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REVIEWER FOR INTENSIVE NURSING (PNLE ED)
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Immunology • Primary target: Synovium = synovial fluid (lubricates)• Synovitis: inflammation of the synovial fluid
The technique of assisting the body to develop immunity by way -results to phagocytosis; have periods of remission
of injecting a diluted antigen in a series of injections of and exacerbation causing a pannus formation
increasing strength, over 1 to 3 year period is known as *pannus: extra growth of synovial tissue = Ankylosis
A. Immunization * Ankylosis: fusion of the bones (bony Ankylosis)
B, Immunotherapy -causes stiffness and pain = Immobility
C. Vaccination *Immobility: contractures or misalignment of bones
D. Anaphylaxis called deformities
DEFORMITIES:
What type of immunity is acquired when the patient contracted 1. Swan-neck: affected is the Distal Interphalangial Joint
varicella? 2. Boutonniere’s: affected is the Proximal Interphalangial Joint
A. Active natural 3. Ulnar Deviation / Drift
B. Active artificial 4. Z- thumb
C.passive natural *have self-care deficit ( eating, brushing teeth, hygiene, etc)
D. Passive artificial Signs and symptoms
1. Articular Features (s/sx seen in joints or musculoskeletal)
During the death process of a cell, which immune system cell is SWEL
responsible for ingesting the fragments of the dying cell? S-swelling
A. T cells W-warmth: due to swelling
B. B cells E- erthythema: due to swelling
C. Neutrophils L- loss of function
D. Macrophages *Morning stiffness: Felt discomfort most of the time d/t inactivity
: duration: 30-45 minutes after waling up
Which statement below is not true regarding the role of the : can perform Exercise
helper t cell? *spongy joints: d/t fluid accumulation
A. The helper t cell releases cytokines to help activate other *Deformities d/t involvement of joints
immune system cells.
B. The helper t cells is part of the adaptive immune system RHEUMATOID ARTHRITIS OSTEOARTHRITIS
C. The helper tcells is cytotoxic and kills invaders -Autoimmune -degenerative
D. The helper t cells has CD4 receptors found on its surface -Systemic -localized
-starts in smaller joints like -starts in larger joints like weight
Which white blood cells are involved in releasing prostaglandin fingers, feet, wrist bearing joints
during pain? -Symmetrical & Bilateral -asymmetrical & Unilateral
A. Basophils -felt on morning d/t inactivity - felt on afternoon to evening d/t
B. Eosinophils activity
C. Monocytes
D. Neutrophils 2. Extra-articular Features (s/sx outside joints; systemic )
· fatigue d/t anemia
WBC (Leukocytes) · Weight loss, fever
1. granulocytes (BEN) · Splenomegaly d/t Autoimmune
a. Basophils: allergy (histamine), prostaglandin (pain), · Scleritis
Bradykinin (inflammation) · Lymph node enlargement
b. Eosinophils: pericarditis
c. Neutrophils: most abundant; 1st Responder to infection Pleurisy can lead to Pleural effusion
2. Agranulocytes SJOGREN’s SYNDROME
.a. Monocytes: macrophages = phagocytosis (cell eating) • dryness of eyes, mouth and vagina
b. Lymphocytes
> B cells: plasma cells (multiple myeloma) responsible for RAYNAUD’s PHENOMENON (digital blanching & cyanosis)
production of antibodies (GAMED) Ig (proteins of • cold and stress induces vasospasm (exposure
antibodies) • Contriction of a small blood vessels
> T cells (CD4 cells) * white: lack of blood flow
1. Helper : activates or initiates the immune response * blue: lack of oxygen
2. Cytotoxic: Killer T-cell * Red: Blood flow returns
3. Suppressor: stops the cytotoxic
4. Memory: remember; adaptive immunity DIAGNOSTIC and Labs
1. RF: Rheumatoid Factor: 80% who have RA have (+) results
*Autoimmune = attacks own immunity 2. ANA: antinuclear antibody: not a confirmatory of RA but
= causes splenomegaly Confirmatory of AUTOIMMUNE
*In RA & SLE: the problem was in the suppressor 3. ESR: elevated (errythrocytes sedimentation Rate) d/t inflam.
