Unit 1 - 211

Types of Hypersensitivity [Type II: Cytotoxic]

- Reaction of IgG with host cell membrane or antigen absorbed by host cell membrane - Examples: Autoimmune hemolytic anemia Goodpasture syndrome Myasthenia gravis

Types of Hypersensitivity [Type 1: Rapid or immediate]

- Reaction of IgE antibody on mast cells with antigen, which results in release of mediators, especially histamine - Examples: Hay Fever [rhinosinussitis] Allergic Asthma Anaphylaxis Angioedema

Client education for TB

- Cover mouth and nose with tissue when coughing, sneezing, laughing. - Burn tissues. - Perform good hand washing. - Practice good nutrition. - Take full course of medications. - Return to clinic for sputum smears.

Methotrexate (Immunosuppressant)

- DMARD - depletes folic acid [take supplement] - Don't get preggo - Causes immunosuppression [Infection and bleeding risk] - Monitor Liver [LFTs and CBC] - Can lower BP and decrease risk of stroke/MI

What is the multiple-puncture [Tine] test?

- A tuberculin test performed with a special disposable instrument that contains multiple sharp points or prongs for piercing the skin. The tines penetrate the skin and introduce the tuberculin applied to them. The test is read in 48 to 72 hr. The tine test has largely been replaced by testing with an intradermal injection of purified protein derivative. - Less accurate

Nucleoside and Nucleotide reverse Transcriptase inhibitors [NRTIs]

- Abacavir [Ziagen] PO - Didanosine [ddl, Videx] PO - Emtricitabine [Emtriva, FTC] PO - Lamivudine [Epivir, 3TC] PO - Stavudine [d4T, Zerit] PO - Tenofovir disoproxil [Viread] PO - Zidovudine [Retrovir, ZDV] PO or IV

Nursing Education for Pyrazinamide [PZA] for TB

- Administer with food to reduce GI upset - Drink at least 8oz of water to decrease uric acid - Assess for jaundice - No alcohol - Wear sunscreen - Drink lots of fluids - Labs - Could cause flare up of gout

allergic rhinitis (hay fever)

- Allergen, antibody, mast cell interactions resulting in release of histamine. - Seasonal vs Perennial - Genetic connection

Type I: Rapid Hypersensitivity Reactions

- Also called atopic allergy; most common type - Reaction of IgE antibody on mast cells with antigen, which results in release of mediators, especially histamine - histamine release: Increase - as long as the antigen is present histamine will be continually released - Acute inflammation: Inhaled; Ingested; Injected; Contracted

Risk Factors for TB

- Breathing - Medical conditions that lower the immune system - Close & frequent contact with infected person - Travel to place with high TB rates - Live in crowded areas - Elderly - Substance use/abuse - Lower socioeconomic Immigrants

Allergic Rhinitis [Drug Therapy]

- Decongestants [Pseudoephedrine (sudafed); Oxymetazoline (Afrin)] - Antihistamines [Diphenhydramine (Benadryl); cetirizine (zyrtec); Loratadine (claritin; Fexofenadine (Allegra)] - Corticosteroids [help inflammation and suppress immunity] - Nasal sprays [mast cell stabilizing agents - 3-4 weeks for them to start working] - Leukotriene Modifier [Montelukast (singular)] - CAM therapies

Nonnucleoside reverse transcriptase inhibitors (NNRTIs)

- Delavidine [Resciptor] - Doravine [Pifeltro] - Efavirenz [Intelence] - Nevirapine [Viramune] - Rilpivirine [Edurant] ALL PO

Entry Inhibitors and Integrase Strand Transfer Inhibitors [INSTI]

- Dolutegravir [DTG; Tivicay] PO - Elvitegravir [Vitekta] PO - Enfuvirtide [Fuzeon] Subcu - Ibalizumab IV - Maraviroc [Selzentry] PO - Ralegravir [Isentress] PO

Physical findings with TB

- Dullness with percussion - Bronchial breath sounds - Crackles - Localized wheezing

TB Key Points: Iggy

- Educate the family and the patient with TB who lives at home about the side effects of anti-TB therapy and when to notify the primary health care provider. QSEN: Patient-Centered Care • - Assess the patient receiving first-line drug therapy for TB for any symptoms of liver impairment (dark urine, clay-colored stools, anorexia, jaundiced sclera or hard palate).

Nursing Education for Isoniazid [INH] for TB

- Empty stomach (1-2 hr before meals) - Take B6 vitamins [prophylaxis for neuritis] - NO TYRAMINE - Avoid ETOH

Surgical options

- End stage RA: TJA or synovectomy

PEP (post-exposure prophylaxis)

- Exposed to HIV - Highly effective when taken within 72 hours of exposure - 2-4 medications taken for 28 days - Truvada [Tenofovir NRTI/emtricitabine NRTI] + raltegravir or dolutegravir [both INSTIs] - Not 100% effective

Types of Hypersensitivity [Type III: Immune complex-Mediated]

- Formation of immune complex of antigen and antibody, which deposits in walls of blood vessels and results in complement release of inflammation - Examples: Serum sickness Vasculitis Systemic lupus erthyematosus RA

Side Effects for Pyrazinamide [PZA] for TB

- Gout, liver, or kidney problems, - Increases uric acid levels - Photosensitivity

cART drug therapy [HIV]

- Guided by CD4T cell count and viral load [q3-6months] - Combination drug regimen [3 meds from 2 different classes] used to suppress virus, maintain CD4 levels, and prevent opportunistic infections - Individualized regimens [2 NRTIs + Either an INSTI or PI] - Strict adherence - Classifications: -- Nucleoside and nucleotide reverse transcriptase inhibitors [NRTIs] -- Nonnucleoside reverse transcriptase inhibitors [NNRTIs] -- Protease inhibitors (PI) -- Entry inhibitors -- Integrase strand transfer inhibitors (INSTI) -- Miscellaneous antivirals - Boosters: -- Cobicistat -- Ritonavir

PrEP (pre-exposure prophylaxis)

