Immune Disorders

CD4 T-cell count

(HIV) above 500 is asymptomatic - once below 200 and opportunistic infection together is diagnostic of aids

Eosinophils

0-5% total white blood cell count 0.0004% total immunoglobulin In WBC differential, if 5-15% allergic response but non specific (Seasonal allergeries), 15-40% is a true allergic disorder

IgM

10% of total immunoglobulin level

IgA

15% of total, gi gu disorders

Food Allergy Assessment and Diagnostic Findings

A careful diagnostic workup is required in any patient with suspected food hypersensitivity. Included are a detailed allergy history, a physical examination, and pertinent diagnostic tests. Skin testing is used to identify the source of symptoms and assists in identifying specific foods as causative agents.

Gout Medical Management

A definitive diagnosis of gouty arthritis is established by polarized light microscopy of the synovial fluid of the involved joint. Uric acid crystals are seen within the polymorphonuclear leukocytes in the fluid. Acute attacks are managed with colchicine (Colcrys) (oral or parenteral), an NSAID such as indomethacin (Indocin), or a corticosteroid Management of hyperuricemia, tophi, joint destruction, and renal disorders is usually initiated after the acute inflammatory process has subsided. Once the acute attack has subsided, uric acid lowering therapy should be considered. Xanthine oxidase inhibitors, such as allopurinol (Zyloprim) and febuxostat (Uloric), are the agents of choice Management between gout attacks needs to include lifestyle changes such as avoiding purine-rich foods, weight loss, decreasing alcohol consumption, and avoiding certain medications. Uricosuric agents, such as probenecid (Benemid) or sulfinpyrazone (Anturane), may be indicated in patients with frequent acute attacks.

Emergency Management for Anaphylaxis

AIRWAY management , O2, & /or CR Call 911 or notify HCP Prepare to administer: Epinephrine Antihistamines: Diphenhydramine Corticosteroids: Prednisone, methylprednisolone If Hx asthma or COPD, may need --Bronchodilator: Albuterol sulfate Vasopressors as needed: Dopamine IVF as needed H2 Blockers as needed: Cimetidine, Fomatidine, Ranitidine Document event, actions taken, patient response

Systemic Lupus Erythematosus Medical Management

Acute disease requires interventions directed at controlling increased disease activity or exacerbations that can involve any organ system. Disease activity is a composite of clinical and laboratory features that reflect active inflammation secondary to SLE. Management of the more chronic condition involves periodic monitoring and recognition of meaningful clinical changes requiring adjustments in therapy. The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complications from therapy. NSAIDs, corticosteroids, antimalarial agents, and cytotoxic agents.

Allergic Rhinitis Immunotherapy

Allergen desensitization (allergen immunotherapy, hyposensitization) is primarily used to treat IgE-mediated diseases by injections of allergen extracts. Immunotherapy, also referred to as allergy vaccine therapy, involves the administration of gradually increasing quantities of specific allergens to the patient until a dose is reached that is effective in reducing disease severity from natural exposure (Fitzhugh & Lockey, 2011; Goroll & Mulley, 2009; Grateau & Duruöz, 2010). This type of therapy provides an adjunct to symptomatic pharmacologic therapy and can be used when avoidance of allergens is not possible. Specific immunotherapy has been used in the treatment of allergic disorders for many years. Goals of immunotherapy include reducing the level of circulating IgE, increasing the level of blocking antibody IgG, and reducing mediator cell sensitivity. Immunotherapy has been most effective for ragweed pollen; however, treatment for grass, tree pollen, cat dander, and house dust mite allergens has also been effective. Indications and contraindications for immunotherapy are presented in Correlation of a positive skin test with a positive allergy history is an indication for immunotherapy if the allergen cannot be avoided. The benefit of immunotherapy has been fairly well established in instances of allergic rhinitis and bronchial asthma that are clearly due to sensitivity to one of the common pollens, molds, or household dust. Unlike antiallergy medication, allergen immunotherapy has the potential to alter the allergic disease course after 3 to 5 years of therapy. Because it may prevent progression or development of asthma or multiple or additional allergies, it is also considered to be a potential preventive measure (Fitzhugh & Lockey, 2011; Goroll & Mulley, 2009). The patient must understand what to expect and the importance of continuing therapy for several years before immunotherapy is accomplished. When skin tests are performed, the results are correlated with symptoms; treatment is based on the patient's needs rather than on the results of skin tests. TABLE 38-3 Leukotriene Modifiers The most common method of treatment is the serial injection of one or more antigens that are selected in each particular case on the basis of skin testing. This method provides a simple and efficient technique for identifying IgE antibodies to specific antigens. Specific treatment consists of injecting extracts of the allergens that cause symptoms in a particular patient. Injections begin with very small amounts and are gradually increased, usually at weekly intervals, until a maximum tolerated dose is attained. Maintenance booster injections are administered at 2- to 4-week intervals, frequently for a period of several years, before maximum benefit is achieved, although some patients will note early improvement in their symptoms. Long-term benefit seems to be related to the cumulative dose of vaccine given over time (Fitzhugh & Lockey, 2011). Immunotherapy should not be initiated during pregnancy; for patients who have been receiving immunotherapy before pregnancy, the dosage should not be increased during pregnancy. Although severe systemic reactions are rare, the risk of systemic and potentially fatal anaphylaxis exists. It tends to occur most frequently at the induction or "up-dosing" phase. Therefore, the patient must be monitored after administration of immunotherapy. Because of the risk of anaphylaxis, injections should not be administered by a lay person or by the patient. The patient must remain in the office or clinic for at least 30 minutes after the injection and is observed for possible systemic symptoms. If a large, local swelling develops at the injection site, the next dose should not be increased, because this may be a warning sign of a possible systemic reaction.

Eosinophil Count

An actual count of eosinophils can be obtained from blood samples or smears of secretions (Fischbach & Dunning, 2009). During symptomatic episodes, smears obtained from nasal secretions, conjunctival secretions, and sputum of patients with allergies usually reveal eosinophils, indicating an active allergic response.

Allergic Rhinitis Pharmacologic Therapy

Antihistamines most effective when given at the first occurrence of symptoms, because they prevent the development of new symptoms. The effectiveness of these medications is limited to certain patients with hay fever, vasomotor rhinitis, urticaria (hives), and mild asthma. Adrenergic Agents nasal spray and oral drops and sprays should be limited to a few days to avoid rebound congestion mast cell stabilizers Intranasal cromolyn sodium (NasalCrom) is a spray that acts by stabilizing the mast cell membrane, thus reducing the release of histamine and other mediators of the allergic response. it is used prophylactically (before exposure to allergens) to prevent the onset of symptoms and to treat symptoms once they occur. Corticosteroids Intranasal corticosteroids are indicated in more severe cases of allergic and perennial rhinitis that cannot be controlled by more conventional medications such as decongestants, antihistamines, and intranasal cromolyn. Leukotriene Modifiers block the synthesis or action of leukotrienes and prevent the signs and symptoms associated with asthma (Table 38-3). Leukotriene modifiers are for long-term use, and patients should be advised to take their medication daily.

Allergic Rhinitis Medical Management

Avoidance Therapy Pharmacologic Therapy Immunotherapy

Allergic Rhinitis: Management

Avoidance therapy Pharmacologic therapy Antihistamines Adrenergic agents Mast cell stabilizers Corticosteroids Immunotherapy (allergy desensitization) Avoidance Seasonal - don't open windows, keep air conditioner on, replace air filters frequently, change clothes immediately when you get home. Mattress cover and pillow cover, get rid of stuff animals or wash them once a week, wash area rugs frequently, hard wood floor is easier to allergens off of.

Allergic Rhinitis Assessment and Diagnostic Findings

Diagnosis of seasonal allergic rhinitis is based on history, physical examination, and diagnostic test results. Diagnostic tests include nasal smears, peripheral blood counts, total serum IgE, epicutaneous and intradermal testing, RAST, food elimination and challenge, and nasal provocation tests. Results indicative of allergy as the cause of rhinitis include increased IgE and eosinophil levels and positive reactions on allergen testing. False-positive and falsenegative responses to these tests, particularly skin testing and provocation tests, may occur

Assessment of the Immune System: Physical Assessment

During the physical examination (see Chart 35-3), the skin and mucous membranes are assessed for lesions, dermatitis, purpura (subcutaneous bleeding), urticaria, inflammation, or any discharge. Any signs of infection are noted. The patient's temperature is recorded, and the patient is observed for chills and sweating. The anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement; if palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Joints are assessed for tenderness, swelling, increased warmth, and limited range of motion. The patient's respiratory, cardiovascular, genitourinary, gastrointestinal, and neurosensory systems are evaluated for signs and symptoms indicative of immune dysfunction. Any functional limitations or disabilities the patient may have are also assessed.

Type II

Fast onset (minutes - hours) Cytotoxic reaction-antigen attach to cell- IgG, IgM, Macrophages attack antigen and self-cells; destroy (lyse) them Ex: medication reactions, blood transfusion reactions

Assessment of the Immune System: History history

Immunization status Allergies Autoimmune disorders Personal history and family history of cancer Chronic illness and surgery Blood transfusions Nutrition

Rheumatoid Arthritis Nursing Management

Nursing care of the patient with RA follows the basic plan of care presented earlier (see Chart 39-2). The most common issues for the patient with RA include pain, sleep disturbance, fatigue, altered mood, and limited mobility (Chamberlain, 2011). The patient with newly diagnosed RA needs information about the disease to make daily self-management decisions and cope with having a chronic disease. Medications used for treating RA may cause serious and adverse effects. The primary provider bases the prescribed medication regimen on clinical findings and past medical history, and then, with the help of the nurse, monitors for side effects using periodic clinical assessments and laboratory testing. The nurse, who can be available for consultation between physician visits, works to help the patient recognize and deal with these side effects (see Table 39-3). Medication may need to be stopped or the dose reduced. If the patient experiences an increase in symptoms while the complication is being resolved or a new medication is being initiated, the nurse's counseling regarding symptom management may relieve potential anxiety and distress

Scleroderma Nursing Management

Nursing care of the patient with scleroderma is based on the fundamental plan of nursing care presented earlier (see Chart 39-2). The most common nursing diagnoses are impaired skin integrity; self-care deficits; imbalanced nutrition: less than body requirements; and disturbed body image. The patient with advanced disease may also have impaired gas exchange, decreased cardiac output, impaired swallowing, and constipation. Providing meticulous skin care and preventing the effects of Raynaud's phenomenon are major nursing challenges. Patient education must include the importance of avoiding cold temperatures and protecting the fingers with mittens in cold weather and when shopping in the frozen food section of the grocery store. Warm socks and properly fitting shoes are helpful in preventing ulcers. Careful, frequent inspection for early ulcers is important. Smoking cessation is critical.

