Labs
• Hbg 12-18
• Hct 37-52%
• WBC 5-10
• RBC 4.2-6.1
• PLT 150-400
• PT 11-12.5 sec (1.5-2.5x normal on Coumadin = 16.5-31.25
... [Show More] sec)
• INR 0.9-1.2 sec (Therapeutic level 2-3x normal = 1.8-3.6 sec)
• PTT 60-70 sec (1.5-2.5x normal on Heparin = 90-175)
• Na 135-145
• K+ 3.5-5
• Creatinine 0.5-1.2
• BUN 10-20
• Albumin 3.5-5
• Mg 1.5-2.5
• Ca 9-10.5
• Cl 98-106
• Phosphorus 2-4.5
• Specific Gravity 1.005-1.030
Discoid lupus
• Affects only the skin and is not lethal - Caused by UV rays
• Macular Rash & Discoid Rash
• Skin biopsy to dx
Systemic Lupus Erythematosus (313-317) ***TEMPERATURE***
• Chronic, progressive, inflammatory connective tissue disorder that affects multiple body systems &organs
o REMISSIONS/EXACCERBATIONS (can end up in the ICU) - Autoimmune
o Attracted to KIDNEY’s—Lupus Nephritis is leading cause of death; this is direct damage to the kidneys
• Poor survival associated with high creatinine, low hematocrit, proteinuria
o Young Women of child bearing age 20-40 Y (primary AA women)
o SLE & DLE both share a disfiguring and embarrassing rash!!
• Clinical manifestations
o Malar rash – red flat or raised rash over cheeks sparing nasolabial folds “butterfly rash”
o Discoid rash – Red raised patches with scaling follicle plugging
o Photosensitivity– discoid skin rash from sun exposure - pt should wear sunscreen or protective clothing
o Oral ulcers–usually painless
o Polyarthritis-multiple joints affected
• Small joints and knees inflamed
• Osteonecrosis from chronic steroid use (5y+)
o Pleuritis with pleural effusion or pericarditis
o Fever is the major sign of exacerbation
o Generalized weakness, fatigue, anorexia, weight loss
o Renal disorders–proteinuria, cellular casts
o Neurologic disorders – seizures, psychosis and also peripheral neuropathies
o Raynaud’s phenomena
• Exposure to cold or extreme stress – red, white, blue & pain of digits
o Alopecia or hair loss common
• Diagnostic Tests
o ANA most sensitive but antinuclear antibodies not specific to SLE
o C reactive protein can help differentiate SLE flare from an infection (remains normal if SLE flare)
o CBC shows pancytopenia (a decrease in all cell types)
• Medical Management
o Topical steroids for skin lesions
o Acetaminophen or NSAIDS (caution with kidneys) – tx joint & muscle pain & inflammation
o Hydroxychloroquine (anti-malarial agent) – dec absorption of ultraviolet light by skin, dec skin lesions
▪ Frequent eye exams – b4 starting and q 6 mon
o Glucocorticoids – Chronic steroid therapy
▪ Take in the am b4 breakfast
▪ Take Ca to prevent osteoporosis
▪ Maintain skin integrity
o Immuno-suppressants – methotrexate, azathioprine
o Belimumab – do not receive live vaccines for 30 days b4 tx
• Teaching
• Protect the skin
o Limit sun/ultraviolet light exposure to prevent exacerbation (fluorescent light too)
▪ Long sleeves, lg-brimmed hat, SPF 30+
o Clean skin with mild soap, pat dry and apply lotion
o Cosmetics ok w/ moisturizers and sun protection, no excess powder or drying substances
• Monitor temperature – first sign of exacerbation
• Avoid large crowds and people who are ill, bc immunosuppressed
• Avoid harsh hair tx (permanents or highlights)
• Pregnancy can cause exacerbation
Systemic Sclerosis (Scleroderma) ***SWALOWING PROBLEM***
• Uncommon, chronic, inflammatory, autoimmune connective tissue disease.
