Immunity - NCM-112 - PDF

IMMUNITY HERMAN M. NICOLAS RN, MD, MAN  Immunity is the body's specific protective response to a foreign agent or organism. The immune system functions as the body's defense mechanism against invasion and allows a rapid response to foreign substances in a specific manner. Genetic and cel...

IMMUNITY HERMAN M. NICOLAS RN, MD, MAN  Immunity is the body's specific protective response to a foreign agent or organism. The immune system functions as the body's defense mechanism against invasion and allows a rapid response to foreign substances in a specific manner. Genetic and cellular responses result. Any qualitative or quantitative change in the components of the immune system can produce profound effects on the integrity of the human organism. Immune function is affected by a variety of factors, such as central nervous system integrity; general physical and emotional status; medications; dietary patterns; and the stress of illness, trauma, or surgery. Dysfunctions involving the immune system occur across the lifespan. Many are genetically based; others are acquired.  Immune memory is a property of the immune system that provides protection against harmful microbial agents despite the timing of re-exposure to the agent. Tolerance is the mechanism by which the immune system is programmed to eliminate foreign substances such as microbes, toxins, and cellular mutations but maintains the ability to accept self-antigens. Disorders of the immune system may stem from excesses or deficiencies of immunocompetent cells, alterations in the function of these cells, immunologic attack on self-antigens, or inappropriate or exaggerated responses to specific antigens Growing numbers of patients with primary immune deficiencies live to adulthood, and many others acquire immune disorders during their adult years. Thus, nurses in many practice settings need to understand how the immune system functions as well as immunopathologic processes. In addition, knowledge about assessment and care of people with immunologic disorders enables nurses to make appropriate management decisions.  Bone Marrow The white blood cells (WBCs) involved in immunity are pr duced in the bone marrow (see Fig. 35-2). Like other blood cells, lymphocytes are generated from stem cells (undifferentiated cells). There are two types of lymphocytes: 1. B lymphocytes (B cells) 2. T lymphocytes (T cells)  Lymphoid Tissues The spleen, composed of red and white pulp, acts somewhat like a filter. The red pulp is the site where old and injured re blood cells (RBCs) are destroyed. The white pulp contain concentrations of lymphocytes. The lymph nodes, which are connected by lymph channels and capillaries, are distribute throughout the body. They remove foreign material.  Function of the Immune System remove foreign antigens such as viruses and bacteria to maintain homeostasis. two general types of immunity: 1. natural (innate). Natural immunity or nonspecific immunity is present at birth 2. acquired (adaptive). Acquired or specific immunity develops after birth Natural Immunity Natural immunity, which is nonspecific, provides a broad spectrum of defense against and resistance to infection. It is considered the first line of host defense following antigen exposure, because it protects the host without remembering prior contact with an infectious agent. Responses to a foreign invader are very similar from one encounter to the next, regardless of the number of times the invader is encountered. Natural (innate) immunity co-coordinates the initial response to pathogens through the production of cytokines and other effector molecules, which either activate cells for control of the pathogen (by elimination) or promote the development of the acquired immune response. The cells involved in this response are monocytes, macrophages, dendritic cells, natural killer (NK) cells, basophils, eosinophils, and granulocytes. The early events in this process are critical in determining the nature of the adaptive immune response.  Inflammatory Response The inflammatory response is a major function of the natural immune system that is elicited in response to tissue injury or invading organisms. Chemical mediators assist this response by minimizing blood loss, walling off the invading organism, activating phagocytes, and promoting formation of fibrous scar tissue and regeneration of injured tissue. The inflammatory response is facilitated by physical and chemical barriers that are part of the human organism. Physical and Chemical Barriers Activation of the natural immunity response is enhanced by processes inherent in physical and chemical barriers. Physical surface barriers include intact skin, mucous membranes, and cilia of the respiratory tract, which prevent pathogens from gaining access to the body. The cilia of the respiratory tract, along with coughing and sneezing responses, filter and clear pathogens from the upper respiratory tract before they can invade the body further. Chemical barriers, such as mucus, acidic gastric secretions, enzymes in tears and saliva, and substances in sebaceous and sweat secretions, act in a nonspecific way to destroy invading bacteria and fungi.  Response to Invasion When the body is invaded or attacked by bacteria, viruses, or other pathogens, it has three means of defense: 1. The phagocytic immune response: WBCs (granulocytes and macro-phages 2. The humoral or antibody immune response: antibody response, begins with the B lymphocytes, which can transform themselves into plasma cells that manufacture antibodies. 3. The cellular immune response Recognition Stage Recognition of antigens as foreign, or non-self, by the immune system is the initiating event in any immune response. Recognition involves the use of lymph nodes and lymphocytes for surveillance. Lymph nodes are widely distributed internally throughout the body and in the circulating blood, as well as externally near the body's surfaces. They continuously discharge small lymphocytes into the bloodstream. These lymphocytes patrol the tissues and vessels that drain the areas served by that node. Lymphocytes recirculate from the blood to lymph nodes and from the lymph nodes back into the bloodstream in a continuous circuit.  Proliferation Stage The circulating lymphocytes containing the antigenic message retun to the nearest lymph node. Once in the node, these sensitized lymphocytes stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate. T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. Enlargement of the lymph nodes in the neck in conjunction with a sore throat is one example of the immune response. Response Stage In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. This stage begins with the production of antibodies by the B lymphocytes in response to a specific antigen. The cellular response stimulates the resident lymphocytes to become cells that attack microbes directly rather than through the action of antibodies. These transformed lymphocytes are known as cytotoxic (killer) T cells. Viral rather than bacterial antigens induce a cellular response. This response is manifested by the increasing num ber of lymphocytes (lymphocytosis) seen in the blood tests of people with viral illnesses such as infectious mononucleosis. Role of Antibodies Antibodies are large proteins, called immunoglobulins, that consist of two subunits, each containing a light and a heavy peptide chain held together by a chemical link composed of disulfide bonds. Each subunit has one portion that serves as a binding site for a specific antigen and another portion that allows the antibody molecule to take part in the complement system. Antibodies defend against foreign invaders in several ways, and the type of defense used depends on the structure and composition of both the antigen and the immunoglobulin. Antigen-Antibody Binding The portion of the antigen involved in binding with the antibody is referred to as the antigenic determinant. The most efficient immunologic responses occur when the antibody and antigen fit like a lock and key. Poor fit can occur with an antibody that was produced in response to a different antigen. This phenomenon is known as cross-reactivity. For example, in acute rheumatic fever, the antibody produced against Streptococcus pyogenes in the upper respiratory tract may cross-react with the patient's heart tissue, leading to heart valve damage. Cellular Immune Response The T lymphocytes are primarily responsible for cellular immunity. Types of T Lymphocytes T cells