Week 7 Edapt information.pdf

Which are common risk factors associated with pressure ulcer development? Select all that apply. Obesity Increased temperature Young age Renal disease Incontinence Ulcer Classifications Which description is discussing a Stage II pressure ulcer? Intact skin with non-blanchable redness of a localized...

Which are common risk factors associated with pressure ulcer development? Select all that apply. Obesity Increased temperature Young age Renal disease Incontinence Ulcer Classifications Which description is discussing a Stage II pressure ulcer? Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Partial thickness loss of dermis, shallow open ulcer with a red-pink wound bed without slough. Full thickness tissue loss with exposed bone, tendon, or muscle; exposed bone or muscle is visible or directly palpable. Full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Ulcer Locations What are common locations for pressure ulcers or sores? Select all that apply. Elbows Ears Coccyx Back of the head Heels Pressure Ulcers Pressure ulcers are localized injuries to tissue and surrounding structures caused by continuous pressure or a combination of pressure and shearing forces. Shearing forces refer to the body lying in one position for an extended time. When moving, the skin slides in the direction of body movement (like repositioning or pulling a client up in bed). Another factor that influences pressure ulcer development is excessive or constant moisture. Ulcers are categorized based on visible or palpable tissue in the ulcer bed (the base or floor of the wound). Stages range from I (minor) to IV (severe). Slough or eschar may have to be removed for accurate staging of some ulcers. Stage III or IV (full skin thickness injury) pressure ulcers acquired after admission to a healthcare setting are considered a serious reportable event (SRE) or a never event. Risk Factors Risk factors for pressure ulcer development include: • • • • • • • obesity immobility advanced age incontinence impaired circulation contractures neurologic disorders/deficits The Braden Scale The Braden Scale, published in 1987, gives healthcare providers a snapshot of the amount of risk a client has in developing pressure or skin integrity issues. The scoring ranges from less than 9 to a high of 23. The lower the number, the higher the risk of developing an acquired ulcer or skin integrity injury. 19-23 = no risk 15-18 = mild risk 13-14 = moderate risk 10-12 = high risk less than 9 = severe risk Six categories are evaluated within the Braden Scale: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Nurses should complete a Braden Scale assessment on all clients at least once a shift, and upon admission. The key to positive outcomes for clients is prevention. The Braden Scale will help healthcare providers anticipate what risk the client has and how to best prevent it in a proactive manner. Review the complete Braden Scale [PDF] for predicting pressure sore risk. Indiana.gov. (n.d.). Braden scale. https://www.in.gov/health/files/Braden_Scale.pdf Staging Pressure Ulcers The nurse will be able to assess and categorize an ulcer by its appearance and invasiveness. Review each stage of pressure ulcers below. Stage I Stage I pressure ulcers are seen with non-blanchable erythema. They are usually found over bony prominences such as the coccyx, heels, and elbows. The client may repo Suspected Deep Tissue Injury How will the nurse best assess the client for a suspected deep tissue injury if they have darker skin tones? Use fluorescent lighting to check the client’s skin for changes. Assess the area for changes in temperature or consistency. Observe for tunneling and undermining. You cannot identify suspected deep tissue injuries in clients with dark skin tones. Dressing Change Preparation When caring for clients at risk of pressure ulcers, the nurse is responsible for preventing skin breakdown. In addition, for clients who enter care with existing pressure ulcers, the nurse is accountable for preventing them from getting worse and promoting healing with evidence-based wound care. Pressure ulcer dressing changes should be done sterile, even if the wound is infected. Equipment needed includes: • gloves (clean and sterile) • personal protective equipment (PPE), including a gown, mask, and eyewear • wound care dressing kit • sterile 0.9% sodium chloride • absorbent pad (or appropriate dressing) • sterile cotton-tipped applicators • wound measuring guide • sterile 4x4 gauze pads If the wound is in a location that is difficult to reach and the client cannot stay in a position during the dressing change, an assistant should be available to support the client during the dressing change. Changing a Sterile Dressing After explaining the dressing change, providing pain medication as needed, and positioning the client, the nurse should perform hand hygiene and don non-sterile gloves to remove the old dressing. • Removing Old Dressing • Cleaning and Dressing the Wound 1. Carefully remove the old dressing and packing, if used, without pulling on the skin . 2. Assess and document (with pictures, if required by the facility) o peri-wound area, granulation tissue, eschar, slough o wound dimensions with wound measuring guide (length, width, depth) o undermining/tunneling with a sterile cotton-tipped applicator 3. Remove and dispose of gloves . 4. Perform hand hygiene . rt pain in the area. • Previous Open supplies maintaining sterile technique and prepare sterile field (as appropriate) . • Don PPE (gown, mask, and protective eye wear or face shield) . • Don sterile gloves and prepare a sterile field . • Establish which hand will remain sterile throughout the procedure . • Draw up sterile solution with a 60 ml syringe and obtain approximately three to four gauze pads from the sterile field . • Clean and irrigate the wound using gauze pads to catch solution and debris. Begin irrigation, starting at the top of the wound. Continue to irrigate until the solution flowing out of the wound is clear . • Pat peri-wound area with gauze pads as needed to dry. Do not reuse the same gauze pad . • Discard gauze into an appropriate receptacle . • Using a cotton-tipped applicator, gently pack the wound with gauze dressing moistened with sterile saline . • Apply dry gauze over the wound to cover wound packing . • Apply appropriate absorbent dressing over dry gauze and secure with tape . • Dispose of supplies into an appropriate receptacle . • Remove and discard gloves and PPE into a trash receptacle. • Perform hand hygiene . • Label the dressing with initials, date, and time . Which documented description is best for this wound? “Dry, pink wound bed that is approximately 4 cm x 6 cm.” “Oval-shaped wound bed that is pink and moist, approximately 6 cm x 4 cm with undermining noted at the 12 o’clock to 1 o’clock position.” “Pink