PN2 NUR2571 Exam 2 study guide, Exams of Nursing

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PN2 Exam 2 study guide

Chapter 25

Heart Failure and Inflammatory Dysfunction

Terms: Hypertrophy – abnormal enlargement; increase in size and mass of a body part or organ. Contractility – capability of muscle fibers to shrink Cardiomyopathy – heart muscle disease Carditis – inflammation of heart muscle Prophylactic – preventing or contributing to prevention of disease Idiopathic – disease state that arises from unknown cause Endocarditis – inflammation of endocardium (inner heart muscle layer) Myocarditis – inflammation of myocardium (middle heart muscle layer) Pericarditis – inflammation of pericardium (thin membrane surrounding whole heart) Inner to outermost – Endo  myo pericardium Myectomy – removal of offending muscle Sequla – any abnormality resulting from disease Valvular regurgitation –backward flow of blood through heart valve Valvular stenosis – narrowing or constricting of the diameter of a bodily passage or orifice Petechiae – small pin point hemorrhages Valvuloplasty –plastic surgery performed to repair a valve in body Mitral facies – florid appearance with cyanosed cheeks Heart Failure – when the heart cannot pump enough blood effectively throughout the body. Two categories – systolic & diastolic. Systolic – inability of ventricles to contract and pump blood adequate. Diastolic- decrease in ventricular filling and impaired diastolic filling of left ventricle. Both lead to decreased amount of blood being circulated to the body. Most common in 40-75 yo males. Affects both genders equally after 75 yo Assessment & findings – health history and physical exam focusing on cardio and pulmonary system. Hh findings - patient needing increased number of pillows to sleep, paroxysmal nocturnal dyspnea (wake up at night from shortness of breath d/t fluid in lungs), ask about shortness of breath and what makes symptoms worse and better?, ask about coping and family dynamics. Assessment findings – possible increase in bp and rapid hr, auscultated s3, decreased level of consciousness, extremities cool, pale, cyanotic, edema and poor healing wounds. R sided HF : swelling of feet and ankles, frequent nocturnal urination, pronounced neck veins, palpitations, irregular or rapid hr, fatigue, weakness, faintness, palpable dysrhythmias, weight gain, distended neck vein, enlarged liver, ankle edema. L sided HF : sob, paroxysmal nocturnal dyspnea, palpitations, tachycardia, cough with frothy blood tinged mucus, fatigue, weakness, syncope, weight gain, oliguria, fluid retention, heart murmur, extra heart sounds, dysrhythmic heart rate, lung crackles, decreased basilar lung sounds.

Diagnostic tests – ECG, chest xray, stress tests (exercise test), cbc, Potassium, sodium and calcium imbalances, fluids and electrolyte levels, cardiac catheterization to see degree of HF, MRI Nursing diagnosis – activity intolerance, risk for ineffective breathing pattern, anxiety Interventions – control volume overload by monitoring sodium and fluid intake, restrict salt intake and fluids if needed, rx: morphine, diuretics, respiratory support: oxygen in nonrebreather mas, PEEP intubation and mechanical ventilation, monitor oxygen and ABGs, position patient for maximum cardio function (dangle legs and elevate head of bed, reassure patient to reduce anxiety and extra workload on heart. Nurse needs to motivate pt toward healthy behaviors by reflective listening, expressing acceptance and affirmation, monitor pt readiness to change, ensure not jumping ahead of pt. Rx- ACE inhibitors to decrease the pressure of the heart (captopril, enalapril), ARBs reduce pressure and work overload (bisoprolol, carvedilol), vasodilators, nitrates, beta blockers, diuretics (furosemide, torsemide), hormones, digitalis, and aspirin. Surgery for severe heart failure – heart valve replacement, implant of cardiac defibrillator, coronary artery bypass grafting. Done under general anesthesia. Dilated cardiomyopathy – heart muscle results in dilated heart chamber. Leads to weakened, thin heart muscle wall that is unable to pump blood efficiently throughout body causing HF. Assessment findings – monitor pt for sob, tiredness, palpitations, syncope, chest pain. Nursing diagnosis – activity intolerance, risk for ineffective breathing pattern, pain. Interventions – assess pt family and support, anxiety and depression. Rx- ace inhibitors, beta blockers, diuretics, anticoagulants, antiarrhythmics. Surgery – cardioversion, heart transplantation, pacemaker, implant defibrillator. Hypertrophic cardiomyopathy – increase in size and thickness of heart muscle. Genetic and/or idiopathic. Assessment findings – sob, chest pain, palpitations, light headedness, black outs, physical exam reveals palpable forceful apical pulse and heart murmur. Abnormal ECG Nursing diagnosis – activity intolerance, risk for ineffective breathing pattern, pain Interventions – educate pt about physical activity recommendations, weight reduction for obese pt, moderate alcohol intake, flu vaccine recommended. Avoid overexertion, acute loss of body fluid volume, fainting situations, hot showers, rx that drop bp quick. Report sudden loss of consciousness, rapid palpitation, chest pain, sob. Rx – calcium channel blockers to reduce stiffness of myocardium. Receive antibiotic prophylaxis before dental procedure. Surgery – myectomy (removing muscle), heart transplantation. Arrhythmogenic right ventricular cardiomyopathy – disease where heart muscle is replaced by fibrous scar and fatty tissue. Genetic link. Assessment – palpitations, light headedness, fatigue, fainting, syncope. ECG test. Interventions – lifestyle advice, refrain from over exertion, and activities that increase heart work overload, encourage and educate obese pt in weight loss, moderate alcohol intake, flu vaccine. Report symptoms of palpitations, chest pain, changes in consciousness, sob.