include effector T cells, suppressor T cells, and memory T cells. The two major categories of effector T cells— helper T cells (also referred to as CD4* cells) and cytotoxic T cells (also referred to as CD8+ cells)—participate in the Cellular Immune Response The T lymphocytes are primarily responsible for cellular immunity. Types of T Lymphocytes 1. effector T cells, 2. suppressor T cells, and 3. memory T cells. The two major categories of effector T cells: 1. helper T cells (also referred to as CD4+ cells) 2. cytotoxic T cells (also referred to as D8+ cells)  Assessment of the Immune System An assessment of immune function begins during the health history and physical examination. Areas to be assessed include nutritional status; infections and immunizations; allergies; disorders and disease states, such as autoimmune dis-orders, cancer, and chronic illnesses; surgeries; medications; and blood transfusions. In addition to inspection of general characteristics, palpation of the lymph nodes and examinations of the skin, mucous membranes, and respiratory, gastro-intestinal, musculoskeletal, genitourinary, cardiovascular, and neurosensory systems are performed (see Chart 35-3 – ACTIVITY 1). Health History The history should note the patient's age along with information about past and present conditions and events that may provide clues to the status of the patient's immune system. Gender There are differences in the immune system functions of men and women. For example, many autoimmune diseases have a higher incidence in females than in males, a phenomenon believed to be correlated with sex hormones. Sex hormones have long been recognized for their role in reproductive function; in the past two decades  Infection Known past or present exposure to tuberculosis is assessed, and the dates and results of any tuberculin tests (purified protein derivative [PPD) test) and chest x-rays are documented. Recent exposure to any infections and the exposure dates are elicited. The nurse must assess whether the patient has been exposed to any sexually transmitted infections (STIs) or bloodborne pathogens such as hepatitis B, C, and D viruses and human immune deficiency virus (HIV). A history of STIs such as gonorrhea, syphilis, human papillomavirus infection, and chlamydia can alert the nurse that the patient may have been exposed to HIV or hepatitis. Patients who have had an ischemic stroke or TRANSIENT ISCHEMIC ATTACK (TIA) are at risk for infection following the event (Ross, Lee, & Brewer, 2014). In an effort to fight infection, patients mount a PERIPHERAL IMMUNE RESPONSE (PIR) consisting of neutrophilia, lymphocytopenia, and elevated monocytes (Ross et al., 2014). Researchers are investigating the time course, trajectory, and significance of the PIR following stroke or TIA A history of past and present infections and the dates and types of treatments, along with a history of any multiple persistent infections, fevers of unknown origin, lesions or sores, or any type of drainage, as well as the response to treatment, are obtained. Allergy: The patient is asked about any allergies, including types of allergens (e.g., pollens, dust, plants, cosmetics, food, medications, vaccines, latex), the symptoms experienced, and seasonal variations in occurrence or severity in the symptoms. A history of testing and treatments, including prescribed and over-the-counter medications that the patient has taken or is currently taking for these allergies and the effectiveness of the treatments, is obtained.  Nutrition: relationship of infection to nutritional status is a key determinant of health. Immunization: vaccinations- protection against influenza, pneumococcal disease (Pneumovax), pertussis, herpes simplex, and the usual childhood diseases (e.g., measles, mumps). Herpes simplex virus infections have a significant impact on health, causing a wide range of diseases (e.g., oral and genital herpes).  Immunization The patient is asked about childhood and adult immunizations, including vaccinations to provide protection against influenza, pneumococcal disease (Pneumovax), pertussis, herpes simplex, and the usual childhood diseases (e.g., mea-sles, mumps). Herpes simplex virus infections have a significant impact on health, causing a wide range of diseases (e.g., oral and genital herpes). Education about the importance of adhering to the recommended schedule for adult vaccines should be initiated. See Chapter 4, Table 4-3: Routine Health Promotion and Screening for Adults for more information about  Disorders and Diseases Autoimmune Disorders Autoimmune disorders affect people of both genders of all ages, ethnicities, and social classes. Autoimmune disorders are a group of disorders that can affect almost any cell or tissue in the body (Grossman & Porth, 2014). As mentioned previously, they tend to be more common in women because estrogen tends to enhance immunity. Androgen, on the other hand, tends to be immunosuppressive. Autoimmune diseases are a leading cause of death by disease in females of reproductive age. The patient is asked about any autoimmune disorders, such as lupus erythematosus, rheumatoid arthritis, multiple sclerosis, or psoriasis. The onset, severity, remissions and exacerbations.  Neoplastic Disease If there is a history of cancer in the family, more information is obtained, including the type of cancer, age at onset, and relationship (maternal or paternal) of the patient to the affected family members. Dates and results of any cancer screening tests for the patient are documented. A history of cancer in the patient is also obtained, along with the type of cancer, date of diagnosis, and treatment modalities used. Immunosuppression contributes to the development of cancers; however, cancer itself is immunosuppressive, as is the treatment for cancer. Large tumors can release antigens into the blood, and these antigens combine with circulating antibodies and prevent them from attacking the tumor cells. Furthermore, tumor cells may possess special blocking factors that coat tumor cells and prevent their  Chronic Illness and Surgery The health assessment includes a history of chronic ill-ness, such as diabetes, renal disease, chronic obstructive pulmonary disease (COPD), or fibromyalgia. The onset and severity of illnesses, as well as treatment that the patient is receiving for the illness, are obtained. Chronic illness may contribute to immune system impairments in various ways. Kidney injury is associated with a deficiency in circulating lymphocytes. In addition, immune defenses may be altered by acidosis and uremic toxins. In diabetes, an increased incidence of infection has been associated with vascular insufficiency, neuropathy, and poor control of serum glucose levels. Recurrent respiratory tract infections are associated with COPD as a result of altered inspiratory and expiratory function and ineffective airway clearance. In addition, a history of organ transplantation or surgical removal of the spleen, Lymph nodes, or thymus is noted, because these conditions may place the patient at risk for impaired immune function (Bronte & Pittet, 2013). Special Problems Conditions such as burns and other forms of injury and infection may contribute to altered immune system function. Major burns cause impaired skin integrity and compromise the body's first line of defense.  PRIMARY IMMUNE DEFICIENCIES The majority of primary immune deficiency diseases (PIDDs) are diagnosed in infancy, with a male-to-female ratio of 5 to 1. However, some PIDDs are not diagnosed until adolescence or early adulthood, when the gender distribution equalizes. Nursing Management Many patients with PIDDs have comorbid autoimmune disorders, such as thyroid disease, rheumatoid arthritis, cytopenias, and inflammatory bowel disease patients require immunosuppression to ensure engraftment of depleted bone marrow during transplantation procedures. For this reason, nursing care must be meticulous. Appropriate hand hygiene and infection prevention precautions are essential. Self- study:  Immune deficiency Immune deficiency can be acquired due to medical treatment such as chemotherapy or infection from agents such as human immune deficiency virus (HIV). Advances have been made in treating HIV infection and acquired immune deficiency syndrome (AIDS); however, AIDS remains a critical public health issue in communities across the country and around the world. Prevention, early detection, and ongoing treatment remain important aspects of care for persons living with HIV infection or AIDS, HIV Infection and AIDS Since the disease now known as AIDS was first identified more than 35 years ago, remarkable progress has been made in improving the length and quality of life for people living with HIV disease.  