- HIV negative but at high risk for contraction - Truvada® [ Tenofovir disoproxil fumarate/emtricitabine] (TDF/FTC) - Descovy® [ Tenofovir alafenamide] (TAF/FTC) --[Both combo NRTIs have BLACK BOX warnings: Avoid in pts with Hep B] -- - Cabotegravir (Apretude®) injections [weekly] - Taken once per day continuously - 99% reduction from sexual activity - 74% reduction from IVDU - Receptive anal - max potential at 7 days - Vaginal or IVDU - max potential at 21 days

Nursing Education for Streptomycin for TB

- IM - Access hearing frequently

Function of Inflammation and Immunity

- Identify and destroy potentially harmful cells - remove cellular debris - Identifies and destroys malignant cells [preventing tumor formation]

Anaphylaxis

- Life threatening - Rapid onset [Widespread vasodilation; Decreased CO; Broncho constriction]

systemic lupus erythematosus (SLE)

- Most Common chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs

Lupus diagnosis

- Must have at least 4 of the 11 key physical features of lupus •Lab analyses: -- Autoantibody tests - ANA, anti-dsDNA, anti-ssDNA, anti-SM, anti-ENA -- Inflammatory markers [ESR and PSA] -- Urinalysis -- Other blood tests •Tissue biopsy •Imaging Tests

Examples of Passive Acquired Immunity

- Natural maternal antibodies - Artificial antibodies from other sources

Nursing Education for Ethambutol for TB

- No aspirin - No alcohol - Get regular eye exams - Drink more fluids- give with 8oz of water - Teach - be careful driving [vision changes]

Nursing Education for Rifampin for TB

- No aspirin, - No alcohol - Secondary birth control - Don't wear contacts - Wear sunscreen - Fluids

Side Effects for Streptomycin for TB

- Ototoxicity, - Nephrotoxicity, - NV, - Exfoliative dermatitis - CNS depression

Prophylactic Drug Therapy HIV

- PrEP (pre-exposure prophylaxis) - PEP (post-exposure prophylaxis)

Care and Use of Epi Pen

- Practice assembly of injection device with a non-drug-containing training device provided through the injection device manufacturer - Keep the device with you at all times - When needed, inject the drug into the top of your thigh, slightly to the outside, holding the device so the needle enters straight down - You can inject the drug right through your pants; just avoid seams and pockets - Use the device when any symptoms are present - before calling 911. - It is better to use the drug when its not needed than to not use it and need it- - Whenever you need to use the device, get to the nearest hospital for monitoring for at least the next 4-6 hours - Have at least two drug-filled devices on hand in case more than one dose is needed - Protect the device from light and avoid temp extremes - Carry the device in the care provided - Keep safety cap in place until you are ready to use - Check the device for: -- Expiration date -- Drug Clarity -- Security of Cap

Allergic Rhinitis [Allergy testing]

- Prick - redness is {+} result - Scratch - Patch - 1 inch red area around patch = positive [+] result [Make sure crash cart and Benadryl is near]

Types of Hypersensitivity [Type IV: Delayed]

- Reaction of sensitized T-cells with antigen and release of lymphokines, which activates macrophages and induces inflammation - Examples: Poison Ivy Graft rejection Positive TB skin test [PPD] Sarcoidosis

Side Effects for Rifampin for TB

- Red/orange urine/fluid - expected finding, don't panic - Decreased effectiveness of birth control, - Peripheral neuropathy, - Photosensitivity, - Affects liver

RA vs Lupus symptoms

- Redness or Warmth near swollen joints [RA] - Rheumatoid nodules [RA] - Hand and Foot deformities [RA] - Joint subluxation or dislocations [RA] - Joint pain [both] - low grade fever [both] - Fatigue [both] - swelling and inflammation [both - Hair loss [lupus] - butterfly rash [lupus] - unexplained weight changes [lupus] - photosensitivity [lupus]

Age-Related changes in immunity [Inflammation]

- Reduced neutrophil function [Neutrophil counts may be normal, but activity is reduced, increasing the risk for infection] - Leukocytosis does not occur during acute infection [Pts may have an infection but not show expected changes in WBC counts] - Older adults may not have a fever during inflammatory or infectious episodes [Not only is there potential loss of protection through inflammation, but also minor infections may be overlooked until the pt becomes severely infected or septic]

Body part involvement [immunity]

- Skin and MM = first defense - tries to stop germs from entering the body - Bone marrow [important part of the immune system] = produces WBCs and blood cells necessary to promote and then they multiply - Thymus: lymphocytes [T Cells] Mature Lymph: acts as filters [collect bad stuff in that area] Swollen lymph nodes are a big sign that immune system is active and working - Spleen: Filter blood -- Produces and stores B cells [b cells are lymphocytes and they create antibodies] - Tonsils: a lot of WBC in the tonsils. - Bowel: more than ½ of the body's cells that produce antibodies are found in the bowel wall.

Four types of lupus

- Systemic lupus erythematosus (SLE) - Cutaneous lupus - Drug-induced lupus - Neonatal lupus

Age-Related Changes in Immunity [Cell-Mediated Immunity]

- The number of circulating T-Lymphocytes decreases [Skin tests for TB may have falsely negative results] [Older pts are more at risk for bacterial and fungal infections, especially on the skin and mucous membranes, in the respiratory tract, and in the genitourinary tract]

Age related changes in immunity [Antibody-Mediated immunity]

- The total number of B-lymphocytes and their ability to mature into antibody-secreting cells are diminished [Older adults are less able to make new antibodies in repsonse to the presence of new antigens. Thus they should receive immunizations such as "flu shots," the pneumococcal vax, and the shingles vax] - The natural antibody response to antigens declines and the amount of time formed antibodies remain present is reduced [Older adults may not have sufficient antibodies to provide protection when they are re-exposed to microorganisms against which they have already generated antibodies. Thus older adults need to receive "booster" shots for old vax and immunizations, especially tetanus and pertussis (whooping cough)]

Describe the QuantiFERON®-TB Gold (QFT-G) test

- Two blood tests - More expensive - More accurate [cannot get false positive] -- Shows how the patient's immune system responds to the TB bacterium. Positive [+] equals infected with TB, doesn't indicate whether latent or active -- Used when patient has had BCG vaccine or is unable to return to get skin test read

Allergic Rhinitis [Physical Assessment]

- Vasodilation, runny nose, red eyes, sneezing, clear drainage, itchy eyes, issues breathing, scratchy throat, cold that wont go away

Examples of Active Acquired Immunity

- natural exposure to infectious agents - Artificial immunization

Drug-induced lupus

10% of lupus cases - 8 drugs can cause - less aggressive than SLE - Once drug is stopped symptoms will subside

After TB infection, how long does it take for a person with an intact immune system to develop a positive PPD [TST] test?

