NUR 265 Exam 4 Full Study Guide
Labs
• Hbg 12-18
• Hct 37-52%
• WBC 5-10
• RBC 4.2-6.1
• PLT 150-400
• PT 11-12.5 sec (1.5-2.5x normal on Coumadin = 16.5-31.25 sec)
• INR 0.9-1.2 sec (Therapeutic level 2-3x normal = 1.8-3.6 sec)
• PTT 60-70 sec (1.5-2.5x normal on Heparin = 90-175)
• Na 135-145
• K+ 3.5-5
• Creatinine 0.5-1.2
• BUN 10-20
• Albumin 3.5-5
• Mg 1.5-2.5
• Ca 9-10.5
• Cl 98-106
• Phosphorus 2-4.5
• Specific Gravity 1.005-1.030
Discoid lupus
• Affects only the skin and is not lethal - Caused by UV rays
• Macular Rash & Discoid Rash
• Skin biopsy to dx
Systemic Lupus Erythematosus (313-317) ***TEMPERATURE***
• Chronic, progressive, inflammatory connective tissue disorder that affects multiple body systems &organs
o REMISSIONS/EXACCERBATIONS (can end up in the ICU) - Autoimmune
o Attracted to KIDNEY’s—Lupus Nephritis is leading cause of death; this is direct damage to the
kidneys
• Poor survival associated with high creatinine, low hematocrit, proteinuria
o Young Women of child bearing age 20-40 Y (primary AA women)
o SLE & DLE both share a disfiguring and embarrassing rash!!
• Clinical manifestations
o Malar rash – red flat or raised rash over cheeks sparing nasolabial folds “butterfly rash”
o Discoid rash – Red raised patches with scaling follicle plugging
o Photosensitivity– discoid skin rash from sun exposure - pt should wear sunscreen or protective
clothing
o Oral ulcers–usually painless
o Polyarthritis-multiple joints affected
• Small joints and knees inflamed
• Osteonecrosis from chronic steroid use (5y+)
o Pleuritis with pleural effusion or pericarditis
o Fever is the major sign of exacerbation
, o Generalized weakness, fatigue, anorexia, weight loss
o Renal disorders–proteinuria, cellular casts
o Neurologic disorders – seizures, psychosis and also peripheral neuropathies
o Raynaud’s phenomena
• Exposure to cold or extreme stress – red, white, blue & pain of digits
o Alopecia or hair loss common
• Diagnostic Tests
o ANA most sensitive but antinuclear antibodies not specific to SLE
o C reactive protein can help differentiate SLE flare from an infection (remains normal if SLE flare)
o CBC shows pancytopenia (a decrease in all cell types)
• Medical Management
o Topical steroids for skin lesions
o Acetaminophen or NSAIDS (caution with kidneys) – tx joint & muscle pain & inflammation
o Hydroxychloroquine (anti-malarial agent) – dec absorption of ultraviolet light by skin, dec skin
lesions
▪ Frequent eye exams – b4 starting and q 6 mon
o Glucocorticoids – Chronic steroid therapy
▪ Take in the am b4 breakfast
▪ Take Ca to prevent osteoporosis
▪ Maintain skin integrity
o Immuno-suppressants – methotrexate, azathioprine
o Belimumab – do not receive live vaccines for 30 days b4 tx
• Teaching
• Protect the skin
o Limit sun/ultraviolet light exposure to prevent exacerbation (fluorescent light too)
▪ Long sleeves, lg-brimmed hat, SPF 30+
o Clean skin with mild soap, pat dry and apply lotion
o Cosmetics ok w/ moisturizers and sun protection, no excess powder or drying substances
• Monitor temperature – first sign of exacerbation
• Avoid large crowds and people who are ill, bc immunosuppressed
• Avoid harsh hair tx (permanents or highlights)
• Pregnancy can cause exacerbation
Systemic Sclerosis (Scleroderma) ***SWALOWING PROBLEM***
• Uncommon, chronic, inflammatory, autoimmune connective tissue disease.
• Similar to SLE, but w/a higher mortality rate
• Doesn’t respond to steroids or immunosuppressants, why mortality higher than SLE
• Inflamed tissue becomes fibrotic and then sclerotic (hard) – renal involvement leading cause of death
• Women 25-55, most in 40s
• Diffuse cutaneous *Major organ problems
o First sx – hand and forearm edema w/ or w/o bilateral carpal tunnel syndrome
o Skin thickening on trunk, face, and proximal and distal extremities (most of the body)
o Painless symmetric pitting edema of hands & fingers (sausage like fingers)
o Changes of pigmentation with loss of skin folds & face can become mask like
o Develop early problems w/ GI tract (GERD to dysphagia), heart(myocardial fibrosis), lungs
(fibrosis & PAH), & kidneys (malignant HTN)
o Complications can be rapid
, • Limited cutaneous *Esophagus
o Skin thickening limited to sites distal to face, neck and distal extremities
o Organ changes rare or late
o CREST Syndrome
▪ Calcinosis – calcium deposits in tissues
▪ Raynaud’s Phenomenon – intermittent vasospasm of finger tips - first CREST symptom that
develops
▪ Esophageal dysmotility - **Dysphagia**
▪ Sclerodactyly – scleroderma of digits – fingers stiff, shiny, and no skin folds
▪ Telangiectasia – capillary dilations that form vascular lesions on face, lips & fingers
• Medical Management
o Medications – Tx sx
▪ Vasoactive agents – CCB for Raynaud’s symptoms
▪ Anti – inflammatory meds - steroids
▪ Immunosuppressants
o Reduce renal complications
▪ ACE inhibitors and HTN control
o Treat PAH (Pulmonary Artery Hypertension)
▪ Bosentan - endothelin receptor antagonist – Liver toxic
• Nursing Management
o Keep HOB elevated 60 degrees during meals and at least an hour after
o Maintain skin integrity– esp with steroids & vasospasm
o Small frequent meals w/semisoft foods – avoid liquids (thick it) due r/f choking – small amounts &
chew well
o Teach to avoid foods that include gastric secretion–spices, caffeine, pepper
o Promote bowel elimination – have both constipation & diarrhea
• Client Education
o How to dress in cold weather-gloves, socks, etc.