Type III

Onset hours-days Immune Complex -(Neutrophils, IgG, IgM)-deposited in small blood vessels, skin, joints, and kidneys Vascular permeability, inflammation, fever, joint pain, rash, lymphadenopathy, hypotension, shock Ex: SLE, serum sickness, RA Igm elevation

Allergic Rhinitis Pathophysiology

Sensitization begins by ingestion or inhalation of an antigen. On re-exposure, the nasal mucosa reacts by the slowing of ciliary action, edema formation, and leukocyte (primarily eosinophil) infiltration. Histamine is the major mediator of allergic reactions in the nasal mucosa. Tissue edema results from vasodilation and increased capillary permeability.

Contact Dermatitis Clinical Manifestations

Symptoms include itching, burning, erythema, skin lesions (vesicles), and edema, followed by weeping, crusting, and finally drying and peeling of the skin. In severe responses, hemorrhagic bullae may develop. Repeated reactions may be accompanied by thickening of the skin and pigmentary changes. Secondary invasion by bacteria may develop in skin that is abraded by rubbing or scratching. Usually, there are no systemic symptoms unless the eruption is widespread.

Fibromyalgia Assessment and Diagnostic Findings

The American College of Rheumatology established preliminary diagnostic criteria and symptom severity indices for fibromyalgia (Wolfe, Clauw, Fitzcharles, et al., 2010). These criteria emphasize the regions of pain, rather than specific points, and take into account the fatigue, cognitive symptoms, and unrefreshed sleep that patients with fibromyalgia also tend to experience

Fibromyalgia Pathophysiology

The amplified pain experienced by patients with fibromyalgia is neurogenic in origin (Clauw, Arnold, & McCarberg, 2011). Specifically, the central nervous system's ascending and descending pathways (that regulate and moderate pain processing) function abnormally, causing central amplification of pain signals (Clauw et al., 2011). Some scientists describe this as if the "volume control setting" for pain were abnormally high (Clauw et al., 2011). Therefore, stimulation that may not normally elicit pain, such as touch, may do so. In addition, there are a number of predisposing factors to pain, including anxiety, depression, physical trauma, emotional stress, and viral infection

Contact Dermatitis Assessment and Diagnostic Findings

The location of the skin eruption and the history of exposure aid in determining the condition. However, in cases of obscure irritants or an unobservant patient, the diagnosis can be extremely difficult, often involving many trial-anderror procedures before the cause is determined. Patch tests on the skin with suspected offending agents may clarify the diagnosis. The patch test most commonly used is the Thinlayer Rapid Use Epicutaneous (T.R.U.E.) test

Assessment of the Immune System: Health history : Infection and Immunization

The patient is asked about childhood and adult immunizations, including vaccinations to provide protection against influenza, pneumococcal disease (Pneumovax), pertussis, herpes simplex, and the usual childhood diseases (e.g., measles, mumps). Herpes simplex virus infections have a significant impact on health, causing a wide range of diseases (e.g., oral and genital herpes). Education about the importance of adhering to the recommended schedule for these vaccines should be initiated. Known past or present exposure to tuberculosis is assessed, and the dates and results of any tuberculin tests (purified protein derivative [PPD] test) and chest x-rays are documented. Recent exposure to any infections and the exposure dates are elicited. The nurse must assess whether the patient has been exposed to any sexually transmitted infections (STIs) or bloodborne pathogens such as hepatitis B, C, and D viruses and human immunodeficiency virus (HIV). A history of STIs such as gonorrhea, syphilis, human papillomavirus infection, and chlamydia can alert the nurse that the patient may have been exposed to HIV or hepatitis. A history of past and present infections and the dates and types of treatments, along with a history of any multiple persistent infections, fevers of unknown origin, lesions or sores, or any type of drainage, as well as the response to treatment, are obtained.

Assessment of the Immune System: Health history : Nutrition

The relationship of infection to nutritional status is a key determinant of health. Traditionally, this relationship focused on the effect of nutrients on host defenses and the effect of infection on nutritional needs. This has expanded in scope to encompass the role of specific nutrients in acquired immune function—the modulation of inflammatory processes and the virulence of the infectious agent itself. Iron and the immune system are linked in homeostasis and pathology, thus making it essential for maximum function (Ward, Crichton, Taylor, et al., 2011). The list of nutrients affecting infection, immunity, inflammation, and cell injury has expanded from traditional proteins to several vitamins, multiple minerals, and, more recently, specific lipid components of the diet (Takagi, Matsui, Ohno, et al., 2009). Vitamin D deficiency has been associated with increased risk of common cancers, autoimmune diseases, and inflammatory disorders (DiRosa, Malaguarnera, Nicoletti, et al., 2011). The role of micronutrients and fatty acids on the response of cells and tissues to hypoxic and toxic damage has been recognized, suggesting that there is another dimension to the relationship. Micronutrients such as zinc may have widespread negative effects on the immune response, which can be reversed by supplementation (Mocchegiani, Malavolta, Costarelli, et al., 2010). The effects exerted by polyunsaturated fatty acids on immune system functions are under investigation. Studies suggest that these elements play a role in diminishing the incidence and severity of inflammatory disorders. Recent studies suggest that diets high in olive oil are not as immunosuppressive as diets rich in fish oil. The contribution of immune modulation by lipids to the high risk of infectious complications associated with the use of parenteral nutrition is unclear; however, a recent meta-analysis revealed that the use of glutamine-supplemented parenteral nutrition decreased the incidence of infections postoperatively (Wang, Jiang, Nolan, et al., 2010). Depletion of protein reserves results in atrophy of lymphoid tissues, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function. As a result, susceptibility to infection is greatly increased. During periods of infection or serious illness, nutritional requirements may be further altered, potentially contributing to depletion of protein, fatty acid, vitamin, and trace elements and causing even greater risk of impaired immune response and sepsis. Nutritional intake that supports a competent immune response plays an important role in reducing the incidence of infections; patients whose nutritional status is compromised have a delayed postoperative recovery and often experience more severe infections and delayed wound healing. The nurse must assess the patient's nutritional status, caloric intake, and quality of foods ingested. There is evidence that nutrition plays a role in the development of cancer and that diet and lifestyle can alter the risk of cancer development as well as other chronic diseases (Strasser, Van, & Jatoi, 2011). The nurse must assume a proactive role in ensuring the best possible nutritional intake for all patients as a vital step in preventing disease and poor outcomes

Fibromyalgia Medical Management

Treatment consists of attention to the specific symptoms reported by the patient. NSAIDs may be used to treat the diffuse muscle aching and stiffness. Tricyclic antidepressants and sleep hygiene measures are used to improve or restore normal sleep patterns (Roizenblatt, Neto, & Tufik, 2011). Cognitive behavioral therapy is also useful in improving sleep and attentional dysfunction (Miró Lupiáñez, Martíez, et al., 2011). In addition, selective serotonin reuptake inhibitors and anticonvulsants have been effective in preliminary reports (Ryan, 2011). Individualized programs of exercise are used to decrease muscle weakness and discomfort and to improve the general deconditioning that occurs in affected patients (Busch, Webber, Brachaniec, et al., 2011). There has also been some promising research in CAM therapies, such as acupuncture, massage, homeopathy, hydrotherapy, craniosacral therapy, and myofascial therapy

Anaphylaxis

Type 1 Hypersensitivity reaction S/S: (Progress rapidly) Nasal congestion/sneezing Pruritus watery eyes Anxiety bronchospasm, laryngeal edema, severe dyspnea, cyanosis hypotension Prevention Strict avoidance of allergens Carry an emergency kit that contains epinephrine Management depends on the severity (antihistamines, epinephrine) Air way swell and close off Nausea vomiting - digestive tract gets inflamed Hives

Allergic Rhinitis

Type I hypersensitivity S/S: Sneezing, congestion Clear, watery nasal discharge Itchy eyes and nose Lacrimation Allergic shiners Pale-blue, boggy nasal turbinate's Includes seasonal allergies and hay fever. If it is not treated, some of the passage ways can get closed off and then the left over mucous starts to breed bacteria. Clear watery drainage. No fever Could start to run a fever if bacteria build up Turbulance blueish?

Cytotoxic (Type II) Hypersensitivity

Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. This reaction may be the result of a cross-reacting antibody, possibly leading to cell and tissue damage. Type II hypersensitivity reactions are associated with several disorders. For example, in myasthenia gravis, the body mistakenly generates antibodies against normal nerve ending receptors. In Goodpasture syndrome, it generates antibodies against lung and renal tissue, producing lung damage and renal failure.

Delayed-Type (Type IV) Hypersensitivity

Type IV, or delayed-type, hypersensitivity, also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen. It is mediated by sensitized T cells that cause cell and tissue damage (Port & Matfin, 2009). Symptoms include itching, erythema, and raised lesions.

Allergic Rhinitis Clinical Manifestations

Typical signs and symptoms of allergic rhinitis include sneezing and nasal congestion; clear, watery nasal discharge; and nasal itching. Itching of the throat and soft palate is common. Drainage of nasal mucus into the pharynx results in multiple attempts to clear the throat and results in a dry cough or hoarseness. Headache, pain over the paranasal sinuses, and epistaxis can accompany allergic rhinitis. The symptoms of this chronic condition depend on environmental exposure and intrinsic host responsiveness. Allergic rhinitis can affect quality of life by also producing fatigue, loss of sleep, and poor concentration

Fibromyalgia

Typically, patients with fibromyalgia have endured their symptoms for a long period of time. They may feel as if their symptoms have not been taken seriously. Nurses need to pay special attention to supporting these patients and providing encouragement as they begin their program of therapy. Patient support groups may be helpful. Careful listening to patients' descriptions of their concerns and symptoms is essential to help them make the changes that are necessary to improve their quality of life

CBC differentional

WBC, ANC, and immunogoblins, esinophils.

