211 Test 3: Inflammation and Immunity

Integumentary indications of AIDS

1.Dry skin, skin lesions 2.• Poor wound healing 3.• Night sweats

HIV symptomatic stage

--CDC category B --200-499 CD4+ lymphocytes/mm3 --CD4 T cells gradually fall --The patient develops symptoms or conditions related to the HIV infection, which are not classified as category C conditions --Patients who are once treated for a category B condition are considered category B

Moderate ulcerative colitis

--Greater than 4 stools daily with or without blood --Minimal symptoms: mild abdominal pain, mild intermittent nausea --Possible increased C-reactive protein or ESR

A client is being scheduled for diagnostic tests to determine the presence of ulcerative colitis. For which diagnostic tests should the nurse plan to provide teaching?

Answer: Barium enema, Colonoscopy, Barium swallow

What is the definition of immunity?

Immunity is the body's protection from illness or disease

Epinephrine (treatment for anaphylaxis)

•First line drug •Constricts blood vessels (raises BP) •Causes airways to open (dilation of smooth muscle) •Improves cardiac contraction •1:1000 concentration, dose at .01mg/kg •Epi-Pen (based on size). •Constricts blood vessels •Causes airways to open (dilation of smooth muscle) • •Can repeat in 5-15 minutes, as needed •Must call 911 for transport to ED •IM injection-thigh •Adult: 0.3 mg pen (above 66 lbs) •Jr: 0.1mg (below 66 lbs)

Early signs and symptoms of RA (Rheumatoid Arthritis)

•Warm, slightly reddened, stiff and swollen joints •Upper extremities affected first (wrists and fingers) •Weakness/fatigue •Loss of appetite/weight loss •Persistent low grade fever •Bilateral and symmetric

5 cardinal signs of inflammation

•Warmth •Redness •Swelling •Pain *Decreased function

Criteria for organ donation

•Advanced disease process in the affected organ..meet specific criteria (labs, function, etc...) •Have a reasonable life expectancy •Medically and surgically able to undergo the procedure

A nurse is caring for a pregnant client who has rheumatoid arthritis (RA). Based on this data, which does the nurse anticipate when providing care to this client?

Answer: A continued risk for anemia.

RA diagnostic tests

(1) Anticyclic citrullinated peptide (anti-CCP) --very specific and sensitive in detecting early RA. The presence of anti-CCP is also a marker for aggressive and erosive late-stage disease. (2) Rheumatoid factor (s) •Titre: measures for presence of unusual antibodies (IgG and IgM) types. •+ Rf is not always diagnostic. (3) ANA •antinuclear antibody (ANA) test measures the titer of a group of antibodies that destroy the nuclei of cells and cause tissue death in patients with autoimmune disease. (4) CRP and ESR •General markers of inflammation (5) CBC •Low Hgb, Hct and RBC's •High WBC's (inflammatory) (6) Xrays-joint changes and deformity (7) MRI -cervical changes (8) Arthrocentesis •Take synovial fluid (knee) and analyze for WBC's and autoimmune complexes (Rheumatoid factor)

Stages of HIV

(1) Primary infection (2) HIV asymptomatic (3) HIV symptomatic (4) AIDS

Transplant complications

(1) Rejection • Primary concern; occurs from an immune response targeted against the transplanted organ. (2) Infection •Due to reduced immunity from the immunosuppressant drugs •Prevention essential

Primary infection of HIV

--AKA acute HIV infection/acute HIV syndrome --Part of CDC category A --Symptoms: none to flu-like syndrome --Window period: lack of HIV antibodies **Period of rapid viral replication and dissemination through the body --Viral set point: balance between amount of HIV and the immune response

Risk factors for inflammation

--Age *Young-immature immune system, leads to increased inflammatory response, unable to control a minor pathogen, infection may be severe *Old-immune system less able to respond, leading to stronger inflammatory response --Compromised immune system --Genetics --Obesity --Vit D deficiency --Inadequate Standard Precautions (leading to infection/inflammation) --Smoking/pollution --Trauma

Diagnostics related to inflammation

--CBC with differential --ESR (erthyrocyte sedimentation rate) and CRP (C reactive protein). --Nonspecific markers of inflammation-anywhere in body. --Serology testing-detects antibodies from past infections (Exp: EBV, HIV, ) --CT, MRI, PET, colonoscopy-determine location and extent in body.

AIDS stage of HIV

--CDC category C --Less than 200 CD4+ lymphocytes/mm3 --As levels drop below 100 cell/mm3 the immune system is significantly impaired --Development of multiple conditions

Ways HIV is NOT Transmitted

--Casually --By sharing household utensils, towels, linens, toilets --Via mosquitoes or insects

GERD patient teaching

--Diet: small, frequent meals, decrease acid foods, decrease fatty foods --Lifestyle changes: decrease smoking, alcohol intake, lose weight, don't eat 3 hours before bed, sleep propped up, and wear loose clothing

GERD symptoms

--Dyspepsia (indigestion) --Burping, belching, flatulence, nausea --Heartburn --Epigastric pain --Abdominal pain (general) --Regurgitation --Dysphagia (difficulty swallowing) --Feeling of something in back of throat (globus) --Odynphagia (painful swallowing) --Coughing, hoarseness, wheezing (especially at night), crackles with auscultation of lungs --Symptoms increase with bending over and lying down