• Similar to SLE, but w/a higher mortality rate
• Doesn’t respond to steroids or immunosuppressants, why mortality higher than SLE
• Inflamed tissue becomes fibrotic and then sclerotic (hard) – renal involvement leading cause of death
• Women 25-55, most in 40s
• Diffuse cutaneous *Major organ problems
o First sx – hand and forearm edema w/ or w/o bilateral carpal tunnel syndrome
o Skin thickening on trunk, face, and proximal and distal extremities (most of the body)
o Painless symmetric pitting edema of hands & fingers (sausage like fingers)
o Changes of pigmentation with loss of skin folds & face can become mask like
o Develop early problems w/ GI tract (GERD to dysphagia), heart(myocardial fibrosis), lungs (fibrosis & PAH), & kidneys (malignant HTN)
o Complications can be rapid
• Limited cutaneous *Esophagus
o Skin thickening limited to sites distal to face, neck and distal extremities
o Organ changes rare or late
o CREST Syndrome
▪ Calcinosis – calcium deposits in tissues
▪ Raynaud’s Phenomenon – intermittent vasospasm of finger tips - first CREST symptom that develops
▪ Esophageal dysmotility - **Dysphagia**
▪ Sclerodactyly – scleroderma of digits – fingers stiff, shiny, and no skin folds
▪ Telangiectasia – capillary dilations that form vascular lesions on face, lips & fingers
• Medical Management
o Medications – Tx sx
▪ Vasoactive agents – CCB for Raynaud’s symptoms
▪ Anti – inflammatory meds - steroids
▪ Immunosuppressants
o Reduce renal complications
▪ ACE inhibitors and HTN control
o Treat PAH (Pulmonary Artery Hypertension)
▪ Bosentan - endothelin receptor antagonist – Liver toxic
• Nursing Management
o Keep HOB elevated 60 degrees during meals and at least an hour after
o Maintain skin integrity– esp with steroids & vasospasm
o Small frequent meals w/semisoft foods – avoid liquids (thick it) due r/f choking – small amounts & chew well
o Teach to avoid foods that include gastric secretion–spices, caffeine, pepper
o Promote bowel elimination – have both constipation & diarrhea
• Client Education
o How to dress in cold weather-gloves, socks, etc.
o Eliminate alcohol, cigarettes, extreme stress, and caffeine (vasoconstrictive)
o Biofeedback for stress management
o Disease process – Only gets worse
Fibromyalgia ***SLEEP & STRETCHING***
• Chronic pain syndrome, NOT inflammatory or autoimmune
• Pain stiffness and tenderness in trigger points – back of neck, upper chest, trunk, low back, and extremities
• Burning and gnawing that comes and goes, worsen w/stress, include activity, and weather conditions
• Women between 30 -50 years, Lyme disease, trauma, & flu-like illness
• Clinical Manifestations
o Fatigue – most common manifestation
o Morning stiffness
o Non refreshing sleep because of lack of stage 4 sleep- most do not get REM sleep
o Post exertional muscle pain
o 1/3 of patients have irritable bowel, tension headaches, PMS, numbness & tingling & Raynaud’s phenomena
o Depression – common with chronic pain
• Medical Management—Directed at symptom relief
o L tryptophan-used to enhance sleep
o TCAs (amitriptyline, nortriptyline) inhibit serotonin uptake - antidepressant
o Benzodiazepines for anxiety associated w/ depression
o NSAIDS for pain control but may need stronger meds if pain not well controlled
o Pregabalin (Lyrica) – FDA approved for fibromyalgia pain
o **LOW INTENSITY EXERCISE WILL DECREASE PAIN**
▪ Stretching, walking, swimming, rowing, biking, and water exercise
o Anticonvulsants like carbamazepine (Tegretol) & gabapentin (Neurontin) to help w/ chronic pain mgmt.
