Module 6: Altered Immunity

What is Systemic Lupus Erythematosus (SLE)?

SLE is a chronic inflammatory autoimmune disease where the immune system attacks the body's own tissues, leading to inflammation and damage in multiple organs.

What are the contributing factors for SLE?

Genetic, immunologic, hormonal, and environmental factors.

What are common triggers for SLE?

Stress, pregnancy, sunlight exposure, illness, major surgery, silica dust exposure, and medication allergies.

What happens when the immune system attacks the body's own tissues in SLE?

The immune system targets components of the cell’s nucleus, treating them as antigens, which leads to antigen-antibody complexes getting trapped in capillaries, causing organ damage.

What organs can be affected by SLE?

SLE can impact the joints, skin, brain, lungs, kidneys, and blood vessels.

What are common symptoms of SLE?

Symptoms include joint pain, fatigue, skin rashes, and organ dysfunction due to widespread inflammation.

What treatments are used for SLE?

There is no cure, but treatments include immunosuppressants, corticosteroids, sun protection, a balanced diet, and stress management to manage symptoms and control disease progression.

What is the most common form of lupus?

Systemic Lupus Erythematosus (SLE) is the most common form of lupus.

What is Subacute Cutaneous or Discoid Lupus?

It is a form of lupus that primarily affects the skin, causing rashes and lesions, and is generally less severe than SLE.

What is Drug-Induced Lupus?

Drug-induced lupus is a lupus-like condition triggered by certain medications. It generally resolves once the medication is discontinued.

How does SLE progress?

SLE progresses in periods of flares and remission, where symptoms worsen during flares and improve during remission.

How much more common is SLE in women compared to men?

SLE is 4 to 12 times more common in women than men.

Which ethnic groups have a higher prevalence of SLE?

SLE is more prevalent in African Americans, Hispanics, Asians, and American Indians/Alaska Natives.

How does socioeconomic status affect SLE control?

Lower socioeconomic status and education levels often correlate with a worse prognosis and less effective disease control in SLE.

What are some common symptoms of SLE?

Common symptoms include butterfly rash, alopecia, CNS symptoms, oral ulcers, anemia, neutropenia, thrombocytopenia, pleuritis, pericarditis, and myocarditis.

What are the common CNS symptoms of SLE?

CNS symptoms include psychosis, cognitive impairment, seizures, peripheral and cranial neuropathies, transverse myelitis, and strokes.

What is transverse myelitis in the context of SLE?

Transverse myelitis is an inflammation of the spinal cord, which can cause weakness, sensory changes, and bowel or bladder dysfunction in SLE patients.

What are common triggers for Systemic Lupus Erythematosus (SLE)?

Sunlight & UV exposure, medications (e.g., hydralazine, minocycline, procainamide), viral infections (e.g., flu, Epstein-Barr virus), silica dust exposure, and medical stressors (e.g., pregnancy, surgery).

What is a key challenge in diagnosing SLE?

SLE can be difficult to diagnose early due to its non-specific symptoms that resemble other diseases.

What are some diagnostic methods for SLE?

Diagnostic methods include symptom assessments, physical examinations (e.g., checking for rashes or joint swelling), X-rays (to identify organ damage or inflammation), and lab tests (e.g., ANA, anti-dsDNA).

What lab tests are used to diagnose SLE?

Key lab tests include the Antinuclear Antibody (ANA) test and Anti-dsDNA (Anti-Double Stranded DNA Antibodies), which are specific markers for SLE.

What does an elevated ANA (Antinuclear Antibody) level indicate?

Elevated ANA levels may indicate an autoimmune disorder, such as SLE.

What does an elevated Anti-dsDNA (Anti-Double Stranded DNA Antibodies) level indicate?

Elevated Anti-dsDNA levels are a specific marker for SLE, indicating the presence of the disease.

What is included in the Complete Blood Count (CBC) for SLE diagnosis?

Leukopenia, anemia, or thrombocytopenia, which are common in SLE patients.

What is a significant finding in a urinalysis for SLE diagnosis?

Proteinuria and elevated creatinine levels are significant findings that may indicate kidney involvement in SLE.

What imaging tests are used to diagnose SLE?

Chest X-rays and X-rays of affected joints can help identify organ damage or inflammation.

What are common complications of Systemic Lupus Erythematosus (SLE)?

Lupus nephritis & renal failure, premature heart disease, interstitial lung disease (ILD), stroke & hypercoagulation, and avascular necrosis of joints.

What is lupus nephritis?

Lupus nephritis occurs when immune complexes accumulate in renal structures (glomeruli, tubules, interstitium), leading to kidney damage.

