Case Analysis 3

Pre-recorded
A Review on the Care of Clients with Inflammatory and Immunologic
Disturbances

Legend (Designated tasks)

Yellow - Cherrie (first 7 minutes)
Blue - Troy (7-14)
Gray - Shawn (14-21)
Violet - Gelsey (21-28)
Green - Shannea (28-35)
Magenta - Thia (35-42)
Light orange - Bren (42-49)
Light red - Janess (49 to end)

Facilitator: Mr. Benedict Dwight Lepiten

First
Focus points:
● Infection vs Inflammation
● Chemical mediators
● Types of inflammation
● Types of exudates
● Medical conditions
○ Rheumatic fever
○ Trichinosis
○ Herpes zoster
○ Herpes simplex
○ Psoriasis
○ Malaria
 ○ Bullous disease/ blistering disorders
○ HIV/ AIDS
● Medical conditions as to its:
○ Disease process
○ Assessment (causes, signs, and symptoms)
○ diagnosis/ diagnostic tests
○ Management
■ Medical
■ Pharmacological
■ Nursing management

Infections vs Inflammation
Infection
- Invasion and multiplication of bacteria or viruses within the body
- Path is from an external to an internal one; an external agent
coming from the outside of the body to injure tissues
- Outward to inward route
- Autoimmune– inward to outward

Inflammation
- The body’s protective response against the infection
- Path is from an internal to an external one; inflammation occurs as
a reaction from the body in response to the external agent
- Inward to outward

Cardinal signs of inflammation

1. Heat (calor)
2. Redness (rubor)
3. Swelling (tumor)
4. Pain (dolor)
 5. Loss of function (functio laesa)

Chemical Mediators
- Chemicals or substances of variation from the circulatory system,
from the inflammatory cells, and from the injured tissues which
are actively contributing and adjusting to the inflammatory
response
● Histamine (most common)
○ Acts to promote vasodilation, thus promoting the increase in
the vascular permeability in response to an acute
inflammatory reaction
○ Changes in vascular permeability
● Kinins
○ Proteins that cause inflammation and affect blood pressure
○ Inc. vasodilation and vascular permeability
○ Attract neutrophils to affected area

Vasodilation- widen the blood vessels to allow more blood to flow

● Bradykinin
○ Suspected of causing pain
● Serotonin
○ Same effect as histamine
○ Also promotes vasodilation
● Prostaglandins
○ Increase vascular permeability
○ Draw leukocytes (WBC) to the area
○ Vasoactive- causes change to the blood vessels
○ Pain and fever inducer
CRITERIA ACUTE CHRONIC
ONSET Immediate Gradual; insidious
DURATION Days; less than 2 Months; years
weeks
PURPOSE Protective function Non-protective
function; debilitating
CAUSE Foreign substances Persistent foreign
that enter the body; agents; autoimmune
physical harm disease
OUTCOME Return to normal; near Scarring; permanent
normal structure and tissue damage
function

Inflammatory process can be caused by either of these two

classifications:
1. Endogenous (primarily results from existing condition or
disease)
- Immunopathological reactions
- Neurological disorders
- Genetic disorders
2. Exogenous (primarily involves external factors and chemicals
which affect the inflammatory process)
- Mechanical
- Physical
- Chemical
- Nutritive
 - Biological

● Duration of Time
1. Acute
- Relatively short duration lasting for minutes to hours or
days
2. Subacute
- May last from two to six weeks
3. Chronic
- It may continue for several months or up to years

● Degree of tissue damage

1. Superficial
- May just affect the skin surface or just below its
surface
2. Profound
- This degree may now entail deeper tissues and some
books also use the term “deep tissue degree”