wound bed that is moist. Measurements unable to be obtained.” “Oval-shaped wound bed that is pale with eschar noted at the 12 o’clock position.” Preventing Pressure Ulcers Part of the nurse’s role is to not only prevent pressure ulcers from occurring, but to stop the ones that are already present from getting any worse. There are many preventative measures that we can institute to keep our clients safe from pressure ulcers or decrease their risk of developing them. Nursing Actions: Pressure Ulcer Prevention Jan (pronouns: she, her) was admitted to the hospital from a residential care facility. Her history includes a stroke with residual musculoskeletal and neurological deficits on her right side. Which nursing action would be most helpful in preventing Jan from developing a pressure ulcer? Place Jan on nothing by mouth (NPO) status. Initiate strict bed rest. Decrease the amount of protein on Jan’s meal trays. Assist Jan to reposition every 2 hours. Delayed Wound Healing Which factors play a role in delaying wound healing? Select all that apply. Diabetes mellitus Obesity High protein intake Smoking Young age Nutrition and Healing A client asks what effect nutrition has on skin integrity. Which response provided by the nurse is most accurate? "Increased dietary intake of protein can cause pressure injuries." “Dietary intake does not impact skin health or the risk of pressure injuries." "Poor dietary intake of kilocalories, protein, and iron can increase the risk of pressure injuries." “Increased dietary intake of carbohydrates and minerals can cause pressure injuries." Case Study: Jan The nurse is completing a skin assessment on Jan (pronouns: she, her), who lives in a nursing care facility after a stroke left her unable to care for herself. Jan developed a pressure ulcer on her coccyx after being in bed for a week with influenza. Recognizing Cues Select all the findings that require follow-up by the nurse. The wound is 8 cm along the vertical axis, 14.5 cm along the horizontal axis, and 4 cm deep; a moderate amount ofthick, yellow-tan, foul-smelling drainage noted at the 9-1 o’clock position and on the old dressing; the wound bed is bleeding between the 5-7 o’clock position. Client moans when wound is touched. Goals Which outcomes are appropriate for a bedfast client with a duodenal feeding tube admitted with a pressure ulcer? Select all that apply. Mobility will increase to become independent. The signs of healing will increase in the current wound. Client teaching will be provided. The intact skin will remain intact until discharge. 90% of meals will be eaten each day. Active Versus Passive Acquired Immunity Which is the best example of active acquired immunity? Administration of an intramuscular influenza vaccine Transfer of immunoglobins through colostrum to the newborn Administration of intravenous gamma globulin Transfer of immunoglobins through the placenta to the fetus Immunoglobulins Which class of immunoglobins increases during an allergic reaction? IgG IgD IgA IgE Artificial Passive Acquired Immunity Which is the best example of artificial passive acquired immunity? Acquisition of antibodies after having chickenpox Administration of intravenous gamma globulin Transfer of immunoglobulins through breastfeeding to the newborn Administration of a rubella vaccination Scope of Immunity Immunity is described as the protection from illness or disease that is maintained by the body’s physiologic defense mechanisms. The body’s immune response serves three functions: 5. Protection against invasions by microorganisms and prevention of infection by attacking foreign antigens and pathogens. 6. Digestion and removal of damaged cellular substances, thereby maintaining homeostasis. 7. Surveillance and destruction of foreign cells. Immunity has the potential to be decreased or suppressed (weakened) or exaggerated (heightened). Decreased immunity results in the inability to fight antigens. Exaggerated immunity results in allergies or autoimmune reactions or diseases. Antigens Antigens are substances that elicit an immune response. Most are composed of proteins, but others are large polysaccharides, lipoproteins, and nucleic acids. All the body’s cells have antigens on their surface that are unique to the individual and enable the body to recognize itself. This ensures that it is nonresponsive to the “self” antigen. However, we know this is not always the case and sometimes the body does attack itself. Types of Immunity Immunity is classified as innate or acquired. Select each tab to learn more. • Innate Immunity • Acquired Immunity Innate (or natural) immunity is present at birth. This type of immunity provides a nonspecific response against pathogens. Neutrophils and monocytes are the primary white blood cells involved. Innate immunity is not antigen-specific. Therefore, it can respond quickly to an invading microorganism without prior exposure to that organism. • • Acquired immunity is developed either actively or passively. • Active acquired immunity results from the invasion of the body by foreign substances, such as microorganisms, and the subsequent development of antibodies and sensitized lymphocytes. This type of immunity develops naturally from a disease, such as chickenpox, or artificially through immunization. • Passive acquired immunity results when an individual receives antibodies to an antigen rather than making them. This can occur naturally through the transfer of immunoglobins from mother to baby across the placenta or through colostrum or passively through injection with gamma globulin (serum antibodies). Immunoglobulins Immunoglobulins, also called antibodies, are glycoprotein molecules produced by plasma cells (white blood cells). They are a critical part of the immune response by specifically recognizing and binding to specific antigens and aiding in their destruction. If immunoglobulins are deficient, infections occur. The five primary classes of immunoglobulins are IgG, IgM, IgA, IgD, and IgE. Each immunoglobulin is in a specific part of the immune system and performs a different function. Review the table here to learn more. Immunoglobulins IgG Location This antibody is commonly found in the blood and bodily fluids. Purpose • IgG establishes and remembers a pathogen in the future after first exposure. • IgG crosses the placental membrane and provides the newborn with passive immunity for about 3 months after birth. IgA This antibody can be found in the lining of the respiratory and digestive tracts. • IgA regulates immune function in the mucous membranes. • IgA is found in colostrum and breastmilk. IgM This antibody is commonly found in the blood and in the lymph. • IgM is created to fight a current pathogen. IgD This antibody can be found in the blood, but in small amounts. • IgD activates basophils, mast cells, and B cells that are part of the inflammatory