o Biofeedback– esp. helpful with pain syndrome
o Oral Mag helpful with muscle pain
Lyme’s Disease ***NO DARK CLOTHING***
• Tick born disease
• Considered a connective tissue disease because the skin, joints, nervous system, and heart are involved
• Sx begin w/i 3-30 days post bite
• Easy to treat when found in time
• Signs and Symptoms
o 1st - Red flat rash that clears in the center (bulls-eye lesion)- near the area of the bite
o Flu-like sx - Severe HA, Fever, Chills, Severe malaise, Fatigue, Stiff neck, & Joint pain
• Medical Management
o Doxycycline is the most common antibiotic used to treat (14-21 days)
o Severe disease- IV antibiotics for 30 days (ceftriaxone or cefotaxime)
o Neurologic abnormalities may occur if tx is ineffective
o Intra-joint steroids & NSAIDS may be used for joint inflammation & pain
o Long term effects include fatigue & arthralgias for many years after initial infection
• Prevention & Early Detection
o Avoid dark clothing, long-sleeved tops and long pants, tuck in shirt and pants into boots
o Insect repellant w/DEET
o Remove with gloves or tissue, do not squeeze or burn, flush down the toilet. Clean area with alcohol
o Wait 4-6 weeks after being bitten b4 being tested, testing b4 is not reliable
Allergy (348-358) ***EPI PEN, STOP INFUSION, LATEX CONDOM USE***
• “Hypersensitivity” inc immune response to the presence of an allergen “antigen”
• Diagnosis
o Allergy skin testing – Has to be red & raised
▪ avoid antihistamines & corticosteroid inhalers 2 weeks before testing
▪ Emergency equipment (resuscitation bag, suction, IV, drugs) for anaphylaxis
o RAST (radioallerosorbent test) or fluroenzyme blood tests used to measure IgE levels to specific allergens
o Pulmonary function measurements for allergic asthma
o Blood test measuring levels of IgE (normal 39 IU/ml)
o CBC may show inc eosinophils (normal 1-2%)
• Allergic Disorders
o Allergic Rhinitis
▪ Histamine causes capillary leak, nasal & conjunctival mucus secretion, & itching w/redness
▪ Allergic rhinitis has rhinorrhea (runny nose), stuffy nose, & itchy, watery eyes
▪ Clear or white nasal drainage, HA or feel pressure
o Food allergy vs food intolerance
▪ 8 foods 90% of true food allergies – milk, eggs, peanut, tree nuts, shellfish, fish, soybeans & wheat
▪ Diagnosis & treatment are avoidance
o Atopic dermatitis
▪ No cure but goal is to control symptoms with antihistamines & topical steroids
▪ Lesions red, itchy, contain exudates – may be drier in elderly
▪ Lesions typically found on cheeks, scalp, & forehead
o Urticaria “hives”
▪ Papules or plaques that often fade within 24 hrs.
▪ If hives last over 6 weeks – chronic urticaria
▪ ASA & NSAIDS can exacerbate hives-
▪ Antihistamines mainstay of treatment
o Anaphylaxis (Distributed Vasodilated Shock)
▪ Most common causes drugs, food, latex exposure, insect bites & stings (BEES)
▪ Symptoms
• Often present with hives, angioedema, dyspnea & wheezing
• Syncope, hypotension
• N&V, diarrhea, abd pain
• Flushing, headache, rhinitis, itching
• CV collapse, shock, resp tract obstruction
▪ Symptoms can begin 5-30 min after encountering trigger or be delayed an hour or more
▪ Treatment
• Assess respiratory status, airway & O2 sat (do not run and get a probe)
• Call the Rapid Response Team
• Oxygen via non rebreather 90-100% and have intubation/tracheostomy equipment ready
• 1st - Immediately discontinue IV drug and changing the tubing and hang NS
• Prepare to administer Epinephrine IV OR EPI PEN
• Elevate HOB 45 degrees if BP normal, 10 degrees if hypotensive
• Reassure patient frequently
• Medical/Nursing Management
o Identify allergen & avoid if possible
o Medications
▪ Antihistamines - diphenhydramine – 2nd line drugs (angioedema & urticaria)
▪ Decongestants – most OTC – are sympathomimetic
▪ Steroids – 2nd line drugs
• Nasal sprays – beclomethasone, triamcinolone, fluticasone (limit 5 days at a time)
• Topical creams for dermatitis - hydrocortisone
• Oral – have systemic effects also - prednisone
• Inhaled steroids for allergic asthma – fluticasone, salmeterol
o Desensitization – allergy shots
• Latex Allergy
o Type 1 hypersensitivity reaction
o People at greatest risk for developing a latex allergy are those with high exposure to natural latex products like patients with spina bifida, frequent use of latex condoms and healthcare workers.