IgE

eosinophils - 0.0007% - allergic reaction

Uric acid

gout, less than 6.8 is normal

Rheumatoid Arthritis

is an autoimmune disease of unknown origin that affects 1% of the population worldwide, with a female-to-male ratio between 2:1 and 4:1, suggesting that there may be a link between RA and sex hormones

IgG

want it to be at 75% of total immunoglobulins is normal. Will be elevated if blood or tissue infection

Anaphylaxis Nursing Management

If a patient is experiencing an allergic response, the nurse's initial action is to assess the patient for signs and symptoms of anaphylaxis. The nurse assesses the airway, breathing pattern, and vital signs. The patient is observed for signs of increasing edema and respiratory distress. Prompt notification of the rapid response team and/or the provider is required. Rapid initiation of emergency measures ( intubation, administration of emergency medications, insertion of intravenous lines, fluid administration, and oxygen administration) are important to reduce the severity of the reaction and to restore cardiovascular function. The nurse documents the interventions used and the patient's vital signs and response to treatment. The patient who has recovered from anaphylaxis needs an explanation of what occurred, instruction about avoiding future exposure to antigens, and how to administer emergency medications to treat anaphylaxis. The patient must be instructed about antigens that should be avoided and about other strategies to prevent recurrence of anaphylaxis. All patients who have experienced an anaphylactic reaction should receive a prescription for preloaded syringes of epinephrine. The nurse instructs the patient and family in their use and has the patient and family demonstrate correct administration

Rheumatoid factors

says that there is a rheumatic disorder ANA and DNA more specific (anti-nuclear antibody) ANA - closely linked with RA Anti double stranded DNA antibody- SLE that on top of symptoms can help diagnose lupus

Osteoarthritis

Chronic non-inflammatory, degenerative disorder S/S: Stiffness Pain Dx: X-ray Arthroscopy Non-pharmacologic treatment Medications Joint pain is on one side Asymmetrical because of wear and tear RICE

Scleroderma

S/S C: Calcinosis R: Raynaud's phenomenon E: esophageal dysfunction S: Sclerodactyly T: Telangiectasia Management depends on the patient's clinical manifestations Prevent joint contractures Meticulous skin care Prevent Raynaud's Inspect for ulcers Smoking cessation Inflammation and calcification of connective tissue Starts off looking like raynauds, with same symptoms but after awhile calcification. To verify pulse ox - run a abg

Fibromyalgia

S/S Chronic pain, Diffuse musculoskeletal achiness, Morning stiffness Fatigue Chronic HA Mood disturbances Treatment NSAIDs Pegabalin Antidepressants Nursing care Exercise Cognitive therapy Medication regimen Overactive nerve endings that cause a lot of pain Diagnosis is difficult, have to rule out lots of things first. Life style modifications - likely to get depressed because of chronic pain, become isolated - antidepressants - Promote exercise, nothing intense, low impact exercise

Anaphylaxis Prevention

Strict avoidance of potential allergens Those at risk for anaphylaxis from insect stings should avoid areas populated by insects and should use appropriate clothing, insect repellent, and caution to avoid further stings. an auto-injector system for epinephrine will be prescribed. The patient should be instructed to carry and administer epinephrine to prevent an anaphylactic reaction in the event of exposure to the allergen. Screening for allergies before a medication is prescribed or first administered is an important preventive measure. Immunotherapy administered after an insect sting is very effective in reducing the risk of anaphylaxis from future stings

Assessment of the Immune System: Nursing Management

The nurse needs to be aware that patients undergoing evaluation for possible immune system disorders experience not only physical pain and discomfort with certain types of diagnostic procedures but also many psychological reactions. It is the nurse's role to counsel, educate, and support patients throughout the diagnostic process. Many patients may be extremely anxious about the results of diagnostic tests and the possible implications of those results for their employment, insurance, and personal relationships. This is an ideal time for the nurse to provide counseling and education, should these interventions be warranted.

Scleroderma Pathophysiology

The pathogenesis is poorly understood. Scleroderma commonly begins with skin involvement. Mononuclear cells cluster on the skin and stimulate lymphokines to stimulate procollagen. Insoluble collagen is formed and accumulates excessively in the tissues. Initially, the inflammatory response causes edema, with a resulting taut, smooth, and shiny skin appearance. The skin then undergoes fibrotic changes, leading to loss of elasticity and movement. Eventually, the tissue degenerates and becomes nonfunctional. This chain of events, from inflammation to degeneration, also occurs in blood vessels, major organs, and body systems (Klippel et al., 2008). Both genetics and environmental factors can influence the disease process.

Assessment of the Immune System: Health history : Allergy

The patient is asked about any allergies, including types of allergens (e.g., pollens, dust, plants, cosmetics, food, medications, vaccines, latex), the symptoms experienced, and seasonal variations in occurrence or severity in the symptoms. A history of testing and treatments, including prescribed and over-the-counter medications that the patient has taken or is currently taking for these allergies and the effectiveness of the treatments, is obtained. All medication and food allergies are listed on an allergy alert sticker and placed on the front of the patient's health or medical record to alert others. Continued assessment for potential allergic reactions in the patient is vital. (See Chapter 38 for more information on allergies.)

Latex Allergy

Type IV hypersensitivity (Can turn into Type 1) Risk: Health care workers Those with atopic allergies or multiple surgeries people working in factories that manufacture latex Types of reactions pg 1045 Table 38-5 Nursing Considerations Assess for allergy Latex-free environments is a priority Be ready to treat affected people Assess for allergy If indicated, make sure that it is on chart, don't use anything with latex - foley catheter, rubber stoppers on medications, Make sure OR knows patient has the allergy

Contact Dermatitis

a type IV delayed hypersensitivity reaction, is an acute or chronic skin inflammation that results from direct skin contact with chemicals or allergens. There are four basic types: allergic, irritant, phototoxic, and photoallergic (Table 38-4). Eighty percent of cases are caused by excessive exposure to or additive effects of irritants (e.g., soaps, detergents, organic solvents). Skin sensitivity may develop after brief or prolonged periods of exposure, and the clinical picture may appear hours or weeks after the sensitized skin has been exposed.

Allergic Rhinitis

(hay fever, seasonal allergic rhinitis) is the most common form of respiratory allergy, which is presumed to be mediated by an immediate (type I hypersensitivity) immunologic reaction Symptoms are similar to those of viral rhinitis (see Chapter 22) but are usually more persistent and demonstrate seasonal variation; rhinitis is considered to be the allergic form if the symptoms are caused by an allergen-specific IgE-mediated immunologic response. However, a sizable proportion of patients with rhinitis have mixed rhinitis, or coexisting allergic and nonallergic rhinitis The proportion of patients with the allergic form of rhinitis increases with age. It often occurs with other conditions, such as allergic conjunctivitis, sinusitis, and asthma If symptoms are severe, allergic rhinitis may interfere with sleep, leisure, and school or work activities Because allergic rhinitis is induced by airborne pollens or molds, it is characterized by the following seasonal occurrences: • Early spring—tree pollen (oak, elm, poplar) • Early summer—rose pollen (rose fever), grass pollen (Timothy, Redtop) • Early fall—weed pollen (ragweed)

Western blot

100% diagnostic test for HIV

Total Serum Immunoglobulin E Levels

High total serum IgE levels support the diagnosis of allergic disease (Fischbach & Dunning, 2009). However, a normal IgE level does not exclude the diagnosis of an allergic disorder. IgE levels are not as sensitive as the paper radioimmunosorbent test (PRIST), the enzyme immunoassay (EIA), or a variant of this test known as enzyme-linked immunosorbent assay (ELISA).

Assessment of the Immune System: Health history : Medications and Blood Transfusions

A list of past and present medications is obtained. In large doses, antibiotics, corticosteroids, cytotoxic agents, salicylates, nonsteroidal anti-inflammatory drugs, and anesthetic agents can cause immune suppression (Table 35-5). A history of blood transfusions is obtained, because previous exposure to foreign antigens through transfusion may be associated with abnormal immune function. Additionally, although the risk of HIV transmission through blood transfusion is extremely low in patients who received a transfusion after 1985 (when testing of blood for HIV was initiated in the United States), a small risk remains. The patient is also asked about use of herbal agents and over-the-counter medications. Because many of these products have not been subjected to rigorous testing, their effects have not been fully identified. It is important, therefore, to ask patients about their use of these substances, to document their use, and to educate patients about untoward effects that may alter immune responsiveness.

Atopic Dermatitis

A type I immediate hypersensitivity disorder Pruritus and hyperirritability of the skin Elevated IgE in blood Nursing care Address body image Self-management Genetically Skin is broken down so allergen can get in . Vaseline, lotions, luke warm, lotion first thing in the morning, Cotton is preferred Humidifier in winter, dehumidifier in the summer. Prograph? Only on infected area, not skin Happens in skin folds first Counseling for body image issues

Osteoarthritis Pathophysiology

All joints consist of bone, particularly subchondral bone to which the articular cartilage is attached. This articular cartilage is a lubricated, smooth tissue that protects the bone from damage with physical activity. Between the articular cartilage of the bones forming the joint is a space (called the joint space) that allows for movement. To aid in fluidity, each joint contains synovial fluid to help lubricate and protect the joint's movement. With OA, the articular cartilage breaks down, leading to progressive damage to the underlying bone and eventual formation of osteophytes (bone spurs) that protrude into the joint space. The result is that the joint space is narrowed, leading to decreased joint movement and the potential for more damage. Consequently, the joint can progressively degenerate (Fig. 39-3). Understanding of OA pathophysiology has been greatly expanded beyond what was previously thought of as simply "wear and tear" related to aging (Wang, Shen, Jin, et al., 2011). The basic degenerative process in the joint exemplified in OA is presented in Figure 39-4. In addition to the degeneration, an infectious arteritis can occur. (See Chapter 42 for discussion of septic [infectious] arthritis.)

Anaphylaxis Pathophysiology

Anaphylaxis is caused by the interaction of a foreign antigen with specific IgE antibodies found on the surface membrane of mast cells and peripheral blood basophils. The subsequent release of histamine and other bioactive mediators causes activation of platelets, eosinophils, and neutrophils. Histamine, prostaglandins, and inflammatory leukotrienes are potent vasoactive mediators that are implicated in the vascular permeability changes, flushing, urticaria, angioedema, hypotension, and bronchoconstriction that characterize anaphylaxis. Smooth muscle spasm, bronchospasm, mucosal edema and inflammation, and increased capillary permeability result. These systemic changes characteristically produce clinical manifestations within seconds or minutes after antigen exposure (Arnold & Williams, 2011; Solensky, 2011). Closely related to anaphylaxis is a nonallergenic anaphylaxis (anaphylactoid) reaction, which is described in Chart 38-2. Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex (Chart 38-3). Antibiotics and radiocontrast agents cause the most serious anaphylactic reactions, producing reactions in about 1 of every 5,000 exposures. Penicillin is the most common cause of anaphylaxis and accounts for about 75% of fatal anaphylactic reactions in the United States each year. The actual prevalence of penicillin allergy in the general population is unknown; however, the incidence of self-reported penicillin allergy ranges from 1% to 10%. It has been reported that 80% to 90% of those patients with self-reported penicillin allergy have no evidence of IgE antibodies to penicillin on skin testing (Adkinson et al., 2009; Solensky, 2011). The diagnosis of risk of anaphylaxis is determined by prick and intradermal skin testing. Skin testing of patients who have clinical symptoms consistent with a type I, IgE-mediated reaction has been recommended

Scleroderma Assessment and Diagnostic Finding

Assessment focuses on the sclerotic changes in the skin, contractures in the fingers, and color changes or lesions in the fingertips. Assessment of systemic involvement requires a systems review with special attention to gastrointestinal, pulmonary, renal, and cardiac symptoms (Haustein, 2011). Limitations in mobility and self-care activities should be assessed, along with the impact the disease has had (or will have) on body image. There is no one conclusive diagnostic test used to diagnose scleroderma. High-resolution CT is used to diagnose the presence of pulmonary hypertension (Pandey, Wilcox, Mayo, et al., 2010). Echocardiography identifies pericardial effusion (often present with cardiac involvement). Echocardiograms show some promise as well in detecting vascular changes in the early stages of the disease process (CusmàPiccione, Bagnato, Zito, et al., 2011). Esophageal studies demonstrate decreased motility in most patients with scleroderma. Blood tests may detect ANAs, indicating a connective tissue disorder and possibly distinguishing the subgroup (diffuse or limited) of scleroderma. A positive ANA test result is common in patients with scleroderma

Nursing Management: The Patient With a Rheumatic Disorder

Assessment: current and past symptoms, such as fatigue, weakness, pain, stiffness, fever, or anorexia, and the effects of these symptoms on the patient's lifestyle and self-image Interventions may relate to: Relief of pain Relief of fatigue and promotion of sleep Promotion of nutrition Increased mobility Skin care becomes a really big factor Pain - affect sleep and quality of life - control it with nsaids - don't want to get more powerful if they don't have to Sleep hygiene Keep them on a schedule Promote sleep by consistant temperature Nsaids 30 mins before sleep Pad any bony prominences if discomfort Stay away from tv screens and bright lights like cell phones an hour before bed.

