exam 3 - infection/HIV/immunology/rheumatic

Healthcare-acquired infection (nosocomial)

an infection that develops 48 hrs. or more after hospital admission or shortly after discharge that was not present or incubating at the time of admission.  

Risk factors: IVs, neutropenia (immunocompromised), catheterization, no deep breathing/coughing after surgery. 

Prevention: hand hygiene, PPE/isolation precautions, IV/central line care, cath care (keep clean and sterile insertion), surgical site prevention, neutropenic precautions,  

Community-acquired infection

infection acquired outside of the hospital or present upon admission 

Risk factors: travel, crowded living, young age, exposure to infected people, travel, poor sanitation, exposure to contaminated food or water.  

Procedures: tattoos, body piercings, animal bites, insect bites, home injections, home dialysis 

Conditions: diabetes, COPD, asthma, HF, HIV/AIDS, cancer, CKD, obesity, smoking 

Prevention: vaccinations, hand hygiene, lifestyle, infection prevention, chronic disease management. 

Airborne precautions

spread through tiny airborne particles that remain suspended in the air for long periods. Infection occurs when a person inhales these particles.  

TB, measles, varicella, herpes zoster 

N95 mask, Negative pressure room 

Droplet precautions

spread through large respiratory droplets produced by coughing, sneezing, talking, and suctioning. Can travel 3-6 ft. 

Influenza, covid, pertussis, meningococcal meningitis, mumps, rubella, RSV 

Surgical mask, gloves, gown, private room; patient wears a mask if transported, hand hygiene. 

Contact precautions

spread through direct contact with the infected person or indirect contact with contaminated surfaces, equipment, or objects. 

MRSA, scabies, impetigo, draining wounds 

Gloves, gowns, private room. Don’t use your own equipment like a stethoscope 

Enteric precautions

spread through the fecal-oral route. Infection occurs by touching contaminated stool or surfaces and then touching the mouth or eating without proper hand hygiene. 

C.diff  

Glove, gown, nurse wash hands with soap and water

WBC

5,000 - 10,000

lactic acid

0.5 - 4.2

measure tissue perfusion and oxygenation

Erythrocyte sedimentation rate (ESR)

men (0-22), women (0-29) 

measures inflammation in the body (higher values, greater inflammation) 

C-reactive protein (CRP)

shows active inflammation

normal is less than 10mg/L 

HIV prevention and contraction

Prevention: standard precautions at work, gown, gloves, handwashing, practice abstinence, Prep and Pep, safe sex (limit sex partners, avoid sharing sexual fluids, toys, razors, toothbrushes or needles)  

Contraction of HIV: most common men to men; transmitted through body fluids containing HIV of infected CD4 lymphocytes (blood, seminal fluid, vaginal secretion, breast milk), most prenatal infections occur during delivery, breaks in the skin or mucosa increase the risk. Infected blood (sharing dirty needles, accidentally poked with needle in the hospital, potentially donated blood), infected semen (any type of sexual contact, other infections present like syphilis or herpes), infected vaginal secretions (sex, birthing process

HIV treatment and side effects

Treatment options: ART (antiretroviral therapy); goal is to suppress viral load, preserve or restore immune function (increase CD4), improve QOL, reduce opportunistic infections, reduce HIV-related death and illness, prevent transmission. Adherence to tx is important and drug holidays are not recommended.  

Side effects:  

• Short term: Nausea and vomiting, Anxiety and fear, Depression and diarrhea, Peripheral neuropathy and pain, Fatigue 

• Long term: Lipodystrophy syndrome (loss of fat from arms, face, legs, sunken cheeks, fat accumulation around the abdomen, back of neck and breasts), Hyperlipidemia, Insulin resistance, Hyperglycemia, Bone disease (osteoporosis, avascular necrosis), Renal disease, CVD 

nutrition for patients with HIV

Provide enough calories, protein, vitamins and fluids; small frequent meals, soft, easy to swallow foods, oral nutritional supplements (high calorie shakes, protein supplements, lactose-free supplements), lots of fluids to prevent dehydration, Advera (a nutritional product specifically designed for people with HIV infection or AIDS 

Avoid spicy, crunchy or rough, sticky, very cold, very hot foods (can increase mouth pain), if pt has diarrhea, avoid high fiber, lactose-containing dairy products, etc.)  

