1. Management of patient with Infectious Disease

2. Chain of Infection

3. The Infectious Process:
Chain of infection and heath care worker’s interventions to interrupt the chain:
A causative organism (Source of infection): Bacteria, Viruses, Protozoa, Fungi, and heliments. Prevention:Rapid accurate identification of organism
Reservoirs : people, Equipment, water, animal, plant. Prevention: Employee health, environmental sanitation, and Disinfection/sterilization.
Portal of Exit: excretion, secretion, skin, and droplets. Prevention: Hand washing, control of excretions and secretions, and trash and waste disposal

4. Cont…
Means of transmission: sexual or parenteral fluids, through direct skin-to-skin, close contact or exposure, through infectious particles in the air, and close noncontact or exposure, and airborn.
Prevention: Isolation, food handling, airflow control, standard precautions, and sterilization, and hand washing
Portal of Entry: Mucous membrane, GI tract, UT, Respiratory tract, Broken skin.
Prevention: Wound care, catheter care, and aseptic technique
Susceptible Host: Immunosuppression, DM, Surgery, Burns, Elderly.
Prevention: Recognition of high risk patients, and treatment of underlying diseases.

5. Cont…….
Colonization: is used to describe microorganism present without host interference or interaction.
Infection: indicates a host interaction with an organism and is recognized both by host reaction (redness, heat, and pain) and by organism identification
Disease ( infectious disease): is the state in which the infected host display a decline in wellness due to infection.

6. Infection control and prevention:
Preventing Infection in the Community:
A. Sanitation technique, regulated health
B. practice ( handling, storage, packaging, and preparation of food),
C. Immunization programs ( one of the most effective means of preventing infection in the community).
Vaccination program: smallpox, measles, mumps, rubella, polio, diphtheria, pertussis, and tetanus.
( See recommended childhood immunization Schedule)

7. Contraindication Of vaccination:
Previous anaphylaxes ( anaphylactic reaction),
patient who have developed an encephalopathy within 7 days of previous DTP dose should not receive further dose,
Sever immunosuppressive people should not receive live vaccine, Pregnant women should not receive MMR.

8. Cont…
2. Preventing infection in the hospitals ( Nosocomial Infection): Acquire infection while hospitalized.

9. Specific organism with nosocomial infection potential:
Clostridium Difficile: gram-positive, spore forming bacterium. Cause pseudomembranous colitis causing destruction to the area which produce profound sepsis. Spores is relatively resistant to clean and hand washing agents and can be spread of health care workers and by contact with equipment that has been previously contaminated.
Methacillin-resistant staphylococcus aureus (MRSA): Colonizes the skin which make them wildly spread. Vancomycin is the drug of choice for treatment
Vancomycin-resistant Enterococus (VRE): Gram-positive bacteria, part of normal flora of the GIT. Resistance to all other antimicrobial therapies

10. 3. Preventing Nosocomial Bloodstream Infections (Bacteremia and Fungemia):
A. Primary bloodstream infections:the host has no pre-existing infection and the bloodstream becomes contaminated through mechanic manipulation (vascular access devices)
B. Secondary bloodstream infection: a host has another site of infection that can serve as a source of contamination to the bloodstream.
Disinfecting skin before inserting vascular access devices
Should not use Guide wires routinely for changes of Vascular access devices (central line) unless no evidence of infection.
Changing infusion sets should not be before 4 days, blood and lipid infusion set should be changed every 24 hrs. blood transfusion should be finished within 4 hrs. Use 70% alcohol to clean the injection port when ever used.

