Med-Surg Exam #1 (Lessons 1-5)

Diagnostic Tests for Pneumonia

#1!!! CXR (shows infiltrates, consolidation, atelectasis, pleural effusion) - 40% of pneumonia pt's have pleural effusions (resolves in couple weeks) 2. Sputum for C & S - before antibiotics preferred - identify bacteria causing issue 3. Sputum for gram stain - before antibiotics preferred - identify bacteria causing issue 4. CBC w/ WBC differential (15,000 or >, so INCREASE or neutrophils shift to the left) 5. Pulse oximetry 6. CT of lung (how severe is the case?) 7. ABG'S (not usually unless very distressed; as progresses, PCO2 INCREASES = resp. acid.) 8. Bronchoscopy (complicated!! or excess sputum)

GI NURSING ASSESSMENT AND DIAGNOSTIC TESTS

* Commonality in all of the diagnostic tests are NPO *

Drug Therapy: Antiretrovirals (ART) for HIV

*NO DRUGS TO REMEMBER* - Main goals *!!! DECREASE viral load *!!! Maintain/INCREASE CD4+T counts * Prevent HIV-related symptoms and opportunistic diseases * Delay disease progression * Prevent HIV transmission (by DECREASING viral load) * Current WHO guidelines for starting ART based on CD4+T cell counts (in other countries) ~ US recommends earlier the better since meds will make them feel better (DECREASE risk of transmission)

Pathophysiology of HIV

*Overview, don't memorize* - HIV is a ribonucleic acid virus (RNA) = discovered in 1983 * Called retroviruses b/c they replicate in a "backward" manner going from RNA to DNA * Replicates inside a living cell * CD4 + T cell is the target cell for HIV ~ Type of lymphocyte (can measure CD4 counts) ~ HIV binds to the cell through fusion

Diagnostic Tests for TB

*Sputum is gold standard for TB testing and takes a couple of days* 1. Sputum smears for AFB (collect from cough or bronchoscopy fluid) 2. Sputum culture (best to collect before breakfast b/c most resp. secretions are pooled) - must collect 3 different times on 3 different days 3. CXR - upper lobe infiltrates, possible cavitary formation (not definitive b/c other diseases look alike) 4. NAA test (MTB/RIF Assay) - Detects resistance to Rifampin but doesn't replace other tests Before initiating drug therapy for active TB: - Liver function tests (ALT, AST) and monitor w/ meds - Vision testing - Audiometric testing

GI Diagnostic Tests

- #1 Abdominal ultrasound (noninvasive) - UGI - barium swallow - LGI - barium enema - Scopes * Esophagoscopy * Esophagogastroduodenoscopy (EGD) * Colonoscopy * Sigmoidoscopy - #1 CT of abdomen (noninvasive) - Fecal analysis - Stool culture

Diagnostic Tests for Immunity

- #1 RBC and WBC w/ differential -*** Antinuclear antibody (ANA, standard evaluation of autoimmune disease) -*** C-reactive protein (systemic marker of autoimmune disease) * Elevated in inflammation -*** Erythrocytes sedimentation rate (ESR) (systemic marker of autoimmune disease) * Elevated in inflammation - Allergy testing (may be done by skin or blood) - Immunoglobulin levels (may do blood test for antibodies) - Rheumatoid factor (specific tests for disease) * 75-80% of RA pt's are (+) for this - Western blot test (specific test for disease) * HIV test - TORCH antibody panel (specific test for disease) * Looks for presence of cytomegalovirus, heroes simplex, rubella, and toxoplasmosis - Organ function tests * Liver (ALT, AST) * Kidney (BUN, Creatinine

Risk Factors for COPD

- #1 tobacco smoking (15% of pt's have COPD) - Secondhand smoke (short-term exposure to INCREASED levels of irritating substances = impaired lung function) - Environmental pollution (short-term exposure to INCREASED levels of irritating substances = impaired lung function) - Chemical irritants in workplace - Recurrent resp. infections - Aging process - Clients w/ asthma - Alpha-antitrypsin (AAT) deficiency (AAT = genetic order that affects ~3% of those diagnosed w/ COPD; it's a protein that protects the lungs and liver from damage)

Pulmonary Tuberculosis

- 1/7 people died in 1900's - Chronic, recurrent infectious disease - WHO estimates that 1/3 of the global population are infected w/ TB bacteria (~200 billion people) - Highest rates in developing countries of Asia, Africa, Middle East and Latin America - 9 million new cases of TB develop annually according to the WHO - Resurgence of TB due to increased rates of TB among clients w/ HIV and the emergence of Drug Resistant Strains of Mycobacterium Tuberculosis * HIV got more well known in 1980's * Drug Resistant Strains occur by poor compliance to meds and need different drug class to treat it

Asthma

- A chronic inflammatory disease of the airways (smaller airways like bronchi and bronchioles which have mucosa lining and Goblet cells that get more inflamed and produce excessive mucus) * Alveoli are NOT involved (alveoli involved in COPD) - Intermittent, reversible airflow limitation (COPD has irreversible changes) - Airways are in a persistent state of inflammation but have periods when asthma is "quiet" or subacute - 22 million adults have asthma - It is a chronic disease of childhood; 9 million children diagnosed w/ asthma and 80-90% have first symptoms before 5 years of age - Asthma is attributed to (pollution, lack of access to healthcare, poverty, lack of treatment, poor control) * Nearly 2 million ER visits * 25 million lost work days yearly * 15 million lost school days yearly * Over $16 billion in healthcare costs annually

RHEUMATOID ARTHRITIS (RA)

- A chronic systemic disease characterized by recurrent inflammatory changes in the synovial membrane/space (synovial tissue lines joints and provides lubrication) - Occurs 3 times more frequently in women than men - Peak incidence 30-50 years of age (but can get at any age) * Incidence INCREASES w/ age - Genetic/familiar factor (cause is unknown) * Genetically susceptible person will have some kind of response to an antigen that triggers inflammatory process - Onset is usually insidious * Changes that occur (fatigue, anorexia, generalized stiffness) before the joint symptoms appear - Autoimmune disease (theory) - Marked by periods of remission and exacerbation * Sometimes it's very active and sometimes it's not * Systemic disease ~ Just b/c it affects synovial tissue (lining around the joints), there's also systemic symptoms

Client Teaching for SLE

- About the disease and its effects - Skin care - Avoid exposure to infection - Minimize stress - Treatment plan * Drugs * Exercise * Pain management -!!! Family planning - Avoid alcohol and smoking to avoid flares

Complications of CD

- Abscesses - Fistula tracts develop/communicate w/ other loops of bowel, skin, bladder, rectum, vagina (pt may/may not be symptomatic w/ these) * If bowel has attached to the bladder, there may be INCREASED signs of UTI's or fecal material in urine (teach pt to report this!!) - Peritonitis (microscopic leaks -> bowel contents into peritoneal cavity) - Strictures can lead to bowel obstruction (located where there's constant inflammation) - Fat intolerance (if terminal ileum is involved) * B/c they'll have issues w/ fat malabsorption - Risk for small intestine cancer

Nursing Diagnoses for SLE

- Acute/Chronic Pain - Fatigue (#1 S/S usually) - Impaired Skin Integrity (very common) - Risk for Infections (alterations in CBC and WBC) - Self Care Deficit - Deficient Knowledge - Disturbed Body Image - Ineffective Coping (Anxiety and Depression) * Need to check each body system for specific diagnoses

Predictors of Uncontrolled Asthma

- Adults * Lower educational level * Lack of insurance * HIGH BMI * Smoking - Children * Lack of compliance to treatment * Colds/flu - THINK Rules of 2 (way to screen) * Ask: Do you have symptoms > 2 days per week? Do you awaken at night w/ symptoms? Do you use short-acting inhaler > 2 times per week? (Answering yes = see Dr. to get better controlled) ~ Goal is to always keep control of the asthma and prevent exacerbations

Crohn's Disease (CD)

- Affects ANY PART OF GI TRACT (mouth to anus) * Most common in terminal ileum and colon - Involves ALL LAYERS of bowel wall - Inflammation is PATCHY...SEGMENTS of normal bowel can occur between diseased portions (skipped lesions) - Ulcerations are deep and longitudinal-cobblestone appearance - Smoking INCREASES risk of Crohn's * Immune system mistake bacteria in GI tract as foreign and attacks it ~ Once it's on, can't shut off

Risk Factors for an Altered Immune Response

- Age * Very young (immature immune system, especially lymphocyte function ~ Babies have passive-acquired immunity from moms but very short-lived * Elderly -> Shrinking thymus ~ T-lymphocytes have DECREASED ability w/ aging - Nonimmunized state (w/ immunization we have active/acquired immunity - Environment * Poor nutrition * Pollutants * Unsanitary conditions (disease transmission) - Chronic illnesses (Diabetes, COPD, Heart Disease have depressed immune system and frequently it is a result from treating these) - Medications (*most common cause of secondary immunodeficiency*) * Chemo, Immunosuppressants (organ transplant OR autoimmune disease) - High-risk behaviors (unprotected sex, sharing needles) - Gender, race, ethnicity (SLE more common in females and African-Americans) * RA more common in females - Genetics - Environmental or Medication exposure (food, pollen, dust inactive ingredients)

Triggers of Asthma

- Allergens (40% of cases, seasonal or nonseasonal) - Air pollution (tobacco smoke, wood-burning) - Occupational exposure (farmers, beauticians) * You may go to work okay and get home terrible -!!! Resp. infections (major precipitating factor of acute attack) - Animals (face swells = narrowing airway) - Exercise (exercise-induced asthma = take inhaler prior - Drug/food additives - GERD (nocturnal = reflux of stomach acid at night = coughing) - Sinus problems (drainage in back of throat -> attack asthma) - Stress (causes symptoms to worsen) - Emotions (extreme = narrow airway like anger/laughing/crying) - Asthma gene (link between obesity and asthma) * Has a component that's inherited - Medications (ASA, NSAIDS) ~ Asthma attack usually happens 30-60 min. after exposure to trigger

Exaggerated Functioning Clinical Manifestations for Immunity

- Allergic symptoms can range from mild to severe - Pain, fatigue - Fever - Autoimmune disorders * Can range from vague findings to findings associated w/ organ failure

ALTERATIONS IN OXYGENATION R/T INFECTIOUS PROCESSES: - Pneumonia

- An infection that inflames air sacs in 1 or both lungs which may fill w/ fluid - A disease that afflicts the populations across the lifespan - Accounts for 10% of all adult hospital admissions (1 of the top 20 reasons for going to ER) - 7th leading cause of death in US and leading cause of death from an infectious disease - Incidence and mortality highest in older adults and clients w/ debilitating disease (and the young)

Exaggerated Immune Response

- An overreaction of the immune response (w/ undesirable results) - Can be allergic reactions, cytotoxic reactions or autoimmune reactions - Ability to differentiate between "self" and "non-self" is lost (characteristic of autoimmune disease) - 4 types of hypersensitivity reactions * Anaphylactic Reaction (susceptible to specific allergen) ~ Local like mosquito bite or systemic and life-threatening * Cytoxic Reaction (antibody-antigen complex) ~ i.e. Hemolytic blood transfusion reaction when incompatible blood is transfused * Immune Complex Reaction (antigen-antibody complex) ~ Can't be removed by body and are deposited in kidneys, skin, joints, and RA and SLE (too big to be removed, can be measured) * Cell-Mediated (Delayed - Hypersensitivity) ~ Takes 24-48 hours to occur ~ i.e. Contact Dermatitis * Can be localized like bee sting or affect many body systems like RA and SLE

Suppressed Immune Response

- Are in a state of immunodeficiency/immunocompromised - Can be primary or secondary - Are unable to provide an adequate defense against microorganisms or foreign proteins (inadequate b/c of lack of cells = Primary!) * Rare and serious - As a consequence are at risk for infection and cancer (Secondary!) * INCREASES incidence of infection = more likely to get super infection like MRSA or C-diff * Most common cause = drugs/meds taken for treatment (i.e. Corticosteroids DECREASE inflammation but as a consequence alters immune system) ~ Other causes: malnutrition, radiation, stress ~ Meds for chemo or immunosuppressants (to treat autoimmune disease) are more examples!!