Management of inflammation

--Goal: Control the inflammatory response so to avoid further injury and promote repair and healing. --Consider the cause... °Infection (get rid of the infection) °Hypersensitivity immune response (allergies, asthma) ...manage the immune response °Autoimmune disease...manage the immune dysfunction --Treatments: °RICE (rest, ice, compression, elevation) °Immobilize °Drugs: ±Steroids (suppress immune system and an inflammatory response). Exp: Prednisone ±NSAIDS (work as COX inhibitors) ±Recombinant DNA and monoclonal antibodies (work by inhibiting interleukin and Tumor Necrosis factor from producing inflammation). Exp: Remicade ±Antipyretics (reduce fever). NSAIDS, aspirin and Tylenol. ±Analgesics (reduce pain). NSAIDs, aspirin and Tylenol. ±Antimicrobials (antibiotics, antivirals, etc) to treat underlying cause of infection/inflammation.

Severe ulcerative colitis

--Greater than 6 bloody stools daily --Symptoms: fever, tachycardia, anemia, abdominal pain, elevated C-reactive protein and/or ESR

Diagnostics for GERD

--History and symptoms (can be diagnosed solely with these) --Barium swallow --Upper endoscopy (EGD)--with or without biopsy --Esophageal manometry --Esophageal pH monitoring (intranasal catheter or wireless capsule inserted to lower esophageal mucosa)--monitors pH continuously for 24-48 hours with a patient diary of activities

Mild ulcerative colitis

--Less than 4 stools daily with/without blood --Asymptomatic --Lab values usually normal

Nursing interventions for RA

--Medications as well as: •Relieve pain and discomfort •Heat or cold (works for acute inflammation) •Support joints (splints, etc) •Medications •Rest and mobility •ROM..keep moving •Get enough sleep and rest •Positioning (avoid flexion) •Firm mattress •Encourage independence and acceptance of limitations. •Reduce inflammation (medications) •Diet (anti-inflammatory diet) •Limit: refined carbs (white bread and pastries), fried foods, soda and sugar beverages, red meat, processed meats, margarine/shortening/lard •Increase: tomatoes, olive oil, nuts, green leafy veggies (spinach, kale), fatty fish (salmon, tuna), fruits (strawberries, blueberries, cherries, oranges, etc).

Risk factors for GERD

--Obesity --Genetics --Carbonated beverages --Caffeine (coffee, tea, colas) --Acidic foods (tomatoes, citrus fruits) --Tobacco and alcohol --High levels of estrogen and progesterone --H. Pylori + --Hiatal hernia --NG tube placement --Pregnancy --Anything that increases intra-abdominal pressure

Acute transplant rejection

--Occurs days (one week) to months after transplantation --T-cytotoxic lymphocytes attack the transplanted organ

More signs and symptoms of anaphylaxis

--Onset within minutes to hours --Skin or mucous membrane problems involving: • swollen lips tongue, soft palate, uvula •widespread hives; pruritus; or flushing --In addition: Respiratory distress or ineffectiveness.... Dyspnea Bronchospasm Wheezes Stridor Hypoxia Cyanosis Peak expiratory rate flow lower than the patient's usual rate Hypotension or any indication of reduced perfusion resulting in organ dysfunction 1.Loss of consciousness 2. Incontinence 3. Hypotonia 4. Absent deep tendon reflexes Persistent GI problems such as nausea or vomiting, cramping, abdominal pain

What happens during the inflammatory response?

--WBC attracted to area of inflammation --Proinflammatory hormones act as mediators (prostaglandins, cytokines, histamines, leukotrienes, serotonin) --End Result: °Increases blood flow to the injured area (vasodilation...redness) °Increases vascular permeability (edema) °Activates immune response (complement system) °Attracts leukocytes to the area (exudate) °Development of new blood vessels °Stimulates connective tissue growth °Platelet aggregation °Causes fever

Hyperacute transplant rejection

--Within minutes to hours --No treatment (organ must be removed)

Common signs and symptoms of transplant rejection

--pain at site of transplant --feeling ill --flu-like symptoms --fever --weight changes --swelling --decreased urine output

Interventions for Anaphylaxis

-Assess GAS EXCHANGE first! -Establish or stabilize airway -Stay with patient -Epinephrine -Antihistamines -Oxygen -Beta-adrenergic agonist -Corticosteroids, oral steroids

HIV stage II

-chronic stage. Diagnosed in this stage, and medication started. Last for 8-10 years. Viral load increasing, CD 4 cells decreasing. •T cells remain >500 cells/mm3. •Still fight infections, some becoming more severe (exp. TB) •If CD 4 count falls between 200-500 cells/mm3, get swollen lymph nodes (lymphadenopathy), oral candidiasis (yeast) and hairy leukoplakia (hairy white patches on the tongue). •Appropriate drug therapy during this stage suppresses viral reproduction, enabling pt. to maintain a level of immunity to fight off infection. •Some respond so well, they have undetectable levels of virus.