11. Isolation Precautions
Guidelines to prevent the transmission of microorganisms in hospitals
1. Standard precautions used for all patients
The primary strategy for preventing HAIs
2. Transmission-based precautions are for patients with known infectious diseases spread by airborne, droplet, or contact routes

12. Isolation Precautions:
Standard Precautions: a set of protective behaviors, replace the previously recommended 1.Universal precautions which were designed solely to prevent blood borne infections) and
2. body substance isolation( which was designed to prevent transmission of pathogens from moist body substance)
Hand washing: effective hand washing calls for at least 10 seconds of vigorous scrubbing with special attention to the area arround nail beds and between fingers where there is high bacterial burden. Hands should be thoroughly rinsed after this washing. Antimicrobial hand washing agents ( such as chlorhexidine gluconate, alcohol) should be used

13. Cont…
2. Gloves use (latex): provide an effective barrier for hand from the microflora associated with patient care. Allergic reaction to latex increased in health care workers ( local skin irritation, general dermatitis, conjunctivitis, asthma, angioedema and anaphylaxis). For reducing the reaction the heath care workers should use of vinyl gloves, powder free gloves, or low protein latex gloves
3. Needlestick prevention: used needle should not be recapped
4. Avoidance of spray and splash Exposure: such as face mask and cover gown

14. II. Transmission-Based Precautions: when the microorganism are so contagious.
Airborne Precautions: are required for patients with TB, chickenpox, or measles. Patient should be in room with negative pressure, door should remain closed, health care workers should wear a mask
Droplet precautions: are used for microorganism that can be transmitted by close, face to face contact such as influenza or meningococcal meningitis. Face mask required
Contact precautions: spread by skin to skin contact such as antibiotic resistant organism. Contact isolation in private room to facilitate hand washing.

15. Diarrheal Diseases: Mood of transmission: oral ingestion
Factors increasing the risk:
Food that neutralize the acidic environment
Decreased gastric acidity with disruption of normal bowel flora
Use of antimicrobial agent which decrease intestinal defence
Immune dysfunction of AIDS.

16. Specific Causes: Viral: Rota virus
Bacterial: Esch. Coli and salmonella, shigella
Parasitic: Giardia, Entamoeba histolytica
Manifestation: diarrhea, Dehydration (dry mucous, sunken eyes, weakened pulse, and loss of skin turgor)

17. Sexual transmitted Diseases (STD):
Is a disease acquired through sexual contact with an infected person
Prevention: use of condom reduce the risk of transmission but not eliminate.
Human immunodeficiency Virus (AIDS): will be discussed later.
Syphilis: An acute or chronic infectious disease caused by the spirochete Treponema Pallidum. May be congenital in origion.
Stages:
Primary: 2-3 weeks after initial inoculation. Painless lesion at the site of infection is called a chancre. Untreated, resolved spont. Within about 2 months

18. Cont…
2. Secondary: hematogenous spread from the chancre leads to generalized infection. 2-8 weeks after chancre and involves the trunk and the extremities, including the palms of the hands and the sole of the feet. Transmission can occur with direct contact with the lesions. Generalized sign of infection may include lymphadenopathy, arithritis, meningitis, hair loss, fever, malaise and wt loss
3. Latency without S/S of syphilis may interrubted with secondary syphilis
4. Tirtialy syphilis: presents as a slowly progressive inflammatory disease with the potential to affect multiple organs. Manifestation include aortitis (most common), and neurosyplilis (dementia, psychosis, paresis, stroke, and maningitis)

19. Cont…..
Assessment and Diagnostic findings: Clinical history and laboratory evaluation ( microorganism identification from the chancre lesion of primary syphilis). Serologic tests used in the diagnosis of secodary ant tertiary.
Medical Management: Administration of Antibiotic ( penicillin G Benzathine is the drug of choice for syphilis of less than one year’s duration, IM at single dose). For more than one year, three injections at 1 week intervals. Doxycylin is used for pt allergic to peniciline
Nursing management: Reporting the case. Wearing gloves in direct contact with the pt, hand washing after removing the gloves, isolation in private room is not required

20. Gonorrhea:
Neisseria Gonorrhoeae is a gram-negative bacterium that is primary transmitted through sexual contact. Can also occur in neonates as a result of contact during birth.
Can cause mucosal, local, or disseminated infection and may be asymptomatic.
Clinical manifestation:
Local manifestations: Urethritis and epididymitis in men, Asymptomatic in women than in men
Uterine Cervix is the primary local site of infection, urinary tract infection, increased vaginal discharge, and itching in women.

