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Definition: Systemic Lupus Erythematosus (SLE) is a chronic inflammatory disease that can affect virtually any organ system, including the musculoskeletal system. It is a major rheumatic disease, with a prevalence of approximately 1 case per 2000 persons. Etiology and Pathophysiology: Its origin is unknown; affects the connective tissue and is thought to be due to a defect in the body s immunologic mechanism, genetic predisposition or environmental stimuli. Immune complex deposits in blood vessels, among collagen fibers and or organ which causes necrosis of the glomerular capillaries, inflammation of the cerebral and ocular blood vessels, necrosis of the lymph nodes, vasculitis of the GI tract and pleura and degeneration of the basal layer of the skin. SLE is more common in females aged 13-40 years. Signs and Symptoms: a) Subjective: y Malaise y Photosensitivity y Joint Pain b) Objective: y Fever y Butterfly erythema on the face y Erythema of the palms y Positive Lupus Erythematosus Preparation ( LE PREP), increased anti-nuclear anti-bodies (ANA) in the blood y Raynaud s phenomenon y Weight loss y Evidence of impaired renal (nephritis), gastrointestinal (esophagitis) cardiac (pericarditis), respiratory (pneumonitis) and neurologic functions. Medications: Medicines cannot cure lupus (systemic lupus erythematosus, or SLE), but they can control many symptoms and often can prevent or slow organ damage.
A) Nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful in reducing inflammation and pain in muscles, joints, and other tissues. Examples of NSAIDs include aspirin, ibuprofen (Motrin), naproxen (Naprosyn), and sulindac (Clinoril). Nursing Responsibilities y y y y y y Prior to administration, obtain a complete health history including allergies, drug history, and possible drug interactions. Monitor for signs of GI bleeding or hepatic toxicity. (NSAIDs can be a local irritantto the GI tract with anticoagulant action that is metabolized in the liver.) Assess for character, duration, location, and intensity of pain and the presence of inflammation. (Pain assessment may indicate need for additional therapies.) Monitor for hypersensitivity reaction. (Hypersensitivity reactions may be a medical emergency.) Monitor urine output and edema in feet/ankles. (Medication is excreted through the kidneys. Longterm use may lead to renal dysfunction.) Monitor for sensory changes such as tinnitus or blurred vision. (Tinnitus and blurred vision may be signs of toxicity.)
B) Corticosteroids are more potent than NSAIDs in reducing inflammation and restoring function when the disease is active. Corticosteroids are particularly helpful when internal organs are affected. Nursing Responsibilities y y Establish baseline and continuing data regarding BP, I&O ratio and pattern, weight, and sleep pattern. Start flow chart as reference for planning individualized pharmacotherapeutic patient care. Monitor bone density. Compression and spontaneous fractures of long bones and vertebrae present hazards, particularly in long-term corticosteroid treatment of rheumatoid arthritis or diabetes, in immobilized patients, and older adults. Assess previous history of psychotic tendencies. Watch for changes in mood and behaviour, emotional stability, sleep pattern, or psychomotor activity, especially with long-term therapy, that may signal onset of recurrence. Report symptoms to physician. The nurse should be aware that long-term corticosteroid therapy is ordinarily not interrupted when patient undergoes major surgery, but dosage may be increased. Monitor for withdrawal syndrome (e.g., myalgia, fever, arthralgia, malaise) and hypocorticism (e.g., anorexia, vomiting, nausea, fatigue, dizziness, hypotension, hypoglycemia, myalgia, arthralgia) with abrupt discontinuation of corticosteroids after long-term therapy. Inform patient to avoid or minimize alcohol and caffeine intake since it may contribute to steroid-ulcer development in long-term therapy.
C) Hydroxychloroquine (Plaquenil) is an antimalarial medication found to be particularly effective for SLE people with fatigue, skin involvement, and joint disease. Consistently taking Plaquenil can prevent flareups of lupus. Nursing Responsibilities: y Hydroxychloroquine is usually taken with food or milk to prevent stomach upset. y Assess if patient is allergic to hydroxychloroquine or other aminoquinolines (e.g., chloroquine) before administering the drug.