Chronic transplant rejection

-occurs over months to years -most common in lung transplants

HIV stage 1

-onset of acute infection after initial invasion. Causes flu like symptoms (fever, fatigue, sore throat, rash, night sweats, chills, headache, muscle aches)..usually within 4 weeks. Start to feel well again, but a "war" is going on in the body. Can last for 12 weeks. •Sexual transmission is possible. •Very infectious in this stage

GI indications of AIDS

1.Diarrhea 2.• Weight loss 3.• Nausea and vomiting

Emergency treatment for anaphylaxis

1.Immediately assess the respiratory status, airway, and oxygen saturation of patients who show any symptom of an allergic reaction. 2.• Call the Rapid Response Team/MSET 3.• Ensure that intubation and tracheotomy equipment is ready. 4.• Apply oxygen using a high-flow, nonrebreather mask at 90% to 100%. 5.• Immediately discontinue the IV drug or infusing solution of a patient having an anaphylactic reaction to that drug or solution. Do not discontinue the IV, but change the IV tubing and hang normal saline. 6.• If the patient does not have an IV, start one immediately and infuse normal saline. 7.• Be prepared to administer epinephrine IM. 1.Repeat drug as needed every 5 to 15 minutes until the patient responds. 8.• Keep the head of the bed elevated about 10 degrees if hypotension is present; if blood pressure is normal, elevate the head of the bed to 45 degrees or higher to improve ventilation. 9.• Raise the feet and legs. 10.• Stay with the patient. 11.• Reassure the patient that the appropriate interventions are being instituted.

Malignancies that can occur with AIDS

1.Kaposi's sarcoma 2.• Non-Hodgkin's lymphoma 3.• Hodgkin's lymphoma 4.• Invasive cervical carcinoma

11 most common findings with SLE

1.Red, macular, facial rash over the cheeks and nose in the shape of a butterfly 2. Coin-shaped lesions (discoid rash) on the face, scalp, and sun-exposed areas 3. Sensitivity to sunlight (photosensitivity) with rash development after exposure 4. Chronic lesions on the mucous membranes of the mouth and throat 5. Nonerosive arthritis of two or more peripheral joints with pain and swelling 6. Inflammation of serosal membranes, especially pericarditis and pleurisy 7. Kidney changes with persistent casts and protein in the urine 8. Neurologic problems such as seizures or psychosis without previous history 9. Hematologic problems with hemolytic anemia (most common), decreased white blood cells (leukopenia), decreased lymphocytes (lymphopenia), decreased platelets (thrombocytopenia) 10. Immunity problems such as autoantibodies to cell nuclear structures and false-positive results of serologic tests for syphilis 11. Presence of antinuclear antibodies (ANAs)

Central Nervous System indications of AIDS

1.• Confusion, dementia, memory loss 2.• Headache 3.• Fever 4.• Visual changes 5.• Personality changes 6.• Seizures

Immunologic indications of AIDS

1.• Low white blood cell counts 2.• CD4+/CD8+ ratio <2 3.• CD4+ count <200/mm3 (0.2 × 109/L) 4.• High blood immunoglobulin levels 5.• Opportunistic infections 6.• Lymphadenopathy

A nurse is receiving a client from the emergency department diagnosed with an acute exacerbation of ulcerative colitis (UC). The nurse anticipates the client may present with which clinical characteristics? Select all that apply.

5-30 diarrhea stools per day with blood and mucus, Cramping in left lower quadrant; relieved by defecation, Fever, malaise, fatigue

Fulminant Ulcerative Colitis

>10 bloody stools/day Increasing symptoms Anemia may require transfusion Colonic distention on x-ray

What is anaphylaxis?

A serious, life threatening allergic reaction. Immune system overreacts to an allergen by releasing chemicals that cause allergy symptoms. An antigen-antibody response Type I hypersensitivity reaction (IgE antibodies) •The most life threatening Type I hypersensitivity reaction •Systemic •Can vary in severity •Occurs fast! Need to react quickly! (IMPORTANT) Involves all blood vessels and bronchiolar smooth muscles What do you see? •Bronchoconstriction •Blood vessel dilation (peripheral vasodilation) •Decreased cardiac output •Activation of other inflammatory pathways (prostaglandins, leukotrienes, kinins, TNF, interleukins, histamine)

The nurse suspects that inflammation has progressed to the cellular level based on which patient assessment finding? A.Warmth B.Redness C.Pus Swelling

ANS: C Responses at the tissue level cause the five cardinal symptoms of inflammation: warmth, redness, swelling, pain, and decreased function. Stage II is the cellular exudate part of the response. In this stage, neutrophilia (an increased number of circulating neutrophils) occurs. Exudate in the form of pus occurs, containing dead WBCs, necrotic tissue, and fluids that escape from damaged cells.

A nurse working in the emergency department is providing care for a group of clients. Which client demonstrates a decline in immune response that typically occurs with the aging process?

An 88-year-old client with pneumonia who has a temperature of 99.5F

A patient has been admitted to the ED with bilateral eyelid swelling and subsequent difficulty seeing. What is the priority nursing assessment? A.Airway B.Nasal cavity C.Home medications History of visual disturbances

Answer: A

The nurse is providing care to several client in an outpatient client. Which client is at high risk of developing gastroesophgeal reflux disorder (GERD)?