Assessment of the Immune System: Health history : Autoimmune Disorders

Autoimmune disorders affect people of both genders of all ages, ethnicities, and social classes. Autoimmune disorders are a group of disorders that can affect almost any cell or tissue in the body (Porth & Matfin, 2009). As mentioned previously, they tend to be more common in women because estrogen tends to enhance immunity. Androgen, on the other hand, tends to be immunosuppressive. Autoimmune diseases are a leading cause of death by disease in females of reproductive age. The patient is asked about any autoimmune disorders, such as lupus erythematosus, rheumatoid arthritis, multiple sclerosis, or psoriasis. The onset, severity, remissions and exacerbations, functional limitations, treatments that the patient has received or is currently receiving, and effectiveness of the treatments are described. The occurrence of different autoimmune diseases within a family strongly suggests a genetic predisposition to more than one autoimmune disease

Atopic Dermatitis Treatment

Avoidance therapy Topical corticosteroids Immunosuppressive agents Antibiotics if infected Skin care Antihistamines

Osteoarthritis Assessment and Diagnostic Findings

Blood tests and examination of joint fluid are not useful in the diagnosis of OA but are occasionally ordered to rule out an autoimmune cause for the joint pain, such as RA. X-rays may show a narrowing of the joint space; osteophyte formation; and dense, thickened subchondral bone

Common Triggers of Hypersensitivity Reactions

Environment (dust, pollen, etc) Food Latex Medications Stings Bites People who come into contact with latex a lot can develop latex. Peanuts, eggs, wheat, milk, soy - most common Penicillin, a lot of people note morphine but you gotta ask what happens cause it can just be itchy. Bee stings, wasps, spider bites

Interpretation of Skin Test Results

Familiarity with and consistent use of a grading system are essential. The grading system used should be identified on a skin test record for later interpretation. A positive reaction, evidenced by the appearance of an urticarial wheal (round, reddened skin elevation) (Fig. 38-4), localized erythema ( diffuse redness) in the area of inoculation or contact, or pseudopodia (irregular projection at the end of a wheal) with associated erythema is considered indicative of sensitivity to the corresponding antigen. False-positive results may occur because of improper preparation or administration of allergen solutions. Interpretation of positive or negative skin tests must be based on the history, physical examination, and other laboratory test results. The following guidelines are used for the interpretation of skin test results: • Skin tests are more reliable for diagnosing atopic sensitivity in patients with allergic rhinoconjunctivitis than in patients with asthma (Bachert, Claeys, Tomassen, et al., 2010). • Positive skin tests correlate highly with food allergy. • The use of skin tests to diagnose immediate hypersensitivity to medications is limited, because metabolites of medications, not the medications themselves, are usually responsible for causing hypersensitivity.

Rheumatoid Arthritis Medical Management Advanced, Unremitting Rheumatoid Arthritis

For advanced, unremitting RA, immunosuppressive agents are prescribed because of their ability to affect the production of antibodies at the cellular level. These include high-dose methotrexate, cyclophosphamide (Cytoxan), and azathioprine (Imuran). However, these medications are highly toxic and can produce bone marrow suppression, anemia, gastrointestinal disturbances, severe birth defects, and rashes (Karch, 2012). The U.S. Food and Drug Administration (FDA) has approved a medical device for use in treating patients with more severe and long-standing RA who have had no response to or are intolerant of DMARDs. The device, a protein A immunoadsorption column (Prosorba), is used in 12 weekly, 2-hour apheresis treatments to bind immunoglobulin G (IgG) (i.e., circulating immune complex). This treatment offers a limited duration of relief, has many side effects, and is therefore limited to the treatment of patients with severe RA (American College of Rheumatology Subcommittee, 2002). For most patients with RA, the emotional and possible financial burden of the disease can lead to depressive symptoms and sleep deprivation (Chamberlain, 2011; Vriezekolk et al., 2010). The patient may require the short-term use of low-dose antidepressant medications, such as amitriptyline (Elavil), paroxetine (Paxil), or sertraline (Zoloft), to reestablish an adequate sleep pattern and manage depressive symptoms. Patients may benefit from referrals for talk therapy or group support.

Rheumatoid Arthritis Medical Management Moderate, Erosive Rheumatoid Arthritis

For moderate, erosive RA, a formal program with occupational and physical therapy is prescribed to educate the patient about principles of joint protection, pacing activities, work simplification, range of motion, and muscle-strengthening exercises (Firth, 2011a). The patient is encouraged to participate actively in the management program. The medication program is reevaluated periodically, and appropriate changes are made if indicated. Cyclosporine (Neoral), an immunosuppressant, may be added to enhance the diseasemodifying effect of methotrexate (Klippel et al., 2008). Combination therapy using one nonbiologic DMARD and one biologic DMARD is common.

Rheumatoid Arthritis Medical Management Persistent, Erosive Rheumatoid Arthritis

For persistent, erosive RA, reconstructive surgery and corticosteroids are often used. Reconstructive surgery is indicated when pain cannot be relieved by conservative measures and the threat of loss of independence is eminent (Woo, Kim, Chung, et al., 2011). Surgical procedures include synovectomy (excision of the synovial membrane), tenorrhaphy (suturing of a tendon), arthrodesis (surgical fusion of the joint), and arthroplasty (surgical repair and replacement of the joint). Surgery is not performed during exacerbations. Systemic corticosteroids are used when the patient has unremitting inflammation and pain or needs a "bridging" medication while waiting for the slower DMARDs (e.g., methotrexate) to begin taking effect. Low-dose corticosteroid therapy is prescribed for the shortest time necessary to minimize side effects (McPhee et al., 2012). Single large joints that are severely inflamed and fail to respond promptly to the measures outlined previously may be treated by local injection of a corticosteroid.

Food Allergy

IgE-mediated food allergy, a type I hypersensitivity reaction, occurs in about 2% of the adult population; it is thought to occur in people who have a genetic predisposition combined with exposure to allergens early in life through the gastrointestinal or respiratory tract or nasal mucosa. More than 170 foods have been reported to cause IgE-mediated reactions (Boyce, Assa'ad, Burks, et al., 2010). Researchers have also identified a second type of food allergy—a non-IgE-mediated food allergy syndrome in which T cells play a major role. Almost any food can cause allergic symptoms. Any food can contain an allergen that results in anaphylaxis. The most common offenders are seafood (lobster, shrimp, crab, clams, fish), legumes (peanuts, peas, beans, licorice), seeds (sesame, cottonseed, caraway, mustard, flaxseed, sunflower), tree nuts, berries, egg white, buckwheat, milk, and chocolate. Peanut and tree nut (e.g., cashew, walnut) allergies are responsible for the most severe food allergy reactions (Fitzharris & Sinclair, 2011; Johnson & Daitch, 2011). Pregnant and breast-feeding women who are aware of a family history of allergy (an unborn infant's mother, father, or sibling with asthma, eczema, hay fever, or other allergy) should avoid peanuts and peanut-containing foods during pregnancy as a precaution (Boyce et al., 2010; Johnson & Daitch, 2011). One of the dangers of food allergens is that they may be hidden in other foods and not apparent to people who are susceptible to the allergen. For example, peanuts and peanut butter are often used in salad dressings and Asian, African, and Mexican cooking and may result in severe allergic reactions, including anaphylaxis. Previous contamination of equipment with allergens (e.g., peanuts) during preparation of another food product (e.g., chocolate cake) is enough to produce anaphylaxis in people with severe allergy.

Type I:

Immediate onset (minutes) IgE formation-histamine and leukotriene release S/S: erythema, edema, pruritus, contraction of bronchial smooth muscle, increased mucous secretion Ex: Anaphylaxis, environmental / food allergy, allergic rhinitis, atopic dermatitis most severe Larngeal swelling, vomiting b.c hypotensive, tachy Red raised rash Elevations in igE

Food Allergy Nursing Management

In addition to participating in management of the allergic reaction, the nurse focuses on preventing future exposure of the patient to the food allergen. If a severe allergic or anaphylactic reaction to food allergens has occurred, the nurse must instruct the patient and family about strategies to prevent its recurrence (Chart 38-8). Patients' food allergies should be noted on their medical records, because there may be risk of allergic reactions not only to food but also to some medications containing similar substances

Anaphylaxis Medical Management

Initially, respiratory and cardiovascular functions are evaluated. If the patient is in cardiac arrest, cardiopulmonary resuscitation (CPR) is instituted (Neumar, Otto, Link, et al., 2010). Supplemental oxygen is provided during CPR or if the patient is cyanotic, dyspneic, or wheezing. Epinephrine, in a 1:1,000 dilution, is administered subcutaneously in the upper extremity or thigh and may be followed by a continuous intravenous infusion. Antihistamines and corticosteroids may also be administered to prevent recurrences of the reaction (Goroll & Mulley, 2009; Tracy, 2011) and to treat urticaria (Schaefer, 2011) and angioedema. Intravenous fluids (e.g., normal saline solution), volume expanders, and vasopressor agents are administered to maintain blood pressure and normal hemodynamic status Patients who have experienced anaphylactic reactions and received epinephrine should be transported to the local emergency department for observation and monitoring because of the risk for a "rebound" or delayed reaction 4 to 10 hours after the initial allergic reaction. Patients with severe reactions are monitored closely for 12 to 14 hours in a facility that can provide emergency care, if needed. Because of the potential for recurrence, patients with even mild reactions must be informed about this risk

