NURS 350 Adult 1: Exam 1 (Module 2)

Drugs to decrease histamine effects and allergic response First-Generation H1 Receptor Antagonists

.Diphenhydramine, the prototype first-generation antihistamine, has a high incidence of drowsiness and anticholinergic effects. Drugs that block the H1 receptors prevent or reduce most of the physiologic effects that histamine normally induces at H1 receptor sites. Thus, they: ●● Inhibit smooth muscle constriction in blood vessels and the respiratory and GI tracts ●● Decrease capillary permeability ●● Decrease salivation and tear formation First-generation H1 antagonists, chemically diverse anti-histamines (also called nonselective or sedating agents), bind to both central and peripheral H1 receptors and can cause CNS depression or stimulation. Many of these drugs are currently marketed with or without a prescription, both alone and in combination formulations such as sleep aids.

CCR5 Antagonists Currently, there is only one member of this antiretroviral class, maraviroc (Selzentry). It blocks the receptor site to which the HIV needs to interact to enter the cell.

Action and Use Maraviroc binds to the human chemokine receptor on the cell membrane. This action prevents the interaction of HIV-1 and CCR5 that is needed for HIV to enter the cell and replicate. People with HIV take maraviroc in combination with other antiretroviral agents for detectable CCR5-tropic HIV-1 possess-ing evidence of viral replication. They may have HIV-1 strains that are resistant to many other antiretroviral drugs. Those with a CrCl less than 30 mL/min or with end-stage renal disease should not take maraviroc.

Corticosteroid Meds: Prototype prednisone

Adverse Effects Administration of more than 5 mg daily of corticosteroids results in adverse reactions. Possible adverse effects include the following: ●● Adrenocortical insufficiency: fainting, weakness, anorexia, nausea, vomiting, hypotension, shock, and death (if untreated) ●● Adrenocortical excess ●● Cushingoid features: "moon face" and buffalo hump due to the redistribution of fat ●● CNS effects: vertigo, headache, paresthesias, insomnia, and seizures ●● Cardiovascular symptoms: hypotension, shock, hyperten-sion, heart failure, thromboembolism, thrombophlebitis, fat embolism, and cardiac dysrhythmias ●● Diminished immunity: increased susceptibility to infection ●● Endocrine effects: diabetes mellitus, hyperglycemia, and hypercholesterolemia; diminished T3 and T4 levels, resulting in hypothyroidism; reduced growth because of altered syn-thesis of DNA ●● Fluid and electrolyte effects: fluid retention, hypokalemia, hypocalcemia ●● Integumentary effects: reddened skin, thinner skin, stretch marks, skin tears, delayed wound healing ●● Musculoskeletal effects: hypocalcemia, which places the patient at risk for osteoporosis and fracture development; serum hypocalcemia, which increases the release parathyroid hormone, increasing the loss of calcium from bone ●● Ocular effects: cataracts and glaucoma ●● Reproductive effects: amenorrhea or irregular menstrual cycles

Drugs For HIV zidovudine (AZT, Retrovir)

Adverse Effects Patients administered zidovudine have reported headache and malaise. Other significant adverse effects include nausea, vomiting, and anorexia. The FDA has issued a BLAcK BOX WARNING ♦ related to the adverse effects of granulocytopenia, aplastic or hemolytic anemia, pancytopenia with bone marrow hypoplasia, leukopenia, and lymphadenopathy with zidovudine. It is neces-sary to adjust the dosage in patients who develop anemia or neu-tropenia. Two other BLAcK BOX WARNINGS ♦ for zidovudine relate to lactic acidosis and severe hepatomegaly with steatosis and symptomatic myopathy and myositis. The risk of liver disease increases in females, obesity, and pregnancy and with prolonged use. If clinical or laboratory signs of lactic acidosis or hepatotoxic-ity develop, it is essential that the drug be discontinued.

CCR5 Antagonists Currently, there is only one member of this antiretroviral class, maraviroc (Selzentry). It blocks the receptor site to which the HIV needs to interact to enter the cell.

Adverse Effects The most common adverse effects of maraviroc are fever; rash; upper respiratory infection with cough; vascular hypertension and CNS depression with dizziness, anxiety, and depression. Other less significant adverse effects are lipodystrophy, pru-ritus, benign skin neoplasms, genital warts, elevated biliru-bin, joint pain, conjunctivitis, and otitis media. The FDA has issued a BLAcK BOX WARNING ♦ for maraviroc, stating that it may lead to drug-induced hepatotoxicity with allergic fea-tures following 1 month of treatment. Allergic reactions such as pruritic rash, fever, eosinophilia, fever, increased IgE, and symptoms of hepatitis that can be life threatening may precede this condition. Assessing for Therapeutic and Adverse Effects The nurse assesses for an increase in T helper CD4 cells. The CD4 count measures the ability to fight against infections. In addition, the nurse assesses the bilirubin, AST, and ALT levels for signs of hepatotoxicity. It is also necessary to assess the temperature for fever and monitor the IgE levels, which are indicative of the onset of hepatitis. The nurse assesses for rash or other skin changes such as the development of neoplasms. He or she assesses for cough and upper respiratory infection. Finally, the nurse assesses the ear canal for otitis media or complaints of ear pain. Patient Teaching The nurse instructs the patient to use caution when changing positions due to possible drug-induced dizziness. He or she also tells the patient to report rash, yellow skin or eyes, muscle pain, or fatigue

Corticosteroid Meds: Prototype prednisone QSEN Alert

Corticosteroids can cause hiccups in patients. In a case review, reported by Peacock (2013), a 40-year-old man was admitted to surgery for placement of a dental implant. Preoperatively, dexamethasone 8 mg was administered orally. Prior to the administration of sedation and the local anesthetic, the patient developed hiccups. Oral triazolam was administered, and the hiccups were diminished. There was evidence that dexamethasone induced hiccups in some patients. Health care providers must be cognizant of the effect oral steroids can have on the development of hiccups

Diagnoses, Outcomes, and Interventions Teaching and counseling for health maintenance and prevention of the spread of HIV are important nursing roles for patients, people at high risk, and the general public. Counseling the patient with a new diagnosis of HIV infection is vital. HIV infection and AIDS continue to carry a social stigma that may interfere with the patient's usual sup-port systems and coping mechanisms. Typically the patient maintains self-care in the community, although acute opportunistic infections may necessitate hospitalization. See the accompanying Case Study & Nursing Care Plan.

Readiness for Enhanced Individual Coping On receiving the test results indicating HIV seropositive status, the person with HIV infection is faced with multiple issues rarely af-fecting other patients. HIV is a chronic infection for which there currently is no known cure. Once the decision to initiate ART has been made, the patient faces a lifelong commitment to therapy that is expensive and associated with multiple adverse effects. Social sup-port systems, family relationships, and the ability to obtain and retain useful work and health insurance may be disrupted by the disease. The patient may experience guilt about his or her lifestyle and how the disease was contracted. As the disease progresses, social isolation, fatigue, body image changes, medication side effects, and multiple other issues affect the patient's ability to cope. Expected Outcome: Patient demonstrates acceptance of change in health status as evidenced by taking active role in healthcare decisions. • Assess social support network and usual methods of coping. This will help both the nurse and the patient identify people and mechanisms that can help the patient cope more effectively with the disease. • Support the patient's social network. Nontraditional families may offer more support than the traditional family. This in turn may ne-cessitate a liberal interpretation of the term family in some healthcare settings. • Employ an interactive helping process focusing on the patient's and significant others' needs, problems, and feelings to en-hance or support coping, problem solving, and interpersonal relationships (Wilkinson, 2014). This is a critical component of patient-centered care for the individual with HIV infection and his or her family. • Use short-term counseling to help the patient cope with the cri-sis presented by the diagnosis of HIV infection or by an AIDS-defining illness. Short-term counseling can help the patient cope with the immediate crisis and return to a normal state of functioning. • Promote interaction between the patient, significant others, and family. The diagnosis of HIV infection and manifestations of HIV disease may bring about isolation from others and decrease the patient's ability to cope. • Provide information, support, and, as appropriate, guidance for the patient in making decisions regarding care and treatment. This gives the patient a greater sense of self-worth and control over the situ-ation, increasing coping abilities. • Provide reassurance, acceptance, and encouragement dur-ing crisis episodes. Providing consistent acceptance and support for the patient with HIV infection enhances coping during times of crisis. • Assist to accept responsibility for actions without blaming others. Effective coping cannot occur without accepting responsibility for one's actions. • Support positive coping behaviors, decisions, actions, and achievements. As self-esteem is enhanced, coping improves (Côté & Pepler, 2005).

Drugs For HIV Fusion Protein Inhibitors

The drugs in this new class inhibit the HIV virus from binding to, fusing with, and entering the human cell. Enfuvirtide (Fuzeon) is the only drug in this class. This drug is for use only by patients who have previously been treated with antiretroviral agents. Antiretroviral therapy-naïve patients should not use it.

Corticosteroid Meds: Prototype prednisone

Assessing for Adverse Effects It is necessary to assess patients for a variety of adverse effects, which may affect every body tissue and organ. The nurse assesses patients with adrenocortical insufficiency for fainting, weakness, anorexia, nausea, vomiting, hypotension, and shock. He or she assesses patients with adrenocortical excess for "moon face," "buffalo hump," diabetes mellitus, nervousness, euphoria, anxiety, and behavioral changes. Adrenocortical excess also leads to the musculoskeletal con-ditions, such as osteoporosis, fractures, muscle weakness and atro-phy, and growth retardation in children. Cardiovascular effects include fluid and electrolyte changes, with fluid retention, edema, hypertension, heart failure, hypernatremia, hypokalemia, and metabolic acidosis. Ocular changes include increased intraocular pressure, glaucoma, and cataracts. The nurse assesses for increased susceptibility to infection and changes to the skin, including red-ness, thinning, stretch marks, and tissue injury. Women may experience menstrual irregularities, acne, and excessive facial hair.

Corticosteroid Meds: Prototype prednisone

Assessing for Therapeutic Effects The goal of corticosteroid therapy is usually to reduce symptoms to a tolerable level. Total suppression of symptoms may require excessively large doses and produce excessive adverse effects. Because systemic corticosteroids can cause serious adverse reac-tions, indications for their clinical use should be as clear-cut as possible. Therapeutic effects depend largely on the reason for use. Prescribers order hydrocortisone for the treatment of Addison's disease. Following the parenteral administration of the medication, the nurse monitors the patient for activity tolerance, ability to move in bed, and restoration of fluid balance. Decreases in weakness, weight loss and anorexia, nausea and

Drugs For HIV zidovudine (AZT, Retrovir)

Assessing for Therapeutic Effects The nurse monitors the patient's CD4 and cell count for increase or decrease in viral load. An increase in the CD4 count indicates a decrease in viral load and the ability to fight viral infections. In addition, the nurse assesses the patient's clinical status for decrease in the development of opportunistic infections. Assessing for Adverse Effects The nurse assesses for malaise (discomfort), CNS depression, and GI symptoms such as nausea, vomiting, and diarrhea. He or she assesses for myalgia and hepatomegaly (enlargement of the liver). The development of anemia usu-ally occurs 2 to 4 weeks after the start of therapy. Neutropenia is most likely to occur in 6 to 8 weeks. It is important to obtain the patient's CBC as a baseline measure before therapy begins and then every 2 weeks from then on. In addition, the nurse assesses the hemoglobin, hematocrit, and granulocyte count for hema-tologic toxicity. If the hemoglobin level is less than 7.5 g/dL or the reduction is greater than 25% of the baseline value, it may be necessary to interrupt therapy and administer transfusions. This is also the case if the granulocyte count is less than 750/mm3 or greater than 50% of the baseline measure. Patient Teaching Box 23.5 identifies general patient teaching guidelines for anti-retroviral drugs. Because lactic acidosis may develop, the nurse teaches the patient the signs and symptoms of this condition, including musculoskeletal pain.

