens ○ Molds ○ Foods ○ Pharmacologic agents ○ Cigarette smoke ○ Feathers ○ Insect venoms Allergic response begins with sensitizations The first encounter with a allergen usually only results in a small amount of antibody production However with a subsequent exposure the body steps up it’s defense by producing large amounts of antibodies, this build up triggers the release of histamine Local manifestations of allergic reactions are: ○ Urticaria ○ Pruritus ○ Conjunctivitis ○ Rhinitis ○ Laryngeal edema ○ Bronchospasm ○ Dysrhythmia ○ GI cramps  10 ○ Malabsorption ○ Angioedema The medical treatment of patients with allergies varies depending on the specific allergy The care of the airway must be the priority Antihistamines are used to reduce symptoms caused by histamine release For asthma sufferers: ○ Bronchodilators ○ Corticosteroids ○ O2 and breathing treatments Topical lotions and ointments may be prescribed to relieve itching Long term medical treatment of allergies involves testing to determine specific allergens The patient may be desensitized by injections of tiny quantities of the allergen Desensitization is aimed at increasing tolerance to the offending agent and decreasing the severity of the allergic response Nursing care for patients with allergies: ○ Allergies should be posted on the patient’s record, on all medication records, on the nursing care plan, and on the patient band ○ Never give any drug that the patient is allergic to ○ Alert pharmacy and dietary to the patient's allergies ○ Notify the provider of patient allergies ○ Ensure patients taking allergy medications continue to do so ○ Teach patient to limit exposure or avoid allergens ○ Teach proper use of allergy medications ○ Teach actions and side effects of medications ○ Teach patient to wear a ID band that identifies their allergies ○ Individuals with allergies should obtain an emergency sting kit and be taught how to self-inject epinephrine ○ Nurses should avoid overuse of perfume ○ Live plants and flowers should not be allowed in patient rooms Anaphylaxis An allergen can cause a life threatening allergic reaction called anaphylaxis Anaphylaxis can quickly deteriorate into shock, coma, and death Histamine release in anaphylaxis cause: ○ Bronchospasms ○ Vasodilation ○ Increased capillary permeability Increased capillary permeability causes fluid to leave circulation and enter the tissues, causing shock from hypovolemia S/S of anaphylaxis: ○ Anxiety ○ Wheezing ○ Difficulty breathing ○ Cyanosis ○ Hives  11 ○ Facial edema ○ Arthralgia ○ Dizziness ○ Hypotension ○ Cardiac arrest The most common cause of anaphylaxis is the use of antimicrobials, especially PCN Other causes are: ○ Use of medicines or serums from animal sources ○ Insect venom ○ Iodine radioactive contrast media ○ Local anesthetic ○ Blood products Be safe guide was created to help patients with allergies to remember steps to take in an allergy emergency: ○ Seek immediate help - call 911 ○ Identify allergens - identify what you might have eaten of come into contact with ○ Follow up - ask for a referral to an allergist or immunologist ○ Carry epinephrine - carry fast acting self administered epinephrine To treat anaphylaxis: ○ O2 ○ IV epinephrine ○ Dopamine or a volume expander (or both) to raise BP ○ A nebulized bronchodilator to relax the bronchi and improve ventilation ○ Diphenhydramine for antihistamine effects ○ Corticosteroids to decrease inflammatory response Nursing care: ○ Prevent anaphylaxis when possible by obtaining a list of allergies and protecting patients from these ○ Prompt recognition of anaphylaxis ○ Minimize patients anxiety ○ Administer prescribed drugs like O2 and IV fluids ○ Monitor RR, color, HR, and SpO2 Autoimmune Diseases Immune tolerance is the process by which the immune system does not attack an antigen When the tolerance is disrupted the immune system reacts against and destroys its own tissues This breakdown in tolerance is called autoimmunity An autoimmune process may be initiated: ○ When injury to tissue occurs ○ Infection ○ Malignancy Some autoimmune disorders have apparent causes, like drug induced anemia or a low platelet count (thrombocytopenia)  12 Infection is often present before the onset of an autoimmune disease Autoimmune diseases cause injury in 3 ways: ○ Effect of antibodies on cell surfaces ○ Through the deposit of antigen-antibody complexes ○ Through the action of sensitized T cells Treatment depends on the specific disease In general corticosteroids and NSAIDs are used to treat inflammation Immunosuppressive therapies may be tried to moderate the autoimmune response Nursing interventions: ○ Adequate rest ○ Optimal hydration and nutrition ○ Prevention of infection ○ Supportive