NCM 112: MEDICAL SURGERY

Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response,
Cellular Aberrations, Acute and Chronic

BSN 3rd Year SY 2022-2023 // First Sem - Finals // transcribed by: DMV // date: November 2022

Topic: IMMUNOLOGY

FINALS
IMMUNE SYSTEM RESPONSE
DISTURBANCES IN IMMUNOLOGIC AND
INFLAMMATORY RESPONSE
1. PHAGOCYTIC IMMUNE RESPONSE
a. First line of defense involving WBC
IMMUNITY (granulocytes and macrophage) that has
- body’s specific protective response to a foreign agent the ability to ingest foreign particles
or organism. b. APOPTOSIS
IMMUNE MEMORY i. Programmed cell death
- is a property of the immune system that provides ii. Body’s way of destroying
protection against harmful microbial agents despite iii. Not renewed or replenished
the timing of re-exposure to the agent 2. HUMORAL IMMUNE RESPONSE
TOLERANCE a. Second line of defense (antibody
- is the mechanism by which the immune system is response)
programmed to eliminate foreign substances such as 3. CELLULAR IMMUNE RESPONSE
microbes, toxins and cellular mutations but maintains a. Third line of defense involving the attack of
the ability to accept self antigens. pathogens by the T-cells

Anatomy and Physiology of the immune system:

Bone Marrow
Lymphatic System
Lymphoid Tissues
- Thymus Gland
- Spleen
- Lymph nodes
- Lymph nodules ( tonsils)

Antigen (Ag) - immunogen; substance that induces the production of

antibodies

Antibodies (Ig) - immunoglobulin (gamma globulin); proteins

produced by plasma cells

Immunocompromised/immunodeficiency - failure of immune

response of an individual

Immunoregulation - regulatory mechanism/ overly stimulated

T-cells (Cellular immune response)

1. Helper T-cells – lymphocytes that attack foreign

RESPONSE TO INVASION
CELL MEDIATED
IMMUNITY
(cellular response)
Basically, my job is to
destroy target cells through
the release of lymphokinase
- Thymus derived
Maturation
- Type of cells
(thymic hormone)
Spleen
Direct = no antibodies
involved
invaders(antigens directly)
2. Cytotoxic T-cells – lymphocytes that lyse cells
infected with virus; play a role in graft rejection
3. Natural killer (NK) cells – defend against
HUMORAL IMMUNITY microorganisms and malignant cells
My job is to produce T- cells
antibodies that, in turn will - Suppressor T-cells - lymphocytes that decrease
attack an antigen B-cell activity to a level at which immune system is
compatible with life
- Bone marrow - Memory T-cells – remember the specific foreign
derived = b cells - antigen and quickly activate an immune response ( if
circulation antigen re-appear)
- Produces
antibodies WBC or Leukocytes
- Granular Leukocytes(Granulocytes)
- fight invasion by foreign bodies/toxins by
releasing cell mediators (histamine,

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Acute and Chronic

bradykinin, prostaglandins) engulfing foreign

bodies or toxins
- Include neutrophils (PMN’s – 1st to arrive at
site of inflammation) , eosinophils and
basophils (Increase in no. during allergic
reactions & stress responses)
- Non granular
- monocytes or macrophages (histiocytes
when they enter tissue spaces); function as
phagocytic cells
60 – 70% - T-cells
10 – 20% - B-cells

4 well defined stages (immune response)

Recognition Stage (recognize)