21. Cont…
The most common complication of localized gonococcal infection in women is pelvic inflammatory disease (PID) in which the organism infect the uterus, fallopian tubes, or peritoneal fluid. PID is increased risk of ectopic pregnancy and bilateral tubal occlusion, which results in infertility.
If the infection is disseminated cause arthritis or dermatitis, and bacteremia, rare instances, valves of the heart can be infected, or meningitis can develop.

22. Assessment and diagnostic findings:
The patient is assed for fever, for urethral, vaginal, and rectal discharge, and signs of arthritis.
Cultural and sensitivity studies are the usual methods of diagnosis
in men the specimens are obtained from the urethra, Anal canal and pharynx
in women the specimen obtained from the endocervix, pharynx, and anal canal
Medical management:
Administration of Ceftriaxone ( or cefixime, ciprofloxacin, or olfoxacin) along with doxycyline
Serological testing for other STD such as syphilis and HIV
Nursing management:
Report the case to the public health department.

23. Chlamydia Trachomatis:
Is bacterium that requires attachment to the host cell, invasion, intracellular growth, and replication.
Clinical manifestation:
In women: PID, long term effect include, chronic pain, increased risk for ectopic pregnancy, post partum endometritis, and infertility. Transmission to vaginally born infant is common, which causes chlamydial conjunctivitis, and chlamydial pneumonia.
In men: urethritis, is the most common illness in heterosexual man, the rectum is the common site of infection among homosexual men

24. Assessment and diagnostic findings:
Cell culture technique, and nunculture technique, including immunologic assays, DNA probes, and enzyme sensitive tests.
Medical Management:
Administration of doxycyline or azithromycin.

25. Home-Based care of the patient with an infectious Disease:
Health care workers should follow standard precautions in the home setting
Patient and family teaching: see Chart 70-4
Establish an environment that facilitates hand hygiene and aseptic technique
Family caregivers should receive annual influenza vaccine
Equipment care
Implement “Common sense cleanliness”
Exercise food preparation and personal hygiene
Establish reasonable barriers to protect family members

26. Nursing Process—Assessment of the Patient With Sexually Transmitted Disease (STD)
Protecting confidentiality and privacy is an important component in the assessment of a patient with STDs
Communication needs to be culturally and emotionally sensitive and clarification of terms may be necessary
Presenting symptoms
Specific information regarding sexual contacts
Patient knowledge
Physical examination: include rashes, lesions, drainage, inguinal nodes, genitalia, rectum, mouth and throat; women need abdominal and uterine exams

27. Noncompliance with treatment
Nursing Process—Diagnosis of the Patient With Sexually Transmitted Disease (STD)
Deficient knowledge
Anxiety
Noncompliance with treatment

28. Collaborative Problems/Potential Complications
Increased risk for ectopic pregnancy
Infertility
Transmission of infection
Neurosyphilis
Gonococcal meningitis
Gonococcal arthritis
HIV-related complications

29. Nursing Process—Planning the Care of the Patient With Sexually Transmitted Disease (STD)
Major goals include increased patient understanding of the natural history and treatment of the infection, reduction in anxiety, increased compliance with therapeutic and preventive goals, and absence of complications

30. Interventions Education about STDs and the spread of infection
Reduce anxiety
Encourage patient to discuss anxieties and fears
Provide factual information and individualized teaching
Assist in planning discussion with partners
Provide referral to social worker or other specialist
Increase compliance
Provide patient teaching in group or individual settings
Provide referral to appropriate agencies

31. Immune System(chap 50)
Immunity: the body’s specific protective response to invading foreign agent or organism
Factors affecting the immune function:
Age: with increasing age the problem with immune system is increased. Production and function of T and B lymphocytes may be impaired, increase incidence of autoimmune disease with age
Nutrition: adequate nutrition is essential for optimal functioning of the immune system, such as Vitamines. Excess or deficiency of trace elements such as copper, iron, manganese, and zinc in the diet generally suppresses immune function.