and immune response. IgE This antibody can be found in the blood, but in small amounts. IgE can increase if a foreign body or microorganism is present. • IgE drives an allergy reaction when sensing an allergen. Immune Responses There are several different immune responses, including humoral, cellmediated, hypersensitivity, and autoimmune. Select each tab below to learn about the type of immune response. • Humoral Immunity • Cell-Mediated Immunity • Hypersensitivity Reaction • Autoimmunity Humoral immunity is antibody-mediated immunity. This type of immunity involves B cells, antigens, and immunoglobulins. Here is how it works! When a pathogen enters the body, the B cell recognizes the antigen because it has receptors on its cell surface specific for that antigen. When the antigen contacts the cell surface receptor, the B cell becomes activated, and most B cells differentiate into plasma cells. The mature plasma cells secrete immunoglobulins. The B cells that remain undifferentiated are memory cells. IgM is the first antibody formed but is confined to the intravascular space. As the immune response progresses, the body makes IgG which can move from the intravascular to extravascular spaces. When a person is exposed to the antigen a second time, a secondary antibody response occurs, but this time it is faster and lasts longer. Memory cells account for the memory of the first exposure and the more rapid production of antibodies. IgG is the primary antibody responsible for the second immune response. Humoral or antibody-mediated immunity occurs when antibodies and antigens interact to slow down or destroy a foreign substance. When the immune response is initiated through specific antigen recognition by T cells, it is termed cell-mediated immunity. This type of immunity involves T cells, macrophages, and natural killer cells. Cell-mediated immunity is important in: • immunity against pathogens that survive inside cells, such as viruses and some bacteria • fungal infections • rejection of transplanted tissues • contact hypersensitivity reactions • tumor immunity Cell-mediated immunity occurs when cells function together to fight off the antigen. • • • • • • • Hypersensitivity Reaction Autoimmunity When an immune response overreacts to an allergen (organic material without a living cell structure), it is called a hypersensitivity reaction. This type of immunity results in a primary inflammatory response without the creation of T cells or B cells. Hypersensitivity reactions are classified by the source of the antigen, time sequence (immediate or delayed), or immunologic mechanisms causing the injury. There are four types: • • • • Type I is IgE mediated and the response is immediate. Type II is cytotoxic and the response is immediate. Type III is immune-complex and the response is immediate. Type IV is related to cell-mediated immunity and the response is delayed. Autoimmune disease is a type of hypersensitivity reaction and occurs when the body does not recognize self-proteins and reacts against selfantigens. So, basically, the body does not recognize what is normal and abnormal. An example of an autoimmune disease is systemic lupus erythematosus. Nursing Considerations As we age, our immune system changes which results in: • increased incidence of cancer • increased susceptibility to infections, even those previously exposed to • lowered response to immunizations • decreased or absent delayed hypersensitivity reaction Immunoglobin levels decrease with age, leading to a suppressed humoral immune response. The thymus shrinks, leading to a decreased number of T cells. Both T and B cells show deficiencies in activation, transit time through the cell cycle, and subsequent differentiation. The most significant change involves the T cells. As the production of T cells decreases, the differentiation of T cells increases. This results in an accumulation of memory cells rather than new precursor cells responsive to previously encountered antigens. Risk Factors for Altered Immune Response Conducting a complete client and family history for risk factors for altered immune response is essential. Risk factors for altered immune response include: • • • • • • • aging lack of immunization chronic illness that weakens the immune system chronic drug therapy, such as corticosteroids and chemotherapy substance use disorder lack of healthy lifestyle genetic risk for decreased or excessive immunity Diagnostic Testing for Altered Immune Response Several diagnostic tests are used to assess the immune system. Diagnostic Studies Purpose Complete blood count with differential *When a differential is included, the types of white blood cells are identified (neutrophils, lymphocytes, monocytes, basophils, and eosinophils). This test will help identify the presence of an infection or altered immune response. Quantitative lymphocyte subsets: • T cells • B cells • NK cells This test is used to diagnose and monitor specific immunodeficiency syndromes, such as HIV. Also, it is used to monitor response to immunosuppressive therapy. IgE, serum This test is used to evaluate for diseases associated with elevations in IgE, such as allergic disease, primary immunodeficiencies, infections, malignancies, and other inflammatory diseases. IgM, serum This test is used to detect or monitor for deficiencies. IgG, serum IgA, serum IgD, serum This test provides information about humoral immune status. C-reactive protein, serum This test is used to detect systemic inflammatory processes. Erythrocyte sedimentation rate, serum This test is used to detect inflammation in the body. Antinuclear antibodies (ANA), serum This test is used to evaluate clients at risk for antinuclear antibodies associated with system autoimmune disease, particularly systemic lupus erythematosus. Rheumatoid factor, serum This test is used to diagnose rheumatoid arthritis. Culture, sputum, nasal, and bronchial secretions This test is used to identify the presence of microorganisms. Skin testing This test is used to identify the specific allergens that are causing allergy symptoms. Skin testing typically involves a scratch or prick test on the arms and back. Allergen extracts are applied to the skin in rows with a corresponding control site. Saline is applied to the control site. Positive results appear within 5–10 minutes. The size of the localized wheal (positive reaction) does not correlate with the severity of the allergy. Neutropenia and Risk for Infection Neutropenia is a decreased number of white blood cells (specifically, neutrophils), which are the body’s main defense against infection. Some medical conditions or medical therapy may cause neutropenia. Clients with neutropenia are at very high risk of developing a serious or lifethreatening infection. Neutropenia is the most serious hematologic consequence of cancer treatment with