caring atmosphere Chapter 31 Organ Transplantation When patients undergo kidney, heart, liver, other organ or tissue transplantation their own healthy immune system may recognize the allograft (implanted organ or tissue) as foreign and try to destroy it Rejection that occurs within 24 hours after transplantation requires removal of the transplanted organs Acute rejection usually occurs within 6 months after transplantation and can usually be reversed with immunosuppressant drugs Chronic rejection occurs months or years after transplantation Tissue matching of donor to recipient minimizes the chance of the recipient’s immune system attacking the allograft after transplantation Various combinations of drugs are given to suppress the recipients immune system and minimize the immune response to the allograft, however these drugs also suppress the patients ability to fight bacteria, viruses, fungi, and parasites, putting the patient at an increased risk for infection Combinations of steroids, methotrexate, and cyclosporine are commonly given to suppress the immune system after a transplant Patients who have undergone organ transplantation may have to take immunosuppressant drugs for the rest of their lives Drugs Used to Treat Immunologic Disorders Corticosteroids ○ Prednisone and prednisolone ○ Used to suppress the immune responses ○ Used to prevent rejection of grafted tissue ○ Treats RA, SLE, and MS ○ You should protect patients taking this from sources of infection Calcineurin Inhibitors (CI) ○ Cyclosporine ○ Used to prevent rejection of transplanted tissue  13 ○ Side effects can be nephrotoxicity and hepatotoxicity Methotrexate ○ Suppresses B and T lymphocyte production by interfering with folate metabolism ○ Prevention of graft vs host disease after transplant Nursing Actions for the Patient at Risk for Infection: Compromised Host Precautions Patient should have a private room All persons entering the room should wash their hands Monitor the patient's vitals every 2-3 hours, notify provider of S/S of infection Invasive procedures should be kept to a minimum Careful attention to aseptic technique should be observed Designate a particular stethoscope and thermometer to be used Masks are not required Clean table tops, equipment, and the floor frequently Patient should be taught to wash their hands Encourage patient to cough and deep breath every 4 hours Only canned or cooked foods can be served Raw fruits, vegetables, and milk products may not be served Tests, scans, and appointments should be coordinated in advance to minimize patients time in waiting areas The patient should wear a clean mask when outside the room Some hospitals allow flowers and plants in the patient's room however the patient should not handle them No humidifiers should be used in the patient's room Teach the patient and family about the underlying pathophysiology that puts the patient at risk for infection and how to minimize the risk Chapter 32 Neutropenia Neutropenia occurs when the total number of neutrophils is abnormally low, an ANC of under 1,500 cells, putting the patient at risk for infection Causes of neutropenia include: ○ Decreased bone marrow production ○ Chemotherapy ○ Radiation therapy ○ Certain drugs ○ Autoimmune reactions Because these patients do not have an adequate number of WBCs to mount an immunologic response, the classic signs of infection may be absent Fever may be the only sign of infection The most common sites of infection in neutropenic patients are the lung (pneumonia), blood (septicemia), skin, urinary tract, and GI tract Most infections in neutropenic patients are caused by bacteria The goal of antibiotic therapy is to support the patient until the patients on WBC’s are available to fight the infection It is important to minimize the patients exposure to infectious agents  14 Systemic Lupus Erythematosus (SLE) SLE is an autoimmune disease in which the person's immune system loses its ability to recognize itself and mounts an immune response against its own proteins Damage results from antibodies and immune complexes directed against organ systems that may include the skin, joints, kidneys, CNS, cardiovascular, membranes lining the body cavities, and hematologic and immune systems The cause of SLE is unknown, however genetics, environmental triggers, and altered immune function all appear to play a role in the occurrence of the disease 90% of cases occur in women, and the disease is much more common in black, latino, and asian americans than in white americans The most common causes of death with this disease are infection, diseases of the cardiovascular system, renal system, pulmonary system, and CNS Factors associated with poor outcome include