Proliferation Stage (proliferation)
MAJOR CHARACTERISTICS OF IMMUNOGLOBULINS
Response Stage (response - cellular/humoral)
Effector Stage (balanced/? - successful immune
response) 1. IgG ( 75% of total Ig)
- Appears in serum and tissues (interstitial
HUMORAL RESPONSES ( B-cells ) fluid)
- Assumes a major role in blood borne and
- Bacterial phagocytosis & lysis tissue infections
- Anaphylaxis - Activates the complement system
- Allergic hay fever - Enhances phagocytosis
- Immune complex disease - Crosses the placenta Immunoglobulins…
- Extracellular infection 2. IgA ( 15% of total Ig )
- Usually bacterial and some viral/fungal - Appears in body fluids
infections - Protects against respiratory, GI,
genitourinary infections
CELLULAR RESPONSE ( T – cells ) - Prevents absorption of antigens from food
- Passes to neonate in breast milk for
- Transplant rejection protection
- Delayed hypersensitivity(tuberculin reaction) 3. IgM ( 10% of total Ig )
- Graft vs. Host disease - Appears mostly in intravascular serum
- Tumor surveillance/destruction - Appears as the first Ig produced in response
- Intracellular infection to bacterial and viral infections
- Viral, fungal and parasitic infection - Activates the complement system
4. IgD ( 0.2% of total Ig )
Agglutination - way to defend against foreign invaders - Appears in small amounts in serum
“Clumping effect” - help clear the antigen by activating - Possibly influences B-lymphocyte
phagocytosis (easy) engulfed phagocytosis differentiation but role is unclear
5. IgE ( 0.004% of total Ig )
Opsonization - Ag-Ig complex coat with a sticky substance - Appears in serum
- Takes part in allergic and some
Immunopathology - study of immune dysfunction hypersensitivity reactions
- Combats parasitic infections
Immune Senescence - immune system in older people;
increased production of immature T cells COMPLEMENT SYSTEM
(Ag + Ig)
TYPES OF IMMUNITY

Naturally Naturally
acquired acquired
active passive
immunity immunity

Results from having the Antibodies obtained through

disease and recovering placenta or breast milk
successfully

Artificially Artificially
acquired acquired
active passive
immunity immunity

Conferred by immunization Antibodies transferred from

with an antigen sensitized person COMPLEMENT SYSTEM
- Proteins that comprise complement interact
Types of Immunoglobulin sequentially in a cascading Effect
- Activation of the complement allows:
- removal of infectious agents and initiation of
the inflammatory response

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Acute and Chronic

COMPLEMENT CASCADE may be activated by any of the Three Distinct Phenomena:

three pathways
1. Vascular Response
1. Classical or Classic pathway 2. Cellular Response
- Triggered after Ig’s bind to microbes or other 3. Reparative Phase
antigens and is part of the humoral type of
adaptive immunity
LOCAL MANIFESTATIONS OF INFLAMMATION
2. Lectin pathway
- Activated when a plasma protein binds to
terminal residue or the surface glycoproteins 1. Redness
of microbes 2. Heat
3. Alternative pathway 3. Pain
- Triggered when complement proteins are 4. Swelling
activated on microbial surfaces 5. Loss of function
- Part of natural immunity
Substances that contribute to Inflammatory Response
COMPLEMENT SYSTEM

a. Histamine
Therapeutic and lifesaving b. Kinins
- if the cell attached by the complement system is a i. phagocytes also stimulate the permeability of
true foreign invader blood vessels, chemotactic agents for
phagocytosis
HOWEVER : c. Prostaglandin
- If cell is part of the human organism, result can be i. released by the damage cells and intensify
devastating disease or even death the effect of histamines and kinins
ii. stimulates the emigration of phagocytes to
CONTINUED or CHRONIC ACTIVATION of the adhere through the capillary walls
COMPLEMENT- chronic inflammation d. Leukotrienes
- AUTO-IMMUNE DISEASES & DISORDERS char. by i. causes increased permeability and helps
chronic infection phagocytes to adhere to pathogens
e. Complement
i. may stimulate histamine release, attracts
INFLAMMATION
neutrophils, destroys bacteria

a. usual response of tissues to stress

b. aids in the disposal of microbes and prepare the site
for tissue repair

INFLAMMATORY REACTIONS

Classification
Acute
Subacute
Chronic

WHY ISOLATE PATIENTS?

a. Designed to prevent transmission of organisms

b. Agent and host factors more difficult to control,
interruption is directed primarily at transmission

TWO TIERS OF ISOLATION PRECAUTION

Standard precautions
Transmission-based Precautions

LOCAL INFLAMMATORY RESPONSES

STANDARD PRECAUTIONS

COMPONENT RECOMMENDATIONS

Hand Hygiene - After touching blood, body

fluids, secretions/excretions,
contaminated items
- After removal of gloves
- Between patient contacts
- Between tasks and procedures