chemotherapy. Neutropenic Precautions Neutropenic precautions are measures taken to prevent infection in clients with moderate to severe neutropenia. Some of the precautions include: • Wash your hands often using soap and water. Dry your hands completely after washing. • Bathing daily lowers the number of microorganisms on the skin, thereby decreasing the risk of infection. Use an electric razor when shaving to prevent cuts where microorganisms can enter the body. • Brush your teeth twice every day to minimize infections in the mouth. • Prevent constipation by increasing fluids. Constipation can cause a tear in the rectum, leading to infection. Stool softeners may be necessary. • Avoid the use of tampons, which can cause vaginal tears leading to infection. • Avoid sharing personal items with others, especially drinking glasses, eating utensils, and bath towels. • Avoid fresh flowers, live plants, and standing water as microorganisms can grow in soil and water. • Avoid contact with animal feces, urine, and saliva which may lead to infection. • Avoid eating raw, unwashed fruits and vegetables. Raw or undercooked eggs and soft cheeses with mold should be avoided as well. • Do not eat undercooked meats. Use a food thermometer to ensure food is cooked to the correct temperature. • Avoid large crowds and anyone with a communicable disease. Neutropenia and the Healthcare Environment When caring for a client with neutropenia, it is important to remember that microorganisms can invade from a variety of places including the client’s normal flora, air, food, water, equipment, and direct contact with healthcare providers, visitors, and other clients. Healthcare workers must minimize exposure to microorganisms. Creating a protective environment includes: • • • • • • Place the client in a single-patient room with a private bathroom. Avoid nurse assignments that include an infectious client and an immunocompromised client. Use a client room with directed positive pressure air flow that is well-sealed to prevent air from the outside. Implement strategies to minimize dust, including routine cleaning. Prohibit dried or fresh flowers and potted plants in the client’s room. If dust-generating activities are ongoing in a healthcare facility (e.g., construction, renovation), then the client should wear a N95 mask when leaving the room. • Nurses should follow standard or transmission-based precautions (as indicated) in the care of immunocompromised clients (Centers for Disease Control and Prevention, 2022). Other strategies include: • • • • Screen visitors for infectious diseases. Avoid fresh, unwashed fruit and vegetables in the diet. Closely monitor the client for signs and symptoms of infection. Administer prophylactic antimicrobials. Management: Allergic Disorders Performing a focused nursing assessment, including objective and subjective data as well as understanding medical management for allergic disorders, is essential when caring for a client with an altered immune response. • Nursing Assessment • Interprofessional Management Conducting a complete client assessment to identify existing problems indicating altered immune response is essential. Important cues to recognize include subjective data, such as: • Past health history: recurrent respiratory problems, seasonal exacerbations, unusual reactions to insect bites or stings, past and present allergies • Medications: unusual reactions, use of over-the-counter or prescription drugs to treat allergies • Nutrition: food intolerances, vomiting • Elimination: abdominal cramps, diarrhea • Activity/exercise: fatigue, hoarseness, cough, dyspnea • Other symptoms: itching, burning, stinging of eyes, nose, throat, or skin, chest tightness Important cues to recognize include objective data, such as: • Integumentary: rash, urticaria, wheals, flares, papules, vesicles, dryness, scaliness, scratches, irritation • Eyes: conjunctivitis, tearing, rubbing or excessive blinking, dark circles under eyes • Ears: diminished hearing, immobile or scarred tympanic membranes, recurrent ear infections • Nose: polyps, nasal voice, nose twitching, itchy nose, rhinitis, pale mucous membranes, sniffling, sneezing, swollen nasal passages, recurrent nosebleeds • Throat: continual throat clearing, swollen lips or tongue, red throat, palpable lymph nodes Image Description After an allergic disorder is diagnosed, treatment is aimed at reducing exposure to the allergen, treating the symptoms, and, possibly, desensitizing through immunotherapy. The major categories of medications used for symptom relief include antihistamines, sympathomimetic/decongestants, corticosteroids, antipruritics, and mast cell stabilizers. When allergies cannot be avoided and drug therapy is not effective, immunotherapy may be indicated. This involves giving small titers of an allergen extract in increasing strengths until hyposensitivity to the specific allergen is achieved. NOTE: Food allergies cannot be safely treated with immunotherapy. Treatment of Allergic Disorders The nurse is caring for a client who has been admitted with an acute asthma exacerbation secondary to an allergic reaction. Albuterol is administered to open the airway. Which medication does the nurse anticipate administering to reduce inflammation? Antipruritic Mast cell stabilizer Decongestant Corticosteroid Anaphylaxis Anaphylactic reactions occur suddenly in hypersensitive clients after exposure to the offending allergen. Management involves speed in recognizing clinical manifestations, maintaining a patent airway, administering medications, and treating shock. Epinephrine is the drug of choice to treat an anaphylactic reaction. It must be given intramuscularly or intravenously. Image Description Emergency adrenaline epinephrine injection Anaphylaxis and Hypovolemic Shock Severe cases of anaphylaxis may result in hypovolemic shock, due to the loss of intravascular fluid into interstitial spaces that occurs because of increased capillary permeability. Peripheral vasoconstriction and stimulation of the sympathetic nervous system occur to compensate for the fluid shift. Unless treated quickly, the body’s compensatory mechanisms will fail and irreversible tissue damage will occur, leading to death. Nurses must be prepared for the rare but life-threatening anaphylactic reaction, which requires immediate medical and nursing interventions. Treatment of Anaphylaxis The nurse is caring for a client who has an anaphylactic reaction following the administration of penicillin. Which medication does the nurse anticipate administering first? Epinephrine Decongestants Antipruritic Corticosteroids Latex Allergies Latex allergies are an ongoing problem affecting both clients and healthcare workers. An increase in allergic reactions is due to the increased use of latex-containing gloves. The more frequent and prolonged exposure to latex, the greater