Organs of Immune System

- Bone marrow (all cells in immune system derived from stem cells in the bone marrow) * Lymphocytes produced here - Thymus (involved in maturation of T lymphocytes) * Once T lymphocytes are mature, they migrate to lymph nodes - Spleen (filters foreign antigens from the blood) - Lymph nodes - Lymphoid tissue in the bronchial, genital, gut and skin (protects us from antigens) * Antigens enter blood, go through lymph nodes, interacts w/ macrophages as well as B and T lymphocytes - Tonsils are part of immune system * They are lymphoid tissue and trap antigens (pussy tonsils are just trapped antigens and immune response)

Collaborative Therapy for COPD

- Cessation of smoking - Treatment of exacerbations and resp. infections - Pharmacologic therapy * Bronchodilators (very common, in forms or nebs/inhalers/po meds) * Corticosteroids (IV/po/inhaled) * Expectorants (help get rid of secretions) - Oxygen therapy (DECREASE flow and humidify b/c if they lose drive to breathe then they won't so don't overflow O2!) - Chest physiotherapy (percussion and postural drainage) - Nutrition (very thin so need INCREASED protein, DECREASED carbs, INCREASED calories) - Exercise conditioning (need regular aerobic exercise to maintain functional capacities) - Pulmonary rehab (6-8 weeks to INCREASE functional capacity) - Vaccinations (i.e. Flu, Pneumonia) - Surgery (uncommon) * Lung reduction * Lung transplantation (rare) ~ Anticholinergics help get rid of secretions and for bronchodilation

Nursing Diagnoses for RA

- Chronic Pain - Impaired Physical Mobility - Disturbed Body Image - Ineffective Health Management -!!! Self-Care Deficit - Altered Family Process - Caregiver Role Strain (mother may have it, whoever takes care of her will be affected) - Risk for Injury (S/E from meds)

HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION

- Chronic disease affecting the global population (up to 40 million people living w/ it) - Over 1 million currently living w/ HIV in the US, 20% have undiagnosed HIV infection - ~50,000 new infections occur in the US each year (men having sex w/ men) - Effective treatment has led to a significant drop in death rates (more chronic) - Retrovirus that causes immunosuppression making persons more susceptible to infection)

Pathophysiology of Asthma

- Chronic inflammation from exposure to allergens or irritants (persistent) - Inflammatory mediators are released which cause (leukotrienes, histamines, cytokines, prostaglandins) * Vascular congestion * Edema formation * Production of thick, tenacious sputum *!!! Bronchoconstriction * Thickening of airway walls (smooth muscle of bronchus eventually hypertrophies) * INCREASE bronchial hyperresponsiveness (bronchial tissue is much more sensitive = prone to spasm)

INFLAMMATORY BOWEL DISEASE (IBD)

- Chronic recurrent inflammation of the GI tract characterized by remissions and exacerbations - Autoimmune disease; there is NO KNOWN CURE - Classified as either Crohn's Disease or Ulcerative Colitis - Peak in teens and early adulthood - Affects both sexes equally - Cultural-more common among Jewish persons and Whites - Etiology unknown, a combination of: (when the immune system is turned on, the body doesn't know how to turn it off; the body has an abnormal immune response to harmless bacteria that everyone has in their GI tract) * Environment (more common in developed countries (Europe, North America) ~ More common in urban areas that rural * Genetics (5-20% chance of those affected, especially w/ Crohn's) * Infectious agents (a result of interaction w/ virus/bacteria that triggers the body's immune response like Ulerative Colitis)

SYSTEMIC LUPUS ERYTHAMOTOSUS (SLE)

- Chronic, progressive, inflammatory, autoimmune disease - Affects all body systems - Manifestations are varied - Characterized by remissions and exacerbations - Usually affects women of childbearing age - Onset most often in childbearing years - 1.5 million Americans live w/ lupus - Average lupus diagnosis takes 4 years

CT of Abdomen

- Common - Noninvasive - X-ray at different depths (multi-dimensional) - Detect biliary, liver and pancreatic disorders - Possible use of contrast medium * NPO 5 hours is used * Will need IV and experience warm flush w/ injection of that contrast * Must check for allergies to iodine

DMARDS for RA

- Cornerstone of RA treatment - Slow down progression of disease before it causes joint damage by inhibiting inflammatory response - Need to take for several weeks in order to see therapeutic effect (once a week) - Monitor hepatic function and evaluate bone marrow suppression - Methotrexate (helps keep pt in remission) - Sulfasalazine (more in Lupus) - Hydroxychloroquine (monitor for vision changes...retinal damage) * Also monitor CBC count, platelets

Clinical Manifestations of Asthma

- Coughing (hallmark symptom after exposure to trigger) * In some pt's, may be the only symptom - Wheezing (hallmark symptom after exposure to trigger) * Frequent but not always the reliable sign to gauge severity of the attack * Major attacks don't have audible wheezing b/c of limited airflow but can be heard in minor attack - Dyspnea (hallmark symptom after exposure to trigger) * Hyperventilation is common in attack causing resp. alk. b/c breathing so fast = releasing CO2) - Chest tightness (hallmark symptom after exposure to trigger) - Tachycardia w/ tachypnea - Prolonged expiratory phase (air trapping b/c of bronchospasm b/c of bronchoconstriction) * Bronchial = upper so it's hard to release air - Anxiety/apprehension (work of breathing INCREASES) * Hypoxemia -> anxiety - Use of accessory muscles - Retractions - Air trapping -> Resp. Acid (can't fully exhale)

Clinical Manifestations of SLE

- Dermatologic (classic) * Butterfly rash on face (> 50-85% of pt/s will have this) * Alopecia (patchy spots, 25% of pt's) * Oral/nasopharyngeal ulcers (33% of pt's) * Sensitivity to sunlight w/ resulting rash (33% of pt's) - Musculoskeletal * Arthritis (> 90% of pt's) * Polyarthralgia w/ morning stiffness - Cardiopulmonary *!!! Dysrhythmias * Pericarditis (general inflammation goes along w/ this) * Tachypnea * Pleurisy (lung problems) ~ Pleural effusion, Dyspnea - Infection - Renal * Lupus nephritis - Nervous System * Cognitive dysfunction (personality changes) ~ Anxiety, Depression * Peripheral neuropathy * Seizures - Hematologic * Anemia (DECREASED HGB/HCT, clotting problems) * Leukopenia (> infection rate INCREASES b/c WBC is DECREASED) * Thrombocytopenia * Avoid sunlight, take extra care w/ skin *

Clinical Manifestations of Active TB

- Develop insidiously and are initially nonspecific (8-10 weeks) - Fatigue - Dim. appetite - Unexplained weight loss - Low-grade fever - Chills - Night sweats - Dry cough (3 weeks or >), which later becomes purulent or hemoptysis * Hemoptysis occurs late in disease only to 10% of pt's

Nursing Diagnoses for IBD

- Diarrhea (r/t bowel inflammation and intestinal hyperactive) * Once controlled, cancel out fluid volume deficit and pain r/t hyperactivity - Imbalanced Nutrition < Body Requirements (possibly) - Fluid Volume Deficit - Activity Intolerance - Pain - Anxiety - Ineffective Coping - R/F Social Isolation

Esophagoscopy for GI

- Direct visualization of esophagus - Detects tumors, Barrett's esophagitis, varices * Barrett's Esophagitis: precursos to cancer of the esophagus ~ Happens w/ continuous reflux over time * Varices: seen w/ those w/ portal hypertension and a hx of alcohol abuse - Can biopsy tissue * A consent for this procedure is needed - NPO 8-12 hours and until gag reflex comes back

Types of Lupus

- Discoid Lupus Erythematosus (DLE) * Affects skin but not internal organs so not too serious * 10% of pt's w/ this develops into SLE - Drug-Induced Lupus (old cardiac meds may cause this and disappears when discontinued) * S/S resolve within 6 months of discontinued - Systemic Lupus Erythematosus (SLE) * No 2 people have the same s/s

UGI (Barium Swallow)/UGI w/ Small Bowel follow through

- Drink a contrast medium (usually barium) - This test gives definitive diagnosis when testing for peptic ulcer disease - Visualization via fluoroscopy from mouth through small intestine * Long flexible tube - Detect abnormalities of esophagus, stomach, duodenum - Usually looking for ulcers or GERD or a reflux - May do biopsy - Must be NPO 8-12 hours - May be given laxative or stool softener to expel barium * Must teach pt that stool can be white for 24-72 hours afterwards as they pass the barium (must drink plenty of fluids to prevent impaction)

Isoniazid (INH)

- Drug of choice for TB prophylaxis and a first line drug for active TB - Different fixed doses available - Administer on an empty stomach - Monitor for s/e: * Numbness and tingling of extremities * Hepatotoxicity (common, monitor w/ ALT and AST) * Anemia - Take pyridoxine (vitamin B6) to prevent peripheral neuropathy - Avoid alcohol - Notify MD if you develop an allergic reaction MNEMONIC: INH I- N- umbness, N- europathy H- epatotoxicity (shown w/ Jaundice, Sclera, Dark Urine)

HIV Prevention

- Education * Risk factors ~ Safe activities ~ Risk-reducing activities (don't expose to illness; keep healthy!) -!!! STANDARD PRECAUTIONS IN HOSPITAL (unless coming in w/ specific disease for isolation) -!!! Preexposure prophylaxis (PREP) for adults at high risk (oral ART meds = 2 pills in 1) - Post exposure prophylsxis (PEP) for health care workers

Risk of new infection affected by

- Extent of air contamination (# of particles) - Duration of exposure (repeated contact w/ TB person) - # of microbes in the sputum (how long have they had it? Is there a Drug Resistant Strain?) - Frequency and force of coughing - Characteristics of infectious person - Susceptibility of the host (Diabetes? Chronically ill? You're more likely to get TB)

Pharmacologic Therapy of TB Handout

- First Line Agents: 1. Isoniazid (INH) 2. Rifampin - Drugs: 1. Pyrazinamide (PZA) 2. Ethambutol 3. Streptomycin (not mentioned in powerpoint) ~ Generally, anti-TB meds are used cautiously in pt's w/ liver dysfunction, renal dysfunction, pregnancy or lactation, gouty arthritis, alcohol intake, optic neuritis