During the first decade, recognition and treatment of opportunistic diseases and prophylaxis against opportunistic infections illnesses -which usually do not cause disease in people with normal immune systems. The second decade - highly active antiretroviral drug therapies (HAART) The third decade has- adherence to antiretroviral therapy (ART), development of second-generation combination medications that affect different stages of the viral life cycle, and continued need for an effective vaccine. The HIV antibody test, an enzyme immunoassay (EIA; or a variant of this test called enzyme-linked immunosorbent assay [ELISAl), became available in 1984, allowing early diagnosis of the infection before the onset of symptoms. Since then, HIV infection has been best managed as a chronic disease, most appropriately in an outpatient care setting, whereas AIDS may involve acute conditions that require hospitaliZATION  The HIV antibody test, an enzyme immunoassay (EIA; or a variant of this test called enzyme-linked immunosorbent assay [ELISA), became available in 1984, allowing early diagnosis of the infection before the onset of symptoms. Since then, HIV infection has been best managed as a chronic disease, most appropriately in an outpatient care setting, whereas AIDS may involve acute conditions that require hospitalization  Epidemiology Since the first cases of AIDS were reported in the United States in 1981, surveillance case definitions for HIV infection and AIDS have undergone several revisions (in 1985, 1987, 1993, 2008, and 2014) in response to diagnostic advances. Criteria for a confirmed case of HIV infection can be met by either laboratory evidence or clinical evidence but laboratory evidence, usually obtained through blood tests, is preferred care clinical evidence infection stages (0, 1, 2, 3, or unknown). Stage 0 indicates early HIV infection, inferred from laboratory testing; stages 1, 2, and 3 are based on the CD4* T-lymphocyte count; no information on CD4* T-lymphocyte count or percentage are classified as stage unknown See Table 36-2 for further explanation of stages. In July 2015, the White House released the National HIV/ AIDS Strategy for the United States: Updated to 2020. This document has four Strategic Goals, which include reducing new infections; increasing access to care and improving health outcomes for people living with HIV; reducing HIV-related health disparities and health inequities; and achieving a more coordinated national response to the HIV epidemic  HIV Transmission Inflammation and breaks in the skin or mucosa result in the increased probability that an HIV exposure will lead to infection. Human immune deficiency virus type 1 (HIV-1) is transmitted in body fluids (blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk) that contain infected cells. Higher amounts of HIV and infected cells in the body fluid are associated with the probability that the exposure will result in infection. Mother-to-child transmission of HIV-1 may occur in utero, at the time of delivery, or through breast-feeding, but most perinatal infections are thought to occur after exposure during delivery. HIV is not transmitted through casual contact (see Chart 36-2). Blood and blood products can transmit HIV.to recipients  Prevention of HIV Infection Nurses need to help in efforts to prevent HIV infection by educating how to eliminate or reduce risks associated with HIV infection and AIDS. behavioral interventions such as encouraging the use of condoms are highly effective in reducing the transmission of HIV, the HIV-negative person must be motivated and have the freedom to choose to use the method. In some situations, however, that freedom is absent. For example, a lack of freedom exists in a discordant couple (those in which only one partner has HIV) if the husband refuses to use condoms and the wife's cultural and religious beliefs require intercourse with her husband. In this context, pre-exposure prophylaxis (PrEP) might be appropriate. PrEP involves taking one pill containing two HIV medications (tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg [Truvada]) daily in order to avoid the risk of sexual HIV acquisition in adults and adolescents age 12 and older (Comerford, 2015). HIV status should be checked every 3 months to be sure that the person has not become infected.  PATHOPHYSIOLOGY Because HIV is an infectious disease, it is important to understand how HIV-1 integrates itself into a person's immune system and how the immune response plays a pivotal role in the course of HIV disease. This knowledge is also essential for understanding medication therapy and vaccine development. Viruses are intracellular parasites. HIV is in the subfamily of lentiviruses and is a retrovirus because it carries its genetic material in the form of RNA &DNA. Two genetically different but closely related forms of HIV (HIV-1 and HIV-2) have been identified. The course of illness is slower when infection is caused by HIV-2, which seems to be more common in Western Africa compared to HIV-1, which is more common in other regions of the globe. Blood tests may be used to screen for both forms of HIV.  HIV consists of a viral core containing viral RNA, surrounded by an envelope consisting of protruding glycoproteins. All viruses target specific cells. HIV targets cells with CD4+ receptors, which are expressed on the surface of T lymphocytes, monocytes, dendritic cells, and brain microglia. Mature T cells (T lymphocytes) are composed of two major subpopulations that are defined by cell surface receptors of CD4+ or CD8+. Approximately two thirds of peripheral blood T cells are CD4+, and approximately one third are CD8+. Most people have about 700 to 1,000 CD4+ cells/mm', but a level as low as 500 cells/mm' can be considered within normal limits.  The HIV life cycle is complex (see Fig. 36-1B) and consists of the following steps (Grossman & Porth, 2014): 1. Attachment/Binding: In this first step, the GP120 and GP41 glycoproteins of HIV bind with the host's uninfected CD4* receptor and chemokine coreceptors, usually CCR5, which results in fusion of HIV with the CD4* T-cell membrane. 2. Uncoating/Fusion: Only the contents of HIV's viral core two single strands 3. DNA synthesis: HIV changes its genetic material from RNA to DNA through action of reverse transcriptase, resulting in double-stranded DNA that carries instruction for viral replication. 4. Integration: New viral DNA enters the nucleus of the CD4* T cell and through action of integrase is blended with the DNA of the CD4* T cell, resulting in permanent, lifelong infection. Prior to this, the uninfected person has been only exposed to, not infected with, HIV. With this step, HIV infection is permanent. 5. Transcription: When the CD4* T cell is activated, the double-stranded DNA forms single-stranded messenger RNA (mRNA), which builds new viruses. 6. Translation: The mRNA creates chains of new proteins and enzymes (polyproteins) that contain the components needed in the construction of new viruses. 7. Cleavage: The HIV protease enzyme cuts the polyprotein chain into the individual proteins that make up the new virus. 8. Budding: New proteins and viral RNA migrate to the membrane of the infected CD4* T cell, exit from the cell, and start the process all over. In resting (nondividing) CD4* cells, HIV survives in a latent state as an integrated provirus that produces few or no viral particles. These resting CD4* T cells can be stimulated to produce new particles if something activates them, such as another  Stages of HIV Infection There are five stages of HIV infection based on clinical history, physical examination, laboratory evidence Signs and symptoms, and associated infections and malignancies. {See Table 36-2} The period from infection with HIV to the development of or acute HIV infection (previously known as the window period) and is part of stage 0 Acute HIV infection is the interval between the appearance of detectable HIV RNA and the first detection of antibodies. Its duration also depends on the design of the antibody immunoassay and the sensitivity of the immunoassay during seroconversion (CDC, 2014b). initially, there is a period during which those who are HIV positive test negative on the HIV antibody patients develop clinical symptoms of a nonspecific viral illness (e.g., fever, fatigue, or rash) lasting 1 to 2 weeks.  