Patho exam 4
explain the major histocompatibility complex molecules
genes expressed on all cells to differentiate between self and non self (Helps immune system know what to attack)
List the manifestations of hypersensitivity
itching, conjunctivitis, hypotension, rhinitis, bronchospasm, dysrhythmias, GI cramps
treatment for inflammation
RICE
The nurse determines that the patient has understood the discharge teaching regarding warfarin based on which of the patients statements? - " I should keep taking ibuprofen for my arthritis" - " I should use a soft toothbrush for dental hygiene" - " I should decrease the dose if I start bruising easily" - " I will double my dose if I forget to take it the day before"
" I should use a soft toothbrush for dental hygiene"
the nurse is assessing a patient who has been prescribed atorvastatin. What instruction should the nurse provide for the patient to ensure proper administration of the medication? -" take the drug after breakfast" -"take the drug in the evening" -"take the drug with an antacid" -"take the drug on an empty stomach"
"take the drug in the evening"
A patient with nonvalvular atrial fibrillation is to be discharged on dabigatran etexilate. which statement should the nurse include in the discharge teaching? 1) " the medication must be stored in the manufacturer-supplied bottle" 2)"once a new bottle is opened, the capsules maintain efficacy for 90 days" 3)"if you have difficulty swallowing the capsule, you can open it and mix it with food" 4) "you will need to learn how to give yourself a subcutaneous injection in your abdomen"
"the medication must be stored in the manufacturer-supplied bottle"
The nurse is caring for a patient who is scheduled to begin warfarin treatment and is currently being treated with amiodarone. Based on this information, the nurse anticipates which change will be made to the medication regimen? -The dosage of warfarin will be increased -the dosage of warfarin will be decreased -the dosage of the amiodarone will be increased -the dosage of the amiodarone will be decreased
-The dosage of warfarin will be decreased -amiodarone increases the effectiveness of warfarin
Low molecular weight heparins (e.g., enoxaparin, Lovenox) dalteparin and fondaparinux, fragmin
-heparin preparations composed of molecules that are shorter than those found in unfractioned heparin -longer 1/2 life (6x as long as IV heparin) -anticoagulant Therapeutic uses: -prevention of DVT following surgery (including replacement of hip and knee) -treatment established DVT -prevention of ischemic complications in patients with cardiac disorders Route: -SUBQ -dosage based on BODY WEIGHT Antidote: PROTAMINE SULFATE Adverse effects: -bleeding (but less than with unfractioned heparin) -immune-mediated thrombocytopenia -severe neurologic injury for patients undergoing spinal puncture or spinal epidural anesthesia *costs more than unfractioned heparin *does not require monitoring; can be given at home
list some adverse effects of corticosteroids
-reduces WBC (decreased immune response and risk for infection), increases tissue breakdown, delayed healing, delayed growth in children, Na and H2O retention
A patient is being discharged from the hospital on warfarin for deep vein thrombosis prevention. Which instructions should the nurse include in the patient's discharge teaching plan? Select all that apply. -wear a medical alert bracelet -check all urine and stools for discoloration -do not start any new medication without talking to the healthcare provider -no lab or home monitoring of INR is required after the first 6 months -eneteric coated aspirin and any aspirin products can be used unless they cause a gastrointestinal ulcer
-wear a medical alert bracelet -check all urine and stools for discoloration -do not start any new medication without first talking to the health care provider
name the 3 ways that antibodies work
1) opsonization: antibody binds to help other immune cells attach 2) activate complement system: results in cell destruction 3) neutralize toxins
which therapeutic lifestyle changes are shown to reduce low-density lipoprotein (LDL) cholesterol? select all that apply 1) active exercise for 30-60 mins five days a week 2) reduction of tobacco to occasional use 3) active exercise for 15 mins 2-3 days a week 4) reduction of saturated fat intake 5) weight loss with metabolic syndrome
1, 4, 5
In which patient would a low dose aspirin be contraindicated? 1) a patient with thrombosis 2) a patient with a heart problem 3) a patient with a hemorrhagic stroke 4) a patient with a deep vein thrombosis
A patient with a hemorrhagic stroke
Warfarin (Coumadin) Normal platelet counts ranges from 150,000-450,000 -having more than 450,000 platelets is a conditioned called thrombocytosis; having less than 150,000 is known as thrombocytopenia