increased creatinine, HTN, large amounts of protein excreted in the urine, anemia, and low socioeconomic status Patients with SLE can experience long periods of remission alternating with periods of symptom exacerbation (flare ups) The most common S/S of SLE: ○ Fatigue ○ Malaise ○ Fever ○ Anorexia ○ Nausea ○ Weight loss ○ Arthralgia ○ Myalgia ○ Swollen and tender joints ○ Joints painful with movement ○ Photosensitivity ○ Butterfly shaped rash across the bridge of the nose and cheeks A positive ANA (antinuclear antibodies) can indicate SLE Blood test results along with clinical manifestations are used to make a diagnosis Using the ACR criteria a diagnosis of SLE can be made if the patient experiences 4 of any of the following: ○ Characteristic ‘butterfly’ rash ○ Discoid rash (red, scaly patches that cause scarring) ○ Photosensitivity with exposure to sunlight ○ Oral ulcers ○ Arthritis ○ Serositis: pleuritis, pericarditis ○ Renal disorder ○ Neurologic disorder ○ Hematologic disorder ○ Immunologic disorder ○ Positive ANA  15 No cure for SLE exists Medical treatment for SLE is symptomatic and aimed at minimizing symptoms, preventing organ damage, and maintaining quality of life Fever, arthralgias, myalgias, and rash are managed with acetaminophen, NSAIDs, corticosteroids, and the antimalarial drug hydroxychloroquine Some alternatives to topical corticosteroids for skin rash are tacrolimus and pimecrolimus If symptoms are not controlled with the above drugs or organ function is threatened immunosuppressive agents can be used to suppress the abnormal immune response Nursing Care related to SLE: ○ Patients are treated primarily as outpatients ○ Patients often become very knowledge about their disease ○ Nursing care varies depending on severity of symptoms Interventions related to SLE: ○ Inflammation of muscles and joints, as well as inflammation of various organs can cause pain. Closely monitor the patient's pain level and medication use ○ Encourage the patient to avoid prolonged exposure to the sun and to use sunscreen with an SPF of at least 30 to prevent the skin rash ○ A diagnosis of SLE is often a shock to patients and their family, encourage the patient to ask questions and talk about their feelings ○ The patient must receive accurate, consistent information from all members of the healthcare team, the patient's understanding of the information is essential Human Immunodeficiency Virus (HIV) Infection with HIV causes destruction of immune cells HIV falls into the category or viruses called retroviruses, the transcription of genetic material is reversed HIV penetrates the body through blood and body fluids Once HIV attaches to the macrophages and T4 helper cells it infuses its genetic material into the host cell Over time HIV destroys CD4+T cells faster than the body can replace them When the body's immune response is severely impaired opportunistic infections can gain access The initial stage of HIV infection last 4-8 weeks from the time of exposure About 50% of people who become infected with HIV experience generalized flu like symptoms, the other 50% have no symptoms The virus enters a latent stage during which it is inactive in the infected resting CD4 host cell When the resting CD4 host cells are activated for an immune response the virus begins to replicate The latent stage can last 2-12 years. During which the patient is asymptomatic and CD4 cells continue to decline During the third stage of HIV infection the patient begins to experience opportunistic infections  16 These infections are called opportunistic because one can say that these microbes take advantage of the opportunity to infected someone who is HIV+ when their T cells are low Levels of CD4 cells are usually less than 500 and declining while levels of the virus in the blood are increasing When CD4 cell levels fall below 200 the patient is considered to have AIDS, virus levels are high in the blood Antiretroviral drug regimens are abbreviated to ART and are also referred to as highly active antiretroviral therapy or HAART Clinical manifestations of HIV: ○ Malaise ○ N/V ○ Decreased appetite ○ Rash ○ Diarrhea ○ Fever ○ Night sweats ○ Swollen lymph nodes ○ Headache ○ Skin lesions that do not heal ○ Sore throat ○ Dyspnea ○ Burning with urination ○ Extreme fatigue and weight loss RIsk factors for HIV: ○ Unprotected sexual contact with someone possibly infected with HIV ○ Hx of IV drug use with shared needles ○ Blood transfusion before 1989 Complications with HIV: ○ Opportunistic infections ○ Wasting ○ Secondary cancers ○ Dementia ○ Patients with AIDS are at a high risk for opportunistic fungal, parasitic, and viral infections ○ Infections that these patients commonly experience include: Oral candidiasis Pneumonia Herpes simplex Meningitis Toxoplasmosis P. jirovecii Cryptosporidium enteritis Cryptococcus neoformans  17 Opportunistic Infections ○ Once the body's CD4 cells, CD8 cells, or HIV antibodies fall below normal levels, infections and cancers that the body can normally resist take advantage of this opportunity and cause infection or cancer Kaposi Sarcoma ○ KS is a type of neoplasm that develops in people with AIDS ○ KS affects the skin first appearing as a macular, painless, nonpruritic lesion ○ As the disease advances the lesions may become swollen, ulcerated, and painful ○ When KS affects the GI system bleeding may result, causing anemia ○ When KS affects the respiratory system hypoxia may occur ○ Less often the liver, bones, and soft tissues are affected ○ KS is diagnosed by clinical appearance but the most definitive method of diagnosis is a biopsy ○ No cure exists and the goal of tx is long term remission ○ Treatment options are antiretroviral drugs, chemotherapy, doxorubicin, daunorubicin, and paclitaxel Diagnosis of HIV: ○ Diagnostic tests for HIV test for both HIV antibodies and p24 antigen ○ The p24 antigen is an HIV protein that is elevated in the first few weeks after a person becomes infected Medical Tx of HIV: ○ No cure for HIV exists ○ The medical tx is aimed at reducing the viral load, preventing and treating infections, and treating malignancies ○ Patients are encouraged to maintain a balanced diet, exercise regularly, maintain good dental hygiene, avoid smoking and use of illicit drugs, limit alcohol intake, minimize stress, and practice safe sex Pharmacology: ○ The regimen compromises of various combinations of protease inhibitors, nucleoside reverse transcriptase inhibitors, and non nucleoside reverse transcriptase inhibitors ○ Before the patient with HIV is started on the medication regimen the provider must evaluate the patient's willingness to comply with the therapy ○ Once the medication regimen is started the patient should not miss a single dose, when a dose is missed the serum drug level falls and allows the medication to mutate and build resistance to the HIV medications ○ If enough resistance builds up the patient will have no medication options, which will lead to their death (RIP) Prevention: ○ Sexual abstinence ○ Sex only in a mutually monogamous relationship with a person who is HIV- ○ Consistent and correct condom use ○ Abstinence from IV drug use ○ Use of PrEP  18 ○ Pre Exposure prophylaxis (PrEP) taken daily can reduce the risk of HIV transmission by more than 90% ○ PrEP can be used one prevention option for: Sexually active adult MSM at risk of HIV acquisition Adult heterosexually active men and women who are at risk for HIV acquisition Adult persons who inject drugs and are at risk for HIV Interventions: ○ A diagnosis of HIV is a shock to patients and their family, encourage the patient to ask questions and talk about their feelings ○ Early detection and prevention of infections are vital ○ Encourage patients to clean their teeth and mouth regularly with dental floss and a soft toothbrush ○ A referral to a dietitian for nutrition education and counseling should be made ○ Many patients with HIV can have fluid and electrolyte imbalances r/t GI tract issues and N/V and poor appetite, the nurse should monitor the patients I&O, daily weight, electrolytes, protein and albumin levels ○ HIV patients should maintain a balanced diet and drink 4-6 8 oz glasses of water daily, patients who are vomiting may be prescribed an antiemetic ○ Patients with HIV induced encephalopathy may experience cognitive and motor impairment, primary treatment is an antiretroviral drug ○ Pain can be caused by opportunistic infections, viral invasion into the nerves and muscles, malignant tumors, and diagnostic problems ○ Patients may experience many emotions such as fear, anxiety, anger, shame, grief, shane, depression, and loss of self esteem Chapter 44 Osteoarthritis OA most frequently occurs in the hands, hips, knees, and spine The cartilage in the joint breaks down, causing joint stiffness, pain, and swelling Risk factors are: ○ Joint injury or overuse ○ Increased age ○ Gender: women are more likely to develop this than men ○ Obesity ○ Genetics ○ Race: asian populations have a lower risk for OA Primary OA an unknown factor triggers the release of chemicals that break down joint cartilage ○ OA that occurs with aging is considered primary and may have a genetic basis Secondary OA may be associated with trauma, infection, congenital deformities, corticosteroid therapy, and a variety of other complications including DM Osteoarthritis is characterized by the degeneration of articular cartilage with hypertrophy of the underlying