CONCEPT OF OXYGENATION: - Alveoli

- Functional unit of the lung - Each adult has 300 million alveoli arranged in clusters (0.3 mm in size) - Are interconnected by pores of Kohn - Produce surfactant (lipoprotein, reduces surface tension) - Surrounded by capillary bed - Gas exchange occurs via diffusion - Gas exchange depends on ventilation-perfusion ratio - Must be blood supply and oxygen for alveoli to work - Alveoli are very unstable and tend to collapse but surfactant helps with that - Deep breathe!!! When lungs expand, alveoli stretches and promote surfactant release - Atelactasis: collapsed, airless alveoli

UC Complications

- Hemorrhage (b/c of ulcerations) - Perforation w/ possible peritonitis (not as common b/c UC involves inner mucosa but MAY occur) * Fistulas and abscesses aren't common in UC b/c not all layers of bowel are affected - Toxic megacolon (dilation and motor paralysis of the colon) * Causes subsequent ileus * Usually involves transverse section of bowel, can be triggered by laxatives, narcotics, anticholinergic meds for hypercholemia ~ S/S: Fever, Tachycardia, DECREASED blood pressure, Cramping, Stool # change - INCREASED risk for colorectal cancer * Someone w/ disease for 8-10 years

Nursing Interventions for Asthma

- High fowler's position - Administer oxygen and medications (short-acting bronchodilators and nebulizers) - Nebulizer treatments w/ humidification - Hydration - Stay w/ client; provide reassurance (pt will be anxious) - Calm environment - Breathing techniques (pursed-lip breathing = extend expiration time) - Assist w/ ADL's - Monitor PEFR's - Correct administration of inhalers - Client/family education (prevents future attacks)

Ambulatory and Home Care for TB

- Hospitalization is rare (ONLY for ruling out or diagnosing it) - Client at home if household contacts have been exposed and there's no exposure to high-risk groups within that home (on home confinement and no visitors allowed if active TB) - Notification of public health department (keeps track of no visitors at home) - If non-compliant w/ med regime DOT is implemented via public health agency * DOT = Direct Observational Therapy = go into health department or local clinic and be observed taking meds (or they can also go to pt's home) and both of these INCREASE compliance - Follow up care for 12 months * For a final evaluation [3 (-) sputums to be deemed cured]

Suppress Functioning Clinical Manifestations for Immunity

- Hx or frequent infections (i.e. Sinus, Ear, Pneumonia, Thrush) - Poor wound healing w/ chronic wounds (poor response to antibiotics) - Fatigue and malaise - Poorly nourished/wasting syndrome (Poorly nourished -> more problems w/ immune system) * Wasting syndrome -> HIV? - Weight loss (bad sign) - Enlarged lymph nodes - Presence or opportunistic infection (others fight it off but people w/ immunosuppression get that disease)

Nursing Interventions for Pneumonia

- Identify clients at risk - Minimize risk of aspiration - Rest during acute phase then ambulate - INCREASE hob to semi/high-Fowler's - Cough/Deep breathe (bronchodilators, chest physiotherapy) - Splint chest (if in pain) - Suctioning (prn, can put bacteria in resp. system, if unable to cough up their own secretions) - Push fluids (liquify secretions) - Positional changes (if INCREASE in pooling of secretions) - Smoking cessation (nicotine patch) - Relaxation techniques - Assist w/ ADL's - Administer meds and O2 (educate!!) - Nutrition - HH, proper use of resp. equipment - Prompt treatment of URI Extra: - Assess lung sounds (improving?) - Check vitals (rr? O2Sat?) - Skin color (cyanotic? Check lips!) - Monitor ABG results - Collect sputum culture (if ordered)

Primary Prevention for Optimum Immune Response

- Immunizations (actively acquired immunity) * i.e. Flu, Pneumonia, Meningitis - Avoid high risk behavior - Nutrition - Exercise - Infection control measures (HH!) - HIV screening

Timeline for Untreated HIV

- In early infection, window period is... - CD4 can't keep up anymore and drops after many years - When it becomes chronic, may appear healthy

Nursing Diagnoses and PC's for TB

- Ineffective Airway Clearance - Imbalanced Nutrition < Body Requirements -!!! Deficient Knowledge (lots of teaching) - Ineffective Therapeutic Regimen Management - Activity Intolerance - R/F Noncompliance - R/F Disturbed Sensory Perception r/t INH

Ulcerative Colitis (UC)

- Inflammation and ulceration of colon and rectum - STARTS IN THE RECTUM AND SPREADS UP THE COLON IN A CONTINUOUS PATTERN - Involves only the INNERMOST LAYERS of bowel wall (mucosal and sub mucosal) * Mucosa becomes hyperemic (INCREASED blood flow) and becomes edematous and red - Ulcerations destroy the mucosal epithelium, causing BLEEDING AND DIARRHEA (common complication) - Large fluid and electrolyte losses secondary to inflammation of mucosal (common complication)

Physical Assessment of GI

- Inspect abdomen for symmetry, contour and observable masses (surgical scars) - Auscultation for bowel sounds (in all 4 quadrants) - Percuss for fluid, distention and masses * Fluid/Masses sound DULL * Distention sounds like HOLLOW DRUM - Palpation for tenderness and rebound tenderness

Respiratory System Age Related Changes

- Lifetime exposure to environmental stimuli (working with coal/farm dust?) - Concurrent chronic disease (COPD, Heart disease, Diabetes) - Structural alterations: * DECREASE in elastic recoil * DECREASE in chest wall compliance * AP diameters INCREASES (barrel chest) * Kyphoscoliosis w/ advancing age * Alveolar surface DECREASES - Defense Mechanism Changes: * DECREASE in cilia function * DECREASE cough reflex (secretion clearance) * DECREASE effectiveness of alveolar macrophages (susceptible to retain mucus/resp. infection) * Muscle atrophy of pharynx and larynx - DECREASE on physical mobility (not always) * may be due to other underlying diseases * Stroke INCREASES risk of aspiration which INCREASES risk of Pneumonia

Pyrazinamide (PZA)

- May be added for the first 2 months of treatment - Concurrent use of pyrazinamide allows a shorter course of therapy - Monitor for s/e: *!!! Hepatotoxicity * Hyperuricemia - Administer w/ meals - Maintain high fluid intake - Monitor liver function tests, CBC, uric acid levels - Avoid alcohol

Streptomycin

- May be used in combination w/ other anti-TB medications for active TB - Monitor for adverse s/e: * Nephrotoxicity *!!! Ototoxicity - Administer by IM injections into large muscle mass - Maintain fluid intake of 2-3 L/day - Monitor renal function studies - Assess hearing and balance frequently - Have audiometric testing

Ethambutol

- May be used in combination w/ other anti-TB meds for active TB - A bacteriostatic drug that reduces development of resistance to first line agents - Monitor for s/e of optic neuritis - Have client get a baseline visual exam and color discrimination before and during treatment - Monitor CBC, renal function (BUN and Creatinine), liver function tests * ETHAMBUTOL = E = EYES = VISION PROBLEMS *

Maternal-to-Infant Transmission of HIV

- Most transmission occurs during or near the time of birth - HIV infected women must be treated w/ ART during pregnancy - Perinatal transmission can be DECREASED from 25% to < 2%! - Breastfeeding is NOT RECOMMENDED in the US for infants w/ moms who are HIV (+)

Diagnostic Testing for HIV

- Most useful screening tests detect HIV-specific antibodies and/or antigens * RAPID HIV ANTIBODY TEST: results within 20 minutes ~ If (+) necessitates a return appointment (must repeat test to be 100% accurate) * MUST BE VERIFIED BY BLOOD TESTING: w/ a standard HIV assay test (EIA, Western Blot) * Combination (4th generation) tests can detect HIV earlier and includes viral load testing (newer test) * Testing done w/ counseling * Reporting ~ (+) to state health department, encouraged to tell sexual partners (make a list) and health department tells them anonymously

Pharmacologic Therapy for SLE

- NSAIDS (Meloxicam, Ibuprofen, Naproxen) * Really hard on stomach so take w/ food - Antimalarial drugs - Hydroxychloroquine (most common one given) * No breastfeeding * Avoid pregnancy - Corticosteroids (frequent but long-term adverse S/E) * DECREASED ability to fight off infection * Vascular Necrosis: the joint is worn away and end up needing joint replacement - Immunomodulators * Meds that end in "mab" * Risk for infection * Allergic reactions - Immunosuppressives * Azathioprine (Imuran) * Cyclophosphamide (Cytoxan) * Benlysta - New IV drug

Abdominal Ultrasound

- Noninvasive - Views internal organs (w/ probe) - Detects masses, gallstones, liver disease - NPO 8-12 hours - No bowel prep - No Post-Test Nursing Care

CD4 T Cell Counts for HIV

- Normal CD4 T cell LIVES 100 DAYS; HIV infected T cells LIVES ~2 DAYS - Normal CD4 Count 800-1200 cells/mm - Asymptomatic HIV (> 500) - Compromised Immune System < 350 - Aids < 200 *Memorize all from above for treatment*

Pneumonia Etiology

- Normal defense mechanisms are impaired (cilia, cough, and phagocytosis) - Acquisition of organisms via * Aspiration: emesis or gastric reflux which causes inflammation * Inhalation: droplets from virus/bacteria taken in * Blood spread: sepsis/infection from alveoli and cause resp. response - Invading organisms colonize the alveoli and initiate an inflammatory response

Post Exposure Prophylaxis (PEP) for HIV

- Nurses must report all blood or potentially infectious materials - Timely treatment important - Administer ART within 2 hours of exposure - Take for at least 4 weeks - This will DECREASE risk of transmission by 80%

Nursing Assessment/History for Immunity

- Past medical history (determines risk for altered response) - Allergies to substances/meds (linked to hypersensitivity) * Many = more likely to have more allergies to different things done in hospital - Current meds (produce risk of immune system) - Lifestyle behaviors - Exposure to microorganisms (that may cause immunosuppression) * i.e. Hep B, Herpes Simplex

Clinical Manifestations of Right-Sided Heart Failure

- Peripheral edema (if in bed, dependent edema in lower legs) - Ascites (build-up of fluid in the space between the lining pf the abdomen and abdominal organs) - Hepatomegaly (enlarged liver) - Bounding pulses (b/c HIGH blood volume) - JVD (Jugular Vein Distention) - Weight gain (each L of water = 2.2 lbs) * Treat w/ diuretics - Cardiac dysrhythmias

* Nursing Interventions for RA *

- Physical mobility * Rest alternate w/ activity (rest periods are important b/c it's systemic) * Proper positioning/Use of splints (to protect joints) ~ Avoid repetitive activities * Ice application during exacerbation * Warm showers vs. tub bath for morning stiffness * ROM exercises (to keep joints mobile) * Water exercises - Safety * Grab bars in bathroom * Nonskid mats in house - Promotions of self-care * Allow client to perform ADL's - Fatigue * Pace activities * Rest periods * Set priorities (whatever best time of day is -> do your most important activity) - Enhancement of Body Image (educate!!!) * Meds S/E * Coping strategies

Diagnostic Tests for RA

- Primarily based on history and physical exam - Blood tests * RF (Rheumatoid Factor): really common! ~ Measure of altered antibodies: (+) in 80% of RA pt's * ESR (General inflammatory marker!) ~ INCREASE when having a flare up (be really sick and lose a ton of weight; maybe anorexic) * C-reactive protein (General inflammatory marker!) ~ INCREASE when having a flare up (be really sick and lose a ton of weight; maybe anorexic) * ANA (anti-nuclear antibiotic): seen more w/ Lupus ~ CBC - Synovial fluid analysis (INCREASED WBC's, changes in CBC) - X-rays (bone scan for baseline and follow progress w/ x-rays) * ESR and C-reactive protein can INCREASE when there is inflammation whether from RA flare up or some other disease

