265 Exam 4 Study Guide
Labs
Hbg 12-18
Hct 37-52%
WBC 5-10
RBC 4.2-6.1
PLT 150-400
PT 11-12.5 sec (1.5-2.5x normal on Coumadin = 16.5-31.25 sec)
INR 0.9-1.2 sec (Therapeutic level 2-3x normal = 1.8-3.6 sec)
PTT 60-70 sec (1.5-2.5x normal on Heparin = 90-175)
Na 135-145
K+ 3.5-5
Creatinine 0.5-1.2
BUN 10-20
Albumin 3.5-5
Mg 1.5-2.5
Ca 9-10.5
Cl 98-106
Phosphorus 2-4.5
Specific Gravity 1.005-1.030
Discoid lupus
Affects only the skin and is not lethal - Caused by UV rays
Macular Rash & Discoid Rash
Skin biopsy to dx
Systemic Lupus Erythematosus (313-317) ***TEMPERATURE***
Chronic, progressive, inflammatory connective tissue disorder that affects multiple body systems &organs
o REMISSIONS/EXACCERBATIONS (can end up in the ICU) - Autoimmune
o Attracted to KIDNEY’s—Lupus Nephritis is leading cause of death; this is direct damage to the kidneys
Poor survival associated with high creatinine, low hematocrit, proteinuria
o Young Women of child bearing age 20-40 Y (primary AA women)
o SLE & DLE both share a disfiguring and embarrassing rash!!
Clinical manifestations
o Malar rash – red flat or raised rash over cheeks sparing nasolabial folds “butterfly rash”
o Discoid rash – Red raised patches with scaling follicle plugging
o Photosensitivity– discoid skin rash from sun exposure - pt should wear sunscreen or protective clothing
o Oral ulcers–usually painless
o Polyarthritis-multiple joints affected
Small joints and knees inflamed
Osteonecrosis from chronic steroid use (5y+)
o Pleuritis with pleural effusion or pericarditis
o Fever is the major sign of exacerbation
o Generalized weakness, fatigue, anorexia, weight loss
o Renal disorders–proteinuria, cellular casts
o Neurologic disorders – seizures, psychosis and also peripheral neuropathies
o Raynaud’s phenomena
Exposure to cold or extreme stress – red, white, blue & pain of digits
o Alopecia or hair loss common
, Diagnostic Tests
o ANA most sensitive but antinuclear antibodies not specific to SLE
o C reactive protein can help differentiate SLE flare from an infection (remains normal if SLE flare)
o CBC shows pancytopenia (a decrease in all cell types)
Medical Management
o Topical steroids for skin lesions
o Acetaminophen or NSAIDS (caution with kidneys) – tx joint & muscle pain & inflammation
o Hydroxychloroquine (anti-malarial agent) – dec absorption of ultraviolet light by skin, dec skin lesions
Frequent eye exams – b4 starting and q 6 mon
o Glucocorticoids – Chronic steroid therapy
Take in the am b4 breakfast
Take Ca to prevent osteoporosis
Maintain skin integrity
o Immunosuppressants – methotrexate, azathioprine
o Belimumab – do not receive live vaccines for 30 days b4 tx
Teaching
Protect the skin
o Limit sun/ultraviolet light exposure to prevent exacerbation (fluorescent light too)
Long sleeves, lg-brimmed hat, SPF 30+
o Clean skin with mild soap, pat dry and apply lotion
o Cosmetics ok w/ moisturizers and sun protection, no excess powder or drying substances
Monitor temperature – first sign of exacerbation
Avoid large crowds and people who are ill, bc immunosuppressed
Avoid harsh hair tx (permanents or highlights)
Pregnancy can cause exacerbation
Systemic Sclerosis (Scleroderma) ***SWALOWING PROBLEM***
Uncommon, chronic, inflammatory, autoimmune connective tissue disease.