Rx – antiarrhythmics, ace inhibitors, diuretics, antigoagulants, prophylactic antibiotics for pt who have concomitant valvular disease Surgery – cardioversion, ablation therapy, heart transplant, pacemaker, defibrillator Restrictive cardiomyopathy – disease of the ventricular heart muscle where becomes stiff. Genetic link – have family tested. Assessment – bibasilar lung crackles, JVD, dependent pitting edema, enlarged liver, fatigue, sob. ECG test Interventions –treat symptoms and sequel (abnormality resulting from disease), assess family and support. Carditis – inflammation of the heart or heart valves. 3 types: endocarditis, myocarditis, pericarditis. Endocarditis – infection from bacteria of hearts inner lining (endocardium). Common cause of sore throat – Group a strep can lead to rheumatic fever and lead to rheumatic heart disease  bacterial endocarditis  get antibiotic treatment ASAP to prevent damage. Assessment – malaise, anorexia, weight loss, cough, back pain, joint pain. Heart murmurs, janeway lesions (flat, painless red to bluish on palms and soles), petechiae (small pin point hemorrhages) in conjunctiva. Patient hx of new onset headaches or transient ischemic attacks. Diagnostic test – obtain serial blood culture, ECG. Interventions – prevention FIRST, assess for heart murmurs, embolism, HF, increased infection, assess effectiveness of antibiotic therapy, pt education and family coping. Rx- antibiotic therapy  long term IV therapy with periodic blood cultures Surgery – surgical valve repair or replacement Myocarditis – inflammation of the myocardium (middle muscle layer of heart). Assessment – fatigue, dyspnea, palpitations, chest discomfort, abd discomfort, heart murmurs, irregular heart rhythm Interventions – prevention FIRST, maintain up to date record related to influenza and hepatitis, reduce heart workload, treat symptoms and causing agent, assess and monitor pt for heart murmurs and HF, pt educate and pt and family coping. Pericarditis – inflammation of the pericardium (thin membrane that surrounds the heart). Assessment – chest pain: sharp and stabbing, fever, dyspnea, abd pain, tachycardia, febrile state, Beck triad (hypotension, elevated jugular pressure, muffled heart sounds), pulsus paradoxus. Diagnostic tests – cbc, erythrocyte sedimentation rate, crp, bun, creatinine, cardiac enzymes, blood culture, ECG, MRI Interventions – reduce chest pain, dyspnea and fever, assess vitals, pulse ox, skin color and temp, pt report sob and weakness, fatigue, telemetry monitoring, AVOID nsaids and corticosteroids.

Mitral valve prolapse – mitral valve leaflets stretch into atria during systole causing uneffective closing and blood being pumped back into left atrium. Higher risk in men over 50 but found more in females over 45. Assessment – fatigue, sob, light headed, dizzy, syncope, palpitations, chest pain, anxiety, auscultate heart: will hear systolic click, use TEE for assessing Interventions – treat symptoms and chest pain, avoid caffeine, alcohol, smoking, ephedrine, epinephrine. Educate pt on symptoms to report, minimize palpitations, chest pain, fatigue or autonomic dysfunction. Minimize anxiety, teach about antibiotic prophylaxis prior to procedures. Exercise for mild MVP. Educate on lifestyle changes, weight loss for obese pt, hypotensive pt increase salt and fluids. Focal neuro event pt avoid tobacco and oral contraceptives. Mitral regurgitation – disorder or mitral heart valve where blood flows from left ventricle into left atrium during systole. Group Strep A and MI may be cause. Assessment – fatigue, general weakness, dyspnea, palpitations, cough, systolic murmur, irregular pulse rhythm. Interventions – ECG, treat same as CHF Surgery – mitral valve replacement or valvuloplasty (plastic surgery performed to repair valve in body). Mitral stenosis – narrowing or constriction of diameter of mitral valve opening. Caused by rheumatic heart disease. May lead to pulmonary hypotension and death. Genetic and more common in women. Assessment – dyspnea on exertion, fatigue, cough with hemoptysis, chest pain, rheumatic fever, dysphagia, wave in jugular venous pulse, edema, enlarged liver, ascites, mitral facies (florid appearance with cyanosed cheeks), diastolic murmur and displaced apex beat, irregular pulse rhythm. Interventions – ECG, prevent recurrence, exacerbation and treat symptoms same as CHF, assess and educate pt: decrease salt intake, avoid strenuous exercise, use antibiotic prophylaxis of recurrence and prevent infection. Surgery – valvuloplastly and valvular defusion Aortic regurgitation – disorder of aortic heart valve where blood back flows through aortic valve into left ventricle during diastole, of ventricular relaxation. More common in adults. Genetic and common sequelar of rheumatic fever. Assessment – increased dyspnea on exertion, fatigue, paroxysmal nocturnal dyspnea, awareness of forceful pulsations in upper thorax and head, diastolic murmur, increased intensity of carotid and temporal pulse, widened pulse pressure Interventions – ECG, MRI, use prophylactic antibiotics to prevent recurrence and exacerbation. Surgery – valvuloplasty or valve replacement Aortic stenosis – narrowing or constriction of the diameter of the orifice between left ventricle and aorta. Most common valvular disease in men. Has characteristic harsh systolic murmur with thrill along left sternal border radiating to neck.

Assessment – dizzy and syncope, dyspnea upon exertion and angina, systolic murmur and thrill, most common findings - chest pain, HF, syncope. Interventions – ECG, prevent recurrence and exacerbation of symptoms, educate pt on identifying new symptoms and know to report, use prophylactic antibiotics Surgery – repair of aortic valve and replacement Preop teaching for surgery – inform pt of event on day of surgery, orientate to ICU, monitor, IV lines, drainage tubes, breathing tubes, ventilator, expectations of activity levels and exercise and pain management, diet changes. Pt on warfarin are at risk for bleeding: monitor for hematuria, excessive bruising, nosebleed, tarry stools, gum bleeding, petechiae, teach pt s/s of excessive bleeding and importance of following rx regime and follow up appointments.

Chapter 28

Hypertension

Terms: Peripheral vascular resistance – pressure against the flow of blood to or from arteries or veings outside the chest. Cardiac output – pressure required to move blood throughout the body per minute provided by pumping action of heart. Systolic bp – bp measured at moment of contraction Diastolic bp – pressure measured when ventricles are relaxed Pulse pressure – difference between the systolic and diastolic pressure. BMI – formula using weight and height to determine percentage of total body fat Orthostatic hypotension – hypotension occurring when changing position from supine to upright Pulsus paradoxus – pathological decrease in systolic bp by 10 mm or more on inspiration Rebound hypertension – rapid increase in bp after abrupt stopping of medications Hypotension – bp lower than needed for adequate tissue perfusion and oxygenation Hypertension – high blood pressure is a sustained elevation of systemic blood pressure to a level that places that pt at risk for target organ damage such as eyes, brain, heart, kidneys and great vessels. SILENT KILLER DISEASE. Risk factors – family hx, excess sodium intake, physical inactivity, obese, high alcohol consumption, African American, smokier, hyperlipidemia, stress Two types: Primary – no known cause. 90% of pt have this type. Secondary – related to another disease. 10% of pt have this. Causes include renal artery stenosis, chronic kidney disease, obstructive uropathy, congenital narrowing of aorta, cushings syndrome, thyroid dysfunction, parathyroid disease, hyperaldosteronism, pheochromocytoma, head trauma, brain tumor, spinal cord injury, sympathetic stimulants, MAOIs, estrogen therapy, NSAIDS, sleep apnea, pregnancy induced hypertension Risk factors – nonmodifiable rf = family hx, age, gender, ethnicity. Modifiable = obesity, substance abuse, stress, diet, sedentary lifestyle