Clinical Manifestations of COPD

- Productive cough (may/may not) * May have INCREASED sputum production = productive cough (thick, whiteish w/ tan/yellow like Bronchitis) - Progressive dyspnea (as disease progresses, sob w/ simple tasks) * Pt may not notice and think it's part of normal aging or they're out of shape - Barrel chest (INCREASE in AP diameter b/c of trapping of air - Use of accessory muscles (intercostals, neck, shoulders), client assumes tripod position (sitting and leaning forward while resting elbows and hands on another surface which makes it easier to breathe) * Become chest breathers - Clubbing of fingernails (LATE SIGN!!!) - Prolonged expiratory phase of respiration (r/t to air trapping; trying to release air) - Dim. breath sounds (b/c alveoli are overinflated) - Wheezing and chest tightness - Bronchospasms at end of coughing episodes - Weight loss/anorexia (hypermetabolic; skinny b/c INCREASED energy used to breathe) * Smoking? Meds? - Hypoxemia w/ hyercapnia LATE in disease (INCREASED PCO2 > 45 Resp. Acid.) - Ruddy appearance/cyanosis (due to polycythemia = INCREASE in RBC production and compensates for chronic hypoxemia (O2Sat < 88%) * LOW oxygen MNEMONIC: LUNG DAMAGE L- ack of energy U- nable to tolerative activity (sob) N- utrition poor (weight loss) due to energy used breathing (especially w/ emphysema) G- ases abnormal (HIGH PCO2 >45, LOW PO2 <90 = resp. acid.) D- ry/Productive cough constant (productive w/ chronic bronchitis) A- ccessory muscle usage during breathing; A- bnormal lung sounds M- odification of skin color from pink to cyanosis in lips/mucous membranes/nail bed A- P diameter INCREASES (barrel chest) ... Emphysema "Pink Puffers" G- ets in Tripod Position during dyspnea E- xtreme dyspnea

Pathophysiology of Chronic Bronchitis

- Productive cough for 3 months in 2 consecutive years w/ no other cause being identified - Chronic inflammation of airways w/ vasodilation, congestion and edema of mucosa which narrows airway - Thick, tenacious mucous in airways leads to INCREASED susceptibility to infection - Narrowed airways and excess secretion obstruct airway - Hypoxemia develops from airway obstruction - Blue Bloater * Cyanosis b/c LOW O2 (INCREASE RBC production to compensate causing blood to shift elsewhere which INCREASES pressure in pulmonary artery) * Bloated (edema and INCREASE in lung volume) ~ Effects of lung disease on heart which causes Cor Pulmonale

Optimal Immune Response

- Protects the body from invasion of microorganisms and other antigens in order to prevent infection - Removes dead or damaged cells - Recognizes and removes cell mutations (really important w/ cancer) *** recognition of self and of foreign proteins is the hallmark of a properly functioning immune system ***

Adherence to Medication Regime (HIV)

- Pt teaching * Will be taking ART for life * 2-4 WEEKS after meds started pt will have viral load tested * Will be taking at least 3 drugs from 2 different classes * Cannot miss a day and need to stay on the schedule * Lab work every 3-6 MONTHS * Use pill boxes, timers, etc * Observe over time for pill fatigue * S/E of meds ~ Metabolic syndrome (INCREASE triglycerides, cholesterol) * Abnormal CBC (DECREASED platelets, anemic, DECREASED WBC) * Lipodystrophy: changes in... ~ Lose lots of muscle mass and get lots of fat in... * Must take meds to not become resistant

Diagnostic Tests for Asthma

- Pulmonary function test (also for COPD) * Air trapping = DECREASED FVC and FEV (this is normal during attacks) - Peak Expiratory Flow Reading (PEFR) (maximum air that can be expelled during expiration) * Green Zone = All clear (Good!); Yellow Zone = Take action; Red Zone = Medical Alert (Severe impairment!) * Keep a diary to recognize when at risk for worsening symptoms and need to INCREASE bronchodilator - CXR (do for baseline) - ABG (may/may not be done depending on severity of the attack) * Early (resp. alk. = pH INCREASE, CO2 DECREASED due to hyperventilation) * Late (CO2 normalizes b/c pt gets tired) - Allergy testing (done in beginning) - Sputum C&S (rules out infection) - O2Sat monitoring (shows DECREASE in oxygenation) ~ Reading determines what actions will be taken

Goals of Care w/ IBD

- Rest body (bed rest) to assist healing - Rest the bowel - Control inflammation - Combat infection (if there is one) - Correct malnutrition - Alleviate stress - Relieve symptoms - Improve quality of life (flare ups pf diarrhea affect life by possibly affecting job b/c of pain and constant need to be near bathroom) - Provide support

Sigmoidoscopy for GI

- Similar to colonoscopy but the visualization isn't as far up - Direct visualization of rectum and sigmoid colon - Detects tumors, polyps, fissures, hemorrhoids, inflammatory disease - Biopsy available

Mycobacterium Tuberculosis

- Slow-growing, rod-shaped, acid-fast organism (stains red on CXR's) - Waxy outer capsule of bacteria makes it resistance to destruction (difficult to treat) - Transmitted via AIRBORNE droplet nuclei - Need to have REPEATED CLOSE contact w/ an infected person to transmit (lasts in the air for several hours) - Bacteria usually attacks the lungs but can attack kidney, brain, and spine - Aerobic = loves O2, high in lungs)

Diagnostic Tests for COPD

- Spirometry and pulmonary function tests * COPD pt can't force normal volume of air in normal amount of time b/c of air trapping (takes much longer!) * Pt breathes into tube that measures how much volume the lungs can hold during inhalation and how much and how fast air volume is ~ FVC ~ FEV - Pulse oximetry (normal = 95% or >, COPD normal = 90%-93% * For home oxygen, < 88% at rest (if exercising pt and O2Sat DECREASES to 88%, make sure long cord is ready and not removed for the bathroom) - CXR - Serum AAT levels (genetic order putting you at risk for COPD) * AAT levels are in blood test - ABG's (Chronic Resp. Acid. is LATE!!! LOW pH, HIGH PCO2) - Sputum C&S, gram stain (if looking for infection) - 6 minute walk test (looking for desaturation in activity) - Blood tests * HGB/HCT (INCREASED level of anemic) * Electrolytes

Community Acquired Pneumonia (CAP)

- Spread by person-to-person via droplets - LRI -!!! Onset in the community OR during the first 2 DAYS of hospitalization (meaning they were already exposed and surfaces) - Highest incidence in winter months - Common organisms are STREPtococcus, pneumoniae, mycoplasma pneumoniae and H influenzae (DON'T MEMORIZE)

Age Related Changes on GI System

- Taste buds DECREASE (revolving around sweet and salty) - DECREASED volume of saliva = dry mouth (eating becomes less pleasurable - INCREASED dysphagia (and possible food intolerances) - DECREASED gastric emptying (if delayed, DECREASES amount of food you can take in) * Also causes INCREASED incidence of nausea and vomiting - Motility of GI system DECREASES (DECREASED GI peristalsis -> irregular bm's and constipation) - DECREASE in liver size (DECREASED ability to metabolize drugs) - DECREASED muscle tone and sphincter tone (can lead to fecal impaction and abdominal distention)

CONCEPT OF IMMUNITY

- The physiologic process that provides protection or defense from disease - Closely r/t the concepts of inflammation and infection - Immune system protects body to keep it healthy through tissues, organ, and cells (protects body from foreign antigens like proteins, things found in pollens, foods, bee stings, snake venom, bacteria, viruses, or parasites) - We have innate, passive immunity present at birth which is short-lived - Acquired immunity: gained after birth - Active/Acquired immunity from a disease can be from immunizations or the disease we get (our body remembers)

ALTERATIONS IN OXYGENATION (Obstructive Disorders) - COPD

- Umbrella term for emphysema and bronchitis - IRREVERSIBLE AIRFLOW LIMITATION on exhalation (air trapping = the air taken in can't effectively be released) - Periodic exacerbations which lead to progressive destructive changes of airways and lung parenchyma (always prevent exacerbations!) - 12 millions Americans diagnosed w/ COPD (24 million additional have impaired lung function) - 3rd leading cause of death in US - Is not curable, but it can be managed - Direct cost of care ~18 billion dollars - Limited airflow (due to thick and swollen bronchioles that have become deformed w/ excessive sputum production) - Inability to fully exhale - Happens gradually

Rifampin

- Used in combination w/ other anti-TB meds for the treatment of active TB - INH and Rifampin given together for 6-12 months (both cause hepatotoxicity) - Administer on an empty stomach - Additive effect when administered w/ INH -!!! Causes body fluids (sweat, urine, saliva, tears) to turn red-orange - DECREASES effectiveness of oral contraceptives - Observe for drug interactions: may DECREASE therapeutic effects of theophylline, steroids, opioids, oral hypoglycemics, oral anticoagulants, beta blockers, benzodiazepines *** RIFAMPIN = R = RED-orange ***

Biologic Response Modifiers or Immunomodulators for RA

- Used to treat clients who have not responded to DMARDS - Used to slow disease progression - Inhibits tumor necrosis factor (TNF) and INCREASES inflammation - Given SubQ injection or IV - Dosing is weekly or monthly - S/E: Risk for infection b/c of altered immunity, allergic reactions - Meds that end in "mab"; called Rituxan, Enbrel, Remicade, Humira on TV - Suppress the body's tumor necrosis factor (TNF) - Maintain remission * Genetically engineered and used in very severe cases

Vancomycin for Pneumonia

- Used to treat severe cases - One of the few that can treat bacteria that may be resistant to other antibiotics -!!! Watch out for Ototoxicity (Hearing Loss)

Esophagogastroduodenoscopy (EGD) for GI

- Very common - Direct visualization of esophagus, stomach and duodenum (scope ~1 in. wide) - Can detect tumors, ulcers, inflammation, varices (just like UGI) - Can biopsy tissue - NPO 8-12 hours and sedated w/ Versed - Nursing Implication: check for gag reflex after test before allowing anything PO * Usually Dr. writes this as an order - Nursing Intervention: if the back of the throat is numbed, they have impaired gag reflex so make sure to check gag reflex before they eat or drink * Check vital signs * Gargle for sore throat

How is SLE Diagnosed

- Very difficult to diagnose - No one specific test to confirm SLE - Diagnosis based on hx, physical exam and labs * College of rheumatology Criteria for SLE - Labs * Anti-DNA antibody testing (antibody testing) ~ Part of ANA panel * Anti-Smith (antibody testing) ~ Part of ANA panel * ESR (general inflammatory marker) ~ And C-reactive Protein * CBC (changes like anemia) * UA (may cause kidney problems) * Skin or kidney biopsy * ANA is (+) in 97-98% of pt's w/ Lupus but can be (+) in other diseases too like RA and other connective tissue disease

Viral Load in Blood and CD4 + T-Cell Counts

- Viral load = how to track progression - > w/ more active state of disease - HIV can be transmitted within few days of contracting it * Want to DECREASE viral load* * Undetectable? = NOT gone! ~ May be hiding in lymph nodes

LGI (Barium Enema)

