Immunity Disorders

1. IMMUNOLOGICAL DISORDER
Ahmed Gamal Fahmy
Fatma Saeed Fahmy
Prof Dr Amira Ahmed
Prepared by:
Under Supervision of

2. OUTLINES
Immune System Basics and Components
Primary Organs (Bone Marrow and Thymus)
 Secondary Organs (Tonsils, Lymph nodes, Spleen, and Adenoid Appendix)
Disorders Related to Heigh Immunity
Ulcerative Colitis
Rheumatoid Colitis
Disorders Related to Low Immunity
Acquired Immune Deficiency Syndrome (AIDS)

3. GENERAL OBJECTIVES:
At the end of this lecture the participants should be able to
Define Immune System
 Identify Components of Immune System
Know Disorders Related to Heigh Immunity
 Ulcerative Colitis
 Rheumatoid Colitis
Know Disorders Related to Low Immunity
 Acquired Immune Deficiency Syndrome (AIDS)

4. INTRODUCTION
• (ih-MYOON SIS-tem) A complex network of
cells, tissues, organs, and the substances they
make that helps the body fight infections and
other diseases. The immune system includes
white blood cells and organs and tissues of the
lymph system, such as the thymus, spleen,
tonsils, lymph nodes, lymph vessels, and bone
marrow.

5.  Bone marrow
 Thymus
 Tonsils
 Lymph nodes
 Spleen
 Adenoid
 Appendix
 Primary Organs:
 Secondary Organ:

6.  All the specialized cells of the immune system are formed in the
bone marrow.
 The bone marrow is the production site of the WBCs involved in
Immunity. Lymphocytes are generated from stem cells, the B
lymphocytes (B cells), and the T lymphocytes (T cells). B
lymphocytes mature in the bone marrow and then enter the
circulation. T lymphocytes move from the bone marrow to the
thymus, where they mature into several kinds of cells capable of
different functions.
 Bone Marrow
 Primary Organs

8.  The thymus gland is found in the thorax in the anterior mediastinum
it gradually enlarges during childhood but after puberty it undergoes
a process of involution resulting in a reduction in the functioning
mass of the gland. (70g in infant -3g in adults).
 Thymus is responsible for maturation of precursors T lymphocytes
from the bone marrow.
 Thymus

9.  Lymphoid Tissues
 Lymphoid tissues include:
 The spleen
 The lymph nodes
 The tonsils
 Adenoids
 Appendix
 Secondary Organs

10.  The spleen, composed of red and white pulp, acts somewhat like a filter for
the blood. The red pulp is the site where old and injured red blood cells are
destroyed. The white pulp contains concentrations of lymphocytes.
 The lymph nodes are distributed throughout the Body (neck, axilla, femoral,
and popliteal area). They are connected by lymph channels and capillaries,
which remove foreign material from the lymph before it enters the
Bloodstream.
 Spleen
 Lymph Nodes:

11.  Defense against microbes (Viruses, Fungi, Bacteria, fungi)
 Defense against the growth of tumor cells
 kills the growth of tumor cells
 Homeostasis
– Destruction of abnormal or dead cells (e.g. dead red or
white bloodcells, antigen-antibody complex)
Role of the immune system:

12. RheumatoidArthritis

13. INTRODUCTION

14. RHEUMATOID ARTHRITIS
 Rheumatoid arthritis, or RA, is an autoimmune and
inflammatory disease, which means that the immune
system attacks healthy cells in the body by mistake,
causing inflammation (painful swelling) in the
affected parts of the body. RA mainly attacks the
joints, usually many joints at once..
 1:3 times greater incidence in women in the child
bearing age
 It is a result of immunologic abnormalities.
 Characterized by exacerbations and remissions.