Corticosteroid Meds: Prototype prednisone

Asthma Corticosteroids are commonly used in the treatment of asthma because of their anti-inflammatory effects. In addition, corticosteroids increase the effects of adrenergic bronchodilators to prevent or treat bronchoconstriction and bronchospasm. The drugs increase the number of beta-adrenergic receptors and increase or restore responsiveness of beta receptors to beta-adren-ergic bronchodilating drugs. Research indicates that responsive-ness to beta-adrenergic bronchodilators increases within 2 hours and that numbers of beta receptors increase within 4 hours. In acute asthma or status asthmaticus unrelieved by inhaled beta-adrenergic bronchodilators, high doses of systemic cortico-steroids are given orally or intravenously along with bronchodi-lators for approximately 5 to 10 days. Although these high doses suppress the HPA axis, the suppression lasts for only 1 to 3 days, and other serious adverse effects are avoided. Thus, systemic corticosteroids are used for short-term therapy, as needed, and not for long-term treatment. People who regularly use inhaled corticosteroids also require high doses of systemic drugs dur-ing acute attacks because aerosols are not effective. As soon as acute symptoms subside, it is necessary to taper the dose; people should take the lowest effective maintenance dose or discon-tinue the drug. In chronic asthma, inhaled corticosteroids are the drugs of first choice. This recommendation evolved from increased knowledge about the importance of inflammation in the pathophysiology of asthma and the development of aerosol corticosteroids that are effective with minimal adverse effects. Inhaled drugs may be given alone or with systemic drugs. In general, inhaled corticosteroids can replace oral drugs when daily dosage of the oral drug has been tapered to 10 to 15 mg of prednisone or the equivalent. When a patient is being switched from an oral to an inhaled corticosteroid, the inhaled drug should be started during tapering of the oral drug, approxi-mately 1 or 2 weeks before discontinuing or reaching the low-est anticipated dose of the oral drug. When a patient requires a systemic corticosteroid, coadministration of an aerosol allows smaller doses of the systemic corticosteroid. Although the inhaled drugs can cause suppression of the HPA axis and adre-nocortical function, especially at higher doses, they are much less likely to do so than systemic drugs. However, the U.S. Food and Drug Administration (FDA) has issued a BLAcK BOX WARNING ♦ for people who are transferred from systemically active corticosteroids to flunisolide inhaler because deaths have occurred from adrenal insufficiency.

Corticosteroid Meds: Prototype prednisone

Cancer Corticosteroids are commonly used in the treatment of lymphomas, lymphocytic leukemias, and multiple myeloma. In these disorders, corticosteroids inhibit cell reproduction and are cytotoxic to lymphocytes. In addition to their anticancer effects in hematologic malignancies, corticosteroids are beneficial in treatment of several signs and symptoms that often accompany cancer, although the mechanisms of action are unknown and drug/dosage regimens vary widely. Corticosteroids are used to treat anorexia, nausea and vomiting, cerebral edema and inflammation associated with brain metastases or radiation of the head, spinal cord compression, pain and edema related to pressure on nerves or bone metastases, graft versus host disease after bone marrow transplantation, and other disorders that occur in patients with cancer. Patients tend to feel better when taking corticosteroids, although the basic disease process may be unchanged. Primary Central Nervous System Lymphomas Formerly considered rare tumors of older adults, central ner-vous system (CNS) lymphomas are being diagnosed more fre-quently in younger patients. They are usually associated with chronic immunosuppression (suppression of the immune sys-tem) caused by immunosuppressant drugs or acquired immu-nodeficiency syndrome (AIDS). Many of these lymphomas are very sensitive to corticosteroids, and therapy is indicated when the diagnosis is established. Other Central Nervous System Tumors Corticosteroid therapy may be useful in both supportive and definitive treatment of brain and spinal cord tumors, and neurologic signs and symptoms often improve dramatically within 24 to 48 hours. Corticosteroids help relieve symptoms by con-trolling edema around the tumor, at operative sites, and at sites receiving radiation therapy. Some patients no longer require corticosteroids after surgical or radiation therapy, whereas oth-ers require continued therapy to manage neurologic symptoms. Adverse effects of long-term corticosteroid therapy may include mental changes ranging from mild agitation to psychosis and steroid myopathy (muscle weakness and atrophy) that may be confused with tumor progression. Mental symptoms usually improve if the drug dosage is reduced and resolve if the drug is discontinued; steroid myopathy may persist for weeks or months. Chemotherapy-Induced Emesis Corticosteroids have strong antiemetic effects; the mechanism is unknown. One effective regimen is a combination of an oral or intravenous (IV) dose of dexamethasone (10-20 mg) and a serotonin antagonist or metoclopramide given immediately before the chemotherapeutic drug. This regimen is the treat-ment of choice for chemotherapy with cisplatin, which is a strongly emetic drug.

The patient with Rheumatoid Arthritis (RA)

Chronic Pain Pain is a constant feature of RA when the disease is active. Some patients say the pain in joints and surrounding tissue is like a deep, constant toothache. Pain can significantly affect the patient's ability to provide self-care and maintain daily activities. It also contributes to the patient's fatigue. Expected Outcome: Patient will report minimal joint pain (2 or lower as measured on a standard pain scale of 0 to 10). • Monitor the level of pain and duration of morning stiffness. Pain and morning stiffness are indicators of disease activity (Oliver, 2010). Increased pain may necessitate changes in the therapeutic treatment plan. • Teach the use of heat and cold applications to provide pain relief. The patient may apply heat by showering or taking tub baths, or by using local applications such as warm compresses or paraffin dips. During periods of acute inflammation, cold packs may re-lieve pain more effectively. Both heat and cold have analgesic effects and can help relieve associated muscle spasms. • Teach about the use of prescribed anti-inflammatory medications and the relationship of pain and disease activity. Anti-inflammatory agents reduce chemical mediators of inflammation and swelling, reliev-ing pain. Increasing pain (level, duration, number of painful joints) is an indicator of increased disease activity and may necessitate a change in the therapeutic regimen.

Histamine effects and allergic response

Clinical Manifestations Allergic Rhinitis Allergic Contact Dermatitis Allergic Food Reactions Allergic Drug Reactions Pseudoallergic Drug Reactions

Drugs For HIV Cytochrome P450 Inhibitor

Cobicistat (Tybost) is a boosting agent administered with ata-zanavir or darunavir or other retroviral agent. The purpose in combining cobicistat with antiretroviral agents is based on its action to increase exposure of CYP3A4 substrates in atazanavir or darunavir. This action increases the antiretroviral activity of these antiretroviral agents.

TYPE I IMMEDIATE HYPERSENSITIVITY

Common hypersensitivity reactions, such as allergic asthma, aller-gic rhinitis (hay fever), allergic conjunctivitis, hives (urticaria), and anaphylactic shock, are typical of type I immediate or IgE-mediated hypersensitivity. This type of hypersensitivity response is triggered when an allergen interacts with IgE bound to mast cells and baso-phils. The antigen-antibody complex prompts release of histamine and other chemical mediators, complement, acetylcholine, kinins, and chemotactic factors (Figure 13-1 •). When a potent allergen such as bee or wasp venom or a drug is injected, resulting in widespread antibody-antigen reaction and re-sponse to these chemical mediators, a systemic response such as ana-phylaxis, urticaria, or angioedema (localized, rapid swelling beneath the skin) results. Anaphylaxis is an acute systemic type I response that occurs in highly sensitive individuals following injection of a specific an-tigen. Substances known to trigger anaphylaxis are summarized in Box 13-1. Anaphylaxis rarely follows oral ingestion although this is possible. The reaction begins within minutes of exposure to the allergen and may be almost instantaneous. The release of histamine and other mediators causes vasodilation and increased capillary permeability, smooth muscle contraction, and bronchial constriction. These chemi-cal mediators cause the typical manifestations of anaphylaxis. Initially, a sense of foreboding or uneasiness, light-headedness, and itching palms and scalp may be noted. Hives may develop, along with angioedema of the eyelids, lips, tongue, hands, feet, and genitals. Swelling can also affect the uvula and larynx, impairing breathing. This is further complicated by bronchial constriction, manifested by air hunger, stridor and wheez-ing, and a barking cough. These respiratory effects can be lethal if the reaction is severe and intervention is not provided immediately. Vasodi-lation and fluid loss from the vascular system can lead to impaired tissue perfusion and hypotension, a condition known as anaphylactic shock. Fortunately, localized responses are the more common mani-festations of type I hypersensitivity. Atopic reactions, which have a genetic predisposition, are localized, rather than systemic, IgE- mediated responses to an allergen. They occur when an allergen contacts cell-bound IgE in the bronchial tree, nasal mucosa, and con-junctival tissues. Chemical mediators are released locally, producing symptoms such as asthma, allergic rhinitis (hay fever), conjunctivitis or atopic dermatitis. Allergens commonly associated with atopic re-actions of this type include pollens, fungal spores, house dust mites, animal dander, and feathers (Grossman & Porth, 2014). When an al-lergic response to food occurs in the digestive system, nausea, vom-iting, diarrhea, and cramping may develop. If the gastrointestinal mucosa is altered by a local allergic response, then the allergen may be absorbed, leading to a systemic reaction. Urticaria (hives) is the most common systemic response to food allergies.

TYPE II CYTOTOXIC HYPERSENSITIVITY

Cytotoxic hypersensitivity reactions are characterized by forma-tion of IgG or IgM antibodies against normal or foreign cells or tis-sues (Grossman & Porth, 2014, Haynes et al., 2012). A hemolytic transfusion reaction to blood of an incompatible type is characteristic of a type II or cytotoxic hypersensitivity reaction. IgG- or IgM-type antibodies are formed to a cell-bound antigen such as the ABO or Rh antigen. When these antibodies bind with the antigen, the comple-ment cascade is activated, resulting in destruction of the target cell (Figure 13-2 •). Type II reactions may be stimulated by an exogenous antigen, such as foreign tissue or cells, or a drug reaction in which the drug forms an antigenic complex on the surface of a blood cell, stimulating the production of antibodies. The affected cell is then destroyed in the resulting antigen-antibody reaction; for example, hemolytic ane-mia is sometimes associated with the administration of drugs such as penicillins, cephalosporins, and streptomycin. Withdrawal of the drug stops the reaction and the cell destruction. Endogenous antigens can also stimulate a type II reaction, re-sulting in an autoimmune disorder such as Goodpasture's syndrome (pulmonary hemorrhage and glomerulonephritis), in which antigens are formed to specific tissues in the lungs and kidneys. Hashimoto's thyroiditis and autoimmune hemolytic anemia are additional exam-ples of autoimmune type II reactions.

The patient with Rheumatoid Arthritis (RA)

Diagnoses, Outcomes, and Interventions Many nursing diagnoses may be appropriate for the patient with RA. This section focuses on those related to its predominant manifesta-tions and their effect on the patient's life. Readiness for Enhanced Self-Health Management Patients newly diagnosed with RA need to become actively in-volved in managing their disease. To do so, the patient needs to understand his or her condition, the prescribed therapeutic regi-men and treatment goals, and how to manage both treatment and manifestations of RA. Disease manifestations such as fatigue, pain, and weakness, and medication effects such as increased risk for infection can interfere with the patient's ability to maintain health. Psychosocial issues such as denial, poor coping, lack of financial and other resources, and inadequate support can also be significant for the patient with RA. Expected Outcome: Patient will demonstrate willingness and the ability to effectively manage prescribed therapeutic regimen. • Assess the patient's understanding of RA, its manifestations and effects, and the anticipated course of the disease. Reinforce and clarify information as needed, providing written material at the patient's level. Newly diagnosed patients need understandable information that is readily available to develop an understanding of their disease and its treatment, and their role in managing RA (Walker, 2012). • Initiate an interprofessional care conference with the patient and family. Patients and families need opportunities to discuss manage-ment strategies and their concerns and perceptions to develop a better understanding of interprofessional team member roles and services (Firth, 2011). • Encourage the patient and family members to discuss the effect of the disease on their lives. Open discussion helps identify the need for practical skills to manage pain, fatigue, and physical limitations of the disease, as well as psychosocial and emotional challenges associ-ated with RA and its treatment (Firth, 2011). • Refer the patient and family to community and social service agencies, and local support groups. These groups and agencies are valuable resources for the patient and family.

The Patient with Systemic Lupus Erythematosus (SLE)

Diagnoses, Outcomes, and Interventions The priority nursing interventions for the patient with SLE are fo-cused on problems with impaired skin integrity, ineffective protec-tion, and impaired health maintenance. Impaired Skin Integrity Skin lesions are a common manifestation of SLE. A rash or discoid lesion interrupts the integrity of the skin, which is the first line of pro-tection against infection, increasing the patient's already high risk of infection. These lesions, which usually appear on exposed parts of the skin, can also be disfiguring and cause the patient emotional distress. Expected Outcome: Patient will verbalize understanding of and will-ingness to employ measures to reduce risk for epidermal manifesta-tions of SLE. • Assess knowledge of SLE and its possible effects on the skin. Assess-ment allows the nurse to base teaching and information on the patient's existing knowledge, improving learning and retention. • Discuss the relationship between sun exposure and disease activ-ity, both dermatologic and systemic. It is important for the patient to understand that sun exposure may not only cause dermatologic manifestations but also trigger an acute episode. • Suggest the following strategies to limit sun exposure: • Avoid being out of doors during hours of greatest sun intensity (10:00 a.m. to 3:00 p.m.). • Use sunscreen with an SPF of 15 or higher when sun exposure cannot be avoided. Apply it 30 minutes before going out into the sun. • Reapply sunscreen after swimming, exercising, or bathing. • Wear loose clothing with long sleeves and wide-brimmed hats when out of doors. These strategies can help the patient maintain a normal lifestyle while helping to prevent acute episodes. • Keep skin clean and dry; apply therapeutic creams or ointments to lesions as prescribed. These measures promote healing and reduce the risk of infection.