Gout

Monosodium urate crystals deposit in joints; Tophi S/S: Acute pain, redness, swelling, warmth of affected joint Triggers: Alcohol, trauma, diet, medications, stress, illness Testing: polarized light microcopy pf synovial fluid, Serum uric Acid level Treatment Xanthine oxidase inhibitor (Allopurinol) Uricosuric agents (Probenecide) NSAIDs Colchicine Nursing care : Rest joint Apply ice Avoid aspirin, stress, ETOH, trauma, food high in purines Drink plenty of fluids Often in the big toe Build up of uric acid in the blood - turns into crystals - deposited in joints Less than 6.8 is normal Treatment Acute attack of gout - lots of joint pain, inflamed - NSAIDS, steroids Chronic gout - allopurinol Drink lots of water to help relieve Purines - any kind of organ meats, wine, beer, shellfish, 2000cc per day of water

Systemic Lupus Erythematosus Nursing Management

Nursing care of the patient with SLE is based on the fundamental plan presented earlier in the chapter (see Chart 39-2). The most common nursing diagnoses include fatigue, impaired skin integrity, body image disturbance, and deficient knowledge for self-management decisions. The disease or its treatment may produce dramatic changes in appearance and considerable distress for the patient. The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care with sensitivity to the psychological reactions of the patient. In particular, patients with SLE report feelings of depression and anxiety as well as difficulty coping with the disease and the financial strain associated with it (Beckerman, 2011). The patient may benefit from participation in support groups, which can provide disease information, daily management tips, and social support. Because sun and ultraviolet light exposure can increase disease activity or cause an exacerbation, patients should be instructed to avoid exposure or to protect themselves with sunscreen and clothing. Because of the increased risk of involvement of multiple organ systems, patients should understand the need for routine periodic screenings as well as health promotion activities. A dietary consultation may be indicated to ensure that the patient is knowledgeable about dietary recommendations, given the increased risk of cardiovascular disease, including hypertension and atherosclerosis. The nurse educates the patient about the importance of continuing prescribed medications and addresses the changes and potential side effects that are likely to occur with their use. The patient is reminded of the importance of monitoring because of the increased risk of systemic involvement, including renal and cardiovascular effects. Due to the immunosuppression associated with systemic corticosteroid usage, the nurse must watch for signs and symptoms of infection, especially with acutely ill patients. Some research suggests that initiation of antibiotic therapy longer than 24 hours after onset of infection symptoms in the patient with SLE can increase mortality (Feng, Lin, Yu, et al., 2010).

Type IV

Onset Delayed (24-72 hours after exposure) Sensitized T cells and macrophages - release lysosomes S/S: edema, erythema, pruritus, ischemia, tissue damage Ex: Latex allergy, TB test, contact dermatitis Tb test falls in under here Latex is listed here because it is a accumalaitve response, that turns into a type 1. you have to look at the timing. Poison ivy

Osteoarthritis Nursing Management

Pain management and optimal functional ability are major goals of nursing intervention. With those goals in mind, nursing management of the patient with OA includes pharmacologic and nonpharmacologic approaches as well as education. The patient's understanding of the disease process and symptom pattern is critical to the plan of care. Because patients with OA usually are older, they may have other health problems. Commonly they are overweight, and they may have a sedentary lifestyle. Weight loss and exercise are important approaches to pain and disability improvement (Walker, 2011). A referral for physical therapy or to an exercise program for people with similar problems can be very helpful. Canes or other assistive devices for ambulation should be considered, and any stigma about the use of these devices should be explored. Exercises such as walking should be begun in moderation and increased gradually. Patients should plan their daily exercise for a time when the pain is least severe or plan to use an analgesic agent, if appropriate, before exercising. Adequate pain management is important for the success of an exercise program. Open discussion regarding the use of CAM therapies is important to maintain safe and effective practices for patients looking for relief.

Atopic Dermatitis Nursing Management

Patients who experience atopic dermatitis and their families require assistance and support from the nurse to cope with the disorder. The symptoms are often disturbing to the patient and disruptive to the family. The appearance of the skin may affect the patient's self-esteem and his or her willingness to interact with others. Instructions and counseling about strategies to incorporate preventive measures and treatments into the lifestyle of the family may be helpful. The patient and family need to be aware of signs of secondary infection and of the need to seek treatment if infection occurs. The nurse also educates the patient and family about the side effects of medications used in treatment.

Rheumatoid Arthritis Medical Management Nutrition Therapy

Patients with RA frequently experience anorexia, weight loss, and anemia. A dietary history identifies usual eating habits and food preferences. Food selection should include the five major groups (grains, vegetables, fruits, dairy, and protein), with emphasis on foods high in vitamins, protein, and iron for tissue building and repair. For the patient who is extremely anorexic, small, frequent feedings with increased protein supplements may be prescribed. Supplemental vitamins and minerals may also be prescribed as needed (Klippel et al., 2008). Certain medications (i.e., oral corticosteroids) used in RA treatment stimulate the appetite and, when combined with decreased activity, may lead to weight gain. Therefore, patients may need to be counseled about eating a healthy, calorie-restricted diet.

Assessment of the Immune System: Physical assessment

Skin Signs of infection Lymph nodes Joints Neurosensory Respiratory Cardiovascular Gastrointestinal Genitourinary Respiratory - adventious breath sounds Cardiovascular - (sepsis, blood pressure drops, HTN, tacky, need fluids) Changes in bowel habits, how many times a day, color, consistency UTI - cloudy urine, hematuria.

Diagnostic Evaluation

Primary Testing: -CBC with differential -C-Reactive Protein (CRP) -Erythrocyte sedimentation rate (ESR) -Uric Acid level -CD4 T-Cell count -Viral load Other system specific tests: Allergy testing -Immunoglobulin blood tests --IgG, IgM, IgA, IgD, IgE -Skin Testing -Radioallergosorbent test ( RAST) -Food Challenge Rheumatoid factors (RFs) -Anti-Nuclear Antibody (ANA) titer -Anti-double stranded DNA antibody HIV/AIDS -Enzyme Linked-Immunosorbent Assay (ELISA) -Western Blot

Radioallergosorbent Test

RAST is a radioimmunoassay that measures allergen-specific IgE. A sample of the patient's serum is exposed to a variety of suspected allergen particle complexes. If antibodies are present, they will combine with radiolabeled allergens. Test results are then compared with control values. In addition to detecting an allergen, RAST indicates the quantity of allergen necessary to evoke an allergic reaction (Nelson & Moward, 2010; Senti, von Moos, & Kündig, 2011). The major advantages of RAST over other tests include decreased risk of systemic reaction, stability of antigens, and lack of dependence on skin reactivity modified by medications. The major disadvantages include limited allergen selection and reduced sensitivity compared with intradermal skin tests, lack of immediate results, and higher cost.

Systemic Lupus Erythematosus (SLE)

Remissions and exacerbations of S/S Fatigue Myalgias/arthralgias Photosensitivity/rash Neurologic/behavioral changes Pericarditis/pleuritis Renal disease Oral ulcers ESR, ANA, creatinine elevated CBC-anemia or thrombocytopenia Treatment - multiple medications Corticosteroids (topical and oral) NSAIDs Glucocorticoids Immuniosuppressive agents Nursing Considerations Butterfly rash across the cheeks and nose Antidouble stranded dna - elevated - lupus RA factor elevated No uv rays on the rash, super hot showers, great skin care swallow percautions.

Rheumatoid Arthritis

S/S Symmetric joint Pain, Swelling, Warmth, Erythema Loss of function Testing RF present in 70-80% patients ESR, CRP: elevated RBC decreased ANA positive Arthrocentesis shows cloudy, milky, dark yellow fluid Treatment NSAIDs, COX-2 inhibitors, disease-modifying antirheumatic drugs (DMARDs) After inflammation for a long time, it causes scar tissue and that causes deformities ' Joint pain is bilateral Feel to see if there is heat, asymmetrical, rom active and passive same or diff in those joints Worse in the morning and decreases during the day Splints help the body keep alignment and prevent deformities to some degree NSAIDS in the beginning DMARDS later Improvement in range of motion, decrease in pain, Once they get the methotrexate in they should be able to move fairly well, so if there is limitations, speak with the physician.

Scleroderma Clinical Manifestations

Scleroderma starts insidiously with Raynaud's phenomenon and swelling in the hands. Raynaud's phenomenon is observed in 90% to 98% of patients with scleroderma and can precede the official scleroderma diagnosis for years (Haustein, 2011). The skin and subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. Wrinkles and lines are obliterated. The skin is dry because sweat secretion over the involved region is suppressed. The extremities stiffen and lose mobility. The condition spreads slowly; for years, these changes may remain localized in the hands and the feet. The face appears masklike, immobile, and expressionless, and the mouth becomes rigid. The changes within the body, although not visible directly, are vastly more important than the visible changes. The left ventricle of the heart is involved, resulting in heart failure. The esophagus hardens, interfering with swallowing. The lungs become scarred, impeding respiration. Digestive disturbances occur because of hardening (sclerosing) of the intestinal mucosa. Progressive kidney failure may occur. The patient may manifest a variety of symptoms referred to as the CREST syndrome. CREST stands for calcinosis (calcium deposits in the tissues), Raynaud's phenomenon, esophageal hardening and dysfunction, sclerodactyly (scleroderma of the digits), and telangiectasia (capillary dilation that forms a vascular lesion) (McPhee et al., 2012).

Rheumatoid Arthritis Assessment and Diagnostic Findings

Several assessment findings are associated with RA: rheumatoid nodules, joint inflammation detected on palpation, and laboratory findings. The history and physical examination focuses on manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints. The patient is also assessed for extra-articular changes; these often include weight loss, sensory changes, lymph node enlargement, and fatigue. Symptoms and examination findings are often recorded using a Disease Activity Score-28 (DAS28) form to evaluate disease activity and help guide treatment decisions (Firth, 2011b). Rheumatoid factor is present in about 80% of patients with RA, but its presence alone is not diagnostic of RA, and its absence does not rule out the diagnosis. Antibodies to cyclic citrullinated peptide (anti-CCP) have a specificity of approximately 95% at detecting RA (McPhee et al., 2012). The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tend to be significantly elevated in the acute phases of RA and are therefore useful in monitoring active disease and disease progression. The red blood cell count and C4 complement component are decreased. Antinuclear antibody (ANA) test results may also be positive (Firth, 2011a). Arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow and contains numerous inflammatory components, such as leukocytes and complement. X-rays show bony erosions and narrowed joint spaces. X-rays of the hands and feet should be performed at baseline to help establish the diagnosis of RA and then every 3 years to monitor the progression of the disease

Latex Allergy Clinical Manifestations

Several different types of reactions to latex are possible (Table 38-6). Irritant contact dermatitis, a nonimmunologic response, may be caused by mechanical skin irritation or an alkaline pH associated with latex gloves. Common symptoms of irritant dermatitis include erythema and pruritus. These symptoms can be eliminated by changing the brand of gloves or by using powder-free gloves. The use of hand lotion before donning latex gloves can worsen the symptoms, because lotions may leach latex proteins from the gloves, thus increasing skin exposure and the risk of developing true allergic reactions (AAAAI, 2011; Mayo Foundation for Medical Education and Research, 2011). Delayed hypersensitivity to latex, a type IV reaction mediated by T cells in the immune system, is localized to the area of exposure and is characterized by symptoms of contact dermatitis, including vesicular skin lesions, papules, pruritus, edema, erythema, and crusting and thickening of the skin. These symptoms usually appear on the back of the hands. This reaction is thought to be caused by chemicals that are used in the manufacturing of latex products. It is the most common allergic reaction to latex. Although usually not life threatening, delayed hypersensitivity reactions often require major changes in the patient's home and work environment to avoid further exposure. People who are sensitized to latex are at increased risk for development of type I allergic reactions (AAAAI, 2011; Holgate et al., 2011). Immediate hypersensitivity, a type I allergic reaction, is mediated by the IgE mast cell system (Menzies, Shepherd, Nibbs, et al., 2011). Symptoms can include rhinitis, conjunctivitis, asthma, and anaphylaxis. The term latex allergy is usually used to describe the type I reaction. Clinical manifestations have a rapid onset and can include urticaria, wheezing, dyspnea, laryngeal edema, bronchospasm, tachycardia, angioedema, hypotension, and cardiac arrest.