● Types of exudate
1. Serous
- Results from outpouring of fluid that has low cell and
protein content
- Early stage of inflammation, found in cellulitis, skin
blisters, pleural effusion
- Serous exudates are clear, thin and watery in
appearance
2. Fibrinous
- Characterized by presence of large fibrins resulting to
adhesions
 - Found in pericarditis, peritonitis
- Type of exudate commonly develops when there is a
presence of vascular leaks that are large or this may be
caused by presence of pro-coagulant or adhesive
stimulus within the cells
3. Membranous
- Characterized by loose white or gray substance lining
the mucous membrane; found in inflammation of gut and
tracheobronchial tree (catarrhal, diphtheria)
- This type of exudate is also common in conditions
relating to the respiratory system
4. Purulent
- Characterized by pus formation
- Found in suppurative infection (boils, abscess formation)
- When we say suppurative, it consist of plasma with both
active and dead blood cells such as neutrophils,
fibrinogen and other necrotic parenchymal cells
5. Hemorrhagic or Sersanguinous
- Results from rupture or necrosis of blood vessels
(hematoma)
- Usually characterized with hematoma formation
- Also described as bloody because of the large component
of our red blood cells released from the ruptured blood
vessels
6. Mucinous
- Characterized by presence of mucus and epithelial cells
- Found in allergic rhinitis, runny nose

DIFFERENT CONDITIONS RELATED TO INFLAMMATION AND IMMUNOLOGY

RHEUMATIC FEVER
- An inflammatory disease (autoimmune inflammatory process)
- Develop after group A beta hemolytic streptococcal (GABHS)
- Pharyngitis (already a condition)
- Persons who have experienced an episode of rheumatic fever are
predisposed and are at risk for its significant complication
(rheumatic heart disease)
- May develop to rheumatic heart disease as evidenced by heart
murmur, cardiomegaly (enlarged heart), pericarditis (due to
presence of fluid), and heart failure

Signs and symptoms: (at least 2 major or 1 major and 2 minor s/s)
- Rheumatic fever has extremely variable manifestations and remains
a clinical syndrome for which no specific diagnostic test exists
being a clinical syndrome. Clients may manifest several signs and
symptoms to support the diagnosis of this disease
● Jones Criteria/Major Criteria (if patients develop at least two of
the following:
○ Carditis
- Affects 3 layers of the heart
- Inflammation of the heart which primarily involves all
of its layers: The pericardium, heart muscle, and the
endocardium
○ Polyarthritis
- Joints affected for up to 4 weeks
- Term used when at least five joints are affected with
arthritis or joint inflammation
- Usually takes up until four weeks
14-21

○ Subcutaneous Nodules
■ Round, firm, painless, free-moving; develop over bony
prominences and tendons; disappear after 1-2 weeks
■ Deep seated lesions in the skin located in the deep
dermis and subcutis often with minimal changes
appreciated on the surface of the skin
■ Usually evident over bony prominences
○ Erythema marginatum
■ Macular or papular, non-itchy rash on the trunk and
proximal extremities
■ Rash that spreads on the trunk and limbs
○ Chorea
■ Rapid, purposeless, erratic, jerky, uncoordinated,
involuntary movement of face and extremities, resolves
within 6 months
○ *HAVING TWO OF THE FIVE SYMPTOMS OF JONES CRITERIA
HIGHLY SUGGESTS THE DIAGNOSIS OF RHEUMATIC FEVER*
● Minor symptoms (supports diagnosis in addition to the discussed
major criteria)
○ Arthralgia
○ Fever
○ Laboratory findings:
■ Increased erythrocyte sedimentation rate
■ Increase C-reactive protein
■ Prolonged PR interval

Diagnostics
 - Gives a higher probability for diagnosing the condition, but is not
definite
● Throat culture
○ Throat is area of concern for group A beta hemolytic
streptococcus
● Rapid antigen detection tests
○ Utilized in determining the presence of the group A beta
hemolytic streptococcus
● ECG (sinus tachycardia; sinus bradycardia; sinus dysrhythmia; 1st
degree heart block; atrial fibrillation; atrial flutter, prolonged P-R
interval)
○ Determines the functioning of the heart in relation to the
possible complications of rheumatic fever
● Elevated erythrocyte sedimentation rate (ESR) = minor criteria
○ Blood is the body product used
● Elevated serum C-reactive protein
○ This type of protein usually present during the active stage
of rheumatic fever