The Patient with HIV Infection Diagnosis

Diagnosis Diagnostic testing is used to screen for and identify the infection, as well as to monitor the patient's disease and immune status. When a preliminary, positive rapid test is explained to patients, phrases like "a possibility of being infected" or "false-positive results do occur" can be used to indicate the likelihood of HIV infection based on the HIV prevalence in the setting and the patient's individual risk. Confirma-tion of positive results is required with an ELISA or Western blot antibody test. See Box 13-2 for current recommendations for HIV testing based on CDC and WHO guidelines. • HIV rapid antibody test. The rapid tests consist of test strips with embedded HIV antigen. If antibodies to HIV are found in the pa-tient's blood, the strip turns a color indicating the test is positive. The results are interpreted visually and are widely used because results can be given immediately. Personnel without formal labo-ratory training (point-of-care testing) can perform rapid antibody tests. Although positive results must be confirmed with further testing, learning results immediately gives the patient important information to make wise choices about his or her behaviors and self-care. • Western blot antibody testing is more reliable but more time con-suming and more expensive than ELISA. When combined with ELISA, however, a specificity of greater than 99.9% is achieved. Specificity is a measure of the probability that a negative test result indicates that no antibodies are present. In this test, the patient's serum is mixed with HIV proteins to detect reaction. If antibodies to HIV are present, a detectable antigen-antibody response will occur. • HIV viral load tests measure the amount of actively replicating HIV. Levels correlate with disease progression and response to an-tiretroviral medications. Several tests are available; the most com-monly used are the RT-PCR assay and the bDNA assay to identify the number of HIV RNA copies in plasma or blood (Fauci & Lane, 2012). Absolute CD4 lymphocyte count is the most widely used test to monitor the progress of the disease and guide therapy. The CD4 cell count correlates very closely with the immunodeficiency dis-orders seen in AIDS. AIDS is now defined not only by the pres-ence of opportunistic infections and other diseases indicative of immunodeficiency, but also by HIV-seropositive status and a CD4 count of less than 200/mm3 or a percentage of CD4 lympho-cytes of less than 14%. CD4 counts are recommended every 3 to 6 months for all people with HIV disease

The Patient With an Autoimmune Disorder Diagnosis

Diagnosis Serologic assays are used to identify and measure antibodies directed toward host tissue antigens or normal cellular components. Many de-tectable autoantibodies are not specific to a single autoimmune disor-der and are used to establish the autoimmune process rather than the specific disorder. Although healthy people often have low levels of autoantibodies, levels are much higher in patients affected by an au-toimmune disorder. The following serologic assays may be ordered: • Antinuclear antibody (ANA) detects antibodies produced to DNA and other nuclear material. These antibodies can cause tissue damage characteristic of autoimmune disorders such as SLE. The patient's serum is combined with nuclear material and tagged antihuman antibody to detect ANA-antihuman antibody complexes. A negative, or normal, result is a titer of less than 1:20. When complexes are detected at higher levels (greater than 1:20), the test is positive for ANA (Kee, 2014). • Lupus erythematosus (LE) cell test is used to detect SLE and moni-tor its treatment. Neutrophils that contain large masses of phago-cytized DNA from the nuclei of polymorphonuclear leukocytes (PMNs) are called LE cells. Like the ANA, the LE cell test is non-specific for SLE. A positive result may also be seen in rheumatoid arthritis (RA) or with selected antibiotic and other medications such as phenytoin and oral contraceptives. • Rheumatoid factor (RF) is an immunoglobulin present in the se-rum of approximately 80% of patients with rheumatoid arthritis. A titer of less than 1:80 (or less than 40 to 60 unit/mL) is considered normal. An RF titer of 1:80 or higher indicates RA. Titers between 1:20 and 1:80 may be present in other autoimmune disorders and diseases such as leukemia, liver cirrhosis, and renal disease. • Complement assay may also be useful in identifying autoimmune disorders. In these disorders, complement may be consumed in the development of antigen-antibody complexes. Decreased levels are seen on examination. Both total complement level and amounts of individual components of the complement cascade can be determined. • Anti-CCP antibody test is a blood test for RA. It measures anti- cyclic citrullinated peptide antibody in blood; the results are spe-cific for RA. These antibodies replace normal protein in the joints of patients with RA.

The Patient with Systemic Lupus Erythematosus (SLE)

Diagnosis The multiple autoantibodies produced in SLE cause a number of abnormalities in laboratory tests. • Antinuclear antibody (ANA) testing is positive in more than 98% of patients with SLE. • Anti-DNA antibody testing is a more specific indicator of SLE, be-cause these antibodies are rarely found in any other disorder. • ESR is typically elevated, occasionally to >100 mm/h. • Serum complement levels are usually decreased as complement is consumed or "used up" by the development of antigen-antibody complexes. • CBC abnormalities include moderate to severe anemia, leukope-nia and lymphocytopenia, and possible thrombocytopenia. • Urinalysis shows mild proteinuria, hematuria, and blood cell casts during exacerbations of the disease when the kidneys are involved. Renal function tests including serum creatinine, blood urea nitrogen (BUN), and eGFR may also be obtained to evaluate the extent of renal disease. • Kidney biopsy may be performed to assess the severity of renal le-sions and guide therapy.

The patient with Rheumatoid Arthritis (RA)

Disease-Modifying Antirheumatic Drugs Disease-modifying antirheumatic drugs are the treatment of choice for RA with the goal of achieving remission or significantly lower disease activity (Singh et al., 2012). DMARDs are a diverse group of medications including drugs that modify immune and inflammatory responses (Table 40-6). They share characteristics that make them useful in the treatment of RA. The DMARDs may be used individually (monotherapy) or in combination. Although beneficial effects are not apparent for several weeks or months following the initiation of therapy, they can produce not only clinical improvement but also evidence of decreased disease activity. Because the desired effects of DMARDs are delayed, NSAIDs often are continued during initial therapy. All of these drugs are fairly toxic, and close monitoring is necessary during the course of therapy. Treatment for active infections such as hepatitis B or C or known latent tuberculosis infection should be started prior to initiation of DMARD therapies

Corticosteroid Meds

Exogenous corticosteroids, or glucocorticoids, are administered to treat disorders of the adrenal cortex or endocrine system. The administration of corticosteroids decreases the inflammatory symptoms and alters the immune response produced by nonendocrine disorders. People once viewed hydrocortisone, a short acting corticosteroid and an exogenous equivalent of endogenous cortisol, as the prototype corticosteroid drug. Now, they consider prednisone, an intermediate-acting corticosteroid, to be the prototype corticosteroid.

Drugs to decrease histamine effects and allergic response

The drugs that antagonize the action of histamine are commonly called antihistamines. There are three main types of receptors for histamine, histamine1 (H1), histamine2 (H2), and histamine3 (H3) receptors. This chapter focuses on those drugs that specifi-cally prevent or reduce most of the physiologic effects that his-tamine normally induces at H1 receptor sites. (Prescribers use some H2 receptor antagonists, such as cimetidine, to treat peptic ulcers.) To understand the use of antihistamines, it is neces-sary to understand histamine and its effects on body tissues, the characteristics of allergic reactions, and the selected conditions for which antihistamines are used.

The patient with Rheumatoid Arthritis (RA)

Fatigue The pain and chronic inflammatory processes associated with RA lead to fatigue. Other factors such as disrupted sleep, anemia, and muscle weakness contribute as well. Expected Outcome: Patient will demonstrate reduced fatigue with increased ability and desire to participate in daily activities. • Encourage a balance of periods of activity with periods of rest. Both joint and whole-body rest are important, while regular activity is important to maintain muscle strength and reduce fatigue (Shah & St. Clair, 2012). • Help patient to prioritize activities, performing the most impor-tant ones early in the day. Assigning priorities helps the patient avoid performing relatively unimportant activities at the expense of more meaningful and important ones. • Encourage dynamic (aerobic) physical activity in addition to pre-scribed ROM exercises. Aerobic exercise promotes a sense of well-being and restful sleep patterns. • Refer to counseling or support groups. Counseling and support groups can help the patient develop effective coping strategies and deal with depression and hopelessness.

Corticosteroid Meds: Prototype prednisone

General Indications The corticosteroids discussed in this chapter are used to treat potentially serious or disabling disorders, including the following: ●● Allergic or hypersensitivity disorders, such as allergic reac-tions to drugs, serum and blood transfusions, and dermato-ses with an allergic component ●● Collagen disorders, such as systemic lupus erythematosus, scleroderma, and periarteritis nodosa. Collagen is the basic structural protein of connective tissue, tendons, cartilage, and bone, and it is therefore present in almost all body tissues and organ systems. The collagen disorders are characterized by inflammation of various body tissues. Signs and symptoms depend on which body tissues or organs are affected and the severity of the inflammatory process. ●● Dermatologic disorders that may be treated with systemic corticosteroids include acute contact dermatitis, erythema multiforme, herpes zoster (prophylaxis of postherpetic neu-ralgia), lichen planus, pemphigus, skin rashes caused by drugs, and toxic epidermal necrolysis. Corticosteroid prepa-rations that are applied topically in dermatologic disorders are discussed in Chapter 61. ●● Endocrine disorders, such as adrenocortical insufficiency and congenital adrenal hyperplasia. Corticosteroids are given to replace or substitute for the natural hormones (both glucocorticoids and mineralocorticoids) in cases of insufficiency and to suppress corticotropin when excess secretion causes adrenal hyperplasia. These conditions are rare and account for a small percentage of corticosteroid use. ●● GI disorders, such as ulcerative colitis and regional enteritis (Crohn's disease) ●● Hematologic (blood) disorders, such as idiopathic thrombocytopenic purpura or acquired hemolytic anemia ●● Hepatic (liver) disorders characterized by edema, such as cirrhosis and ascites ●● Neoplastic disease, such as acute and chronic leukemias, Hodgkin's disease, other lymphomas, and multiple myeloma (see later discussion) ●● Neurologic conditions, such as cerebral edema, brain tumor, acute spinal cord injury (see later discussion), and myasthe-nia gravis ●● Ophthalmic disorders, such as optic neuritis, sympathetic ophthalmia, and chorioretinitis. Corticosteroid preparations that are applied topically in ophthalmologic disorders are dis-cussed in Chapter 59. ●● Organ or tissue transplants and grafts (e.g., kidney, heart, bone marrow). Corticosteroids suppress cellular and humoral immune responses (see Chap. 13) and help prevent rejection of transplanted tissue. Drug therapy is usually continued as long as the transplanted tissue is in place. ●● Renal disorders characterized by edema, such as the nephrotic syndrome ●● Respiratory disorders, such as asthma, status asthmaticus, chronic obstructive pulmonary disease (COPD), and inflam-matory disorders of nasal mucosa (rhinitis) ●● Rheumatic disorders, such as ankylosing spondylitis, acute and chronic bursitis, acute gouty arthritis, rheumatoid arthri-tis, and osteoarthritis ●● Shock. Corticosteroids are clearly indicated only for shock resulting from addisonian crisis (also known as adrenal or adrenocortical insufficiency), which may mimic hypovolemic or septic shock. The use of corticosteroids in septic shock has been highly controversial, and randomized studies and meta-analyses have indicated that corticosteroids are not beneficial in treating septic shock. However, more recent small studies indicate possible clinical usefulness in septic shock, because this form of shock may be associated with relative adrenal insufficiency. In anaphylactic shock resulting from an allergic reaction, corticosteroids may increase or restore cardiovascu-lar responsiveness to adrenergic drugs.

The Patient with Systemic Lupus Erythematosus (SLE)

Treatments Because exposure to ultraviolet light can trigger a disease flare, the patient with SLE should be cautioned to avoid sun exposure. Patients should use sunscreens with a sun protection factor (SPF) rating of 15 or higher when out of doors. Topical corticosteroids may be used to treat skin lesions. Some physicians recommend avoiding the use of oral contraceptives because estrogen can trigger an acute episode. Patients with lupus nephritis who progress to develop end-stage renal disease are treated with dialysis (hemodialysis or peritoneal dialysis) and kidney transplantation.