2-10 weeks [doesn't definitively tell if it is active or latent. Must do a blood test]

The following regimens are recommended choices for the initial therapy [of most people] with HIV

● Dolutegravir [INSTI] + abacavir [NRTI] + Lamivudine [NRTI] ● Dolutegravir [INSTI] + Emtricitabine [NRTI] + Tenofovir [NRTI] ● Elvitegravir [INSTI] + Cobicistat [boost] + Emtricitabine [NRTI] + Tenofovir [NRTI] ● Ralegravir [INSTI] + Emtricitabine [NRTI] + Tenofovir [NRTI]

Normal WBC range

4,000/5,000-10,000

A nurse is interpreting the results of a TST on an adolescent who is HIV positive. Which induration size indicates a positive result for this child 48-72 hours after the test? A: 5mm B: 10mm C: 15mm D: 20mm

A

A client has been diagnosed with TB. What action by the nurse take highest priority? A: Educating the client on adherence to the treatment regimen B: Encouraging the client to eat a well-balanced diet C: Informing the client about follow-up sputum cultures D: Teaching the client ways to balance rest with activity

A [The regimen often ranges from 26 weeks, but can be up to 2 years]

A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? A: Ask the spouse to explain the fear of visiting in further detail. B: Inform the spouse that the precautions are meant to keep other clients safe. C: Show the spouse how to follow the Isolation Precautions to avoid illness. D: Tell the spouse that he or she has already been exposed, so it's safe to visit.

A [address them]

DMARDs (disease modifying anti-rheumatic drugs)

A classification of medications that modify rheumatic disease, instead of just treating symptoms [Takes 4-6 weeks to take affect - Encourage them to keep taking]

A person with Latent TB infection

● Has no symptoms ● Does not feel sick ● Cannot spread TB bacteria to others ● Usually has a [+] skin test &/or blood test result indicating TB infection ● Has a normal chest xray and a negative sputum smear ● Needs treatment for latent TB infection to prevent TB disease [can develop into active]

Describe the intradermal PPD [Mantoux] test. [TST]

A small amount (0.1ml) of purified protein derivative (PPD) is placed intradermally in the forearm

A client is taking Ethambutol for TB. What instructions does the nurse provide the client regarding this drug? SELECT ALL THAT APPLY A: Contact HCP if preexisting gout becomes worse B: Report any changes in vision immediately to the HCP C: Avoid drinking alcoholic beverages due to the chance of liver damage D: Do not take antacids or eat within 2 hours after taking this med E: You will take this med along with some others for 8 weeks F: Take this med with a full glass of water

A, B, E, F

A nurse is reviewing the plan of care for a client who has SLE. Which lab findings should the nurse anticipate? SELECT ALL THAT APPLY A: Positive ANA titer B: Increased WBC count C: 2+ urine protein D: Increased serum C3 and C4 E: Elevated BUN

A, C, E

A pt is newly prescribed Isoniazid [INH] to treat their active TB. What instructions are the most important to teach this pt? SELECT ALL THAT APPLY A: Monitor for numbness and tingling B: Report blurred vision C: Use additional forms of BC D: Avoid wine at night E: Notify HCP if urine turns dark F: Take B6 daily

A, D, E, F

A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera

A, G [Ethambutol can cause Optic Neuritis][Jaundice]

Three stages of HIV

HIV-I: acute infection HIV-II: chronic infection HIV-III: AIDS

TB transmission

Airborne

Tuberculosis

An infectious disease that may affect almost all tissues of the body, especially the lungs

Protease Inhibitors (PIs)

Atazanavir (Reyataz) Darunavir (Prezista) Fosamprenavir (Lexiva) Indinavir (Crixivan) Lopinavir/Ritonavir (Kaletra) Nelfinavir (Viracept) Ritonavir (Norvir) Saquinavir (Invirase) Tipranavir (Aptivus) [ALL PO]

Allergic Rhinitis [Avoidance therapy]

Avoid contact with allergen

Which consideration is the most important in managing tuberculosis (TB) in children? a. Skin testing annually b. Pharmacotherapy c. Adequate nutrition d. Adequate hydration

B

A client has been taking Isoniazid for TB for 3 weeks. What lab results need to be reported to the primary HCP immediately? A: Albumin 5.1 g/dL B: Alanine aminotransferase [ALT] 180U/L C: RBC count 5.2/million/uL D: WBC count 12,5000/mm^3

B [INH can cause liver damage - this is a liver enzyme]

A client in the ED is taking Rifampin for TB. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What lab results correlate to this condition? SELECT ALL THAT APPLY A: BUN 19 mg/dL B: INR 6.3 C: PTT 35 seconds D: Serum sodium 130 mEq/L E: WBC count 72,000/mm^3

B, C

Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. A, 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with AIDS who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

B, C, D, E

A pt with TB has been taking Ethambutol for 2 months. Which adverse effects should be reported to the HCP? SELECT ALL THAT APPLY A: red, orange tears B: Blurred vision C: New numbness or tingling D: color changes E: elevated liver enzymes

B, D

A nurse has educated a client on isoniazid. What statement by the client indicates that teaching has been effective? A: "I need to take extra vitamin C while on isoniazid." B: "I should take this medicine with milk or juice." C: "I will take this medication on an empty stomach." D: "My contact lenses will be permanently stained."

C [either 1 hr before or 2 hours after]

A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best? A: Teach the client about possible drowsiness. B: Instruct the client to drink plenty of water. C: Consult with the Primary HCP about the medication. D: Encourage the client to take the medication with food.

C [first gen antihistamines are not appropriate for use in older adults]

How should PPD [TST] TB test results be interpreted?