Assess patient s medical history for alcohol dependency, certain blood disorder (porphyria), certain genetic problem (G-6-PD deficiency), kidney disease, liver disease, certain skin problems (e.g., atopic dermatitis, psoriasis). Instruct patient that this drug causes dizziness, thus patient should not drive, use machinery, or do any activity that requires alertness. Instruct patient to avoid alcoholic beverages because they may increase risk of liver problems.
Nursing Diagnosis: y Anxiety y Body Image Disturbance y Fluid Volume Excess y Impaired Gas Exchange y Risk for Injury y Pain y Impaired Physical Mobility y Impaired Skin Integrity Nursing Interventions: y Administer corticosteroids as ordered and observe for side effects while teaching the patient to do the same. y Help the client and his/her family cope with the severity of the disease as well as with its poor prognosis. y Give positive reinforcement of progress and encourage endeavours towards attainment of rehabilitation goals. y Restrict fluid intake as indicated, spacing allowed fluids through-out a 24 hour period. y Provide alternative pain relief measures, such as relaxation techniques, biofeedback and distractions visual, auditory, guided imagery. Nursing Discharge Plan: y Teach the patient the purpose, dosage and possible side effects of all medications. y Explain to the patient the disease process, the purpose of treatment regimens, and the importance of compliance. y Teach female patient the importance of planning pregnancies with medical supervision because pregnancy is likely to cause an exacerbation of the disease. y Discuss all precipitating factors that need to be avoided, including fatigue, vaccination, infections, stress, surgery, certain exposures to drugs and exposure to ultraviolet light. y Teach patient how to minimize ultraviolet exposure such as wearing sunblock, use an umbrella and not go out of the sun from 10am to 4pm. y Teach patient to ask advice of physician for approval before using any cosmetics. y Teach patient that small frequent meals may be tolerated for presence of esophagitis.
Definition: Malignant melanoma is a highly aggressive cancer that tends to spread to other parts of the body. It develops in melanocytes, the pigment cells present in the skin. Etiology and Pathophysiology: Assess for: y Asymmetry: One half of the mole is different from the other half. y Border irregularity: The spot has borders which are not smooth and regular but uneven or notched. y Color: The spot has several colors in an irregular pattern or is a very different color than the rest of your moles. y Diameter: The spot is larger than the size of a pencil eraser. Risk Factors: y Caucasian (white) ancestry y Fair skin, light hair, and light-colored eyes y A history of intense, intermittent sun exposure, especially in childhood y Many (more than 100) moles y Large, irregular, or "funny looking" moles y Close blood relatives - parents, siblings, and children - with melanoma. Treatment: In general, melanoma is treated by surgery alone. Doctors have learned that surgery does not need to be as extensive as was thought years ago. When treating many early melanomas, for instance, surgeons only remove
1 centimeter (less than ½ inch) of the normal tissue around the melanoma. Deeper and more advanced cancers may need more extensive surgery. Depending on various considerations (tumor thickness, body location, age, etc.), the removal of nearby lymph glands may be recommended. For advanced disease, such as when the melanoma has spread to other parts of the body, treatments like immunotherapy are sometimes recommended. Medications: A) Yervoy (ipilimumab) is a cancer medication that interferes with the growth and spread of cancer cells in the body. It is used to treat melanoma (skin cancer) that cannot be treated with surgery and has not spread to other parts of the body. Nursing Responsibilities y Assess if patient s medical history for liver damage, an autoimmune disorder such as lupus or sarcoidosis, Crohn's disease, ulcerative colitis, or if patient have received an organ transplant. y Inform patient about serious and and fatal reactions that may occur during treatment with Yervoy or months after stopping. Contact doctor right away if you have symptoms such as: diarrhea, increased bowel movements, black or bloody stools, stomach tenderness; pain in your upper stomach, dark urine, jaundice (yellowing of the skin or eyes), easy bruising or bleeding; unusual muscle weakness, numbness or tingling in your hands or feet. B) Proleukin (Aldesleukin) is used for Treating skin cancer and kidney cancer that has spread to other parts of the body. Proleukin is an antineoplastic. It works by helping enhance many aspects of the immune system, which helps to decrease growth of the cancer cells. Nursing Responsibilities: y Assess if patient is allergic to any ingredient in Proleukin. y Assess patient s medical history for history of an abnormal heart stress test or lung function test, heart rate or rhythm problems, chest pain (angina), or a heart attack. Nursing Diagnosis: y Impaired skin integrity related to excision of melanoma y Risk for infection related to surgical wound y Acute pain related to wide excision of melanoma y Anxiety related to diagnosis of skin cancer Nursing Interventions: Impaired Skin Integrity related to excision of melanoma and Risk for Infection related to surgical wound: y Monitor temperature since an increase in result is a sign of infection. y Perform wound care using sterile technique to prevent infection. y Monitor nutritional intake and increase protein in the diet as indicated, to aid in wound healing. Acute pain related to wide excision of melanoma: y Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. y Teach the use of nonpharmacologic techniques (e.g relaxation, guided imagery and massage) before, after and if possible during painful activities; before pain occurs or increases. y Evaluate the effectiveness of the pain control measures used.