Assessment – Pt may remain without symptoms until target organs are damaged, secondary symptoms include fatigue, dizzy, angina, palpitations, dyspnea, headache on back of head in morning MOST OFTEN REPORTED SYMPTOM. Classified based on avg of two or more properly measured, seated bp readings on each of two or more separate occasions. Normal bp = less than or equal to 120/80. Prehypertension = 120-139/80- Stage 1 hypertension = 140-159/90- Stage 2 hypertension = greater than or equal to 160/ Interventions – lifestyle modifications: weight loss, moderate alcohol, caffeine and sodium, quit smoking, reduce stress and get regular exercise (30-60 min/day of moderate exercise and 25 min 3x/week of vigorous exercise). DASH diet – rich in grains, fruits, veggies, and low fat dairy products. Have 7-8 daily servings of grains, 8-10 daily servings fruits and veggies, 2-3 daily servings dairy, 2 or less daily servings meat poultry and fish, 2.5 daily servings fats, 4-5 weekly servings of nuts, seeds, legumes and sweets. Rx – antihypertensive meds: Diuretics – thiazides, loop (furosemide), potassium sparing (spironolactone), aldosterone receptor blockers Vasodilators – hydralazine, minoxidil Sympatholytics – methyldopa, clonidine, guanethidine, alpha blockers - (prazosin), beta blockers – atenolol, metoprolol. Combined - carvedilol ACE inhibitors – benazepril, captopril, enalapril ARBS – candesartan, eprosartan, losartan Calcium channel blockers – amloidipine, felodipine, nifedipine, diltiazem, verapamil Pt education – teach pathophysiology, explain tests being performed, how to interpret test, teach lifestyle changes, observe for changes, and when to report changes, if lifestyle choices do not help and bp is above 140/90 rx will begin, teach rx regime and names of medications and what they do, side effects, teach how to measure bp and pulse once a week to keep record and follow up appointments, report sudden changes in bp or pulse, pt CANNOT suddenly stop taking rx or may lead to rebound hypertension, do not take too much of bp rx or may lead to hypotension. Depression may be result of disease – refer pt to counseling if needed. Monitor potassium with salt substitute if pt on it, consume less than 2.3 g/day sodium, diet low in fat, saturated fat and cholesterol. Consume foods rich in potassium, calcium and magnesium. Complications – hypertensive crisis. Occur when pt does not adhere to rx regime. Assessment findings = severe headache, extremely high bp, blurred vision, dizzy, disorientation, epistaxis. Administer IV antihypertensives (nitropress and labetalol hydrochloride as prescribed, monitor bp every 5-15 min, asses neuro status such as pupils, level of consciousness, muscle strength, monitor ECG to assess cardiac status.

Chapter 27

Cardiovascular/ Coagulation Integrity Terms: Aphonia: loss of the ability to speak by disease or damage to the larynx Aneurysm: bulging/ stretching of an artery by 2 or 3 times the size- leads to weakness in arterial wall and great risk for complications. Arteriosclerosis: hardening of the arteries- thickening and solidifying of the endothelial lining of the walls in the small arteries and arterioles. Atherosclerosis: Development of plaque in the intimal layer of larger arteries, developing blockage of the vessel lumen- symptoms don’t develop until 60 percent is occluded- happens with aging adult. Bruits: abnormal tone, a murmur. Buerger’s Disease: clot formation and fibrosis of vessel walls- occlusive disease that is in arteries and less in veins. Debridement: Removal of dead, damaged or infected tissue to improve healing. Homans sign: dorsiflexion of the foot causing pain in the calf: sign of DVT Hyperlipidemia: Elevated levels of cholesterol and triglycerides in the blood. Raynaud’s Disease: Body feeling numb and cool in certain circumstances Subclavian steal syndrome: SSS retrograde blood flow in the vertebral artery associated with proximal ipsilateral occlusion. Thrombophlebitis: Blood clot in a vein causes inflammation and pain Varicose veins: enlarged veins seen in the legs and feet. Venous stasis ulcers: Pressure in the veins to increase, resulting in edema. Heart Disease is the leading cause of death in the Untied States Impaired clotting can affect anyone but certain people are increased risk of impaired coagulation. ➢ Age: older adults have increased platelet adhesiveness ➢ Genetics: conditions like hemophilia ➢ Immobility: leads to blood stasis

➢ Smoking: causes hypercoagulability ➢ Medications: Estrogen (birth controls), anticoagulants, aspirin. Diagnostics

• PT: Prothrombin time
• INR: International Normalized Ratio
• PTT: Partial Thromboplastin Time
• Fibrinogen
• Platelet Count
• D-Dimer
• CBC: RBC count and H/H
• Bone Marrow Exam
  • Ultrasound
• Arteriogram Interventions / Management Medications o Bleeding: clotting factor or platelet replacement o Clotting: anticoagulant, antiplatelet, thrombolytic Nutrition therapy: Vitamin K Invasive procedures: Phlebotomy, Thrombectomy and filters. Arteriosclerosis and Atherosclerosis Long-term development are associated with CVD- cardiovascular disease. Occur as an accrual of lipids, calcium, blood, carbohydrates and Fibrous tissue. The buildup of these products lead to the development of plaques (narrowing the vessels lumen). Fatty streaks: project into the vessel lumen, are smooth and people of all ages have it, they also do not cause symptoms. Fibrous plaques: project into the vessel wall and often occlude the lumen- decreasing blood flow. Hypertension and heart disease are often first identified in people with ART and ATH. ➢ Laboratory tests : Serum cholesterol- less than 200mg LDL- Less than 100mg HDL- Less than 35mg Triglycerdies- Less than 200 ➢ Treatment: Lower cholesterol- reduce amount of saturated fat and cholesterol from animal sources, exercise ( helps lower lipid level), smoking cessation and pharmaceutics. o Medication : ➢ Antiplatelet aggregating agents: Aspirin- inhibits platelet adhesion and aggregation, preventing formation of blood clots.

