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Med/Surg I Module 4, Part 2 of 4 Connective Tissue Diseases Rheumatoid Arthritis Lupus Erythematosus Gout.

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Presentation on theme: "Med/Surg I Module 4, Part 2 of 4 Connective Tissue Diseases Rheumatoid Arthritis Lupus Erythematosus Gout."— Presentation transcript:

1 Med/Surg I Module 4, Part 2 of 4 Connective Tissue Diseases Rheumatoid Arthritis Lupus Erythematosus Gout

2 2 Rheumatoid Arthritis Pain, morning stiffness Early: Joint inflammation Late: deformities Photo courtesy of Charles Goldberg, M.D., UCSD Image Bank,

3 3 Complications Bakers cysts: enlarged popliteal bursae Synovitis, effusions in joints Subcutaneous nodules: usually ulnar surface of arm, fingers, along Achilles tendon Sjogrens syndrome: dry eyes, mouth and vagina – secretory glands are obstructed Feltys syndrome: hepatosplenomegaly, leucopenia Caplans syndrome: rheumatoid nodules in lungs

4 4 Laboratory Assessment Inflammatory connective tissue disease Rheumatoid factor (RF) Antinuclear antibody titer (ANA) Erythrocyte sedimentation rate (ESR)

5 5 Collaborative Management Analgesic/anti-pyretic/anti-inflammatories Disease-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

6 6 Collaborative Management, cont… Immunosuppressants: Biological response modifiers: Glucocorticoids (steroids) Watch! Gastrointestinal inflammation & blood sugar elevation Gold therapy

7 7 Alternative Therapies Hypnosis, acupuncture, imagery, magnet or music therapy Omega-3 fatty acids: fish oil capsules Antioxidant vitamins A, C, E Trace elements: zinc, selenium, copper, iron

8 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 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

10 10 Collaborative Management: Discoid Lupus Rash: Topical cortisone Skin protection from sun, ultra-violet Teach: mild soap, no perfumes, use lotion, avoid drying substances Alopecia (hair loss) is common: mild protein shampoo

11 11 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

12 12 Gout Manifestations: 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 Center

13 13 Acute Episode of Gout Sudden, severe joint pain and swelling Shiny red or purple skin around the joint Extreme tenderness in the joint area

14 14 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 15 Human Immunodeficiency Virus (HIV) Image Source: Wikimedia Commons, Public Domain, HIV_Viron.png

16 16 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

17 17 Manifestations HIV: Fever, chills, night sweats, headaches, muscle aches AIDS: 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

18 18 Prevention Sexual Parenteral Health care workers Perinatal

19 19 Immunocompromised? No crowds Dont share personal items, bathe q day Wash hands, wash dishes, cups Low bacteria diet Avoid pet litter Check temperature daily No gardening

20 20 Anti-HIV Drugs CategoryActionExamples Nucleoside analog reverse transcriptase inhibitors Inhibit HIV replicationzidovudine (Retrovir), didanosine (Videx), zalcitabine (HIVID), Non-nucleoside analog reverse transcriptase inhibitors Suppress viral replication, do not kill the virus nevirapine (Viramune), efavirenz (Sustiva) Protease inhibitorsBlock protease enzyme, prevents viral replication ritonavir (Norvir), indinavir (Crixivan) Fusion inhibitorsBlock fusion of HIV with host cell enfuvirtide (Fuzeon)

21 21 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 Kaposis sarcoma: Image Source: Wikimedia Commons, Public Domain,

22 22 Organ Transplants AutograftHighest success rate IsograftHighest success rate Allograft with compatibility Xenograftlowest success rate

23 23 Nursing Care Protect from infection Prevent rejection Patient teaching Photo source: Wikimedia Commons, Public Domain, US Government

24 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 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)

26 26 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

27 27 Emergency Management Airway: Assess for laryngospasm, stridor – may need immediate intubation Breathing: oxygen at high flow rate, 10-15 L/minute, monitor oxygen saturation Circulation:Assess for dysrhythmias, hypotension

28 28 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

29 29 Stabilize Intravenous fluids: crystalloids, colloids Monitor for decompensation, repeat epinephrine

30 30 Diabetes Mellitus Type 1 Type 2 Type 3 (gestational) Image Source: Wikimedia Commons, Public Domain,

31 31 Diagnosis Fasting blood glucose Oral glucose tolerance test Glycosylated hemoglobin assay (HgA1C) Serum protein and albumin 24-hour urine creatinine clearance

32 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 33 Common Signs and Symptoms of Hyperglycemia The Classic Symptoms Polyphagia (frequently hungry) Polyuria (frequently urinating) Polydipsia (frequently thirsty)

34 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 Kussmauls respirations: increased rate and depth Ketone breath: fruity, alcohol-like

35 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 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 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 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 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.

40 40 Insulin Injection Sites Photo source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),

41 41 Common Signs and Symptoms of Hypoglycemia Early Symptoms Hunger Trembling Palpitations Anxiety Sweating Clamminess

42 42 Late Symptoms Might Include Difficulty thinking Confusion Headache Seizures

43 43 Emergency Treatment: Hypoglycemia Glucagon intravenous or Dextrose 50% intravenous – repeat according to blood sugar NOTE: high glucose will damage the tissue if it leaks 5% dextrose in water intravenously

44 44 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 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

46 46 Diabetic Diet Different categories Portion size 1600-2800 calories Diabetes Food Pyramid Source: National Diabetes Education Program/NIH

47 47 Diabetes Food Serving per Day Grains and starches: 6-11 Vegetables: 3-5 Fruit: 2-4 Milk: 2-3 Meat and meat substitutes: 4-6 oz Fats, sweets and alcohol: 0?

48 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 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 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 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 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 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),

54 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 55 Endocrine Organs Hypothalamus Pituitary Thyroid Thymus Parathyroids Adrenal glands Pancreas Ovaries/Testes Source: U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program

56 56 Pituitary Disorders Secondary hormonal imbalances TSH, ACTH, FSH Acromegaly Overproduction of growth hormone Diabetes Insipidus ADH deficiency SIADH Excess ADH

57 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 58 Thyroid Disorders Hyperthyroidism (Graves Disease) Hypothyroidism (Myxedema) Fatigue, hair loss, cold intolerance, constipation

59 59 Thyroidectomy Position: Semi-fowlers, avoid neck extension Watch! Hemorrhage 1 st 24 hours Laryngeal stridor Tetany (what are the early signs?) Laryngeal nerve damage Thyroid storm

60 60 Parathyroid Disorders Hyperparathyroidism Hypercalcemia Bone damage Hypoparathyroidism Muscle cramps Chvosteks & Trousseaus signs

61 61 Adrenal Disorders Addisons crisis Hypovolemia, low Na + Hypoglycemia Hyperkalemia => acidosis Cushings disease Moon face, buffalo hump, truncal obesity Hypertension Bruising

62 62 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.

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