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NUR 204 Nursing Care of Client 4 /Exam 1 Study guide
Rheumatology
- Noninflammatory: - Osteoarthritis - Most common type of arthritis.
- Inflammatory:
- Rheumatoid arthritis
- Systemic lupus erythematosus (SLE)
- Autoimmune disease Osteoarthritis
- Progressive loss of cartilage
- Most common type of arthritis - History:
- Usually older than 60
- Physical assessments:
- Joint pain/stiffness
- Crepitus
- Heberden’s nodes - nodules on distal joints
- Bouchard’s nodes - nodules on proximal joints
- Joint effusions - most common is synovial joint
- Atrophy of skeletal muscle - Diagnosis:
- ESR
- hsCRP - higher sensitive test, also show wide spread inflammation
- Imaging
- MRI/CT - Nonsurgical management:
- Drug therapy
- Rest
- Immobilization
- Positioning
- Thermal modalities
- Weight control
- Integrative therapies ✓ Turmeric and glucosamine-supplements for inflammation.
- Surgical management:
- Early: joint stiffness/swelling/pain/fatigue/generalized weakness
- Late: joints become progressively inflamed and painful - Diagnosis:
- Laboratory :
- Rheumatoid factor (positive)
- Antinuclear antibody titer (increased)
- ESR (increased)
- Serum complement (C3 and C4)
- Alpha 1 globulin/Gamma globulin (increased)
- Serum immunoglobins - Diagnostic tests
- XR
- CT scan
- Arthrocentesis
- Bone scan - Systemic Complications
- Weight loss, extreme fatigue, low grade fever, anorexia
- Exacerbations
- Subcutaneous nodules
- Respiratory, cardiac complications
- Vasculitis - inflammation of the blood vessels
- Periungual lesions - wart-like lesions
- Paresthesias - Associated syndromes:
- Sjogren’s syndrome – dry eyes, dry mouth, and DX of RA.
- Felty’s syndrome – complication of long-term RA; triad – DX of RA, enlarged spleen, and abnormally low WBC’s
- Caplan’s syndrome – nodules within the intrapulmonary layer of the lung tissue
- Can also acquire this disease from prolonged exposure of coal dust - Pharmacological management:
- DMARDs – Rheumatrex/MTX/Leflunomide/Plaquenil - NSAIDS – anti-inflammatory
- BRMs – Embrel/Remicade/Humira
- helps to make immune system stronger
- Prednisone – decrease inflammation
- Give with food
- Taper down
- Can raise glucose in diabetic patients; can also decrease calcium level
- Give vitamin D and calcium supplement
- Immunosuppressive agents – Imuran/Cytoxin
- Suppresses immune system therefore suppresses the progression of the disease process. - Non-pharmacological management:
- Adequate rest
- Proper positioning
- Ice/Heat
- Plasmapheresis – removes antibodies
- Heated paraffin
- Warm shower/batH - Self-Management:
- Dietician for strategies to eat
- OT for utensils to assist with eating/dressing
- Manage fatigue – set priorities/rest
- Include family in teaching - Joint protection: (KNOW THIS!!)
- Hold objects with two hands
- Use larger joints
- Adaptive devises
- Bend at knees to lift
- Sit in hard back chair-slouching causes more damage ✓ Main goal is for the patient to remain independent. Systemic Lupus Erythematosus (SLE)
- Chronic, progressive, inflammatory autoimmune connective tissue disorder
- Remissions/exacerbations ✓ Butterfly rash-associated with Lupus ✓ Can cause major organs to fail in the body
- Assessment :
- Skin involvement (butterfly rash)
- Polyarthritis
- Osteonecrosis
- Muscle atrophy
- Fever/fatigue
- Renal involvement
- Pleural effusions
- Pericarditis
- Limited: ▪ fingers/hands/face ▪ CREST Syndrome **✓ Usually attacks women between the ages of 25 - 55 but commonly in their 40’s
- Assessment: -** Hand and forearm edema with possible bilateral carpal tunnel - Arthralgia-pain in the joint - Renal/Cardiac/Respiratory system involvement - GI tract complications-due to esophageal disfunction - Hard, thick skin loses elasticity and ROM - Digits may become necrotic/autoamputate **✓ First symptom-possible bilateral carpal tunnel ✓ Do not use ice for pain because of Raynaud’s syndrome
- Labs: -** Same as for Lupus - Interventions: - Medications - * Steroids and immunosuppressants - Prevent chilling, room temperature, gloves/socks - Avoid smoking/stress - Dietary – frequent, high protein, easy to swallow foods - Speech therapy Gout
- “Gouty arthritis”
- Urate crystals deposit in joints and other body tissues causing inflammation
