Med/Surg IModule 4, Part 2 of 4Connective Tissue

DiseasesRheumatoid ArthritisLupus ErythematosusGout

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Rheumatoid Arthritis

Pain, morning stiffnessEarly: Joint inflammationLate: deformities

Photo courtesy of Charles Goldberg, M.D., UCSD Image Bank, http://medicine.ucsd.edu/clinicalimg/upper-rheumatoid-arthritis.html

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Complications Baker’s cysts: enlarged popliteal bursae Synovitis, effusions in joints Subcutaneous nodules: usually ulnar

surface of arm, fingers, along Achilles tendon

Sjogren’s syndrome: dry eyes, mouth and vagina – secretory glands are obstructed

Felty’s syndrome: hepatosplenomegaly, leucopenia

Caplan’s syndrome: rheumatoid nodules in lungs

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Laboratory AssessmentInflammatory connective tissue

diseaseRheumatoid factor (RF)Antinuclear antibody titer

(ANA) Erythrocyte sedimentation rate

(ESR)

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Collaborative ManagementAnalgesic/anti-pyretic/anti-

inflammatoriesDisease-modifying anti-rheumatic

drugs (DMARDs)Methotrexate (Rheumatrex):

mainstay of therapy •Watch! For bone marrow

suppression & liver toxicity Lefunomide (Arava): Similar to

methotrexate, same side effects

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Collaborative Management, cont…

Immunosuppressants: Biological response modifiers: Glucocorticoids (steroids)

•Watch! Gastrointestinal inflammation & blood sugar elevation

Gold therapy

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Alternative Therapies

Hypnosis, acupuncture, imagery, magnet or music therapy

Omega-3 fatty acids: fish oil capsules

Antioxidant vitamins A, C, ETrace elements: zinc, selenium,

copper, iron

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Non-pharmacologic Therapies

Rest and positioning for comfort

Ice during inflammation Heat: paraffin wax dips or hot

packs to manage pain, increase mobility

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Lupus Erythematosus

•Discoid: affects only the skin•Systemic: chronic, progressive connective tissue inflammation causing nephritis (leading cause of death), pericarditis, pleural effusions, esophagitis, joint inflammation and inflamed skin

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Collaborative Management: Discoid Lupus

Rash: Topical cortisoneSkin protection from sun, ultra-

violetTeach: mild soap, no perfumes,

use lotion, avoid drying substancesAlopecia (hair loss) is common:

mild protein shampoo

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Exacerbation

Fever (major sign), abdominal pain, increased fatigue, headache, dizziness

Caused by stress Signs of inflammation in affected

organs Will need hospitalization, may become

rapidly critically ill•Systemic corticosteroids

•Cytotoxics: Imuran, Cytoxan

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GoutManifestations:

•Renal calculi (stones)

•Hyper-uricemia - elevated serum uric acid

•Joint inflammation - very painful

•Tophi - sodium urate crystal deposits, commonly on outer ear, fingers

Image Source: UCSD, Catalog of Clinical Images. Photography by Charlie Goldberg, M.D., University of California, San Diego School of Medicine, San Diego VA Medical Centerhttp://medicine.ucsd.edu/clinicalimg/Upper-tophaceous-gout4.html

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Acute Episode of Gout

Sudden, severe joint pain and swelling

Shiny red or purple skin around the joint

Extreme tenderness in the joint area

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Collaborative Management of Acute Episode Colchicine (Colsalide) NSAID Allopurinol (Zyloprim) or probenecid (Benemid) Watch! Aspirin and diuretics may start an

attack Avoid emotional stress Low-urine diet: avoid organ meats, shellfish,

oily fish with bones Avoid excess alcohol Prevent stones - drink more fluids, increase

acidity of urine with alkaline ash foods (citrus, milk)

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Human Immunodeficiency Virus (HIV)

Image Source: Wikimedia Commons, Public Domain, http://commons.wikimedia.org/wiki/Image:800px-HIV_Viron.png

