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Med/Surg I Module 4, Part 2 of 4 Connective Tissue Diseases Rheumatoid Arthritis Lupus Erythematosus...
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Transcript of Med/Surg I Module 4, Part 2 of 4 Connective Tissue Diseases Rheumatoid Arthritis Lupus Erythematosus...
Med/Surg IModule 4, Part 2 of 4Connective Tissue
DiseasesRheumatoid ArthritisLupus ErythematosusGout
2
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
3
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
4
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
8
Non-pharmacologic Therapies
Rest and positioning for comfort
Ice during inflammation Heat: paraffin wax dips or hot
packs to manage pain, increase mobility
9
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)
15
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
22
Organ Transplants
Autograft Highest success rate
Isograft Highest success rate
Allograft ↑ with compatibility
Xenograft lowest success rate
23
Nursing Care
Protect from infection
Prevent rejectionPatient teaching
Photo source: Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Kidtransplant.jpgPublic Domain, US Government
24
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
25
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
30
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
32
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)
33
Common Signs and Symptoms of Hyperglycemia
The Classic Symptoms
•Polyphagia (frequently hungry)
•Polyuria (frequently urinating)
•Polydipsia (frequently thirsty)
34
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
35
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
36
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
37
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
38
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
39
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
45
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
47
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?
48
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.
49
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
50
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
51
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
52
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
53
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
54
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
55
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
56
Pituitary DisordersSecondary hormonal imbalances
•TSH, ACTH, FSHAcromegaly
•Overproduction of growth hormoneDiabetes Insipidus
•ADH deficiencySIADH
•Excess ADH
57
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
58
Thyroid Disorders
Hyperthyroidism (Grave’s Disease)
Hypothyroidism (Myxedema)•Fatigue, hair loss, cold
intolerance, constipation
59
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
60
Parathyroid DisordersHyperparathyroidism
•Hypercalcemia
•Bone damageHypoparathyroidism
•Muscle cramps
•Chvostek’s & Trousseau’s signs
61
Adrenal Disorders
Addison’s crisis•Hypovolemia, low Na+
•Hypoglycemia
•Hyperkalemia => acidosis
Cushing’s disease•Moon face, buffalo hump, truncal obesity
•Hypertension
•Bruising
62
Photo Acknowledgement:All unmarked photos and
clip art contained in this module were obtained from the
2003 Microsoft Office Clip Art Gallery.