Prep

medications taken by HIV-negative people before exposure to help prevent HIV infection. It is recommended for people at high risk for HIV (have an HIV positive partner, have multiple sex partners, do not consistently use condoms, inject drugs and share needled). Tenofovir and Emtricitabine (daily oral pill), cabotegravir (IM infection every 2 months).  

Nursing considerations for Prep: confirm pt is HIV negative before starting, stress strict medication adherence (missing doses reduced protection), encourage routine follow up visits and HIV testing, continue teaching safe sex (Prep does NOT protect against other STIs), monitor kidney function.  

PEP

emergency HIV medications started after possible HIV exposure to prevent infection (EX needle stick, unprotected sex with an HIV positive person, sexual assault, shared needles), should be started within 72 hours of exposure, it is taken for 28 days (4 weeks), DO NOT stop treatment  

Nursing considerations for PEP: treat as a medical emergency, do not delay tx, obtain baseline HIV testing before or at the time of starting tx, stress the importance of taking ALL medications for the full 28 days, scheduled f/u appts., provide emotional support and counseling  

primary HIV infection

viral load becomes very high, CD4 count drops quick but rebounds

virus is there but the body has not made antibodies to fight it off yet

There is a time called the window period which is the time after the infection when the pt is infected and very contagious, and HIV antibody tests may still be negative because antibodies still have not developed.

Sx usually starts 2-4 weeks after infection (fever, swollen lymph nodes, rash, muscle aches, HA), sx usually resolves in 1-3 weeks.

Viral set point will happen after the initial infection (the viral load will decrease and stabilize, a higher viral set point = worse prognosis)  

asymptomatic HIV

CD4 >500, pt usually feels well and has few or no sx, HIV is still present and can be transmitted; this stage can last 8-10 years. If untreated, can go from HIV to AIDS 

symptomatic HIV (chronic)

CD4 count decreases and nears 200-499, the immune system weakens and HIV related sx begin to appear (persistent fever, chronic diarrhea, wt loss, oral candidiasis, recurrent infections)

AIDS

CD4 count <200, the immune system is very damaged and pts are at high risk for opportunistic infections, and some cancers

if the CD4 count drops below 100, the immune system is very impaired and the risk of serious opportunistic infections is even further (Fungal—pneumocystis jiroveci pneumonia (weakened immune system), thrush, Viral, Protozoal, Bacterial—mycobacterium tuberculosis 

criterium for aids

CD4 count <200 or <14%; once diagnosed, this diagnosis never changes, even if the ART raises the CD4 count above 200.  

These pts are at extreme risk for opportunistic infections (Fungal—pneumocystis jiroveci pneumonia (weakened immune system), thrush, Viral, Protozoal, Bacterial—mycobacterium tuberculosis) 

HIV nursing diagnosis

• Impaired skin integrity related to cutaneous manifestations of HIV infection, excoriation, and diarrhea 

• Diarrhea related to enteric pathogens, HIV infection, or ARV medications 

• Risk for infection related to immunodeficiency 

• Activity intolerance related to weakness, fatigue, malnutrition, impaired fluid and electrolyte balance, and hypoxia associated with pulmonary infections 

• Disturbed thought processes related to shortened attention span, impaired memory, confusion, and disorientation associated with HIV-related cognitive decline 

• Ineffective airway clearance related to PCP, increased bronchial secretions, and decreased ability to cough related to weakness and fatigue 

• Pain related to impaired perianal skin integrity secondary to diarrhea, KS, and peripheral neuropathy 

• Imbalanced nutrition, less than body requirements, related to decreased oral intake 

• Social isolation related to stigma of the disease, withdrawal of support systems, isolation procedures, and fear of infecting others 

• Anticipatory grieving related to changes in lifestyle and roles and unfavorable prognosis 

• Deficient knowledge related to HIV infection, means of preventing HIV transmission, and self-care 

nursing interventions for HIV

• Promote skin integrity  

• Perineal care (if diarrhea) 

• Promote normal bowel function 

• Prevent infection  

• Improve activity tolerance (balance activity with rest, encourage energy conservation, etc.) 