adjacent bone Deterioration of the articular cartilage means shock absorbing protection is gradually lost  19 New bone growth is stimulated by exposed bone surfaces, causing bone spurs to develop OA is considered non inflammatory but tissue breakdown can cause inflammation of the joints in advanced conditions Clinical manifestations: ○ Joint pain (primary symptom) ○ Pain associated with activity and relieved by rest ○ A fall in barometric pressure in the atmosphere before the onset of severe weather may precipitate pain ○ Stiffness ○ Limitation of movement ○ Mild tenderness ○ Swelling ○ Deformity ○ Enlargement of the joint ○ Joint stiffness occurs after periods of rest, especially in the morning, and is relieved by activity within about 30 minutes ○ OA is usually asymmetrical, occurring on one side of the body Diagnosis: ○ Based on health history ○ Radiographic studies ○ The extent of the disease process is not necessarily related to the severity of symptoms ○ Synovial fluid may be aspirated to assess for presence of leukocytes ○ With OA ESR should be normal, RF should be negative, and synovial fluid should show little or no leukocytes Treatment: ○ No cure exists ○ Reduce pain ○ Maintain mobility ○ Minimize disability Physical Treatment: ○ Isometric exercises are recommended ○ Exercise should be followed by periods of rest during the day ○ Wearing cushioned shoes and using a cane to walk can reduce stress on affected joints ○ Cold compresses and moist heat applications can be used to help relieve pain ○ Heat can prepare the muscles and joints for exercise ○ TENS devices are often effective for treating back pain Drug Treatment: ○ Acetaminophen ○ NSAIDs, may decrease pain and improve mobility in patients with OA, but the side effects are more dangerous than acetaminophen  20 ○ Indomethacin (Indocin) is effective in reducing inflammation but may cause serious adverse effects ○ Salicylates are relatively inexpensive but a risk of toxicity occurs Injections: ○ Intra Articular injections can be beneficial ○ Hyaluronic acid is injected into the knee joints to supplement naturally occurring hyaluronic acid that may break down In healthy joints hyaluronic acid acts as a shock absorber and lubricant, allowing the joints to move smoothly over each other Injecting this into a joint may lessen pain and inflammation The infections are given weekly for 3-5 weeks A small amount of joint fluid is removed first to make room for the hyaluronic acid ○ Corticosteroids are injected directly into the knee joint for quick relief of pain and inflammation Benefits may last a few days to more than 6 months These may be limited to 3-4 times a year because repeated injections can lead to cartilage breakdown Arthrocentesis is the removal of fluid from the joint space of the knee ○ This can ease pain and swelling Assessment: ○ Ask patient about joint pain or tenderness ○ Examine joints for crepitus, deformity, or decreased ROM ○ Compare affected joints to unaffected joints ○ Observe Pts movement and gait ○ Determine how the disease is affecting ADLs ○ Subjective: Pain Stiffness Rest and activity Sleep disturbance Knowledge of condition ○ Objective: Joint crepitus, enlargement, deformity ROM Comparison of affected vs. unaffected Movement and gait Mobility Joint swelling and warmth Ability to do ADL’s Interventions: ○ Administer analgesic and antiinflammatory drugs as prescribed or instruct the patient on self medication ○ Instruct the patient on hot or cold treatments as ordered  21 ○ Monitor and record the effects of interventions designed to relieve pain ○ Inform the provider if pain relief measures are not effective Decreased mobility: ○ Recommend a regular exercise program to maintain muscle mass ○ Aerobic, muscle strengthening, and water based exercises are appropriate ○ Patients who are overweight can benefit from weight loss ○ Emphasize importance of balancing rest and activity ○ Suggest clothing with velcro and paints with an elastic waist if hands are affected Give the patient opportunity to discuss concerns about OA and how it affects their lifestyle Patient teaching: ○ Maintain proper posture and body alignment ○ Attain and maintain a healthy body weight ○ Identify activities that require assistance ○ Plan activities when help is available ○ Wear splints or supportive devices that rest or relieve painful, unstable joints ○ Push or slide heavy objects rather than pull ○ Wear shoes with low heels and shock absorbent soles ○ Avoid stairs ○ Sit rather than stand ○ Use high stools when sitting at a counter ○ Use high chairs over a sofa ○ Inch to the edge of a seat and use armrests to stand ○ Use large diameter pencils and pens and use eating utensils with large round