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88 Cards in this Set
- Front
- Back
The Immune System: Immunity
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Immunity: the body's specific protective response to invading foreign agent or organism
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The Immune System: Immunopathology
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the study of diseases that result from dysfunction of the immune system
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The Immune System: Immune deficiencies:
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Primary and secondary
-Primary immunodeficiency diseases are genetic in origin and are caused by intrinsic defects in the cells of the immune system -Secondary immunodeficiencies, such as acquired immunodeficiency syndrome (AIDS), are caused by triggers such as infection with human immunodeficiency virus (HIV). |
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Immune Function
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Natural Immunity: Nonspecific response to any foreign invader
Acquired Immunity: specific against a foreign antigen through immunization |
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Natural Immunity
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-White blood cell action is the key to the effective initiation of the immune response
-Inflammatory response elicits a response to tissue injury or invading organisms -Physical barriers, such as intact skin, chemical barriers and acidic gastric secretions or enzymes in tears and saliva |
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Acquired Immunity
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- result of prior exposure to an antigen
- Active or passive |
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Variable that affect immune system function
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-age and gender
-nutrition - presence of conditions and disorders; cancer/neoplasm, chronic illness, autoimmune disorders, surgery/trauma -allergies -history of infection and immunization -genetic factors -lifestyle -medications and transfusions |
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Tests to evaluate Immune Function
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-WBC count and differential
- Bone Marrow biopsy - Humoral and cellular immunity tests - phagocytic cell function test -Hypersensitivity tests - Specific antigen-antibody tests - HIV infections tests |
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HIV- Transmissions of
HIV- Transmissions of (con't) |
Transmitted by body fluids containing HIV or infected CD4 lymphocytes
- blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk - most prenatal infections occur during delivery - casual contact does not cause transmission - breaks in skin and mucosa incease risk |
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high-Risk Behaviors
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- Sharing infected injection equipment
- having sexual relations with infected individuals |
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Prevention of HIV
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-Standard precautions
-Practice safer sex practices and safer behaviors - abstain from sharing sexual fluids - reduce the number of sexual partners to one - always use latex condoms; if allergic to latex, use nonlatex condoms - do not share drug injection equipment - blood screening and treatment of blood products |
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Stages of HIV dx
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- primary infection
- HIV asymptomatic - HIV symptomatic - AIDS |
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Primary Infection
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-Acute HIV infection
- Part of CDC category A - Symptoms: none to flu-like syndrome - Window period: lack of HIV antibodies - Period of rapid viral replication and dissemination through the body - Viral set point: balance btw amount of HIV and the immune response |
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HIV: Asymptomatic
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- CDC category A
- More than 500 CD4 + T lymphocytes/mm3 -Upon reaching the viral set point, chronic asymptomatic state begins - Body has sufficient immune response to defend against pathogens |
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HIV Symptomatic
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-CDC catergory B
- 200- 499 CD4 + lymphocytes/mm3 - CD4 T cells gradually fail - The pt develops symptoms or conditions related to the HIV infection that are not classifed as catergory C condition - Pts who are once treated for a catergory B condition are considered category B |
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AIDS
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-CDC category C
- less than 200 CD4 + lymphocytes/mm3 - As levels drop below 100 cells/mm3, the immune system is significantly impaired - development of listed conditions |
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Treatment of AIDS
Treatment of AIDS (con't) |
- treatment and protocols are continually evolving
- Antiretroviral agents : 1. Nucleoside reverse transcriptaase inhibitors (NRTIs) 2. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) 3. Protease inhibitors (PIs) 4. Fusion inhibitors 5. Use of combination therapy - Management focuses upon the treatment of specific manifestations and conditions related to the disease |
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Manifestations of AIDS-Respiratory
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- Pneumocystis carinii pneumonia (PCP)
1. most common infection 2. initial symptoms may be nonspecific and may include nonproductive cough, fever chills, dyspnea, and chest pain 3. if untreated, progresses to pulmonary impairment and respiratory failure - treatment: TMP-SMZ or pentamidine; prophylatic TMP-SMZ - Mycobacterium avium complex (MAC) -Tuberculosis |
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Manifestations of AIDS-GI
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-Oral candidiasis