o Allergic to bananas, avocados, and some nuts more likely to have latex allergy
HIV/AIDS
• Infection w/ human immunodeficiency virus (HIV) results in destruction of the body’s defenses & immune system
• Risk Factors
o Virus is spread through sexual practice (primary), exposure to blood & body fluids and through perinatal
o Male homosexual activity still greatest risk for most Americans
o Increased risk with IV drug users, women & heterosexuals noted recently
o Women over 50 acquire HIV primarily through heterosexual contact
o IV drug use accounts for largest number of HIV infections through exposure to infected blood
o Accidental needle stick exposure poses greatest hazard to healthcare workers
o Standard Precautions markedly reduce healthcare workers exposure
• Pathophysiology
o Retrovirus infects T helper cells, macrophages & B cells
o Normal CD4+ T cell level is 500 – 1600/mm3 – Decrease w/age
o With CD4+ T cell level < 200/mm3 - infection is likely to develop
o Antiretrovirals inhibit ability of virus to enter cells or replicate, reduce amount circulating virus & halting its destructive activity
o Usually at least two to three drug protocol
o 5 % of HIV people after 10 y show no progression and are called long-term non-progressors (LTNP’s)
o Main target of HIV is immune system but also damages other parts of body as a result of HIV in body tissues
▪ Cranial & peripheral neuropathies
▪ Cardiomyopathy
▪ Pneumonitis
▪ Malabsorption in small intestine
▪ Nephritis
▪ Arthritis, psoriasis
▪ Adrenalitis
▪ Anemia, granulocytopenia, thrombocytopenia
• Clinical Manifestations—Must know
o Classification based on:
▪ CD4+ T cell counts, viral load (amount of virus present in the body)
▪ Clinical presentation
o Primary infection–initial period after a person acquires HIV
▪ Fever, fatigue, lymphadenopathy, N/V
▪ HA, truncal rash, ulcers of mouth & genitals, thrush, pharyngitis, diarrhea, hepatomegaly, myalgia, arthralgia, leukopenia
▪ CD4+ count may rapidly drop to below 100/mm3 (But rebounds)
▪ This is the time when antibodies are developed but not detected for 4-12 weeks – seroconversion
• HIV enzyme immunoassay – if positive Western Blot is performed to confirm HIV infection
▪ Preliminary studies show that starting retrovirals at this time can prevent damage to the immune system and other body systems
• Once you start the antiretrovirals you cannot come off of them
▪ Some not dx bc of mild sx, not seeking medical attention or healthcare professional does not recognize & take adequate hx (symptoms can mimic mono)
• AIDS criteria
o CDC definition - patient has AIDS if he or she is infected with HIV & presents with ONE of the following:
o A CD4+ T-cell count < 200 OR
o Patient has one of the defining illnesses ***NO DROPLET OR CONTACT, ONLY STANDARD***
▪ Candidiasis of lung, bronchi, or esophagus; Coccidioidomycosis; Cryptosporidiosis; CMV; TB; Histoplasmosis; Kaposi’s sarcoma (cancer); Pneumocystis Jiroveci Pneumonia (kills most AIDS pt.)
▪ Defining illnesses usually do not make us sick, with a heathy Immune system (standard precautions) EXCEPT for TB which needs airborne and standard.
• Until parameters other than a skin test come back negative for TB in a pt w/ AIDS who has TB sx, maintain airborne precautions along with standard precautions.
• Complications
o Opportunistic infections–CMV(visual disturbances), pneumocystis
o Kaposi’s sarcoma
▪ Most common AIDS related malignancy
▪ Small, purplish brown, raised lesions on skin or mucous membranes, not painful or itchy
• Painful if large lesions, open, and weeping
▪ Make-up ok if lesions are closed
▪ With HAART therapy many lesions will disappear
o AIDS dementia– most antiretrovirals do not cross the blood brain barrier
o Wasting syndrome– HIV affect absorption in small intestine
• Clinical Management
o Medication administration
▪ Antiretrovirals
• Inhibits viral replication, but doesn’t kill the virus
• Offer treatment asymptomatic with CD4+ < 250-300
• CD4+ >350 can defer if asymptomatic or consider if viral load is high
• Buffalo humps or cervical (neck) fat development & lg abd fat accumulations
▪ HAART – Highly Active Antiretroviral Therapy, uses 4 classes of antiretroviral to reduce viral load, improve CD4+ T-cell counts, and slow disease progression
• Multiple drugs taken to prevent drug resistance
• Drugs need to be taken correctly 90% of the time forever
• Missed doses of drugs contributes to drug resistance due to inc viral replication
• Drawbacks
o Expensive, food and timing requirements, significant s/e
o IRIS – Immune Reconstruction Inflammatory Syndrome
▪ T-cells slowly rebound and generate inflammatory reaction from opportunistic infections
▪ High fever, chills, and worsening of infection (ex. TB becomes worse)
▪ Tx with short term corticosteroids to reduce inflammatory response
o Preventing infection (when neutropenic, low WBCs)
▪ Clean toothbrush weekly by running it through dishwasher or bleaching
▪ Avoid fresh fruits and veges; undercooked meats, fish, and eggs; and pepper and paprika
▪ Do NOT drink water, milk, juice that have been standing for longer than 1 hour
▪ Do not change pet litter boxes, if unavoidable, use gloves & wash hands
▪ Take temp once a day and report if > 100, have persistent cough, cloudy urine, etc.