the risk of developing a latex allergy. Latex proteins can become aerosolized through powder on gloves, resulting in serious reactions when inhaled by someone with latex sensitivity. For this reason, healthcare facilities should use powder-free gloves. In addition to gloves, many healthcare supplies contain latex, including blood pressure cuffs, stethoscopes, tourniquets, IV tubing, syringes, electrode pads, oxygen masks, ostomy pouches, urinary catheters, and adhesive tape. Two types of latex allergies can occur: contact dermatitis and allergic reactions. • Contact dermatitis is caused by the chemicals used when latex gloves are made. This type of reaction is typically delayed 6 to 48 hours and includes dryness, pruritis, and cracking of the skin. The initial response is quickly followed by redness, swelling, and crusting. If exposure continues, lichenification, scaling, and hyperpigmentation occur. • An allergic reaction to latex is a response to the natural rubber latex proteins and occurs within minutes of exposure. Manifestations vary from skin redness, urticaria, rhinitis, conjunctivitis, or asthma to a serious anaphylactic reaction and shock. Certain foods contain proteins that are similar to those found in rubber and may cause an allergic reaction. This is called latex-food syndrome. High-risk foods include bananas, avocados, chestnuts, kiwis, tomatoes, guavas, hazelnuts, potatoes, peaches, grapes, and apricots. Autoimmunity Autoimmunity is an immune response against the body in which the immune system no longer differentiates itself from non-self. For unknown reasons, immune cells that are normally unresponsive to self-antigens are activated. Autoantibodies and auto-sensitized T cells cause pathophysiologic tissue damage. Two factors play into the development of autoimmunity: • genetic predisposition through the inheritance of susceptible genes • initiation of autoreactivity by triggers, such as infections or medications, which activate self-reactive lymphocytes Gender and hormones also play a role in autoimmune disease. More women than men are diagnosed with an autoimmune disease. During pregnancy, many autoimmune diseases get better. However, after pregnancy, exacerbations occur. Review this table for a list of many autoimmune diseases and the specific body systems affected. Body System Autoimmune Diseases Systemic diseases • rheumatoid arthritis • systemic lupus erythematosus Hematopoietic system • autoimmune hemolytic anemia • immune thrombocytopenic purpura Central nervous system • Guillain-Barre syndrome • multiple sclerosis Endocrine system • Addison’s disease • Grave’s disease • diabetes mellitus type 1 Gastrointestinal system • celiac disease • inflammatory bowel disease Cardiovascular system • rheumatic fever Renal system • glomerulonephritis Liver • autoimmune hepatitis • primary biliary cirrhosis Musculoskeletal system • myasthenia gravis Medical therapy focuses on suppressing the immune system to reduce the damage associated with cellular attacks. Specific medications used include disease-modifying anti-rheumatics (DMARD) and biological response modifiers (BRM). Some examples of triggers for autoimmune disorders: • Diabetes mellitus type 1 is thought to be triggered by a virus. • Rheumatic fever and rheumatic heart disease are triggered by streptococcal infections. • Hemolytic anemia can result from methyldopa administration . • Procainamide can induce the formation of antinuclear antibodies, causing a lupus-like syndrome. Apheresis Apheresis is a procedure to separate components of the blood followed by the removal of one or more components. It is an effective treatment for several autoimmune diseases. • Plateletpheresis is the removal of platelets, usually for infusion into clients with a low platelet count. • Leukocytapheresis is the removal of white blood cells, which are used to treat leukemia. • Plasmapheresis is the removal of plasma-containing components causing disease. Organ Transplantation Deliberate Immunosuppression In some cases, the immune system is intentionally suppressed to treat an underlying problem. Using a combination of medications, the immune system is blocked from doing its job. Unfortunately, blocking the immune system can increase the risk of a pathogen attack. Organ Transplantation Common tissue transplants include corneas, skin, bone marrow, heart valves, bone, and connective tissues. Organ transplants may include the heart, kidney, pancreas, lung lobes, or liver. If the immune system is not suppressed after a transplant, rejection can occur. Transplant rejection happens because an organ that was donated is considered a “foreign object” by the body. The immune system will fight against this foreign object unless it is weakened. Select each tab below to learn more about types of transplant rejections. Hyperacute Rejection Hyperacute rejection occurs within 24 hours of an organ transplant due to rapid blood vessel destruction. Preexisting antibodies attack the transplanted organ. There is no treatment for hyperacute rejection and the transplanted organ must be removed. Immunosuppression medications can prevent this type of rejection from occurring Acute Rejection Acute rejection typically occurs within the first six months following an organ transplant and is a cell-mediated immune response. The organ recipient’s lymphocytes are activated against the donated organ. Acute rejection may also include a humoral response in which the recipient develops antibodies against the transplanted organ. Acute rejection episodes are usually reversible with immunosuppressive therapy. To prevent acute rejection, the client will need life-long immunosuppressants, placing them at high risk for infection. Chronic Rejection Chronic rejection is a process that occurs over months or years and is irreversible. It can occur for unknown reasons or due to repeated episodes of acute rejection. Large numbers of T and B cells infiltrate the transplanted organ, causing a chronic immune-mediated injury (scaring and fibrosis). Treatment is supportive as there is no cure for this type of rejection. The prognosis is poor for the donated organ. Susie Goodman (pronouns: she/her/hers), age 42, presents to the emergency department (ED) with a rash over most of the body, urticaria, pruritis, tearing, sniffling, severe headache, and constant throat clearing. She has a history of food allergies but denies exposure to allergens. Her daughter recently adopted a cat. Susie takes amlodipine for hypertension and glyburide for diabetes mellitus type 2. Question 2 / 5 Prioritizing Hypotheses The nurse analyzes the assessment findings and determines which is the most likely cause of the allergic reaction? Amlodipine Food allergies Glyburide Pet allergies Body Fluids Containing Human Immunodeficiency Virus Which body fluids transmit human immunodeficiency virus (HIV)? Select all that apply. Vaginal fluid Urine Breast milk Blood Sweat Semen Common Transmission Routes Most adults are infected with human immunodeficiency virus (HIV) through blood transfusion sexual intercourse and sharing drug injection equipment workplace exposure . The most common way that children acquire HIV is through blood transfusion perinatal transmission . Transmission-Based Precautions When caring for a client infected with human immunodeficiency virus (HIV), which transmission-based precautions should be implemented? Droplet precautions Standard precautions Airborne precautions Contact precautions Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome Timeline Human immunodeficiency virus (HIV) in humans came from a type of chimpanzee in Central Africa. It is thought that the virus may have “jumped” from chimpanzees to humans as far back as the late 1800s. The virus was likely passed to humans when the chimpanzees were hunted for food and humans came in contact with their infected blood (CDC, 2022). Over decades, HIV slowly spread across Africa and into other parts of the world. The virus has existed in the United States since the mid to late 1970s, but the first official report of what would eventually be known as acquired immunodeficiency syndrome (AIDS) was not until 1981 (CDC, 2022). The first report of AIDS, likely from a blood transfusion, occurred in 1982 and reports also hinted at the possibility of perinatal transmission (CDC, 2022). Through the remainder of the 1980s, researchers worked to track cases, identified major routes of HIV transmission, made recommendations to prevent occupational exposure for healthcare workers, and started public health campaigns. In the 1990s, the CDC issued recommendations for healthcare workers living with HIV, defined AIDS based on CD4 cell count, published guidelines for preventing the spread of HIV through tissue and organ transplants, and issued the first national treatment guidelines (CDC, 2022). In the 2000s, the CDC announced major public health initiatives to reduce HIV infections and improve the diagnosis and treatment of those already affected. In 2006, new HIV testing recommendations were released (CDC, 2022). In the 2010s, the CDC revised and launched a new framework to reduce new HIV infections and launched new public health campaigns aimed at testing, open communication, and treatment. In 2019, the CDC announced its Ending the HIV Epidemic initiative. In March 2020, the CDC published an article showing the link between pre-exposure prophylaxis (PrEP) and lowered HIV diagnosis rates (CDC, 2022). Of course, this is just a snapshot of the work that has been ongoing for several decades in the fight against HIV. To read more about this work, review the HIV and AIDS Timeline (CDC, 2022). Transmission of Human Immunodeficiency Virus Semen, vaginal fluid, breastmilk, and blood can carry the human immunodeficiency virus (HIV). Most adults are infected with HIV through anal or vaginal intercourse or sharing drug injection equipment (CDC, 2022). The highest risk for infection is assumed by the partner receiving the semen. HIV can be transmitted from mother to baby during pregnancy, childbirth, or breastfeeding, which are the most common ways that children acquire HIV. The CDC recommends that all pregnant clients be tested for HIV early in pregnancy and treatment started immediately if positive. If a client takes HIV medication throughout pregnancy and childbirth and administers HIV medication to the baby for 4 to 6 weeks, the risk of perinatal HIV transmission is less than 1% (CDC, 2022). In the past, blood transfusions and organ transplants have resulted in HIV transmission. However, stringent testing requirements now in place make this method of transmission very unlikely (CDC, 2022). Healthcare personnel have a low risk of acquiring HIV at work, even after a needle-stick injury. HIV cannot be transmitted during blood collection procedures, provided that disposable or sterilized equipment is used. HIV cannot be transmitted by consuming food handled by someone with HIV, through intact skin, transfer of saliva (kissing), or casual touch (CDC, 2022). Casual touch includes hugging and shaking hands. HIV is not transmitted via tears, urine, emesis, sputum, feces, sweat, respiratory droplets, or enteric routes. HIV is not transferred to toilet seats or shared eating utensils. Pathophysiology of Human Immunodeficiency Virus Infection Human immunodeficiency virus (HIV) is a retrovirus because it replicates in a “backward” manner, moving from RNA to DNA. Like all viruses, HIV cannot replicate unless it is inside a living cell. The CD4 T cell, a type of lymphocyte, is the target cell for HIV. HIV enters the CD4 cell by binding to protein receptors on the outside of the cell in a process called fusion. Once HIV is fused to the CD4 cell, HIV RNA enters the cell and triggers the release of reverse transcriptase, an enzyme that transforms HIV RNA into a single strand of DNA. This single strand copies itself, becoming a doublestranded viral DNA. Another enzyme, called integrase, allows the double-stranded DNA to integrate itself into the individual’s genetic structure. This causes two problems: • The genetic material is duplicated during cell division. • Viral DNA directs the cell to make new HIV. Protease, another enzyme, divides the newly formed strands of HIV into smaller pieces and new virions are formed and released. As the virions are released, the CD4 cell is destroyed. HIV destroys about 1 billion CD4 cells daily. The body will attempt to make new CD4 cells to replace the destroyed ones and this process will be successful for many years. However, over time, the ability of HIV to destroy CD4 cells exceeds the body’s ability to replace the cells, resulting in a significantly decreased CD4 cell count and altered immune function. 