• Maintain thought processes (assess for confusion, memory loss, speak slow, reorient, use calendars and schedules, etc.) 

• Improve airway clearance (encourage coughing and deep breathing, postural drainage and percussion, maintain hydration)  

• Relive pain  

• Improve nutritional status  

• Decrease social isolation (educate that HIV is not spread through casual contact) 

osteoarthritis

Slowly progressing NON inflammatory disorder of synovial joints, gradual loss of cartilage (start 20s-30s), degenerative joint disease, formation of bony growths (osteophytes), knees, hips, joints in fingers change, synovial membrane and joint capsule, NOT normal part of aging, >40 

What a person may experience: worse with activity, improved with rest, usually not present at night, morning stiffness that lasts <30 minutes and improves with movement, decreased ROM, crepitus, joint enlargement, Heberden Nodes (enlarged DIP joints) and Bouchard nodes (enlarged PIP joints) on hands, sitting down and rising becomes difficult, asymmetrical, referred pain, joint pain is the primary sx, NOT systemic 

osteoarthritis care and teaching

nonpharmacological treatment is first line; exercise is strongly recommended (walking, swimming, cycling, etc.), weight loss (less body weight = less joint stress), heat and cold application (cold for inflammation), protect the joints, use assistive devices, avoid long periods of immobilization  

Rheumatoid arthritis

chronic SYSTEMIC autoimmune disease that attacks the synovial lining of joints. Occurs in adults ages 30-50. Can be rapid or gradual with flare-ups. Effects the hands and feet mostly.  

What a person may experience: functional impairment may result if it's not treated. There will be non-specific sx at first (fatigue, anorexia, weight loss, stiffness); stiffness becomes more localized as the disease progresses. Sometimes stress can be a trigger. joints—pain, stiffness, limited motion, inflammation (heat, tenderness), function. Morning stiffness can last hours; pt may have joint stiffness after activity. Pain increases with activity, sx of carpal tunnel and unable to grasp objects, Raynaud’s. Ulnar drift, Hallux valgus, Swan neck deformity may be present.

Rheumatoid arthritis care and teaching

teach pt to protect the joints (use assistive devices, use larger joints when lifting, balance rest with activity, etc.), prevent infection (RA meds can suppress the immune system), prevent falls, encourage exercise (walking, swimming, cycling, stretching, etc.), advise that RA is chronic but manageable, use heat for stiffness and cold for inflamed joints, avoid smoking.

Diet: No specific to reverse effects, “Mediterranean Diet” (Fatty fish, fruits/veg., whole grains, nuts, peas, beans, decrease inflammation, protein needs), May have difficult time with preparing food, may not want to eat/hard time eating, may need assistive devices, Corticosteroids may lead to weight gain 

RA medications

DMARDs are the most important med for RA; they slow or stop the disease, prevent permanent joint damage and protect the joints long term; they take weeks to months to start working.

• Methotrexate: first line medication, given once weekly, can cause bone marrow suppression, liver damage, GI upset, mouth sores – monitor CBC.

• Hydroxychloroquine, Leflunomide blocks overproduction of immune cells. Cannot become pregnant and must use contraception. Caution due to liver failure. NSAIDS for pain relief.

Biologic DMARDs (get TB test before starting),

JAK inhibitors (Tofacitinib) used when Methotrexate is not working well

corticosteroids to decrease inflammation 

OA medications

NSAIDS and ASA

Corticosteroids: injections (intraarticular)—use aseptic techniques, may feel worse immediately after, avoid overusing, joint after injections, Systemic (hydrocortisone, methylprednisolone) use after other meds fail. Make sure to taper off slowly as, withdrawal can occur

Topical agents: diclofenac (Voltaren), Bengay, Arthricare, capsaicin cream: no heat applied with the cream

Injection: Hyaluronic acid—lubrication, and may have anti-inflammatory effect 

causes, prevention and education for OA

Causes: aging is the #1 risk factor, obesity, previous joint injury, repetitive joint stress, genetics joint malalignment, female sex  

Prevention: maintain a healthy weight to reduce stress on joints, exercise regularly, prevent joint injury, maintain good body mechanics, treat joint injuries early  