Medical Management
● One-time IM injection of penicillin (doc)
● 10-day course of oral penicillin
● Erythromycin (alternative to penicillin)
● Cephalosporin
● Azithromycin
● Prophylactic antibiotics after initial antibiotic treatment (IM
penicillin every 3-4 weeks; for 5 years if patient did not have
carditis; for 10 years if with carditis)
- Why antibiotics over other medications?
 ○ To treat and manage the presence of the bacteria causing the
rheumatic fever which is the group a beta hemolytic
streptococcus
● Antiinflammatory meds (salicylates[aspirin],
corticosteroids[prednisone])
○ Anti Inflammatory medications are given since RF is an
autoimmune inflammatory disease
● Diazepam(Valium) or phenobarbital = chorea
○ Anxiolytics for symptomatic management of chorea

Nursing Management
● Teach patient about:
○ The disease
○ Treatment and management of symptoms
○ Preventive steps needed to minimize recurrent and
complications not to proceed Rheumatic Heart Disease
○ Cardiac reevaluations
○ To report any signs of thromboembolism or heart failure
■ Embolus - clot that moves, more dangerous; migratory
■ Thrombus - clot that are stagnant/stationary

TRICHINOSIS (Trichinellosis)
- Primarily caused by eating raw or undercooked meat of animals
infected with the larvae of Trichinella spiralis
- Causative agent
- After an adequate inflammatory response develops in the intestine,
the female adult larvae is eventually expelled in the feces
- Results to intense inflammation, leading to further cardiac and
neurological complications if the larvae is found in other areas
- In tissues other than skeletal muscle, such as the myocardium and
brain, the parasites soon disintegrate, causing intense
inflammation, and are then reabsorbed
Gelsey (21-28)

Signs and symptoms:

● Abdominal discomfort
● Cramping
● Diarrhea
● Facial swelling around eyes (periorbital edema)
● Fever
● Muscle pain
● Muscle weakness
● The signs, symptoms, severity and duration of this condition may
vary.
● Note: If the infection is heavy clients mya have difficulty
coordinating movements and may have heart and breathing
problems and in severe cases, death can occur.
*associated with GI infection/problem coz it attack GI through
small&large intestine

Diagnostic tests:
1. Muscles biopsy - done to supplement blood exams; done by
removing a sample tissue or a small piece of muscle and it is
examined under the microscope for the trichinella larvae
2. CBC- typically enough to establish the diagnosis of trichinosis
3. Creatinine kinase and Lactate dehydrogenase: (increase in blood
when muscles cells are damaged or destroyed)
4. Inc. eosinophils (when new larvae invade tissues)
5. Indirect Immunofluorescence, latex agglutination, enzyme-linked
immunosorbent assays - detect antibodies developed by the
infected person's immune response to the parasites
Medical Management:
● Anti-parasitic medications - effective in eliminating the worms and
larvae in the intestine
○ Mebendazole
○ Albendazole
● Pain Killers -for symptomatic treatment; for muscle sorenesss
● NSAID, Antipyretic, Anti-inflammatory & Corticosteroids meds

Nursing Management:
● Educate patient - especially on how to promote proper food
handling and preparation
● Adequate Rest - better pace of recovery
● Administer medications as ordered
● Emphasize prevention - through proper nutrition and dietary
practices

HERPES ZOSTER
● Shingles
● Varicella-zoster virus (reactivation; the same virus that causes
varicella or chickenpox
● After chickenpox, the virus lie dormant inside nerve cells, spinal
cord, brain
● Reactivated due to declining cellular immunity
● Travel by way of the peripheral nerves to the skin
○ Difference between chickenpox & shingles is more on the
location of the rashes
● Creation of red rash of small, fluid-filled blisters

Assessment:
 ● Painful vesicular eruption along the sensory nerves from one or
more posterior ganglia
● Early vesicles contain serum, later become purulent, rupture, then
form crusts; confine din face or trunk
● Itching
● Tenderness
● Malaise and Gl disturbances precede eruption
● Inflammation is unilateral (thoracic, cervical, cranial nerves in
band-like configuration)
● The presence of rashes or vesicles are only localized in one side
unlike in chicken pox

Medical Management:
● Acyclovir (Zovirax)
● Valacyclovir (Valtrex)
● Famciclovir (Famvir)
* These three Orally administered antiviral medication are most
effective when started within 72 hours after the onset of the rash