Anxiety related to diagnosis of skin cancer y Assess how the patient feels about his/her current situation and help the patient think of ways he can help his/her current situation and ask the patient to verbalize. y Teach the patient non-pharmacological techniques to help with anxiety and have the patient reciprocate. Nursing Discharge Plan: y On discharge, provide adequate dressings and tape for the first home dressing change; include in discharge instructions necessary information about where to buy supplies and how many dressing supplies will be needed. y Review and provide written instructions for prescribed systemic antibiotic and pain medication. y Provide written instructions for dressing change, manifestations of infection, and phone number of clinic; stress importance of calling if any abnormal symptoms occur. y Teach how to protect the incision from bumps and to protect the site from irritants. y Discuss diagnosis, positive outlook for treatment of melanoma in situ, and the client s concerns. y Stress importance of lifelong regular health care evaluations to identify any recurrence or metastasis.
HIV INFECTION AIDS
Definition: AIDS stands for "acquired immunodeficiency syndrome." AIDS is a disease that weakens the immune system to the point where an affected person is vulnerable to a wide range of infections and cancers that result in death if not treated. Etiology and Pathophysiology AIDS is caused by the human immunodeficiency virus (HIV). The virus is spread through contact with infected blood or secretions. At first (stage 1 HIV infection), there is little evidence of harm. Over time, the virus attacks the immune system, focusing on special cells called "CD4 cells" which are important in protecting the body from infections andcancers, and the number of these cells starts to fall (stage 2). Eventually, the CD4 cells fall to a critical level and/or the immune system is weakened so much that it can no longer fight off certain types of infections and cancers. This advanced stage of infection (stage 3) with HIV is called AIDS. HIV is a very small virus that contains ribonucleic acid (RNA) as its genetic material. (Animal cells, plant cells, bacteria, parasites, and some viruses use deoxyribonucleic acid [DNA] as their primary genetic material rather than RNA.) When HIV infects animal cells, it uses a special enzyme, reverse transcriptase, to turn (transcribe) its RNA into DNA which, in turn, directs the formation of HIV RNA that can be used to form new HIV. This is different from the way human cells reproduce (directly transcribing their DNA into RNA), so HIV is classified as a "retrovirus." When HIV reproduces, it is prone to making small genetic mistakes or mutations, resulting in viruses that vary slightly from each other. This ability to create minor variations allows HIV to evade the body's immunologic defences, essentially leading to lifelong infection, and has made it difficult to make an effective vaccine. The mutations also allow HIV to become resistant to medications. Staging of HIV - AIDS
CDC Classification System for HIV Infection The CDC categorization of HIV/AIDS is based on the lowest documented CD4 cell count and on previously diagnosed HIV-related conditions. For example, if a patient had a condition that once met the criteria for category B but now is asymptomatic, the patient would remain in category B. Additionally, categorization is based on specific conditions, as indicated below. Patients in categories A3, B3, and C1-C3 are considered to have AIDS. CDC Classification System for HIV-Infected Adults and Adolescents CD4 Cell Categories Abbreviations: PGL = persistent generalized lymphadenopathy A Asymptomatic, Acute HIV, or PGL (1) 500 cells/µL (2) 200-499 cells/µL (3) <200 cells/µL A1 A2 A3 B* Symptomatic Conditions, not A or C B1 B2 B3 C# AIDS-Indicator Conditions C1 C2 C3 Clinical Categories