32. Infection and immunization:
Allergy:
Disorders and diseases: Autoimmune disorders, Neoplastic disease, Chronic illness and surgery
Medications and blood transfusion.
Lifestyle

33. Immune Function
Natural immunity: nonspecific response to any foreign invader
White blood cell action: release cell mediators such as histamine, bradykinin, and prostaglandins, and engulf (phagocytize) foreign substances
Inflammatory response
Physical barriers, such as intact skin, chemical barriers, and acidic gastric secretions or enzymes in tars and saliva
Acquired immunity: specific against a foreign antigen
Result of prior exposure to an antigen
Active or passive

34. Defenses Phagocytic immune response Humoral or antibody response
Cellular immune response

35. Cellular Immune Response
B lymphocytes: humoral immunity
Produce antibodies or immunoglobulins
T lymphocytes: cellar immunity
Attack invaders directly, secrete cytokines, and stimulate immune system responses
Helper T cells
Cytotoxic T cells
Memory cells
Suppressor T cells (suppress immune response)

36. Non-T and Non-B Lymphocytes Involved in Immune Response
Null cells
Destroy antigen coated with antibody
Natural killer cells
Defend against microorganisms and some malignant cells

37. Management of Patients With HIV Infection and AIDS

38. HIV invades the helper T cells (CD4) to replicate itself
Acquired Immunodeficiency Syndrome (AIDS) Human Immunodeficiency Virus (HIV) infection
HIV is a specific type of virus called retrovirus in which the virus carry its genetic material in the RNA rather than the DNA
HIV invades the helper T cells (CD4) to replicate itself
AIDS limits the body’s ability to fight infection
A person with AIDS has a very weak immune system
NO cure

39. HIV Infection: Casual contact does not cause transmission
Mode of transmission:
Through body fluids: Blood products, semen, vaginal fluids, breast milk
Through IV drug use: sharing needles without sterilization
Through sex: intercourse, oral, anal, digital sex
Mother-to-baby: before birth, during birth, post partum
HIV cannt be transmitted through sweat, saliva, tears, urine, Mosquito bites
Casual contact does not cause transmission
Breaks in skin and mucosa increase risk

40. High-Risk Behaviors Sharing infected injection equipment
Having sexual relations with infected individuals

41. Prevention Of HIV Infection:
Education:
Safe sexual practice (use latex condom intercourse)
Avoiding sexual contact with multiple partner or people who are known to be HIV positive
Instruct people who are HIV positive or use injection drug not to donate blood or share drug equipment with others
Instruct drug user on methods to clean their syringes
Instruct people to not share needles, razors, toothbrushes, or other blood-contaminated articles.

42. Prevention cont.. Related reproductive education:
Inform the pregnant women that need to have adequate information about the risks of transmitting HIV infection to partner, and their future children
Teach the pregnant women about the benefits of antiretroviral agents in reducing perinatal HIV transmission
Instruct that the condom has been the only method that has proved to decrease the risk of sexual transmission of HIV infection
Inform women that certain contraceptive methods may pose additional heath risks for women (Estrogen in oral contraceptive and intrauterine contraceptive device (IUD)

43. Transmission to health care providers: Standard precaution:
Prevention cont…
Transmission to health care providers:
Standard precaution:
Were developed to prevent the transmission of infection during pt care for all pt, regardless of known or unknown infectious status
Standard precautions apply to blood, all body fluids, secretions, and excretions, except sweat.
Including hand washing, gloves, mask, eye protection, face shield, gown, pt care equipment, environmental control, linen, and pt placement

44. Prevention cont… Postexposure prophylaxis for health care providers:
Offer all health care provides who have sustained a significant exposure to HIV anti-HIV postexposure prophylaxis
Wash the affected area with soap and water,
inform you supervisore, identify the patient, report to the employee health services,
give consent for baseline testing for HIV, hebatitis B, and hebatitis C,
Start prophylaxis immediately after exposure to HIV within 2 hrs (before 72 hr of exposure), follow up with postexposure testing at 6 weeks, 3 months, and 6 months and perhaps one year,
and document the exposure in details.