➢ Law molecular weight heparin: Lovenox(enoxaparin) - prevent vascular claudication and DVT. Patient Teaching : Compliance with diet, medications, exercise are crucial- nurses can give information about smoking cessation (programs and medication) – Nicoderm and Bupropion ( antidepressant) that provides withdraw support. Peripheral Arterial Occlusive Disease Most common in lower extremities and patient cannot ambulate far due to arterial insufficiency. Ischemia of the distal extremities is demonstrated by persistent, increased pain, cramping and fatigue usually worse at night. Risks: Higher in males than females, genetics, and age. Modifiable Risks: smoking, hypertension, hyperlipidemia, obesity, stress and low activity and commonly seen in patients with diabetes mellitus. Most common cause: Embolus originating from the heart!!! ➢ Clinical Findings : The affected extremity frequently described by the six P’s: Pulseless, pain, pallor, parentheses, paralysis and poikilocythemia. ➢ Diagnostics Tests: Doppler to find pulse, Fontaine staging system to find severity, ultrasounds. ➢ Treatment: Need to watch for circulation complications: surgery and pharmacological interventions o Pharm: Intravenous (IV) anticoagulants first intervention (Heparin)

• discharge with low molecular weight heparin or antiplatelet aggregating agent. 2 nd: thrombolytic: to dissolve acute thrombus- have to be continuously evaluated for side effects: bleeding, hematoma, bruising. Hemoglobin, hematocrit and platelet counts need to be done!!! o Surgery: Stent is places to allow blood to pass through the vessel and decrease the occlusion- only indicated for patient who do not respond to other forms of treatment and risk amputation. ➢ Patient Teaching: encourage lifestyle changes to support healthy life, watch pulse presence and strength, temp of extremity’s, watch for bleeding, cap refill less than 3 seconds. Aneurysms and Aortic Dissections Aneurysm: bulging artery that puts patient at great risk: occur at specific anatomic sites, most common the aortic arch. Men greater risk than women and increased with age. Aneurysm is described by the type: DO NOT FOCUS ON THIS TOO MUCH!! o False aneurysm: pulsating hematoma on all three layers of the artery, injury with the blood clot formed on the exterior vessel wall. o True aneurysm: Involvement of one, two or all three layers of the artery o Fusiform: symmetric and diffuse involvement of the entire vessel o Saccular: One-sided protrusion or out-poaching of one distinct area of the vessel. (like a bubble) o Dissecting: splits the layers of the vessel wall and forms a hematoma.

Aortic dissection: tear in the aorta where blood can enter into the vascular wall separation. Causing sever decrease in cardiac output- sever pain, in abdomen and back- this is a surgical emergency will lead to hypovolemic or cardiogenic shock. An aneurysm that is stretching can lead to dissection- life threatening complications like hemorrhage, shock need surgery ASAP!!!!! ➢ Findings : nausea, you may hear a bruit at the site of an aneurysm- DO NOT PALPATE AS RISK FOR RUPTURE!! If decreased blood flow may see tissues with blueish color, and decrease kidney function as low blood to kidneys. ➢ Tests : X-Rays to identify location, followed by CT. ➢ Treatment : Less than 6cm- monitored every 6 months. Larger than 5cm (Marfans syndrome) surgery because risk for rupture. Other: nutrition- low fat and low cholesterol minimizing risk for aneurysm. o Pharm : Antihypertensive Medication: to keep BP in safe range to decrease risk of rupture. o Surgery : Placement of Dacron graft- after make sure to watch pulse closely, color changes, abdominal distention and pain- can mean complications ➢ Patient Teaching: pain management after surgery, no heavy lifting 6- weeks, wound care instructions, pillow for support when coughing. Thrombophlebitis Inflammation of a vein accompanied by the formation of thrombus (blood clot)- can dislodge and lead to pulmonary emboli. DVT- deep veins in lower extremities (25% of all hospital deaths- start in the calf) Develop by surgery, pregnancy, trauma, sitting for long periods, fractures, heart failure, and shock! Thant promote venous restriction and obstruct blood flow! Can lead to Pulmonary Embolism: will see tachycardia, crushing chest: give patient oxygen, call code, position patient on the left side to encourage embolism to stay in the right side of the heart! ➢ Findings : swelling at the site, redness, tenderness (will not always find this) Also do not use Homans signs as it is unreliable(pg. 716) Can use the Wells scale to develop plan of care with DVT. ➢ Diagnostic Tests : Venogram- dye instilled into venous system. Duplex ultrasound and Doppler flow- less risk but harder to interpret! IPG- Impedance plethysmography more accurate test to locate DVTs. ➢ Prevention is Key !!!- promote activity shortly after surgery/ birth etc. to prevent clot formation use elastic stocking and PPDs to promote venous circution, change position every 2 hours, and leg exercises. ➢ Pharmacology : 1 st: Anticoagulants inhibit thrombus and clot formation- heparin( need to know the PT and INR before admin of IV anticoagulant) o LMWH : Lovenox: longer half life than heparin, can be taught home management

o Warfarin : given for 6 months for DVT and will start at low dose 5 days before ending heparin or LMWH- give Vit K if excessive bleeding. o Watch patient for bleeding, hematuria, blood in stools, bruising and Petechiae( purple spot under skin) ➢ Patient Teaching: Lab monitoring, alcohol use decrease, use of supportive stockings, avoiding long periods of inactivity. Buerger’s Disease Occlusive disease mostly in small to medium arties and not in veins, in upper and lower extremities with clot formation and fibrosis of the vessel wall. Inflammation occurs, lesions appear that occlude blood flow. Rare disorder, more common in young adult males who smoke- smoking will increase the progression of the disease, and stopping can stop the disease progress- also seen with autoimmune disease. As disease progresses, pain occurs due to tissue death, skin sloughs, ulcers form and extremity’s are at risk for gangrene. ➢ Findings: heat and col sensitivity, nail bed thickens, pulse weak and thread, skin blackish. ➢ Tests: Doppler ultrasounds, to find location of diminished blood flow. And Arteriograms. ➢ Treatment : Restrict tobacco use; avoid long exposer to cold to prevent vasoconstriction. o Pharm: Analgesics for pain relief, and vasodilators to increase tissue perfusion. Subclavian Steal Syndrome Occurs when the subclavian artery is occluded- blood flow diminished or obstructed to upper extremities. Arms will have ischemia, pain and weakness. Atherosclerosis is a risk for SS syndrome. ➢ Tests : bilateral blood pressure and pulse, subclavian bruit, Doppler ultrasound and test to find locations. – treatment with Stent. Raynaud’s Phenomenon – hands and feet Unilateral vasospasm of the upper and lower extremities.- age 30 and over and equal between male and female. Raynauds Disease : BILATERAL vasospasm- Ages 17-50 and more in females. Both are treated the same, caused by lupus, systemic sclerosis and connective tissue diseases. ➢ Findings: Blood flow restriction, pain and cyanosis, redness, ulcerations, numb and col and gangrene occurs with progression.