*In HIV: problem in the helper T-cells (CD4) 4. CRp elevated (c-reactive Protein) d/t inflammation
- no initiation of immune response 5. XRAY / MRI: bone envisions or narrowed joint spaces
6. Arthrocentesis: aspiration of the synovial fluid
RHEUMATOID ARTHRITIS -For diagnostic: check components
• systemic: affects the organs -For treatment: to relieve swelling
• Chronic: with periods of remission and exacerbations(on & off) Normal synovial fluid: clear, straw and viscous
• Autoimmune and inflammatory RA synovial fluid: dark yellow, decrease viscosity, w/ leukocytes
, The client with rheumatoid arthritis tells the nurse, i have a friend
Management: who took gold shots and had a wonderful response. Why didn’t
Medical my physician let me try that? Which of the following responses by
1. NSAIDS the nurse woulds be most appropriate?
-for anti-inflammatory effect A. Its the physician’s prerogative to decide how to treat you. The
-indomethacin , Ibuprofen physician has chosen what is best for your situation
-GI irritants; taken with meals B. Tell me more about your friends arthritic condition. Maybe i
-frequent use can cause ulcer can answer that question for you.
-use of COX2 inhibitor celecoxib D. Every person is different. What works for one client may
-less GI irritation because no COX1 (which protects GI lining) not always be effective for another
Non-Opioids The nurse teaches a client about heat and cold treatment to
-Acetaminophen (Tyelenol) manage arthritis pain. Which of the following client’s statements
NSAIDs indicates that the client still has a knowledge deficit?
- ibuprofen (advil) ; anti inflammatory A. I can use heat and cold as often as i want
*NSAIDs and Non-Opioids are analgesic & antipyretic B. With heat i should apply for no longer than 20 mins at a time
C. Heat producing liniments can be used with other heart
2. Corticosteroids (-SONE) devices
-GI irritants D. Ten to 15 minutes per application is the maximum time for cold
applications
3. DMARDs: (disease modifying Anti-rheumatic drugs) (GAPS)
G-old containing Compounds / gold shots After teaching the client with rheumatoid arthritis about measures
A-ntimalarial to conserve energy in activities of daily living involving the small
P-enicillamine joints, which of the following if stated by the client would indicate
S-ulfasalazine the need for additional teaching?
A. Pushing with palms when rising from a chair
4. Immunosuppressive Agents B. Holding packages close to the body
a. Cyclophosphamide (cytoxam) C. Sliding object
b. Methotrexate (Rheumatrex) D. Carrying a laundry basket with clinched fingers and fist
Nursing Responsibilities: Systemic lupus Erythematosus (SLE)