45. Prevention cont…
The medications recommended for postexposure prophylaxis are those used to treat established HIV infection
Encourage pt to take prescribed medications for 4 weeks
Prepare those who choose postexposure prophylaxis for the side effects of the medications because HIV often become resistant to the medications used to treat it

46. Stages of HIV disease
Primary infection ( acute HIV infection or acute HIV syndrome):
The period from infection with HIV to the development of antibodies to HIV
There is intense viral replication and widespread of HIV throughout the body
Short, flue-like illness, occur one to six weeks after infection
No symptoms at all
Infected person can infect other people
Viral set point: balance between amount of HIV and the immune response

47. 2. HIV Asymptomatic: More than 500 CD4+ T lymphpocytes/mm3
CDC category A (asymptomatic)
Last for an average of ten years
More than 500 CD4+ T lymphpocytes/mm3
Free of symptoms
There may be swollen glands
By about 6 months, the level of HIV in the blood drops to very low levels
HIV antibodies are detectable in the blood
The immune system rarely if ever fully eliminate the virus

48. 3. HIV symptomatic:
CDC category B (Has HIV symptoms, need treatment for complications of HIV
200 to 499 CD4+ lymphpocytes/mm3
CD4 T cells gradually fall
The symptoms are mild
The immune system deteriorates
Emergence of cancer and opportunistic infection (OI) organism ( illness caused by various organisms, some of which usually do not cause disease in persons with normal immune system)

49. 4. HIV……….> AIDS: CDC C category ( Aids-Indicator condition)
The immune system weakens
The illness become more sever leading to an AIDS diagnosis.
Less than 200 CD4+ lymphocytes/mm3
As levels drop below 100 cells/mm3, the immune system is significantly impaired

50. Diagnostic findings:
EIA (enzyme immunoassay) or ELIZA test (enzyme-linked immunosorbent assay): Antibodies are detected
Western blot: antibodies detected to confirm ELIZA
Viral load: measure HIV RNA in the plasma
CD4/CD8 ratio: lymphocytes, HIV kills CD4 cells

51. Treatment of HIV infection:
Antiretroviral:
Nucleoside reverse transcriptase inhibitors….. AZT ( Zidovudine)
Non-nucleoside transcriptase inhibitors…. Viramune (Nevirapine)
Protease inhibitors … Norvir (Ritonavir)
Immunomodulator therapy:
Therapies are used to restore immune function ( Interleukin-2 and interleukin-12) which stimulate the growth of T- cells
Vaccines:
A vaccine is a substance that triggers the production of antibodies to destroy the offering organism

52. Manifestations of AIDS—Respiratory
Pneumocystis carinii pneumonia (PCP)
Most common infection
Initial symptoms may be nonspecific and may include nonproductive cough, fever chills, dyspnea, and chest pain
If untreated, progresses to pulmonary impairment and respiratory failure
Treatment: TMP-SMZ (Trimethobrin sulfamethazone) or pentamidine; prophylactic TMP-SMZ
Mycobacterium avium complex (MAC)
Tuberculosis

53. Manifestations of AIDS—GI
Oral candidiasis
May progress to esophagus and stomach
Treatment with Mycelex troches or nystatin and ketoconazole
Diarrhea related to HIV infection or enteric pathogens
Octreotide acetate for severe chronic diarrhea
Wasting syndrome
10% weight loss and chronic diarrhea or chronic weakness and fever with absence of other cause
Protein energy malnutrition
Anorexia, diarrhea, GI malabsorption, and lack of nutrition may contribute

54. Manifestations of AIDS—Oncologic
Kaposi's sarcoma
Cutaneous lesions (brownish pink to deep purple) but may involve multiple organ systems
Lesions cause discomfort, disfigurement, ulceration, and potential for infection
B cell lymphomas

55. Lesions of Kaposi’s Sarcoma

56. Manifestations of AIDS—Neurologic
HIV encephalopathy
Progressive cognitive, behavioral, and motor decline
Probably directly related to the HIV infection
Cryptococcus neoformans: fungus that can cause meningitis
Peripheral neuropathy: pain, numbness in the extremities, weakness, diminshed deep tendon reflexes, orthostatic hypotension, and impotance.
Depression