➢ Treatment: warm environment, stress reduction, watch for gangrene, med compliance. o Pharm: Analgesic for pain, Vasodilators to increase tissue perfusion. Varicose Veins Veins are dilated and lack surrounding muscle support. – Age over 30, and as many as 60 percent of the US has them. Caused by obesity, prolonged standing, thrombophlebitis. Lead to decrease venous return, can cause localized edema and impaired circulation. Treatment: weight loss, avoid long standing, surgery: vein stripping. Keeping the legs elevated after, support stockings, and avoid constrictive clothing. Do not cross knees, Venous Stasis Ulcer Lower extremities, appear as an erosion of the skin- leading to open wounds, necrosis, black and hardened skin (eschar) Elderly more at risk, diabetes, burns, injuries, and blood disorders. ➢ Treatment : high protein to help wound healing- as open wound can form and puss. Keeping wound clean with debridement. Oral Antibiotics. o Hydrocolloids : wound treatment ➢ Tests : Doppler, cultured draining wounds.

Chapter 29

Terms Agranulocytosis: sever neutropenia, less than 200 cells/mm Allogeneic transplantation: stem cells are collected from the Matching donor and transpanted into the patient. Autologous transplantation : uses the persons own stem cells in advance and replace stem cells that have been damaged by chemotherapy. Cheilosis: Inflammation and small cracks on the sides of the mouth- lack of iron Erythromelalgia: Affecting the hands and feet, intense burning pain with severe erythema and increased tempature. Heinz bodies: Inclusions within the red blood cell composed of denatured hemoglobin. Hemarthrosis: untreated bleeding into the joint- in hemophilia. Hemolysis: the rupture or destruction of red blood cells.

Leukopenia: decreased number in the WBC found in the body, increasing infections. – Lower than 4, Lymphadenopathy: disease of the lymph nodes, making them abnormal in size. Neutropenia: Abnormal low count of neutrophils in WBC- less than 1,500. : watch for uncooked veggies, salad bars deli, only pasteurized milk and cheese. Petechiae: Purple spot on the skin, by broken capillary blood vessels. Pica: Eating food with no nutritional value- seen in anemia Plasmapheresis: Replaces your blood plasma with new plasma to stop antibodies from attacking healthy cells.- used in autoimmune disorder. Schistocytes: seen with hemolytic anemia- erythrocyte fragments (RBC) that circulate, smaller than normal and different shapes. Anemia Condition in which the hemoglobin concentration is lower than normal, which means there are fewer RBC circulating within the plasma witch decrease the oxygen carrying capacity. Increased risk for anemia : iron deficiency from poor nutrition or other, menorrhagia from menstrual, sickle cell anemia, trauma from excessive bleeding, lack of erythropoietin from renal disease, immunosuppression- from leukemia or lymphoma and medication therapy that depresses bone marrow activity. ➢ Findings : The quicker the onset the more serious the condition. Slowly becoming anemic may adapt to low hemoglobin levels: common symptoms fatigue, weakness, skin pallor, tachycardia, shortness of breath. – severe may need to consider cardiovascular implications- heart pump faster in attempt to make up for low oxygen. Most common found in active adults, who will show a sign of anemia. ➢ Tests : hemoglobin, hematocrit, RBC indices, reticulocyte count, iron studies, and serum vitamin B12 are looked over. Later CBC and erythropoietin and bone marrow are considered ➢ Planning and Treatment : Arrhythmias can occur from anemic condition, as well as Hypovolemic shock when anemia continues to deteriorate- interventions like giving oxygen; blood and blood products, fluid and monitoring are all important steps to consider. ➢ Hemolytic Anemia’s : type of anemia that occurs hemolysis outside RBC o Genetic, Burns, radiation, drugs, toxins, autoimmune disease, transfusion reactions and bacterial infections can all cause. o Enlarged spleen from removing damages RBCs. Liver is pushed to it limits and can increase bilirubin levels and jaundice! Most sever bone marrow can fracture, patient having deoxygenating and skin pallor, tachycardia and hypotension.

Thalassemia Is an inherited disease whereby hemoglobin synthesis is missing either the alpha or beta chain of the hemoglobin molecule. Resulting in hemoglobin production being deficient and weak, hypochromic RBCs are formed and labeled target cells (bull eye appearance). If children get this young, rarely live to adulthood, most common in Asians from China, Philippines and Thailand. Four genes causes alpha chain formation, with either one, two, three, or all four may cause the thalassemia conditions. If all 4 are defective, the result is labeled alpha thalassemia major and is fatal, most commonly in utero. ➢ Findings : mild to moderate anemia, bone marrow hyperplasia, bronze skin coloring- more serious results in heart failure, liver and spleen dysfunction from increased RBC destruction, sever anemia, and fractures to long bones, ribs . Glucose- 6- Phosphate Dehydrogenase Anemia G6PD- form of anemia caused by genetic defect in RBC metabolism. Contracted most commonly from medication that caused inflammatory disorder. It is more common in males as it is on the X chromosome, usually Mediterranean people. ➢ Findings : will normally have normal hemoglobin levels, but certain medication cause hemolytic effects- jaundice, skin pallor, hemoglobinuria (in urine). ➢ Test : screening test, Heinz bodies may be identified, as well as hemoglbinuria. ➢ Medication that heighten hemolytic affects : Vitamin K, Thiazide diuretics, Sulfonamides, oral hypoglycemic, antimalarial drugs, and Nitrofurantoin. Hereditary Spherocytosis Also known as congenital hemolytic anemia, and is the MOST COMMON HEMOLYTIC DISORDER. There is no abnormality of the hemoglobin and it is found in 1-5000. Autosomal dominant disorder- abnormality of the erythrocyte membrane, and prematurely destroyed in the spleen. ➢ Findings : starts in utero or early infancy exhibits anemia and hyperbilirubinema, higher severity so does jaundice appearance. Gallstones develop young, and Aplastic crises are the most serious complication. ➢ Test: family history, blood smear, no single test to identify. Sickle Cell Anemia Autosomal Recessive defect and a type of hemolytic anemia, causing synthesis of an abnormal form of hemoglobin within the red blood cells. Common in African descent, from parent to offspring- giving 50 percent chance of transmitting the gene to child. Deoxygenation is the most important variable! ➢ Findings : fatigue, pallor, jaundice, irritability- occluded circulation. ➢ Tests : Hematological test and essential and family history- presence of Hbs in the blood.