Similar to SLE, but w/a higher mortality rate
Doesn’t respond to steroids or immunosuppressants, why mortality higher than SLE
Inflamed tissue becomes fibrotic and then sclerotic (hard) – renal involvement leading cause of death
Women 25-55, most in 40s
Diffuse cutaneous *Major organ problems
o First sx – hand and forearm edema w/ or w/o bilateral carpal tunnel syndrome
o Skin thickening on trunk, face, and proximal and distal extremities (most of the body)
o Painless symmetric pitting edema of hands & fingers (sausage like fingers)
o Changes of pigmentation with loss of skin folds & face can become mask like
o Develop early problems w/ GI tract (GERD to dysphagia), heart(myocardial fibrosis), lungs (fibrosis & PAH), &
kidneys (malignant HTN)
o Complications can be rapid
Limited cutaneous *Esophagus
o Skin thickening limited to sites distal to face, neck and distal extremities
o Organ changes rare or late
o CREST Syndrome
Calcinosis – calcium deposits in tissues
Raynaud’s Phenomenon – intermittent vasospasm of finger tips - first CREST symptom that develops
Esophageal dysmotility - **Dysphagia**
Sclerodactyly – scleroderma of digits – fingers stiff, shiny, and no skin folds
Telangiectasia – capillary dilations that form vascular lesions on face, lips & fingers
Medical Management
, o Medications – Tx sx
Vasoactive agents – CCB for Raynaud’s symptoms
Anti – inflammatory meds - steroids
Immunosuppressants
o Reduce renal complications
ACE inhibitors and HTN control
o Treat PAH (Pulmonary Artery Hypertension)
Bosentan - endothelin receptor antagonist – Liver toxic
Nursing Management
o Keep HOB elevated 60 degrees during meals and at least an hour after
o Maintain skin integrity– esp with steroids & vasospasm
o Small frequent meals w/semisoft foods – avoid liquids (thickit) due r/f choking – small amounts & chew well
o Teach to avoid foods that inc gastric secretion–spices, caffeine, pepper
o Promote bowel elimination – have both constipation & diarrhea
Client Education
o How to dress in cold weather-gloves, socks, etc.
o Eliminate alcohol, cigarettes, extreme stress, and caffeine (vasoconstrictive)
o Biofeedback for stress management
o Disease process – Only gets worse
Fibromyalgia ***SLEEP & STRETCHING***
Chronic pain syndrome, NOT inflammatory or autoimmune
Pain stiffness and tenderness in trigger points – back of neck, upper chest, trunk, low back, and extremities
Burning and gnawing that comes and goes, worsen w/stress, inc activity, and weather conditions
Women between 30 -50 years, Lyme disease, trauma, & flu-like illness
Clinical Manifestations
o Fatigue – most common manifestation
o Morning stiffness
o Non refreshing sleep because of lack of stage 4 sleep- most do not get REM sleep
o Post exertional muscle pain
o 1/3 of patients have irritable bowel, tension headaches, PMS, numbness & tingling & Raynaud’s phenomena
o Depression – common with chronic pain
Medical Management—Directed at symptom relief
o L tryptophan-used to enhance sleep
o TCAs (amitriptyline, nortriptyline) inhibit serotonin uptake - antidepressant
o Benzodiazepines for anxiety associated w/ depression
o NSAIDS for pain control but may need stronger meds if pain not well controlled
o Pregabalin (Lyrica) – FDA approved for fibromyalgia pain
o **LOW INTENSITY EXERCISE WILL DECREASE PAIN**
Stretching, walking, swimming, rowing, biking, and water exercise
o Anticonvulsants like carbamazepine (Tegretol) & gabapentin (Neurontin) to help w/ chronic pain mgmt
o Biofeedback– esp. helpful with pain syndrome
o Oral Mag helpful with muscle pain
Lyme’s Disease ***NO DARK CLOTHING***
Tick born disease