After 2 to 3 weeks, antibodies to the glycoproteins of the HIV envelope can be detected in the sera of people infected with HIV, but most of these antibodies lack the ability to totally control the virus. By the time neutralizing antibodies can be detected (stage 1), HIV-1 is firmly established in the host. Primary or acute infection is characterized by high levels of viral replication, widespread dissemination of HIV throughout the body, and destruction of CD4+ T cells, which leads to dramatic drops in CD4+ T-cell counts normally 500 to 1,500 cells/ mm' of blood). The host responds to the HIV infection through a CD4+ T-cell response that causes other immune cells, such as CD8+ lymphocytes, to increase their killing of infected, virus-producing cells. The body produces antibody molecules in an effort to contain the free HIV particles (out-side cells) and assist in their removal. During this stage, the virus is widely disseminated in lymphoid tissue, and a latent reservoir within resting memory CD4+ T cells is created.  The amount of virus in the body after the initial immune response subsides is referred to as the viral set point, which results in an equilibrium between HIV levels and the immune response that may be elicited. This can last for years and is inversely correlated with disease prognosis. The higher the viral set point, the poorer the prognosis. After the viral set point is reached, a chronic stage persists in which the immune system cannot eliminate the virus despite its best efforts. This set point varies greatly from patient to patient and dictates the subsequent rate of disease progression; on average, 8 to 10 years can pass before a major HIV-related complication develops. In this prolonged, chronic stage, patients feel well and have few, if any, symptoms. Apparent good health continues because CD4+ T-cell levels remain high enough to preserve immune defensive responses.  Findings in HIV Infection During the first stage of HIV infection, the patient may be asymptomatic or may exhibit various signs and symptoms HIV Tests Several screening tests are used to diagnose HIV infection, and others are used to determine the stage and severity of the infection. A serologic testing algorithm for recent HIV seroconversion (STARHS) analyzes HIV-positive blood samples to determine whether an HIV infection is recent or has been ongoing. In 2006, the CDC (2006) released recommendations for routine HIV testing in health care settings. Subsequently, the U.S. Preventive Services Task Force (Moyer, 2013) recommended routine screening of all persons aged 15 to 65 years, as well as screening for younger or older persons who are at risk.  DIAGNOSTIC TESTS There are three types of HIV diagnostic tests: 1. Antibody tests detect antibodies, not HIV itself, while antigen and RNA tests directly detect HIV. The updated CDC recommendations (2014) tests for HIV antigens and HIV nucleic acid because studies from populations at high risk for HIV demonstrated that antibody testing alone might miss a considerable percentage of HIV infections detectable by virologic tests, especially during stage 0: Blood tests can detect HIV infection sooner after exposure than oral fluid tests because the level of antibody in blood is higher than it is in oral fluid. Likewise, antigen/antibody and RNA tests detect infection in blood before antibody tests. Some newer antigen/antibody laboratory tests can sometimes find HIV as soon as 3 weeks after exposure to the virus. 2. antigen/antibody or RNA tests are available for oral fluid. Follow-up testing is performed if the initial test result is positive to ensure a correct diagnosis. These tests include (CDC, 2015f): antibody differentiation tests, which distinguishes HIV-1 from antibodies 3. HIV-1 nucleic acid tests, which looks for the virus RNA directly antibody differentiation tests, which distinguishes rue-from antibodies HIV-1 nucleic acid tests, which looks for the virus RNA directly Table 36-3 identifies common blood tests used for screening. Since negative perceptions and judgments associated with being HIV infected continue to persist, stigma remains one  Follow-up testing is performed if the initial test result is positive to ensure a correct diagnosis: These tests include (CDC, 2015f): a. antibody differentiation tests, which distinguishes HIV-1 from antibodies b. HIV-1 nucleic acid tests, which looks for the virus RNA directly antibody differentiation tests, which distinguishes rue-from antibodies Since negative perceptions and judgments associated with being HIV infected continue to persist, stigma remains one  Treatment of HIV Infection The U.S. Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents (Panel) (2016) is composed of HIV specialists from across the country who regularly meet to review the latest scientific evidence. The CD4+ count serves as the major laboratory indicator of immune function and prophylaxis for opportunistic infections, and is the strongest predictor of subsequent disease progression and survival (Panel, 2016). New drugs that offer new mechanisms of action, improvements in potency and activity even against multidrug-resistant viruses, dosing convenience, and tolerability have been approved. The overarching goal of ART is to suppress HIV replication to a level below which drug-resistant mutations do not emerge; related goals are to 1) reduce HIV-associated morbidity and prolong the duration and quality of survival, 2) restore and preserve immunologic function, 3) maximally and durably suppress plasma HIV viral load, and 4) prevent HIV transmission (Panel, 2016).  In the United States, ART is now recommended for all HIV-infected patients regardless of their viral load or CD4+ count (Panel, 2016). Optimal viral suppression is defined generally as a viral load persistently below the level of detection (HIV RNA less than 20 to 75 copies/ mL, depending on the assay used). Clinicians, in partnership with patients, make treatment decisions based on a number of factors, including whether the patient has already taken ART or is ART-naive  Drug Resistance Drug resistance is the ability of pathogens to withstand the effects of medications that should be toxic to them. There are two major components of ART resistance: 1) transmission of drug-resistant HIV at the time of initial infection and 2) selective drug resistance in patients who are receiving non- suppressive regimens.  Clinical Manifestations Patients with HIV/AIDS experience a number of symptoms related to the disease, side effects of treatment, and other AIDS are widespread and may involve virtually any organ system. Patients in stage 3 or AIDS (see Table 36-2) are severely immune depressed and can develop opportunistic infections. Nurses need to understand the causes, signs and symptoms, and interventions, including self-management strategies that can enhance the quality of life for patients throughout the different stages of the illness. Symptom assessment tools can be used to assess patients' symptom intensity and severity. People with HIV/AIDS use a variety of self-management strategies to minimize common symptoms Respiratory Manifestations Shortness of breath, dyspnea (labored breathing), cough, chest pain, and fever are associated with various opportunistic infections, such as those caused by Pneumocystis jirovecii, Mycobacterium avium- intracellulare, Pneumocystis Pneumonia Pneumocystis pneumonia (PCP) is caused by P. jirovecii (formerly P. carinii) and the incidence has declined substantially with widespread use of PCP prophylaxis, which is used to prevent PCP, and ART. The most common manifestations of PCP are subacute onset of progressive dyspnea, fever, nonproductive cough, and chest discomfort that worsens within days to weeks. In mild cases, pulmonary examination usually is normal at rest. With exertion, tachypnea, tachycardia, and diffuse dry (cellophane) rales may be auscultated. Oral thrush is a common co-infection. Fever is apparent in most cases and may be the predominant symptom. Hypoxemia is the most characteristic laboratory abnormality, along with elevated lactate dehydrogenase levels. Because clinical presentation, blood tests, and chest radiographs are not pathognomonic for PCP, and because the organism cannot be cultivated routinely, histopathologic or cytopathologic demonstration of organisms in tissue, bronchoalveolar lavage fluid, or induced sputum samples is required for a definitive diagnosis Mycobacterium