➢ Treatment : IV fluids for dehydration, antibiotic therapy, and bone marrow transplants, splenectomy. o Pharm : Oxygen as it effect oxygenation, Antisickling agents like urea, cyanate are given. Folic acid supplements must be given to meet RBC production- and blood transfusion are often needed. Iron Anemia : loss of iron becomes inadequate for RBC production- common in elderly Folic Acid Deficiency Anemia: Normally in green leafy vegetables, fruits, and cereals. Found in drug abusers, elderly and alcoholics. Vitamin B12 Anemia: lack of intake or malabsorption, higher if cognitive disability, Platelet and Coagulation Disorders Normally, the vessels constrict and platelets aggregate to the site of bleeding, where fibrin assists coagulation of the site. In addition, the platelets are controlled by thrombopoietin, a protein produced by the liver, kidney, bone marrow, and smooth muscle: when it dysfunction bleeding disorder result. Thrombocytopenia Platelet count less than 100,00ml of blood- less than 20,000 can cause spontaneous bleeding from various locations. Two types: ITP: immune thrombocytopenia purpura and TTP: thrombotic thrombocytopenic purpura. ITP: more common in children and ages 20-40 higher in women. TTP: rare witch thrombi occlude arterioles and capillaries- fatal within months from coma state. ➢ Findings : bruising without trauma, bleeding gums, black stools, headache, fever, nosebleeds, weight loss, long menstrual periods, petechial, low platelet. ➢ Pharmacology : corticosteroids to suppress the autoimmune process. Platelet transfusions- plasmapheresis: plasma that is removed from the patient and replaced with fresh frozen plasma. Hemophilia Hereditary bleeding disorders that result from not clotting. Ranges from Sever, Moderate and Mild. ➢ Findings : joint and muscle hemorrhages, easy bruising, hemorrhage after surgery. Loss of cartilage, leads to limited range of motion and deformity and disability. ➢ Treatment: Fresh frozen plasma, VIII factors!!! And for pain, acetaminophen or opioids. Neutropenia

Decreased number of circulating neutrophils, less than 1500 cells, while Agranlocytosis is sever form with less than 200 cells. Neutroiphils are valuable part of the immune response, common causes are starvation, infection, inflammation and autoimmune disorders. ➢ Findings : infections in many parts of the body, malaise, chillis, fever and weakness. ➢ Treatment : Antibiotic therapy is normally what is given for infections that cause neutropenia. ➢ Leukemia Cancer of the blood- malignancy bone marrow cells when stem cells lose the ability to differentiate into WBC, RBC and platelets leading to one type of abnormal WBC. ➢ Findings : fatigue, dyspnea, pallor, infections, flu like symptoms, enlarged lymph nodes and spleen, bleeding, bruising, bone and joint pain. ➢ Test : Bone Marrow biopsy. ➢ Treatment : teach about what is expected- hair loss, fatigue, reproductive issues, gastric irritations due to the Radiation therapy- damaging cancer and healthy cells, can also try stem cell transplantation and bone marrow transplantation. Treatment follows induction, consolidation, maintenance and CNS prophylaxis. o Types : o Acute lymphoblastic leukemia: ALL- most common in children o Acute Myeloid Leukemia: AML – aggressive o Chronic Myelogenous Leukemia: CML ages 40-50 progresses more slowly and higher in women, have its own three phases. o Chronic Lymphocytic Leukemia: CLL is the most common type of leukemia, not curable!!! Treatment delayed until patient has signs and symptoms. Multiple Myeloma : Cancer of the plasma cells- one of the most costly cancers as need for stem cell transplant and medications, high rate in African Americans. Causes are unknown, but exposer to radiation, chemicals has increased myeloma. ➢ Findings : most people go without symptoms- but common ones reported are fatigue, anemia, bone pain, renal dysfunction and LOW BACK PAIN and watch for HYPERCALCEMIA!!!!! ➢ Treatment : depending on age and level of disease- watch progression use of NSAIDS, and good hydration, as well as gabapentin. More sever: Chemotherapy. Hodgkins Disease Spread through the lymphatic system, low survival rate and accounts for 12 percent of lymphomas- cancer that develops in a single lymph node or chain that spread through the lymph system of single axial nodes- If infected the contain Reed Sternberg Cells. Starts from 1 stage and goes until stage 4 (IV). Have to take biopsy of lymph node to dected is Reed Cells are present. ➢ Treatment: radation, chemotherapy or both. Bone marrow and stem cell transplants. Chemo Treatment: ABVD: Adriamycin, Bleomycin, Vinblastine and Dacarbazine.

Non- Hodgkins Lymphoma Malignant mutations of the lymphoid system not mictoscopically identified by Reeds- Sternberg cells.- unknown how it begin but it is spread through the blood stream, and is fast growing, cure is more likely. NHL are more multiple in peripheral nodal sites than Hodgkin’s disease. ➢ Treatment : chemotherapy and radiation. And Rituxan can be used to enhance the effects of chemotherapy.

Chapter 42: immunodeficiency and HIV infection

• Immunodeficiency: (Pg.1168) o Inability to produce a normal complement of antibodies or immunologically sensitized T cells in response to specific antigens o The hallmark of immunodeficiency is unusual or recurrent serve infections
• Immunity: (Pg.1168) o Is the quality or state of being immune o Where one can resist a particular disease through preventing development, or counteracting effects of pathogenic microorganisms
• Antigen can either be part of nonspecific defense system or specific defense system (Pg.
  1169. there is a diagram on page 1169 of this o Nonspecific defense system ▪ Skin, mucous membranes, phagocytes, natural killer cells ▪ Acts as a guard against any foreign agent o Specific defense system ▪ Is broken into two immune response
        • Primary immune response: o Antigens is initially introduced into the system (Pg. 1168) o Phagocytes: engulf antigens and present them to helper T lymphocytes o Helper T lymphocytes: secrete lymphokines, activate and stimulate divisions of T lymphocytes and B lymphocytes ▪ T lymphocytes: split into CD4 (destroys infected cells by disturbing the cell’s plasma membrane) and memory T (help destroy the same pathogen that the body was already in contact with) ▪ B Lymphocytes: Split into Plasma cells (which secretes antibodies: destruction of bacteria and some viruses by agglutination) and memory B

lymphocytes (help destroy the same pathogen that the body was already in contact with)