¢ Area of induration greater than 10mm in diameter indicates exposure to and possible infection of TB ¢ Adults with reduced immunity - induration of 5 mm is a positive result ¢ Reevaluate after 72 hrs because false negative readings occur more often after only 48 hrs

Allergic Rhinitis [Lab Assessment]

CBC - WBC Eosinophils spike [Jump to 12% - normally 1%] Serum IgE

Discuss typical combination drug therapy and why it is necessary. [TB]

Combination drug therapy is most effective to prevent the emergence of resistance to individual drugs - Cuts treatment from 6-12m to only 6m ● Rifampin ● INH ● Pyrazinamide ● Ethambutol ● Streptomycin - With all - avoid alcohol; these cause liver issues

A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority? A: Might make the client feel jittery or nervous. B: Can cause sodium and fluid retention. C: Long-term effects include fat redistribution. D: Never stop prednisone abruptly.

D

Skin testing for TB [the Mantoux test] is recommended: A: Every year for all children older than 2 B: Every year for all children older than 10 C: Every 2 years for all children starting at age 1 yr D: Periodically for children who reside in high-prevalence regions

D

A client is being discharged on long-term therapy for TB. What referral by the nurse is most appropriate? A: Community social worker for Meals on Wheels B: OT for job training C: PT for homebound therapy services D: Visiting nursing for directly observed therapy

D [watch em']

What are the 2 fastest tests for identification of TB?

¢ Chest x-ray - read in minutes ¢ NAAT- nucleic acid amplification test -- Like PCR test -- Not always accurate- expensive

Hydroxychloroquine (Immunosuppressant)

DMARD - decreases inflammation and muscle pain - Causes immune suppression - Retinal damage [vision loss] - Teach regular eye exams!

Leflunomide

DMARD - given to help joint swelling and stiffness - don't get prego take BC

ANA (antinuclear antibody test)

Detects an antibody present in serum of patients with systemic lupus erythematosus [SLE]

Anti-dsDNA

Double Stranded DNA [70% SLE]

Normal EXPECTED SE of giving Epi

Tachycardia Palpitations Dizziness

Anaphylaxis Interventions

Emergency Management - Maintain airway - Stop infusion if drug related [Hang NS with NEW tubing] - Call RR - Medications - Epi, Antihistamines, bronchodilators, vasopressors, corticosteroids - CPR

Area of Induration significance [TB] <5mm

Essentially negative

Types of Hypersensitivity [Type V: Stimulated]

Example: Graves disease

Nucleoside and Nucleotide reverse Transcriptase inhibitors [NRTIs] Adverse Effects:

Fatigue, generalized weakness, myalgia, nausea, ha, abd pain, vomiting, anorexia, rash Bone marrow suppression, neutropenia, anemia, granulocytopenia, lactic acidosis with steatorrhea, peripheral neuropathy [stavudine], pancreatitis [Lamivudine], hypersensitivity reactions [Abacavir], Fanconis syndrome [Tenofovir]

Side Effects of Isoniazid [INH] for TB

I : Interferes with absorption of B6 [Low B6 = Peripheral Neuropathy] - Take B6 or B-complex supplements N : Neuropathy [Report: numbness; tingling extremities; Ataxia] H : Hepatotoxicity Report immediately! -Jaundice [yellow skin or sclera] - Dark Urine - Fatigue - Elevated liver enzymes [AST/ALT] - Hold Med - No ETOH

Nurse implementations for the TB pt within the Hospital

In the hospital: - Implement airborne precautions. - Admit into airborne infection isolation room. - Notify infection control. - Provide all personnel with proper respirators and masks. - Administer prescribed medications. - Obtain sputum smear. - Ensure isolation protocol maintained constantly. - Teach client to wash hands after coughing. - Monitor pulmonary function and lung sounds. - Ensure client receives rest. - Identify signs and symptoms of: -- Loneliness. -- Fear. -- Depression. - Address psychological symptoms appropriately. - Notify Department of Public Health as per requirement. - Following acute infection - monitor medication adherence until sputum culture and chest x-ray are clear.

What are the manifestations of TB on the reproductive system?

Irregular menses ED

RA - Late signs and symptoms

Joint - Deformaties [swan neck; ulnar deviation] - Mod to severe pain and morning stiffness Systemic - Osteoporosis - Severe fatigue - Anemia - Weight loss - Subcu nodules - Peripheral neuropathy - Vasculitis - Pericarditis - Fibrotic lung disease - Sjogren syndrome - Kidney disease - Felty syndrome

RA - Early signs and symptoms

Joint - Inflammation Systemic - Low-grade fever - Fatigue - Weakness - Anorexia - Paresthesias

HIV/AID is not transmitted through:

Kisses Touching Hand shaking Mosquitoes Food/drinks Air Water toilets/bathroom

Plasmapheresis PLEX (plasma exchange)

Like dialysis but for plasma - done in later stages of RA

What are DMARDs?

Methotrexate, Hydroxychloroquine, sulfonamides

Bacteria [TB]

Mycobacterium tuberculosis

Protease Inhibitors (PIs) Adverse Effects:

N/V/D, Abd Pain, HA Anemia, leukopenia, DVT, pancreatitis, lymphadenopathy, hemorrhagic colitis, nephrolithiasis [indinavir], increased bilirubin and serum cholesterol [atazanavir], thrombocytopenia [saqulnavir], pancytopenia [saqulnavir], Stevens-johnson syndrome [Darunavir], hepatotoxicity [darunavir, ritonavir, tipranavir], new onset DM [fosamprenavir], intracranial hemorrhage [tipranavir]

Function of Self vs Non-Self

Non-self proteins and cells include infected body cells, cancer cells, cells from other people, and invading organisms. Self-tolerance prevents the different immune system cells and products from harming healthy body cells.

Rifampin Key points:

Normal: - Red, orange: tears, urine, sweat [wear glasses instead of contacts] Oral contraceptives ineffective [Use Non-hormonal back up BC] Monitor for Jaundice

Side Effects of Ethambutol for TB

Optic Neuritis, Severe N/V Vision changes [report blurred vision or color changes]

Entry Inhibitors and Integrase Strand Transfer Inhibitors [INSTI] Adverse Effects:

Pain and inflammation at the injection site [Enfuviritde], nausea, diarrhea, fatigue, abd pain, cough, dizziness, musculoskeletal symptoms, pyrexia, rash, URI Hepatotoxicity, myocardial infarction, hypersensitivity, neutropenia, thrombocytopenia, nephrotoxicity [enfuvirtide], myopathy [raltegravir], Fanconi's syndrome [Elvitegravir]

Patho of TB

Pathophysiology: - Mycobacterium tuberculosis - airborne gram-positive bacteria. - Infection occurs primarily in the lungs. - Can be transported via lymph system to other organs. - Bacilli enter lungs - ingested by alveolar macrophages and multiply. - Non-immunocompromised - granulomas isolate infection leading to latency. - Immunocompromised - ongoing permanent damage can lead to death.