Answer: A client who is 6 weeks pregnant

A 30-year-old man with HIV is admitted to the acute care unit. Which assessment findings does the nurse recognize that may indicate that the patient currently has AIDS? (Select all that apply.) A.Kaposi's sarcoma B.HIV-positive status C.Wasting syndrome D.Esophageal candidiasis E.Persistent generalized lymphadenopathy

Answer: A, C, D

A nurse is administering a new medication intravenously to a patient. The patient becomes short of breath and begins to experience itching and hives. What is the priority nursing response? A.Assess blood pressure B.Stop the intravenous infusion C.Discuss anxiety with the patient D.Review the patient's allergies

Answer: B

A patient is fearful that he has been infected with HIV. The nurse recognizes which as the first symptom associated with possible HIV infection? A.Lymphocytopenia B.Opportunistic infection C.Fever, night sweats, muscle aches D.Reduced numbers of CD4+ T-cells

Answer: C

Immune function is most efficient when people are which age? A.Infancy B.Teen years C.20 to 30 years 50 years and older

Answer: C Immune function is most efficient when people are in their 20s and 30s and slowly declines with increasing age. The immune system is developing and changing during infancy and teen years.

Causes of anaphylaxis

Anything can cause an Anaphylactic Reaction!! Community Setting •Foods (eggs, nuts, peanut butter, milk and soy, shellfish, some fruits) •Insect stings (wasps and bees) Acute Care Setting •Drugs (antibiotics and NSAIDS-aspirin) Imaging contrast medias (dyes)

Which questions are most important for the nurse to first ask a client who comes to the emergency department with signs of severe angioedema? Select all that apply.

Are you able to swallow? What drugs do you take on a daily basis?

A client with systemic lupus erythematosus (SLE) is being treated with immunosuppressant drugs and corticosteroids. When providing teaching for this client, which topics are appropriate for the nurse to include? Select all that apply.

Avoid large crowds Use contraception to prevent pregnancy Refrain from taking aspirin products Report signs of infection

A patient with AIDS is having difficulty maintaining body weight. Which nursing interventions are most appropriate for this patient? (Select all that apply.) A.Encourage the patient to drink at least 1 L of fluid per day. B.Collaborate with the dietician. C.Provide foods that are high in calories. D.Encourage low fat food choices. E.Provide three large meals a day. F.Ensure regular mouth care.

B, C, D, F

Drugs to avoid with GERD

BCP's, anticholinergics, NSAIDs, calcium channel blockers

GERD complications

Barret's esophagus •Chronic reflux or irritation of the esophagus causes changes in the lining (epithelium) of the esophagus •Cells are premalignant, increases risk for cancer •Need to monitor with periodic Upper endoscopy Esophageal strictures •Inflammation causes fibrosis and scarring of the esophagus •Get narrowing of esophagus •Difficulty swallowing Aspiration pneumonia Asthma exacerbations Dental decay Chest pain (r/o MI) Laryngitis Hemorrhage of the esophagus

Nursing care pre-surgery for transplants

Blood typing •Needs to be the same blood type Immunologic studies •HLA (human leukocyte antigen studies) •Need them to be as similar as possible, for best chance at organ acceptance and avoidance of rejection Patient assessment/Coordination of diagnostic tests •Vital sign baselines •Renal, liver and cardiovascular studies •Respiratory and CNS baseline assessment •Baseline labs: CBC (H/H and platelets) and WBC's Education •Procedure itself •Care after surgery

The nurse in a rheumatology clinic is managing care for clients who receive nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of their disease processes. Which are the primary laboratory tests the nurse will assess prior to initiation of this type of therapy? Select all that apply.

Complete blood count (CBC) Liver function tests

Respiratory indications of AIDS

Cough, shortness of breath

Complications of Ulcerative Colitis and Crohn's disease

Hemorrhage/perforation, abscess formation, toxic megacolon (massive dilation that can lead to gangrene and peritonitis), intestinal malabsorption, nonmechanical bowel obstruction, fistulas, colorectal cancer, extraintestinal complications (arthritis, hepatic, and biliary disease, oral and skin lesions, ocular disorders), and osteoporosis

What is the definition of inflammation?

Inflammation is a tissue response to injury, allergy or invasion by pathogens

Important point about inflammation and immunity

Inflammation is always present with infection, but inflammation may also occur without infection.

Chronic inflammation

Long term. Due to: Sensitivity issues (hypersensitivity to an external trigger...results in an allergy). Exposure: long term, low level exposure to an irritant. Exp: chemical Autoimmune disorders: immune system attacks healthy tissue. Exp: psoriasis, RA /JRA Persistent acute inflammation: acute (unresolved) can lead to chronic inflammation

A client is admitted with airway edema, bronchoconstriction, and increased mucus production after being exposed to an allergen. Which nursing interventions are appropriate to address this inflammation to the respiratory system? Select all that apply.

Monitor oxygen saturation, Administer oxygen as prescribed, monitor lung sounds

A pediatric client is diagnosed with gastroesophageal reflux disorder (GERD). The nurse is observing a return demonstration of the mother preparing and feeding the infant formula. Which observation demonstrates correct procedure for preventing GERD symptoms?

Positioning the infant upright for a minimum of 30 minutes

Nursing focus and treatment for Inflammatory Bowel Disease

Prioritization of Care: •Diarrhea due to inflammation of the bowel mucosa •Acute or persistent pain due to inflammation and ulceration of the bowel mucosa and skin irritation •Potential for lower GI bleeding and anemia. ***medical emergency*** Nonsurgical: • Physical and emotional rest, frequent weights, • High cal diet (high protein and vitamins), avoid caffeine, alcohol and milk, supplements (Ensure) •Low residue diet •Bowel rest (if severe sx), TPN (total parenteral nutrition) as nutrition supplement • Skin care.. Surgical: • Fistula management, abscess management (I and D) •Bowel resections or possible colostomy (see more in UC).