avium Complex Mycobacterium avium complex (MAC) disease is a common opportunistic infection that typically occurs in patients with CD4+ T-lymphocyte (CD4+) cell counts less than 50 cells/ mm'. MAC is caused by infection with different types of mycobacterium: Mycobacterium avium, Mycobacterium intra-cellulare, or Mycobacterium kansasii. Early symptoms may be minimal and can precede detectable mulan  Tuberculosis The estimated annual risk of reactivation with TB among those with untreated HIV infection and latent TB infection is 3% to 16% and approximates the lifetime risk for individuals without HIV infection who have latent TB infection. TB disease can occur at any CD4* T- lymphocyte (CD4* cell) count, although the risk increases with progressive immune deficiency. Testing for latent TB at the time of HIV diagnosis should be routine, regardless of an individual's risk of TB exposure. Individuals with negative diagnostic tests for latent TB who have stage 3 HIV infection should be retested once their CD4* count increases due to ART. Screening for symptoms (asking for cough of any duration) coupled with chest radiography is recommended to exclude TB disease in a patient with a positive skin test or interferon-gamma release assays. Latent TB in a person with HIV infection is treated with isoniazid (INH), supplemented with pyridoxine (Aminoxin) to prevent peripheral neuropathy, for 9 months since it has proven efficacy, good tolerability, and infrequent severe toxicity. TB disease can develop in the lungs as well as in extra-pulmonary sites such as the central nervous system (CNS), bone, pericardium, stomach, peritoneum, and scrotum and initial diagnostic testing is directed at the anatomic site of symptoms or signs, such as the lungs, lymph nodes, and cerebrospinal fluid. TB in individuals with advanced immune deficiency can be rapidly progressive and fatal if treatment is You sent The gastrointestinal manifestations of HIV infection and AIDS include loss of appetite, nausea, vomiting, oral and esophageal candidiasis, and chronic diarrhea. Gastrointestinal symptoms may be related to the direct inflammatory effect of HIV on the cells lining the intestines. Some of the enteric pathogens that occur most frequently, identified by stool cultures or intestinal biopsy, are Cryptosporidium muris, Salmonella species, Isospora belli, Giardia lamblia, cytomegalovirus (CMV), Clostridium difficile, and M. avium-intracellulare. In patients with AIDS, the effects of diarrhea can be devastating in terms of profound weight loss (more than 10% of body weight), fluid and electrolyte imbalances, perianal skin exco-riation, weakness, and inability to perform the usual activities of daily living. Candidiasis Oropharyngeal and esophageal candidiasis (fungal infec-tions) are common in patients with HIV infection. Oropha-ryngeal candidiasis is characterized by painless, creamy white, plaque-like lesions that can occur on the buccal surface, hard or soft palate, oropharyngeal mucosa, or tongue surface. Lesions can be easily scraped off with a tongue depressor or other instrument which is in contrast to lesions associated with oral hairy leukoplakia. In women with early-stage HIV infection, Candida vulvovaginitis usually presents the same as in women without HIV infection, with white adherent vaginal discharge associated with mucosal burning and itching of mild-to-moderate severity and sporadic recurrences (Ol-Panel, 2015). You sent HIV Wasting Syndrome Wasting syndrome is defined as the involuntary loss of more than 10% of one's body weight while having experienced diarrhea or weakness and fever for more than 30 days. Wasting refers to the loss of muscle mass, although part of the weight loss may also be due to loss of fat. Oncologic Manifestations Those with HIV/AIDS are at greater risk of developing certain cancers. These include Kaposi sarcoma (KS), lym-phoma, and invasive cervical cancer. KS and lymphomas are discussed next. Cervical carcinoma is described later in the Gynecologic Manifestations section. Kaposi Sarcoma KS is caused by human herpesvirus-8 (HHV-8); affects eight times more men than women; and may spread through sexual contact. It involves the epithelial layer of blood and Lymphatic vessels. AIDS-related KS exhibits a variable and gressive course, ranging from localized cutaneous lesions to disseminated disease involving multiple organ systems. You sent AIDS-Related Lymphomas AIDS-related lymphomas include both Hodgkin lymphoma and non-Hodgkin lymphoma. Non-Hodgkin lymphoma is more common. AIDS-related lymphoma is usually aggressive; there are three main types: diffuse large B-cell; B-cell immu-noblastic; and small noncleaved cell lymphoma. Symptoms include weight loss, night sweats, and fever. The complete blood count might be abnormal and a biopsy will confirm the diagnosis (National Cancer Institute NCI), 2015). Neurologic Manifestations HIV-related brain changes have profound effects on cogni-tion, including motor function, executive function, atten-tion, visual memory, and visuospatial function. Neurologic dysfunction results from direct effects of HIV on nervous system tissue, opportunistic infections, primary or metastatic neoplasm, cerebrovascular changes, metabolic encephalopa-thies, or complications secondary to therapy. Immune system response to HIV infection in the CNS includes inflamma-tion, atrophy, demyelination, degeneration, and necrosis. You sent Peripheral Neuropathy Peripheral neuropathy is the most common neurologic symptom at any stage of HIV infection. It may be a side effect of some ART drugs, and may occur in a variety of patterns, with distal sensory polyneuropathy or distal symmetric poly-neuropathy the most frequently occurring type. It can lead to significant pain of feet and hands and functional impair-ment. Patients use a variety of physical and psychological self-management strategies to minimize this symptom (Nicholas, Corless, & Evans, 2014). HIV Encephalopathy HIV encephalopathy was formerly referred to as AIDS dementia complex (see Chart 36-10). It is a clinical syndrome that is characterized by a progressive decline in cogni-tive, behavioral, and motor functions as a direct result of HIV infection. HIV has been found in the brain and cerebrospinal fluid (CSF) of patients with HIV encephalopathy. The brain cells infected by HIV are predominantly the CD4* cells of monocyte-macrophage lineage. HIV infection is thought to trigger the release of toxins or lymphokines that result in cellular dysfunction, inflammation, You sent Cryptococcus Neoformans A fungal infection, Cryptococcus neoformans is another common opportunistic infection among patients with AIDS, and it causes neurologic disease. Cryptococcal meningitis is characterized by symptoms such as fever, headache, malaise, stiff neck, nausea, vomiting, mental status changes, and seizures. Diagnosis is confirmed by CSF analysis. Progressive Multifocal Leukoencephalopathy Progressive multifocal leukoencephalopathy (PML) is a demyelinating CNS disorder that affects the oligodendroglia. Clinical manifestations often begin with mental confusion and rapidly progress to include blindness, aphasia, muscle weakness, paresis (partial or complete paralysis), and death. ART has greatly reduced the threat of mortality associated with this disorder. Other Neurologic Disorders Other infections involving the nervous system include Toxoplasma gondi, CMV, and Mycobacterium tuberculosis infections. You sent Depressive Manifestations Depression and apathy are neuropsychiatric complications of HIV infection. Estimates suggest that the prevalence of current depression is between 30% and 40% in persons with HIV/AIDS. Similarly, apathy, which refers to reduced, self-initiated, cognitive, emotional, and behavioral activity, is also commonly reported among those living with a diagnosis of HIV with rates as high as 65% (Bryant, Whitehead, Burrell, et al., 2015). Alcohol and cocaine use both current and former-have been associated with depression and apathy in this population, and depression has been associated with less adherence with ART. Integumentary Manifestations Cutaneous manifestations are associated with HIV infection and the accompanying opportunistic infections and malig-nancies. KS (described earlier) and opportunistic infections such as herpes zoster and herpes simplex are associated with painful vesicles that disrupt skin integrity. Molluscum conta-giosum is a viral infection characterized by deforming plaque formation. Seborrheic dermatitis