● Analgesics (Aspirin, Meperidine) - symptomatic treatment

● Corticosteroids - symptomatic treatment
● Triamcinolone (Aristocort, Kenacort, Kenalog)
● Subcutaneous injection under painful areas as an anti-inflammatory
agent
* Zostavax (vaccine for prevention in adults above 60 who had
chicken pox)

(28-35)
Nursing Management:
 ● Educate about the importance of medication compliance and ff. up
appointments
● Teach application of wet dressing
● Proper hand hygiene
● Relaxation techniques
● Diversionary activities
● Loose clothing- to prevent rupturing of vesicles
● Adhere medication compliance

HERPES SIMPLEX

2 Causative agents:
- Herpes simplex type 1 (mouth)
- Herpes simplex type 2 (genitals; lower prevalence; appears at
onset of sexual activity)
*either agents can occur in both areas
*difference between location of HSV from chickenpox is it is more
specific to one area of the body (Mouth, lips and genitals)
● Diagnostics:
○ Viral cultures (older, crusted patches)
○ Rapid assays (acute, vesicular lesions)
● Medical management:
○ Use of sunscreen
○ Suppressive therapy
■ Acyclovir (Zovirax)
■ Valacyclovir (Valtrex)
■ Famciclovir (Famvir)
*Use of sunscreen
 PSORIASIS
- Chronic, noninfectious, inflammatory disease that causes
overproduction of keratin (Thickens the skin)
*Keratin is a protective barrier of the skin (help form the
tissues of the hair, nails, and the outer layer of the skin)
- Hereditary defect
- More common in ages 15 to 35
- Tend to improve then recur periodically throughout life
- Aggravated by: emotional stress, anxiety, trauma, infections,
seasonal and hormonal changes
- Production process may occur in just a few days. Because of this,
skin cells don’t have time to fall off. This rapid overproduction
leads to the buildup of skin cells particularly with keratin.
● Assessment:
○ Lesions= red, raised patches covered with silvery scales
(flaky skin)
○ Nails= pitting, discoloration, crumbling beneath the free
edges, separation of nail plate
○ Palms and soles= pustular lesions called palmar pustular
psoriasis
● Complications:
○ Arthritis of multiple joints (MULTIPLE ARTHRITIS)
○ Erythrodermic psoriasis (involves total body surface area)
● Medical management:
○ No known cure
○ Gentle removal of scales with baths
■ Oils (olive oil, mineral oil)
■ Coal tar preparations (Balnetar)
○ Emollient creams with alpha-hydroxy acids or salicylic acids
○ Regular skin care
 ○ Stress management
● Pharmacologic therapy:
○ Topical agents
■ Corticosteroids with occlusive dressings
■ Non-steroidal agents Calcipotriene (Dovonex) and
Tazarotene (Tazorac) prevent development of epidermal
cells
○ Systemic agents
■ Systemic cytotoxic preparations:
- Methotrexate, Hydroxyurea (Hydrea), Cyclosporine
A, Oral retinoids (synthetic derivatives of vit. A
and it’s metabolite, Vit. A acid) Etretinate
● Nursing Management:
○ Explain psoriasis, control, medications
○ Do not pick or scratch skin
○ Use of warm water
○ Pat dry
○ Use of emollients with occlusive dressings
○ Oil bath
○ Psychological support
○ Arthritis- rest, heat application, salicylates or
anti-inflammatory medications
(35-42)
MALARIA
- Malaria is an acute febrile illness caused by plasmodium parasites
which are spread through humans through the bites of an infected
female anopheles mosquito
- Found in palawan

Causative agents:
- Plasmodium vivax
- Plasmodium falciparim
- Plasmodium ovale
- Plasmodium malariae
➔ Among these species plasmodium falciparum and vivax pose the
greatest threat

● Mode of transmission:
○ Bite of female Anopheles species mosquito

● Chain of Infection
1. Causative agent
2. Reservoir
3. Portal of exit
4. Mode of transmission
5. Portal of entry
6. Susceptible host

● Incubation period (time between an exposure to an infection and

the appearance of the first symptoms):(2-3days?)
○ 12-30 days

● Clinical Symptoms
○ Coughing
○ Fatigue
○ Malaise
○ Shaking chills
○ Arthralgia aka joint pain
○ Myalgia aka muscle pain
 ○ Paroxysm of fever; definitive sign (malarial rigor)
characterized by
■ shaking chills, and sweats (every 48 or 72 hours),
depending on species)

→ malaria signs and symptoms typically begin within a few weeks after
being bitten by an infected mosquito however some types of malaria
parasite can lie dormant in your body for up to 1 year.