• Secondary immune response:

o Activation of B cells and memory cells (IgG, IgM, IgA, and IgE) and activation of T cells (Pg. 1168) o Begins when the body is in contact with the same antigen ▪ Memory T lymphocytes and memory B lymphocytes

• 4 classifications of immunological disorders (Pg.1168)

o 1: immunodeficient ▪ AIDs o 2: autoimmune (both autoimmune and hypersensitive response) ▪ Myasthenia gravis ▪ Rheumatoid arthritis ▪ Grave’s disease ▪ SLE known as systemic lupus erythematosus o 3: immunoproliferative ▪ Leukemia o 4: Hypersensitive ▪ Allergies ▪ Asthma ▪ Contact dermatitis

• HIV (Pg. 1169)

o It results in AIDs ▪ AIDs leads to CD4 T lymphocytes to be destroyed which results in the body’s immune system to be impaired

• This is due to that HIV is a retrovirus and it enters the T

lymphocytes to alter the RNA of normal T lymphocytes (Pg. 1170) o THERE IS NO CURE OR VACCINE o We can slow down the progression of the disease through drug therapy o Risk factors: ▪ Unsafe sexual practices (genital lesions, anal intercourse, and intercourse during menstruation) ▪ Rape ▪ Prostitution and multiple sexual partners ▪ Exposure to contaminated blood and needles ▪ Occupational exposure ▪ Perinatal exposure (baby born the a HIV positive mother vaginally) o Can be transmitted by ▪ Blood ▪ Semen ▪ Vaginal or cervical secretions ▪ Breast milk

o Most common sources of HIV are contact with infected breast milk, vaginal or semen, and exposure to blood in laboratory (Pg. 1170) o Workers at risk should do standard precautions when handling body fluids and blood (1170) o HIV is not transmitted by: (1171) ▪ Casual contact (shaking hands, sharing eating utensils, using toilet seats, or working alongside ▪ Tears ▪ Saliva ▪ Urine ▪ Emesis ▪ Sputum ▪ Feces ▪ Sweat o The presence of HIV antibodies can occur in 1-6 months after exposure o INDIVIDUAL IS STILL INFECTIOUS WHEN NO SYMPTOMS ARE PRESENT o HIV damages ▪ immune system, cranial and peripheral neuropathy, cardiomyopathy, pneumonitis, malabsorption in the small intestine, nephritis, cervicitis, arthritis, psoriasis, and gonad dysfunctions, and anemia o Diagnosis of AIDs: (Pg. 1172) ▪ One must have at least one of the following conditions:

• CD4 below 200cells
• Development of one or more fungal, viral, protozoal, or bacterial opportunistic infections
• Development of opportunistic cancer (cervical, Kaposi’s sarcoma, Burkitt’s lymphoma, immunoblastic lymphoma, or primary lymphoma of the brain
• Wasting syndrome (loss of 10% or more body mass)
• Development of dementia o Preexisting comorbidities that associate with the transmission and progress of HIV/AIDs (Pg. 1172) ▪ Alcoholism ▪ Drug dependency ▪ Liver, kidney, and other organ disease ▪ History of STIs ▪ Psychiatric illnesses o The key to survival rate is early diagnosis with antiretroviral medication (Pg.

o Early manifestation: (1172) ▪ Chills, fever ▪ Myalgia

▪ Malaise ▪ Sort throat ▪ Nausea ▪ Photophobia ▪ Maculopapular rash ▪ headache o Late Manifestation (1172) ▪ Chills and fever ▪ Night sweats ▪ Dry productive cough ▪ Dyspnea ▪ Lethargy ▪ Confusion ▪ Stiff neck ▪ Seizures ▪ Headaches ▪ Malaise ▪ Fatigue ▪ Oral lesions ▪ Skin rash ▪ Abdominal discomfort ▪ Diarrhea ▪ Weight loss ▪ Sustained lymphadenopathy ▪ Wide variety of emotional response o Most common infection is Pneumocystis carinii pneumonia (Pg. 1172) o Diagnostic test (Pg. 1173) ▪ High viral load ▪ Drop in CD4 cell count

• Current monitoring emphasis is on CD4 count
• HALLMARK OF HIV INFECTION ▪ ELISA
• Can be false negative if done too early in the progression of HIV
• Results can also provide an indeterminate report
• Detects HIV antibodies ▪ Western Blot can be done but it may not confirm the original immunoassay test
• Often used as a confirmation of a positive ELISA TEST. ▪ HIV antigen test
• Use of diagnosis in the early stage of acute infection ▪ Home test kits ▪ Salivary tests ▪ Urine test

o Patient will have periodic testing to determine the patient’s status and progress of the disease (Pg. 1173) o In beginning stage of HIV our goal is to (Pg. 1174) ▪ Provide education of safe sex ▪ Identify risk of drug use ▪ Decreasing risk of perinatal transmission ▪ Improve nutrition ▪ Learn how to decrease fatigue o In the later stage of HIV our goal is to (Pg. 1174) ▪ Reduce Social isolation ▪ Noticing and letting the patient expressing his or her feelings o Terminal stage of HIV our goal is to (Pg. 1175) ▪ Maintain a safe environment ▪ Reorientation ▪ Stress reduction ▪ Support to family o Medications (Pg. 1176) ▪ Haart (highly active antiretroviral therapy) combination of antiretroviral drugs and current method of avoiding development of viral resistance to drugs

• Side effects: nausea and vomiting, anemia, myopathy, nasal congestion, hepatitis, sore throat,
• Long term use can cause: hypertension, diabetes, osteopenia, and hyperlipidemia
• Kaposi’s sarcoma (Pg 1172) o Raised red-violet plaques, or tumors o We do palliative care which consist of chemotherapy, irradiation, and HARRT
• Immunodeficiency disorders (Pg. 1177) o Are caused due to dysfunction or impairment of one or more of the immune response o Primary immunodeficiency ▪ Associated with various cell-mediated deficiencies
• Chronic granulomatous
• DiGeorge syndrome
• IGA IGM AND IGG deficiency o Secondary immunodeficiency (Pg. 1177) ▪ Can be treatment-related (radiation or surgery) ▪ Drugged induced (chemotherapy or corticosteroid) ▪ Infectious disease (AIDs, chronic liver or renal disease, SLE and stress) o YOUNGER CHILDREN AND OLDER PEOPLE HAVE SUPRESSED IMMUNE SYSTEMS AND MORE SUSCEPTIBLE TO INFECTION THAN YOUNG AND MIDDLE AGED ADUTLTS o Graft-versus-host-disease (Pg. 1178)