is associated with an indu-rated, diffuse, scaly rash involving the scalp and face. Patients with AIDS may also exhibit a generalized folliculitis associated with dry, flaking skin or atopic dermatitis, such as eczema or psoriasis. Many patients treated with the antibacterial agent trimethoprim-sulfamethoxazole (TMP- SMZ) develop a drug-related rash that is pruritic with pinkish-red macules and papules (Comerford, 2015). Patients You sent  Medical Management Treatment of Opportunistic Infections Guidelines for the treatment of opportunistic infections should be consulted for the most current recommendations (Ol-Panel, 2015). Although ART is highly effective You sent Cytomegalovirus Retinitis Retinitis caused by CMV is a leading cause of blindness in patients with AIDS. Oral valganciclovir (Valcyte), IV gan-ciclovir (Cytovene), IV gancilovir followed by oral valgan-ciclovir, IV foscarnet (Foscavir), IV cidofovir (Vistide), and a ganciclovir intraocular implant coupled with valganciclo-vir are all effective treatments for CMV retinitis (Ol-Panel, 2015). All of these drugs have significant toxicities (bone marrow suppression, neutropenia, hepatitis, renal toxicity, seizures, etc.) and are used with caution (Comerford, 2015). Antidiarrheal Therapy Although many forms of diarrhea respond to treatment, it is not unusual for this condition to recur and become a chronic problem for the patient with HIV infection. Therapy with octreo-tide acetate (Sandostatin), a synthetic analog of somatostatin, has been shown to effectively manage chronic severe diarrhea. High concentrations of somatostatin receptors have been found in the gastrointestinal tract and in other tissues. Somatostatin inhibits many physiologic functions, including gastrointestinal motility and intestinal secretion of water and electrolytes. Chemotherapy Kaposi Sarcoma KS can be treated with local therapy, radiation therapy, che-motherapy, and biologic therapy depending upon the location of the lesions. Lymphoma There is no standard treatment for AIDS-related peripheral or systemic lymphoma. The treatment plan is adjusted for each patient and usually includes one or more of combination chemotherapy, high-dose chemotherapy and stem cell transplant. There are many ongoing clinical trials (using monoclonal antibodies; different treatment combinations) that patients with AIDS-related lymphoma may be eligible to enter (NCI, 2015). Antidepressant Therapy Treatment for depression in people with HIV infection involves cognitive behavioral therapy integrated with phar-macotherapy. If depressive symptoms are severe and of sufficient duration, treatment with antidepressants may be ini-tiated. Antidepressants such as imipramine (Tofranil), You sent Antidepressant Therapy Treatment for depression in people with HIV infection involves cognitive behavioral therapy integrated with phar-macotherapy. If depressive symptoms are severe and of sufficient duration, treatment with antidepressants may be ini-tiated. Antidepressants such as imipramine (Tofranil), desip-ramine (Norpramin), and fluoxetine (Prozac) may be used, because these medications also alleviate the fatigue and lethargy that are associated with depression. A psychostimulant such as methylphenidate (Ritalin) may be used in low doses in patients with neuropsychiatric impairment. Electroconvulsive therapy may be an option for patients with severe depression who do not respond to pharmacologic interventions. Nutrition Therapy Alterations in lipid metabolism are associated with HIV infection and ART. Malnutrition increases the risk of infection and the incidence of opportunistic infections. Nutrition therapy should be part of the overall management plan and should be tailored to meet the nutritional needs of the You sent NURSING PROGESS The Patient With HIV/AIDS m The nursing care of patients with HIV/AIDS is ch lenging because of the potential for any organ system be involved due to infections or cancer. In addition, You sent KNOwLeDgE LEVEL The patient's level of knowledge about the disease, modes of disease transmission, and adherence to ART are evalu-ated. In addition, the level of knowledge of family (bio-logic and family of choice) and friends is assessed. The patient's psychological reaction to the diagnosis of HIV infection or AIDS is important to explore. Reactions vary among patients and may include denial, anger, fear, shame, withdrawal from social interactions, and depressive symptoms. It is often helpful to gain an understanding of how the patient has dealt with illness and major life stresses in the past. The patient's resources for support are also identified. Diagnosis NuRSING DIAgNosES The list of potential nursing diagnoses is extensive because of the complex nature of HIV/AIDS. However, based on the assessment data, major nursing diagnoses may include the following: Impaired skin integrity related to cutaneous manifestations of HIV infection, excoriation, and diarrhea Diarrhea related to enteric pathogens or HIV infection Risk for infection related to immune deficiency You sent Activity intolerance related to weakness, fatigue, mal-nutrition, impaired fluid and electrolyte balance, and hypoxia associated with pulmonary infections Chronic confusion related to cognitive changes associated with HIV encephalopathy Ineffective airway clearance related to infection, increased bronchial secretions, and decreased ability to cough related to weakness and fatigue Acute and chronic pain related to impaired perianal skin integrity secondary to diarrhea, KS, and peripheral neuropathy Imbalanced nutrition: less than body requirements related to decreased oral intake Social isolation related to stigma of the disease, withdrawal of support systems, isolation procedures, and fear of infecting others Grieving related to changes in lifestyle and roles and unfavorable prognosis Deficient knowledge related to HIV infection, means of preventing HIV transmission, ART, and self-manage-ment strategies COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Possible complications may include the following: Opportunistic infections Impaired breathing or respiratory failure You sent Evaluation Expected patient outcomes may include: 1. Maintains skin integrity 2. Resumes usual bowel habits 3. Experiences no infections 4. Maintains adequate level of activity tolerance 5. Maintains usual thought processes 6. Maintains effective airway clearance 7. Experiences increased sense of comfort and less pa 8. Maintains adequate nutritional status 9. Experiences decreased sense of social isolation 10. Progresses through grieving process 11. Reports increased understanding of AIDS, prevent of HIV transmission, and ART, and participates self- management strategies as possible 12. Remains free of complications You sent ALLERGIC ASSESSMENT Physiologic Overview An allergic reaction is a manifestation of tissue injury resulting from interaction between an antigen and an antibody. Allergy is an inappropriate and often harmful response of the immune system to normally harmless substances, called allergens (e.g., dust, weeds, pollen, dander). Chemical mediators released in allergic reactions may produce symptoms that range from mild to life-threatening. In allergic reactions, the body encounters allergens that are types of antigens, usually proteins that the body's defenses recognize as foreign, and a series of events occurs in an attempt to render the invaders harmless, destroy them, and remove them from the body. When lymphocytes respond to the antigens, antibodies (protein substances that protect against antigens) are produced. Antibodies combine with antigens in a special way, which has been likened to keys fitting into a lock. Antigens (the keys) fit only certain antibodies (the locks). Hence, the term specificity refers to the specific reaction of an antibody to an antigen. There are many variations and complexities in these patterns. Function of Immunoglobulins Antibodies that are formed by lymphocytes and plasma cells in response to an immunogenic stimulus constitute a group of serum proteins called immunoglobulins. Grouped into five classes (IgG, IgA, gM, gD, and gE), immunoglobulins can be found in the lymph nodes, tonsils, appendix, and Peyer patches of the intestinal tract or circulating in the blood and lymph. These antibodies are capable of binding with a wide variety of antigens. Immunoglobulins of the IgE class are involved in allergic disorders and some parasitic infections.  