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Diagnosis Leukopenia Less than 500-16000 CD4+ cells/mm3

in AIDS Enzyme-linked immunosorbent assay

(ELISA) Western blot Viral load testing Quantitative RNA assays P24 Antigen assay

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ManifestationsHIV: Fever, chills, night sweats,

headaches, muscle achesAIDS: Signs of an opportunistic

infection:• shortness of breath or dry cough• fatigue• weight loss, nausea and vomiting, diarrhea• swollen lymph nodes• visual changes, memory loss and confusion• seizures, skin lesions

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PreventionSexualParenteralHealth care workersPerinatal

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Immunocompromised?No crowdsDon’t share personal items, bathe q

dayWash hands, wash dishes, cupsLow bacteria dietAvoid pet litterCheck temperature dailyNo gardening

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Anti-HIV Drugs

Category Action Examples

Nucleoside analog reverse transcriptase inhibitors

Inhibit HIV replication

zidovudine (Retrovir), didanosine (Videx), zalcitabine (HIVID),

Non-nucleoside analog reverse transcriptase inhibitors

Suppress viral replication, do not kill the virus

nevirapine (Viramune), efavirenz (Sustiva)

Protease inhibitors

Block protease enzyme, prevents viral replication

ritonavir (Norvir), indinavir (Crixivan)

Fusion inhibitors

Block fusion of HIV with host cell

enfuvirtide (Fuzeon)

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Opportunistic Infections Pneumocystis carinii (most common) Toxoplasmosis gondii - from cat feces,

undercooked meat Candida albicans Cryptococcus neoformans Histoplasma capsulatum Mycobacterium avium Mycobacterium tuberculosis Cytomegalovirus (CMV) Herpes simplex Kaposi’s sarcoma:

Image Source: Wikimedia Commons, Public Domain, http://commons.wikimedia.org/wiki/Image:Kaposi%27s_Sarcoma.jpg

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Organ Transplants

Autograft Highest success rate

Isograft Highest success rate

Allograft ↑ with compatibility

Xenograft lowest success rate

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Nursing Care

Protect from infection

Prevent rejectionPatient teaching

Photo source: Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Kidtransplant.jpgPublic Domain, US Government

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Transplant Rejection

Hyperacute: Immediate or up 2-3 days after new tissue transplanted

Acute: 1 week to 3 months after transplant

Chronic: 4 months to years after transplant

Graft-versus-Host Disease: First 100 days

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Rejection Prophylaxis/Rx Cyclosporine (Sandimmune, Neoral) Azathioprine (Imuran) Mycophenolate (CellCept) Tacrolimus FK 506 (Prograf) Sirolimus (Rapamune) Corticosteroids (prednisone) Interleukin-2 receptor antagonists Antithymocyte globulin (Atgam) Muromonab –CD3 (Orthoclone OKT3)

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Anaphylaxis Difficulty breathing Wheezing Abnormal high-pitched breath sounds Confusion, slurred speech Rapid, weak pulse, palpitations Skin redness, hives, generalized itching Profound hypotension Bronchospasm and laryngospasm Pulmonary edema

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Emergency Management

Airway: Assess for laryngospasm, stridor – may need immediate intubationBreathing: oxygen at high flow rate, 10-15 L/minute, monitor oxygen saturationCirculation:Assess for dysrhythmias, hypotension

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Reverse the Reaction

Place tourniquet per protocol proximal to allergen point of entry

Epinephrine (Adrenalin) intravenous: (Does patient have an Epi-Pen?)

Diphenhydramine (Benadryl) intravenous

Dopamine for persistent hypotension to vasoconstrict

Give antidote if appropriate

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StabilizeIntravenous fluids:

crystalloids, colloidsMonitor for decompensation,

repeat epinephrine

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Diabetes MellitusType 1Type 2Type 3 (gestational)

Image Source: Wikimedia Commons, Public Domain, http://commons.wikimedia.org/wiki/Image:Orange_juice_1.jpg

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Diagnosis

Fasting blood glucoseOral glucose tolerance testGlycosylated hemoglobin assay

(HgA1C)Serum protein and albumin24-hour urine creatinine

clearance

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Common Signs and Symptoms of Hyperglycemia

Other Symptoms Might Include •Fatigue

•Blurred vision

•Weight loss

•Poor wound healing (cuts, scrapes, etc.)