Anticoagulant MOA: -(ACTS ON EXTRINSIC PATHWAY, in the liver) Blocks Vitamin K which is needed for the synthesis of factors II, VII, IX, X, proteins C and S⇒ inhibits formation of thrombin⇒inhibits conversion of fibrinogen to fibrin (monitor w/ PT) -inhibits synthesis of vitamin K dependent clotting factors including prothrombin and factor X Route: -PO: slow onset(hours) duration of action is prolonged (days) Therapeutic uses: -not useful in emergencies -long term prophylaxis of thrombosis -prevention of venous thrombosis and associated pulmonary embolism -prevention of thromboembolism-in patients with prosthetic heart valved -prevention of thrombosis -in patients with atrial fibrillation Lab value monitoring parameters: -PT/INR (prothrombin time/ International Normalizing Ratio) -INR drawn today is going to predict the INR in3 days- working on factors already in circulation Antidote: VITAMIN K- administered IV -patient must be closely monitored during administration -dietary sourced of vitamin K: mayonnaise, canola oil, soy bean oil, green leafy vegetables Adverse effects: -hemorrhage -fetal hemorrhage + teratogenesis from use during pregnancy-crosses placenta Drug interactions: -drugs that increase anticoagulant effects: heparin -drugs that promote bleeding: aspirin -drugs that decrease anticoagulant effects: oral contraceptives, vitamin K
Rivaroxaban (Xarelto)
Anticoagulant.-Direct Factor Xa Inhibitor. MOA: -binds directly to the active center of factor Xa -inhibits production of thrombin Route: -administered PO Drug interactions: -levels can be altered by drugs that inhibit or induce CY3A4 and P-glycoprotein Uses: -DVT prevention after orthopedic surgery -stroke prevention in patients with atrial fibrillation Adverse effects: -bleeding -spinal/epidural hematoma-prolonged or permanent paralysis Advantages over Warfarin: -rapid onset -fixed dosage -low bleeding risk -few drugs interactions -no need for lab monitoring Disadvantages: -no antidote for overdose -must be administered on schedule due to rapid onset -renal impairment can delay excretion -should not be used in patients with hepatic alterations -unsafe to use in pregnancy-can cause hemorrhage
Amiodarone (Cordarone)
Antidysrhythmic agent. Prolongs repolarization, relaxes smooth muscles, decreases vascular resistance. For ventricular fibrillation and unstable ventricular tachycardia. Incompatible with heparin, may be given in PO maintenance dose, monitor for respiratory complications.
Clopidogrel (Plavix)
Antiplatelet (Adenosine Diphosphate receptor agonist) Therapeutic uses: -prevents blockage of coronary artery stents -reduces thrombotic events in patients with acute coronary syndromes (MI, ischemic stroke and vascular death) Antiplatelet actions: -blocks P2Y12 ADP receptors on platelets and thereby prevents ADP-stimulated platelet aggregation (irreversible) Pharmacokinetics: -rapidly absorbed from GI tract, both in presence and absence of food -prodrug that undergoes metabolism to its active form, primarily by hepatic CYP2C19 Adverse Effects: -abdominal pain, dyspepsia (indigestion), diarrhea, rash -increases risk for GI bleeding and hemorrhagic stroke -thrombotic thrombocytopenic pupura (TTP)-rare Drug interactions: -drugs that promote bleeding -proton pump inhibitors (PPIs)-omeprazole (Prilosec, losec) Nursing interventions: -use with caution in combination with other drugs that promote bleeding
Steroids
Corticosteroids: -Antiinflammatory effects: decreased capillary permeability enhanced effectiveness of epinephrine + norepinephrine reduced number of leukocytes and mast cells reduces immune response -Adverse Effects: reduces WBC (decreased immune response + risk for infection) increased tissue breakdown delayed healing delayed growth in children Na + H20 retention Glucocorticoids: raises blood sugar levels; mimics effects of cortisol; adrenal cortex -adverse effects: atrophy of lymphoid tissue; reduced number of WBC decreased immune response increased risk of infection catabolic effects increased tissue breakdown; decreased protein synthesis delayed healing delayed growth in children retention of sodium and water b/c of aldosterone-like effect in the kidney
Dabigatron etexilate (Prodaxa)
Direct Thrombin Inhibitor MoA: -direct, reversible inhibitor of thrombin -prevents the conversion of fibrinogen into fibrin -prevents the activation of factor XIII and thereby prevents the conversion of soluble fibrin into insoluble fibrin Therapeutic uses: -atrial fibrillation -DVT -PE -Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation Pharmacokinetics: -food delayed absorption -plasma peak 1-hr without food; 3 hrs with food -well absorbed in GI tract- administered PO Adverse Effects: -bleeding -FDA Black Box warning: doesn't require monitoring of anticoagulation Advantages of Prodaxa: -rapid onset -doesn't require monitoring of anticoagulation (blood tests)- which may make it less desirable or more dangerous (ex. patient in MV accident may hemorrhage to death b/c they were too anti coagulated and bleed to death) -few food and drug interactions -same dose can be used for all patients regardless of age or weight
list the chemical mediators and their function in inflammation