handles Surgical Management: ○ Surgical management is reserved for patients with persistent pain and disability despite conservative treatment ○ Arthroscopic surgery removes loose bodies and repairs defects; may be useful for patients with OA of the knees, shoulder, ankle, and spine ○ The surgical treatment of choice for OA of the hip or knee is total joint replacement (arthroplasty) ○ Total joint replacement usually relieves pain and restores function to the joint Rheumatoid Arthritis RA is a chronic, progressive, inflammatory disease No single cause is known but triggers for RA antigens in a patient's system are: ○ Viruses or bacteria ○ Genetic predisposition ○ Environmental factors ○ Hormonal factors ○ Smoking Onset of the disease symptoms is characterized by synovitis (inflammation of synovial tissues)  22 RA can be manifested in rheumatoid nodules, diminished lacrimal and salivary secretions, inflammation of the eye, enlargement of the spleen and lymph nodes, pulmonary disease, and blood dyscrasias Rheumatoid nodules are firm, nontender masses that develop on the fingers, elbows, base of the spine, back of the head, sclera, and lungs Manifestations: ○ Pain in the affected joints that is aggravated by movement ○ Morning stiffness lasting more than 1 hour ○ Weakness ○ Easily fatigued ○ Anorexia ○ Weight loss ○ Muscle aches and tenderness ○ Warmth and swelling of affected joints ○ Symmetrical joint changes, same joints in both extremities are affected simultaneously ○ Blood vessels can become inflamed, called vasculitis Secondary effects on bones can cause osteoporosis, making bones susceptible to fxs Some patients with RA develop clusters of symptoms called Sjogren syndrome, Felty syndrome, or Caplan syndrome. ○ Sjogren syndrome is characterized by dryness of mouth, eyes, and vagina ○ Felty syndrome is characterized by liver and spleen enlargement and neutropenia ○ Caplan syndrome is marked by rheumatoid nodules in the lungs, occurs most often in coal miners and asbestos workers Diagnosis: ○ Health hx ○ Physical exam ○ Laboratory findings ESR CRP (c-reactive protein) ACPA (anti citrullinated protein antibodies) Anti-CCP (anti-cyclic citrullinated peptide) RF (rheumatoid factor) ○ The presence of RF does not establish a diagnosis of RA but may support a diagnosis in patients who have other S/S ○ CRP, ESR, and anti-CCP antibodies also help support a diagnosis ○ Synovial fluid is analyzed for viscosity, WBC’s, and glucose is subject to mucin clot test ○ MRIs, and DXA scans provide more detailed information and may be used to monitor disease progression and response to treatment Medical Treatment: ○ NSAIDs ○ Corticosteroids  23 ○ Methotrexate ○ Disease-modifying antirheumatic drugs (DMARDs) ○ Biologic response modifiers that are a subset of DMARDs ○ Janus Kinase inhibitors ○ Leflunomide (arava) is a DMARD that can reportedly slow the progression of the disease ○ Etanercept (Enbrel) and infliximab (Remicade) have shown success with remission of the disease ○ Joint injections of corticosteroids 2-3 times a year ○ Systemic glucocorticoids to control inflammation; they are gradually lowered to the lowest effective dose as the DMARDs take effect ○ Maximal effects of DMARDs may take 2-6 months ○ Rest ○ Joint splints ○ Orthotic devices to support deformed joints ○ Exercise like walking, cycling, aerobics, yoga, and aquatics ○ Vitamin D supplements ○ Surgical management Assessment: ○ Collect data related to pain, joint swelling, tenderness, joint deformities, limitations of movement, fatigue, and decreased ability to do ADL’s Interventions: ○ Administer drugs as prescribed and teach patients about their drug therapy ○ Develop a plan of activities around periods of rest and activity ○ Spend time with the patient exploring concerns, answering questions, teaching skills, and planning care ○ Visit patients often so they do not feel isolated and lonely ○ Teach patient about disease process, drug therapy, and need for balance rest and activity Patient Teaching: ○ Take medications as prescribed ○ Keep appointments ○ Balance activity and rest ○ Avoid prolonged bed rest ○ Use assistive devices as needed ○ Support joints in functional positions ○ Do as much as you can for yourself but do not hesitate to ask for help ○ Avoid heavy lifting Gout Gout is an inflammatory arthritis characterized by sudden, severe attacks of pain, redness, and tenderness in joints, especially the joint at the base of the big toe Gout is more prevalent among men than women Peak onset in men is between ages 30 and 45  24 Risk factors for developing gout: ○ Obesity ○ HTN ○ Chronic kidney disease ○ Overeating or prolonged fasting ○ Consuming excessive amounts of alcohol regularly ○ Consuming