Health Promotion

Health Promotion Health promotion activities include helping patients identify possi-ble allergens that prompt a hypersensitivity response and discussing strategies to avoid these allergens. Anyone with severe food allergies may need referral to a dietitian to discuss necessary dietary changes and ways to continue meeting nutrient needs. It is important for in-dividuals with hypersensitivities to inform healthcare personnel of all allergens. People who experience anaphylactic reactions should wear a medical alert bracelet or tag at all times to identify the substance(s) that provokes this response. Patients who have experienced an ana-phylactic reaction to insect venom or other potentially unavoidable allergens should carry a kit (commonly called a bee sting kit) for immediate treatment of future exposures. This kit typically includes a prefilled syringe of epinephrine and an epinephrine nebulizer, allow-ing prompt self-treatment

Drugs For HIV

Health care providers use a variety of antiretroviral drugs to fight HIV, an infection that infects the immune system caused by a retrovirus. The broad classification of these drugs are the NRTIs, nonnucleoside reverse transcriptase inhibi-tors (NNRTIs), protease inhibitors (PIs), the integrase strand transfer inhibitors, the fusion protein inhibitors, and the CCR5 antagonists (Fig. 23.1). In general, newer drugs and drug com-binations are more effective for viral suppression, cause fewer serious adverse effects, and are more convenient for patients to take. The regimen usually consists of two NRTIs with an NNRTI or a PI. Highly active antiretroviral drug therapy (HAART) involves the use of several combinations of antiretroviral drugs in the treatment of HIV/AIDS. Authorities do not recommend using some of the older drugs for initial treat-ment but may suggest them when drug-resistant infections develop with the newer drugs. Patients often undergo geno-typic or phenotypic testing for drug resistance to guide anti-retroviral therapy.

Hypersensitivity

Hypersensitivity is an altered immune response to an antigen that results in harm to the patient

The patient with Rheumatoid Arthritis (RA)

Ineffective Role Performance RA can interfere with the patient's ability to pursue a career and fill other life roles, such as parent, spouse, or homemaker. As the patient's role changes, so must the roles of other family members. This can contribute to changes in family processes, increased stress, and fur-ther difficulty coping with the effects of RA. Expected Outcome: Patient will acknowledge impact of disease on roles and relationships and express willingness to use available resources. • Discuss the effects of the disease on the patient's career and other life roles. Encourage the patient to identify changes brought on by the disease. Discussion helps the patient to accept the changes and begin to identify strategies for coping with them. • Encourage the patient and family to discuss their feelings about role changes and grieve lost roles or abilities. Verbalization al-lows family members to validate and accept feelings about losses and changes, thus helping them to move into new roles. • Listen actively to concerns expressed by the patient and family members; acknowledge the validity of concerns about the disease, prescribed treatment, and the prognosis. Demonstrating accep-tance of these feelings and concerns promotes trust and validates their reality. • Help the patient and family identify strengths they can use to cope with role changes. Identifying strengths helps the patient and family to consider role changes that maintain self-esteem and dignity. Encourage the patient to make decisions and assume personal responsibility for disease management. Patients who assumea personal and active role in managing their disease maintain a greater sense of self-control and self-esteem, which is associated with an improved quality of life

Drugs For HIV Integrase Strand Transfer Inhibitors

Integrase strand transfer inhibitors block the action of inte-grase, a viral enzyme of HIV-1 essential for viral replication. The only member of this drug class approved by the FDA is raltegravir (Isentress). This drug is comparable to efavi-renz in terms of its ability to suppress HIV.

The patient with Rheumatoid Arthritis (RA)

Joint Manifestations The onset of RA is typically insidious, although it may be acute, precipitated by a stressor such as infection, surgery, or trauma. Joint manifestations are often preceded by systemic manifesta-tions of inflammation, including fatigue, anorexia, weight loss, and nonspecific aching and stiffness. Patients report joint swelling with associated stiffness, warmth, tenderness, and pain. The pattern of joint involvement is typically polyarticular (involving multiple joints) and symmetric. The proximal interphalangeal (PIP) and metacar-pophalangeal (MCP) joints of the fingers, the wrists, the knees, the ankles, and the toes are most frequently involved, although RA can affect any joint. Stiffness is most pronounced in the morning, lasting more than 1 hour. It may also occur with prolonged rest during the day and may be more severe following strenuous activity. Swollen, inflamed joints feel "boggy" or sponge-like on palpation because of synovial edema (Figure 40-8 •). ROM is limited in affected joints, and weakness may be evident. Without effective treatment, the persistent inflammation of RA causes deformities of the joint itself and supporting structures such as ligaments, tendons, and muscles. As the joint is destroyed, ligaments, tendons, and the joint capsule are weakened or destroyed. Joint carti-lage and bone are also destroyed. Weakening or destruction of these supporting structures results in lack of opposition to muscle pull, causing deformity. Characteristic changes in the hands and fingers include ulnar deviation of the fingers and subluxation at the MCP joints. Swan-neck deformity is characterized by hyperextension of the PIP joint with compensatory flexion of the distal interphalangeal (DIP) joints (Figure 40-9 •). A flexion deformity of the PIP joints with extension of the DIP joint is called a boutonnière deformity. The ability to effect a pinch is limited by hyperextension of the interphalangeal joint and flexion of the MCP joint of the thumb. Wrist involvement is nearly universal, leading to limited move-ment, deformity, and carpal tunnel syndrome. Inflammation of the elbows often causes flexion contracture. The knees are frequently affected in RA, with visible swelling often obliterating normal contours. Instability of the knee joint along with quadriceps atrophy, contractures, and valgus (knock-knee) deformities can lead to significant disability. Ambulation may be limited by pain and deformities when the ankles and feet are in-volved. Typical deformities of the feet and toes include subluxation, hallux valgus (deviation of the great toe toward the other digits of the foot), lateral deviation of the toes, and cock-up toes (interphalangeal joint hyperextension). Spinal involvement is usually limited to the cervical vertebrae. Neck pain is common, and neurologic complications can occur.

Latex Allergy

Latex Allergy Although protective against infection, the repetitive use of latex gloves creates a persistent exposure to latex for healthcare workers. An esti-mated 5% to 15% of healthcare workers are allergic to latex, whereas less than 1% of the general population has this allergy (American Academy of Allergy, Asthma & Immunology, 2012). When gloves are powdered with cornstarch to facilitate donning and removing gloves, the cornstarch particles aerosolize when the gloves are removed. The cornstarch includes latex particles. This creates a respiratory exposure as well as dermal exposure to latex. In addition, chemicals used in the manufacture of latex products may be irritating. Products such as bal-loons, condoms, and rubber bands are commonly made of latex. Sensitivity to latex can present as a simple irritant dermatitis, the most common negative reaction to latex. Type IV hypersen-sitivity (contact dermatitis) typically presents 24 to 96 hours after contact. Type I systemic allergic reactions, including hives, itching, wheezing, or difficulty breathing, develop within minutes to hours after exposure (National Institute for Occupational Safety and Health [NIOSH], 2012). It is important to protect the patient and the health-care worker who is allergic to latex. Employers can aid in prevention by selecting products free of latex. Nonlatex gloves are recommended for use where there is no contact with infectious materials or blood Powder-free latex gloves reduce latex exposure, as does avoiding use of oil-based creams and lotions when using latex gloves. Hand hy-giene after using latex products also limits exposure

The Patient With an Autoimmune Disorder

Maintaining optimal health and preventing disease depend not only on the immune system's ability to recognize and destroy foreign tis-sues and other antigens, but also on the immune system's ability to recognize self. When self-recognition (also known as self-tolerance) is impaired and immune defenses are directed against normal host tissue, the result is an autoimmune disorder. Autoimmune disorders can affect any tissue in the body. Some are tissue or organ specific, affecting a particular tissue or a par-ticular organ. Hashimoto's thyroiditis is an example of an organ-specific autoimmune disorder. Circulating antibodies are formed to certain thyroid components, ultimately resulting in destruction of the gland. In type 1 diabetes mellitus, cytotoxic T cells attack and destroy beta cells in pancreatic islets (Powers, 2012). Autoim-mune disorders may also be systemic, with neither the immune re-sponse nor the resulting inflammatory lesions confined to any one organ. Rheumatologic disorders, such as rheumatoid arthritis and systemic lupus erythematosus (SLE), are characteristic of systemic autoimmune disorders.

The Patient with Systemic Lupus Erythematosus (SLE)

Manifestations Typical early manifestations of SLE mimic those of rheumatoid arthritis, including systemic manifestations of fever, anorexia, mal-aise, and weight loss, and musculoskeletal manifestations of multiple arthralgias and symmetric polyarthritis. Joint symptoms affect more than 90% of patients with SLE. Although synovitis may be present, the arthritis associated with SLE is rarely deforming. Most people affected by SLE have skin manifestations at some point during their disease. In fact, SLE was originally described as a skin disorder and named for the characteristic red butterfly rash across the cheeks and bridge of the nose (Figure 40-10 •). Many patients with SLE are photosensitive; a diffuse maculopapular rash on skin exposed to the sun is common. Other cutaneous manifes-tations include discoid lesions (raised, scaly, circular lesions with an erythematous rim), hives, erythematous fingertip lesions, and splin-ter hemorrhages. Alopecia is common in patients with SLE, although the hair usually grows back. Painless mucous membrane ulcerations may occur on the lips or in the mouth or nose. Common manifesta-tions of SLE are listed in an accompanying box. Approximately 50% of people with SLE experience renal mani-festations of the disease, including proteinuria, cellular casts, and nephrotic syndrome. Up to 10% develop renal failure as a result of the disease. Hematologic abnormalities such as anemia, leukopenia, and thrombocytopenia are common with SLE. Up to 40% of patients with SLE develop pericarditis. Myocarditis is less common, but may de-velop. Vascular disorders such as vasculitis and Raynaud's phenom-enon often occur. Patients with SLE have an increased risk for acute thrombotic events such as transient ischemic attack (TIA), stroke, and myocardial infarction. Pleuritis, pleural effusions, and lupus pneumonitis are common pulmonary manifestations of SLE. Nervous system effects of the disease are common, including cog-nitive dysfunction with a decline in intellect, memory loss, and disori-entation. Other possible neurologic manifestations include headache, psychosis, and seizures. Ocular manifestations of SLE include conjunc-tivitis, photophobia, and transient blindness due to retinal vasculitis. GI manifestations of SLE, such as anorexia, nausea, abdominal pain, and diarrhea, may affect up to 45% of patients with the disease. The liver may be enlarged, and liver function tests may yield abnor-mal results.

The Patient With an Autoimmune Disorder Medications

Medications Newer treatments for autoimmune disorders focus on suppressing au-toimmune responses and restoring normal regulatory mechanisms to prevent target organ damage (Diamond & Lipsky, 2012). Therapy may be intermittent, used only during periods of exacerbation, or may be long term to prevent acute flares. Because these drugs suppress the im-mune system, the patient taking them has an increased risk for infection. • Immunosuppressive drugs such as azathioprine (Imuran), meth-otrexate (Rheumatrex, Trexall), abatacept (Orencia), etanercept (Enbrel), anakinra (Kineret), cyclophosphamide (Cytoxan), and cyclosporine (Sandimmune) may be used to inhibit immune re-sponses in autoimmune disorders. These drugs may be cytotoxic, killing proliferating B cells and T cells, or may suppress the pro-duction of cytokines critical to the immune response (Adams & Urban, 2013; Lehne, 2013). • Corticosteroids such as prednisone also suppress immune re-sponses and have potent anti-inflammatory effects. Corticoste-roids may be prescribed to reduce the inflammatory response and minimize tissue damage. Doses required for immunosup-pression are large, increasing the risk for infection and cushingoid effects such as thin, fragile skin and osteoporosis-related fractures (Lehne, 2013). • Drugs known as biologicals are laboratory-produced antibodies that bind tumor necrosis factor alpha (TNF-α) and interleukin-1 (IL-1), both inflammatory elements. These medications decrease the inflammatory process in autoimmune disorders, and include adalimumab (Humira), efalizumab (Raptiva), and infliximab (Remicade) (Adams & Urban, 2013).