Clinical Manifestations [TB]

Progressive fatigue Lethargy Nausea Anorexia Weight loss Irregular menses Low-grade fever Night sweats Cough Mucopurulent sputum, Possible hemoptysis [blood streaks] Chest tightness

Typical Infection with TB

Pulmonary

Anaphylaxis Assessment

Rash Swelling Can't breathe N/V Shock Impending doom Wheezing Stridor Suffocating Hypotension Dizziness Diaphoresis

Nonnucleoside reverse transcriptase inhibitors (NNRTI) Adverse Effects:

Rash, fever, nausea, diarrhea, HA, stomatitis Parasthesia, hepatoxicity, Stevens-Johnson syndrome, CNS toxicity [Efavirenz], increased risk for depressive disorder [rilpivirine], immune reconstitution syndrome [doravine]

Desensitization therapy

Repeated exposure to stimulus which gradually reduces intense reaction. [Allergy Shots]

Anti-SM

Smith antibodies [30% SLE]

[Front line WBC] - Recognition of self vs non-self - Destruction - Production of antibodies - Complement activation - Formation of cytokines

The first thing that is created and released - increased with infection [These WBC are going to destruct and recognize self vs non-self .. Your WBC are actually what form the B cells [it's a type of WBC] so we know that those WBC are forming the antibodies. Then you have the complement activation. Confusing - watch the video! Then you have your formation of cytokines and that is going to stimulate leukocyte production in the bone marrow. Cytokines are just cells that help stimulate production

Which patients with TB should receive directly observed therapy [DOT]?

Those with drug-resistant TB. Warn them that adherence to therapy is critical for survival.

What is the organism that causes TB and how is it transmitted?

Transmitted via airborne ● Mycobacterium tuberculosis - airborne gram-positive bacteria. ● Mycobacterium bovis - from animals ● Infection occurs primarily in the lungs. ● Can be transported via lymph system to other organs. ● Bacilli enter lungs - ingested by alveolar macrophages and multiply

T or F Getting pregnant can exacerbate Lupus symptoms.

True

Human Leukocyte Antigen (HLA)

Unique to everyone, marks your own cells, essential for transplants

Neonatal Lupus

a rare condition acquired from the maternal autoantibodies which can affect the skin, heart, and blood of the fetus & newborn; associated w/ a rash that appears w/in several weeks of life & may persist for about six months before disappearing

inflammation

a syndrome of normal tissue responses to cellular injury, allergy, or invasion of pathogens.

Types of Acquired Immunity

active [own antibodies - Vax or exposure] and passive [ready-made antibodies; breastmilk]

lupus erythematosus

an autoimmune disorder characterized by a red, scaly rash on the face and upper trunk

What is the bronchoscopy pre and post-procedure care for client with TB?

○ Crucial for TB diagnosis ○ Done for sputum samples and for.. ● pre → NPO 6 hours prior, discontinue feeding for intubated pts, consent, IV access, Monitor VS and Resp (prior, during, and post) ● post → NPO after 2h until gag reflex comes back (before you give them anything to drink), coughing/sore throat expected ● NPO to prevent aspiration

Autoimmune disorder effects

disorders immune system loses ability to recognize own self, begins to attack its own tissues

Anti-ENA

extractable nuclear antibodies

Types of Immunity

innate [born with it] and acquired [developed later in life]

RA - Assessment

joint pain and swelling limited joint movement contractures; deformities weakness, fatigue high fever and rheumatoid rash, particularly seen in juvenile RA nodules over bony prominences ulnar deviation periods of remissions and exacerbations

two TB-related conditions:

latent TB infection and active TB disease

cutaneous lupus

limited to the skin; evidenced by a characteristic rash, especially on the face, neck, and scalp [rash; ulcers; hair loss; sun sensitivity] [70-80% will end up with SLE]

Hypersensitivity effects

overreaction of immune system to antigen [seasonal allergies]

Immunity

protection from illness or disease that is maintained by the body's physiologic defense mechanisms.

Hydroxychloroquine for Lupus

reduces flareups, joint inflammation, and fever [can cause vision changes]

Goal of RA treatment

remission and slow progression - reduce pain - increase mobility - decrease destruction of joints

Anti-ssDNA

single stranded DNA

complement activation

stimulates inflammation, attracts phagocytes, and enhances phagocytosis

Function of Antigens

targets that identify any pathogen or foreign compound [capable of triggering an immunity response]

Latent TB infection

type of tuberculosis in which the person carries the disease but does not show symptoms and cannot infect others.

How long does it take for sputum cultures to determine a + or - TB result?

¢ 4 weeks - slow growing bacteria ¢ We go off other data until the results come off ¢ Will treat even without this result ¢ Negative after three months of treatment

When are the results read for the PPD [TST] test for TB?

¢ 48-72 hours ¢ Risk of false positive at 48hrs ¢ Best time to read is at 72 hours

Equipment and Injection angle of the PPD [TST] test ---- TB

¢ Administered intradermally ¢ 27 gauge needle ¢ 1mL - Tuberculin syringe [[0.1 admin of PPD]]

What type of isolation precautions are needed when caring for a client with active TB?