Role of T Cells T cells, or T lymphocytes, assist the B cells. T cells secrete substances that direct the flow of cell activity, destroy target cells, and stimulate the macrophages. The macrophages present the antigens to the T cells and initiate the immune response. They also digest antigens and assist in removing cells and other debris. Unlike a specific antibody, a T céll does not bind free antigens. Function of Antigens Antigens are divided into two groups: complete protein antigens and low-molecular-weight substances. Complete protein antigens, such as animal dander, pollen, and horse serum, stimulate a complete humoral response. See Chapter 35 for a discussion of humoral immunity. Low-molecular-weight substances, such as medications, function as haptens (incom-plete antigens), binding to tissue or serum proteins to produce a carrier complex that initiates an antibody response. In an allergic reaction, the production of antibodies requires active communication between cells. When the allergen is absorbed through the respiratory tract, gastrointestinal tract, or skin, allergen sensitization occurs. Macrophages process the antigen and present it to the appropriate cells. These cells mature into allergen-specific secreting plasma cells that synthesize and secrete antigen-specific antibodies. Function of Chemical Mediators Mast cells, which are located in the skin and mucous mem-branes, play a major role in lgE-mediated immediate hyper-sensitivity. When mast cells are stimulated by antigens, powerful chemical mediators are released, causing a sequence of physiologic events that result in symptoms of immediate hypersensitivity (see Fig. 37-1). There are rwo types of chemical mediators: primary and secondary. Primary mediators You sent Prostaglandins Prostaglandins produce smooth muscle contraction as as vasodilation and increased capillary permeability. sensitize pain receptors and increase the pain associated inflammation. In addition, prostaglandins induce inflan tion and enhance the effects of mediators of inflamm: response. Local manifestations include erythema, heat, edema (Frandsen & Pennington, 2014). Secondary Mediators Leukotrienes Leukotrienes are chemical mediators that initiate the inf matory response. Many manifestations of inflammation be attributed in part to leukotrienes. In addition, leukotri cause smooth muscle contraction, bronchial constric mucus secretion in the airways, and the typical wheal-flare reactions of the skin. Compared with histamine, kotrienes are 100 to 1000 times more potent in cal bronchospasm. Bradykinin Bradykinin is a substance that has the ability to c increased vascular permeability, vasodilation, hypc sion, and contraction of many types of smooth muscle, as the bronchi. Increased permeability of the capill results in edema. Bradykinin stimulates nerve cell fiber: produces pain.  Allergic Rhinitis Allergic rhinitis (hay fever, seasonal allergic rhinitis) is the most common form of respiratory allergy, which is presumed to be mediated by an immediate (type 1 hypersensitivity) immunologic reaction. It is among the top 11% of all primary care visits and affects about 12% (1 in 8 adults) in the United States (Rosenfeld, Piccirillo, Chandrasekhar et al., 2015). Symptoms are similar to those of viral rhinitis (see Chapter 22) but are usually more persistent and demonstrate seasonal variation; rhinitis is considered to be the allergic form if the symptoms are caused by an allergen-specific IgE-mediated immunologic response. However, approximately one third of patients with rhinitis have associated conjunctivitis, sinusitis, and asthma (Baran et al, 2014; Lehrer, Mullol, Agredo, et al., 2014). The proportion of patients with the allergic form of rhinitis increases with age. It often occurs with other conditions, such as asthma, and cystic fibrosis (Rosenfeld et al., 2015). If symptoms are severe, allergic rhinitis may interfere with sleep, leisure, school, and overall quality of life (Sheikh, 2015). Chronic rhinitis accounts for an average of 1 to 2 missed work days per patient per year. These patients experience a 36% reduction in on-the-job effectiveness and 38% loss of productivity (Sheikh, 2015). Early diagnosis and adequate treatment are essential to reduce complications and relieve symptoms. Because allergic rhinitis is induced by airborne pollens or molds, it is characterized by the following seasonal occurrences (Sheikh, 2015): Early springtree pollen (oak, elm, poplar) Early summer-grass pollen (Timothy, Redtop) Early fall—weed pollen (ragweed) You sent Contact Dermatitis Contact dermatitis, a type IV delayed hypersensitivity reac-tion, is an acute or chronic skin condition caused by contact with an exogenous substance that elicits an allergic response. There are four basic types: allergic, irritant, phototoxic, and photo allergic (see Table 37-4). Eighty percent of cases are caused by excessive exposure to or additive effects of irritants (e.g., soaps, detergents, organic solvents). Skin sensitivity may develop after brief or prolonged periods of exposure, and the clinical picture may appear hours or weeks after the sensitized skin has been exposed. You sent Atopic Dermatitis Atopic dermatitis is a type I immediate hypersensitivity disorder characterized by inflammation and hyper reactivity of the skin. The term is used synonymously with atopic eczema (AAAAI, 2015). Other terms used to describe this kind of You sent single swelling appear at one time, although one may develop while another is disappearing. Infrequently, swelling recurs in the same region. Individual lesions usually resolve in 24 hours (Fleisher et al., 2013; AAAAI, 2015). On rare occasions, swelling may recur with remarkable regularity at intervals of 3 to 4 weeks. Several frequently prescribed medications, such as angio-tensin:converting enzyme inhibitors (captopril [Capoten]) and penicillin, may cause angioedema. The nurse needs to be aware of all medications the patient is taking and be alert to the potential of angioedema as a side effect. Hereditary Angioedema Hereditary angioedema is a rare, potentially life-threat-ening, autosomal dominant disorder (Cicardi & Zuraw, 2015). Although not an immunologic disorder in the usual sense, this condition is included because of its resem blance to allergic angioedema and because of the potential You sent Rheumatic Diseases An estimated 52.5 (22.7%) million adults in the United States have self-reported arthritis or other rheumatologic disease. Approximately 22.7 million (43.2% of those diagnosed with arthritis) have arthritis-attributable activity limi-tation. By 2030, an estimated 67 million (25%) adults will have arthritis or a rheumatologic condition, and an estimated 25 million adults (37%) will report arthritis-attributable activity limitations (Barbour, Helmick, Theis, et al., You sent Systemic Lupus Erythematosus SLE is an inflammatory, autoimmune disorder that affects nearly every organ in the body. The overall incidence of SLE is estimated to be 1.8 to 7.6 per 100,000 persons (Centers for Disease Control and Prevention [CDC], 2015a). It occurs 6 to10 times more frequently in women than in men and occurs 3 times more in African American populations than among Caucasians (CDC, 2015a; Lim, Bayakly, Helmick, et al., 2014). In addition to SLE, many other forms of adult lupus exist, including discoid lupus erythematosus (which primarily affects the skin on the face), subacute cutaneous lupus erythematous (sun exposed areas affected with sores), and drug-induced lupus (rarely includes brain or kidney effects and is usually temporary). You sent Clinical Manifestations SLE is an autoimmune, systemic disease that can affect any body system. The disease process involves chronic states where symptoms are minimal or absent and acute flares where symptoms and lab results are elevated. Systemic symptoms include fever, malaise, weight loss, and anorexia. The muco-cutaneous, musculoskeletal, renal, nervous, cardiovascular, and respiratory systems are most commonly involved. Less commonly affected are the gastrointestinal tract and liver as well as the ocular system. Some type of cutaneous system manifestation is experienced in 80% to 90% of patients with SLE (Bartels, 2015; Klippel et al., 2008). Four of the 11 criteria used for diagnosing SLE by the American College of Rheumatology involve the cutaneous system. The most familiar skin manifestation (occurring in less than 50% of patients with SLE) is an, acute cutaneous lesion consisting of a butterfly-shaped erythematous rash across the bridge of the nose and cheeks (see