Considered a connective tissue disease because the skin, joints, nervous system, and heart are involved
Sx begin w/i 3-30 days post bite
Easy to treat when found in time
Signs and Symptoms
o 1st - Red flat rash that clears in the center (bulls-eye lesion)- near the area of the bite
o Flu-like sx - Severe HA, Fever, Chills, Severe malaise, Fatigue, Stiff neck, & Joint pain
Labs
Hbg 12-18
Hct 37-52%
WBC 5-10
RBC 4.2-6.1
PLT 150-400
PT 11-12.5 sec (1.5-2.5x normal on Coumadin = 16.5-31.25 sec)
INR 0.9-1.2 sec (Therapeutic level 2-3x normal = 1.8-3.6 sec)
PTT 60-70 sec (1.5-2.5x normal on Heparin = 90-175)
Na 135-145
K+ 3.5-5
Creatinine 0.5-1.2
BUN 10-20
Albumin 3.5-5
Mg 1.5-2.5
Ca 9-10.5
Cl 98-106
Phosphorus 2-4.5
Specific Gravity 1.005-1.030
Discoid lupus
Affects only the skin and is not lethal - Caused by UV rays
Macular Rash & Discoid Rash
Skin biopsy to dx
Systemic Lupus Erythematosus (313-317) ***TEMPERATURE***
Chronic, progressive, inflammatory connective tissue disorder that affects multiple body systems &organs
o REMISSIONS/EXACCERBATIONS (can end up in the ICU) - Autoimmune
o Attracted to KIDNEY’s—Lupus Nephritis is leading cause of death; this is direct damage to the kidneys
Poor survival associated with high creatinine, low hematocrit, proteinuria
o Young Women of child bearing age 20-40 Y (primary AA women)
o SLE & DLE both share a disfiguring and embarrassing rash!!
Clinical manifestations
o Malar rash – red flat or raised rash over cheeks sparing nasolabial folds “butterfly rash”
o Discoid rash – Red raised patches with scaling follicle plugging
o Photosensitivity– discoid skin rash from sun exposure - pt should wear sunscreen or protective clothing
o Oral ulcers–usually painless
o Polyarthritis-multiple joints affected
Small joints and knees inflamed
Osteonecrosis from chronic steroid use (5y+)
o Pleuritis with pleural effusion or pericarditis
o Fever is the major sign of exacerbation
o Generalized weakness, fatigue, anorexia, weight loss
o Renal disorders–proteinuria, cellular casts
o Neurologic disorders – seizures, psychosis and also peripheral neuropathies
o Raynaud’s phenomena
Exposure to cold or extreme stress – red, white, blue & pain of digits
o Alopecia or hair loss common
, Diagnostic Tests
o ANA most sensitive but antinuclear antibodies not specific to SLE
o C reactive protein can help differentiate SLE flare from an infection (remains normal if SLE flare)
o CBC shows pancytopenia (a decrease in all cell types)
Medical Management
o Topical steroids for skin lesions
o Acetaminophen or NSAIDS (caution with kidneys) – tx joint & muscle pain & inflammation
o Hydroxychloroquine (anti-malarial agent) – dec absorption of ultraviolet light by skin, dec skin lesions
Frequent eye exams – b4 starting and q 6 mon
o Glucocorticoids – Chronic steroid therapy
Take in the am b4 breakfast
Take Ca to prevent osteoporosis
Maintain skin integrity
o Immunosuppressants – methotrexate, azathioprine
o Belimumab – do not receive live vaccines for 30 days b4 tx
Teaching
Protect the skin
o Limit sun/ultraviolet light exposure to prevent exacerbation (fluorescent light too)
Long sleeves, lg-brimmed hat, SPF 30+
o Clean skin with mild soap, pat dry and apply lotion
o Cosmetics ok w/ moisturizers and sun protection, no excess powder or drying substances
Monitor temperature – first sign of exacerbation
Avoid large crowds and people who are ill, bc immunosuppressed
Avoid harsh hair tx (permanents or highlights)
Pregnancy can cause exacerbation
Systemic Sclerosis (Scleroderma) ***SWALOWING PROBLEM***
Uncommon, chronic, inflammatory, autoimmune connective tissue disease.