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Acute and Chronic

Contact Precautions
Gloves - When touching blood, body
- Apply to specified patients known or suspected to be
fluids, secretions/excretions,
infected or colonized with epidemiologically important
contaminated items
organisms transmitted primarily by the contact route
- When touching mucous
membranes and non-intact skin
Infections Requiring Contact Precautions
Mask, Eye - During procedures and patient
protection, Face care activities likely to generate Multidrug-resistant bacteria Herpes simplex virus
shield splashes or sprays of blood or Herpes zoster, Varicella
body fluids
Diarrhea,Enteroviruses, Impetigo Major
Gown - During procedures and patient Shigella Hepatitis A, noncontained abscesses
care activities when contact Rotavirus
with clothing/exposed skin with
blood and body fluids, Viral and hemorrhagic Scabies
secretions/excretions is conjunctivitis
anticipated
Cutaneous diphtheria S. aureus cutaneous
Patient Care - Handle in a manner which infection
Equipment prevents cross-contamination
of clean/sterile supplies and
Nursing Interventions
minimizes the potential for
A. Private room
exposure to others
A. Clean, non- sterile gloves at all times
- Ensure that reusable
B. Hand washing after glove removal
equipment is cleaned and
C. Gowns at all times
reprocessed appropriately
D. Remove gloves and gowns before leaving patient’s
before reused
room
- Discard single-use items
a. masks not needed, doors do not need to be
appropriately
closed
Environmental - Develop procedures for
Droplet Precautions
Control ROUTINE care, cleaning, and
- Used for organisms such as influenza or
disinfection of frequently
meningococcus that can be transmitted by close
touched environmental
respiratory or mucous membrane contact with
surfaces
respiratory secretions
- Ensure that procedures are
followed!

Textiles and - Handle in a manner which

Laundry prevents contamination of
personal clothing or skin and
clean environmental surfaces

Needles and - DO NOT recap used needles

Sharps or manipulate them using both
hands
- Use a one-handed “scoop
technique” if recapping a used
needle is necessary
- Place in puncture-resistant
containers for disposal

Patient - Prioritize for single/private

Placement room if the patient is likely to
contaminate the environment,
does not maintain appropriate
hygiene or environmental
control.
TRANSMISSION-BASED PRECAUTIONS
Airborne Precautions
- Airborne transmission occurs when droplet nuclei (<5
microns) are disseminated in the air and inhaled by a
susceptible host
- Droplet nuclei can remain suspended in the air for
long periods of time and can be carried on air currents
over long distances.

Isolation Categories
- Contact Precautions INFECTIONS REQUIRING AIRBORNE PRECAUTIONS
- Droplet Precautions
- Airborne Precautions Pulmonary tuberculosis SARS

Varicella Measles
Transmission-Based Precautions

- Designed for patients documented or suspected to be Nursing Interventions

infected with highly transmissible or epidemiologically A. Isolation room / special ventilation room
important pathogens for which ADDITIONAL a. Negative air-pressure ventilation
precautions beyond Standard Precautions are needed b. HEPA filtered air if recirculated
to interrupt transmission B. Keep the door closed at ALL times

Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular
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Acute and Chronic

C. Patient should wear a mask when transported out of Ex. Myasthenia Gravis, Good Pasture Syndrome
room
D. Should wear fitted respirator mask (N95 mask) 3. Type III ( Immune Complex Hypersensitivity)
a. involves immune complexes that are formed
when antigen bind to antibodies
SUMMARY OF TRANSMISSION-BASED PRECAUTIONS
Ex. SLE, Rheumatoid Arthritis
Single Mask Gown Gloves
4. Type IV ( Delayed Type Hypersensitivity )
Room
a. also known as cellular hypersensitivity
CONTACT / / b. occurs 24-72 hrs after exposure to allergen

DROPLET / Ex. Effect of intradermal injection(PPD), contact

dermatitis(cosmetics, adhesives, topical agents, povidone
AIRBORNE / / iodine

Sensitization – initiates the humoral response or the build up

REVERSE ISOLATION of antibodies

Primary exposure – results in sensitization

- Protective Isolation
- Placement of immunocompromised person in a Re-exposure – causes hypersensitivity reaction
specialized room that attempts to minimize exposure - Common causes of anaphylaxis: foods, medications,
to pathogens pharma/biological agents, insect stings, latex