Gout Nursing Management

Severe dietary restriction is not necessary; however, the nurse encourages the patient to restrict consumption of foods high in purines, especially organ meats, and to limit alcohol intake. Maintenance of normal body weight should be encouraged. In an acute episode of gouty arthritis, pain management with prescribed medications is essential, along with avoidance of factors that increase pain and inflammation, such as trauma, stress, and alcohol. Medication adherence is critical; therefore, counseling needs to be initiated by the nurse when appropriate. Between acute episodes, the patient feels well and may abandon preventive behaviors, which may result in an acute attack. Acute attacks are most effectively treated if therapy is begun early

Latex Allergy Medical Management

The best treatment available for latex allergy is the avoidance of latex-based products, although avoidance is often difficult because of the widespread use of such products. Patients who have experienced an anaphylactic reaction to latex should be instructed to wear medical identification. Antihistamines and an emergency kit containing epinephrine should be provided to these patients, along with instructions about emergency management of latex allergy symptoms. Patients should be counseled to notify all health care workers, as well as local paramedic and ambulance companies, about their allergy. Warning labels can be attached to car windows to alert police and paramedics about the driver's or passenger's latex allergy in case of a motor vehicle crash. People with latex allergy should be provided with a list of alternative products and referred to local support groups; they are also urged to carry their own supply of nonlatex gloves. People with type I latex sensitivity may be unable to continue to work if a latex-free work environment is not possible. This may occur with surgeons, dentists, operating room personnel, or intensive care nurses. Occupational implications for employees with type IV latex sensitivity are usually easier to manage by changing to nonlatex gloves and avoiding direct contact with latex-based medical equipment. Although latex-specific immunotherapy has been attempted, this method of treatment remains experimental.

Food Allergy Clinical Manifestations

The clinical symptoms are classic allergic symptoms (urticaria, dermatitis, wheezing, cough, laryngeal edema, angioedema) and gastrointestinal symptoms (itching; swelling of lips, tongue, and palate; abdominal pain; nausea; cramps; vomiting; and diarrhea).

Latex Allergy Assessment and Diagnostic Findings

The diagnosis of latex allergy is based on the history and diagnostic test results (OSHA, 2010; Pollart et al., 2009). Sensitization is detected by skin testing, RAST, EIA, or ELISA, or the level of Hevea latex-specific IgE antibody in the serum. Testing for the chemicals found in the rubber production that makes latex is performed using the patch test. Skin patch testing is the preferred method for patients with contact allergies. The T.R.U.E. test and other skin tests should be performed only by clinicians who have expertise in their administration and interpretation and who have the necessary equipment available to treat local or systemic allergic reactions to the reagent. Nasal challenge and dipstick tests may be useful in the future as screening tests for latex allergy.

Osteoarthritis Medical Management

The goals of management are to decrease pain and stiffness and to maintain or, when possible, improve joint mobility. Exercise, especially in the form of cardiovascular aerobic exercise and lower extremity strength training, have been found to prevent OA progression and decrease symptoms of OA (Esser & Bailey, 2011). Along with exercise, weight loss, which in turn decreases excess load on the joint, can also be extremely beneficial (Losina et al., 2011). Occupational and physical therapy can help the patient adopt self-management strategies. Wedged insoles, knee braces, and other modalities are being evaluated as possible therapies aimed at treating the abnormalities in biomechanics found in OA (Waller, Hayes, Block, et al., 2011). The use of orthotic devices (e.g., splints, braces) and walking aids (e.g., canes) can improve pain and function by decreasing force on the affected joint (Walker, 2011). Patients with arthritis often use CAM therapies, such as massage, yoga, pulsed electromagnetic fields, transcutaneous electrical nerve stimulation (TENS), and music therapy. These may also include herbal and dietary supplements, other special diets, acupuncture, acupressure, wearing copper bracelets or magnets, and participation in T'ai chi. Research is under way to determine the effectiveness of many of these treatments. To date, no definitive evidence has been found regarding their efficacy Some patients respond to the nonselective NSAIDs, and patients who are at increased risk for gastrointestinal complications, especially gastrointestinal bleeding, have been managed effectively with COX-2 enzyme blockers opioids and intra-articular corticosteroids. osteotomy (to alter the distribution of weight within the joint) and arthroplasty. In arthroplasty, diseased joint components are replaced

Assessment of the Immune System: Health history : Chronic Illness and Surgery

The health assessment includes a history of chronic illness, such as diabetes, renal disease, chronic obstructive pulmonary disease (COPD), or fibromyalgia. The onset and severity of illnesses, as well as treatment that the patient is receiving for the illness, are obtained. Chronic illness may contribute to immune system impairments in various ways. Renal failure is associated with a deficiency in circulating lymphocytes. In addition, immune defenses may be altered by acidosis and uremic toxins. In diabetes, an increased incidence of infection has been associated with vascular insufficiency, neuropathy, and poor control of serum glucose levels. Recurrent respiratory tract infections are associated with COPD as a result of altered inspiratory and expiratory function and ineffective airway clearance. Additionally, a history of organ transplantation or surgical removal of the spleen, lymph nodes, or thymus is noted, because these conditions may place the patient at risk for impaired immune function

Rheumatoid Arthritis Clinical Manifestations

The initial clinical manifestations of RA include symmetric joint pain and morning joint stiffness lasting longer than 1 hour. Over the course of the disease, clinical manifestations of RA vary, usually reflecting the stage and severity of the disease. Symmetric joint pain, swelling, warmth, erythema, and lack of function are classic symptoms. Palpation of the joints reveals spongy or boggy tissue. Often, fluid can be aspirated from the inflamed joint. Characteristically, the pattern of joint involvement begins in the small joints of the hands, wrists, and feet (Klippel, Stone, Crofford, et al., 2008; McPhee et al., 2012). As the disease progresses, the knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints are affected. The onset of symptoms is usually acute. Symptoms are usually bilateral and symmetric. In the early stages of disease, even before the presentation of bony changes, limitation in function can occur when there is active inflammation in the joints. Joints that are hot, swollen, and painful are not easily moved. The patient tends to guard or protect these joints by immobilizing them. Immobilization for extended periods can lead to contractures, creating soft tissue deformity. Deformities of the hands (e.g., ulnar deviation and swan neck deformity) and feet are common in RA (see Fig. 40-6 in Chapter 40). The deformity may be caused by misalignment resulting from swelling, progressive joint destruction, or the subluxation (partial dislocation) that occurs when one bone slips over another and eliminates the joint space. Deformities of RA differ from those seen with osteoarthritis (OA), such as Heberden's and Bouchard's nodes. RA is a systemic disease with multiple extra-articular features. Most common are fever, weight loss, fatigue, anemia, lymph node enlargement, and Raynaud's phenomenon (coldand stress-induced vasospasm causing episodes of digital blanching or cyanosis). Rheumatoid nodules may be noted in patients with more advanced RA, and they develop at some time in the course of the disease in about 20% of patients (McPhee et al., 2012). These nodules are usually nontender and movable in the subcutaneous tissue. They usually appear over bony prominences such as the elbow, are varied in size, and can disappear spontaneously. Nodules occur only in people who have rheumatoid factor. The nodules often are associated with rapidly progressive and destructive disease. Other extra-articular features include arteritis, neuropathy, pericarditis, splenomegaly, and Sjören's syndrome (dry eyes and dry mucous membranes).

Osteoarthritis Clinical Manifestations

The main clinical manifestations of OA are pain, stiffness, and functional impairment. The joint pain is usually aggravated by movement or exercise and relieved by rest. If morning stiffness is present, it is usually brief, lasting less than 30 minutes. Onset is routinely insidious, progressing over multiple years. On physical examination, the affected joint may be enlarged with a decreased range of motion. Although OA occurs most often in weight-bearing joints (hips, knees, cervical and lumbar spine), the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are also often involved causing bony enlargements of the DIP (Heberden's nodes) and PIP (Bouchard's nodes) joints. Crepitus may be palpated, especially over the knee. Joint effusion, a sign of inflammation, is usually mild. No systemic manifestations are found.

Types of Skin Tests

The methods of skin testing include prick skin tests, scratch tests, and intradermal skin testing (Fig. 38-3). After negative prick or scratch tests, intradermal skin testing is performed with allergens that are suggested by the patient's history to be problematic. The back is the most suitable area of the body for skin testing because it permits the performance of many tests. A multitest applicator with multiple test heads is commercially available for simultaneous administration of antigens by multiple punctures at different sites. A negative response on a skin test cannot be interpreted as an absence of sensitivity to an allergen. Such a response may occur with insufficient sensitivity of the test or with the use of an inappropriate allergen in testing. Therefore, it is essential to observe the patient undergoing skin testing for an allergic reaction even if the previous response was negative.

Anaphylactic (Type I) Hypersensitivity

The most severe hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is rapid in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type I or anaphylactic hypersensitivity is an immediate reaction beginning within minutes of exposure to an antigen. Primary chemical mediators are responsible for the symptoms of type I hypersensitivity because of their effects on the skin, lungs, and gastrointestinal tract. If chemical mediators continue to be released, a delayed reaction may occur and may last for up to 24 hours. Clinical symptoms are determined by the amount of the allergen, the amount of mediator released, the sensitivity of the target organ, and the route of allergen entry. Type I hypersensitivity reactions may include both local and systemic anaphylaxis.