57. Nursing Process—Assessment of the Patient With AIDS
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

58. Nursing Process—Diagnosis of the Patient With AIDS
Impaired skin integrity
Diarrhea
Risk for infection
Activity intolerance
Disturbed thought processes
Ineffective airway clearance
Pain
Imbalanced nutrition
Social isolation
Anticipatory grieving
Deficient knowledge

59. Collaborative Problems/Potential Complications
Opportunistic infections
Impaired breathing or respiratory failure
Wasting syndrome
Fluid and electrolyte imbalance
Adverse reaction to medication

60. Nursing Process—Planning the Care of the Patient With AIDS
Goals may include:
Achievement and maintenance of skin integrity
Resumption of usual bowel patterns
Absence of infection
Improved activity tolerance
Improved thought processes
Improved airway clearance

61. Nursing Process—Planning the Care of the Patient With AIDS (cont.)
Goals may include (cont.)
Increased comfort
Improved nutritional status
Increased socialization
Expression of grief
Increased knowledge regarding disease prevention and self-care
Absence of complications

62. Skin Integrity Conduct frequent routine assessment of skin and mucosa
Encourage patient to maintain balance between rest and activity
Reposition at least every two hours and as needed
Use pressure reduction devices
Instruct patient to avoid scratching
Use gentle, nondrying soaps or cleansers
Avoid adhesive tape
Provide perianal skin care

63. Promoting Usual Bowel Pattern
Assess bowel pattern and factors that may exacerbate diarrhea
Avoid foods that act as bowel irritants, such as raw fruits and vegetables, carbonated beverages, spicy foods, and foods of extreme temperatures
Small, frequent meals
Administer medications as prescribed
Assess and promote self-care strategies to control diarrhea

64. Activity Intolerance Maintain balance between activity and rest
Instruction regarding energy conservation techniques
Relaxation measures
Collaboration with other members of the health care team

65. Maintaining Thought Processes
Assess mental and neurologic status
Use clear, simple language if mental status is altered
Establish and maintain a daily routine
Use orientation techniques
Ensure patient safety and protect from injury
Implement strategies to maintain and improve functional ability
Instruct and involve family in communication and care

66. Nutrition
Monitor weight, I&O, dietary intake, and factors that interfere with nutrition
Provide dietary consultation
Control nausea with antiemetics
Provide oral hygiene
Treat oral discomfort
Administer dietary supplements
May require enteral feedings or parenteral nutrition

67. Decreasing Isolation
Promote an atmosphere of acceptance and understanding
Assess social interactions and monitor behaviors
Allow patient to express feelings
Address psychosocial issues
Provide information related to the spread of infection
Educate ancillary personnel, family, and partners

68. Other Interventions Improve airway clearance
Use semi-Fowler's or high-Fowler’s position
Pulmonary therapy; coughing and deep breathing; postural drainage; percussion; and vibration
Ensure adequate rest
Pain
Administer medications as prescribed
Provide skin and perianal care

69. Medical management:
Treatment of infection: Trimethoprine-sulfamethazone (TMP-SMZ) is antibacterial agent for treating various organism causing infection
Antidiarrheal therapy: octreotide acetate (Sandostatin), effective in management chronic sever diarrhea
Chemotherapy: alpha-interferone is used to treat pt with cutaneous KS
Radiation therapy is effective measures to relieve localized pain due to tumor mass (especially in the legs) or for KS lesions that are in site such as the oral mucosa, conjunctiva, face and soles of the feet. Combination of chemotherapy and radiation therapy may be effective to treat lymphoma
Antidepressant therapy: such as Imipramine, Fluoxetine, Desipramine. Methylphenidate is used for neuropsychatric impairment. Electroconvulsive therapy may be an option for pt with sever depression

70. Cont…..
Nutritional therapy: appetite stimulant, oral supplement with high calories and easily digested protein, low in fat with the fat easily digestable, inexpensive, and tolerated without causing diarrhea (Lactose free). Parenteral nutrition is the final option because of the costs and associated risks
Supportive Care:
Nutritional support: parenteral feeding, IV fluid and electrolyte replace.
Pain support: Analgesia at regular intervals, relaxation and guided imagery.
Skin support: regular turning, cleansing, applying medicated oitments, dressing
Pulmonary support: O2 therapy, relaxation training, energy conservation technique, mechanical ventilation