REBOUND REACTION – occurs 4 to 10 hrs after initial allergic

reaction

ALLERGIC RHINITIS

- Is a reaction to airborne allergens

- The resulting rhinitis may occur seasonally or
year-round

Causes: Common triggers

- Perennial allergens and irritants
- Windborne pollens

Signs and Symptoms

Seasonal Allergic Rhinitis Perennial Allergic Rhinitis

- Paroxysmal - Chronic Extensive

sneezing, profuse Nasal obstruction
watery rhinorrhea, - Conjunctivitis and
nasal obstruction other extranasal
and pruritus of the effects
nose and eyes - dark circle under
(throat & soft pt’s eyes (
palate) ALLERGIC
SHINERS)

Complications

Sinus and Middle Ear Nasal Polyps

Infections

DIAGNOSTIC TESTS

- Pt’s personal and family history of allergies

- Skin Testing

1. Microscopic examination of sputum and nasal

HYPERSENSITIVITY REACTION (4 TYPES)
secretions
2. Blood Chemistry
1. Type I ( Anaphylactic Hypersensitivity )
- most severe form that is explosive in onset Medical Management
- immediate reaction beginning within minutes 1. Elimination of environmental antigens
of exposure to an antigen 2. Drug therapy
2. Type II ( Cytotoxic Hypersensitivity ) a. Antihistamine
a. occurs when system mistakenly identifies a b. Inhaled intranasal steroids
normal constituent of the body as foreign c. Nasal Decongestant
d. Cromolyn (Nasalcrom)

Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular
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e. Leukotriene Inhibitor Other symptoms include:

3. Long-term management 1. Rapid pulse
a. Desensitization with injections of extracted 2. Mental confusion
allergens 3. Low blood pressure
4. Abnormal heart rhythm
Nursing management 5. Fluid in the lungs
1. Monitor the patient’s compliance with prescribed drug 6. Syncope
treatment regimens 7. Diffuse erythema
2. Advise the patient to use intranasal steroids regularly, 8. Hypotension
as prescribed
a. Offer suggestions for reducing environmental DO NOT
exposure to airborne allergens - Place a pillow under the person’s head if he or she is
b. Suggest that the patient consider drastic having trouble breathing. This can block the airway.
changes in lifestyle - Give the person anything by mouth if they are having
trouble breathing
ANAPHYLAXIS
ATOPIC DERMATITIS
- Acute,potentially life-threatening type 1 (immediate)
hypersensitivity reaction - Chronic skin disorder characterized by superficial skin
Causes inflammation and intense itching
- Ingestion of or systemic exposure to sensitizing drugs
or other substances Cause = Unknown

Understanding Anaphylaxis
Signs and Symptoms
1. Response to the Antigen
Erythematous, weeping Scaly and lichenified lesions
2. Released Chemical Mediators
lesions in areas of flexion and
3. Intensified Response
extension
4. Respiratory Distress
5. Deterioration
Pink pigmentation and Double fold under lower lid
6. Failed Compensatory Mechanism
swelling of the upper eyelid (Morgan’s line or Dennie’s
sign)
Signs and Symptoms
Diagnostic Test
Physical distress Feeling of impending doom
or fright Patient’s history of atopy CBC

Sweating Sneezing, shortness of Blood Chemistry

breath, nasal pruritus,
urticaria and angioedema Management

SYSTEMIC MANIFESTATIONS
Non pharmacologic Measures
1. Application of non irritating topical lubricants
hypotension, shock, and edema of the upper
2. Avoidance of hot tubs
sometimes cardiac respiratory tract
3. Minimizing exposure to allergens or irritants
arrhythmias - hoarseness, stridor,
- nasal mucosal wheezing and
Medical Management: Drug therapy
edema, profuse accessory muscle
1. Topical Corticosteroids
watery rhinorrhea, use
2. Immunomodulator
itching, nasal severe stomach cramps,
3. Oral antihistamine
congestion and nausea, diarrhea and
4. Antibiotics
sudden sneezing urinary urgency and
5. Phototherapy, systemic oral steroids or coal tar
attacks incontinence
preparation
6. Immunosuppressant
DIAGNOSTIC TESTS