Latex Allergy Nursing Management

The nurse can assume a pivotal role in the management of latex allergies in both patients and staff. All patients should be asked about latex allergy, although special attention should be given to those at particularly high risk (e.g., patients with spina bifida, patients who have undergone multiple surgical procedures). Every time an invasive procedure must be performed, the nurse should consider the possibility of latex allergies. Nurses working in operating rooms, intensive care units, short procedure units, and emergency departments need to pay particular attention to latex allergy. (See Fig. 17-1 in Chapter 17 for a latex allergy assessment form.) Although the type I reaction is the most significant of the reactions to latex, care must be taken in the presence of irritant contact dermatitis and delayed hypersensitivity reaction to avoid further exposure of the person to latex. Patients with latex allergy are advised to notify their health care providers and to wear medical identification. Patients must become knowledgeable about what products contain latex and what products are safe, nonlatex alternatives. They must also become knowledgeable about signs and symptoms of latex allergy and emergency treatment and self-injection of epinephrine in case of allergic reaction. Nurses can be instrumental in establishing and participating in multidisciplinary committees to address latex allergy and to promote a latex-free environment. Latex allergy protocols and education of staff about latex allergy and precautions are important strategies to reduce this growing problem and to ensure assessment and prompt treatment of those affected by allergy to latex.

Complete Blood Count With Differential

The white blood cell (WBC) count is usually normal except with infection. Eosinophils, which are granular leukocytes, normally make up 0% to 3% of the total number of WBCs (Fischbach & Dunning, 2009). A level between 5% and 15% is nonspecific but does suggest allergic reaction. Higher percentages of eosinophils are considered to represent moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and may be found in patients with allergic disorders.

Food Allergy Medical Management

Therapy for food hypersensitivity includes elimination of the food responsible for the hypersensitivity (Chart 38-8). Pharmacologic therapy is necessary for patients who cannot avoid exposure to offending foods and for patients with multiple food sensitivities not responsive to avoidance measures. Medication therapy involves the use of H1 blockers, antihistamines, adrenergic agents, corticosteroids, and cromolyn sodium. All patients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed. Another essential aspect of management is educating patients and family members about how to recognize and manage the early stages of an acute anaphylactic reaction (Boyce et al., 2010). Many food allergies disappear with time, particularly in children. About one third of proven allergies disappear in 1 to 2 years if the patient carefully avoids the offending food. However, peanut allergy has been reported to persist throughout adulthood in some people

Atopic Dermatitis Medical Management

Treatment of patients with atopic dermatitis must be individualized. Guidelines for treatment include decreasing itching and scratching by wearing cotton fabrics; washing with a mild detergent; humidifying dry heat in winter; maintaining room temperature at 20°C to 22.2°C (68°F to 72°F); using antihistamines such as diphenhydramine (Benadryl); and avoiding animals, dust, sprays, and perfumes. Keeping the skin moisturized with daily baths to hydrate the skin and the use of topical skin moisturizers is encouraged. Topical corticosteroids are used to prevent inflammation, and any infection is treated with antibiotics to eliminate Staphylococcus aureus when indicated. The use of immunosuppressive agents, such as cyclosporine (Neoral, Sandimmune), tacrolimus (Prograf, Protopic), and pimecrolimus (Elidel), may be effective in inhibiting T cells and mast cells involved in atopic dermatitis (Nijhawan, Matiz, & Jacob, 2009). Research is needed to assess the effectiveness and the adverse side effects of medications used to treat atopic dermatitis.

Scleroderma Medical Managemen

Treatment of scleroderma depends on the clinical manifestations. All patients require counseling, during which realistic individual goals may be determined. Support measures include strategies to decrease pain and limit disability. A moderate exercise program is encouraged to prevent joint contractures. Patients are advised to avoid extreme temperatures and to use lotion to minimize skin dryness. No medication regimen is effective in modifying the disease process in scleroderma, but various medications are used to treat organ system involvement. Calcium channel blockers and other antihypertensive agents may provide improvement in symptoms of Raynaud's phenomenon. Anti-inflammatory medications can be used to control arthralgia, stiffness, and general musculoskeletal discomfort. Proton pump inhibitors are used for symptoms of gastric reflux. Aspirin and HMGCoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors (statins) are used to help reduce cardiovascular risk factors. Given the propensity toward digital ulcers due to Raynaud's phenomenon and the potential for pulmonary hypertension, vasoactive medications such as epoprostenol (Flolan), bosentan (Tracleer), and sildenafil (Viagra) are used. Immunosuppressive agents such as cyclophosphamide and methotrexate have been used to improve skin and lung function. The antifibrotic agent imatinib mesylate is used to decrease fibrosis in various organs. Ultraviolet A irradiation is sometimes used to decrease the synthesis of collagen in dermal fibrosis and improve skin symptoms

Food Allergy

Type I hypersensitivity reaction Allergic symptoms and gastrointestinal symptoms Treatment H1-blockers Antihistamines adrenergic agents Corticosteroids Cromolyn sodium Nursing Management Educate to recognize and manage anaphylaxis Read food labels Monitor food preparation Cross contamination Medical alert bracelet Treat symptoms. Corticosteroid nasal inhalers. Avoidance - edu pt how to avoid, read food labels, understand how to shop, safe ways to eat at resturants, edu about cross contamination, wear a medical alert bracelet.

Immune Complex (Type III) Hypersensitivity

Type III, or immune complex, hypersensitivity involves immune complexes that are formed when antigens bind to antibodies. These complexes are cleared from the circulation by phagocytic action. If these type III complexes are deposited in tissues or vascular endothelium, two factors contribute to injury: the increased amount of circulating complexes and the presence of vasoactive amines. As a result, there is an increase in vascular permeability and tissue injury.

Contact Dermatitis

Type IV delayed hypersensitivity reaction S/S: Itching, Burning Erythema Skin lesions (vesicles) Edema Management Avoidance Systemic or Topical corticosteroids Oral antihistamines Antibiotics for infection Reaction to a chemical that comes into contact with the skin Take off clothes socks shoes etc after going outside because it can stay on materials for moths If rurual area - steer clear of anyone who is burning some things because poison ivy can get into the airway if burnt. Corticosteroids - jus taper off when stopping Antibiotics - because itching and scratching causes microscratches that can allow in backter, so its not for contact dermatits., but for infections that could happen

Viral load

how effective is the treatment for an HIV patient.

Osteoarthritis

a noninflammatory degenerative disorder of the joints. It is the most common form of joint disease and is routinely referred to as degenerative joint disease. OA is classified as either primary (idiopathic), with no prior event or disease related to the OA, or secondary, resulting from previous joint injury or inflammatory disease, similar to RA

Gout Clinical Manifestations

acute gouty arthritis (recurrent attacks of severe articular and periarticular inflammation), tophi (crystalline deposits accumulating in articular tissue, osseous tissue, soft tissue, and cartilage), gouty nephropathy (renal impairment), and uric acid urinary calculi. The metatarsophalangeal joint of the big toe is the most commonly affected The tarsal area, ankle, or knee may also be affected. Less commonly, the wrists, fingers, and elbows may be affected. Trauma, alcohol ingestion, dieting, medications, surgical stress, or illness may trigger the acute attack. The abrupt onset often occurs at night, awakening the patient with severe pain, redness, swelling, and warmth of the affected joint. Early attacks tend to subside spontaneously over 3 to 10 days even without treatment. The attack is followed by a symptom-free period (the intercritical stage) until the next attack, which may not come for months or years. However, with time, attacks tend to occur more frequently, involve more joints, and last longer.

Systemic Lupus Erythematosus Clinical Manifestations

an autoimmune, systemic disease that can affect any body system. The disease process involves chronic states where symptoms are minimal or absent and acute flares where symptoms and lab results are elevated. Systemic symptoms include fever, malaise, weight loss, and anorexia. The mucocutaneous, musculoskeletal, renal, nervous, cardiovascular, and respiratory systems are most commonly involved. Less commonly affected are the gastrointestinal tract and liver as well as the ocular system. an acute cutaneous lesion consisting of a butterfly-shaped erythematous rash across the bridge of the nose and cheeks including subacute cutaneous lupus erythematosus, which involves papulosquamous or annular polycyclic lesions, and a discoid rash, which is a chronic rash with erythematous papules or plaques and scaling and can cause scarring and pigmentation changes. arthralgias and/or arthritis ( synovitis), Pericarditis is the most common cardiac manifestation, Nephritis psychosis, cognitive impairment, seizures, peripheral and cranial neuropathies, transverse myelitis, and strokes

Systemic Lupus Erythematosus

an inflammatory, autoimmune disorder that affects nearly every organ in the body. The overall incidence of SLE is estimated to be 1.8 to 7.6 per 100,000 persons (Centers for Disease Control and Prevention [CDC], 2012a). The lifetime risk of developing SLE is 0.91% for women and 0.21% for men (Crowson et al., 2011). It occurs 6 to10 times more frequently in women than in men and occurs more in African American populations than among Caucasians (CDC, 2012a). It also appears to affect African American women at an earlier stage in life (before 40 years) than in Caucasians (after 40 years) (Pons-Estel, Alarc?, Scofield, et al., 2010). The focus here is on SLE; however, there are three other forms of lupus: discoid lupus (which primarily affects the skin on the face), druginduced lupus (which rarely includes some brain or kidney effects and has a clearer pathophysiology), and neonatal lupus (which is passed to the newborn during childbirth and usually resolved by 6 months of age)

Skin testing

call the patient, explain pretest instructions, don't take any antihistamines from 48-96 hours before the test, use non scented soaps before, prep the site, mark the site with sharpie labeling the sites to what they are using. Always have resuscitation equip: airway, epipens, benadryl,. If they are going to react, you will see it in 30 mins. Always keep eyes on patient just incase of anaphylactic shock. 30 min to 1 hr, after, document wheals, size, redness, oozing, gi, resp problems, anything less than 0.5 cm is negative.

Gout Pathophysiology

caused by hyperuricemia (increased serum uric acid). Uric acid is a by-product of purine metabolism; purines are basic chemical compounds found in high concentrations in meat products. Urate levels are affected by diet, medications, overproduction in the body, and inadequate excretion by the kidneys. Hyperuricemia (serum concentration greater than 6.8 mg/dL) can, but does not always, cause urate crystal deposition With repeated attacks, accumulations of sodium urate crystals, called tophi, are deposited in peripheral areas of the body, such as the great toe, the hands, and the ear. Renal urate lithiasis (kidney stones), with chronic renal disease secondary to urate deposition, may develop. Primary hyperuricemia may be caused by severe dieting or starvation, excessive intake of foods that are high in purines (shellfish, organ meats), or heredity. In secondary hyperuricemia, gout is a clinical feature secondary to any of a number of genetic or acquired processes, including conditions in which there is an increase in cell turnover (leukemia, multiple myeloma, some types of anemias, psoriasis) and an increase in cell breakdown.

Fibromyalgia

chronic pain syndrome that involves chronic fatigue, generalized muscle aching, stiffness, sleep disturbances, and functional impairment

Systemic Lupus Erythematosus Assessment and Diagnostic Findings

complete history, physical examination, and blood tests The skin is inspected for erythematous rashes. Cutaneous erythematous plaques with an adherent scale may be observed on the scalp, face, or neck. Areas of hyperpigmentation or depigmentation may be noted, depending on the phase and type of disease Cardiovascular assessment includes auscultation for pericardial friction rub, possibly associated with myocarditis and accompanying pleural effusions. The pleural effusions and infiltrations, which reflect respiratory insufficiency, are demonstrated by abnormal lung sounds Joint swelling, tenderness, warmth, pain on movement, stiffness, and edema may be detected on physical examination. The neurologic assessment is directed at identifying and describing any central nervous system changes. The patient and family members are asked about any behavioral changes, including manifestations of neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations.