The Patient with HIV Infection Medications

Medications Pharmacologic management of the patient with HIV disease has four primary goals: (1) to suppress the infection itself, decreasing symptoms and prolonging life (2) to provide prophylaxis (prevent disease) of opportunistic infections (3) to stimulate hematopoietic response; and (4) to treat opportunistic infections and malignancies. Today the drugs have been combined and dosing schedules simplified, which helps patients adhere to medication administration schedules Antivirals The Panel on Antiretroviral Guidelines for Adults and Adolescents (2012) and the International AIDS Society—USA Panel (Thompson et al., 2010) strongly recommend initiation of treatment when the CD4 count falls to 500/mm3 or lower. Treatment should be initiated regardless of CD4 count in patients who are symptomatic (e.g., have an AIDS-defining disease), are co-infected with hepatitis B, have HIV-associated neuropathy, and in women who are pregnant. Effectiveness of treatment is monitored by viral load and CD4 cell counts; positive results are indicated by a reduction in viral load along with preserving the CD4 count above 350/mm3. Starting treatment before immune failure, when the CD4 count is above 500 or 1000, may protect the immune system. The action of antiretroviral drugs can be broadly classified as agents that inhibit replication of the virus, and agents that block entry of the virus into cells. Nucleoside/nucleotide reverse tran-scriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and integrase inhibi-tors (INSTIs) inhibit enzymes required for viral replication. Fusion inhibitors and CCR5 antagonists, in contrast, interfere with viral entry into cells. The current standard of treatment is a combina-tion of three or more antiretroviral drugs from at least two different classes (Zolopa & Katz, 2012). Combination therapies increase the likelihood of decreasing viral load, and adherence to administration schedules has been eased by making various combinations available in one pill (Hodder et al., 2010; Juday et al., 2011). Patients begin-ning the ART protocol must understand the benefits, risks, costs, and effects on daily life. ART does not eradicate HIV infection. Each patient must be able to adhere to the treatment regimen. It may be preferable to delay initiating therapy until the patient is able to agree to adhere so irregular dosing does not lead to viral resistance. Some providers gauge patient ability to follow the ART regimen by the patient's success with prophylaxis for an opportunistic infection. Discontinuation or interruption of ART is considered dangerous; because of the burden of adverse reactions, patients may desire brief holidays from taking the medications. When treatment must be in-terrupted (for example, for surgery or due to drug toxicities), stag-gered discontinuation of the drugs is recommended (Thompson et al., 2010). Ingersoll and Heckman (2005) found that the most effective provider-patient relationship for fostering adherence is a balance of appropriate challenge and support. Providers who were never con-frontational seem to be perceived by patients as giving permission to be less adherent. Although depression, substance use, and financial considerations undoubtedly influence adherence to ART, and need to be addressed, provider-patient relationships have a significant influence on adherence behavior (Mohammadpour et al., 2010). See the accompanying box addressing ART considerations in the older adult with HIV infection.

The Patient with Systemic Lupus Erythematosus (SLE)

Medications The patient with mild or remittent SLE may need little or no therapy other than supportive care. Arthralgias, arthritis, fever, and fatigue can often be managed with acetaminophen, aspirin, or NSAIDs. As-pirin is particularly beneficial for patients with SLE because its anti-platelet effects help prevent thrombosis. It may, however, cause liver toxicity and hepatitis. NSAIDs are used with caution because they may increase the risk of renal dysfunction or myocardial infarction. Skin and arthritic manifestations of SLE may be treated with antimalarial drugs such as hydroxychloroquine (Plaquenil). Hy-droxychloroquine has also been shown to be effective in reducing the frequency of acute episodes of SLE in people with mild or inac-tive disease. Retinal toxicity and possibly irreversible blindness are the primary concerns with this drug. For this reason, the patient taking hydroxychloroquine undergoes ophthalmologic exam every 6 months. Patients with severe and life-threatening manifestations of SLE (such as nephritis, hemolytic anemia, myocarditis, pericarditis, or CNS lupus) require corticosteroid therapy in high doses. Such pa-tients may require 40 to 60 mg of prednisone per day initially. The dosage is tapered as rapidly as the patient's disease allows, although lowering the dosage may precipitate an acute episode. Some pa-tients with SLE require long-term corticosteroid therapy to manage symptoms and prevent major organ damage. These patients are at increased risk for corticosteroid side effects, such as cushingoid ef-fects, weight gain, hypertension, infection, accelerated osteoporosis, and hypokalemia Immunosuppressive agents such as cyclophosphamide (Cy-toxan), mycophenolate (CellCept), or azathioprine (Imuran) may be used, alone or in combination with corticosteroids, to treat patients with active SLE or lupus nephritis (see the accompanying Medication Administration box). When these agents are used in combination, lower, less toxic doses of each drug can be used. The patient receiving immunosuppressive agents is at increased risk for infection, malig-nancy, bone marrow depression, and toxic effects specific to the drug prescribed. Studies involving use of biologic therapies targeted at T or B lymphocytes are ongoing.

The Patient with Systemic Lupus Erythematosus (SLE) Multisytsem Effects

Neurologic • Neuropathies (peripheral and central) • Seizures • Depression • Psychosis Potential Complications • Stroke • Organic brain syndrome - Intellectual impairment - Memory loss - Personality changes - Disorientation Cardiovascular • Pericarditis • Myocarditis • Endocarditis • Vasculitis • Venous or arterial thrombosis Respiratory • Pleurisy • Pleural effusion • Pneumonitis • Interstitial fibrosis Gastrointestinal • Anorexia • Nausea • Abdominal pain • Diarrhea • Hepatomegaly Potential Complications • Nephrotic syndrome • Renal failure Musculoskeletal • Arthralgias • Symmetric polyarthritis • Joint swelling and effusion • Morning stiffness Urinary • Proteinuria • Cellular casts Endocrine • Thyroid abnormalities • Hyperparathyroidism • Glucose intolerance Hematologic • Anemia • Leukopenia • Thrombocytopenia • Splenomegaly Reproductive • Pregnancy-induced hypertension, edema, and proteinuria • Fetal loss Metabolic Processes • Low-grade fever • Malaise • Weight loss Sensory • Conjunctivitis • Photophobia • Retinal vasculitis with transient blindness • Cotton-wool spots on retina Integumentary • Butterfly rash on face • Photosensitivity • Maculopapular rash on exposed body surfaces • Discoid lesions • Erythematous fingertip lesions • Splinter hemorrhages • Alopecia • Ulcers (lip, mouth, nose)

The patient with Rheumatoid Arthritis (RA)

Nonsteroidal Anti-Inflammatory Drugs A number of NSAIDs are available for use in the management of RA. All NSAIDs act by inhibiting prostaglandin synthesis. Although the efficacy of all NSAIDs, including aspirin, is equivalent, patient responses are individual. Several trials of different NSAIDs may be necessary to find the most effective drug. Gastric irritation, ulceration, and bleeding are the most com-mon toxic effects of NSAIDs. They can also affect the lower intestinal tract, leading to perforation or aggravation of inflammatory bowel disorders. All NSAIDs can also be toxic to the kidneys. With the ex-ception of the COX-2 inhibitor celecoxib, most NSAIDs also inhibit platelet function, increasing the risk for bleeding. Aspirin is the only drug in this group that has been found to lower the risk of cardiovas-cular disease; all others actually increase cardiovascular risk.

The Patient with HIV Infection Medications

Nucleoside Reverse Transcriptase Inhibitors The NRTIs (also called nucleoside analogs) are mainstays of ART. This class of drugs inhibits the action of viral reverse transcriptase, a retroviral enzyme that catalyzes the substrates for conversion and copying of viral RNA to DNA sequences. This enzyme is necessary for viral integration into cellular DNA and replication. The nucleoside analogs act as a chemical decoy for building blocks of the formation of the DNA copy, preventing the RNA from being copied into DNA. Each drug substitutes for a particular nucleoside base at different points on the chain. See the accompanying Medication Administration box for this group of drugs. Zidovudine (Retrovir, AZT), the first antiretroviral agent approved for use with HIV infection, now is generally reserved for second- or third-line regimens because it causes anemia and neu-tropenia. Zidovudine is often given in combination with lamivu-dine (Combivir) or in combination with lamivudine and abacavir Trizivir). Zidovudine may also be used prophylactically following a documented parenteral exposure to HIV.

Priorities of Care

Nursing care priorities for the patient with HIV infection change over the course of the disease. Health maintenance activities, education, and support of coping mechanisms are important in the early stages of the disease. As the disease progresses and the patient experiences more physical symptoms, direct care needs become more important while the need for psychosocial support continues.

The Patient with HIV Infection Opportunistic Infections

Opportunistic Infections Opportunistic infections are the most common manifestation of AIDS, often occurring simultaneously. The risk of opportunistic infections is predictable by the CD4 T-cell count. The normal CD4 T-cell count is greater than 1000/mcL. When the CD4 count falls to less than 500/mcL, manifestations of immunodeficiency are seen. With a count of less than 200/mcL, opportunistic infections and cancers are likely. Pneumocystis Pneumonia Pneumocystis pneumonia (PcP) is the most common pneumonia affecting patients with AIDS. PcP is an opportunistic infection; it rarely develops when the CD4 count is above 250/mcL (Zolopa & Katz, 2012). PcP is caused by P. jiroveci, a common environmental organism that is not pathogenic in patients with intact immune systems. Unlike many pneumonias, the manifestations of PcP are nonspecific and may progress insidiously. Patients often present with fever, cough, dyspnea, tachypnea, and tachycardia. Complaints of mild chest pain and sputum may also be present. Breath sounds may initially be normal. With severe disease, the patient may present with cyanosis and significant respiratory distress. The most common cause of pulmonary disease in individuals with HIV infection who have been treated with ART is community-acquired bacterial or viral pneumonia rather than PcP (Zolopa & Katz, 2012). Tuberculosis An estimated 4% of patients with AIDS develop tuberculosis (TB), contributing significantly to the rise in incidence of this disease in the United States (Zolopa & Katz, 2012). In some patients, active TB results from reactivation of a prior infection. In other patients, it is a new, primary disease facilitated by impaired immune function. Worldwide, TB is the leading cause of death among those with HIV infections (CDC, 2011a). Rapid progression, diffuse pulmonary infiltrates, and disseminated disease occur more commonly in patients with AIDS. Multiple-drug-resistant strains of tuberculosis present a significant problem. Patients with pulmonary TB present with a cough productive of purulent sputum, fever, fatigue, weight loss, and lymphadenopa-thy. Disseminated disease affects the bone marrow, bone, joints, liver, spleen, CSF, skin, kidneys, gastrointestinal tract, lymph nodes, brain, and other sites. Kaposi's Sarcoma Early in the epidemic, Kaposi's sarcoma (KS) was often the presenting symptom of AIDS. With the advent of ART, it is seen in fewer than 1% of patients with HIV. Kaposi's sarcoma is caused by a herpes virus transmitted primarily through sexual contact; men who have sex with men are more likely to be infected with the virus responsible for KS. KS also may develop in people whose immune system is suppressed due to immunosuppressive medications. A tumor of the endothelial cells lining small blood vessels, KS presents as vascular macules, papules, or violet lesions affecting the skin and viscera (Figure 13-10 •). The palate, toe webs, the face (especially the tip of the nose and pinnae of the ears), and visceral organs including the gastrointestinal tract, lungs, and lymphatic sys-tem are common sites for KS lesions. The lesions of KS are initially painless, but may become pain-ful as the disease progresses. Internally, the tumors may obstruct organ function or cause bleeding. When the lungs are involved, gas exchange may be severely impaired, resulting in pulmonary hemor-rhage. Rapidly progressing KS is treated with chemotherapy; milder forms may improve with the initiation of ART

Drugs For HIV zidovudine (AZT, Retrovir)

Other Drugs in the Class Abacavir sulfate (Ziagen) inhibits the viral reverse transcriptase through competition with the natural DNA nucleoside and incor-poration into viral DNA. It is contraindicated in moderate to severe hepatic impairment. Abacavir is administered in combination with other antiretroviral agents. The FDA has issued a BLAcK BOX WARNING ♦ stating that patients taking abacavir may have serious and sometimes fatal hypersensitivity reactions. Patients who test positive for HLAB*5701 allele are at greatest risk for hypersensitiv-ity reactions. Patients may also be at risk for lactic acidosis. Didanosine (Videx, Videx EC) is an oral antiretroviral that is administered 30 minutes before meals or 2 hours after meals. The drug blocks the HIV replication in T cells and monocytes to block viral DNA synthesis and replication. Patients should not combine it with alcohol due to the increased risk of pancreatitis. It is necessary to reduce the drug dosage in renal impairment. Emtricitabine (Emtriva) inhibits HIV-1 reverse transcrip-tase to inhibit HIV activity. Again, dosage reduction in renal impairment is necessary. Prior to beginning therapy, it is important to check liver function and assess it periodically through-out treatment. The nurse also assesses patients with depression for suicidal ideation. In addition, the nurse instructs patients to avoid driving or operating machinery until their response to the medication is known. Stavudine is an NRTI that is administered in combina-tion with other antiretroviral medications. The World Health Organization recommends 30 mg every 12 hours in all adult and

The Patient with Systemic Lupus Erythematosus (SLE)

Pathophysiology The pathophysiology of SLE involves the production of a large variety of autoantibodies against normal body components such as nucleic acids, erythrocytes, coagulation proteins, lymphocytes, and plate-lets. Autoantibody production results from hyperreactivity of B cells (humoral response) because of disordered T-cell function (cellular immune response). The most characteristic autoantibodies in SLE are produced in response to nucleic acids, including DNA, histones, ribonucleoproteins, and other components of the cell nucleus. SLE autoantibodies bind with their target tissue to form im-mune complexes, which are then deposited in the connective tissue of blood vessels, lymphatic vessels, and other tissues. The deposits trigger an inflammatory response with release of chemotaxins, cyto-kines, vasoactive peptides, and destructive enzymes, which results in local tissue damage. The kidneys are a frequent site of complex depo-sition and damage; other tissues affected include the musculoskeletal system, brain, heart, spleen, lung, GI tract, skin, and peritoneum. The autoantibodies produced and their target tissue determine the mani-festations of SLE. A number of drugs can cause a syndrome that mimics lupus in patients with no other risk factors for the disease. Procainamide (e.g., Procan-SR, Pronestyl) and hydralazine (Apresoline, Hydralyn) are the most common drugs implicated, along with isoniazid (INH). Renal and CNS manifestations of SLE rarely occur with drug-induced lupus, but arthritic and other systemic symptoms are com-mon. Manifestations of drug-induced lupus usually resolve when the medication is discontinued.