Education: OA cannot be cured but sx can be managed, exercise is one of the best treatments, lose weight if overweight, use heat for stiffness and cold for swelling, take medications exactly as prescribed, report worsening pain or decreased mobility, use assistive devices when needed, keep f/u appts.  

arthritis medication considerations - acetaminophen and NSAIDS

Acetaminophen: max 3,000mg/day, avoid alcohol, too much can cause liver damage  

NSAIDs: first line for OA, relieves pain in RA, take with food or milk, avoid alcohol, report black stools, stomach pain, vomiting blood, or decreased urine output. Monitor kidney and liver function  

arthritis medication considerations - COX-2 inhibitors and corticosteroids

COX-2 inhibitors: has less stomach irritation but increases risk for heart attack, stroke and clots, use the lowest effective dose for the shortest time  

Corticosteroids: do not stop abruptly, take with food, monitor blood sugar, report s/s of infection, increase calcium and vit d if taking long term 

arthritis medication considerations - DMARDs

DMARDs: stops/slows disease progression in RA.

• Methotrexate: taken once weekly, avoid alcohol, use a reliable birth control, do not become pregnant, can cause bone marrow suppression, liver toxicity, infection, mouth ulcers and birth defects 

• Hydroxychloroquine: can lead to vision loss, have regular eye exams.

• Leflunomide: not to be used during pregnancy, liver function is important

Biologic DMARDs: used for moderate to severe RA when Methotrexate alone is not enough, get tested for TB before starting, do not get live vaccines, wash hands, be careful with infections b/c these meds cause immunosuppression. 

arthritis medication considerations - Leflunomide (DMARD)

do not get pregnant, monitor liver function, report yellowing skin, dark urine or abdominal pain  

anaphylaxis

rapid and severe life-threatening allergic reaction where sx can start in seconds and can progress to airway obstruction, resp. Failure, severe hypotension, shock, cardiac arrest and death.

Common triggers are foods, medications, insect stings, latex or blood products.  

Treatment: Epinephrine is the first line tx. Do not delay epinephrine while waiting for antihistamine, corticosteroid, IV lab result or provider evaluation. IV isotonic fluids (NS) can be used; antihistamines, corticosteroids, bronchodilators, and vasopressors can also be used.  

Nursing considerations: assess airway, breathing, and circulation. Look for tounge swelling, facial swelling, stridor, wheezing, hypotension, etc. Call rapid response, give IM epi immediately in the anterolateral thigh. Apply high flow of oxygen as needed, monitor resp. status; possible intubation of airway swelling worsens.

allergic rhinitis

most common chronic inflammation of the upper airway. It is a type I hypersensitivity reaction that occurs when the immune system overacts to harmless allergens. Can be seasonal, perennial, or nonallergic.  

Treatments: Avoidance therapy is the first line tx; teach pts to avoid what triggers is. Antihistamines, decongestants 

Nursing considerations: assess severity of sx, sleep quality, resp. Status, asthma sx, trigger exposure, monitor for complications like sinus and ear infections, asthma, sleep disturbances. Teach pt to avoid triggers  

atopic dermatitis

aka eczema is a chronic inflammatory skin disease caused by a type I hypersensitivity reaction. It causes dry skin, intense itching, red, inflamed skin, and there are periods of flare-ups and remission.  

scleroderma

“hard skin”, subcutaneous tissue cannot be pinched.

it is a rare, chronic connective tissue disease that causes inflammation, blood vessel damage, autoimmune activity, excess collagen builds, and fibrosis or hardening of the skin and organs. There is no known cure. There is localized and systemic. 

scleroderma tx and education

Treatment: tx is based on the effect of the organ system, and there is no medication that completely stops or cures it. Client’s clinical manifestations and comorbidities, Counseling to understand their desired outcome and goals, decrease pain, limit disability, maintain moderate exercise, prevent joint contractures, avoid cold, warm socks, Proper fitting shoes, QUIT SMOKING

• Antiarthritic meds

• Calcium channel blockers—Raynaud’

• ACE inhibitors—renal involvement

• Pulmonary hypertension medications 

Education: avoid cold exposure, stop smoking, protect the hands and feet, inspect skin daily, take meds as prescribed, monitor BP, report new SOB, perform ROM exercises, eat small meals and remain upright after eating, attend f/u appts.

atopic dermatitis tx and considerations

Treatment: wear soft cotton clothing, avoid rough fabrics, use mild fragrance-free soaps, use moisturizer after bathing, avoid harsh soaps or long baths, antihistamines, topical corticosteroids, abx, immunosuppressants, photo therapy, and systemic therapy can be used.  