- Serum IgE - Skin test Nursing Management

1. Monitor the patient’s compliance with drug therapy
2. Teach the patient when and how to apply topical
Medical Management corticosteroids
- Immediate administration of Epinephrine 3. Emphasize the importance of regular personal
- Tracheostomy or Endotracheal Intubation hygiene
- Oxygen therapy 4. Be alert with the signs and symptoms of secondary
- Longer acting epinephrine, corticosteroid and infection, and teach the patient how to recognize them
Diphenhydramine as well
- Albuterol 5. If the patient’s diet is modified to exclude food
- Cimetidine allergens, monitor his nutritional status.
- Aminophylline 6. Offer support to help the patient and his family cope
- Volume expander with this chronic disorder
- IV Vasopressor 7. Discourage use of laundry additives
- CPR 8. Dissuade the patient from scratching urticaria

Nursing Management
1. Perform measures to prevent anaphylaxis LATEX ALLERGY
2. Closely monitor a patient undergoing diagnostic test

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- Is a hypersensitivity reaction to products that contain

natural latex American Rheumatism Association
Causes Criteria for Classifying SLE
- exposure to latex proteins
- frequent contact with latex-containing products - malar or discoid rash
- Photosensitivity
- oral or nasopharyngeal ulcerations
Signs and Symptoms
- nonerosive arthritis
- pleuritis or pericarditis
Hypotension Tachycardia
- profuse proteinuria
- seizure or psychoses
Urticaria and pruritus Difficulty breathing,
- hemolytic anemia, leukopenia, lymphonemia or
bronchospasm, wheezing
thrombocytopenia
and stridor
- (+) findings of antiphospholipid antibodies
Angioedema - abnormal antinuclear antibody titer

Diagnostic Test Diagnostic Test

History and Physical Radioallergosorbent test Complete Blood Count ESR

Assessment
Serum Electrophoresis ANA and Lupus
Patch Test erythematosus cell test

Medical Management Anti-double-stranded DNA Urine studies

- Prevention of exposure antibody
- Drug therapy
Serum Complement blood Chest X-ray
- Corticosteroid
studies
- Antihistamine
- H2 receptor antagonists
Electrocardiogram Kidney Biopsy

Acute EMERGENCY Lupus anticoagulant and

anticardiolipin test
1. Administer Epinephrine
2. Maintain airway patency Medical Management
3. Volume Expander 1. Drug therapy
4. IV Vasopressors a. NSAIDs
5. CPR b. Topical corticosteroid cream
6. Longer-acting Epinephrine, corticosteroids, c. Antimalarials
diphenhydramine d. Systemic Corticosteroid
7. Aminophylline and Albuterol e. Immunosuppressant
f. Antihypertensive Drugs
Nursing Management g. IV Gamma globulin
1. Make sure items are latex free 2. Dialysis or Kidney transplant
2. Place the patient in a private room or with another
patient who requires a latex-free environment Nursing Management
3. Urge the patient to wear an identification tag 1. Watch for constitutional symptoms
mentioning his latex allergy 2. Observe for dyspnea, chest pain and edema of the
4. Teach the patient and his family how to use an extremities
epinephrine auto injector 3. Note the size, type, and location of the skin lesions
5. Instruct patient to consider foods that may contain 4. Check for hematuria, hair loss, and skin and mucous
some proteins similar to those in rubber membranes for petechiae, bleeding, ulceration, pallor
6. Teach the patient to be aware of all latex containing and bruising
products 5. Provide a balanced diet
6. Urge the patient to get plenty of rest
7. Explain all tests and procedures
LUPUS ERYTHEMATOSUS
8. Apply heat packs
9. Encourage regular exercise
- Chronic inflammatory autoimmune disorder of the 10. Administer prescribed medications
connective tissues 11. Monitor patient’s VS, I&O, weight, and lab results
- Appears in 2 forms: 12. Monitor the patient for hypertension, weight gain and
a. Discoid other signs of renal involvement
b. SLE 13. Assess for signs of neurologic damage
Cause: Unknown 14. Refer the patient to the Lupus Foundation and
- Contributing factors Arthritis Foundation as necessary