1. may progress to esophagus and stomach 2. treatment with nystatin - Diarrhea related to HIV infection or enteric pathogens - Wasting syndrome 1. 10% weight loss and chronic diarrhea or chronic weakness and fever with absence of other cause 2. protein energy malnutrition 3. anorexia, diarrhea, GI malabsorption, and lack of nutrition may contribute |
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Manifestations of AIDS- Oncologic
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-Kaposi's sarcoma
1. Cutanous lesions but may involve many organ systems 2. lesions cause discomfort, disfigurement, ulceration and potential for infection - B cell lymphomas |
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Manisfestations of AIDS- Neurologic
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-HIV encephalopathy
1. progressive cognitive, behavioral, and motor decline 2. probably directly related to the HIV infection - Depression |
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Nursing Process- Assessment of the Pt with AIDS
Nursing Process- Assessment of the Pt with AIDS (con't) |
-assess physical and psychosocial status
- identify potential risk factors: IV drug abuse and risky sexual practices - assess immune system function - assess nutritional status - assess skin integrity - assess respiratory status and neurologic status - assess fluid and electrolyte balance - assess knowledge level |
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Nursing Process- Diagnosis of the Patient with AIDS con't
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-Impaired skin integrity
- diarrhea -risk for infection -activity intolerance -disturbed thought processes -ineffective airway clearance -pain -imbalanced nutrition -social isolation -anticipatory grieving -deficient knowledge |
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Collaborative Problems/Potential Complications
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-opportunistic infections
-impaired breathing or respiratory failure -wasting syndrome -fluid and electrolyte imbalance -adverse reaction to medication |
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Nursing Process-Planning the care of the pt with AIDS
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-Goals may include:
1. achievement and maintenance of skin integrity 2. resumption of usual bowel patterns 3. absence of infection 4. improved activity tolerance 5. improved throught processes 6. improved airway clearance |
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Systemic Lupus Erythematosus:
After the Diagnosis: Caring for the client with Lupus |
Lupus is a chronic inflammatory disease that can affect various parts of the body, especially the skin, joints, blood and kidneys
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Pathophysiology of Lupus
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results from an abnormal reaction of the body to its own tissues, cells and serum proteins
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Manisfestations of Lupus
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-arthritis
-joint swelling, tenderness, pain upon movement -morning stiffness -subacute cutaneous lupus erythematosus -butterfly shaped rash across the bridge of the nose and cheeks -pericarditis, atherosclerosis -CNS involvement -Renal involvement |
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Medical Management of Lupus
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-prevent progressive loss of organ function
- reduce exacerbations and likelihood of acute dx - minimize dx-related disabilities - prevent complications from therapy |
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Pharmacologic Therapy of Lupus
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-treatment approaches are based on the specific needs and symptoms of each person
1. NSAIDS-ASA, Motrin, Naprosyn, Indocin 2. Corticosteroids- Prednisone 3. Antimalarials - Aralen, Plaquenil 4. Immunosuppressive agents- Imuran, Cytoxan |
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Additional Therapy for Lupus
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-Dialysis
- Renal transplant |
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Nursing Considerations for Lupus
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- fatigue
- restricted salt intake - impaired skin integrity - body image disturbance - knowledge deficit - routine screenings |
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Organizations for Lupus
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-Arthritis Foundation
-American Lupus Society |
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Gout
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-over secretion of uric acid
- decreased excretion of uric acid by the kidneys |
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Gout is related to
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-severe dieting
- starvation - excessive intake of foods high in purines (shellfish, organ meats) -heredity -secondary-cell turn over from chemotherapy, radiation |
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Clinical manisfestations of Gout
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- joint pain, redness, swelling, warmth
- big toe, ankle, knee |
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Acute Attacks of Gout
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-Triggered by:
ETOH Dieting Stress Illness |
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Testing and Diagnostic Procedures for Gout
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uric acid level:
Uricosuric agents: 1. Probenecid 2. Colchicine 3. NSAIDS 4. Allopurinol 5. Intra-articlar injections of corticosteroids |
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Nursing for Gout
Nursing for Gout (con't) |
-restrict consumption of foods high in purines
- normal body weight - pain management in acute attacks - monitor uric acid level - hydration -limit alcohol |
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Elevated Uric Acid
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greater than 7 mg/dl
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Chronic, systemic disease
-inflammation of connected tissue in the synovial joints - remission and exacerbations -Late Stages of R.A.: Boutonniere deformity of thumb, Ulnar deviation of metacarpophalangeal joints, Swan-neck deformity of fingers |
Rheumatoid Arthritis
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Incidence of R. A.