● Diagnostics:
○ CBC - checks for anemia or evidence of other possible
infections
■ Anemia sometimes develop in people with malaria
because the parasites damage and destroy RBCs
○ Electrolyte panel -
■ electrolytes play an important role in the normal
functioning of the human body.
■ Electrolyte imbalance, mineral disturbances are the
common clinical manifestations in several infectious
diseases including malaria.
■ Electrolyte levels of sodium, potassium, calcium, and
magnesium are monitored for this exam
○ Renal function tests
■ Check the severity of malaria which may affect the
kidney functioning
○ Urine and blood cultures
■ To determine the presence of the causative agent
○ Thick and think blood smear
■ To assess the characteristics & features of the RBC
under a microscope
 ○ Chest radiography
■ Check for severity of malaria which may affect other
organs of the body
○ CT scan
■ Check for severity of malaria which may affect other
organs of the body
○ Peripheral blood smear
○ Antigen detection methods (under development)

● Medical Management
○ Antimalarial drugs -main drug of choice
■ Artemether 20mg/lumefantrine 120mg (Coartem)
■ Mefloquine (Lariam)
● Antimalarial drugs are used for the treatment and
prevention of a malaria infection
● Most antimalrial drugs target the erythrocytic
stage of malaria infection which is the phase of
the infection that causes symptomatic illness
○ Antipyretics
■ Given to treat and manage fever
○ Antiprotozoals
→ in general antiprotozals are given to treat protozoal
infections which include amoebiasis, giardiasis,
cryptosporidiosis, microsporidiosis, and malaria
→ these drugs kill or inhibi the growth of organisms known
as protozoans which are mainly the cause of malaria
■ Chloroquine phosphate (Aralen)
■ Clindamycin (Cleocin)
■ Doxycycline (Vibramycin, Vibra-Tabs, Doryx)
■ Primaquine
 ■ Quinine sulfate (Formula Q)
■ Quinidine gluconate (Cardioquin, Quinalan, Quinidex,
Quinoa)
■ Tetracycline (Achromycin V, Sumycin)

● Nursing Management
○ Prevention - focus of main goal
○ Assess and monitor for bleeding - prevent complications of
malaria
○ Administer medications as prescribed - administer
antimalarial and antiprotozoal medications together w/ other
supplementary regimen for symptomatic treatment

Bullous Diseases/Blistering Disorders

● A blistering disease is a condition in which there are fluid filled
skin lesions
● Chronic disorder that results in the development of blisters (bullae)
● In this condition the vesicles are small in size in < 5mm in
diameter and the blisters may break or the roof of the blisters may
become detached forming an erosion.
● Increased incidence:
○ Jewish and mediterranean people
○ Middle and older adults
 ● Associated with:
○ Other autoimmun disorders
○ Use of penicillamine and captopril
■ Use of such medications may have a severe reaction to
one’s integumentary system
● Types:
○ Pemphigus vulgaris (most common)
○ Pemphigus foliaceus
○ Pemphigus erythematosus