Signs and Symptoms RHEUMATOID ARTHRITIS

Cardiovascular changes Constitutional changes

Dermatologic changes
Musculoskeletal changes
Pulmonary changes
Hematologic changes
Neuropsychiatric changes
Renal changes
- Chronic, systemic inflammatory disease that primarily
attacks peripheral joints and the surrounding muscles,
tendons, ligaments, and blood vessels
Cause
*Unknown
*Possible causes

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4 Stages (Inflam process in joints) 11. Encourage a balanced diet

1. Synovitis 12. Urge the pt to perform ADLs
2. Pannus 13. Provide emotional support
3. Fibrous Ankylosis 14. Teach the pt how to stand, walk and sit correctly
4. Fibrous tissue calcifies resulting in bony ankylosis and 15. Instruct the pt to pace daily activities
total immobility 16. Stress the importance of getting adequate sleep and
using correct sleeping posture
17. Teach the pt ways to avoid putting undue stress on
Signs and Symptoms
joints
18. Suggest using assistive devices to help with ADLs
Fatigue, malaise, anorexia, Specific localized, bilateral
19. Advise the pt who has trouble maneuvering fingers
weight loss, persistent and symmetric articular
into gloves to wear mittens
low-grade fever, symptoms
20. Tell the patient to dress while in a sitting position
lymphadenopathy, and
21. Refer the pt to the Arthritis Foundation
vague articular symptoms

Spindle-shaped fingers Joint pain and tenderness URTICARIA AND ANGIOEDEMA

Feeling of warmth at joint Diminished joint function and

Flexion deformities
Gradual appearance of
rheumatoid nodules
Pericarditis, pulmonary
nodules, pleuritis,
inflammation of the sclera
and overlying tissues of the
eye
deformities Urticaria
- is an episodic,usually self-limited skin reaction
Carpal tunnel syndrome characterized by local dermal wheals surrounded by
an erythematous flare
Vasculitis Angioedema
- subcutaneous and dermal eruption that produces
deeper, larger wheals and a more diffuse swelling of
Peripheral neuropathy loose subcutaneous tissue
Signs and Symptoms
Urticaria Angioedema

Stiff, weak, or painful muscles - distinct, raised, - non pitted swelling

evanescent dermal of deep
Diagnostic Test wheals surrounded subcutaneous
- X-ray by an erythematous tissue
- Rheumatoid Factor titer flare
- Synovial fluid analysis
- Serum protein electrophoresis Diagnostic Test
- ESR and C-reactive protein - Accurate patient history
- CBC - Physical Assessment
- MRI - Skin testing and food diary
- ANA test (+) - CBC, Urinalysis, ESR and Chest X-ray
- Serum levels of complement 1 and 4 esterase
Treatment: Medical Management inhibitor
Treatment
1. Drug therapy 1. Non-pharmacologic
a. Salicylates 2. Drug therapy
b. NSAIDs a. Hydroxyzine
c. DMARD b. Corticosteroid
d. Corticosteroids Nursing Considerations
e. Immunosuppressants 1. Teach the patient about the drugs
f. Leflunomide and biologic response modifier 2. Inspect the skin for signs of secondary infection
g. Protein A-immunoadsorption therapy 3. Instruct the patient to keep his fingernails short
2. Surgical Management
a. Synovectomy
b. Osteotomy
c. Tendon transfer
d. Joint reconstruction or Total Joint
Arthroplasty
e. Arthrodesis
f. Tenorrhaphy

Nursing Considerations

1. Assess all joints carefully

2. Monitor the pt’s VS, weight changes, sensory
disturbances, and level of pain
3. Administer drugs as ordered
4. Provide meticulous skin care
5. Explain all diagnostic tests and procedures
6. Monitor the duration of morning stiffness
7. Encourage the pt to take hot showers or bath
8. Apply splint as ordered
9. Observe for pressure ulcers
10. Explain the nature of the disease

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