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-occurs globally
-affects all ethnic groups - occurs at any age - increases with age -affects women more often than men -smoking linked |
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Pathophysiology of R.A.
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-cause unknown
- autoimmune response defect |
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Clinical manifestations of R.A.
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-insidious onset
-fatigue, anorexia, wgt loss -generalized stiffness Can proceed to: -pain, stiffness, limitation of motion, signs of inflammation -joint pain may be symmetrical; after rest -small joints of the hands and feet -larger joints-elbows, hips, ankles |
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Complications of R.A.
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-joint destruction
-flexion contractures -deformities -nodules -cataracts |
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Diagnostic Tests for R.A.
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-essential sedimentation rate
- C-reactive protein - Antinuclear titer - Synovial fluid analysis - Rheumatoid factor - X-rays of involved joints |
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Management of R.A.
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-Nutritional counseling
-Therapeutic exercises - rest & joint protection - assistive devices - heat & cold - herbal products |
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Pharmacology for R.A.
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-Disease-modifying antirheumatic drugs (DMARDS)-(plaquenil)
-Methotrexate - NSAIDS -Steroids |
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Nursing for R.A.
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-chronic pain
-pain management - mobility - body image -self-care deficit - knowledge deficit |
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The nurse is performing an assessment on a female pt who complains of fatique, weakness, muscle and joint pain, anorexia, and photosensivity. lupus is suspected. The nurse further assesses for which of the following that indicates the presence of Lupus?
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butterfly rash on nose and cheeks
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A fluorescent antinuclear antibody titer is performed on a client suspected of having R.A. The nurse reviews the lab results and determines that the test is positive if which of the following values is noted?
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a value greater than 1.8
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a rheumotoid factor is performed on a client with a diagnosis of rheumotoid arthritis. The nurse understands that this test measures for the presence of?
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Unusual antibodies of the immunoglobin G and M type
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An erythrocyte sedimentation rate is prescribed for a client with a connective tissue dx. The client asks the nurse about the purpose of the test. The nurse tells the client?
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this test is to confirm inflammation or infection in the body. - the rate of 30-40 mm/hr indicates mild inflammation, 40-70 is moderate and 70-150 is severe
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The nurse notes that a lupus cell preparation has been ordered. The nurse understands that this test is used to screen primarily for?
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systemic lupus erythemalosis
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A complete bl.cell count is performed on a client with SLE (lupus). The nurse suspects that the test will show?
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decrease of all cell types including white, red, neutrophil called pancytopenia
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A client with AIDS has been started on therapy with zidovudine (AZT, Retrovir). The nurse carefully assesses which lab result during this treatment?
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A complete blood count- anemia and agranulocytopenia are common with these therapies - monitor monthly for 3 months then every 3 mths after
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The home care nurse provides instruction to the client with lupus about measures to combat fatigue. which statement by the client shows the need for further instruction?