Nursing considerations: assess severity of itching, skin integrity, s/s of infection, sleep quality, teach pts to not scratch, keep nails short, watch for s/s of infection, avoid triggers like heat, sweating, stress, perfumes, dust, animal dander, winter weather, harsh soaps, alcohol, resp. Infections. Provide emotional support as pts often have anxiety, depression, and poor self-esteem so they should be routinely screened.

fibromyalgia dx and sx

chronic pain syndrome that causes widespread muscle and soft tissue pain, tenderness, fatigue, sleep problems, and problems with memory and concentration. The pain is not caused by inflammation or tissue damage; the nervous system processes pain abnormally.  

Diagnosis: based on widespread pain lasting >3 months, fatigue, sleep problems, cognitive sx, physical assessment, and ruling out other disorders.  

Clinical manifestations: widespread pain that usually occurs on both sides of the body, above or below the waist, in the neck, back or chest, in muscles and soft tissues. Pt may describe the pain as burning, aching, throbbing, deep, constant, widespread. Pt will have tenderness, fatigue, sleep disturbances, “fibro fog” (poor concentration, memory problems, difficulty finding words, slower thinking, etc.), chronic headaches, mood disturbances.

fibromyalgia considerations and complications

nursing considerations: validate the pts sx and listen, avoid implying that sc are imagined, acknowledge that the pain is real, use supportive and non-judgmental communication   

Complications: pain, fatigue, & poor sleep can interfere with the ability to function at home or on the job. Depression & health-related anxiety

gout

Gout is a type of inflammatory arthritis caused by the buildup of uric acid (monosodium urate) crystals in the joints. When these crystals collect in a joint, the body's immune system reacts, causing sudden, severe pain, redness, warmth, and swelling. The big toe (podagra) is the most commonly affected joint, but the ankles, knees, wrists, fingers, and elbows can also be involved. Gout can also lead to tophi (urate deposits), kidney stones, and kidney damage if left untreated 

gout labs and priority needs

Labs: uric acid: men 3.4 - 7, women 2.4 - 6. crystals are more likely to form when uric acid reaches 6.8 or higher. For pts being treated for gout, the goal is <6.

Synovial fluid analysis is the goal standard and identifies monosodium urate crystals in joint fluid.

Priority needs: PRIE—protect, rest, ice, elevation, teach stress reduction technique, avoid alcohol, smoking, weight reduction, diet change, restrict red meat, sodium, fat, cholesterol, no starvation diets, avoid foods/drinks high in fructose (corn syrup, soda, etc.), 2,000 ml non-alcoholic fluids day, Vitamin C. relieve acute pain, reduce inflammation, protect kidneys (2-3 L of fluid daily), prevent future attacks, important to monitor kidney function (BUN and creat.)

systemic lupus erythematosus

chronic autoimmune disease in which the immune system attacks the body’s own healthy tissues and causes chronic inflammation, periods or flares and remission, and damage to multiple organs. More common in women of childbearing age than men.  

systemic lupus erythematosus - sx and care

Manifestations: fatigue, fever, weight loss, weakness, malaise, butterfly rash, photosensitivity, discoid lesions (round scaly scars), sunlight can trigger flares, joint pain, arthritis w/o joint destruction, kidney involvement, heart and lung problems (pericarditis, pleuritis), nervous system effects (HAs, depression, mood changes, memory problems, cognitive dysfunction)  

Care: reduce inflammation, prevent organ damage, control flares, preserve organ function, improve QOL, NSAIDs for joint pain, arthrits, fever (monitor for GI bleeding and kidney injury), hydroxychloroquine (take consistently, eye exams), corticosteroids, immunosuppressants, biologic medications. Monitor kidney function, protect the skin, prevent infection, provide emotional support, fatigue management.