15.  Chronic inflammation of synovial membrane
 Cellular proliferation and damage to the
microcirculation
 Synovial membrane becomes irregular
 Swelling, stiffness and pain
 Cartilage and bone destruction
 Ankylosis or fusing of joints
 Ligaments and tendons also affected

18. CAUSES OF RA
 Autoimmune disease
 Develops after an immune response
 Bacterium, mycoplasma or virus
 Original response is IgG mediated
 May destroy microorganism
 Other antibodies produced (IgM or IgG)
 Self-directed antibodies called rheumatoid factors (RF)
form against IgG.
 Genetic predisposition
 Women affected more
 Various cytokines contribute to the inflammation

19. PATHOPHYSIOLOGY - RA
 The autoimmune reaction primarily occurs in the synovial tissue.
 Phagocytes produces enzymes within joint.
 The enzymes break down collagen causing:
 Edema
 Proliferation of the synovial membrane
 Ultimately pannus formation
 Pannus (granulation tissue) covers synovium destroys cartilage
and erodes the bone.
 Spreads throughout joint
 The consequence is loss of articular surfaces and joint motion.
 RA is an erosive deforming arthritis

21. JOINTS INVOLVED IN RA

22. CLINICAL MANIFESTATION
 PRESENTATION:
 Joint pain
 Swelling
 Warmth
 Erythema
 Lack of function (limited ROM)
 Joint stiffness specially in the morning, lasting for
more than one hour. Difficult to flexsion

23.  Begins with small joints in the hands & feet, and wrists.
 As the disease progresses, the knees, shoulders, hips, elbows and
ankles are involved.
 Symptoms are bilateral and symmetric (same joint on both
sides of body).
 Palpation of the joints reveals spongy or boggy tissue.
 Limitation in function can occur when there is active inflammation
in the joints.
 Joints that are hot, swollen, and painful are not easily moved.
 The patient tends to protect these joints through
immobilization.

24.  Immobilization for extended periods in addition to erosion lead
to contractures and deformity
 Rheumatoid nodules may occur in patients with advanced RAand
these nodules are usually nontender and movable in the
subcutaneous tissue
 They usually appear over bony prominences such as the elbow,
are varied in size, and can disappear spontaneously

25.  Other extra-articular features include:
 Dry eyes
 Dry mouth
 Vasculitis
 Neuropathy
 Scleritis / episcleritis
 Pericarditis / pleurisy
 Splenomegaly/ hepatomegaly
 Lymphadenopathy
 Weight loss, anorexia ,fever, & fatigue

26. Class I: No Limitations
Class II: Adequate for Normal Activities Despite
Joint Discomfort & Limitation of Movement
Class III: Inadequate for Most Self-Care and
Occupational Activities
Class IV: Largely or Wholly Unable to Manage Self-

27. ASSESSMENT & DIAGNOSTIC FINDINGS
 Laboratory findings:
 Rheumatoid factor (RF) is positive in more than 80% of
patients.
 (ESR) The erythrocyte sedimentation rate
elevated
 C-reactive protein elevated.
 Anemia may also present.
 Arthrocentesis (joint aspiration) shows synovial fluid that is
cloudy, milky, or dark yellow and contains numerous
leukocytes.
 X-ray joints shows characteristic bony erosions
and narrowed joint spaces.

28. Nursing Assessment
The assessment of a patient with RA can contribute to its diagnosis.
 History and physical exam. The history and physical examination
address manifestations such as bilateral and symmetric stiffness,
tenderness, swelling, and temperature changes in the joints.
 Extra-articular changes. The patient is also assessed for extra-
articular changes and these include weight loss, sensory
changes, lymph node enlargement, and fatigue

29. Nursing Diagnosis
Bases on the assessment data, the major nursing diagnoses appropriate for the
patient are:
 Acute and chronic pain related to inflammation and increased disease activity,
tissue damage, fatigue, or lowered tolerance level.
 Fatigue related to increased disease activity, pain, inadequate sleep/rest,
deconditioning, inadequate nutrition, and emotional stress/depression
 Impaired physical mobility related to decreased range of motion,
muscle weakness, pain on movement, limited endurance, lack or improper use of
ambulatory devices.
 Self-care deficit related to contractures, fatigue, or loss of motion.
 Disturbed body image related to physical and psychological changes and
dependency imposed by chronic illness.
 Ineffective coping related to actual or perceived lifestyle or role changes.

30. Nursing Care Planning & Goals
The major goals for a patient with RA are:
 Improvement in comfort level.
 Incorporation of pain management techniques into daily life.
 Incorporation of strategies necessary to modify fatigue as part of the
daily activities.
 Attain and maintain optimal functional mobility.
 Adapt to physical and psychological changes imposed by the
rheumatic disease.
 Use of effective coping behaviors for dealing with actual or
perceived limitations and role changes.