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I should take a hot bath every evening- these pts should avoid hot baths- prolonged rest promotes joint stiffness
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The CD4 lympocyte test for HIV is used to
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determine the stage of HIV - if the count is under 500 cells/ml than antiretroviral therapy is begun
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To determine whether Kaposi's sarcoma is present the test given will be
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biopsy= represents as purplish lesions on the skin. Dyspnea occurs if they are in the lungs. Can occur in GI tract so biopsys are taken from these systems
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In an HIV pt. toxoplasmosis would present with symptoms of?
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mental status changes
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The client with AIDS is experiencing nausea and vomiting. which dietary alteration should be made?
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avoid fatty products such as diary products and red meats. Meals should be small and frequent
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Which food item should the pt with Lupus avoid?
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steak- these pts are at risk for cardiovascular dx. client is advised to avoid fats,salt, and cholesteral intake
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Which group of drugs would the nurse expect to find prescribed for a Lupus pt?
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corticosteroids, anti-inflammatory, and immunosuppresents
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Plaquenil, for lupus, can cause?
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ocular toxicity
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The nurse knows that a positive diagnosis for HIV infection is made based on?
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Positive ELISA and Western Blot test
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Blood screening tests of the immune system of a client with AIDS would indicate?
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A decrease in CD4 T cells=
HIV selectively infects helper T cell lymphocytes: therefore 300 or fewer CD4 T cells per cubic ml of blood or CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS |
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in a pt with AIDS what is Pneumocystis carinii and what nursing diagnosis is appropriate to this?
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it is a protozoan that causes pneumonia in these pts, which can cause death in 60% - the client's respiratory status is priority so Impaired gas exchange
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during a routine checkup,the nurse evaluates a client with R.Arthritis. To access for the most obvious dx manifestations first, the nurse checks for?
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joint abnormalities
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What assessment findings support a suspicion of SLE (lupus)?
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facial erythema,profuse proteinuria, pleuritis, fever and wgt loss
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The test to confirm that a client has SLE lupus?
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an above-normal anti-deoxyribonucleic acid test (DNA)
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In an end stage AIDS pt with the Cryposporidium infection what is the highest nursing intervention?
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fluid replacement, this protazoan causes massive diarrhea
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Which blood test should be monitored for an AIDS pt taking AZT?
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RBC count- AZT cause anemia
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A pt newly diagnosed with AIDS wants to know all about the dx. When teaching about the immune system which type of white blood cell provides adaptive immunity?
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Lympocytes
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A client is taking prednisone for R.Arht.which are the common adverse affects of this med?
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fluid retention and wgt gain, hypertension and insomnia
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In a client with HIV infection, CD4 levels are measured to determine the?
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extent of immune system damage
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For discharge planning with a pt with SLE lupus, which should be included in the teaching?
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monitor your body temperature
-fever can signal an exacerbation and should be reported to the MD |
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A client in end stage AIDS shows signs of dementia. Which nursing diagnosis takes priority
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Risk for Injury
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Which of the following microorganisms is known to cause retinitis in people with HIV/AIDS?
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Cytomegalovirus
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This statement reflects the treatment of HIV infection
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treatment of HIV infection for an individual pt is based on the clinical condition of the pt. CD4 T-cell count level and HIV RNA (viral load)
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Which of the following is the greatest risk if the pt does not take non-nucleoside reverse transcriptase inhibitors (NNRTs)as prescribed? (for AIDS)
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rapid onset of drug resistance
- cross resistence will develop in all others of the same class, making the therapy ineffective |
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The term used to define the balance between the amount of HIV in the body and the immune response is?
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viral set point
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More than 500 CD4+ T lymphocytes/mm3 indicates which stage of HIV infection?
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CDC category A- HIV asymptomatic
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Passive range-of-motion exercises are indicated during which stage of rheumatic dx?
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Acute- pt cannot perform these exercises during an acute stage without help
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What are Tophi?
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Accumulation of crystalline depositions in articular surfaces, bones, soft tissues,and cartiledge
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Which of the following immunity types becomes active as a result of the infection of a specific microorganism?