Fig. 38-2). Several other skin manifestations may occur in patients with SLE, including subacute cutaneous lupus erythematosus, which involves papulosquamous or annular polycyclic lesions, and a discoid rash, which is a chronic rash with erythematous papules or plaques and scaling and can cause scarring and pigmentation changes. In some cases, the only skin involvement may be a discoid rash. In some patients with SLE, the initial skin involvement is the precursor to more systemic involve-ment. The lesions often worsen during exacerbations (flares)  Nursing Management Nursing care of the patient with SLE is based on the fundamental plan presented earlier in the chapter (see Chart 38-2). The most common nursing diagnoses include fatigue, impaired skin integrity, body image disturbance, and deficient knowledge for self- management decisions. The disease or its treatment may produce dramatic changes in appearance and considerable distress for the patient. The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care with sensitivity to the psychological reactions of the patient. In particular, patients with SLE report feelings of depression and anxiety as well as difficulty coping with the disease and the financial strain associated with it (Fonseca, Bernardes, Terroso, et al., 2014). The patient may benefit from participation in support groups, which can provide disease information, daily management tips, and social support. Because sun and ultraviolet light exposure can increase disease activity or cause an exacerba-tion, patients should be instructed to avoid exposure or to protect themselves with sunscreen and clothing. You sent Sjögren's Syndrome Sjögren's syndrome is a systemic autoimmune disease that rogressively affects the lacrimal and salivary glands of the ody. More than 90% of patients affected are women, and the onset tends to begin between 35 and 50 years of age (Carter et al., 2015). It is one of the most common autoimmune disorders, affecting approximately 1 out of 1000 people or 2 to 4 million people in the United States (Carter et al., 2015). Sjögren's syndrome very commonly manifests in conjunction with other autoimmune diseases such as RA or SLE. You sent Scleroderma Scleroderma is a compilation of autoimmune diseases affecting the connective tissue of the skin, blood vessel walls, and internal organs. There are two general types: localized (affecting only the cutaneous system) and systemic (routinely referred to as systemic sclerosis and affecting multiple organ systems). Scleroderma is a rare disease affecting 250 patients per million population (Klippel et al., 2008). Similar to other autoimmune diseases, women are affected three to five times more than men, and the onset occurs typically between the ages of 30 and 50 years. African American patients are affected much younger and have more diffuse symptoms with móre severe lung disease. Scleroderma has a variable You sent Polymyositis Polymyositis is a group of diseases that are termed idiopathic inflammatory myopathies (Klippel et al., 2008). They are rare conditions, with an incidence estimated at 2 cases per 10,000 adults per year. Polymyositis is most commonly seen in women versus men (2:1) and usually seen between 40 and 50 years of age (Miller & Viegels, 2016). You sent Osteoarthritis (Degenerative Joint Disease) OA is a noninflammatory degenerative disorder of the joints. It is the most common form of joint disease and is routinely referred to as degenerative joint disease. OA is classified as either primary (idiopathic), with no prior event or disease You sent Spondyloarthropathies The spondyloarthropathies are another category of systemic inflammatory disorders of the skeleton. The spondyloarthrop-athies include ankylosing spondylitis (AS), reactive arthritis (formerly known as Reiter's syndrome), and psoriatic arthri-tis. Spondyloarthritis is also associated with inflammatory bowel diseases such as Crohn's disease (regional enteritis) and ulcerative colitis (Grossman & Porth, 2014). These rheumatic diseases share several clinical features. The inflammation tends to occur peripherally at the sites of attachment—at tendons, joint capsules, and ligaments. Periosteal inflammation may be present. Many patients have arthritis of the sacroiliac joints. The onset tends to occur during young adulthood, with the disease affecting men more often than women. There is a strong tendency for these conditions to occur in families. Frequently, the HLA-B27 genetic marker is found. In addition, more than one of these conditions can be found simultaneously in the same person or another family member (Carter et al., 2015). You sent Ankylosing Spondylitis AS is a chronic and inflammatory disease of the spine. It is more prevalent in males than in females and is usually diagnosed in the second or third decade of life. The disease is also more severe in males, and significant systemic involvement is likely. AS affects the cartilaginous joints of the spine and surrounding tissues, making them rigid, decreasing mobility, and leading to kyphosis (a stooped position). This kyphosis can, in turn, lead to decreased stability and balance. Back pain is the characteristic feature. The back pain can be so severe that it may mask symptoms of a cervical fracture, which can lead to neurologic problems if left untreated. Occasionally, the large synovial joints, such as the hips, knees, or shoulders, may be involved (Carter et al., 2015). AS also exhibits systemic effects. Uveitis You sent Reactive Arthritis (Reiter's Syndrome) The disease process involved in reactive arthritis is called reactive because the arthritis occurs after an infection, primarily gastrointestinal or genitourinary (Carter et al., 2015). It mostly affects young adult males and is characterized primarily by urethritis, arthritis, and conjunctivitis. Dermatitis and ulcerations of the mouth and penis may also be present. Low back pain is common. You sent Metabolic and Endocrine Diseases Associated With Rheumatic Disorders Metabolic and endocrine diseases may be associated with rheumatic disorders. These include biochemical abnormalities (amyloidosis and scurvy), endocrine diseases (diabe-tes and acromegaly), immune deficiency diseases (human immune deficiency virus infection, acquired immune deficiency syndrome), and some inherited disorders (hypermobil-ity syndromes). However, the most common conditions are the crystal-induced arthropathies, in which crystals such as monosodium urate (gout) or calcium pyrophosphate (calcium pyrophosphate dihydrate disease or pseudogout) are deposited within joints and other tissues (Papadakis et al., 2015). Gout Gout is the most common form of inflammatory arthritis. More than 8.3 million Americans self-report the diagnosis of gout (CDC, 2015). The prevalence is reported to be about 3.9% and appears to be on the rise. Men are three to four times more likely to be diagnosed with gout than women. The incidence of gout increases with age, body mass index, alcohol consump-tion, hypertension, and diuretic use (CDC, 2015b). Evidence links the consumption of fructose-rich beverages with the risk of gout for both men and women (CDC, 2015b). Patients with gout have an increased risk of cardiovascular disease. Comor-bid conditions such as hypertension, dyslipidemia, diabetes; OA, and kidney disease may be present in patients with gout (Papadakis et al., 2015). Given that the incidence of gout increases with age, its management can be complicated by other medical condi-tions, medications, and age-related changes You sent Fibromyalgia Fibromyalgia is a chronic pain syndrome that involves chronic fatigue, generalized muscle aching, stiffness, sleep disturbances, and functional impairment. It is estimated to affect more than 5 million Americans, representing 2% to 5% of the general population, with women affected more than men. Berween 25% and 65% of patients with fibromyalgia have other rheumatologic conditions such as RA, SLE, and AS (CDC, 2015c). Pathophysiology The amplified pain experienced by patients with fibromyalgia is neurogenic in origin (Carter et al., 2015). Specifically, the central nervous system's ascending and descending pathways (that regulate and moderate pain processing) function abnor-mally, causing amplification of pain signals. Some scientists describe this as if the "volume control setting" for pain were abnormally high (Carter et al., 2015). Therefore, stimulation that may not normally elicit pain, such as touch, may do so. In addition, there are a number of