immune 4

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Author:
Prittyrick
ID:
309073
Filename:
immune 4
Updated:
2015-10-05 20:50:01
Tags:
germs
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Description:
RA
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  1. Diffuse connective tissue disease
    • systemic and chronic in nature
    • diffuse inflammation and degeneration of connective tissue
    • course: periods of exacerbations and remissions
    • cause: unknown tend to have immune abnormalities
    • ex: RA, SLY, sclerodema
  2. Rheumatoid Arthritis RA
    • chronic
    • progressive
    • systemic
    • autoimmune
    • inflammatory
    • collagen/connective tissue disease
    • effects connective tissues
  3. RA etiology
    • Patho: unknown
    • most widely aceepted: Auto immune
    • - other possible causes: genetics, trigger event
    • Aberrant immune response that leads to synovial inflammation and destruction of the joint caused by IgG immunecomplexes
    • body attacks itselfs and leads to synovial inflammation and destruction to joint by IgG
    • decre symptoms
  4. Patho RA cont
    • phagocytosis produces enzymes in the synovial tissue
    • the enzyme break down collagen, causing edema, proliferation of synovial membrane and utimately pannus formation
    • Pannus (thickening synovial tissue) destroys cartilage/erodes the bone
    • leads to destruction of articular cartilage and bone destructive changes are irreversible
  5. S/s of RA
    • onset is insidous
    • non specific s/s may precede articular s/s
    • articular s/s:
    • - usually begins small joints of hands, wrist, feet
    • - can progress to larger joints
    • - acute onset and symmertrical s/s
    • -joint pain, swelling, warmth, erythema, joint stiffiness, lack of function, deformity
    • - local symptoms or inflammation
  6. s/s of RA
    extraarticular s/s
    • Extraatricular s/s:
    • - fever, weight loss, fatigue, anemia, lymph node enlargement
    • - Rheumatoid nodules
    • -- 25% of pt with advanced RA (+RF)
    • -- subcutaneus nodules, firm, nontender, movable
    • -- on exterior surfaces of joints
    • Arteritis
    • raynaud;s phenomenon
    • pericarditis
    • splenomegaly
    • neuropathy
  7. Dx RA***
    • PE/Assessment
    • positive rheumatoid factor (RF)
    • ESR
    • synovial fluid aspiration (arthrocentesis)- to make sure no inflammation. dec tension
    • positive c reactive protein
    • positive antinuclear antibody (ANA)
    • CBC w diff- worry about circulation or infection
    • x-rays- how much damage was done
  8. Criteria for RA
    • morning stiffiness (last > 1 hour) for 6 weeks
    • stimultaneous swelling of three or more joints for 6 weeks
    • swelling in hand joints for 6 weeks
    • symmerical joints swelling for 6 weeks
    • Rh nodules
    • positive RF
    • erosions or decalcifications seen on handwrist xray
    • RA stages
  9. Treatment RA
    • goal: reduce pain
    • minimize stiffiness and swelling
    • maintain mobility- bc of contracture
    • aggressive and early treatment
  10. Drug therapy RA
    • 1st line:
    • NSAID's- new studies show no need to waste time with aggressive treatment
    • salicylates- pain
    • cox 2 inhibitors- dec inflammation, blocking prostagladins
    • corticosteriod- incr dose
    • disease modifying anti rheumatic agent (DMARDS)
    • 2nd line:
    • DMARDS - aggressive
    • 3rd line:
    • immunomodulators ie flu pneum.
  11. ANemia
    • MCV can tell u what type of anemia a person has
    • 80-100 normocystic- inflammation, acute blood loss
    • < 80 microcystic iron deficiency anemia
    • > 100 macrocystic- vita B12 and folic acid
  12. Drug therapy RA
    corticord steriods
    • Corticorsteriod (prednisone)
    • anti-inflammatory effects and symptom control
    • used with flare ups/early dx not long term management
    • can also be used as a bridge to wait for DMARDS to have full effect
    • review systemic side effects- long term c/o osteoporosis, AVN avascular necrosis
    • (osteoporosis, look at the cbc- check on for anemia)
  13. drug therapy RA second
    DMARDS
    • disease modifying anti rheumatic drugs (DMARDS)
    • - start with the confirmation of the dx
    • - decrease inflammation, pain and immunoregulatory effects
    • - slow onset
    • review 1638-1639
  14. drug therapy 3RA
    methotrexate and plaquenil
    • methotrexate **
    • immune suppression affect DNA synthesis and other cellular effects
    • gold standard for RA tx
    • used for RA/SLE
    • S/e
    • Teratogenic- make sure not prego
    • hepatoxicity- check LFT
    • alopecia

    • Plaquenil
    • antiinflammatory, inhibits lysosomal enzymes
    • used for RA/SLE and malaria
    • S/e
    • damage retina - make sure pt gets eyes check
    • photosensitivity
    • opthamo exam q 6-12mons
  15. drug therapy 4 ra
    biologic DMARDS,
    • tumor necrosis factor (TNF) inhibitors
    • decrease TNF, inhibits inflammatory response and modulates cellular immune responses
    • contraindication: TB active, fungal and bacterial infections (not much to fight with)
    • - remicade: Adm IV over 2 hours, given with methotrexate, s/e h.a rash, GI, UTI
    • enbrel: adm sc 2xweek, given with methotrexate, se irritation at injection site,, h.a, URI, rhinitis
  16. Drug therapy RA
    immunodulary/cytotoxic agents
    • utilized for life threaten extra-articular sympts- systemic vasculitis, severe articular dx that is refractive of other therapy
    • rarely used bc of high toxicity
    • Azthioprine (imuran)
    • cyclosporine
  17. drug therapy
    antidepressants
    • SSRI (prozac, paxil, zoloft)
    • assist with mood, sleep changes and chronic pain
    • s/e dry mouth, constipation, h/a
    • NI: full effects seen in 2-4 weeks, give with food to decr side effects
  18. Nursing management of RA
    • rest
    • - activity with rest
    • - positioning- no contracture
    • - joint stiffiness- warm showers
    • - avoids repitition-
    • - good activity swimming
    • - use ice when flared up

    • Joint protection
    • - maintain joints in neutral position
    • - distribute weight evenly over the joints
    • - avoid repition activity
    • - change position frequently
    •   heat and cold
    • - ice- excerabation
    • - moist heat/warm bath morning stiffiness > 1hr

    exercise: rom, aquatic exercises, PT
  19. Nursing management RA
    • nutrition
    • - balanced
    • - high in protein, vitamins , Fe for tissue building, low NA diet supplements

    • Assistive device
    • - PT/OT
    • - splints- avoid contracture

    • Supports
    • - chronic pain, fatigue, change in body image, sleep disturbance, fear of disability, depression, changes in mobility status/ADL
    • - national support resources

    • Pt education
    • you don't know what pt knows
  20. nursing dx
    • pain
    • infection
    • knowledge deficit
    • psychological
    • self image
  21. complication of ra
    • flexion contracture and hand deformities
    • cataract/loss of vision
    • bone destruction
    • vasculitis
    • Rh nodules- skin ulcers
    • myocardial infarction, cva
    • cardiomyopathy, pleural effusions

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