large amounts of seafood or meat ○ Consuming beverages high in fructose corn syrup ○ Taking medications that affect blood levels of urate (like diuretics) Gout is characterized by hyperuricemia (excess uric acid in the blood) that occurs because of excessive production or decreased excretion of uric acid by the kidney ○ This results in accumulation of urate crystals in and around the joints ○ When crystals are deposited, painful inflammation known as gouty arthritis occurs Diagnosis: ○ Joint fluid test can reveal urate crystals in synovial fluid ○ Blood test measure the level of uric acid and creatinine ○ A musculoskeletal ultrasound can detect urate crystals in a joint or tophus Criteria for suspected gout are: ○ Rapidly developing pain and inflammation, especially in the big toe ○ Complete resolution of symptoms between flares ○ High levels of urate in the blood Medical Treatment: ○ NSAIDs ○ Corticosteroids ○ Oral colchicine ○ Naproxen or indomethacin are recommended for a gout flare and are best given within 48 hours of onset of symptoms ○ When a single joint is affected, prednisone may be injected into the joint ○ Oral glucocorticoids (prednisone or prednisolone) may be prescribed if injections are contraindicated ○ Colchicine in low doses is the drug of choice for preventative treatment of gout flares ○ Uricostatic agents, which include allopurinol and febuxostat, prevent urate formation ○ Probenecid is a uricosuric agent, meaning it increases excretion of uric acid ○ Pegloticase is a uricolytic agent, it breaks down uric acid ○ Patients are advised to avoid foods high in purines (liver, kidney, sweetbreads), and limit animal proteins, alcohol, and fructose Interventions: ○ Elevate the affected extremity, give prescribed medications, encourage rest, avoid pressure on the area ○ Drink 8-16 8oz cups of fluid daily ○ Patient should have at least 2000 ml of UO a day  25 Osteoporosis At around 30 years of age bone absorption surpasses bone formation The net result is loss of bone mass, which leaves the patient susceptible to fxs The most common sites of fxs caused by osteoporosis are the wrist, vertebrae, and hip, followed by the pelvis and humerus Risk factors: ○ Older women who have small frames, and who are white or northern european heritage and have red or blonde hair ○ Estrogen deficiency ○ Physical inactivity ○ Low body weight ○ Inadequate calcium, protein, or vitamin D intake ○ Long term corticosteroid or heparin use ○ Use of cigarettes, caffeine, and alcohol ○ Cushing disease ○ Hyperparathyroidism ○ Hypogonadism ○ Cirrhosis ○ Leukemia ○ DM Manifestations: ○ Back pain ○ Fractures ○ Loss of height ○ Kyphosis ○ Often the patient has no symptoms until a fracture occurs Diagnosis: ○ Noninvasive tools to assess bone density ○ DEXA scan ○ Radiographs, but these do not show decreased bone density until loss of 30-50% of bone mass occurs Medical Treatment: ○ Aimed a preventing fxs and stimulating bone formation ○ Bisphosphonates (fosamax, boniva, actonel, and reclast), these are bone resorption inhibitors ○ Calcitonin (fortical and miacalcin) ○ Hormone therapy or estrogen therapy ○ Parathyroid hormone Forteo, Tymlos, and Evenity ○ SERMs (selective estrogen receptor modules such as evista) ○ Prolia, a biologic drug ○ Calcium supplementation and estrogen replacement is thought to slow bone loss ○ Calcium intake should be 1000mg per day for premenopausal women and for postmenopausal women who are on estrogen replacement therapy  26 ○ Postmenopausal women who are not on estrogen replacement therapy need 1200-1500 mg of calcium a day ○ Patients who have spinal fxs caused by osteoporosis may be considered for vertebroplasty, an outpatient procedure in which bone cement is injected into a crack bone or broken vertebra Assessment: ○ Ask about patients diet, calcium intake, and exercise ○ Note if the patient is menopausal or had an oophorectomy, and is taking estrogen replacement therapy ○ Describe the patient's posture Interventions: ○ Determine patients ability to carry out ADLs ○ Obtain a complete description of the patients pain, and administer analgesics are ordered Other CBC: full blood count Antinuclear Antibody ANA: looks for antibodies in your blood that attack healthy cells instead of foreign substances ELISA: detects and measures HIV antibodies CD4 Count: measures CD4 T cells, it is an indicator of immune function in patients with HIV C-Reactive Protein CRP: a CRP more than 10 mg/L means there is inflammation somewhere in your body Erythrocyte Sedimentation Rate ESR: shows inflammation in the body Rheumatoid Factor RF: proteins made by your immune system that attack healthy tissue in the body, high levels are often related to autoimmune diseases