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naturally acquired active immunity
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TABLE 52-2 Selected Laboratory Tests for Diagnosing and Tracking HIV and Assessing Immune Status
Test Findings in HIV Infection EIA (enzyme immunoassay) Antibodies are detected, resulting in positive results and marking the end of the window period Western blot Also detects antibodies to HIV; used to confirm EIA Viral load Measures HIV RNA in the plasma CD4/CD8 ratio These are markers found on lymphocytes. HIV kills CD4+ cells, which results in a significantly impaired immune system. |
Chart 52-6 HIV Test Results: Implications for Patients
Interpretation of Positive Test Results Antibodies to HIV are present in the blood (the patient has been infected with the virus, and the body has produced antibodies). HIV is active in the body, and the patient can transmit the virus to others. Despite HIV infection, the patient does not necessarily have AIDS. The patient is not immune to HIV (the antibodies do not indicate immunity). Interpretation of Negative Test Results Antibodies to HIV are not present in the blood at this time, which can mean that the patient has not been infected with HIV or, if infected, the body has not yet produced antibodies (window period—usually 3 weeks to 6 months). The patient should continue taking precautions. The test result does not mean that the patient is immune to the virus, nor does it mean the patient is not infected; it just means that the body may not have produced antibodies yet. |
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FIGURE 54-1. (A) Synovial swelling and fluid accumulation. (B) Pannus (a proliferation of synovial tissue), eroded articular cartilage, and joint space narrowing—all of which contribute to muscle atrophy and ankylosis (joint rigidity and immobility).
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TABLE 54-2 Goals and Strategies for Rheumatic Diseases
Major Goals Management Strategy Suppress inflammation and the autoimmune response Optimize pharmacologic therapy (anti-inflammatory and disease-modifying agents) Control pain Protect joints; ease pain with splints, thermal modalities, relaxation techniques Maintain or improve joint mobility Implement exercise programs for joint motion and muscle strengthening and overall health Maintain or improve functional status Make use of adaptive devices and techniques Increase patient's knowledge of disease process Provide and reinforce patient teaching Promote self-management by patient compliance with the therapeutic regimen Emphasize compatibility of therapeutic regimen and lifestyle |
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Lupus:Nursing Management
Nursing care of the patient with SLE is based on the fundamental plan presented earlier in the chapter (see Chart 54-2). P.1912 The most common nursing diagnoses include fatigue, impaired skin integrity, body image disturbance, and lack of knowledge for self-management decisions. The disease or its treatment may produce dramatic changes in appearance and considerable distress for the patient. The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care and sensitivity to the psychological reactions of the patient. The patient may benefit from participation in support groups, which can provide disease information, daily management tips, and social support. Because sun and ultraviolet light exposure can increase disease activity or cause an exacerbation, patients should be taught to avoid exposure or to protect themselves with sunscreen and clothing. Because of the increased risk of involvement of multiple organ systems, patients should understand the need for routine periodic screenings as well as health promotion activities. A dietary consultation may be indicated to ensure that the patient is knowledgeable about dietary recommendations, given the increased risk of cardiovascular disease, including hypertension and atherosclerosis. The nurse instructs the patient about the importance of continuing prescribed medications and addresses the changes and potential side effects that are likely to occur with their use. The patient is reminded of the importance of monitoring because of the increased risk of systemic involvement, including renal and cardiovascular effects |
Gout:Nursing Management
Historically, gouty arthritis was thought to be a condition of royalty and the very rich, with the disease attributed to “high living.” This has not been shown to be entirely true. Although severe dietary restriction is not necessary, the nurse should encourage the patient to restrict consumption P.1919 of foods high in purines, especially organ meats, and to limit alcohol intake. Maintenance of normal body weight should be encouraged. In an acute episode of gouty arthritis, pain management with prescribed medications is essential, along with avoidance of factors that increase pain and inflammation, such as trauma, stress, and alcohol. During the intercritical period, the patient feels well and may abandon preventive behaviors, which may result in an acute attack. Acute attacks are most effectively treated if therapy is begun early in the course |