31. Nursing Interventions
 Relieving Pain and Discomfort
 Provide a variety of comfort measures (eg, application of heat or cold; massage,
position changes, rest; foam mattress, supportive pillow, splints; relaxation
techniques, diversional activities).
 Administer anti-inflammatory, analgesic, and slow-acting antirheumatic
medications as prescribed.
 Individualize medication schedule to meet patient’s need for pain management.
 Encourage verbalization of feelings about pain and chronicity of disease.
 Teach pathophysiology of pain and rheumatic disease, and assist patient to
recognize that pain often leads to unproven treatment methods.
 Assist in identification of pain that leads to use of unproven methods of treatment.
 Assess for subjective changes in pain.

32.  Reducing Fatigue
 Provide instruction about fatigue: Describe relationship of disease
activity to fatigue; describe comfort measures while providing them;
develop and encourage a sleep routine (warm bath and relaxation
techniques that promote sleep); explain importance of rest for
relieving systematic, articular, and emotional stress.
 Explain how to use energy conservation techniques
(pacing, delegating, setting priorities).
 Identify physical and emotional factors that can cause fatigue.
 Facilitate development of appropriate activity/rest schedule.
 Encourage adherence to the treatment program.
 Refer to and encourage a conditioning program.
 Encourage adequate nutrition, including source of iron from food and
supplements.

33.  Increasing Mobility
 Encourage verbalization regarding limitations in mobility.
 Assess need for occupational or physical therapy consultation:
Emphasize range of motion of affected joints; promote use of
assistive ambulatory devices; explain use of safe footwear; use
individual appropriate positioning/posture.
 Assist to identify environmental barriers.
 Encourage independence in mobility and assist as needed:
Allow ample time for activity; provide rest period after activity;
reinforce principles of joint protection and work simplification.
 Initiate referral to community health agency.

34.  Facilitating Self Care
 Assist patient to identify self-care deficits and factors that interfere
with ability to perform self-care activities.
 Develop a plan based on the patient’s perceptions and priorities on
how to establish and achieve goals to meet self-care needs,
incorporating joint protection, energy conservation, and work
simplification concepts: Provide appropriate assistive devices;
reinforce correct and safe use of assistive devices; allow patient to
control timing of self-care activities; explore with the patient different
ways to perform difficult tasks or ways to enlist the help of someone
else.
 Consult with community health care agencies when individuals have
attained a maximum level of self-care yet still have some deficits,
especially regarding safety.

35.  Improving Body Image and Coping Skills
 Help patient identify elements of control over disease symptoms and treatment.
 Encourage patient’s verbalization of feelings, perceptions, and fears.
 Identify areas of life affected by disease. Answer questions and dispel possible
myths.
 Develop plan for managing symptoms and enlisting support of family and friends to
promote daily function.
 Monitoring and Managing Potential Complications
 Help patient recognize and deal with side effects from medications.
 Monitor for medication side effects, including GI tract bleeding or irritation, bone
marrow suppression, kidney or liver toxicity, increased incidence
of infection, mouth sores, rashes, and changes in vision. Other signs and
symptoms include bruising, breathing problems, dizziness, jaundice, dark urine,
black or bloody stools, diarrhea, nausea and vomiting, and headaches.
 Monitor closely for systemic and local infections, which often can be masked by
high doses of corticosteroids.

36.  Teaching Points
 Focus patient teaching on the disease, possible changes related to it,
the prescribed therapeutic regimen, side effects of medications,
strategies to maintain independence and function, and safety in the
home.
 Encourage patient and family to verbalize their concerns and ask
questions.
 Address pain, fatigue, and depression before initiating a teaching
program, because they can interfere with patient’s ability to learn.
 Instruct patient about basic disease management and necessary
adaptations in lifestyle.

37.  Continuing Care
 Refer for home care as warranted (eg, frail patient with significantly limited
function).
 Assess the home environment and its adequacy for patient safety and management
of the disorder.
 Identify any barriers to compliance, and make appropriate referrals.
 For patients at risk for impaired skin integrity, monitor skin status and also instruct,
provide, or supervise the patient and family in preventive skin care measures.
 Assess patient’s need for assistance in the home, and supervise home health aides.
 Make referrals to physical and occupational therapists as problems are identified
and limitations increase.
 Alert patient and family to support services such as Meals on Wheels and local
Arthritis Foundation chapters.
 Assess the patient’s physical and psychological status, adequacy of symptom
management, and adherence to the management plan.
 Emphasize the importance of follow up appointments to the patient and family.