Similar to SLE, but w/a higher mortality rate
Doesn’t respond to steroids or immunosuppressants, why mortality higher than SLE
Inflamed tissue becomes fibrotic and then sclerotic (hard) – renal involvement leading cause of death
Women 25-55, most in 40s
Diffuse cutaneous *Major organ problems
o First sx – hand and forearm edema w/ or w/o bilateral carpal tunnel syndrome
o Skin thickening on trunk, face, and proximal and distal extremities (most of the body)
o Painless symmetric pitting edema of hands & fingers (sausage like fingers)
o Changes of pigmentation with loss of skin folds & face can become mask like
o Develop early problems w/ GI tract (GERD to dysphagia), heart(myocardial fibrosis), lungs (fibrosis & PAH), &
kidneys (malignant HTN)
o Complications can be rapid
Limited cutaneous *Esophagus
o Skin thickening limited to sites distal to face, neck and distal extremities
o Organ changes rare or late
o CREST Syndrome
Calcinosis – calcium deposits in tissues
Raynaud’s Phenomenon – intermittent vasospasm of finger tips - first CREST symptom that develops
Esophageal dysmotility - **Dysphagia**
Sclerodactyly – scleroderma of digits – fingers stiff, shiny, and no skin folds
Telangiectasia – capillary dilations that form vascular lesions on face, lips & fingers
Medical Management
, o Medications – Tx sx
Vasoactive agents – CCB for Raynaud’s symptoms
Anti – inflammatory meds - steroids
Immunosuppressants
o Reduce renal complications
ACE inhibitors and HTN control
o Treat PAH (Pulmonary Artery Hypertension)
Bosentan - endothelin receptor antagonist – Liver toxic
Nursing Management
o Keep HOB elevated 60 degrees during meals and at least an hour after
o Maintain skin integrity– esp with steroids & vasospasm
o Small frequent meals w/semisoft foods – avoid liquids (thickit) due r/f choking – small amounts & chew well
o Teach to avoid foods that inc gastric secretion–spices, caffeine, pepper
o Promote bowel elimination – have both constipation & diarrhea
Client Education
o How to dress in cold weather-gloves, socks, etc.
o Eliminate alcohol, cigarettes, extreme stress, and caffeine (vasoconstrictive)
o Biofeedback for stress management
o Disease process – Only gets worse
Fibromyalgia ***SLEEP & STRETCHING***
Chronic pain syndrome, NOT inflammatory or autoimmune
Pain stiffness and tenderness in trigger points – back of neck, upper chest, trunk, low back, and extremities
Burning and gnawing that comes and goes, worsen w/stress, inc activity, and weather conditions
Women between 30 -50 years, Lyme disease, trauma, & flu-like illness
Clinical Manifestations
o Fatigue – most common manifestation
o Morning stiffness
o Non refreshing sleep because of lack of stage 4 sleep- most do not get REM sleep
o Post exertional muscle pain
o 1/3 of patients have irritable bowel, tension headaches, PMS, numbness & tingling & Raynaud’s phenomena
o Depression – common with chronic pain
Medical Management—Directed at symptom relief
o L tryptophan-used to enhance sleep
o TCAs (amitriptyline, nortriptyline) inhibit serotonin uptake - antidepressant
o Benzodiazepines for anxiety associated w/ depression
o NSAIDS for pain control but may need stronger meds if pain not well controlled
o Pregabalin (Lyrica) – FDA approved for fibromyalgia pain
o **LOW INTENSITY EXERCISE WILL DECREASE PAIN**
Stretching, walking, swimming, rowing, biking, and water exercise
o Anticonvulsants like carbamazepine (Tegretol) & gabapentin (Neurontin) to help w/ chronic pain mgmt
o Biofeedback– esp. helpful with pain syndrome
o Oral Mag helpful with muscle pain
Lyme’s Disease ***NO DARK CLOTHING***
Tick born disease
Considered a connective tissue disease because the skin, joints, nervous system, and heart are involved
Sx begin w/i 3-30 days post bite
Easy to treat when found in time
Signs and Symptoms
o 1st - Red flat rash that clears in the center (bulls-eye lesion)- near the area of the bite
o Flu-like sx - Severe HA, Fever, Chills, Severe malaise, Fatigue, Stiff neck, & Joint pain