1. Rest and Activity (balance for fatigue); ROM; low impact · Systemic
activities like swimming, walking, stationary bikes, stress ball) ·Chronic
2. Moisture Replacement (Artificial tears, increase OFI, lip balm, ·Autoimmune
oral care, proper lubrication) ·Inflammatory
3. Promote non-stressful environment / avoid cold environment * Problem: Suppressor T cells. = ↑ Antibodies
4. Heat(stiffness) and cold application (inflammation)
Heat max is 20mins. Cold max is 15 mins Risk Factors: GHEMS
5. Diet: High Protein, iron, folic acid, and b12 supplements • Genetics-African Americans
6. Promote safety • Hormones - Female (10x chances than Male).
7. Assist in Self-care activities Ages - Childbearing Age
• Environmental Factors (UVRays, Thermal Burns)
Surgical management Medications
1. Surgical cleansing (joints) * Drugs-induced lupus:
2. Artificial Joint Replacement - Hydralazine, Isoniazid, Chlorpromazine
3. Arthroplasty • Stress-triggers "Flares"
4. Synovectomy
5. Arthrodesis: fusion of bones using screws/metal plates Signs and symptoms: RA like symptoms
*bone graft (pelvic, tibia, bone bank) 1. Musculoskeletal: presenting symptom (1st manifestation)
2. Integumentary: alopecia/ lesions/ rashes
A client with rheumatoid arthritis states “I can’t do household *butterfly rash (cheeks & bridge of nose): hallmark
chores without becoming tired. My knees hurt whenever I 3. CNS: decrease cognition/ behavioral changes / depression
walk“ Which nursing diagnosis would be most appropriate? 4. GIT: oral ulcers or mouth sores
A. Activity intolerance related to fatigue and pain 5. Renal: HPN * renal failure is the most common cause of death
B. Self-care deficit related to increasing joint pain 6. Cardio: pericarditis
C. Ineffective coping related to chronic pain 7. Respiratory: pleurisy (sharp chest pain during inhalation)
D. Disturbed body image related to fatigue and joint pain 8. Bone marrow: bone marrow suppression
-decrease RBC(fatigue), WBC (immunocompromised) and
On a visit to the clinic, a client reports the onset of early symptoms platelets (bleeding)
of rheumatoid arthritis. The nurse should conduct a focused • must have 6 months remission before allowed pregnancy
assessment for: * Discoid Lupus Erythematous (only affects the skin)
A. Limited motion of joints
B. Deformed joints of the hand Diagnostics and labs:
C. Early morning stiffness 1. RF (+). 6 .ESR
D. Rheumatoid nodules
2. ANA (+). 7. CPR
3. ANTI- DNA (+)
4. CBC
5. SERUM CREATININE and BUN
,Management: You’re providing education to a SLE support group about
1. Corticosteroids: given topical (skin), oral (minor s/sx), preventing flares. Which statement by a participant requires re-
IV(flares major) education about this topic?
2. NSAIDs: add to corticosteroids to decrease steroidal A. Emotional stress and illness are triggers for a flare up
requirement B. I always wear large-brimmed hats and long sleeves when I’m
3. Antimalarial outside
4. Methotrexate: for severe cases C. Exercise should be avoided due to the physical stress it
5. Plasmapheresis: exchange causes on the body
-remove antibodies and change into iv fluids or albumin D. I will make it priority to receive my yearly influenza vaccine
Nursing considerations: A patient is diagnosed with SLE. You mote the patient has a red
1. Rest and activities rash that starts on the nose and expands onto the cheeks of the
2. Oral care face. This is known as what type of rash
3. Avoid infection (avoid crowded place; isolate) A. Discoid
4. Non-stress environment (stress triggers flares) B. Malar
5. Avoid exposure to UV rays C. Miliaria
If cannot avoid= have protection: D. Eczema
-hat, lotions, long sleeves, umbrella, glasses)
6. Diet: low fat, low sodium, high fiber diet (avoid raw foods) After an extensive diagnosis workup, a client is diagnosed with
7. Support groups SLE which statement about incidence of SLE is true?
-remind patient to have routine periods screening A. SLE is most common in women ages 45-60
Multiple Myeloma B. SLE affects more whites than blacks
• malignancy in plasma cells that produces Immunoglobulin G C. SLE tends to occur in families
D, SLE is more common in underweight than overweight
Pathophysiology
Cancer in plasma cells = Ig (over production of Ig) = monoclonal Risk Factors
protein rich in blood = increase in Osteoclast Activating Factor • Age (60 above)