•Dry mouth

•Dry or itchy skin

•Impotence (male)

•Recurrent infections such as vaginal yeast infections, groin rash, or external ear infections (swimmers ear)

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Common Signs and Symptoms of Hyperglycemia

The Classic Symptoms

•Polyphagia (frequently hungry)

•Polyuria (frequently urinating)

•Polydipsia (frequently thirsty)

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Ketoacidosis Hyperglycemia: > 250 mg/dL Dehydration: hot, dry, flushed skin Metabolic acidosis: pH < 7.3 Electrolyte imbalance: loss of

potassium, sodium Nausea and vomiting Kussmaul’s respirations: increased

rate and depth Ketone breath: fruity, alcohol-like

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Treatment for Ketoacidosis Fluid replacement Replace electrolytes Give insulin: Initial bolus dose followed by

infusion of regular insulin•NOTE: insulin may adsorb into the plastic or

glass container, decreasing its potency – flush IV line with at least 50 ml of insulin infusion before connecting to patient

Closely monitor blood sugar at least hourly Keep a syringe of 50% dextrose immediately

available for hypoglycemia Treat Acidosis

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Patient Education: Hyperglycemia

Follow sick day rules Monitor capillary glucose every 4 hours Continue to take insulin or oral antidiabetic

agents Drink 8-12 ounces of liquids every hour Continue to eat at regular times Get plenty of rest Call physician for persistent nausea,

vomiting, glucose elevation despite medication, high or increasing fever, diarrhea

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Hyperosmolar Hyperglycemic Non-ketotic Syndrome (HHNS) Type II diabetic, some insulin secreted Ingests large amount sugar,

decreased fluid In HHNS the hyperglycemia is more

profound, increasing the blood osmolarity and diuresis. •Dehydration

•Electrolyte imbalance

•Decreased neurologic function

•Seizures

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Collaborative Management First priority: replace fluid volume with

intravenous saline. The preferred solution is 0.45% saline to

correct the water deficit rapidly and the sodium deficit more slowly (to prevent seizures)

Give 1000 ml/hr until central venous pressure, blood pressure and urine output are adequate

Reduce the rate to 100-200 ml/hr until the estimated water deficit is replaced

Monitor hourly for: cerebral edema, mental status changes, abnormal neurologic signs, signs of fluid overload

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Insulin:Intravenous insulin is given at

a rate of 10 units/hr to supplement blood glucose reduction by rehydration.

Blood sugar should decrease no faster than 10% per hour.

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Insulin Injection Sites

Photo source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.htm

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Common Signs and Symptoms of Hypoglycemia

Early Symptoms•Hunger

•Trembling

•Palpitations

•Anxiety

•Sweating

•Clamminess

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Late Symptoms Might IncludeDifficulty thinking Confusion Headache Seizures

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Emergency Treatment: HypoglycemiaGlucagon intravenous orDextrose 50% intravenous

– repeat according to blood sugar

NOTE: high glucose will damage the tissue if it leaks

5% dextrose in water intravenously

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Patient Teaching: Hypoglycemia

Check blood sugar: if less than 60 mg/dL: •Treat with 15

grams of glucose or equivalent

•Wait 15 minutes and retest

•If blood sugar is still less than 60 mg/dL, treat with another 15 grams of glucose

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To prevent hypoglycemia:

•Eat and take medications on time

•Make sure to eat enough food for the medication you are taking

•Do not drink alcohol without eating food

•Carry some form of carbohydrates with you in case there is a meal delay

•Be aware of the time of day - if you are taking insulin, your blood sugar will be the lowest before a meal

•Plan your exercise

•Report all unexplained hypoglycemia episodes to your doctor

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Diabetic DietDifferent

categoriesPortion size1600-2800

calories

Diabetes Food Pyramid

Source: National Diabetes Education Program/NIH

http://ndep.nih.gov/diabetes/MealPlanner/pyramid.htm

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Diabetes Food Serving per DayGrains and starches: 6-11Vegetables: 3-5Fruit: 2-4Milk: 2-3Meat and meat substitutes: 4-6

ozFats, sweets and alcohol: 0?