Acute inflammation

Protective, short term (minutes to days), repairs and restores. Example: ankle sprain, infected wound.

A client, recently diagnosed with rheumatoid arthritis (RA), asks the nurse whether RA will affect her in other ways. When responding to the client, which systems will the nurse include as possibly being affected by the diagnosis? Select all that apply.

Respiratory Cardiovascular Exocrine Hematologic

A nurse is caring for a client with systemic lupus erythematous (SLE) who is taking hydroxychloroquine (Plaquenil). When providing care for this client, the nurse monitors for which adverse effects associated with the prescribed medication?

Retinal toxicity

The nurse is caring for a client who is hospitalized due to an exacerbation of systemic lupus erythematosus (SLE). The nurse is reviewing the client's lab work and finds the white blood cell count (WBC) is shifted to the left. Based on this information, which is a priority nursing diagnosis for this client?

Risk for infection

Felty Syndrome

Seen in pts with severe, long standing > 10 years RA A disorder that includes rheumatoid arthritis, a swollen spleen, decreased white blood cell count, and repeated infections. It is rare. "SANTA" S-Splenomegaly A-Anemia N-Neutropenia T-Thrombocytopenia A-Arthritis (rheumatoid)

Stage 1 of inflammatory response

Stage 1: Vascular Response °Injured tissue (secretes histamine, bradykinin, serotonin, etc..) °Causes vasodilation (redness and warmth noted) °Increased blood flow and capillary permeability cause edema/swelling and pain °Edema protects the tissues from further damage °Lasts 24-72 hours

Stage 2 of inflammatory response

Stage 2: Cellular Exudate °Increased Neutrophils in circulation °Exudate/pus forms °Neutrophils, basophils, eosinophils and mast cells activated °Inflammatory cascade starts, enzyme COX triggers. Inflammatory mediators working (histamine, leukotrienes, prostoglandins, serotonin and kynins).

Stage 3 of inflammatory response

Stage 3: Tissue Repair and Replacement ° Repair starts (glucose and oxygen to the area). °WBC's trigger new blood vessel growth and tissue formation

A nurse working in an intensive care unit (ICU) is assigned a client diagnosed with acquired immunodeficiency syndrome (AIDS). Based on this data, which type of precaution does the nurse implement when providing direct care?

Standard precautions

Assessment findings with inflammation

Swelling, pain, fever, induration, warmth, decreased or absent functioning of the tissue or organ (local or systemic). Severe: Shock, multiorgan failure, seizure, coma or death

The nurse is reviewing the laboratory values of a client who is newly diagnosed with acquired immunodeficiency syndrome (AIDS). Which values should be reported to the client's healthcare provider? Select all that apply.

T4 cell count 150 CD4 lymphocytes 12% Viral load 11,500 copies/mL

The nurse is caring for a client with severe inflammation. Which assessment findings would indicate a systemic reaction to inflammation? Select all that apply.

Tachypnea, tachycardia

An adolescent is being discharged on Cyclosporin after receiving a kidney transplant. Which of the following should the nurse include in discharge teaching? Select all that apply.

Take your medicine at the same time every day. You will be taking immunosuppressants life-long. Take your blood pressure daily.

A nurse is caring for a client with systemic lupus erythematosus (SLE). The client begins to cry stating, "I am afraid I will be disfigured because of all of these lesions." Which interventions does the nurse plan to teach this client to minimize skin infections associated with SLE? Select all that apply.

Use sunscreen with an SPF of 50 or greater Avoid sun exposure between 10:00 a.m. and 3:00 p.m.

The nurse is discharging a pediatric who recently developed acquired immunodeficiency syndrome (AIDS). When discussing appropriate health promotion activities for this child, which immunization is not appropriate for this client to receive due to AIDS diagnosis?

Varicella vaccine

HIV asymptomatic stage

a period of time during which a person infected with HIV has no symptoms; a person may show no signs of illness for 6 months to 10 years or more. However, the viruses continue to grown and the infected person can still transmit the virus to others. --CDC category A --More than 500 CD4+ T lymphocytes/mm3 --Upon reaching the viral set point, chronic asymptomatic state begins --Body has sufficient immune response to defend against pathogens

Sjogren's syndrome

destruction of lacrimal and minor salivary glands, often with RA

Foods to avoid with GERD

mint, chocolate, lemonade, fatty foods, oil dressings high in fat, tomatoes, carbonated beverages, wine

Neutrophils (type of WBC)

°Job: destroy and eliminate foreign invaders (phagocytosis and enzyme activity) °Mature neutrophils make up 55-70 % of total WBC's °Also called granulocytes (granules), segmented neutrophils "segs'-mature, polymorphonuclear cells (PMN's or polys), bands (less mature cells) °ANC (total number of mature neutrophils). Measure of resistance to infection. °Mature neutrophil lives 12-18 hours °Bands. # of Immature neutrophils. Increase in response to infection. Not capable of effective phagocytosis. "babies" ±"left shift" is when the # of band neutrophils is higher than the # of mature neutrophils. Bone marrow is pumping out bands in response to infection.