ELISA

draw on two separate occasions - positive twice before western blot run

Skin Tests

entails the intradermal injection or superficial application (epicutaneous) of solutions at several sites. Depending on the suspected cause of allergic signs and symptoms, several different solutions may be applied at separate sites. These solutions contain individual antigens representing an assortment of allergens most likely to be implicated in the patient's disease. Positive (whealand-flare) reactions are clinically significant when correlated with the history, physical findings, and results of other laboratory tests. The results of skin tests complement the data obtained from the history. They indicate which of several antigens are most likely to provoke symptoms and indicate the intensity of the patient's sensitization. The dosage of the antigen (allergen) injected is also important. Most patients are hypersensitive to more than one allergen. Under testing conditions, they may not react (although they usually do) to the specific allergens that induce their attacks. In cases of doubt about the validity of the skin tests, a RAST or a provocative challenge test may be performed. If a skin test is indicated, there is a reasonable suspicion that a specific allergen is producing symptoms in a patient with allergies. However, several precautionary steps must be observed before skin testing with allergens is performed: • Testing is not performed during periods of bronchospasm. • Epicutaneous tests (scratch or prick tests) are performed before other testing methods, in an effort to minimize the risk of systemic reaction. • Emergency equipment must be readily available to treat anaphylaxis.

Allergic Rhinitis Avoidance Therapy

every attempt is made to remove the allergens that act as precipitating factors. Simple measures and environmental controls are often effective in decreasing symptoms. Examples include the use of air conditioners, air cleaners, humidifiers, and dehumidifiers; removal of dustcatching furnishings, carpets, and window coverings; removal of pets from the home or bedroom; the use of pillow and mattress covers that are impermeable to dust mites; and a smokefree environment (Distler, 2011; Lambert, 2009; Shoup, 2011). Additional measures include changing clothing when coming in from outside, showering to wash allergens from hair and skin, and using a Neti Pot (an over-the-counter nasal irrigation device) or saline nasal spray to reduce allergens in the nasal passages (Thornton, Alston, Dye, et al., 2011). Because multiple allergens are often implicated, multiple measures to avoid exposure to allergens are often necessary (Distler, 2011; Shoup, 2011). High-efficiency particulate air (HEPA) purifiers and vacuum cleaner filters may also be used to reduce allergens in the environment. Research suggests that multiple avoidance strategies tailored to a person's risk factors can reduce the severity of symptoms, the number of work or school days missed because of symptoms, and the number of unscheduled health care visits for treatment (Distler, 2011). In many cases, it is impossible to avoid exposure to all environmental allergens, so pharmacologic therapy or immunotherapy is needed.

(radioallergosorbent) RAST test

introduce blood to allergens,

Anaphylaxis

is a clinical response to an immediate (type I hypersensitivity) immunologic reaction between a specific antigen and an antibody. The reaction results from a rapid release of IgE-mediated chemicals, which can induce a severe, life-threatening allergic reaction. It is estimated that between 33 and 43 million people in the United States are at risk for anaphylaxis

Scleroderma

is a compilation of autoimmune diseases affecting the connective tissue of the skin, blood vessel walls, and internal organs. There are two general types: localized (affecting only the cutaneous system) and systemic (routinely referred to as systemic sclerosis and affecting multiple organ systems). Scleroderma is a rare disease affecting 286 patients per million population (Klippel et al., 2008). Similar to other autoimmune diseases, women are affected three to five times more than men, and onset occurs typically between the ages of 30 and 50 years. Scleroderma has a variable course with remissions and exacerbations.

Atopic Dermatitis

is a type I immediate hypersensitivity disorder characterized by inflammation and hyperreactivity of the skin Most patients have significant elevations of serum IgE and peripheral eosinophilia. Pruritus and hyperirritability of the skin are the most consistent features of atopic dermatitis and are related to large amounts of histamine in the skin. Excessive dryness of the skin with resultant itching is related to changes in lipid content, sebaceous gland activity, and sweating. In response to stroking of the skin, immediate redness appears on the skin. Pallor follows in 15 to 30 seconds and persists for 1 to 3 minutes. Lesions develop secondary to the trauma of scratching and appear in areas of increased sweating and hypervascularity. Atopic dermatitis is chronic, with remissions and exacerbations. This condition has a tendency to recur, with remission from adolescence to 20 years of age.

Gout

is the most common form of inflammatory arthritis incidence increases with age, body mass index, alcohol consumption, hypertension, and diuretic use Evidence links the consumption of fructose-rich beverages with the risk of gout for both men and women

Food challenge

is the patient really allergic, moderately allergic, minimally allergic - pretest edu, no antihistamines, steroids, benydrl, 96 hours before. 5 days. Morning of the test, do not eat anything, come in on an empty stomach, only exception is other medications for Heart, etc. baseline, have resuscitation equipment available, lick the food first, and wait. Then take a little bit and eat it, look for burning sweating, itching nausea, vomit, if at any point the person starts to react it is a duel doctor patient decision to push forward to see when pt will have anaphylactic shock or if they want to stop. Keep pt in hospital for at least 1 hour.

CRP

only measures inflammation in the body

Anaphylaxis Clinical Manifestations

produce a clinical syndrome that affects multiple organ systems. Reactions may be categorized as mild, moderate, or severe. The time from exposure to the antigen to onset of symptoms is a good indicator of the severity of the reaction—the faster the onset, the more severe the reaction. The severity of previous reactions does not determine the severity of subsequent reactions, which could be the same or more or less severe. The severity depends on the degree of allergy and the dose of allergen (Holgate, Church, Bromid, et al., 2011; Peakman & Vergani, 2009; Solensky, 2011). Mild systemic reactions consist of peripheral tingling and a sensation of warmth, possibly accompanied by a sensation of fullness in the mouth and throat. Nasal congestion, periorbital swelling, pruritus, sneezing, and tearing of the eyes can also be expected. Onset of symptoms begins within the first 2 hours after exposure. Moderate systemic reactions may include flushing, warmth, anxiety, and itching in addition to any of the milder symptoms. More serious reactions include bronchospasm and edema of the airways or larynx with dyspnea, cough, and wheezing. The onset of symptoms is the same as for a mild reaction. Severe systemic reactions have an abrupt onset with the same signs and symptoms described previously. These symptoms progress rapidly to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing), abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac arrest and coma may follow.

Systemic Lupus Erythematosus Pathophysiology

starts with the body's immune system inaccurately recognizing one or more components of the cell's nucleus as foreign, seeing it as an antigen. The immune system starts to develop antibodies to the nuclear antigen. In particular, B cells begin to overproduce antibodies with the help of multiple cytokines such as B-lymphocyte stimulator (BLyS), which is overexpressed in SLE The antibodies and antigens form antigen-antibody complexes and have the propensity to get trapped in the capillaries of visceral structures. The antibodies also act to destroy host cells. It is thought that those two mechanisms are responsible for the majority of the clinical manifestations of this disease process (McPhee et al., 2012). It is hypothesized that the immunoregulatory disturbance is brought about by some combination of four distinct factors: genetic, immunologic, hormonal, and environmental

Latex Allergy

the allergic reaction to natural rubber proteins—has been implicated in rhinitis, conjunctivitis, contact dermatitis, urticaria, asthma, and anaphylaxis. Natural rubber latex is derived from the sap of the rubber tree (Hevea brasiliensis). The conversion of the liquid rubber latex into a finished product entails the addition of more than 200 chemicals. The proteins in the natural rubber latex (Hevea proteins) or the various chemicals that are used in the manufacturing process are thought to be the source of the allergic reactions. Not all objects composed of latex have the same ability to stimulate an allergic response. For example, the antigenicity of latex gloves can vary widely depending on the manufacturing method used. Those at risk include health care workers, patients with atopic allergies or multiple surgeries, people working in factories that manufacture latex products, females, and patients with spina bifida. Because more food handlers, hairdressers, automobile mechanics, and police wear latex gloves, they are at risk for latex allergy Routes of exposure to latex products can be cutaneous, percutaneous, mucosal, parenteral, or aerosol. Allergic reactions are more likely with parenteral or mucous membrane exposure but can also occur with cutaneous contact or inhalation. The most frequent source of exposure is cutaneous, which usually involves the wearing of natural latex gloves. The powder used to facilitate putting on latex gloves can become a carrier of latex proteins from the gloves; when the gloves are put on or removed, the particles become airborne and can be inhaled or settle on skin, mucous membranes, or clothing. Mucosal exposure can occur from the use of latex condoms, catheters, airways, and nipples. Parenteral exposure can occur from intravenous lines or hemodialysis equipment.

Rheumatoid Arthritis Pathophysiology

the autoimmune reaction (see Fig. 39-1) originates in the synovial tissue. It is hypothesized that both environmental factors, such as cigarette smoking, and genetic factors coalesce to produce inflammatory and destructive synovial fluid, starting in the more distal joints This RA synovium breaks down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation annus destroys cartilage and erodes the bone. The consequence is loss of articular surfaces and joint motion. Muscle fibers undergo degenerative changes. Tendon and ligament elasticity and contractile power are lost.

Rheumatoid Arthritis Medical Management Early Rheumatoid Arthritis

treatment should begin with either a nonbiologic or biologic DMARD. In the past, a step-wise approach starting with NSAIDs was the standard of care. However, evidence clearly documenting the benefits of early DMARD treatment has changed national guidelines for management (Firth, 2011b). Now it is recommended that treatment with the nonbiologic DMARDs (methotrexate [Rheumatrex], antimalarial agents, leflunomide [Arava], or sulfasalazine [Azulfidine]) begin within 3 months of disease onset. At this time, methotrexate is the initial nonbiologic DMARD used for patients with RA. After initiating treatment, patients generally report a beneficial effect within 2 to 6 weeks and tolerate the medication relatively well (McPhee et al., 2012). Research suggests that methotrexate combined with low-dose prednisone improves patient outcome compared to the use of methotrexate alone for early RA Another treatment approach for RA is the use of biologic DMARDs. These agents have been specifically engineered to target the most prominent proinflammatory mediators in RA—TNF-α, B cells, T cells, IL-1, and IL-6 NSAIDs and specifically the cyclo-oxygenase 2 (COX-2) enzyme blockers are used for pain and inflammation relief. NSAIDs, such as ibuprofen (Motrin) and naproxen (Naprosyn), are commonly prescribed because of their low cost and analgesic properties. They must be used, however, with caution in long-term chronic diseases because of the possibility of gastric ulcers