What activates immune pathways in lupus nephritis?

Autoantibodies activate immune pathways, causing damage to renal structures.

What are the common symptoms of lupus nephritis?

Symptoms include proteinuria, nocturia, foamy urine, and edema.

How is lupus nephritis diagnosed?

Diagnosis involves urinalysis with 24-hour protein collection, elevated creatinine, and renal biopsy for classification of lupus nephritis.

What is the medical management of SLE?

Medical management includes both nonpharmacological (e.g., sun protection, balanced diet, stress reduction) and pharmacologic interventions (e.g., hydroxychloroquine, NSAIDs, glucocorticoids, methotrexate, belimumab).

What urinalysis findings are indicative of lupus nephritis?

Findings include ≥0.5g protein, +3 dipstick protein, hematuria, and casts.

What nonpharmacological treatments are recommended for SLE?

Recommendations include avoiding prolonged sun exposure, using sunscreen, maintaining a balanced diet and regular sleep, regular exercise (strength and ROM), and stress reduction.

What is the role of hydroxychloroquine in SLE treatment?

Hydroxychloroquine is used to treat fatigue, skin, and joint symptoms in SLE patients.

What are NSAIDs used for in SLE management?

NSAIDs are used to manage headaches, myalgias, and fever in SLE patients.

What role do glucocorticoids play in SLE treatment?

Glucocorticoids suppress inflammation and pain in SLE patients.

What is methotrexate used for in SLE?

Methotrexate is an immunosuppressant used to treat joint inflammation in SLE.

What does belimumab do for SLE patients?

Belimumab reduces the immune response in SLE patients.

How is organ-specific treatment for SLE determined?

Organ-specific treatment is tailored based on clinical manifestations, with adjustments for flare versus remission states.

What should be monitored in patients with Systemic Lupus Erythematosus (SLE)?

Monitor joint pain, weakness, fever, fatigue, chills, dyspnea, chest pain, peripheral edema, urine, skin, and mucous membranes for petechiae, ulcers, or bruising. Also, monitor vital signs, intake/output (I/O), weight, and lab values (CBC, BUN, creatinine, urinalysis, coagulation studies).

What are some key nursing interventions to promote for SLE patients?

Promote a balanced diet, emotional support, and referrals to specialists like pulmonologists, nephrologists, neurologists, cardiologists, and dermatologists.

What fluids can transmit HIV?

HIV can be transmitted through blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk.

What happens during the Acute Viral Infection stage of HIV?

Initial infection causes an inflammatory reaction at the site of infection, a rapid decrease in CD4+ lymphocytes, and an increase in viral load. Flu-like symptoms may appear, and seroconversion occurs when HIV antibodies are first detectable.

What occurs during the Asymptomatic Chronic Infection stage of HIV?

The CD4+ count increases to >500, viral load stabilizes at a low set point, and viral replication continues. There is a gradual loss of 50-100 CD4+ cells per year. This stage can last 3-10 years.

What happens during the Symptomatic Chronic Infection stage of HIV?

The CD4+ count drops, the immune system fails to control HIV replication, and opportunistic infections like Kaposi’s sarcoma, oral hairy leukoplakia, and skin infections develop. This stage typically lasts around 2 years.

What are the characteristics of AIDS in HIV patients?

The CD4+ count falls below 200 cells, leading to the development of opportunistic infections and AIDS-defining illnesses such as Pneumocystis pneumonia, Mycobacterium avium complex, Toxoplasmosis, and Non-Hodgkin’s lymphoma.

What are common clinical manifestations of HIV?

Common symptoms include cough, weakness, nausea/vomiting, diarrhea, dysphagia (difficulty swallowing), forgetfulness, shortness of breath (dyspnea on exertion), headache, and vision changes.

What is important regarding sun protection for HIV/AIDS patients?

HIV/AIDS patients should use sunscreen with an SPF of 30 daily and wear protective clothing to avoid sun exposure.

What dietary advice is essential for HIV/AIDS patients?

Emphasize the importance of eating a well-balanced diet to support the immune system and overall health.

How can HIV/AIDS patients conserve energy?

Prioritize activities to conserve energy and reduce stress, ensuring that patients do not overexert themselves.

Why is medication adherence crucial for HIV/AIDS patients?

Consistent medication therapy is essential to minimize flare-ups, complications, and prevent resistance to HIV medications.

What symptoms should HIV/AIDS patients monitor and report to their doctor?

Patients should contact their doctor if symptoms such as fever, cough, rash, chest pain, abdominal pain, or joint pain develop or persist

Why are regular medical appointments important for HIV/AIDS patients?

Regular appointments ensure proper management, monitoring of the disease progression, and that vaccinations remain current.