Eosinophils (type of WBC)

°Make up 1-4% of total WBC's °Work in later phase of inflammation, prolongs the response °During allergic responses/allergies, eosinophils increase.

Lymphocytes

°Make up 20-40 % of all WBC's °Come from Lymph stem cell °T cells (directly attack specific foreign invaders/antigens and produce cytokines...which activate immune responses) ° B cells (produce antibodies that destroy bacteria/viruses) °Natural killer cells (have granules with enzymes that kill virus/tumors)

Basophils (type of WBC)

°Make up only 1 % of total WBC's °Act on blood vessels with chemical mediators (histamine, heparin, serotonin, leukotrienes) °End result is vasodilation, capillary permeability (edema)

Monocytes (type of WBC)

°Mature into macrophages (involved in phagocytosis) °2-8 % of total WBC's °Job: destroy and eliminate foreign invaders °Big and live long time

Rheumatoid Arthritis (RA)

•A chronic, progressive, systemic inflammatory autoimmune disease process. • Affects primarily the synovial joints. •Systemic means this disease can affect any or all parts of the body(anywhere connective tissue is located...vessels), while affecting many joints •Autoantibodies are formed (Rheumatoid factors, RF) that attack healthy tissue...esp. synovial joints. •Causes inflammation •Begins to involve the articular cartilage, joint capsule, and surrounding ligaments and tendons. •Immunity and inflammatory factors involved: •CD4 helper T-cells and other immune cells in synovial fluid promote cytokine release, especially interleukin-1 (IL-1) and tumor necrosis factor-alpha (TNFA), which attack cartilage. • Neutrophils and other inflammatory cells in the joint are activated and break down the cartilage. • Immune complexes deposit in synovium, and osteoclasts are activated. • B- and T-lymphocytes of the immune system are stimulated and increase the inflammatory response.

How are organs allocated?

•ABO blood type •Medical emergency •Time on the waiting list •Geographic location

Contraindications for organ donation

•Active cancer •Current Infection •Active Psychiatric illness •Active substance abuse •Non-adherence with medical regimen

More about Rheumatoid Arthritis

•Affects women more than men (2-3 X more) •Synovium thickens and becomes hyperemic. •Fluid accumulates in the joint space, and a pannus forms. •Pannus is vascular granulation tissue (made of inflammatory cells) •Articular cartilage eroded and bone is destroyed. •Late in the disease, fibrous adhesions, bony ankyloses (abnormal fusion of bones in the joint), and calcifications occur. •Bone loses density, and secondary osteoporosis exists.

The immune system's rule in transplant rejection

•Allotransplantation (transfer of living organs or tissues from one part of the body to another or one individual to another). •Innate insults to the organ from the transplant itself (ischemia/repurfusion injury). •The injury starts/promotes the immune response. •2 pathways: •Immune pathways (inflammatory mediators) are started (from the donor organ) •Neutrophils, macrophages and NK cells (natural killer) •Host immune pathways are triggered (T-cells primarily) •Results in injury/rejection of the transplanted organ

What is angioedema?

•Angioedema is a severe type I hypersensitivity reaction that involves the blood vessels and all layers of the skin, mucous membranes, and subcutaneous tissues in the affected area •Deep, firm swelling of face, lips, tongue and neck •Can be other areas..intestines •May cause burning, numbness or pain •Causes: ACE inhibitors and NSAIDs (most common) •Assessment is ABC's •Treat with Epinephrine and Steroids

More about Lupus

•Blood vessels are targets (causes vasculitis)...reducing perfusion to organs....leads to permanent damage. •Autoimmune complexes tend to be attracted to glomeruli of the kidneys •Organs affected: •Vasculitis and rash (70 to 80%) •Kidney damage (40 to 50%) •Hematologic problems (50%) •Cardiovascular problems (30 to 50%) •Spontaneous remissions and exacerbations

Pathophysiology of anaphylaxis

•Bronchoconstriction/inflammation/mucosal edema and increased production •Blood vessel dilation (peripheral vasodilation) •Decreased cardiac output (coronary artery vasoconstriction)

Lab assessment for HIV/AIDS

•CBC with differential (looking at lymphocytes!) --WBC's decreased (<3,500)...called leukopenia (normal range is 5,000-10,000) --Lymphocytes (norm 1,500-4,500). See <1,500 (lymphopenic •CD4 + T cells (lower) and CD8 + T cells (are normal) •Antigen Antibody Tests --Measure pts. Response to the virus. --Antibody made 3 weeks to 3 months after infection --Does not indicate disease severity or progression, only presence of the virus and antibody. •ELISA and Western Blot (confirmatory) (measures HIV antibodies. Was gold standard..but takes longer..up to 28 days). •New test...Fourth Generation HIV assay. Looks for IgM and IgG antibodies. Can be positive in as little as 14 days. Can also differentiate between HIV 1 and 2 infection.

Systemic Lupus Erythematosus

•Chronic, progressive, chronic inflammatory connective tissue disorder •Can cause major body organs/systems to fail •Autoimmune process (Type III hypersensitivity reaction) •Form immune complexes that precipitate and deposit in various tissues •Autoantibodies focus on the cells of connective tissue...get systemic inflammation. •Autoimmune complexes tend to be attracted to glomeruli of the kidneys •Often some degree of kidney involvement

How is HIV transmitted?