- Primary:
- Hereditary error in purine metabolism
- Secondary:
- Hyperuricemia ✓ Yellow spots-Tofi
- Interventions: - Drug therapy - Nutrition therapy - Limit proteins - Avoid trigger foods - Plenty of fluids - pH increased with alkaline foods - Low purine diet ✓ Medications - allopurinol - NSAIDs for pain - Krystexxa (pegloticase)-another uric acid reducer ✓ No questions on the exam about gout!!! Other Connective Tissue Diseases
- Polymyositis – an autoimmune inflammatory disease of muscle
- White blood cells invade muscles – muscle pain/tenderness
- Systemic necrotizing vasculitis – inflammation of blood vessels
- Small and medium vessels
- Polymyalgia rheumatica – stiffness/weakness/aching of shoulders and pelvis girdle
- Low grade fever, arthralgias, stiffness, weight loss
- Responds to low-dose steroids for several days
- Temporal arteritis
- associated with headaches/vision disturbances ✓ Systemic necrotizing vasculitis-causes ischemia-treated by prednisone and immunosuppressants ✓ Temporal arthritis can lead to blindness if untreated Lyme Disease
- Caused by deer tick infected with Borrelia burgdorferi
- Stages I, II, and III
- Chronic complications:
Chronic Fatigue Syndrome (CFS)
- Severe fatigue lasting 6 months or longer followed by flu-like symptoms plus 4 or more of the following: - Sore throat - impaired short-term memory/concentration - tender lymph nodes - muscle pain
- No laboratory tests.
- No cure
- Supportive therapy – antidepressants/massage/acupuncture **✓ KNOW ALL SYMTPOMS!!
- multiple joint pain without redness nor swelling
- new headache type
- altered sleep
- post exertional malaise longer than 24 hours HIV/AIDS**
- A virus that can progress to AIDS
- HIV gets into blood and alters CD4 and T cells
- Gets into DNA and changes role in immune system
- Immune system becomes weakened due to removing CD4 and T cells leading to viral load increase
- Without treatment death from opportunistic infections
- Healthcare workers should always use Standard Precautions **✓ Was also called the “cancer of homosexuality”
- HIV Infectious Process**
✓ When HIV gets into the body, it “docks” onto the CD4+ cells. ✓ Medications attack on different stages of the disease. ✓ Truvada acts on the beginning of the disease processes
- Effects of HIV Infection - CD4 and T cells become “HIV factory” to make new viral particles daily - Gradually, CD4 and T cell count falls, viral load rises - Immune system weakens - Everyone with AIDS has HIV; not everyone with HIV has AIDS **✓ CD4 and T cells are decreased due to disease process causing the viral load to raise.
- Health Promotion**
- HIV usually transmitted via: ▪ Sexual contact ▪ Parenterally ▪ Perinatally
- HIV is not transmitted: ▪ Casually ▪ By sharing household utensils, towels, linens, toilets ▪ Via mosquitoes or insects
- Progression: ▪ Frequency of re-exposure to HIV ▪ Presence of other STDs (STIs) ▪ Nutrition status ▪ Stress ✓ Semen and blood have the highest concentration of HIV virus but any body fluid can have it. ✓ During sexual contact; anal penetration has the highest chance of contraction.
o Asymptomatic
- Stage 3: o Symptomatic o Severe drop in immune cells o Swollen glands/weight loss/yeast infections
- Stage 4: o Severely damaged immune system o One or more illnesses and infections o AIDS Acquired Immunodeficiency Syndrome - Diagnosis: - HIV positive - CD4 count < 200/mm - Opportunistic infection ✓ A lot the opportunistic infections are AIDS specific. ✓ **Pneumocystis Jiroveci Pneumonia-yeast-like fungal pneumonia. (does not need to be in isolation)
- Integumentary -** Dry skin - Poor wound healing - Night sweats - Skin lesions - Respiratory - Cough - Shortness of breath - Gastrointestinal - Diarrhea - Weight loss - Nausea/vomiting - CNS
- Confusion
- Dementia
- Headache
- Visual changes
- Memory loss
- Personality changes
- Pain • Seizure - Opportunistic Infections:
- Protozoal infections
- Fungal infections
- Bacterial infections
- Viral infections - Malignancies:
- Kaposi’s sarcoma – Most common AIDS related malignancy
- Non-Hodgkin’s lymphoma
- Hodgkin’s lymphoma
- Invasive cervical carcinoma - Kaposi’s Sarcoma ✓ Usually starts in the legs and face and spreads throughout the body. Lesions are not painful. Progress into the organs during late stage AIDS.