* Category B Symptomatic Conditions Category B symptomatic conditions are defined as symptomatic conditions occurring in an HIV-infected adolescent or adult that meets at least one of the following criteria: They are attributed to HIV infection or indicate a defect in cell-mediated immunity. y They are considered to have a clinical course or management that is complicated by HIV infection. Examples include, but are not limited to, the following:
y y y y y y y y y y y
Bacillary angiomatosis Oropharyngeal candidiasis (thrush) Vulvovaginal candidiasis, persistent or resistant Pelvic inflammatory disease (PID) Cervical dysplasia (moderate or severe)/cervical carcinoma in situ Hairy leukoplakia, oral Herpes zoster (shingles), involving two or more episodes or at least one dermatome Idiopathic thrombocytopenic purpura Constitutional symptoms, such as fever (>38.5ºC) or diarrhea lasting >1 month Peripheral neuropathy Category C AIDS-Indicator Conditions Bacterial pneumonia, recurrent (two or more episodes in 12 months) Candidiasis of the bronchi, trachea, or lungs Candidiasis, esophageal Cervical carcinoma, invasive, confirmed by biopsy Coccidioidomycosis, disseminated or extrapulmonary Cryptococcosis, extrapulmonary
y y y y y y
y y y y y y y y y y y y y y y y
Cryptosporidiosis, chronic intestinal (>1 month in duration) Cytomegalovirus disease (other than liver, spleen, or nodes) Encephalopathy, HIV-related Herpes simplex: chronic ulcers (>1 month in duration), or bronchitis, pneumonitis, or esophagitis Histoplasmosis, disseminated or extrapulmonary Isosporiasis, chronic intestinal (>1-month duration) Kaposi sarcoma Lymphoma, Burkitt, immunoblastic, or primary central nervous system Mycobacterium avium complex (MAC) or Mycobacterium kansasii, disseminated or extrapulmonary Mycobacterium tuberculosis, pulmonary or extrapulmonary Mycobacterium, other species or unidentified species, disseminated or extrapulmonary Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) Progressive multifocal leukoencephalopathy (PML) Salmonella septicemia, recurrent (nontyphoid) Toxoplasmosis of brain Wasting syndrome caused by HIV (involuntary weight loss >10% of baseline body weight) associated with either chronic diarrhea (two or more loose stools per day for 1 month) or chronic weakness and documented fever for 1 month WHO Clinical Staging of HIV/AIDS and Case Definition The clinical staging and case definition of HIV for resource-constrained settings were developed by the WHO in 1990 and revised in 2007. Staging is based on clinical findings that guide the diagnosis, evaluation, and management of HIV/AIDS, and it does not require a CD4 cell count. This staging system is used in many countries to determine eligibility for antiretroviral therapy, particularly in settings in which CD4 testing is not available. Clinical stages are categorized as 1 through 4, progressing from primary HIV infection to advanced HIV/AIDS. These stages are defined by specific clinical conditions or symptoms. For the purpose of the WHO staging system, adolescents and adults are defined as individuals aged 15 years. WHO Clinical Staging of HIV/AIDS for Adults and Adolescents Primary HIV Infection
Asymptomatic Acute retroviral syndrome Clinical Stage 1
Asymptomatic Persistent generalized lymphadenopathy Clinical Stage 2
y y y y y y
Moderate unexplained weight loss (<10% of presumed or measured body weight) Recurrent respiratory infections (sinusitis, tonsillitis, otitis media, and pharyngitis) Herpes zoster Angular cheilitis Recurrent oral ulceration Papular pruritic eruptions
Seborrheic dermatitis Fungal nail infections Clinical Stage 3
y y y y y y y y y y y
Unexplained severe weight loss (>10% of presumed or measured body weight) Unexplained chronic diarrhea for >1 month Unexplained persistent fever for >1 month (>37.6ºC, intermittent or constant) Persistent oral candidiasis (thrush) Oral hairy leukoplakia Pulmonary tuberculosis (current) Severe presumed bacterial infections (e.g., pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteremia) Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis Unexplained anemia (hemoglobin <8 g/dL) Neutropenia (neutrophils <500 cells/µL) Chronic thrombocytopenia (platelets <50,000 cells/µL) Clinical Stage 4