(OAF) = increase osteoclast (bone breakdown) • Race (African-Americans)
• Radiation exposure
Presenting sign of Multiple Myeloma = • Obesity
1. BONE PAIN at back/ribs
*bone pain relieved by rest
2. fractures (Ca increases in blood) Management:
3. hypercalcemia = high risk for renal calculi = renal failure 1. Chemotherapy: 1st line of treatment
4. Osteoporosis 2. Radiation therapy
5. Hyperviscosity 3. Plasmapharesis: exchange plasma with albumin of IV fluids
6. Pancytopenia: Bone marrow suppression - to decrease the immunoglobulin G from the blood
4. Medications
Diagnostics / Labs a. Biphosphonates: pamidronate (Aredia)
1. CBC: decrease all Zoledronate Acid (zometa)
2. X-ray: fractures -lower OAF preventing fractures / strengthening the bones
3. bone marrow aspiration: sheets of plasma cells b. Thalidomide: anti myeloma medication
*Best site: Iliac crest (anterior or posterior) - teratogenic; can cause Amelia (x pregnant)
*Alternative: Sternum for adults Common SE: dizziness, fatigue, rashes
*best site for children is Tibia
*biopsy: confirmatory in all cancer Nursing responsibilities:
4. Deca scan: osteoporosis ; bone density 1. Safety is the priority: due to fractures and bleeding
5. Urine Analysis: proteinuria 2. Increase Oral Fluid Intake: for hypercalcemia
6. 24-h urine collection: Bence-Jones protein 3. Vitamin D & C : increase calcium absorption
7. Serum creatinine: elevated (renal involvement) 4. Rest and activity
8. BUN: elevated (renal involvement)
9. Serum Calcium: elevated (hypercalcemia)
A patient with SLE is experiencing s complication called lupus
nephritis. What are some signs and symptoms that correlate with
this complication of SLE? Select all that apply:
1. Decreased creatinine
2. Increased BUN
3. 48 hour urinary output of 720ml
4. Proteinuria
5. Weight loss
6. Edema in upper and lower extremities
A. 1234
B. 246
C. 236
D. 2346
, HIV & AIDS
• 6months to 10 years HIV to AIDS
• Causative agent is Retrovirus
• HIV discovered 1981 in USA
• Acquired from chimpanzees
• AIDS: first 100 cases in 1982
• 1984: 1st case in the Philippine
• People living with HIV - called to patients (not like (+) HIV)
Mode of Transmission
• Blood
a. needle or syringes prick (common to IV drug users)
*needle exchange program
b. BT is rare (screening) it just because of window period
c. piercings and tattoos (rare) (single use/disposable)
d. transplacental (incidence rate < 10%)
*if taking antiretroviral 1% chance only
e. Anal sex (with with wound)
f. NSD delivery
• Sexual Activity : vaginal and semen secretions
*Fellatio (if w/ wound) (recommend condom & dental dam)
*Cunnilingus (if with wound)
• breastfeeding : breast milk
HIV
• starts asymptoma
• Minor s/sx (flu like symptoms, fatigue, fever, stomatitis,
diarrhea, night sweats and infections)
AIDS
• opportunistic infections
- PCP (P. Jiroveci)
-cytomegalo vorus
-candidiasis
-histoplasmosis
- PTB
-cryptosporidiasis
• rare cancers: kapsi’s sarcoma & non-Hodgkin’s lymphoma
• HIV encephalopathy (Aids dementia complex)
* pneumonia most common cause of death
Diagnostics
1. EIA (ELISA): Enzyme Immuno-Assay
- presumptive test
-window period: 3weeks to 3 months (24-90days)
2. Western Blot: confirmatory test for HIV
HIV & AIDS 3. CD4 T cell count of <200: confirmatory for AIDS
• 6months to 10 years HIV to AIDS NORMAL IS: above 500
• Causative agent is Retrovirus
• HIV discovered 1981 in USA 4. RT-PCR: virus isolation
• Acquired from chimpanzees
• AIDS: first 100 cases in 1982 Management:
• 1984: 1st case in the Philippine 1. HAART (Highly active antiretroviral therapy)
• People living with HIV - called to patients (not like (+) HIV) ART IN PH (antiretroviral therapy) only
• zidovudine (Azt)(Retrovir)
Mode of Transmission • Abacavir (ABC)
• Blood • Didanosine (ddl)
a. needle or syringes prick (common to IV drug users) -decrease viral load
*needle exchange program -slows down the progression of the virus
b. BT is rare (screening) it just because of window period -expensive but free medication
c. piercings and tattoos (rare) (single use/disposable) Prevention: (ABCD
d. transplacental (incidence rate < 10%) • Abstinence
*if taking antiretroviral 1% chance only • Be Faithful
e. Anal sex (with with wound) • Condom use (LAM skin condom if allergic latex)
f. NSD delivery • Diagnosis
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