- Visualization via fluoroscopy of colon - Identifies polyps, tumors, lesions of colon - Must drink plenty of fluids to expel barium - NPO for 8-12 hours - Bowel Prep: * Clear liquids evening before test * Laxatives/enemas till clear * Administer enema of contrast medium during test - May be given laxatives to expel barium

Colonoscopy for GI

- Visualizes entire colon up to ileocecal valve - Detects IBD, diverticulosis, polyps, tumors - Biopsy possible * Most consents list this - Bowel must be cleansed prior to this - NPO w/ sedation and consent *Important* ~ Check for complications post-op like bleeding or severe pain which could be perforation of the bowel ~ Abdominal cramping b/c of air in colon

Nursing Interventions for IBD

- Vital signs (q 4 hours post-op) - Daily weight and I&O - Bowel rest (to help DECREASE inflammation) - Hydration (for replacement of fluid and electrolytes) - Nutrition (advanced as tolerated) * Diet (start clear liquids) * Enteral * TPN (Total Parenteral Nutrition if long-term NPO) - Post-op care -ostomy care - Skin care (Peri-anal care especially w/ lots of diarrhea) - Coping strategies - Teaching/Education (plan of care)

RA Systemic Manifestations

- Weakness -*** Malaise w/ fatigue (most common!) - Anorexia w/ weight loss - Low-grade fever (common) - Generalized stiffness - Rheumatoid nodules (may/may not) * Firm and nontender (even though they appear to be tender) - Sjogrens syndrome (10-15% of pt's w/ RA have this as well) * DECREASED lacrimal and salivary gland excretions = dry eyes and dry mouth - Vasculitis, pericarditis, cardiomyopathy * CV complications: heart symptoms, vein inflammation, infection, inflammation in lining of heart

Clinical Manifestations of UC

-!!! Bloody diarrhea w/ mucus (2-20 episodes/day) * Exacerbation may be > * Mild case = < 5/day * Severity is related to # of diarrhea - Rectal bleeding (hallmark!) - Lower abdominal pain - Fever (systemic symptom) - Fatigue (systemic symptom) - Dehydration possible w/ severe disease (develop anemia) - Less weight loss b/c it's primarily in colon

Diagnostic Tests of IBD

-!!! CBC (anemia?) - WBC (INCREASES, especially w/ toxic megacolon complication in UC) - BMP (fluid loss through diarrhea) * K+ levels w/ GI loss - ESR (INCREASES, inflammatory marker) - Electrolyte levels (K+, Cl-) - Albumin level (DECREASES b/c of malabsorption/malnutrition/protein loss) - Stool cultures (may be done to rule out infection) - Sigmoidoscopy and Colonoscopy (for bowel inspection) * Yearly colonoscopy if had disease > 10 years (incidence of cancer INCREASES so check for any more serious problems) - Rectal Biopsy - Double contrast barium enema (get barium and air)

Discharge Teaching for Pneumonia

-!!! Complete prescribed medication regime (don't build antibiotic resistance) * Antipyretics, IV Fluids, Antibiotics (Bacterial), Antifungal (Fungal), VANCOMYCIN - Avoid smoking or secondhand smoke - Limit activities and increase rest periods (Pneumonia is very tiring!) - Cough and deep breathe for 6-8 weeks (clear lungs by getting rid of sputum) *Incentive Spirometer (10 times q 1-2 hr while awake) - Adequate fluid intake and nutrition (to liquify secretions) * 2-3L (fever dehydrates and we lose 300-400 mL/day w/ respirations ALONE) * Not if contraindicated like HF, Renal Disease - Report any changes in symptoms (i.e. Fever, Sputum Changes - COCA!) Others: - Stay up-to-date w/ vaccines (i.e. Flu, Pneumonia q 5 years after 65) ***Recurrence is common so prevent***

Complications of COPD

-!!! Cor Pulmonale/Right-side hf (hypertrophy) * LATE sign! - Acute exacerbations of COPD (change in baseline of dyspnea, cough, or sputum) * Average person has 1-2 exacerbations per year (progressive worsening of their function) - Pneumonia (lung infections INCREASE risk of lung cancer) - Resp. failure - GERD/ulcers (GERD = when forcefully cough, stimulates hydrochloric acid production and reflux causes INCREASED airway constriction) - Depression - Pneumothorax: spontaneous d/t forming of air sacs - Heart disease: Hf

Clinical Manifestations of CD

-!!! Diarrhea - Colicky abdominal pain (can be constant and more common in RLQ) - Fever (systemic symptom) - Fatigue (systemic symptom) - Weight loss if small intestine involved (b/c absorption happens here) * Systemic symptom - Nutritional deficits (goes along w/ small intestine)

Preventative Nursing Interventions for SLE

-!!! Limit sun exposure (wear a hat) * DECREASES risk of flare -!!! Sunscreen; limit use of cosmetics - Cleanse skin w/ mild soap - Avoid use of powders, drying agents and household chemicals - Avoid chemical treatments to the hair - Prevent infection - Rest periods - Manage S/E's of meds - Avoidance of triggers for disease flares - Support groups/Emotional support

Collaborative Care for RA

-!!! Pharmagolic Therapy (very important to prevent long-term changes) - PT and OT * PT: keep functional capacity * OT: help deal w/ ADL's - Nutrition and weight loss * Need nutrition supplement * INCREASE protein if anorexic -!!! Hot and cold therapy (really important; use combo) * Hot: best for joint stiffness * Cold: better after an activity for inlammation - Balance or rest and activity (b/c of INCREASED fatigue) * Encourage cat naps throughout the day - Reconstructive therapy (may need joint replacement) - Protection of small joints (avoid repetitive action in those joints) * If they do have problems w/ the joint, may need to wear a splint to protect that joint

Clinical Manifestations and PC's for HIV

1. Acute infection (how it starts) - Flulike symptoms * Fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, or a diffuse rash * Occurs about 2-4 weeks after infection (lasts 1-2 weeks) * Highly infectious (during the 1-2 weeks)

Risk Factors for Alteration in Oxygenation

1. Age - Infants and young children - Older adults 2. Air pollution 3. Allergies 4. Tobacco use 5. Altered LOC 6. Chronic diseases 7. Immunosuppression (meds are most common, other diseases) 8. Genetics

Risk Factors for Pneumonia

1. Aging Process (resp. changes occur like DECREASE cough reflex = INCREASE pooling of secretions, DECREASE muscle tone and feeling in pharynx and larynx) 2. Altered LOC (b/c of narcotics or anesthesia) 3. Altered oropharyngeal flora 4. Chronic diseases (i.e. Stroke) 5. Compromised immune system (i.e. Cancer = chemo) 6. Drugs (Arthritis meds, corticosteroids) 7. Immobility 8. Gastric feedings (risk of aspiration) 9. Malnutrition (DECREASES WBC's and ability to fight off infection) 10. Tracheal intubation (ventilators right into lungs) 11. URI's (cilia are damaged) 12. Smoking/Air pollution (kills cilia) 13. Alcohol/Drug abuse (DECREASES action of cilia and cough) 14. Inhalation of noxious substances 15. Prolonged hospitalization 16. Pediatric differences (kids are more at risk b/c they have shorter and narrower airways and are born w/ only 25 million alveoli which INCREASES surface tension

RA Drug Therapy

1. Analgesics (Aspirin or Tylenol) 2. Anti-inflammatory drugs (NSAIDS) - Used to be cornerstone for drug therapy of RA - Ibuprofen, Naproxen, Meloxicam (may upset stomach) 3. Immunosuppressants 4. Corticosteroids (Prednisone) - Can be given PO, topical, IV, injection into the joint or IM - Meant to be put on remission but many times will be continued at all times - S/E: Hyperglycemia, Weight gain, Edema, Thin and Fragile skin (bruises and tears easily) - Decrease inflammation but also alters immunity = more susceptible to infections 5. DMARDS 6. Biologic Response Modifiers/Immunomodulators

RA Pathophysiology

1. Autoantibodies (rheumatoid factor) form against abnormal IgG 2. Form immune complexes that deposit in synovial membrane - Rheumatoid factor combines w/ immunoglobulin G and deposit on membranes and cartilage 3. Inflammatory response occurs (neutrophils release proteolytic enzymes and T cells release cytokines and tumor necrosis factor (TNF) - Neutrophils: run to site - Proteolytic enzymes: cause damage - Cytokines: cause inflammation - Tumor Necrosis Factor (TNF): type of cytokine 4. Chronic inflammation results in joint damage - W/ time, deformities can happen

Diagnostic Tests

1. CBC ( HIGH WBC = infection, LOW HGB/HCT = anemia) 2. ABGs (pH oxygenation; acid base status) 3. Pulse Oximetry (monitors oxygen saturation) - Normal = 94%-99%, Older = 92% 4. CXR (problems w/ bones, tumors, fluid) - TB? Pneumonia? - Pleural effusion in lung cancer, hf, pneumonia (resolves on its own if small enough) 5. CT of lung (visualize lesions - cancerous?) - PE? 6. Sputum studies (smear - put on slide, culture for 48-72 hours) - Sensitivity? susceptible -! Sputum received before providing antibiotic 7. Skin tests 8. Ventilation-Perfusion scan (diagnose PE) 9. Pulmonary Function studies (Incentive Spirometer - measures air movement in/out of lungs) - Diagnose COPD 10. Peak Expiration Flow Rate (PEFR) - shows max. air flow in expiration - Use w/ Asthma 11. Exercise test (diagnose resp. issues) 12. Bronchoscopy w/ possible lung biopsy (scope in lungs during surgery - Advanced; must be sedated 13. Thoracentesis (needle in pleural space and removes fluid for diagnosis that may be collected abnormally in lungs) - Look for hypoxia!!! Deep breathe - Check for gag reflex before giving fluids so they don't aspirate - May be some minor bleeding - Pneumothorax may occur if needle from thoracentesis in wrong spot (CXR afterwards)

Pathophysiology of Cor Pulmonale

1. COPD 2. Hypoxia 3. Polycythemia 4. Hyperviscosity 5. Pulmonary hypertension 6. Right ventricular hypertrophy (may/may not stop here) 7. Cor pulmonale 8. Hf (right-sided) OR 1. COPD 2. Hypoxia 3. Pulmonary vasoconstriction 4. INCREASED Pulmonary vasculature resistance 5. Pulmonary hypertension 6. Right ventricular hypertrophy (may/may not stop here) 7. Cor pulmonale 8. Hf (right-sided) OR 1. COPD 2. Reduction of pulmonary vascular bed 3. INCREASED Pulmonary vasculature resistance 4. Pulmonary hypertension 5. Right ventricular hypertrophy (may/may not stop here) 6. Cor pulmonale 7. Hf (right-sided) OR 1. COPD 2. Acidosis and hypercapnia 3. Pulmonary vasoconstriction 4. INCREASED Pulmonary vasculature resistance 5. Pulmonary hypertension 6. Right ventricular hypertrophy (may/may not stop here) 7. Cor pulmonale 8. Hf (right-sided)