▪ Do not dig in garden or work with houseplants
o Pain management - esp. with neuropathies
▪ Pregabalin (Lyrica), TCAs- amitriptyline (Elavil)
▪ Anticonvulsants- gabapentin (Neurontin), phenytoin (Dilantin), carbamazepine (Duragesic)
▪ Opioids – hydrocodone, tramadol, or codeine, oxycodone, morphine, hydromorphone or fentanyl
o Maintenance of skin integrity
• Client education
o Recurrent labs
o Annual TB test
o PAP test- every 6 months
o Chest x-rays
o Long term medication, dosing, S/E, timing around the clock
o Diet high in calories and protein, 2-3 L H2O, avoid fatty foods (causes diarrhea) due to intolerance from s/e of antiretrovirals.
• Home care and infection spreading control
o Do not share razors or toothbrushes
o Wipe up body fluids, flush, and clean area with bleach
o Needles or sharps in coffee can or bleach bottle & decontaminate when full w/bleach, seal w/tape, place in paper bag, and put in regular trash
o Condoms all the time
Organ Transplants
• Contraindications to Transplant
o Presence of active systemic infection
o HIV/AIDS
o Malignant disease(except skin cancer)
o Active peptic ulcer disease
o Active abuse of alcohol or other substances
o Severe damage to organ systems other than one to be transplanted (ex. Cardiac Disease)
o Severe psychiatric disease- to where they can’t understand and follow the post-transplant protocol
o Demonstration of past or current inability to comply with a prescribed medical regimen
o Lack of a functional social support system
o Lack of resources to pay for surgery, hospitalization, medication, and follow up care
• Nurses Role in Organ Donation
o Identifying potential donors, notifying OPO, assisting in management of donor
▪ In Kentucky & S. Indiana all hospital deaths must be called to KODA
▪ Potential brain death with low GCS must be called prior to death
o Preparation of recipient – organs have limited viability outside the body
▪ Heart 4 - 5 hrs
▪ Lung 4 - 6 hrs
▪ Liver 24 - 30 hrs
▪ Pancreas - 24 hrs
▪ Kidney – 48 – 72 hours- often a 72 hr kidney will need dialysis before it starts on its own
• Hyperacute Graf t Rejection
o Within 48 hrs after surgery
o Caused by presence of antibodies – results in organ necrosis
o Prevented by histocompatibility testing, crossmatching & PRA (preformed reactive antibody) testing
o Tx w/ plasmapheresis - but if it fails the patient needs a new organ transplant
o Diagnosis is made based on serologic labs, physical assessment data & hemodynamic measures
• Acute Graf t Rejection
o W/i first three months after transplant
o Either a cellular immune response mediated by T cells or an antibody mediated response or a combination
o Diagnosis is made based on clinical manifestations, labs & results of a biopsy
o S/S of acute graft rejection
▪ Fever
▪ Graft tenderness
▪ Fatigue
▪ Heart – SOA, irregular heartbeat
▪ Lung – SOA
▪ Liver- tachycardia, RUQ or flank pain, diminished bile drainage, change in bile color, inc jaundice
▪ Pancreas- kidney issues occur before pancreatic problems; high glucose levels is a late sign
▪ Abnormal Labs
• Kidney – inc BUN & creatinine
• Liver - inc total bilirubin & liver enzyme levels (AST and ALT)
• Pancreas – inc urine amylase/lipase, inc creatinine
• Heart- BNP
▪ Diagnosis of rejection is by organ biopsy (both acute & chronic rejection)
▪ Treatment of acute rejection is called rescue therapy and includes: DON’T NEED TO KNOW NAMES
• High dose steroids
• Muromonab-CD3 (Orthoclone OKT3)
• Antilymphocyte globulin
• Includes 2-3 antirejection meds, to further immunosuppress - high risk for infection
• Chronic Rejection
o Gradually during period of months to years, after the first 3 months after transplantation
o May be a result of frequent acute rejection episodes, increased ischemic time, or CMV infection
o Usually slow progressive loss of graft function
o Transplanted organ develops persistent perivascular inflammation associated with local myocyte necrosis
o Treated like acute rejection & new organ transplant may be needed
• Other Post Transplant Issues
o Infection
▪ Leading cause of morbidity & mortality after transplant
▪ Results from immunosuppression or altered immune defenses
▪ First month postop – nosocomial infections common
▪ 1-6 months – opportunistic infections - pneumocystis carinii, candida, & CMV
▪ Lungs are most common infection site followed by blood, urine, & GI tract
o Malignancy
▪ Development of post-transplant malignancy is well documented
▪ Basal cell & squamous cell skin & lip cancer, Ca of vulva, perineum & lungs
▪ All patients should be screened for [Show Less]