71. Assessment and Management of Patients With Rheumatic Disorders

72. Rheumatic Diseases
Also called arthritis, rheumatic diseases include more than 100 different disorders
They primarily affect the joints, but also muscles, bone, ligament, tendons, and cartilage
Known as diffuse connective tissue disease
Onset acute or insidious, marked by period of remission and exacerbation.
Classification
Monoarticular or polyarticular
Inflammatory or noninflammatory

73. Synovial Swelling and Fluid Accumulation

74. Pannus, Eroded Cartilage, and Muscle Atrophy

75. Characteristic Degenerative Changes— “Degradation”

76. Pathophysiology and Associated Physical Signs of Rheumatoid Arthritis

77. Clinical Manifestations
Pain
Joint swelling
Limited movement
Stiffness
Weakness
Fatigue

78. Patient Assessment and Diagnostic Findings
Health history: include onset of and evolution of symptoms, family history, past health history, and contributing factors
Functional assessment
Arthrocentesis
X-rays, bone scans, CT scans, and MRIs
Tissue biopsy
Blood studies: (CRP,RF, c3 and c4 complements level see Table 54-1
See Chart 54-1

79. Medical Management:
Pharmacological therapy: To control inflammation and to modify the disease.
Salicylates: Aspirin
NSAIDs: may cause peptic ulcer, Cox-2 inhibitors such as Celocoxib (celebrix) which ihibit only Cox-2 enzyme which produce during inflamation and spare Cox-1 enzyme which can be protective to stomach and kidneys.
Disease-Modifying Antirheumatic Drugs (DMARDs) such as antimalarial, sulfazaline, and immunosuppressive (methotrexate)

80. Cont… Non opioid medications: for management of pain Corticosteroids
Nonpharmacological pain management: therapeutic heat and cold device
Exercise and activity: ranged from passive to active motion according to the inflammatory process

81. Diffuse Connective Tissue Diseases
A group of chronic disorders characterized by diffuse inflammation and degeneration in the connective tissue
Cause is unknown but thought to have an immunologic basis
Characterized by a clinical course of exacerbations and remissions
Includes rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), scleroderma, polymyositis, and polymyalgia rheumatica

82. Clinical manifestations:
Diffuse connective tissue disease: Systemic Lupus Erythromatosus (SLE):
Is a result of an exaggerated production of autantibodies. As a resultant of genetic, hormonal, and environmental factors (sunlight, thermal burns) or drug-induced SLE (hydralazin, isoniazid, and some anticonvusant, Chlorpromazine
Clinical manifestations:
May remain undiagnosed for many years, clinical features involve many systems:
Musculoskeletal: arthralgias and arthritis (joint swelling, tenderness, and pain on movement, companied with morning stiffness)

83. Cont…
Skin: subacut cutaneous lupus erythematosus (scarring and pigmentation changes), most common is acute cutaneous lesion consisting of a butterfly shaped rashes across the bridge of the nose and cheeks. Oral ulcers, skin lesions
Cardiopulmonary: Pericarditis (most common), may accompanied with pleural effusion, and pleuritis.
Vascular and lymphatic: inflammation of terminal arterioles, papular, erythematous, and purpuric lesions develops on the fingetips, elbows, toes, and extensor surfaces of the forearms or lateral side of the hand, and lymphadenopathy
Renal: affecting glomeruli and can cause RF
Neurologic and behavior: changes in the behavior pattern or cognitive ability, depression and psychosis are common

84. Assessment and diagnostic findings:
Compete history, physical examination, and blood tests.
Serum testing reveals moderate to sever anemia, thrombocytopenia, leukocytosis, or leukopenia and positive antinuclear antibodies
Medical management:
Intervention directed at controlling increased disease activity or exacerbations that may involve any organ system.
Pharmacologic therapy: NSAID used along with corticosteroids which are the single most important medication available for treatment. Immunosuppressive agents
Nursing management:
Caring of the complications associated with the disease.