Corticosteroid Meds: Prototype prednisone

Patient Teaching Realize that in most instances, corticosteroids are used to relieve symptoms; they do not cure the underlying disease process. However, they can improve comfort and quality of life. When taking an oral corticosteroid (e.g., prednisone) for longer than 2 weeks, take the drug as directed. This is extremely important. Missing a dose or two, stopping the drug, changing the amount or time of administration, taking extra drug (except as specifically directed during stress situations), or any other alterations may result in complications. Some complications are relatively minor; several are serious, even life threatening. When these drugs are being discontinued, the dosage is gradually reduced over several weeks. They must not be stopped abruptly.

The patient with Rheumatoid Arthritis (RA)

Priorities of Care Nursing care priorities for the patient with RA will vary depending on the circumstances of the nurse-patient interaction. The newly diagnosed patient who is just starting treatment to reduce disease activity with the goal of achieving remission has very different care needs than the patient experiencing a treatment complication such as infection or gastrointestinal bleeding, or the patient who has under-gone a total joint arthroplasty.

The patient with Rheumatoid Arthritis (RA) Multisystem Effects

Respiratory • Pleural disease • Interstitial fibrosis • Pneumonitis Sensory • Scleritis • Episcleritis Exocrine glands Sjögren's syndrome • Dry eyes • Dry mouth Cardiovascular • Vasculitis • Pericarditis Hematologic Felty's syndrome • Splenomegaly • Neutropenia • Anemia Integumentary • Rheumatoid nodules Metabolic Processes • Fatigue • Weakness • Anorexia • Weight loss • Low-grade fever Musculoskeletal General • Symmetric polyarticular joint swelling • Joint redness, warmth, pain, tenderness • Morning stiffness Spine • Cervical pain • Neurologic manifestations Wrists • Limited range of motion • Deformity • Carpal tunnel syndrome Hands • Ulnar deviation • Swan-neck deformity • Boutonnière deformity Knees • Joint effusion • Instability Ankles • Limited range of motion • Pain on ambulation Feet • Subluxation • Hallux valgus • Lateral toe deviation • Cock-up toe

The patient with Rheumatoid Arthritis (RA)

Rheumatoid arthritis (RA) is a chronic systemic autoimmune dis-ease that causes inflammation of connective tissue, primarily in the joints. Its course and severity are variable, and the range of manifesta-tions is broad. Manifestations of RA may be minimal, with mild inflam-mation of only a few joints and little structural damage, or relentlessly progressive, with multiple inflamed joints and marked deformity. Most patients exhibit a pattern of symmetric involvement of multiple periph-eral joints and periods of remission and exacerbation.

Skin Tests for Allergies

Skin Tests for Allergies Skin tests are also used to determine causes of hypersensitivity reac-tions. These tests are used to identify specific allergens to which an individual may be sensitive. Allergens for testing are selected ac-cording to the patient's history. Test solutions made from extracts of inhaled, ingested, or injected materials, such as pollens, mites, venoms, or some drugs, are used for the prick test and intradermal testing. Epicutaneous testing (prick testing) is generally done first to avoid a systemic reaction; it may be followed by intradermal testing of allergens with a negative response to prick testing. • Prick (epicutaneous or puncture) test: A drop of diluted allergenic extract is placed on the skin, and the skin is then pricked or punc-tured through the drop. With a positive test, a localized pruritic (itchy) wheal and erythema occur. The response is maximal at 15 to 20 minutes. • Intradermal: A small amount of allergen extract at a 1:500 or 1:1000 dilution is injected intradermally in the forearm or intra-scapular area. If several allergens are being tested, injections are spaced 0.25 to 0.5 inch apart. As control measures, plain diluent (negative control) and histamine (positive control) are injected. If there is no response to a particular allergen at 15 to 20 minutes, the test is negative. The appearance of a wheal and erythema, with a wheal diameter at least 5 mm greater than that produced by the control, indicates a positive response (Figure 13-5 •). • Patch: A 1-inch patch impregnated with the allergen (e.g., per-fume, cosmetics, detergents, or clothing fibers) is applied to the skin for 48 hours. Absence of a response indicates a negative test result. Positive responses are graded from mild (erythema in the exposed area) to severe (erythema, papules, vesicles, or ulceration).

Drugs For HIV Saquinavir mesylate (Invirase)

Use The main purpose of using saquinavir is to reduce the viral load in HIV—in combination with other antiretrovi-ral agents. Prescribers may also order it with colchicine for familial Mediterranean fever, gout prophylaxis, and gout flare-up and with phosphodiesterase -5 enzyme inhibitors for pulmonary hypertension or erectile dysfunction. Table 23.9 summarizes route and dosage information for saquinavir and the other PIs. Use in Older Adults Administration in the elderly warrants caution because of the risk of organ dysfunction.

Corticosteroid Meds: Prototype prednisone

Specific Uses Allergic rhitinis Arthritis Asthma Cancer Chronic Induced Emesis Inflammatory Bowel disease spinal Cord Injury Prevention of Acute Adrenocortical Insufficiency

The Patient with Systemic Lupus Erythematosus (SLE)

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease that affects almost all body systems, including the musculoskeletal system. The manifestations of SLE are widely variable and are thought to result from cell and tissue damage caused by deposition of antigen-antibody complexes in connective tissues.

Drugs For HIV Nonnucleoside Reverse Transcriptase Inhibitors efavirenz (Sustiva).

The NNRTIs inhibit viral replication in infected cells by directly binding to reverse transcriptase and preventing its function. NRTIs and NNRTIs inhibit reverse transcriptase by different mechanisms, and therefore, they may have synergistic antiviral effects. The prototype NNRTI is efavirenz (Sustiva).

Treatment of Anaphylaxis

The immediate treatment for anaphylaxis is parenteral epinephrine, an adrenergic agonist (sympathomimetic) drug that has both vasoconstricting and bronchodilating effects. These qualities, combined with its rapid action, make epinephrine ideal for treating an anaphy-lactic reaction. For mild reactions with wheezing, pruritus, urticaria, and angioedema, an intramuscular or subcutaneous injection of 0.3 to 0.5 mL of 1:1000 epinephrine is generally sufficient (Austen, 2012; Mustafa, 2011). For patients with an injected toxin such as a bee sting, an additional amount equivalent to one-half the above may be injected directly into the site of the sting and a tourniquet applied above it to prevent further systemic absorption. Intravenous epinephrine diluted to a 1:100,000 concentration may be used in the patient with a more severe anaphylactic reaction.

The Patient with HIV Infection Manifestations

The manifestations of HIV infection range from no symptoms to severe immunodeficiency with multiple opportunistic infections and cancers (see the Pathophysiology Linkage box on page 318). Most patients develop an acute mononucleosis-type illness within days to weeks after contracting the virus. Typical manifestations in-clude fever, sore throat, arthralgias and myalgias, headache, rash, and lymphadenopathy. Pathologic changes are also noted in the CNS of many infected individuals although the mechanism of neurologic dysfunction is unclear. The patient may also experience nausea, vomiting, and abdominal cramping. The patient often attributes this initial manifestation of HIV infection to a common viral illness such as influenza, upper respiratory infection, or stomach virus. Following this acute illness, patients who are treated enter a pro-longed asymptomatic period. Although the virus is present and can be transmitted to others, the infected host has few or no symptoms. Most HIV-infected individuals are in this stage of the disease. The length of the asymptomatic period varies widely, but its mean length is estimated to be 8 to 10 years in untreated individuals and signifi-cantly longer in those undergoing ART. Some patients with few other symptoms develop persistent gen-eralized lymphadenopathy. This is defined as enlargement of two or more lymph nodes outside the inguinal chain with no other illness or condition to account for the lymphadenopathy. The move from asymptomatic disease or persistent lymphade-nopathy to AIDS is defined by a CD4 T-cell count of less than 200/mcL, with or without the presence of opportunistic disease (Fauci & Lane, 2012). The patient may complain of general malaise, fever, fatigue, night sweats, and involuntary weight loss (Figure 13-9 •). Persistent skin dryness and rash may be a problem. Diarrhea is common, as are oral lesions such as hairy leukoplakia, candidiasis, and gingival inflammation and ulceration. With the development of significant constitutional disease, neurologic manifestations, or opportunistic infections or cancers, the patient has manifestations that are char-acteristic of AIDS and a very poor prognosis. When manifestations develop, the outcome varies. Antiretroviral therapy is credited with prolonging the asymptomatic period of HIV disease, decreasing the incidence of opportunistic infections, and improving survival

The Patient With an Autoimmune Disorder Pathophysiology

The mechanism that causes the immune system to recognize host tis-sue as a foreign antigen is not clear. The following factors are under study as possible contributors to the development of autoimmune disorders: • The release of previously "hidden" antigens into the circulation, such as DNA or other components of the cell nucleus, elicits an immune response. • Chemical, physical, or biologic changes in host tissue cause self-antigens to stimulate the production of autoantibodies. • The introduction of an antigen, such as a bacteria or virus, whose antigenic properties closely resemble those of host tissue, result-ing in the production of antibodies that target not only the foreign antigen but also normal tissue. This is termed molecular mimicry. Heart damage in rheumatic fever and acute glomerulonephritis following beta-hemolytic streptococcal infections are examples of the development of antibodies against normal tissue (Grossman & Porth, 2014). • A defect in normal cellular immune function that allows B cells to produce autoantibodies unchecked. Although the exact mechanism producing autoimmunity is unclear, several characteristics of autoimmune diseases are known. It is apparent that genetics plays a role because a higher incidence is seen in family members of people with autoimmune disorders. More than one genetic change is likely occurring to cause development of these disorders. Additional factors believed to contribute to the de-velopment of autoimmune disorders include age, gender, and envi-ronmental factors such as exposure to infectious agents (Diamond & Lipsky, 2012). The disorders tend to overlap, so that the patient with one au-toimmune disorder may develop another or some manifestations of another. The onset of an autoimmune disorder is frequently as-sociated with a physical or psychologic stressor. Autoimmune dis-orders are frequently characterized by periods of exacerbation and remission. Specific autoimmune disorders are discussed in the sections of this textbook related to the affected organ systems or functional disruption.

The Patient with HIV Infection How is HIV transmitted?