▪ Is a primary immunodeficiency disease ▪ Result from a transfusion of blood or tissue transplant that are incompatible ▪ The donor’s product starts to attack and destroy vulnerable cells of the host ▪ Acute rejection

• Happens around 7-30 days after the transplant
• One will see maculopapular rash, pruritus, or pain
• Great concern after transplant when a great reduction in granulocytes happens are bacterial and fungal infection
• We can use corticosteroids to halt the rejection process, but it increase the risk of infection ▪ Chronic graft-versus-host disease
• Appears 100 days after transplant
• One will see the skin is taut, firm, hard and edematous state, lacrimal ducts and mucous membranes are dry ▪ Allograft or homograft
• Cells and tissues that are obtained from the same species, such as close relative or unrelated donor of the same compatibility
• To find compatibility a histocompatibility test is done to figure out the similarities and differences ▪ Bone Marrow Transplant
• Used for hematological, malignant and nonmalignant disorders
• There are two types done o Syngeneic transplant: bone marrow cells donated by an identical twin with no incompatibility o Autologous transplant: removal of bone marrow from individual (the doctors will treat the marrow then store it then return it to the individual that is receiving chemotherapy or radiation) ▪ Process eliminates graft-versus-host disease
• Blood from umbilical cords o Are used for rapid therapy from patient diagnosed with leukemia, lymphoma and other life threatening disease o Do not need a close match, so it is the best choice for ethic and racial minority groups o Immunosuppressive Therapy (Pg.1178) ▪ Monoclonal antibodies:
• To prevent graft rejection ▪ Apheresis:
• Treating autoimmune disease
• Withdraws blood from a donor and removing one or more components (plasma, blood platelet or WBC) from the blood and

transfusing the disorder components into the patients with low platelet or WBC, then the rest of the blood goes back to the donor

• Side effects are: hypotension, and hypocalcemia
• Hypersensitivity disorder (Pg. 1179) o Is from and heighten immune response to an antigen o IGE antibody is responsible for it
• Autoimmune Disorders (Pg. 1179) o The presence of antinuclear antibodies in the blood is a hallmark of autoimmune and rheumatoid disease (Pg. 1177) o Common tissues and organs that are affected are ▪ Blood components (RBC) ▪ Blood vessels ▪ Connective tissues ▪ Endocrine glands (thyroid or pancreas) ▪ Muscles ▪ Joints ▪ Skin o Where the body does not recognize self and starts to attack self, causing a hypersensitivity reaction o Common in women than men o Autoimmunity: controlled through balanced suppression of the immune system ▪ The goal is to reduce the immune response against normal body tissue while leaving the immune response intact for abnormal foreign concepts o Rheumatoid Arthritis (Pg. 1180) ▪ Chronic inflammation of the synovial membranes of movable joints ▪ Leads to swelling, pain, and erosion of the joint cartilage ▪ THERE IS NO CURE ▪ Factors that may cause RA
• Genetic
• Hormonal
• Environmental
• Reproductive ▪ Joints that are commonly affects are (Pg. 1181)
• Knees
• Ankles
• Shoulder
• Wrist
• Proximal interphalangeal and metacarpophalangeal joints ▪ Clinical Manifestations (Pg. 1181)
• Early: o Diffuse muculokeletal pain o Low grade fever o Anorexia

o Loss of weight

• Late o Synovitis (inflammation of synovial capsule) o Subsequent hypertrophy o Symmetrical joint deformity o pain
• Hallmark of the progression of the disease is stiffness and diminished function after prolonged activity especially arising in AM (Pg. 1181) ▪ Diagnosis (Pg. 1182)
• Most common is through lab of the serum RF (Rheumatoid factor)
• Bone scans detect early joint changes and confirms diagnosis of RA
• WBC will be 3,500-25,000
• American College of Rheumatology Criteria for Diagnosis of RA o Moring stiffness lasting more than one hour o Arthritis of three or more joints o Arthritis of hand joints o Symmetrical arthritis o Rheumatoid nodules over extensor surface or bony prominences o Serum RF o Radiographic changes
• Treatment: (Pg. 1184) o Goal is manage pain, reduce inflammation, promote remission, increase ADL function, and help people cope o Nutrition: ▪ Monounsaturated fats: olive oil and avocados ▪ Omega 3: walnuts, fish, eggs, grass fed beef o Pharmacology: ▪ NSAIDs
• OTC and prescription as first line and used to alleviate the symptoms
• Watch for GI bleed, and impaired renal function ▪ DMARDs ▪ Corticosteroids ▪ Aurothioglucose
• Given IM
• Relive joint inflammation and slow down progress of RA and JRA
• Watch for metallic taste in mouth o Hot and cold therapy

o During an acute flare up avoid massage because it makes it worse o Surgery ▪ Joint replacement (arthroplasty)

• Most common are total hip and knee ▪ Synovectomies (removal of synovial membrane) ▪ Joint fusion ▪ Tendon transfer ▪ Juvenile Rheumatoid Arthritis (Pg. 1181)
• Most prevalent chronic disease in children under 16
• Onset occurs around 8 but peaks during puberty
• Symptoms o Growing pains o Enlarged knuckles that are warm to touch o Pain in ankles, feet or knees o Decreased range of motion
• Children have the better response to the medication Methotrexate
• Common responses from children are anger, sadness, self- pity, being resentful, assuming the sick role o Our role as nurses is to implement positive coping strategies o Systemic Lupus Erythematosus (SLE) (Pg. 1186) ▪ Discoid type: affects the skin primarily the face, neck, and upper chest ▪ Third type is reversible and is due to reactions to various medications ▪ Affects younger women between 15-40 ▪ More common in African American, Hispanics and Asian ▪ Manifestations:
• Polyarthritis and polyarthralgia (pain in joints)
• Lethargy
• Malaise
• Fever
• Weight loss
• Acute phase one will see butterfly rash o the face ▪ Common cause of death from SLE is glomerulonephritis ▪ Diagnosis: (Pg. 1187)
• Will have an elevated ANA titer (can be misread due to other concepts
• The main one used and specific to SLE are double stranded DNA antigen (anti-dsDNA) and sm nuclear antigen (anti-Sm) ▪ Treatment: (Pg. 1187)
• NSAIDs (reduce pain and inflammation)
• Antimalarial drugs: hydroxychloroquine sulfate (control fatigue, rash)