3D image of T cells Prevention of Human Immunodeficiency Virus Infection Related to Sex Infection with the human immunodeficiency virus (HIV) is preventable. Avoiding and modifying risky behaviors is the most effective prevention method. Nurses who are comfortable with and know how to talk about sensitive topics such as sexuality and drug use are best prepared to provide prevention education. Many activities can reduce the risk of HIV infection. Prevention techniques are divided into two categories: safe sexual practices (those that eliminate risk) and risk-reducing sexual practices (those that decrease but do not eliminate risk). Select each tab to learn more. Safe Sexual Practices Safe sexual practices eliminate the risk of exposure to HIV in semen and vaginal secretions. • Abstaining from sexual activity is the most effective way to prevent exposure. • Sexual activities that do not include the transference of body fluids (e.g., masturbation, mutual masturbation) are effective to prevent exposure. • Sexual penetration between partners who are not infected and not at risk of infection is considered safe. Abstinence Risk-Reducing Sexual Practices Risk-reducing sexual practices decrease the risk of contact with HIV through the use of barriers. When sexual penetration occurs with a partner who has HIV or whose status is unknown, a barrier should always be used. • The most commonly used barrier is the male condom, which offers protection during anal, vaginal, and oral intercourse. • Female condoms are the alternative to male condoms. Female condom (top) and male condom (bottom) used to prevent HIV infection Prevention of Human Immunodeficiency Virus Infection Related to Drug Use Infection with the human immunodeficiency virus is preventable. Avoiding and modifying risky behaviors is the most effective prevention method. Nurses who are comfortable with and know how to talk about sensitive topics such as sexuality and drug use are best prepared to provide prevention education. Drug use, including alcohol and tobacco, can cause immunosuppression, poor nutrition, and psychosocial problems. However, typical drug use does not cause HIV infection. The major risk for HIV related to drug use involves sharing injection equipment or having unsafe sexual experiences while under the influence of drugs. Prevention of HIV infection includes the following: • Do not use drugs! • If drugs are used, do not share equipment. • Do not have sexual intercourse when under the influence of drugs, which impairs decision making. Prevention of Human Immunodeficiency Virus Infection Related to Other Risks The human immunodeficiency virus (HIV) can be transmitted from mother to baby and via workplace exposure. Click on each tab to learn more. Perinatal Transmission The best way to prevent human immunodeficiency virus (HIV) infection in infants is to prevent infection in women. All pregnant women should be tested for HIV infection in early pregnancy. If a woman with HIV becomes pregnant, antiretroviral therapy (ART) is needed throughout pregnancy to reduce the risk of perinatal transmission. Breastfeeding is contraindicated if the mother has HIV. The infant should receive ART for 4–6 weeks after birth. When ART is used appropriately, the risk of perinatal transmission drops from 25% to less than 1% (CDC, 2022). Occupational Exposure The risk of human immunodeficiency virus (HIV) infection from occupational exposure is small but it does occur. Exposure from splashes with body fluids is almost zero. Exposure from percutaneous (needlestick) injury is less than 1% (CDC, 2019). If exposure occurs, testing, timely treatment, and counseling are essential. Taking precautions decreases the risk of direct contact with blood and body fluids. Some ways to prevent occupational exposure include: • Use standard precautions and personal protective equipment when anticipating contact with blood or body fluids. • Wash your hands immediately after contact with blood or body fluids. • Be careful when handling and disposing of sharp devices. • Use safety devices to prevent needlestick injuries. • Dispose of used syringes and other sharp instruments in a sharps container (CDC, 2019). Pre-Exposure Prophylaxis Pre-exposure prophylaxis (PrEP) is a medication that can reduce the chance of contracting the human immunodeficiency virus (HIV) from sexual activities and unsafe drug injection practices. PrEP should be used in conjunction with other prevention strategies. When taken as prescribed, PrEP reduces the risk of contracting HIV through sexual activities by 99% and through drug injection by at least 74% (CDC, 2022). Watch this video, "PrEP (Pre-Exposure Prophylaxis)", to learn more about PrEP. Reference Centers for Disease Control and Prevention. (2021, April 7). PrEP (Preexposure prophylaxis) [Video]. YouTube. https://youtu.be/1_eo17YahCo There are two pills and one injectable approved for use: • Emtricitabine/tenofovir disoproxil fumarate ( Truvada) is recommended for clients at risk through sex or drug injection. • Emtricitabine/tenofovir alafenamide ( Descovy) is recommended for clients at risk through sex. • Cabotegravir ( Apretude) is an injection approved for use in people who are at risk through sexual activities. Post-Exposure Prophylaxis Post-exposure prophylaxis (PEP) is taken after possible exposure, including occupational exposure, to the human immunodeficiency virus (HIV) to prevent transmission. PEP should only be used in emergency situations and must be started within 72 hours after a possible exposure. PEP must be taken 28 days after exposure. PEP involves a 3-dose regimen of medications. The preferred regimen is raltegravir twice daily and emtricitabine/tenofovir disoproxil fumarate (Truvada) once daily (Markelz & Okulicz, 2021). PEP is effective in preventing HIV infection, but it is not 100% effective. The sooner PEP is started after possible exposure, the better. Every hour counts! While taking PEP, it is important that the client continues using other HIV prevention methods. Remember, PrEP is for pre-exposure, whereas PEP is for post-exposure. Clinical Manifestations of Human Immunodeficiency Virus Clinical manifestations of human immunodeficiency virus (HIV) depend on the duration of time that has passed since contracting the virus. Select each tab to review the differences between acute infection and chronic infection. • Acute HIV Infection • Chronic HIV Infection Acute HIV Infection (2 to 4 weeks after contracting the infection) What is going on? There is a high viral load, meaning the amount of HIV circulating in the blood. The CD4 cell count temporarily falls but quickly returns to normal or near normal levels. The client is the most infectious during this stage. Clinical Manifestations Symptoms include fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, and diffuse rash. These symptoms are often mistaken for influenza or mononucleosis. Complications Complications include aseptic meningitis, peripheral neuropathy, facial palsy, or Guillain-Barre syndrome. During the first several years after infection, clients are typically asymptomatic with no symptoms or limited signs of infection. Screening Tests Diagnosis of human immunodeficiency virus (HIV) is made by testing for HIV antibodies and antigens. Watch this short video, "HIV Testing," about the importance of testing. Reference Centers for Disease Control and Prevention. (2021, April 7). HIV testing [Video]. YouTube. https://youtu.be/uScEAA9LlZw Screening tests can be done with either blood or saliva. However, it takes several weeks after infection before a screening test can detect evidence of HIV. The typical window period for most tests to detect HIV infection is about three weeks. Testing inside the window period may result in a false negative result. There are three types of screening tests for HIV infection: antibody