•Contaminated blood or body fluids (semen, vaginal secretions, , sharing IV drug needles, sexual contact, transplacental, and possibly thru breast milk.

Psychosocial assessment for SLE

•Decreased activity due to chronic fatigue and generalized weakness •Avoid social gatherings •Withdraw from family •Fear and anxiety due to chronic nature of the disease •Fear of fatal outcome Intervention: •Assess patient and family feelings •Identify areas of intervention •Identify coping skill and support systems

Assessment for Inflammatory Bowel Disease

•Family h/o of IBD •Surgeries? Previous and current therapies for the illness? •Nutrition history (food intolerances?) •Bowel elimination patterns? (blood, color, #, consistency, character) •Abdominal pain, fatigue, weight loss, fever? •Hydration status, VS •Relationship between food intake, diarrhea, stress, activity •Travel •Use of NSAIDS? •Extraintestinal (arthritis, mouth sores, vision issues, skin issues) •Labs: CBC (H and H low), WBC's increased, CRP and ESR elevated, Na+K+ and Cl- low (diarrhea), low albumin (protein loss in stool) •Other: MRI, CT scans, upper and lower endoscopy, barium enemas (UC and Crohn's-show differences) •Psychosocial: Symptoms can produce anxiety and depression, loss of love for eating.

Stage III of HIV

•Final and most serious. Known as AIDS (acquired immune deficiency syndrome). •CD 4 cells fall below 200 cells/mm3. •See decreasing WBC's, decreased lymphocytes, production of incomplete/poorly functioning antibodies and macrophages. •Big reduction in immunity. HIV in blood increases dramatically. •Persistent fever, weight loss, fatigue and diarrhea. •Poor protection against infection and cancers. May get many opportunistic infections. •With good care and drug therapy, may live for many years.

About HIV

•HIV (human immunodeficiency virus) is a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases. •It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex (sex without a condom), or through sharing injection drug equipment. Can also be passed from mother to baby. •If left untreated, HIV can lead to the disease AIDS (acquired immunodeficiency syndrome). •The human body can't get rid of HIV and no effective HIV cure exists. So, once you have HIV, you have it for life. •A worldwide health problem.

Management of transplant rejection

•Immunosuppressants are used to inhibit the immune system & prevent organ rejection. •Immunosuppressants are drugs that decrease or prevent an immune response, thus suppressing the immune system •These drugs are used to prevent or treat rejection of transplanted organs •Transplant patients are on immunosuppressant therapy for the duration of their lifetime. Cost of therapy can average more than $2500 per month

Nursing care of the post-transplant patient

•Infection prevention •Hand washing!!! •Restrict visitors who are sick •Avoid crowds •Isolation as needed... •Really good personal hygiene •Recognition of S/S of infection •May be subtle (due to suppressed immune response) •Low grade fever, sore throat, chills, fatigue, mental status changes, vague reports of discomfort •Sepsis can occur quickly •Always consider the possibility of infection with a transplant patient •Monitor WBC's...notify if are decreased

Ulcerative colitis

•Inflammation of rectum/sigmoid colon and can extend up to the entire colon. •Remissions and exacerbations •Intestinal mucosa has increased blood flow, edema and reddened. Bleeding (hemorrhage) and ulcers. •Abcesses, edema and mucosal thickening, narrowing and bowel obstruction

Crohn's disease

•Inflammation of small intestine (most often), colon or both •Gum to bum! •Involvement of multiple regions of intestine with normal sections in between •Remissions and exacerbations •Strictures and deep ulcers, causing fistulas (common between bowel and bladder) •Severe diarrhea and malabsorption (of vital nutrients), see anemia due to iron deficiency.

High risk groups for getting HIV

•Male to male sex (increases with multiple sex partners) •Male to female sex •Female to male sex •IV drugs •Mother to child (placenta and/or delivery) Receiving contaminated blood products (esp. prior to 1985)

GERD (gastroesophageal reflux disease)

•Most common GI disorder •Backward flow of stomach contents into the esophagus •Esophageal mucosa gets irritated by gastric/duodenal contents which results in inflammation.

More nursing care for post-transplant patient

•Oral antifungal drugs are usually given with these drugs to treat oral candidiasis that may occur. •Assess the oral cavity often for white patches on the tongue, mucous membranes, and oral pharynx. •Education •*** Medication compliance..essential to prevention of rejection •Keep all appointments! •S/S of rejection and infection...call provider immediately •Oral forms are used when possible (decrease IV infection risk) •Take with food to reduce GI upset •Grapefruit juice interacts with some of these drugs •Self care (exercise, promotion of self esteem)

Management of SLE

•Persistent pain management •NSAIDs •Drugs therapy for disorder management •Steroids prn •Moist heat (warm baths and showers) •Fatigue •Prioritize daily activities (cooking, cleaning, etc..) •Adjust work roles prn •Keep moving (low impact and weight bearing exercises) •Preventing Organ Failure •Drug therapy •Lifestyle changes •Induces and prolongs remission...preventing organ damage. •Enhance self esteem

Diagnostics for SLE

•Physical findings and lab findings together to diagnose. •Laboratory •No single lab test to definitively diagnose •Presence of ANA's (anti nuclear circulating antibodies). •Lack of ANA's excludes SLE diagnoses, does not confirm it. •ESR •Serum Complement levels (C3 and C4) •CBC (often shows pancytopenia) •Specific body system function

Late signs and symptoms of RA (Rheumatoid Arthritis)

•Progressive inflammation and pain (esp. in AM) •Joints feel soft and look puffy •Contractures/deformities •Nodules over bony prominences •Eventually, most joints will be affected •TMJ and cervical joints rare.