y y y y y y y y y y y y y y y y y y y y y y y y
HIV wasting syndrome, as defined by the CDC (see Table 1, above) Pneumocystis pneumonia Recurrent severe bacterial pneumonia Chronic herpes simplex infection (orolabial, genital, or anorectal site for >1 month or visceral herpes at any site) Esophageal candidiasis (or candidiasis of trachea, bronchi, or lungs) Extrapulmonary tuberculosis Kaposi sarcoma Cytomegalovirus infection (retinitis or infection of other organs) Central nervous system toxoplasmosis HIV encephalopathy Cryptococcosis, extrapulmonary (including meningitis) Disseminated nontuberculosis mycobacteria infection Progressive multifocal leukoencephalopathy Candida of the trachea, bronchi, or lungs Chronic cryptosporidiosis (with diarrhea) Chronic isosporiasis Disseminated mycosis (e.g., histoplasmosis, coccidioidomycosis, penicilliosis) Recurrent nontyphoidal Salmonella bacteremia Lymphoma (cerebral or B-cell non-Hodgkin) Invasive cervical carcinoma Atypical disseminated leishmaniasis Symptomatic HIV-associated nephropathy Symptomatic HIV-associated cardiomyopathy Reactivation of American trypanosomiasis (meningoencephalitis or myocarditis)
y y y
Have unprotected sex. Unprotected sex means having sex without using a new latex or polyurethane condom every time. Anal sex is more risky than is vaginal sex. The risk increases if you have multiple sexual partners. Have another STD. Many sexually transmitted diseases (STDs) produce open sores on your genitals. These sores act as doorways for HIV to enter your body. Use intravenous drugs. People who use intravenous drugs often share needles and syringes. This exposes them to droplets of other people's blood. Are an uncircumcised man. Studies indicate that lack of circumcision increases the risk for heterosexual transmission of HIV.
Medications: Medications that fight HIV are called anti-retroviral medications. Different anti-retroviral medications attack the virus in different ways. When used in combination with each other, they are very effective at suppressing the virus. These effective combinations are called highly active anti-retroviral therapy or HAART. It is important to note that there is no cure for AIDS or for HIV. HAART only suppresses reproduction of the virus.
A) Nucleoside Reverse Transcriptase Inhibitors (NRTIs) suppress replication of retroviruses by interfering
with the reverse transcriptase enzyme. The nucleoside analogs cause premature termination of the proviral (viral precursor) DNA chain. All NRTIs require phosphorylation in the host's cells prior to their incorporation into the viral DNA. The class of NRTIs includes such drugs as AZT, ddI, ddC, d4T, 3TC, and abacavir.
B) Protease Inhibitors (PIs) disable protease, a protein that HIV needs to make more copies of itself. Long
term side effects of protease inhibitors: change in blood sugar levels, increase in blood fat levels, deposition of fat in the abdomen and on the back of the shoulders.
Entry Inhibitors are a new class of anti-HIV drugs that work by blocking the virus ability to infect a cell.
D) Integrase Inhibitors. In order for HIV to successfully take over a CD4 cell's machinery so that it can produce
new viruses, HIV's RNA is converted into DNA by the reverse transcriptase enzyme (nucleotide/nucleoside reverse transcriptase inhibitors can block this process). After the "reverse transcription" of RNA into DNA is complete, HIV's DNA must then be incorporated into the CD4 cell's DNA. This is known as integration. As their name implies, integrase inhibitors work by blocking this process. Nursing Diagnosis:
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