¢ Airborne precautions ¢ Negative pressure room ¢ Private room ¢ Keep door closed at all times ¢ Wear N-95 or Hepa mask

[NSG DX INTERVENTIONS] Risk for Infection [spread/reactivation]

¢ Combination drug therapy is the most effective method of treating and preventing transmission ¢ Strict adherence to prescribed drug regimen is crucial for suppressing the disease ---- Direct observation therapy - go to home and make sure they are taking their medication every day ¢ Hospitalized pt with active TB- placed on airborne precautions, negative pressure room, N95 mask when entering room/caring for patient, patient needs mask when going outside room ¢ TB testing for all members of the household or anyone in close contact with infected person ¢ Teach- cover mouth and nose with tissue when coughing or sneezing, placed used tissues in plastic bags, wear a mask in crowds, used social distancing until the drugs suppress the infection ¢ Sputum specimens needed q 2-4 weeks [book says 4, not 2-4 but ‍♀️] once drug therapy started, when 3 consecutive cultures are negative the patient is no longer contagious ¢ Hand hygiene

Treatment for TB

¢ Combination: - Rifampin - INH [Isoniazid] - Pyrazinamide - Ethambutol

What are the manifestations of TB on the pulmonary system?

¢ Cough with mucopurulent sputum often streaked with blood, ¢ chest tightness, ¢ dull achy chest pain, dullness with percussion, ¢ bronchial breath sounds, ¢ crackles, ¢ localized wheezing with partial obstruction of a bronchus or compression of lymph node, ¢ hemoptysis, ¢ dyspnea on exertion

What type of TB home care client education is needed?

¢ Educate client on medication adherence (especially abx), avoiding public areas, when to call HCP, when to go to the ER ¢ Disposable tissues for 2 wks, avoid crowds/people with infectious diseases, promote diet/rest, mindful when driving/walking (one med can cause vision changes - ethambutol) ¢ Cultures every 2-4 weeks (after 3 negative tests, they are in the clear)

[NSG DX INTERVENTIONS] Knowledge Deficit

¢ Educate the client and use teach back method - regime, side effects, when to call HCP ¢ Hygiene, medication administration/adherence

What are the manifestations of TB on the general body system?

¢ Fatigue, ¢ lethargy, ¢ low grade fever ¢ weight loss ¢ night sweats

[NSG DX INTERVENTIONS] Imbalanced Nutrition [<body requirements]

¢ Have a diet rich in iron, protein, and vitamin B/C ¢ Medications - may cause need for extra supplements - INH1 (isonoside) [vitamin B6 supplements]

Assessment for TB

¢ History or Interview ¢ Past exposure ¢ Country of origin or travels ¢ Previous TB skin test results ¢ BCG vaccine ¢ Physical Findings

Redness vs Induration for the PPD [TST] test for TB

¢ Induration measuring 10mm or more in diameter indicates exposure to TB and possible infection ¢ Adults with reduced immunity - induration of 5 mm is a positive result ¢ Induration will feel hard and raised in the middle on palpation

Area of Induration significance [TB] ≥10mm

¢ Is considered positive in: -People born in countries where TB disease is common, including Mexico, the Philippines, Vietnam, India, China, Haiti, and Guatemala, or other countries with high rates of TB -People who abuse drugs -Mycobacteriology laboratory workers -People who live or work in high-risk congregate settings (e.g., nursing homes, homeless shelters, or correctional facilities) -People with certain medical conditions that place them at high risk for TB (e.g., silicosis, diabetes mellitus, severe kidney disease, certain types of cancer, and certain intestinal conditions) -People with a low body weight (<90% of ideal body weight) -Children younger than 5 years of age -Infants, children, and adolescents exposed to adults in high-risk categories

Area of Induration significance [TB] ≥15mm

¢ Is considered positive in: -People with no known risk factors for TB

What are the manifestations of TB on the Musculoskeletal system?

¢ Joint pain [inflammation process throughout body] ¢ Limited ROM

Implications with TB

¢ Lab testing ¢ Prevent nausea ¢ Diet rich in iron, protein, and Vit B & C ¢ Rest ¢ Preventing spread of infection ¢ Sputum testing every 2 to 4 weeks ¢ Isolation precautions ¢ Educate

Bodily location for the PPD [TST] Test --- What if no wheal forms? [TB]

¢ Left forearm [non-dominant] on inside ¢ Wheal shows that injection was properly done - we want this to happen ¢ If no wheal forms - must redo test

What are the manifestations of TB on the Neuro system?

¢ Meningitis ¢ Decline LOC [HA; vomiting; seizures; hydrocephalus; tuberculoma; cranial nerve palsy]

What is the significance of a positive acid-fast bacilli sputum smear Versus a negative one?

¢ Negative = no infection present ¢ Needs about 5-10k cells to examine - sometimes hard to get good sample, bad sample can cause false negative ¢ Can have a negative smear and a positive culture

What are the manifestations of TB on the Cardiovascular system?

¢ Pericarditis [inflammation around the heart] ¢ Edema ¢ JVD

[NSG DX INTERVENTIONS] Social Isolation

¢ Promote support systems ¢ Telephone/Skype

[NSG DX INTERVENTIONS] Fatigue

¢ Resume activity slowly ¢ Plenty of rest ¢ Educate that fatigue will improve as therapy progresses, and disease is controlled ¢ Encourage full night sleep with short day time naps ¢ Cluster activities

NANDA for TB

¢ Risk for infection (spread/reactivation) RT inadequate primary defenses, malnutrition, environmental exposure ¢ Impaired gas exchange RT disease progression ¢ Knowledge deficit RT lack of exposure or information misinterpretation ¢ Fatigue RT poor tissue oxygenation and increased metabolism ¢ Imbalance nutrition: Less than body requirements RT increased metabolism, poor appetite, drug regimen, or fatigue ¢ Social isolation RT altered state of wellness or changed appearance

[NSG DX INTERVENTIONS] Impaired gas exchange or Ineffective airway clearance:

¢ Similar to pneumonia or COPD ¢ Drink plenty of fluids ¢ Take a deep breath before coughing ¢ Incentive Spirometer ¢ O2 ¢ Monitor ABG, breath sounds ¢ HOB elevated ¢ Chest PT if they can't expectorate mucus

What would be the concern if sputum cultures remained positive after 3 months of treatment?

¢ Treatment was not effective, could be antibiotic resistant strain (multiresistant TB) ¢ If in contact with person who had multiresistant TB - you will get that same strain and have difficulty getting rid of it ¢ Patient could have been non-adherent with medication regimen - not finishing complete dose, not taking as often as needed, may not be able to afford the long term medication

Diagnostics for TB

¢ Tuberculin skin test/Mantoux test (TST)[PPD] ¢ TB blood tests/Interferon-gamma release assays (IGRAs) - QuantiFERON®-TB Gold In-Tube test (QFT-GIT) - T-SPOT® TB test (T-Spot) ¢ Sputum Culture ¢ Positive AFB smear ¢ Chest X ray ¢ Nucleic Acid [NAAT]

What are the manifestations of TB on the GU system?