- Candida Albicans – Chronic yeast infections of the tongue. - HAART Therapy - Highly Active Antiretroviral Therapy - Inhibits viral replication – does not kill virus - Drug cocktails – (more than 1 med, not monotherapy) - Daily/lifelong/expensive - MUST TAKE ALL DOSES ON TIME! (same time every day) ✓ Extremely important that they adhere to this regimen. If not, virus will start to replicate again.
- CBC with diff: - Increased eosinophils - RIST: - Radio-immunosorbent test-measures IgE
- Food challenges : done by process of elimination - RAST:
- Radio-allergosorbent test-blood test **Anaphylaxis: Clinical Criteria
- Clinical Criteria 1:**
- Onset within minutes to hours of skin or mucous membrane problems involving swollen lips, tongue, soft palate, uvula; widespread hives, pruritis; flushing along with any one of these new onset symptoms: ▪ Respiratory distress or ineffectiveness ▪ Hypotension or indication of reduced perfusion resulting in organ dysfunction - Clinical Criteria 2:
- Onset within minutes to hours of two or more of these symptoms after a patient has been exposed to a potential allergen ▪ Skin/mucous membrane problems ▪ Respiratory distress ▪ Hypotension ▪ Persistent GI problems - Clinical Criteria 3:
- Onset within minutes to hours of hypotension with systolic blood pressure lower than 90 mmHg or 30% lower than the patient’s baseline systolic pressure. Angioedema
- Severe type 1 hypersensitivity reaction
- Involves blood vessels and all layers of skin, mucous membranes, subcutaneous tissues
- Deep, firm swelling of the face/lips/tongue/neck
- Priority interventions:
- Airway obstruction – from mucosal swelling
- Anxiety – from cerebral hypoxia
- Emergency Care - Always check for medical-alert bracelet if unconscious - Assess oxygenation, pulse - Call Rapid Response Team – stay with patient - Start IV if none exists - Be prepared for intubation/tracheostomy - If due to IV medication, stop medication and change tubing - Give Epi (1:1000) 0.3 to 0.5 ml IM or IV – can be repeated every 5 to 15 min - Raise HOB, provide O - Meds for bronchospasm - Antihistamines (second line Rx) - Vasopressors for BP support - Corticosteroids (second line Rx) - Nursing Intervention - If patient is unconscious and ordered medications, look for medical alert ID - If patient says they are allergic, check chart for missed information, ask what reaction was, notify health care provider - Document allergy on chart - If EpiPen is prescribed, teach proper use to patient **Principles of Cancer Development
- Benign Tumor Cells**
- Normal cells growing in the wrong place or at wrong time
- Continuous or inappropriate cell growth
- Small nucleus to cytoplasm ratio, normal chromosomes, low mitotic index
- Differentiated tight adherence, nonmigratory
- Grows by expansion
• G1:
• G2:
• G3:
• G4:
▪ Can’t be determined ▪ Well differentiated, resembles other cells, slow growing ▪ Moderately different, still retains some characteristics of normal cells ▪ Poorly differentiated, still can somewhat tell tissue of origin ▪ Poorly differentiated, no normal cells, may be impossible to tell tissue of origin
- Metastasis - Same cancer/spread to another part of the body. - A tumor that has spread from the original site, usually through blood or lymph, into other tissues and organs, where it can establish metastatic or secondary tumors that grow and cause more damage and dysfunction. - If patient has cancer and develops pain elsewhere, evaluate for metastasis ▪ Prostate pain in back/legs ▪ Breast lungs etc. - Staging: TNM Classification - T – Tumor ▪ TI: primary tumor cannot be assessed ▪ TO: no evidence of primary tumor ▪ T 1 – 4: increasing tumor size - N – Node ▪ NX: regional lymph nodes can’t be assessed ▪ NO: No lymph metastasis ▪ N 1 – 4: increasing node involvement - M – Metastasis ▪ MX: distant metastasis can’t be assessed ▪ MO: no distant metastasis ▪ MI: distant metastasis **✓ KNOW THIS INFORMATION!!!!
- Cancer Etiology**
- Oncogene activation (theory)
- Chemical carcinogenesis-30% of all related to smoking
- Physical carcinogenesis-radiation, chronic irritation, UV radiation
- Viral carcinogenesis-HPV, Hep B/C
- Dietary factors
- Personal factors: ▪ Immune function-underlying disorder ▪ Advancing age ▪ Genetic risk - Cancer Prevention
- Primary prevention: ▪ Avoidance of known carcinogens ▪ Modifying associated risk ▪ Removal of “at risk tissue” - mastectomy ▪ Chemoprevention
▪ Vaccination (HPV)
- Secondary prevention ▪ Regular screening
- Tertiary prevention ▪ Cancer treatment ✓ KNOW THIS INFORMATION!!!!