tests, antigen/antibody tests, and nucleic acid tests. Review this table to learn more. Type of Test Body Fluid Used Antibody Test Blood or oral fluid Purpose To detect HIV antibodies Result Time 20–30 minutes Important Information • Most rapid tests and selftests are antibod y tests. • Using blood from a vein can detect HIV infectio n sooner than blood from a finger stick or oral fluid. • The window period is 23– 90 days. Antigen/ Antibody Test Blood To detect HIV antibodies and antigens If rapid, 30 minutes. If not, several days. • A rapid antigen /antibo dy test is availabl e. • Blood can be collecte d from a vein or a finger stick. • The window period is 18– 90 days if rapid, or 18– 45 days if not rapid. Nucleic Acid Test Blood To detect the actual virus and viral load in the blood Several days • Blood from a vein is require d. • This test can detect HIV infectio n sooner than other types of tests (10–33 days after exposur e). • This test should be perfor med on people with recent exposur e, early sympto ms, and who have tested negativ e with antibod y or antigen /antibo dy tests. Tests to Manage Human Immunodeficiency Virus Progression Two laboratory tests are used for monitoring human immunodeficiency virus (HIV) progression: CD4 cell count and viral load. Review this table for details. Tes t Purpose CD 4 cell cou nt CD4 cell count is a marker of immune function. 800–1200 cells per microliter Vira l loa d This test measures the viral levels in the blood. None detected or undetectable Normal Range *A CD4 cell count below 200/microliter means the client has progressed to AIDS. *Undetectable does not mean that HIV has been eliminated from the body, only that the amount of circulating virus is Important Information As the disease progresses, the CD4 cell count decreases. The lower the viral load, the less active the disease. The goal of medical therapy is to suppress the viral load to the lowest possible level. too low to be detected by the test. Other tests to monitor include the complete blood count, liver function studies, and a hepatitis detection panel. • Decreased white blood cells, platelets, and red blood cells are common due to HIV infection, opportunistic infections, or complications of therapy. • Altered liver function is common due to HIV infection, drug therapy, and co-infection with hepatitis B or C. Similar to culture and sensitivity testing, resistance tests can determine if a client has become resistant to certain antiretroviral drugs. Medical Management Goals Medical management of clients with human immunodeficiency virus (HIV) focuses on: • monitoring disease progression and immune function • initiating and monitoring antiretroviral therapy (ART) • preventing the development of opportunistic diseases • detecting and treating opportunistic diseases • managing symptoms • preventing or decreasing complications of treatment • preventing transmission of HIV To achieve these goals, ongoing assessment, client teaching, and support are essential. Drug Therapy Drug therapy in the management of human immunodeficiency virus (HIV) is aimed at decreasing the viral load, maintaining or increasing the CD4 cell count, preventing HIV-related symptoms and opportunistic diseases, delaying disease progression, and preventing transmission. There is no cure for HIV, but antiretroviral therapy (ART) can delay disease progression by decreasing viral replication. However, it must be taken consistently and correctly. When that is done, ART can reduce the viral load by up to 99%. Adherence to the treatment regimen is extremely important. Since medications used to treat HIV work at various points in the virus replication cycle, combination therapy using several different drug classes is important. Review this table for common classes and medications used to treat HIV. Drug Classification Mechanism of Action Generic Name(s) Attachment inhibitors Interrupts the ability of HIV to attach to the CD4 cell. Ibalizumab Entry inhibitors Prevents the binding of HIV to cells, thus preventing entry of HIV into cells where replication would occur. Enfuvirtide Maraviroc Integrase inhibitors Binds with integrase enzyme and prevents HIV from incorporating its Bictegravir Dolutegravir Elvitegravir genetic material into the host cell. Protease inhibitors Prevents the protease enzyme from cutting HIV proteins into the proper lengths needed to allow viable virions to assemble and bud out from the cell membrane. Atazanavir Darunavir Fosamprenavir Nonnucleoside reverse transcriptase inhibitors Inhibits the action of reverse transcriptase. Efavirenz Etravirine Delaviridine Nucleoside reverse transcriptase inhibitors Inserts a piece of DNA into the developing HIV DNA chain, blocking further development of the chain and leaving the production of the new strand of HIV DNA incomplete. Abacavir Didanosine Doravarine Nucleotide reverse transcriptase inhibitors Combines with reverse transcriptase enzyme to block the process needed to convert HIV RNA into HIV DNA. Tenofovir Nursing Management Nursing care for the client with human immunodeficiency virus (HIV) focuses on early detection, promoting health and limiting disability, managing problems caused by HIV, maximizing quality of life, and resolving life and death issues. Assessment • risk factors • risky lifestyle behaviors • comprehensive physical assessment (objective and subjective data collection) • mental health • resources • laboratory values Nursing Diagnoses • • • • Plan • adhere to a drug regimen • adopt a healthy lifestyle • protect others from contracting HIV • maintain or develop healthy, supportive relationships • maintain activities and quality of life • resolve issues related to disease, disability, and death • cope with symptoms caused by HIV and treatments Implementation • interventions are based on assessment findings • monitor for complications caused by HIV or its treatment Evaluation • evaluate interventions to determine if goals were met risk of infection knowledge deficit difficulty coping imbalanced nutrition End-of-Life Care With advances in antiretroviral therapy, many clients are living longer and aging with the human immunodeficiency virus (HIV). However, despite new developments in treatment, many clients eventually have disease progression, leading to disability and death. Nursing care during the terminal phase of the disease should focus on comfort care, emotional and spiritual acceptance, and supporting family members and close friends. Therapeutic Communication The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who states, “I feel that there is no hope or reason to live.” Which response by the nurse is most appropriate? “Why do you feel this way?” “I’m so sorry that you feel this way. I understand how you feel.” “Can you tell me more about how you are feeling?” “Let’s focus on your treatment right now so you can get better.”