¢ Urgency ¢ frequency ¢ Dysuria ¢ Hematuria [bloody urine]

What are the manifestations of TB on the Lymphatic system?

¢ enlarged lymph nodes throughout the body ¢ bone marrow may be involved causing anemia ¢ low platelets ¢ High WBC count

Area of Induration significance [TB] ≥5mm

¢ is considered positive in: -People living with HIV -A recent contact of a person with infectious TB disease - People with chest x-ray findings suggestive of previous TB disease -People with organ transplants -Other immunosuppressed people (e.g., patients on prolonged therapy with corticosteroids equivalent to/greater than 15 mg per day of prednisone or those taking TNF-a antagonists)

What are the manifestations of TB on the GI system?

¢ nausea, ¢ anorexia, ¢ weight loss, ¢ distention, ¢ peritonitis, ¢ abdominal pain

Lupus assessment

•Any tissue or organ can be affected •Diagnostic Findings: •Butterfly facial rash •Discoid rash on sun-exposed areas [coin] •Photosensitivity •Oral ulcers •Non erosive arthritis/Pain •Serositis [inflam of serous tissue - Pericardium/peritoneum] •Proteinuria •Neurological changes •Hematologic problems •Immunity problems •Abnormal ANA [Antinuclear Antibodies] •Raynauds - constriction of blood vessels

Lupus

•Chronic, autoimmune disease •Tissue integrity loss •Inflammation [excessive] •Overactive Immunity •More common among women of childbearing age •Etiology unclear with genetic link - 4 types

Rheumatoid Arthritis

•Connective Tissue Disease - chronic progressive inflammatory AI disease that primarily affects the synovial joints •Systemic - can affect multiple body systems, other joint and tissues including major organs of the body •Etiology - Unknown but genetic and environmental factors are believed to be a factor [Epstein Barre can lead to RA; Juvenile onset before 12yo; typical onset 40-60 yo]

RA - treatment

•DMARDS [Disease modifying Anti Rheumatic Drugs] -- Methotrexate -- Leflunomide -- Hydroxychloroquine •Conventional, Biologic/TNF inhibitors, Kinase Inhibitors •NSAIDs •Steroids •Plasmapheresis (PLEX) •Surgical •CAM

Pregnancy complications [HIV]

•High risk [HIV +] •Screen all pregnant women •Weekly non-stress testing starting at 32 weeks •Ultrasounds, biophysical profiles •Scheduled cesarean birth •At risk for postpartum complications

Epinephrine Auto-Injector

•Now available in generic form, much cheaper than "Epi-Pen" •Can only be obtained with a prescription •Delivers 0.3mg of epinephrine solution directly into subq tissue or muscle •Anyone that is at risk for anaphylactic reaction will be given prescription

RA - Pathophysiology

•Rheumatoid factors [proteins that attack healthy tissue] •Cd4 T helper cells [promote cytokine release], Neutrophils [breakdown Cartlidge] , and Lymphocyte [increase inflame response] action •Joint changes [deformities] •Systemic changes

RA - diagnosis

•Rheumatologist •Medical History •Physical Assessment •Laboratory •↑ESR, ↑CRP, ↓albumin •RF and CCP antibodies •Diagnostic Imaging •Xray [joints, bone], CT/MRI [if spine is involved], Arthrocentesis [needle in fluid - testing it]

RA collaboration

•Rheumatologist + PCP •OT/PT [cont mobility and fine motor skills] •Self management/promotion [independence] •Enhancing body image •Social worker •Case Manager •Resources

Lupus Treatment

•Symptom management [Fatigue, nausea, pain] •Skin Protection [sunscreen, lotion, big hats, safe gentle cosmetics with moisturizer, avoid fragrance] •Pharmacological Interventions -- Antimalarials - Hydroxychloroquine -- NSAIDs or Acetaminophen [reduce rash, fever, pain] -- Corticosteroids [reduce inflammation - only if bad or no response to antimalarials] -- Immunosuppressants - cyclophosphamide, methotrexate [wait until body shows damage to other organs before starting] -- Targeted therapy - belimumab [new - infusion or injection - lowers antibody counts that are targeting bodys cells and tissues - plummets immune system - no live vax for 30 days after; no crowds]

Immunocompetent effects

•clients have immune system that identifies antigens effectively destroys or removes them

Immunodeficiency effects

•develops when immune system incompetent, unable to respond effectively as in HIV/AIDS [certain meds too - steroids; anti rejection]

HIV complication [Cervical Cancer]

■Increased r/f HPV infection ■40% of women with HIV have cervical dysplasia ■Aggressive cancer can develop ■PAP smear q 6 months IUD not recommended for HIV+ women [CIN aka Cervial Dysplasia = precancerous diagnoses]

HIV complication [Kaposi's Sarcoma]

■Most common ■Late stage [18 months to live] ■Brownish purplish spots ■Painless [face, trunk, legs, feet, mouth, genital] ■If not caught immediately - metastasis ■Decrease viral load and manage spots

HIV complication [Lymphoma]

■Non-Hodgkin's Lymphoma ■Affect lymphoid tissues, lymph nodes, lymphocytes, and lymphoid organs ■Symptoms depend on location ■Painless lung or swelling ■HA, mental status changes [CNS] ■[Bowel] indigestion, diarrhea, weight loss ■Chest: cough, can't swallow, SOB ■General: fever; night sweats, weight loss

A person with TB disease

● Has symptoms that may include the following: •A bad cough that lasts 3 wk or longer •Pain in the chest •Coughing up blood or sputum •Weakness or fatigue •Weight loss •No appetite •Chills •Fever •Sweating at night ● Usually feels sick ● May spread TB bacteria to others ● Usually has a skin test or blood test result indicating TB infection ● May have an abnormal chest xray, or positive sputum smear or culture ● Needs treatment to treat TB disease

What is miliary TB?