Pharmacologic Therapy for TB

1. Clients w/ LTBI (drug therapy prevents TB infection from developing into Active TB) - INH (isonoziad) 300 mg daily for 6-12 months - Rifapentine 900 mg and INH 900 mg once weekly for 3 months (more expensive = more compliance = DECREASE resistance strain) 2. Clients w/ Active TB (repeated sputum testing is done, sensitivity checked, CXR's done, look at disease) - 4 drugs used in initial phase for effectiveness * INH (isonioziad) * Rifampin * PZA (pyrazinamide) * Ethambutol ~ Initial PHASE of drug treatment used for 2 months THEN continuation phase (2-6 months) combination of drugs ~ Feel better within 2-3 weeks, sputum becomes (-) ~ Treated at home settings MNEMONIC: PERI or RIPE P- yrazonamide (PZA) E- thambutol R- ifampin I- sonioziade (INH)

Types of Pneumonia

1. Community Acquired Pneumonia (CAP): Classification - MOST COMMON - Mostly treated at home depending on symptoms 2. Medical Care Associated Pneumonia (MCAP): Classification - make up 15% of HAI's; very serious; can INCREASE hospital stay by 2 weeks - costs > $40k and if occurs to someone w/ medicare, it won't be covered since it was hospital acquired 3. Aspiration Pneumonia: Cause 4. Fungal Pneumonia: Cause - Histoplasmosis: fungal spores are trapped in lung and become immunosuppressed so they're active and get the disease 5. Opportunistic Pneumonia: Cause - B/c of altered immunity (Cancer, Drug addict, HIV, Malnourished)

Properties of Lung Tissue

1. Compliance: measures expandability/ease of expansion of the lungs - Low: lungs are stiff and difficult to inflate (i.e. Pulmonary Fibrosis, Pulmonary Edema) - High: lungs have lost elasticity and overdistend (i.e. COPD, Emphysema) 2. Elastic Recoil: the ability of the lungs to reduce in volume after being stretched (as we age, elastic recoil may DECREASE)

Assessment Interview

1. Current problem -!!! Restlessness (unexplained? EARLY SIGN of Inadequate Oxygenation; moving in bed a lot? picking at things?) - Changes in breathing pattern/dyspnea (EARLY sign of Inadequate Oxygenation) * Tachypnea: > 20 rr, older adult: > 25 rr * Bradpnea: < 10 rr b/c of Narcotics, Pain meds (i.e. Morphine), Surgery (i.e. Fentanyl) * Dyspnea: subj. feeling of sob; at rest? (LATE SIGN OF INADEQUATE OXYGENATION; from anemia or heart disease) w/ exercise? w/ ADL's? * Orthopnea: sob when laying down (relieves when sitting up) - Cough/sputum (cough > 3 weeks = chronic cough) * productive? Assess COCA! (normal = clear-white, purulent = green-yellow = infection) (COPD = no blood = yellow-tan) * Hemoptosis: cough blood in sputum (i.e. Pulmonary Edema, TB, CANCER) - Chest pain (differentiate! occurs w/ breathing = Pleural, sudden = PE, Pneumonia? Musculoskeletal? GI? GERD? Gallbladder Pain = chest OR cardiac pain) * Have frequent resp. infections? (w/ COPD and asthma ask: how often? how long are exacerbations?) - Adventitious lung sounds 2. Hx of Resp. Disease 3. Lifestyle 4. Allergies 5. Medication Hx

Collaborative Care for IBD

1. Drug therapy - Aminosalicylates (Sulfasalazine/Adulfidine and 5-ASA, Pentasa, Cloazal) * Sulfasalazine: anti-inflammatory ~ Will cause yellow-orange discoloration of skin and urine (may also cause sensitivity to sun) * Active ingredient helps * Pentasa and Cloazal: also contain 5-ASA * First line of therapy * Oral or rectal administration - Corticosteroids (for acute exacerbations) * Used to achieve remission (not long-term therapy) * Various forms of delivery - Immunosuppressant (Sandimmune, Imuran, Methotrexate) * Given to maintain remission *!!! CBC monitoring (b/c of bone marrow suppression S/E from Methotrexate) - Analgesics (for pain) - Antimicrobials (Flagyl, Ciprofloxacin) * W/ or w/o infection - Biologic therapies (Remicade, Humira, Cimzia) * Inhibits TNF (TNF = pro-inflammatory mediator) * Suppress immune response (monitor CBC, report fever b/c maybe infection) 2. Nutrition (no universal trigger) - Bland diet w/ small meals encouraged! (pt's often lactose intolerant so stay away from soda and caffeine) - HIGH calorie and HIGH protein -!!! LOW residue diet (avoid whole grain/HIGH fiber foods (i.e. Fruits) * Opposite of what's usually encouraged - Vitamin and iron supplements - Elemental diet (liquid diet w/ all nutrients needed) 3. Surgery (b/c of obstruction if many exacerbations occur or failure of treatment) - Bowel resection (segments of bowel are removed) - Total colectomy (entire colectomy is removed) - Total protocolectomy w/ ileostomy (may be curable w/ UC) * Colon/rectum removed and anus is closed (ileum brought out through abdominal wall to form a stoma) ~ Ileostomy loses absorbative function by the colon as well as delay provided by ileocecal valve * Monitor for stomal viability (remain brick-to-rose color; Pale/black = DECREASED blood supply) * Output may be high (1500-2000 mL/24 hours) ~ Quite liquid; firm in few weeks ~ May need to be irrigated prior (eventually 500 mL/day) * Skin care (b/c of digestive juices in output; barriers used, warm water when changing q 4-7 days unless leaking) ~ Empty when 1/3's full 4. Complementary therapy - Herbs, teas, yoga, hypnosis, aromatherapy 5. Support groups

Respiratory Defense Mechanisms

1. Filtration of Air: nares warm/humidify the nasal hairs, nasal hairs filter the air we breathe in - Changes in direction of air flow: as air flows through the pharynx and larynx, bacteria/particles get caught so they don't make it to the lungs 2. Mucociliary Clearance: accomplished by mucociliary system below the larynx - Goblet cells make ~100 mL of mucus per day which traps debri that we may breathe in - Cilia covers areas in Bronchus and Trachea; they beat rhythmically and move debri - RUINS System: dehydration, infection, anesthesia drugs, alcohol, cocaine, COPD - Smoking DECREASES effectiveness 3. Cough Reflex: response to irritation - IMPAIRED BY: fatigue, pain, aging process 4. Reflex Bronchoconstriction: keeps things from entering lungs (i.e. breathing in dust/dirt) 5. Alveolar Macrophages: cilia don't reach down to alveoli so macrophages down there phagocyze any inhaled particles and bring them up to cilia so they're exhaled - Smoking DECREASES effectiveness

Prevention of Asthma Attacks

1. Focus is on client and family education - Allergy-proof home (avoid this trigger) - Avoid triggers (exercise is a trigger so puff inhaler prior) - Proper hydration, nutrition and rest - Avoidance of cold air (during exacerbation) - Correct administration of meds/inhalers - Daily PEFR - Develop a written asthma action plan - Keep a diary r/t asthma attacks - Early treatment of URI's (can trigger asthma attack so treat infection promptly)

Physical Exam/Assessment

1. INSPECTION - Anatomy of nares/mouth/pharynx - Breathing pattern (rr?) - Chest configuration (using accessory muscles in neck/shoulders/ribs? - Skin color (Cyanosis = LATE SIGN of hypoxemia) * Light skin person: assess lips/nail bed * Dark skin person: assess conjuctiva, palms, under tongue - Clubbing of fingernails (sponginess of distal portion of fingers) * Changes of angles on nail from edge to tip; INCREASES in depth/bulk * Chronic hypoxemia, NOT overnight (takes years) 2. PALPATION - Tracheal position (midline!) - Thoracic Expansion (symmetrical; first inhale, then exhale -> there should be 1 in. movement on each side) - Tactile fremitus (assess changes in fluid-filled lungs) (Advanced NP does this) * say "99", feel between scapulas (vibrations = fluid; done before chest x-ray) - Chest Wall (tumors? scars? previous surgeries? bruising?) * INCREASE AP diameter (appears barrel chest) 3. PERCUSSION (assess density of lung) - Resonant: low-pitch, heard over normal lungs - Hyperresonant: loud, low-pitch booming heard over hyper-inflated lungs - Dull: dull/muffled sound heard over fluid-filled area 4. AUSCULTATION - Normal (bronchial, bronchovesicular, vesicular) * Bronchial: over trachea, hollow tube * Bronchovesicular: over bronchi, medium-pitch * Vesicular: over lesser bronchi in lower lobes, soft/low-pitch -!!! Adventitious (crackles, rhonchi, wheezes, pleural friction rub) * Crackles: air moving through mucus-filled airways or 1 w/ an unstable bronchial wall (i.e. HF, COPD, Pneumonia); DISCONTINUOUS sound that sounds like opening a bag of chips * Rhonchi: caused by secretions in long airway; CONTINUOUS rattling, much louder, sounds like being under water * Wheezes: heard in a bronchial spasm (i.e. Asthma); CONTINUOUS high-pitched squealing sounds that may be audible w/o stethoscope and sounds musical (or like a whining dog) * Pleural Friction Rub: obstruction in trachea/larynx, very loud high-pitched crowing (sounds like crying dog)

Possible Nursing Diagnoses for Immunity

1. Immunosuppression -*** Risk for Infection - Impaired Skin Integrity - Activity Intolerance - Imbalanced Nutrition - Risk for Social Isolation - Risk for Injury 2. Exaggerated response -*** Ineffective Thermal Regulation (Fever!) - Acute Pain (very likely) - Impaired Skin Integrity - Risk for Ineffective Airway Clearance - Risk for Impaired Gas Exchange - Activity Intolerance - Risk for Injury

Nursing Diagnoses for Alteration in Oxygenation

1. Ineffective Breathing Pattern 2. Ineffective Airway Clearance 3. Impaired Gas Exchange 4. Activity Intolerance or Fatigue (b/c it's hard to breathe) 5. Ineffective Tissue Perfusion 6. Imbalanced Nutrition < Body Requirements (taking lots of energy to breathe = not eating much)

Nursing Interventions

1. Infection Control (HH, avoid large crowds when ill) 2. Positioning of pt (semi-fowler's = easy breathing) 3. Coughing/Breathing exercises (keep alveoli from collapsing) 4. Chest physiotherapy and postural drainage 5. Nutritional support (receive extra calories especially during exacerbations) 6. Hydration (PO or IV) (liquify secretions and get rid of them; 2-3L/day) 7. O2 administration (room air only has 21% oxygen; start w/ nasal cannula but may progress to mask prn) 8. Airway suctioning 9. Smoking cessation 10. Current on vaccinations/immunizations (i.e. Flu, Pneumonia) 11. Medication administration - Antibiotics (infection) - Bronchodilators (open lung passages) - Mucolytics and Expectorants (DECREASE viscosity and bring up secretions) - Corticosteroids (DECREASES inflammation especially in exacerbating COPD) 12. Nebulizers 13. Exercise (maintain lung function) 14. Rest and Assistance w/ ADL'S (lots of work to breathe causes mobility issues, anxiety b/c of sob, depression b/c of being unable to take care of themselves adequately)