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Glycemic Index Ranks carbohydrate-rich foods according

to their glycemic response. •Foods that raise the blood glucose level quickly

have a higher GI rating than foods that raise blood glucose level more slowly. In general, the lower the rating, the better the quality of carbohydrate.

Choose low and medium GI foods more often than high GI foods. •A GI of 55 or less ranks as low, a GI of 56 to 69

is medium, and a GI of 70 or more ranks as high.

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LOW GLYCEMIC INDEX FOODS (55 or less) choose most often Skim milk Plain Yogurt Soy beverage Apple/plum/orange Sweet potato Oat bran bread All-Bran™ Converted or Parboiled rice Pumpernickel bread Al dente (firm) pasta Lentils/kidney/baked beans Chick peas

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MEDIUM GLYCEMIC INDEX FOODS (56-69) choose more often

Banana Pineapple Raisins New

potatoes Oatmeal Split pea or

green pea soup

Brown rice Couscous Basmati rice Shredded

wheat cereal Whole wheat

bread Rye bread Popcorn

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Teach: Exercise Regular exercise is essential for

carbohydrate metabolism and insulin sensitivity.

Hypoglycemia can occur during and for 24 hours after exercise•Check glucose levels before and after

exercise•Do not exercise within one hour of

insulin injection or at peak insulin action•Insulin dosage may need to be

decreased before exercise

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Teach: Exercise(cont…)

A carbohydrate snack for exercise will help maintain glucose levels: 15-30 g for every 30-60 minutes of exercise

Take a simple sugar (hard candy) when exercising if symptoms of hypoglycemia occur

Low intensity aerobic exercise for longer periods is most effective

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Complications Cardiovascular disease Kidney disease Retinopathy Neuropathy Foot complications Skin complications Gastroparesis Erectile dysfunction Depression

Photo source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.htm

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Transplantation

Whole pancreas or islet cell transplants will provide normal glucose control. Organ or cell availability continues to be limited. Potential complications include:

•long-term immunosuppression

•venous thrombosis

•rejection

•infection

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Endocrine OrgansHypothalamusPituitaryThyroid ThymusParathyroidsAdrenal glandsPancreas Ovaries/Testes

Source: U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Programhttp://training.seer.cancer.gov/module_anatomy/unit10_3_dige_regions.html

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Pituitary DisordersSecondary hormonal imbalances

•TSH, ACTH, FSHAcromegaly

•Overproduction of growth hormoneDiabetes Insipidus

•ADH deficiencySIADH

•Excess ADH

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Trans-Sphenoidal Hypophysectomy

Neuro checks Watch! Diabetes Insipidus Watch dressing: Postnasal drip? Teach: avoid cough, blow nose,

sneeze Watch for Meningitis Replace hormones

•Thyroid•Glucocorticoids

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Thyroid Disorders

Hyperthyroidism (Grave’s Disease)

Hypothyroidism (Myxedema)•Fatigue, hair loss, cold

intolerance, constipation

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Thyroidectomy Position: Semi-fowler’s, avoid neck

extension Watch!

•Hemorrhage 1st 24 hours

•Laryngeal stridor

•Tetany (what are the early signs?)

•Laryngeal nerve damage

•Thyroid storm

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Parathyroid DisordersHyperparathyroidism

•Hypercalcemia

•Bone damageHypoparathyroidism

•Muscle cramps

•Chvostek’s & Trousseau’s signs

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Adrenal Disorders

Addison’s crisis•Hypovolemia, low Na+

•Hypoglycemia

•Hyperkalemia => acidosis

Cushing’s disease•Moon face, buffalo hump, truncal obesity

•Hypertension

•Bruising

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Photo Acknowledgement:All unmarked photos and

clip art contained in this module were obtained from the

2003 Microsoft Office Clip Art Gallery.