(42-49)
Pemphigus Vulgaris
● Most common type of blistering disorder
● Mainly affect the oral mucous membrane
● Caused by Immunoglobulin G antibodies and HLA-A10 antigen, both
of these materials play a vital role in maintaining our skin
integrity particularly our epidermal layer
● The process of Acantholysis is also evident in this condition in
which the epidermal layer will be disrupted due to the autoimmune
reaction
● Common cause of death of individuals w/ this condition is
Septicemia or infection to the bloodstream caused by Staphylococcus
aureus
● The blisters:
○ Appear first in the mouth and scalp then the face, back,
chest, umbilicus and then towards the groin area it follows a
downward direction
○ The bister usually form in the epidermis due to the process
of acantholysis in the said layer
 ○ The process of acantholysis cause epidermal cells to separate
above the basal layer which increases the risk for the cells to
rupture denuded skin and form crust
○ oozing fluids w/ musty odor can also be observed
○ Lesions described to be painful
○ Pathognomonic sign: Nikolsky’s signs- elicited upon the
application of pressure on a blister which then causes it to
spread to the adjacent skin
Diagnostics
● Immunofluorescence microscopy
○ to identify IgG antibodies in the epidermal layer and in
the blood
● Skin Biopsy
○ To determine the presence of acantholysis
● Tzanck test
○ To assess the fluid of the blister to help in the
identification of an acantholytic cell
Goals of Treatment
● Control the severity of the disease
● Prevent development of the other types of infection
● Prevent loss of fluids or dehydration
● Promote the integrity and healing of the skin

HIV/AIDS
● HIV or human immunodeficiency virus the causative agent for the
condition of AIDS
● HIV is a retrovirus
○ Called retrovirus bec. it works in a back to front way
■ Immune System is the target
■ “immunocompromised”
 ■ NCP: Risk for Infection
○ Unlike other viruses, retroviruses store their genetic
information using RNA instead DNA. Meaning they need to
make DNA when they enter a human cell in order to make
new copies of themselves
● Transmitted through:
○ Sexual intercourse w/ infected person
■ To prevent the best way is to Abstinence
○ Exposure to HIV-infected blood and other blood products
■ No recapping
■ Proper PPE
■ Double gloving
■ Proper disposal of sharps
○ Perinatal transmission upon delivery
○ breastfeeding
● HIV infects cells w/ CD4 receptors such as lymphocytes, monocytes
or macrophages
● HIV cannot replicate on its own so in order to make new copies of
itself, it must infect cells of the human immune system called the
CD4 Cells
○ CD4 Cells are WBC that play a central role in responding to
infections in the body
● HIV also primarily cause damage to and destruction of the CD4
plus T cells in which more CD4 receptors are present
● CD4+T cells play a key role in the ability of the immune system to
recognize and defend against pathogens
● Viral Load is a blood test that measures the amount of HIV in our
blood.
○ Consider at high level during the first 6 months of infection
and during the late stages
 ● 4 Stages according to CDC
1. Primary infection/Acute HIV Infection/Acute HIV syndrome
2. HIV Asymptomatic (CDC Category A)
3. HIV Symptomatic (CDC Category B)
4. AIDS/Acquired immunodeficiency syndrome (CDC Category C)

(49 to end)
Diagnostic Tests:
- EIA (enzyme immunoassay)/ ELISA (enzyme-linked immunosorbent
assay)
Used to detect HIV antibodies. It checks for certain proteins
that the body makes in response to HIV The blood sample will
then be added to a cassette that contains the viral protein
called an antigen
- Western blot
It separates the blood proteins and detects the specific
proteins called your HIV antibodies that indicate an HIV
infection. The western blood exam is used to confirm a
positive ELISA and the combined tests are 99.9% accurate.
- Viral load test
This is to assess the levels of HIV in our blood
- CD4/ CD8 ratio
Is one of the blood tests used to monitor our immune system
if we have HIV, it compares the proportion of so-called
helper CD4 T cells to the killer CD4 T cells and the value of
which can help predict the likely course of the disease.

Medications:
- Nucleoside Analog Reverse Transcriptase Inhibitors (NRTI’s)
 Becomes part of the HIV DNA and derail its building process
Zidovudine (Retrovir, AZT)
- Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI’s)
Attach to reverse transcriptase prevents conversion of HIV
RNA to DNA
Etravirine 200 mg

Nursing Management:
- Client education
Health education and how to manage symptoms and to prevent
the condition at a later stage.
- Prevent infection
Since the immune systems of these individuals are already
compromised thus increasing the risk of being infected.
- Controlling fatigue/ conserve energy
Conservation techniques and activities.
- Supporting individual coping
Refer clients to support groups to enhance their coping.
- Promoting effective therapeutic management
Particularly on medication compliance to better the condition