o Eliminate alcohol, cigarettes, extreme stress, and caffeine (vasoconstrictive)
o Biofeedback for stress management
o Disease process – Only gets worse
Fibromyalgia ***SLEEP & STRETCHING***
• Chronic pain syndrome, NOT inflammatory or autoimmune
• Pain stiffness and tenderness in trigger points – back of neck, upper chest, trunk, low back, and extremities
• Burning and gnawing that comes and goes, worsen w/stress, include activity, and weather conditions
• Women between 30 -50 years, Lyme disease, trauma, & flu-like illness
• Clinical Manifestations
o Fatigue – most common manifestation
o Morning stiffness
o Non refreshing sleep because of lack of stage 4 sleep- most do not get REM sleep
o Post exertional muscle pain
o 1/3 of patients have irritable bowel, tension headaches, PMS, numbness & tingling & Raynaud’s
phenomena
o Depression – common with chronic pain
• Medical Management—Directed at symptom relief
o L tryptophan-used to enhance sleep
o TCAs (amitriptyline, nortriptyline) inhibit serotonin uptake - antidepressant
o Benzodiazepines for anxiety associated w/ depression
, o NSAIDS for pain control but may need stronger meds if pain not well controlled
o Pregabalin (Lyrica) – FDA approved for fibromyalgia pain
o **LOW INTENSITY EXERCISE WILL DECREASE PAIN**
▪ Stretching, walking, swimming, rowing, biking, and water exercise
o Anticonvulsants like carbamazepine (Tegretol) & gabapentin (Neurontin) to help w/ chronic pain
mgmt.
o Biofeedback– esp. helpful with pain syndrome
o Oral Mag helpful with muscle pain
Lyme’s Disease ***NO DARK CLOTHING***
• Tick born disease
• Considered a connective tissue disease because the skin, joints, nervous system, and heart are involved
• Sx begin w/i 3-30 days post bite
• Easy to treat when found in time
• Signs and Symptoms
o 1st - Red flat rash that clears in the center (bulls-eye lesion)- near the area of the bite
o Flu-like sx - Severe HA, Fever, Chills, Severe malaise, Fatigue, Stiff neck, & Joint pain
• Medical Management
o Doxycycline is the most common antibiotic used to treat (14-21 days)
o Severe disease- IV antibiotics for 30 days (ceftriaxone or cefotaxime)
o Neurologic abnormalities may occur if tx is ineffective
o Intra-joint steroids & NSAIDS may be used for joint inflammation & pain
o Long term effects include fatigue & arthralgias for many years after initial infection
• Prevention & Early Detection
o Avoid dark clothing, long-sleeved tops and long pants, tuck in shirt and pants into boots
o Insect repellant w/DEET
o Remove with gloves or tissue, do not squeeze or burn, flush down the toilet. Clean area with alcohol
o Wait 4-6 weeks after being bitten b4 being tested, testing b4 is not reliable
Allergy (348-358) ***EPI PEN, STOP INFUSION, LATEX CONDOM USE***
• “Hypersensitivity” inc immune response to the presence of an allergen “antigen”
• Diagnosis
o Allergy skin testing – Has to be red & raised
▪ avoid antihistamines & corticosteroid inhalers 2 weeks before testing
▪ Emergency equipment (resuscitation bag, suction, IV, drugs) for anaphylaxis
o RAST (radioallerosorbent test) or fluroenzyme blood tests used to measure IgE levels to specific
allergens
o Pulmonary function measurements for allergic asthma
o Blood test measuring levels of IgE (normal 39 IU/ml)
o CBC may show inc eosinophils (normal 1-2%)
• Allergic Disorders
o Allergic Rhinitis
▪ Histamine causes capillary leak, nasal & conjunctival mucus secretion, & itching w/redness
▪ Allergic rhinitis has rhinorrhea (runny nose), stuffy nose, & itchy, watery eyes
▪ Clear or white nasal drainage, HA or feel pressure
o Food allergy vs food intolerance
▪ 8 foods 90% of true food allergies – milk, eggs, peanut, tree nuts, shellfish, fish, soybeans &
wheat
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