Opportunistic infections that can happen with AIDS

•Protozoal-like Infections 1.• Toxoplasmosis 2.• Cryptosporidiosis 3.• Isosporiasis, microsporidiosis 4.• Strongyloidiasis 5.• Giardiasis •Fungal Infections 1.• Candidiasis 2.• Pneumocystis jiroveci pneumonia 3.• Cryptococcosis 4.• Histoplasmosis 5.• Coccidioidomycosis •Bacterial Infections 1.• Mycobacterium avium complex 2.• Tuberculosis 3.• Nocardiosis •Viral Infections 1.• Cytomegalovirus 2.• Herpes simplex virus 3.• Varicella-zoster virus

Pathophysiology of HIV

•RNA virus, enters and replicates inside a living cell. •Transcribes into DNA •Enters the cell's nucleus, becoming permanent part of the genetic structure. •Replicates like crazy, the cell becomes a virus factory. •Affects primarily CD4 + T cell, helper T-cell or T4 cell (different names). •Normal range of CD4 T lymphocyte cells is 700-1,000 cells/mm3. •This cell directs immunity and increases the activity of most immune system cells.

AIDS "defining" conditions

•Recurrent bacterial pneumonias (mycobacterium, TB) •Pneumocystis pneumonia (SOB, chest tightness, dry cough, dyspnea and tachypnea, fever, hypoxic, cyanotic) •Fungal infections (candida of the esophagus) (changes in taste, difficulty swallowing, retrosternal pain, white exudate, inflammation of mouth and back of throat). •CMV (fever, malaise, weight loss, fatigue, lymphadenopathy, visual impairment, colitis, encephalitis, pneumonitis, hepatitis) •Big factor in morbidity and mortality. •Tumors •Kaposi's sarcoma (skin lesions). Most common. Small, purplish-brown, non painful, non pruritic, palpable lesions occurring on any part of body. •Primary lymphoma (Hodgkins, non-Hodgkins). •HPV (leads to cervical and anal cancers) •HIV associated dementia complex (cognitive and motor impairments, behavior changes..confusion to severe dementia).

Signs and symptoms of anaphylaxis

•Remember...symptoms can be subtle at first! •Feelings of apprehension, weakness and impending doom, anxious, scared •Severe abdominal cramping and diarrhea •Then, generalized itching and urticaria (hives) •Symptom progression.....to airway and circulatory compromise

Signs/Symptoms of SLE (Lupus)

•Skin involvement •Butterfly rash •Polyarthritis •Osteonecrosis (from long term steroids) •Muscle atrophy •Fever (unexplained and intermittent) •Fatigue •Renal involvement (proteinuria) •Pleural effusions •Pericarditis •Raynaud's phenomenon •Neurologic manifestations •Serositis (serous membrane inflammation..pleura, pericardium or peritoneum)

Onset of Systemic Lupus Erythematosus (SLE)

•Slow onset •Present in women 10X more than men •Incidence in African Americans to Caucasians is 8:1 •Most commonly diagnosed between 30-44 years of age •Symptoms may be mild, vague, general •Time from onset of symptoms to diagnoses is 6 years

Sequence of inflammatory responses

•Stage I (vascular) change in blood vessels •Phase I—constriction •Phase II—hyperemia and edema •Stage II (cell exudate) neutrophilia, pus •Stage III (tissue repair and replacement) WBC's trigger new blood vessel and growth & scar tissue formation

Lab assessment for HIV/AIDS continued

•Viral Load testing --Directly measures amount of HIV RNA in the blood, used for diagnosis. --Used to measure therapy effectiveness --Higher the load, the greater the risk for transmission. --Viral load is present 10 days after infection --Positive result requires further testing •Other testing (based on pts. Overall health and infection status) •Urine, blood chemistries, other titres, LFT's, STI testing, TB testing, stool for O and P, biopsies of skin, lymph nodes, lungs, liver, GI tract, CXR's, colon or bronchoscopy, CT scans, PFT's, etc...

Type I: Rapid Hypersensitivity Reactions

■Also called atopic allergy ■Most common type ■Some reactions occur only in areas of antigen exposure ■Caused by increased production of immunoglobulin E (IgE) antibody class ■Allergens contracted by -Inhalation (pollens, spores, animal dander, dust, grass, ragweed) -Ingestion (foods, food additives, drugs) -Injection (bee venom, drugs, biologic substances) -Contraction (latex, pollens, foods, environmental proteins) ■Anaphylaxis is an example (medical emergency) -Blood vessel dilation -Decreased cardiac output -Bronchoconstriction

Anaphylaxis

■Life-threatening type I hypersensitivity reaction ■Rapid, systemic ■Can be fatal S/S: -Feelings of uneasiness, apprehension, doom -Generalized itching, urticaria -Erythema, angioedema -Wheals or hives -Congestion, rhinorrhea, dyspnea, respiratory distress