Histamine: vasodilation and increase capillary permeability Prostaglandins: vasodilation, capillary permeability, pain Bradykinin: increase capillary permeability and pain
list the antibody classes and functions:
IgA: mucous membranes of GI tract and lungs; transferred via breast milk IgD: found on B cells serves as a receptor for antigen recognition IgE: causes the symptoms of allergies (EEEEEEs), binds to parasites (Evil worms) allowing eosinophils to lyse the parasite IgG: "G" greatest amount of antibody, promotes target cell lysis, phagocytosis, crossed the placenta to protect newborns IgM: first antibody produced, promotes target cell lysis, presents on surface of "B" cells to serve as a receptor for antigen recognition
Aspirin (ASA)
MOA: -supresses platelet aggregation by causing irreversible inhibition of cyclooxyrgenase, an enzyme required by platelets to synthesize TXA2 (a factor that can promote platelet activation) - also acts on vascular smooth muscle to promote vasoconstriction (both promote hemostasis) Therapeutic uses: -ischemic stroke -transient ischemic attack (TIA) -chronic stable agin-pain relieved with rest -unstable angina -coronary stenting -Acute MI -Previous MI -primary prevention MI Adverse effects: -increases risk for GI bleeding and hemorrhagic stroke -enteric coated tablets may not reduce the risk for GI bleeding Increased risk for GI bleeding (coffee ground emesis, black tarry stool) Increase Prothrombin time (PT/INR) ...stop a week before surgery due to platelet life of 7 days Enteric coated = prevent GI bleed/upset Toxicity = tinnitus, humming, dizzy, bad balance, nausea Caution = with heparin, lovenox, coumadin, Nsaids
Heparin (unfractioned) EMERGENCY : rapid acting anticoagulant; effects begin immediate after administration
MOA: -inhibits thrombin indirectly -enhances the activity of antithrombin -reduces the activity of thrombin and factor Xa (suppresses the formation of thrombi in veins) -production of thrombin is reduced -clotting is suppressed -primarily used to prevent venous clots -deep vein thrombosis Sources: -lungs of cattle -intestines of pigs *normal aPTT: 30-40 seconds; with heparin PTT is 120-140 seconds and aPTT is 60-80 seconds (higher # indicated bleeding disorder or liver disease) *evaluation for effectiveness (activated partial thromboplastin time aPTT) - how well are they being coagulated and to monitor continuous therapy (continuous therapy has higher risk of bleeding) Routes: -continuous IV (heparin drip) -intermittent IV (heparin blogs) -deep sub Q -cannot be administered PO b/c it cant cross the membranes of the GI tract Therapeutic uses: -preferred anticoagulant when rapid anticoagulation is required -pulmonary embolism -massive deep venous thrombosis (DVT) -open heart surgery -renal dialysis -low dose therapy postoperatively (DVT prophylaxis) -maintain patency of central lines Adverse Effects: -hemorrahage -heparin-induced thrombocytopenia (allergic run to heparin) -antibodies form against heparin-platelet protein complexes -potentially life threatening reduction in platelet count
Ibuprofen
NSAID MoA: -reversible inhibition of COX1 and COX2 -anti-inflammatory, analgesic, antipyretic actions Uses: -fever -mild to moderate pain -arthritis -rheumatoid arthritis + osteoarthritis -bursitis (joints) -tendinitis -dysmenorrhea (menstural cramps) Adverse Effects : -may pose a risk of MI +stroke *does not protect against MI and stroke, the opposite actually occurs and it may increase the risk of thrombotic events (relatively low) *Ibuprofen should not be taken by anyone who has kidney issues, high blood pressure, stomach ulcers and, in some cases, asthma.
A patient is receiving an intravenous heparin drip. Which laboratory value requires immediate action by the nurse? - platelet count of 150,000 mm3 -international normalized ratio (INR) of 1.0 -blood urea nitrogen (BUN) level of 12 mg/dL -activated partial thromboplastin time (aPTT) of 120 seconds
activated partial thromboplastin time (aPTT) of 120 seconds
define hypersensitivity
altered immunologic response to an antigen that results in disease or damage
differentiate between antigenic shift and antigenic drift
antigenic shift: major changes in antigenicity antigenic drift: virus undergoes yearly mutations in surface antigens (DNA)
A patient with warfarin toxicity is prescribed phytonadione. which nursing assessment ensures patient safety? -assess the amount of blood lost -assess the prothrombin time (PT) -assess the white blood cell (WBC) count - assess the partial thromboplastin time (PTT)
assess the prothrombin time (PT)
T/F: most serum cholesterol comes from dietary sources
false: endogenous sources--produced in the liver
differentiate between cell mediated and humoral response
cell mediated: CD8 (cytolytic T cells) and macrophages attack the foreign object after being activated by CD4 cells (helper T cells) humoral: B cells make antibodies to attach to the foreign substance
The body's first line of defense is... the second line of defense...