Nursing Interventions for TB

1. Infection control in hospital - Private room - negative airflow (door closed, module outside, air cycled out and refreshed) - Standard precautions recommended by CDC (N-95 respirator mask picks up air droplets and must be fit-tested) - Minimize spread and contamination (hh! pt should wear surgical mask when outside of their room) - Proper collection of sputum specimen 2. Infection control at home - Cover mouth/nose and cough/sneeze into tissue - Proper disposal of tissues (paper bag, flush/burn) - Collect sputum in well ventilated area - Sleep alone - No visitors until noninfectious - avoid crowds - Does not travel outside of US until sputum smears are negative 3. Nutrition - High protein, high CHO diet (i.e. Eggs, Dairy products) - Fluid intake (2-3 L/day) 4. Patient education - Medication regime/infection control - Avoid alcohol; stop drug usage 5. Support system 6. Incentives to follow treatment program (many homeless people get it so incentives are places to live, money for food, or money for transportation)

Pathophysiology of Emphysema

1. Inflammatory cells in airway destroy elastic fibers in bronchioles and alveolar ducts (elasticity of lung is destroyed and doesn't repair itself) 2. Alveolar walls are destroyed leading to enlarged air spaces and loss of capillary bed w/ loss of surface area for diffusion (impaired gas exchange) 3. Destruction of elastin and loss of elastic recoil (and ability of lung to passively DECREASE in volume) 4. Airways collapse on expiration w/ air trapping in alveoli (major hyperinflation = barrel chest) - Pt has dyspnea since they're always working very hard to try and expel air out of lung - Pink Puffer * Pink complexion (relatively normal O2) * Puffing to breathe (Hyperventilation)

RA Clinical Manifestations

1. Joint stiffness especially in morning (classic) - Can last 60 minutes to several hours 2. Joint swelling and tenderness - Upper extremity joints (hand) * And smaller joints first - Bilateral and symmetrical * Starts in fingers, hands, then move on to wrists, then elbows * Usually symmetrical but it may be worse in the limb that's used more than the other - Involves 3+ joints - SubQ nodules 3. Joint deformities (happen w/ long-term) - Boutonnier or buttonhole (affects proximal inter-phalangeal joint) - Swan neck (changes in the distal inter-phalangeal joint) * Finger becomes crooked - Ulnar drift (zig-zag-deformity) * Really affects ADL's * Hand permanently goes to the side - Rheumatoid nodules * 25-50% of pt's get this but no everyone * Gets worse as it progresses; at the beginning it's fine THE 7 S's S- unrise Stiffness (severe pain) S- oft feeling in the joints S- welling in the joint (warm) S- ymmetrical S- ynovium (affected and inflamed) S- ystemic (affects not only the joints...pt will feel achy, tired, and it can affect the lungs, heart, anemia S- tages (synovitis, pannus, ankylosis)

Collaborative Care for Suppressed Immune Response

1. Monitor immune function (w/ diagnostic tests) 2. Nutrition and vitamin supplements (provide Ensure) 3. Hydration and electrolyte balance (Dehydrated = more likely to get sick) 4. Prevent opportunistic infections (stay away from crowds) 5. Treat opportunistic infections (w/ antibiotics) 6. Drug Therapy

Pneumonia Pathophysiology

1. Organism enters into lung/alveoli 2. Inflammatory response initiated - INCREASE WBC's (neutrophils) and release of inflammatory mediators 3. Alveolar edema and exudate formation (inflammation and fluid) - Bacteria multiplies in this environment 4. Alveoli and bronchioles fill with exudate, blood cells, fibrin and bacteria 5. Consolidation of lung tissue (Impaired Gas Exchange)

Collaborative Care for Acute Asthma Attack

1. Oxygen therapy 2. Medication (similar to COPD meds) - Bronchodilators (long-acting is for long-term relief, NOT acute attack; short-acting like albuterol is rescue inhaler and must be used in acute attack) * Beta-agonists (Spivia) ~ Antocholinergics ~ Methylxanthines ~ Leukotriene modifiers - Corticosteroids (IV or long-term in inhaler like flow rent) 3. Nebulizer treatments (earlier for children b/c no coordination of breathing) 4. SaO2 monitoring (keep > 90%!! Continuous pulse ox) 5. ABG's (may/may not) 6. Hydration (so secretions don't thicken) 7. Positioning (hob up) 8. Relaxation therapy 9. Possible intubation and assisted ventilation (if not responding to regular therapy) ***Silent chest = Resp. Arrest***

Cells in Immune Response

1. Phagocytes (capture, process and present antigen to lymphocytes) - Macrophages - Neutrophils 2. Lymphocytes (produced in bone marrow) - B lymphocytes (activated = produce antibodies called immunoglobulins which mark antigens for destruction) * Memory B cells remain behind to respond quickly if same virus attacks again called Humoral Immunity - T lymphocytes * Cytoxic/CD4 (like memory B cells) ~ Has memory of previous antigens (once antigen is encountered, created intense self-mediated immune response on second exposure) * Helper (help regulate self-mediates immune response ~ Also helps Humoral Immune response 3. Cytokines (act as messengers between cell types; promotes inflammation) - Corticosteroids alters body own response and inhibits cytokine production (INCREASE infection susceptibility) 4. Immunoglobulins (antibodies; 5 classes w/ each own characteristics) - IGG, IGA, IGM, IGE, IGD 5. Complement system (plasma proteins; works to enhance immune response) *** Only intro to understand immune system, don't memorize ***

Acute Collaborative Care for Pneumonia

1. Pharmacologic Therapy - Antibiotics (broad spectrum at first, changed to narrow later) - Analgesics (for pleuritic/chest pain) - Antipyretics (for Fever -> Tylenol) - Bronchodilators (opens airways by nebulizer) - Mucolytics (breaks up and brings up sputum) 2. Oxygen Therapy (depends on severity; DECREASED O2?) 3. Nutritional Support (small frequent meals b/c of slow metabolic demand; DECREASED appetite) 4. Hydration (IV or PO, up to 3L if not contraindicated like in HF; liquidizes secretions and help bring them up) 5. Chest Physiotherapy (percussion and postural drainage) 6. Vaccinations (primary prevention: Flu, Pneumonia) - Older adult gets at 65 and q 5 years afterwards - Immunosuppressed? More than q 5 years

Nursing Management for HIV

1. Promote healthy lifestyle to maintain immune function 2. Rest, nutrition, exercise (malnutrition = DECREASED immune function) 3. Prevent transmission to others 4. ABC's of safe sex ( A=Abstinence, B=Be faithful, C=Condom) 5. Prevent infection 6. Have supportive relationships (may be shame in contracting) 7. Explore spirituality 8. Counseling 9. End-of-Life care 10. Hospice (only for AID's pt) 11. Comfort (best quality of life) 12. Safe environment

Collaborative Care for Exaggerated Immune Response

1. Remove exposure (allergic to bees? Stay away!) 2. Airway support if anaphylaxis occurs (ABC's!) 3. Drug therapy - Decrease response * Antihistamines (Benadryl) ~ For anaphylaxis, subQ, Sudafed (minor) * Sympathomimetic (Epinephrine) ~ For anaphylaxis, subQ, Sudafed (minor) * Corticosteroids (DECREASE inflammation) * Mast cell stabilizers (mast cells release histamine) * Immunotherapy (allergy shots?) - Symptomatic relief * Antipruritic (lotion) ~ Most effective if skin isn't broken * Decongestant (Sudafed) * Analgesics (acetaminophen)

SLE Pathophysiology

1. SLE autoantibodies develop and react w/ antigens 2. Form complexes in connective tissue of blood vessels, lymphatic vessels and other tissues (Complement is activated which activates inflammatory process) 3. Trigger inflammatory response and tissue damage 4. Target areas are kidney, brain, heart, spleen, lung and musculoskeletal (arthritis-type symptoms are very common but different between people)

*HIV Modes of Transmission*

1. Sexual contact (semen, vaginal secretions) - Receive semen in anal? At risk b/c of mucus membranes! 2. Blood and blood products (DECREASE risk) - Accidental sticks, splatters or transfusions 3. Perinatal transmission from mother to fetus (through pregnancy, delivery, breastfeeding) - Give mom antibiotics! 4. IV drug use - Ability to transmit continues for life - NOT saliva, sputum, airborne, toilet - In healthcare, deep puncture wound is more likely

Nursing Interventions for COPD

1. Smoking cessation techniques (nicotine patches, oral meds, e-cigs) - E-cigs may have harmful chemicals but safer than cigarette smoke 2.!!! Dyspnea Management - Breathing techniques * Pursed-lip breathing (prolongs expiration, prevents airway collapse and airway trapping; inhale slowly and deeply through nose, exhale through pursed lips, repeat 3-4 times a day w/ 8-10 sets each time) * Diaphragmatic breathing (hard unless early in COPD) - Airway clearance techniques/devices (only helpful if they have retained secretions; loosens mucus and secretions to be cleared w/ coughing) * Acapella (handheld; causes vibrations in airways to mobilize secretions) * Flutter (handheld; causes vibrations in airways to mobilize secretions) * Vests (inflatable, hose and pulse generator and vibrates) - Effective coughing techniques (Huff-coughing: forcefully exhaling quickly creating huff sound that moves secretions to larger airways and cough out) - Positioning semi/high-Fowler's/orthopneic (elevate bottom of bed) - Rest/assist w/ ADL's - Fans (cool air is easier to breathe) - Relaxation techniques/music and imagery - Medications 3. Nutrition Therapy (need INCREASED protein, INCREASED calories, DECREASED carbs) - Diet (5-6 small meals daily) * Take bronchodilator prior to DECREASE dyspnea * If on O2, helpful to wear during meals * Rest 30 minutes prior meals (eating uses lots of energy) - Medications (Megace stimulates appetite) - Fluids (2-3 L daily unless contraindicated like HF) - Oral care (inhalers w/ steroids require mouth rinse) 4. Psychosocial Needs - Lifestyle changes - Guilt (about having smoked) - Depression (about health status and lack of sex) * Sex takes same amount of energy as walking up a flight of stairs - Social isolation - Sexuality 5. Client/Family Teaching - Disease process (what to expect) * They expect to get better but they won't, they just manage it - Prevention of infection (i.e. Flu shot, stay away from crowds when ill) - Correct use of MDI's/spacers - Home O2 therapy (i.e. teach O2 is flammable, how to work equipment, how to read tank, how to work tank, how to turn on/off) - When to contact primary care provider (i.e. fever, bronchodilator not working, sputum COCA changes, fatigue/dyspnea INCREASES) 6. End of Life Care - Hospice - Dyspnea management ~ Morphine: resp. depressant that slows down respirations and DECREASES anxiety (multiple routes, not only IV) ~ Xanax: anti-anxiety meds b/c they'll have tons of anxiety when working so hard to breathe

Nursing Assessment for Asthma

1. Subjective Data - Current symptoms w/ duration of attack - ID of trigger for attack - Frequency of attacks - Measures instituted to relieve attack - Meds and allergies 2. Objective Data - Vitals (INCREASED r.r. and h.r.) * r.r. slowing a lot and shallow MAY be exhaustion so MAY potentially go into resp. arrest - Positioning of client - Resp. excursion (Dyspnea? Sob?) - Use of accessory muscles (They shouldn't!) - Lung sounds (Wheezing? Dim. but not too dim?) - Sputum production - O2 Sats - PEFR (depends on where we're at) * Pt must figure out best personal reading (check when asthma is under control and measure 1 time in the morning and 1 time before bed and take the highest # of 3) - Labs/ABG - Assess cyanosis, retractions, ease of speaking