What are some complications of HIV/AIDS?

Complications include opportunistic infections like Herpes Zoster, Tuberculosis (TB), Oral Candidiasis, Pneumocystis Carinii Pneumonia (PCP), Cryptococcal Meningitis, Cryptosporidiosis, Candida Esophagitis, Toxoplasmosis, Cytomegalovirus (CMV), and Mycobacterium Avium Complex (MAC).

What is Mycobacterium Avium Complex (MAC)?

MAC is a group of bacteria closely related to tuberculosis, primarily affecting individuals with weakened immune systems, such as those with HIV/AIDS.

What is essential for the oxygenation of patients infected with MAC?

Ensure adequate oxygenation for patients infected with MAC, as respiratory function may be compromised due to infection in the lungs.

What is Progressive Multifocal Leukoencephalopathy (PML) in HIV/AIDS?

PML is a rare, often fatal infection of the brain caused by the JC virus, seen in patients with severe immunosuppression, such as those with HIV/AIDS.

What are universal precautions for HIV assessment?

Universal precautions include using personal protective equipment (PPE), such as gloves, masks, and gowns, to prevent the transmission of HIV.

What should be regularly monitored in HIV patients?

Vital signs should be regularly monitored, and physical exams should assess for swollen lymph nodes, oral candida infection, skin breakdown, nutrition, weight, and appetite. Be alert to new symptoms like fever, headache, blurred vision, changes in LOC, and night sweats.

What should be done if abnormal findings occur during HIV assessment?

Notify the healthcare provider (HCP) of any abnormal findings for further evaluation.

What is important in the assessment of HIV with a normal CD4+ T count?

Lymph node palpation should be done regularly to assess for swelling, which may indicate infection or inflammation. Regular monitoring of CD4+ T cells and viral load is essential for disease progression, even with a normal CD4+ count.

Why is monitoring disease progression important in HIV patients with a normal CD4+ T count?

The disease may progress over time, even with a normal CD4+ count, especially if viral load increases. It is essential to continue monitoring CD4+ T cells and viral load to detect early signs of HIV progression or immunosuppression.

What is oral candidiasis (thrush)?

Oral candidiasis is a fungal infection in the mouth, presenting as white patches that can be painful, making it difficult to eat or speak.

Who is most at risk for oral candidiasis?

It is more common in infants and toddlers, older adults, and individuals with compromised immune systems, including those with AIDS or those taking immunosuppressive medications.

What is the rapid test for HIV?

The rapid test provides results in 5-30 minutes and detects HIV antibodies.

What is the Enzyme-Linked Immunosorbent Assay (ELISA) for HIV?

ELISA is a blood test that provides results in 24-48 hours. If the result is negative, the test should be repeated in 3-6 months.

What is the HIV Western Blot test?

The HIV Western Blot is a confirmatory test used after a positive ELISA result. It is typically used for individuals over 12 months of age.

What is the role of viral load testing in diagnosing HIV in infants?

Viral load testing is used to confirm the presence of HIV in infants under 12 months of age.

What should be communicated to patients regarding HIV testing?

Reassure the patient not to panic and advise follow-up testing for confirmation. Encourage understanding that a positive rapid test or ELISA result does not necessarily mean the patient has HIV and further confirmation is needed.

What is the purpose of the ELISA test in HIV testing?

ELISA is the initial screening test for HIV. It is inexpensive, generally accurate, and has few false positives. If the result is positive, further confirmation is needed.

What is the purpose of the Western Blot Analysis in HIV testing?

Western Blot is used to confirm HIV seropositivity when the ELISA test is positive. It is more expensive than ELISA, so it's typically used only for confirmation of results.

What is Pre-exposure Prophylaxis (PrEP) for HIV?

PrEP involves taking Truvada to reduce the chance of contracting HIV in high-risk individuals.

What is Post-exposure Prophylaxis (PEP)?

PEP involves taking antiretroviral medications within 72 hours of possible HIV exposure to reduce the risk of infection.

What is Highly Active Antiretroviral Therapy (HAART)?

HAART is combination therapy to suppress HIV replication using medications such as:

• Protease Inhibitors (PIs) like Ritonavir

• Nucleoside Reverse Transcriptase Inhibitors (NRTIs) like Tenofovir and Retrovir

• Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) like Nevirapine and Efavirenz

What are the monitoring requirements for HIV/AIDS patients?

Regular checks include CD4+ T cell count, viral load, plasma HIV RNA, CBC, and liver function tests (LFTs).

Why are immunizations important in HIV/AIDS management?

Vaccinations help reduce the risk of infections due to the compromised immune system in HIV/AIDS patients.