The most common mode of transmission is heterosexual intercourse. The cofactors that increase the risk of HIV trans-mission include the presence of ulcerative or inflammatory sexually transmitted infections, trauma, menses, and lack of male circumcision. It is clear that HIV is not transmitted by casual contact, nor is there any evidence of its transmission by vectors such as mosquitoes. Blood donation poses no risk of contracting HIV to the donor, be-cause only new sterile equipment is used. A small but real occupa-tional risk exists for healthcare workers. Percutaneous exposure to infected blood or body fluids through a needlestick injury or nonin-tact skin is the primary route of transmission. Documented evidence indicates that parenteral exposure poses a 1:300 risk of becoming HIV

The Patient with HIV Infection Risk Factors

The risk factors for HIV infection are behavioral. Among adults in the United States, 61% of reported new HIV infections are MSM, including homosexuals, bisexuals, and such groups as prison populations. Unprotected anal intercourse is the major route of transmission in this group. Heterosexual intercourse also is a risk, accounting for an estimated 27% of new HIV infections in 2009 (CDC, 2012a). Injection drug use is another leading risk factor, accounting for approximately 17% of cases, with sharing of needles and other drug paraphernalia the primary route of trans-mission. Heterosexual intercourse with an infected drug user and exchanging sex for drugs are major risk factors for women. In the United States, HIV disproportionately affects African Americans and Hispanics/Latinos. See the accompanying Moving Evidence into Action box.

The patient with Rheumatoid Arthritis (RA)

Treatments The primary objectives in treating RA are to prevent joint damage and disability, reduce pain and inflammation, and minimize side effects of treatment. Rest and Exercise A balanced program of rest and exercise is an important component in the management of patients with RA. Physical and occupational therapists can design and monitor individualized activity and rest programs. Regular rest periods during the day may be beneficial to reduce manifestations of the disease. Additionally, splinting of inflamed joints reduces unwanted motion and provides local joint rest. A va-riety of orthotic devices are available to reduce joint strain and help maintain function. A balanced program of physical therapy and exercise is critical to maintain muscle strength and joint mobility. Dynamic strength training (e.g., isometric exercises, use of resistance bands) is used to improve muscle strength without increasing joint stress. Low-impact aerobic exercises, such as swimming and walking, have been shown to benefit patients with RA without adversely affecting joint inflammation or prompting acute episodes. A program that includes 30 minutes of moderately intense activity most days of the week has been shown to improve both muscle strength and perceived health in patients with RA (Shah & St. Clair, 2012). Heat and Cold Heat and cold are used for their analgesic and muscle-relaxing effects. Moist heat is generally the most effective, and can be provided by a tub bath or shower. Joint pain is relieved in some patients through the application of cold. Assistive Devices and Splints Assistive devices, such as a cane, walker, or raised toilet seat, are most useful for patients with significant hip or knee arthritis. Splints provide joint rest and prevent contractures. Night splints for the hands and/or wrists should maintain the extremity in a position of maximum function. The best "splint" for the hip is lying prone for several hours a day on a firm bed. In general, splints should be applied for the shortest period needed, should be made of lightweight materials, and should be easily removed to perform ROM exercises once or twice a day. Nutrition For most patients with RA, an ordinary, well-balanced diet is recommended. Some patients may benefit from substitution of usual dietary fat with omega-3 fatty acids found in certain fish oils. Surgery Surgical intervention may be employed for the patient with RA when medical management has failed to prevent joint damage. Arthrodesis (joint fusion) may be used to stabilize joints such as cervical vertebrae, wrists, and ankles. Arthroplasty, or total joint replacement, may be necessary in cases of gross deformity and joint destruction. Total joint replacement and nursing care of patients undergoing this surgery are discussed in the preceding section on OA.

TYPE Ill IMMUNE COMPLEX-MEDIATED HYPERSENSITIVITY

Type III hypersensitivity reactions result from the formation of IgG or IgM antibody-antigen immune complexes in the circulation. When these complexes are deposited in vessel walls and extravas-cular tissues, complement is activated and chemical mediators of inflammation such as histamine are released. Chemotactic factors attract neutrophils to the site of inflammation. When neutrophils at-tempt to phagocytize the immune complexes, lysosomal enzymes are released, increasing tissue damage (Figure 13-3 •). Either systemic or local responses may be seen with type III re-actions. For example, serum sickness is a systemic response, named because it was first identified after administration of foreign serum (e.g., horse antitetanus toxin). Although foreign serums are no lon-ger administered, serum sickness still occurs in response to some drugs, such as penicillin and sulfonamides. Immune complexes are deposited in the walls of small blood vessels, the kidneys, and joints. Manifestations of serum sickness include fever, urticaria or rash, ar-thralgias, myalgias, and lymphadenopathy. Localized responses may occur at a number of different sites. As immune complexes accumulate in the glomerular basement mem-brane of the kidneys—for example, following a streptococcal infec-tion or with systemic lupus erythematosus—glomerulonephritis develops. An acute alveolar inflammatory response can occur when an antigen (such as dust from moldy hay), is inhaled by agricultural workers.

Type IV Delayed Hypersensitivity

Type IV reactions differ from other hypersensitivity responses in two ways. First, these reactions are cell mediated rather than anti-body mediated, involving T cells of the immune system. Second, type IV reactions are delayed rather than immediate, developing 24 to 48 hours after exposure to the antigen. Type IV hypersensitivity responses result from an exaggerated interaction between an an-tigen and normal cell-mediated mechanisms. This exaggerated interaction results in the release of soluble inflammatory and im-mune mediators (from the lysozymes within the macrophages) and recruitment of killer T cells, causing local tissue destruction (Figure 13-4 •). Contact dermatitis is a classic example of a type IV reaction. Intense redness, itching, blister formation, and thickening affect the skin in the area exposed to the antigen. Many antigens can provoke this response; poison ivy is a prime example. In the healthcare setting, an allergic response to latex can produce contact dermatitis (see next section). Other examples of cell-mediated responses include a posi-tive tuberculin test and graft rejection episodes.

Drugs For HIV zidovudine (AZT, Retrovir)

Use Patients take zidovudine for the treatment of HIV infection— in combination with two or more other antiretroviral agents. Pregnant women who are infected with HIV take the drug as monotherapy to prevent the transmission of HIV to the fetus. Should the mother not receive antiviral therapy during her pregnancy, intravenous zidovudine is administered at the onset of labor. An unlabeled use is postexposure prophylaxis for HIV exposure with a multidrug regimen Use in Children To prevent maternal-fetal HIV transmission in neonates, experts recommend that zidovudine be given as soon as pos-sible after birth—6 to 12 hours after delivery. It is necessary to continue the dose until the neonate is 6 weeks of age. Infants born to mothers whose viral load (number of HIV RNA par-ticles within the blood) is significantly below normal should receive zidovudine combined with nevirapine. If the infant develops a rash, there should be no dosage increase during the 14-day lead-in period.

Corticosteroid Meds: Prototype prednisone

Use in Older Adults Corticosteroids are used for the same conditions in older adults as in younger ones. Older adults are especially likely to have conditions that are aggravated by the drugs (e.g., heart failure, hypertension, diabetes mellitus, arthritis, osteoporosis, increased susceptibility to infection, concomitant drug therapy that increases risks of GI ulceration, and bleeding). Adverse effects such as mania, depression, psychosis, and delirium are extremely common in older patients treated with corticosteroids. Consequently, it is important to consider risk-benefit ratios of systemic corticosteroid therapy carefully, especially for long-term therapy. When used, lower doses are usually indicated because of decreased muscle mass, plasma volume, hepatic metabolism, and renal excretion in older adults. In addition, therapeutic and adverse responses should be monitored regularly by a health care provider (e.g., blood pressure, serum electrolytes, and blood glucose levels at least every 6 months). As in other populations, adverse effects are less likely to occur with oral or nasal inhalations than with oral drugs.

Corticosteroid Meds: Prototype prednisone

Use in Patients With Critical Illness Use of corticosteroids in the treatment of serious illness has been extensive, with much empiric usage. Adrenal Insufficiency Adrenal insufficiency is the most clear-cut indication for use of a corticosteroid, and even a slight impairment of the adre-nal response during severe illness can be lethal if corticosteroid therapy is not instituted. Adrenal insufficiency is covered in depth in Chapter 45. Acute Respiratory Failure in Chronic Obstructive Pulmonary Disease Some studies of patients with COPD have found that the par-enteral administration of methylprednisolone may be effective for the treatment of acute respiratory failure. However, if other medications do not produce adequate bronchodilation, IV cor-ticosteroid therapy is a reasonable treatment choice in the first 72 hours of the illness. The nurse assesses the patient for pulmo-nary infection because corticosteroid therapy places the patient at increased risk for pulmonary infection. Adult Respiratory Distress Syndrome Although corticosteroids have been widely used in the past to assist in the treatment of patients with adult respiratory distress syndrome (ARDS), the current literature indicates that the ben-efits of corticosteroid therapy are uncertain. Studies examining the benefit of corticosteroid therapy revealed that improved gas exchange decreased the number of days patients with ARDS were on mechanically assisted ventilation (Siegel, 2016). The studies reviewed by Siegel revealed the importance of monitor-ing individual patients who are administered corticosteroids for signs and symptoms of infection. Acquired Immunodeficiency Syndrome (AIDS) Health care providers are increasingly recognizing adrenal insufficiency in patients with AIDS, who require assessment and treatment for the condition, if indicated. Corticosteroids improve survival and decrease risks of respiratory failure with pneumocystosis, a common cause of death in patients with AIDS. The recommended regimen is prednisone 40 mg twice daily for 5 days, then 40 mg once daily for 5 days, then 20 mg daily until completion of treatment for pneumocystosis. The effect of corticosteroids on risks of other opportunistic infec-tions or neoplasms is unknown.

Medications

When it is impossible to avoid the offending allergen and allergic manifestations are severe or disrupt the patient's activities of daily living (ADLs), medications may be prescribed. Immunotherapy, also called hyposensitization or desensitization, consists of injecting an extract of the allergen(s) in gradually increasing doses. Immunother-apy is used primarily for allergic rhinitis or asthma related to inhaled allergens. It has also been shown to be effective in preventing anaphy-lactic responses to insect venom. With weekly or biweekly subcutane-ous injections of the allergen, the patient develops IgG antibodies to the allergen that appear to block effectively the allergic IgE-mediated response. Once a therapy plateau is reached, injections may be dis-continued or continued indefinitely either monthly or bimonthly. Antihistamines are the major class of drugs used in treating the symptoms of hypersensitivity responses, type I in particular. They are also useful to some extent in relieving manifestations (such as urticaria) of some type II and type III reactions. Anti-histamines block H1-histamine receptors, acting as a competitive antagonist to histamine, but they do not affect the production or release of histamine. The prototype antihistamine is diphen-hydramine (Benadryl). It and other antihistamines alleviate the systemic effects of histamine such as urticaria and angioedema (localized tissue swelling). They are also useful in relieving allergic rhinitis, drying respiratory secretions through an anticholinergic effect. The preferred route of administration is oral, although di-phenhydramine and others can be given parenterally, particularly when immediate action is needed, as in anaphylaxis. Side effects include drowsiness and dry mouth. Antihistamines are not effec-tive in relieving asthmatic responses to allergens and may actually worsen symptoms by their drying effect on respiratory secretions. Antihistamines are often combined with a sympathomimetic agent such as pseudoephedrine to improve their decongestant activity and counteract their sedative effect. Glucocorticoids (corticosteroids) are used in both systemic and topical forms for many types of hypersensitivity responses. Their anti-inflammatory effects, rather than their immunosup-pressive effects, are of most benefit. A short course of corticosteroid therapy is often used for severe asthma, allergic contact dermatitis, and some immune complex disorders. Corticosteroids in topical forms or delivered by inhaler may be used for longer periods of time with few side effects; however, systemic absorption can occur.

Allergy

When the antigen is environmental or exogenous, it is called an allergy, and the antigen is referred to as an allergen.

Drugs For HIV zidovudine (AZT, Retrovir)

action Like all NRTIs, zidovudine has the ability to incorporate into the DNA chains by viral reverse transcriptase. (HIV needs this enzyme to convert RNA to DNA and replicate.) Thus, the drug blocks the addition of further nucleotides and terminates viral replication

Drugs For HIV Nonnucleoside Reverse Transcriptase Inhibitors efavirenz (Sustiva).

action and use Efavirenz binds to reverse transcriptase to block RNA-dependent and DNA-dependent polymerase activities that includes HIV-1 replication. People take the medication in combination with other antiretroviral agents for HIV-1 infection.