Exemplars for Immunity

1. Suppressed Immune Response - Deficiencies of Immunoglobulins A, G, D or M - Hodgkin's or non-Hodgkin's lymphoma - HIV - Primary immunodeficiency - Secondary immunodeficiency (result of disease or treatment) * Most common is drug therapy 2. Exaggerated Immune Response - Hypersensitivity Reactions - Autoimmune diseases * RA, SLE, MS, Crohn's Disease * Myasthenia Gracia

Scope of Concept for Immunity

1. Suppressed Immune Response (puts you at risk for infection) 2. Optimal Immune Response (keeps you healthy) 3. Exaggerated Immune Response (most covered in this chapter) - Occurs when body is overactive against foreign antigens and reacts against its own tissue resulting in tissue damage - 1/4 sensitivity reactions range from anaphylactic reaction to dermatitis (RA, SLE = our exemplars)

SLE Etiology

1. Suspected that genetics, environment, and hormones act together to trigger the disease - Genetics (Indians, African Americans, and Hispanics are more prone) * 100 genes may contribute to genetic predisposition * Familial link (person w/ lupus is 10-12% more likely to have a close relative w/ it) - Environmental (triggers) * Exposure to UV light/sunburns * Stress, food, toxic chemicals * Drugs - Hormones * Female sex hormone estrogen (enhances antibody response) ~ Affects more Females than Men

Pathophysiology of TB

1. TB passed down from person to person via airborne droplets 2. Bacteria inhaled in alveoli 3. Macrophage engulf bacteria, but response is inadequate 4. Replicates slowly and spreads via lymphatics 5. Clinically active disease OR 1. TB passed down from person to person via airborne droplets 2. Bacteria inhaled in alveoli 3. Effective immune response 4. Granuloma formed (walls of the infection) - Encapsulated like a golf ball 5. No replication (infection controlled) 6. No active TB disease = Latent TB infection

Testing for TB

1. Tuberculin skin test (Mantoux Test) = injected w/ PPD w/ tuberculin needle - Induration of 48-72 hours after the test indicates client has been exposed to TB and developed antibodies - Site of induration (raised not red area): ~ 5-9 mm (+) if immunocompromised or had organ transplant ~ 10-15 mm (+) if recent immigrant/resident of a high-risk setting, IV drug user, child < 5 ~ > 15 mm (+) for everyone 2. TB Bloods Tests (for people that have received BCG vaccine) * Benefit: no need to return for results - Quantiferon - T-Spot Test * Healthcare workers test yearly!!! * Neither of these differentiate between latent or active TB (need CXR and sputum culture)

Medical Care Associated Pneumonia (MCAP)

3 different forms: 1. Hospital Acquired Pneumonia (occurs 48 hours or longer AFTER hospital admission and not incubating at time of hospitalization) 2. Ventilator Associated Pneumonia 3. Healthcare Associated Pneumonia - Common organisms are staphylococcus, psuedomonas aeruginosa, E coli, Klebsiella pneumoniae

Advanced Disease: Criteria for AIDS for HIV

3. Late Chronic Infection or AIDS - Immune system severely compromised * Viral load INCREASES * CD4 < 200 * Development of opportunistic cancers: invasive cervical CA, Kaposi's sarcoma, Burkitt's lymphoma, immunoblastic lymphoma or primary lymphoma of the brain * Wasting Syndrome - i.e. Loss of 10% or more of ideal body mass (massive diarrhea -> lose Liter's of fluids every day) * AIDS dementia * Kaposi Sarcoma: Malignant vascular lesions ~ Very common! Found in aids * Pneumocystis jiroveci Pneumonia: common fungal infection ~ 75-80% of AID's pt's develops this

Spectrum of HIV

Chronic Period: Lasts 10-12 years (don't need to memorize) 1. Early Chronic - Appears well, CD4 count > 500, generally asymptomatic - Can have fatigue, headaches, low-grade fever, night sweats, 2. Intermediate Chronic - CD4 DECREASES to 200-500 - Viral load INCREASES - Persistent fever, INCREASED weight loss, diarrhea, night sweats, fatigue, headaches * Severe enough to interfere w/ normal routines - Most common infection: Candida, Varicella-zoster (shingles), genital herpes, bacterial infections and Kaposi sarcoma and Oral hairy leukoplakia * Susceptible to all kinds of infections * Candida Organism: Oral Thrush ~ Can get vaginal infections w/ this * Oral Hair Leukoplakia: Epstein Barr Virus

Laboratory Testing for HIV

HIV progression is monitored by 1. CD4 + T-cell counts - CD4 + T-cell count provides a MARKER OF IMMUNE FUNCTION 2. Viral load - The lower the viral load, the less active the disease *When CD4 is LOW, viral load is HIGH* * When viral load is HIGH, CD4 is HIGHER b/c virus destroys CD4 count

NUTRITION

MALNUTRITION VS. OBESITY

Pharmacologic Therapy of COPD Handout

MNEMONIC: CHRONIC PULMONARY MEDS SAVE LIVES C- orticosteroids: decreases inflammation and mucous production in airway (given PO, IV, inhaled, and used in combination w/ bronchodilators) * Symbicort: combination of steroid and long-acting bronchodilator * Other corticosteroids: Prednisone, Solu-medrol, Pulmicort * S/E: easy bruising, hyperglycemia, risk of infection, bone problems (long term use) ~ Pt education: rinse mouth after using inhaled corticosteroids (can develop thrush, use corticosteroid AFTER using bronchodilator inhaler) P- hosphodiestrace-4 Inhibitors: "Roflumilast" used for people who have chronic bronchitis and it works by DECREASING COPD exacerbation...not a bronchodilator * S/E: can cause suicidal thoughts (remember the word "last" in the drug's name...it could be the pt's last day if they aren't assessed for this s/e) and can cause weight loss M- ethylxanthines: Theophylline (most commonly given PO) type of bronchodilator used long-term in pt's who have severe COPD * Remember: Narrow therapeutic range of 10-20 mcg/mL * INCREASE risk for digoxin toxicity and DECREASES the effects of lithium and Dilantin S- hort-acting bronchodilators: relaxes the smooth muscle of the bronchial tubes and are used in emergency situations where quick relief is needed * Albuterol (beta 2 agonist) and Atrovent (anticholinergic) L- ong-acting Bronchodilators: relaxes the smooth muscle of the bronchial tubes (same as short-acting bronchodilators BUT their effects last longer) used over a longer period of time...taken 1-2 times a day * Beta 2 agonist: Salmeterol * Anticholinergics: Spiriva * Pt education: let them know which drug is short and long-acting, how to use inhaler and to use bronchodilator inhaler BEFORE steroid inhaler (wait 5 minutes in between) ~ WHY? TO OPEN UP THE AIRWAYS SO THE STEROID CAN GET IN THERE AND DO ITS JOB) * S/E of beta 2 agonists: INCREASED h.r., urinary retention * S/E of anticholinergic: dry mouth, blurred vision

Pharmacologic Therapy of Asthma Handout

MNEMONIC: O SHIT O- xygen S- albutamol (Albuterol) H- ydrocortisone I- pratropium (Anticholinergic inhaled) T- hophylline (Methylxanthines) 1. Bronchodilators: open the airways to increase air flow...different types - Beta-agonists (inhaled) and Anticholinergics (inhaled), Theophylline (PO) * Short-acting beta-agonist (SABA) = Albuterol/Salbutamol: ~ Inhaler or nebulizer: used as the FAST ACTING RELIEF DURING AN ASTHMA ATTACK or prior to exercise for asthma that is exercise-induced NOT FOR DAILY TREATMENT ~ ***If pt is using their inhaler > 2 times a week, then the pt's asthma plan needs to be readjusted b/c their asthma is not under good control *** * Long-acting beta-agonist (LABA) = Salmeterol + Symbicort (this drug is a combo of a LABA AND corticosteroid) ~ NOT FOR AN ACUTE ASTHMA ATTACK ~ S/E: tachycardia, feeling nervous/jittery, monitor heart rhythm for dysrhythmia * Anticholinergics (inhaled): ~ Ipratropium: a bronchodilator that also is SHORT-ACTING and relaxes airway...used when a pt can't tolerate SABA ~ Tiotropium: a bronchodilator that is LONG-ACTING ~ These drugs can cause dry mouth...sugarless candy and fluids help w/ this * Methylxanthines = Theophylline given PO ~ Not as common b/c of possible toxicity and maintaining blood levels of 1-20 mcg/mL ~ AVOID consuming products w/ caffeine while taking this med...WHY? Caffeine has the same properties as Theophylline, which can increase the toxic effects of the med *** Always administer the bronchodilator FIRST and then 5 MINUTES LATER THE CORTICOSTEROID *** 2. Anti-inflammation: decreases swelling and mucus production...used as long-term treatment to control asthma not an acute attack - Leukotriene Modifiers * Leukotriene Modifiers (PO) = Montelukast/Singulair ~ Blocks the function of leukotriene which causes the smooth muscle on the airways to constrict and plays a role in mucus production. When this function is blocked it leads to the relaxation of the smooth muscle and decreased mucous production...NOT FOR AN ACUTE ATTACK

Clinical Manifestations of Pneumonia

MNEMONIC: PNEUMONIA P- roductive cough, P- leuritic pain (Purulent drainage; older adult may be dehydrated = dry cough) N- euro changes (elderly pt w/ fatigue, INCREASE rr, confusion) E- levelated labs: PCO2 > 45, INCREASE WBC's U- nusual breath sounds (crackles in lower lobes, dim. breaths, dyspnea) M- id-high fever (bacteria INCREASES temp >104 degrees = CHILLS) O- xygen Saturation < 90% (need supplemental oxygen) N- ausea, Vomiting I- NCREASED hr (r/t to DECREASED bp and fever), INCREASED rr (hypoxemia) A- ching, A-ctivity Intolerance w/ sob Extras: - INCREASED tactile fremitus - Retractions and nasal flaring in children

Individuals at Risk for TB

MNEMONIC: TB RISK T- ight living quarters (i.e. Homeless shelters, Prisons, Residential facilities, Nursing homes) B- elow or at poverty line (Disadvantaged population, Homeless) R- efugee (immigrants from Asia, Africa, Middle East, Latin America) I- mmune system issue (HIV/AIDS, using meds causing immunosuppression) S- ubstance abuser (IV drugs, Alcoholics) K- ids < 5 years of age Others: - Healthcare workers (working w/ Bronchoscopy, Surgery, X-ray Tech)

Nursing Diagnoses and PC's for COPD

ND's: 1. Ineffective Breathing Pattern 2. Impaired Gas Exchange 3. Ineffective Airway Clearance 4. Imbalanced Nutrition: < Body Requirements 5. Activity Intolerance 6. Social Isolation 7. Ineffective Coping 8. Decisional Conflict: Smoking PC's: - Resp. Acid. - Pneumonia - Cor pulmonale - Resp. Failure - Depression

Nursing Diagnoses and PC's for Pneumonia

ND's: 1. Ineffective Breathing r/t Inflammation and Pain (tachypnea) 2. Impaired Gas Exchange (alveolar collapse) 3. Ineffective Airway Clearance (fatigue, muscle weakness, poor cough) 4. Deficient Fluid Volume (fever, INCREASE metabolic rates) 5. Acute Pain (inflammation of the pleura) 6. Imbalanced Nutrition < Body Requirements 7. Fatigue PC's: 1. Hypoxia 2. Pleural Effusion 3. Sepsis 4. Resp. Acid.

Nutrition Interventions for Nutrition

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