How are viral load and CD4+ count used in HIV diagnosis and monitoring?

• At diagnosis, both viral load and CD4+ count are measured.

• CD4+ count is checked every 3-6 months for the first 2 years, then annually.

• Viral load is measured every 3 months for the first 2 years (for adherent patients), then every 6-12 months.

• Viral load is the primary indicator of treatment success or failure, but not recommended for hospitalized patients.

What is the needle stick risk for healthcare workers in HIV exposure

• Healthcare workers have a 0.3% risk of becoming HIV-infected if exposed to needle sticks involving HIV-infected blood (CDC, 2018a). The risk is very low.

What are the recommendations for Antiretroviral Therapy (ART) in HIV patients?

The Department of Health and Human Services (DHHS) recommends ART for all HIV+ individuals. ART interferes with the replication of HIV to reduce viral load.

Why are immunizations important for HIV+ patients?

HIV+ patients must maintain up-to-date immunizations due to their compromised immune systems. This helps prevent infections that can be dangerous for them.

What is the Pneumovax vaccination for HIV+ patients?

Pneumovax is administered every 5 years for HIV+ patients with a CD4+ count ≥200 cells/µL to reduce the risk of pneumococcal pneumonia.

What are the nursing management responsibilities for HIV patients?

• Adhere to standard precautions like PPE and hand hygiene.

• Ensure timely administration of HAART as prescribed.

• Provide nutritional support with small, frequent, and nutritionally dense meals.

• Offer emotional support, counseling, and encouragement.

• Make referrals to social work for support, especially pre and post-test.

Why is adherence to HAART important for HIV patients?

HAART is a lifelong therapy, and 100% adherence is critical to prevent viral resistance and achieve optimal results.

What should patients be educated on regarding side effects of HAART?

Patients should be informed about the potential side effects of HAART medications to better manage and report any adverse reactions.

Why is it important for HIV patients to take HAART medications at the same time each day?

A consistent schedule helps maintain drug levels in the body, ensuring optimal viral suppression and preventing resistance.

When should HAART initiation be considered, regardless of CD4+ count?

HAART should be started in patients with Hepatitis B, HIV-associated neuropathy, or pregnant women, regardless of their CD4+ count.

What infection control measures should HIV patients be taught?

Patients should be taught how to prevent transmission through high-risk behaviors, including safer sex practices and harm reduction.

Why are regular medical appointments important for HIV patients?

Regular doctor’s appointments ensure proper monitoring of HIV progression, HAART efficacy, and timely immunizations.

How does diet and rest affect HIV management?

A balanced diet and adequate rest are important for maintaining overall health, supporting the immune system, and managing the side effects of treatment.

What are the negative attitudes often associated with HIV?

Negative beliefs about individuals with HIV are often based on fear, lack of knowledge, and social stigma.

How does the stigma of HIV affect testing and care?

Stigma can prevent individuals from getting tested for HIV and can lead to feelings of shame, isolation, and despair for those diagnosed.

What cultural considerations should be kept in mind when providing care for HIV patients?

Healthcare providers should be sensitive to psychosocial, cultural, and economic factors, as they can influence a patient’s experience with HIV care and treatment.

What is an Antinuclear Antibodies (ANA) Titer?

An ANA titer is a blood test that detects autoantibodies attacking the body's own tissues, specifically the cell nucleus. It is used to diagnose autoimmune disorders, such as SLE.

What does a positive ANA titer indicate?

A positive ANA titer suggests an autoimmune disorder, such as SLE. A high ANA titer indicates an overactive immune response, leading to inflammation and tissue damage.

Why is a patient prescribed Hydroxychloroquine?

Hydroxychloroquine is prescribed to reduce inflammation, prevent lupus flares, and improve long-term disease outcomes. It helps with joint and skin symptoms and reduces fatigue.

What are the teaching points for a patient prescribed hydroxychloroquine?

• Take it daily before meals at the same time.

• Regular eye exams (every 6–12 months) are required to monitor for retinal toxicity, as long-term use can cause vision changes.

• It may take weeks to show benefits, so adherence is important.

• Report any visual disturbances, muscle weakness, or unusual bruising to the doctor.

What are the side effects and precautions for Prednisone?

Prednisone may cause weight gain, hyperglycemia, and osteoporosis. It should not be stopped abruptly. Gradual tapering is important.

What should be monitored for patients taking Lisinopril?

Monitor blood pressure regularly. Report dizziness or persistent cough to the healthcare provider.

What precautions should be taken for patients on Statin therapy?

Avoid grapefruit juice and monitor for muscle pain, as statins can cause rhabdomyolysis (muscle breakdown).