Drugs For HIV Fusion Protein Inhibitors

action and use Enfuvirtide inhibits the fusion of the membrane of the HIV-1 virus with that of the cell, thus preventing HIV from entering the cell. It is used in combination with other antiretrovirals in treating HIV-1. Table 23.10 gives route of administration and dosage information for enfuvirtide. adverse effects and contraindications The most commonly reported adverse effects to enfuvirtide are fatigue, insomnia, nausea, and diarrhea. Injection site reactions such as rash, pain, discomfort, redness, hyper-sensitivity, rash, and nodule development may also occur. Researchers have reported bacterial pneumonia in 3% of the patients who used enfuvirtide. Less than 10% of the patients may have elevated serum creatine phosphokinase, myalgia, and limb pain. Assessing for Therapeutic and Adverse Effects The nurse assesses for an increase in T helper CD4 cells. The CD4 count measures the ability to fight against infections. Also, the nurse assesses the injection site for signs of hyper-sensitivity such as rash, redness, nodules, or pain. He or she also assesses for diarrhea, nausea, or other signs of GI distress. In addition, it is necessary to assess the serum creatine phospho-kinase for elevation along with myalgia or limb pain. Finally, the nurse assesses pulmonary status, looking for cough, fever, or bacterial pneumonia. Patient Teaching The nurse instructs the patient or family about the proper tech-nique for the administration of the enfuvirtide. Daily admin-istration is necessary, and if a dose is missed, it is important to notify the primary care provider. Instruct the rotation of injec-tion sites and assessment of site for changes. Box 23.5 provides general patient teaching guidelines for antiretroviral drugs.

Drugs For HIV Nonnucleoside Reverse Transcriptase Inhibitors efavirenz (Sustiva).

adverse effects CNS adverse effects include dizziness, headache, insomnia, altered ability to concentrate, abnormal dreams, nervousness, and depression. Genitourinary adverse effects are renal calculus and hematuria. Patients may experience fever and fatigue, skin rash, erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis. In addition, patients may have increased levels of serum cholesterol, AST, and ALT. Assessing for Therapeutic Effects The nurse assesses the CD4 count for increased ability to fight against viral infections. Assessing for Adverse Effects The nurse assesses for skin rash and onset of Stevens-Johnson syndrome as well as for lack of concentration, increased ner-vousness, and impaired psychiatric effects. It is also necessary to assess for alterations in GI status such as nausea, vomiting, and diarrhea, as well as urinary output for bleeding and complaints of pain related to renal calculi. In addition, the nurse assesses the serum cholesterol, AST, and ALT values for possible increases. Patient Teaching Box 23.5 identifies general patient teaching guidelines for antiretroviral drugs. The nurse should teach patients to use barrier contraceptives when taking efavirenz, not to drive or operate machinery until the effects of the medica-tion are known, and to notify the prescriber in the event of pregnancy. other drugs in the class Delavirdine mesylate (Rescriptor) is an NNRTI that is indicated for combined use with other antiretroviral agents. The potential for life-threatening adverse effects have been noted when delavirdine is combined with CYP3A4 inducers. The drugs of greatest concern are dysrhythmic agents, clarithromycin, dapsone, rifabutin, ben-zodiazepines, calcium channel blockers, ergot derivatives, indina-vir, saquinavir, quinidine, and warfarin. In patients who have an absence of hydrochloric acid in the gastric juices, it is necessary to administer the drug with an acidic beverage. Taking delavirdine requires mixing it with a minimum of 3 ounces of water. The solu-tion should stand for a few minutes, and then the patient should drink the solution. After rinsing the glass, the patient should drink the rinse to obtain the entire dosage of the medication. Then he or she should rinse the mouth and swallow that solution. Etravirine (Intelence) is an NNRTI that is used in combi-nation with a minimum of two additional antiretroviral agents to treatment-experienced HIV patients. Patients should take it with food to aid absorption. Metabolism by CYP3A4, CYP2C9, and CYP2C19 occurs in the liver; this leads to reduced serum levels of other medications metabolized by the same substrates. For example, administration of etravirine with antifungal agents increases serum levels of etravirine and decreases antifungal activity. Nevirapine (Viramune) is an NNRTI used in combination with other antiretroviral agents. Pregnant women with HIV may also take the drug in combination with zidovudine for the pre-vention of transmission of HIV to the fetus. It is essential that nevirapine not be given to children exposed to the drug dur-ing prevention of transmission of HIV from the mother to the fetus. Patients may take the drug without regard to food intake. The bLacK bOX Warning ♦ issued by the FDA states that the most significant adverse effect of nevirapine is the abrupt onset of flulike symptoms, abdominal pain, fever with or with-out a rash, and jaundice. These adverse effects may progress to hepatic failure and encephalopathy. Rilpivirine is useful in treatment-naïve patients whose viral load is less than 100,000 copies/mL and whose CD4 count is ≥200 cells/μL. It is administered alone or in combination with emtricitabine-tenofovir-disoproxil fumarate and rilpivirine- emtricitabine-tenofovir alafenamide. Caution is warranted in patients with long QT syndrome or torsades de pointes. It is important to avoid the use of rilpivirine in patients with reduced kidney function. During the administration of rilpivirine, it is necessary to monitor a patient's cholesterol levels because changes may occur (less than or equal to 48 weeks).

Drugs For HIV Saquinavir mesylate (Invirase)

adverse effects Cardiovascular adverse effects include hypertension, hypoten-sion, and chest pain. CNS adverse effects include back pain, fatigue, neuropathy, paresthesia, anxiety, depression, and sui-cidal ideation. Dermatologic adverse effects are pruritus, rash and eczema. Hematologic adverse effects are thrombocytopenia, pancytopenia, and anemia. Elevations in creatinine kinase, AST and ALT, and bilirubin have occurred Assessing for Therapeutic Effects The nurse assesses for an increase in T helper CD4 cells. The CD4 count is a measure of the ability to fight infections. Assessing for Adverse Effects The nurse assesses for ECG-related changes, specifically QT prolongation. Also, he or she also assesses for signs and symp-toms of peripheral neuropathy. In addition, the nurse assesses the mouth for signs of ulcerations related to increase gastric acid. It is important to check laboratory results. The nurse assesses the CBC and bilirubin for anemia, thrombocytopenia, and pancytopenia; serum potassium and magnesium levels; and AST or ALT for elevation. Other Drugs in the Class Atazanavir (Reyataz) is a PI that is administered to treatment-naïve and treatment-experienced patients, often with ritonavir. It is necessary to take the drug with food. Monitoring of the patient's cholesterol level for increase of greater than 240 mg/ dL is important. Contraindications to atazanavir include hyper-sensitivity to the drug—because of the risk of Stevens-Johnson syndrome. Darunavir (Prezista) is very similar to atazanavir. Fosamprenavir (Lexiva) is an oral PI administered with or without ritonavir. It is 63% absorbed and hydrolyzed to ampre-navir by the stomach enzymes, reaching a peak of action in 2.5 hours. It is metabolized in the liver by CYP3A4 and eliminated in the urine and feces. Fosamprenavir has similar adverse effects as other drugs in the class. Indinavir (Crixivan) is an oral PI administered with rito-navir. The medication binds to the site of HIV-1 protease activ-ity to inhibit the functional proteins of infectious HIV, resulting in noninfectious viral particles. Patients should take it without food and they should drink 48 ounces of fluids per day. Lopinavir/ritonavir (Kaletra) is an oral PI administered in treatment-naïve and treatment-experienced patients. It is impor-tant to monitor patients who take lopinavir/ritonavir for signifi-cant adverse effects, including hypertriglyceridemia, myocardial infarction, and GI toxicity. Lopinavir, in this combination, may be part of a multidrug antiretroviral regimen. Patients should take it with food. Monitoring for signs and symptoms of pancre-atitis, onset of diabetes, and triglyceride elevation is necessary. The nurse should instruct the patient about blood glucose test-ing and keeping regularly scheduled laboratory appointments to check amylase, triglycerides, inorganic phosphorus, thyroid function, and CBC. Nelfinavir mesylate (Viracept) is an oral PI that patients should take with food to enhance absorption. It is distributed with 98% of the drug being protein bound. The nurse instructs the patient to take nelfinavir exactly as prescribed and not to alter the dose. The patient should report the onset of diarrhea. If necessary, the patient may mix the oral powder preparation of the drug with dietary supplements, regular or soy milk, or water but not with acidic liquids. Ritonavir (Norvir) is an oral PI administered alone or in combination with other antiretroviral agents. Authorities do not recommend it as a primary PI. The medication is contraindi-cated with saquinavir in patients who have cardiac conduction insufficiency disorders. It is necessary to assess for GI distress, peripheral neuropathy, palpitations, syncope, tachycardia, and a prolonged QT interval. Tipranavir (Aptivus) is a PI for treatment-experienced patients or patients with HIV-1 strains that are resistant to mul-tiple PIs. Caution is warranted when administering it to patients receiving sulfonamides. It is necessary to monitor blood glucose to check for loss of glycemic control. The nurse instructs the patient to apply sunscreen because of possible photosensitivity reactions.

Corticosteroid Meds: Prototype prednisone

use in Children Corticosteroids are used for the same conditions in children as in adults; a common indication is for treatment of asthma. With severe asthma, continual corticosteroid therapy may be required. For children with asthma, evidence indicates that with inhaled corticosteroids, starting with a moderate dose of the drug is comparable with starting with a high dose and titrating down. A concern with children is growth retardation, which can occur short term with small doses and administration by inhalation. Many children have a growth spurt when the corticosteroid is discontinued. Adult stature does not appear to be affected by inhaled corticosteroid therapy during childhood. Parents and prescribers can monitor drug effects by record-ing height and weight weekly. ADT is less likely to impair normal growth and development than daily administration. In addition, for both systemic and inhaled corticosteroids, each child's dose should be titrated to the lowest effective amount.

Drugs For HIV Saquinavir mesylate (Invirase)

prOtease inHiBitOrs The PIs are antiretroviral drugs that exert their effects against HIV at a different phase of its life cycle than reverse transcrip-tase inhibitors. They inhibit the HIV enzyme protease, which is required to process viral protein precursors into mature par-ticles capable of infecting other cells. Thus, they are active in both acutely and chronically infected cells. Compared with the NNRTIs and the integrase inhibitors, the PIs have a high genetic barrier to resistance. Saquinavir mesylate (Invirase) is the prototype PI. Note that other PIs have replaced saquinavir as the PI of choice because of increasing resistance and adverse effects. If saquinavir is administered, electrocardiogram (ECG) monitoring for long QT syndrome is necessary. Reportedly, diminished resistance results with lopinavir/ritonavir (Kaletra), atazanavir/ritonavir, and darunavir/ritonavir (Fletcher, 2016). The PIs are most commonly administered in combination with the nucleosides. In addition ritonavir is a PI and cobicistat is a cytochrome P-450 inhibitor. Each of these medications are administered in combination with other antiretroviral agents to boost antiretroviral activity. These agents are described as boosting agents. Pharmacokinetic boosting improves the plasma trough concentrations and increases the drug's half-life and maximum concentration.

Corticosteroid

steroid hormone produced by the adrenal cortex; examples include androgens, glucocorticoids, and mineralocorticoids

Drugs For HIV: Nucleoside Reverse Transcriptase Inhibitors zidovudine (AZT, Retrovir)

the prototype, is able to substitute for thymidine. The drugs are more active in slowing the progression of acute infection rather than in treating chroni-cally infected cells. Thus, they do not cure HIV infection or pre-vent transmission of the virus through sexual contact or blood contamination.

Corticosteroid Meds: Prototype prednisone

use Corticosteroids are administered to control symptoms but do not cure underlying disease processes. They are extensively used to treat many different disorders. Except for replace-ment therapy in deficiency states, the use of corticosteroids is largely empiric. Because the drugs affect virtually every aspect of inflammatory and immune responses, they are used in the treatment of a broad spectrum of diseases with an inflammatory or immunologic component.

Drugs For HIV Integrase Strand Transfer Inhibitors

use Raltegravir is a first-line antiviral agent that is administered with tenofovir and emtricitabine to treatment-experienced adults. These patients must have evidence of viral replication and HIV-1 strains resistant to multiple antiretroviral drugs. Table 23.10 supplies information about the route of administra-tion and dosage for raltegravir. adverse effects and contraindications Few adverse effects occur with raltegravir. The most common include headache, dizziness, nausea, diarrhea, vomiting, abdom-inal pain, fever, and rhabdomyolysis. Sometimes serum glucose level, hepatic enzymes, and lipase level increase. However, in a double-blind study of treatment-naïve patients over 192 weeks of follow-up, researchers found that patients showed excellent tolerance and lack of effect on lipids (Bartlett, 2016). Contraindications include a known hypersensitivity to the medication. The drug is not suitable for treatment-naïve patients and breast-feeding women. Assessing Therapeutic and Adverse Effects The nurse assesses for an increase in T helper CD4 cells. The CD4 count measures the ability to fight against infections. In addition, the nurse assesses for GI upset, headache, diz-ziness, fever, and rhabdomyolysis. It is necessary to monitor blood sugar, liver enzymes, and lipase levels for increases.