first: skin and secretions second: inflammation, phagocytosis, NK cells
lab reports indicate that a patients serum cholesterol concentration is 250 mg/dL and triglyceride levels are 450 mg/dL. The health care provider prescribes atrovastatin to lower cholesterol levels. What is the desired effect of the drug on the patient's lipoprotein levels?
decrease in LDL
The nurse is monitoring a patient receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding most likely relates to an adverse effect of heparin? -discolored urine -heart rate of 60 bpm -respiratory rate of 14 breaths per min -blood pressure of 160/80 mm Hg
discolored urine
the patient being treated with a continuous intravenous (IV) infusion of heparin. What is the nurses highest priority? -ensure that protamine sulfate is readily available at all times -ensure that the patients lab values are monitored correctly -ensure that a loading dose was initially administered when treatment began -ensure that the patient is taught dietary restrictions while on the medication
ensure that protamine sulfate is readily available at all times
list the signs and symptoms of inflammation
erythema, heat/fever, swelling, pain, loss of function
Statins Normal levels -triglycerides <150 md/gL high: >200 mg/dL -cholesterol < 200 mg/dL. high: >240 mg/dL -LDL <100 mg/dL (normal)
lower cholesterol in the blood and reduce its production in the liver by blocking the enzyme that produces it (HMG-CoA Statins) (Atorvastatin; Lipitor, Fluvastatin, Lorastatin, Pravastatin, Rosurastatin, Simvastatin) MOA: -increases the number of LDL receptors on liver cells -elevates HDL cholesterol -reduces triglyceride levels -promote plaque stability -reduce the risk for cardiovascular events -increased bone formation Potential Adverse effects: -headache, rash, GI disturbances *myopath/rhabdomyosis-can injure muscle tissue -hepatotoxicity - liver function tests Drug to food interactions: -GRAPEFRUIT JUICE can inhibit CYP3A4 thus raising the level of statins -erythromyocin, anti fungal agents, amiodarone, can cause statin blood levels to rise Nursing Implications: -can use in pregnancy-classified as category X -***dose should be administered once daily in the evening -evaluate patient for complaints of MUSLCE PAIN -liver function studies *other products used to alter plasma lipid levels: FISH OIL -high in omega-3 fatty acids -can lower TG levels -may reduce platelet aggregation
differentiate between macrophages and the different types of granulocytes
macrophages/monocytes: main function is phagocytosis, found in acquired/natural/ inflammation, helps CD4 in delayed hypersensitivity eosinophils: bind to IgE or parasitic worms, moderate inflammatory response Basophils: release histamine neutrophils: phagocytize bacteria bind to IgG
A patient with the cardiovascular disease is taking rosuvastatin. Which finding would indicate a potential adverse effect of this drug ? -muscle pain and tenderness -platelet count of 100 x 10 3/mm 3 -blood pressure of 140/90 mm Hg -wheezing and shortness of breath
muscle pain and tenderness
is inflammation the same as infection?
no, but infection can cause inflammation
The patient is being treated with heparin. The nurse assesses the patient's laboratory test results an finds that the platelet count has dropped to 75,000/mm 3. What action will the nurse perform next? -prepare to administer protamine sulfate -no action is needed this is a normal finding -notify the primary healthcare provider of this finding -document the finding and continue to monitor the patient
notify the primary healthcare provider of this finding
a patient who has been receiving an infusion of heparin has an activated partial thromboplastin time (aPTT) of 120 seconds what is the nurses first action? 1) assess for bleeding 2) shut off the heparin drip 3) call the healthcare provider 4) keep the patient on bed rest
shut off the heparin drip
The nurse assesses the patient's prothrombin time (PT) to determine the effectiveness of anticoagulant therapy and notes that it is 32 seconds. How will the nurse interpret this value? -the PT is within normal limits -the PT is significantly elevated -the PT is significantly decreased - The PT is inadequate to evaluate treatment
the PT is significantly elevated
Alteplase (Activase)
thrombylytic drug MoA: -binds to plasminogen to form active complex -converts plasminogen to plasmin Therapeutic uses: -massive pulmonary emboli -ischemic stroke-clot in the brain (can give within 4-6 hours of symptoms -FAST- otherwise it can cause bad effects -acute coronary thrombosis (acute MI) if cardiac cauterization lab is not available Adverse effects: -bleeding -destroys pre-existing clots -degrades clotting factors
a patient who has been taking warfarin is admitted with coffee-ground emesis. what can the nurse anticipate being prescribed for this patient? -vitamin E -vitamin K -protamine sulfate -calcium glutinate
vitamin K