● Spread of TB throughout the body when a large number of organisms enter the blood ● Becomes systemic ● If left untreated - fatal :( ● Usually missed - found on autopsy after death

"When" and "Notes" for Isoniazid [INH] for TB

● When: - Can be prophylactic, started first with Rifampin - Used for whole course ● Notes: - First line therapy - Prophylactically/ w/ tx

"When" and "Notes" for Pyrazinamide [PZA] for TB

● When: - First 2 months - 3rd in regime ● Notes: - Given with RIF and INH

"When" and "Notes" for Rifampin for TB

● When: - Usually started at same time as isoniazid - Used for whole course ● Notes: - Often with other meds like INH

"When" and "Notes" for Streptomycin for TB

● When: - IM Injection prenatally ● Notes: - none

"When" and "Notes" for Ethambutol for TB

● When: - Initial or when resistant - 4th line ● Notes: - Added to initial Tx or sub for INH when resistant strain expected

When and where is the bacillus Calmette-Guerin [BCG] vaccine used? How does it alter TB screenings?

● administration → given to health care workers during ongoing transmission of drug resistant TB, continually exposed, some countries will give to everyone as routine vaccination ● screening → vaccination with BCG may cause a positive reaction to a TB skin test ○ TB blood tests are unaffected by BCG ● Interferes with testing - anyone with BCG within past 10 years will have a positive skin test ○ Could be latent - will do blood test

Complications of HIV

●AIDS [when CD4T drops below 200 or development of infection] ●Opportunistic Infections -- Pneumocystis Pneumonia (PCP) -- TB [rapid progression to disseminated stage][Needs TB test q6months [can be + but have a false [-] PPD test] [[if they have symptoms - treat like TB + but do other tests] [5mm + for TB] -- Candidiasis [mouth thrush] - usually first sign of HIV -- HSV or zoster -- Cytomegalovirus [CMV] -- Wasting Syndrome [unwanted weight loss of 10% of body weight - severe diarrhea, fever lasting at least 30 days]

Adjunct therapy for HIV

●Agents used in combination with antiretroviral therapy - Interpherons - Other agents to prevent/treat OIs - Vaccines [no live] - Antibiotics [All] - Symptom management

Nursing considerations HIV

●Avoid bias ●Maintain confidentiality ●Psychosocial support/Advocacy ●Close monitoring ●Assessments ●Prevention Education ●Medication Education ●Promote Adherence ●Management Education ●Standard Precautions ●Maintain skin integrity ●Manage nutrition

Drug therapy [Pregnancy HIV]

●Delay until 2nd trimester if possible ●No known teratogenic drugs ●Dolutegravir and emtricitabine/tenofovir alafenamide fumarate (DTG+FTC/TAF) - regimen for Pregnancy ●PrEP and PEP [encourage - to prevent HIV] - NOT Truvada ●Zidovudine [NRTI] to prevent spread to newborn --- 3 step [admin to mom - receive IV ZDV during labor - then ZDV 2mg/kg q6h PO to newborn for 6 weeks] 8 hrs after birth = 1st dose] ●Breastfeeding increases r/f transmission

Transmission of HIV/AIDS

●Found in body fluids (other than saliva) ●Sexual transmission ●Parenteral transmission [IV drug use - blood transfusions] ●Perinatal transmission [thru placenta - infant exposure to breast milk - explain need to be treated during pregnancy] ●Transmission to healthcare workers ●Urine or feces may have blood in it so it could potentially transmit ●More viral load that they have the more likely it is for transmission

Pediatrics and HIV

●Has drastically decreased in recent years ●Shorter interval from infection to onset ●Opportunistic disease and prematurity [Primary causes of mortality] ●Nonspecific findings -- General and asymptomatic - Wasting syndrome looks like FTT -- Delayed developmental milestones -- Talk to HCP about immunizations [No live vax]

Assessment HIV

●Monitoring for development or worsening of Opportunistic Infections ●VS ●Respiratory assessment [airway, lung function - esp with TB] ●Skin assessment [breakdown, ulcers, Kaposi's Sarcoma] ●Mucus membranes [ulcers, thrush] ●Weight [loss of appetite] ●Bowel habits [chronic diarrhea is common = dehydration] ●Knowledge r/t disease [How to take meds, prevent infection, prevent transmissions] ●Focused on specific infection

Pathophysiology of HIV

●Retrovirus ●Attacks CD4 T lymphocytes (Helper T cells) ●Leads to severe immunodeficiency ●Virus replication ●Three identified stages [When CD4 T cells drops - no immunity - Virus replication: fast and into the DNA and converts cell into a damaging cell. - Can stay latent for many years [8-10yrs] - Antibodies take 6 weeks to 6 months to develop to show HIV +

Diagnostic tests for HIV

●Screening recommended for everyone ages 16-34 at least once ●Higher risk should be screened q6mo to annually ●Rapid diagnostic tests [if +, must do follow up tests] ●Enzyme-linked immunosorbent assay (ELISA) - detects at 13 weeks to 3 months ●PCR [detects proviral DNA] ●Western Blot ●Specific Markers --- Viral Load - measures amount of actively replicating virus --- CD4 count [lower the #; worst then condition] ●Nonspecific Markers [NOT DIAGNOSTIC] -- CBC [anemia] -- ESR [inflammation] -- Albumin [inflammation] -- LFTs [liver function]

Evaluation of Drug Therapy for HIV

●Treatment Goals -- Suppress infection itself -- Provide prophylaxis of opportunistic infections -- Stimulate hematopoietic response -- Treat infections and malignancies ●Effectiveness of Treatment -- Monitored by viral load, CD4 cell counts -- Symptoms of severe disease always treated

Manifestations of HIV

●Unique from person to person ●Can be asymptomatic with treatment ●Early flu-like symptoms ●Related to opportunistic infections: -- Low body weight r/t body wasting syndrome -- Night sweats -- Diarrhea -- Fatigue -- Thrush -- Oral hairy leukoplakia (white patches on tongue) -- Purple spots on the skin r/t Kaposi's Sarcoma -- Abdominal cramps -- Reduced vision acuity r/t retinitis caused by cytomegalovirus -- AMS -- Fever blisters r/t HSV Resp compromise r/t PCP - CD4T drops = Viral HIV load increases