38.  Evaluation
Expected outcomes include:
 Improved comfort level.
 Incorporated pain management techniques into daily life.
 Incorporated strategies necessary to modify fatigue as part of the daily
activities.
 Attained and maintained optimal functional mobility.
 Adapted to physical and psychological changes imposed by the
rheumatic disease.
 Used effective coping behaviors for dealing with actual or perceived
limitations and role changes.

39.  Discharge and Home Care Guidelines
Patient teaching is an essential aspect of discharge and home care.
 Disorder education. The patient and family must be able to explain
the nature of the disease and principles of disease management.
 Medications. The patient or caregiver must be able to describe the
medication regimen (name of medications, dosage, schedule pf
administration, precautions, potential side effects, and desired effects.
 Pain management. The patient must be able to describe and
demonstrate use of pain management techniques.
 Independence. The patient must be able to demonstrate ability to
perform self-care activities independently or with assistive devices.

40.  Documentation Guidelines
 The focus of documentation include:
 Client’s description of response to pain.
 Specifics of pain inventory.
 Expectations of pain management.
 Acceptable level of pain.
 Manifestations of fatigue and other assessment findings.
 Degree of impairment and effect on lifestyle.
 Level of function, ability to participate in specific or desired activities.
 Functional level and specifics of limitations.
 Needed resources and adaptive devices.
 Available and use of community resources.
 Observations, presence of maladaptive behavior, emotional changes, level of independence.
 Prior medication use.
 Plan of care.
 Teaching plan.
 Response to interventions, teachings, and actions performed.
 Attainment or progress towards desired outcomes.
 Modifications to plan of care.
 Long term needs.

41. MEDICAL MANAGEMENT
 (NSAID) Non-Steroidal Anti-inflammatory for quick control
of joint inflammation but cannot use for long term due to side
effects (Osteoporosis, cataracts, weight gain, insulin
resistance, dyslipidemias)
 Corticosteroids
 (DMARD) Disease Modifying Anti-Rheumatic Drugs
 Methotrexate is the gold standard in the treatment of RA
because of its success in improving disease parameters (ie,
pain, tender and swollen joints, quality of life).
 Hydroxychloroquine or Sulfasalazine -for mild disease, to
reduce inflammation
 Biologic therapies: such as tocilizumab (Actemra),
certolizumab (Cimzia)- target specific immune mediators of
RA such as tumor necrosis factor (TNF).

42. COMPLICATIONS - RA
 Extrasynovial rheumatoid nodules develop on:
 Cardiac valves
 Lungs
 Eyes (retinal degeneration)
 Spleen
 Rheumatoid Vasculitis thrombosis & infarction
 Ankylosis (joint fixation) leads to loss of ability to carry
out ADL
 Joints appear red, swollen, tender, with deformity (e.g.,
swan neck deformity of fingers)

43. PULMONARY NODULES

45.  Ulcerative colitis is a recurrent ulcerative &
inflammatory disease of the mucosal &
submucosal layers of the colon & rectum.
 The peak incidence is between 30 & 50 years of
age.
 10% to 15% of the patients develop carcinoma of
the colon.

46. ETIOLOGY
 Genetic predisposition.
 Environmental factors may trigger disease (viral or
bacterial pathogens, dietary).
 Immunologic imbalance or disturbances.
 Defect in intestinal barrier causing hypersensitive
mucosa & increased permeability.
 Defect in repair of mucosal injury, which may develop
into a chronic condition.

47. PATHOPHYSIOLOGY:-
Etiological factors
Superficial mucosa of colon
Diffuse inflammations, or shedding of the colonic epithelium.
Bleeding occurs
Ulcerations.
(The mucosa becomes edematous & inflamed )
The disease process usually begins in the rectum & spreads proximally
to involve the entire colon.

48. CLINICAL MANIFESTATIONS:-
 Diarrhea
 painful straining
 Increased bowel sounds
 There often is weight loss, fever, dehydration, hypokalemia,
anorexia, nausea & vomiting, iron-deficiency anemia
 Crampy abdominal pain.
 Anal area may be irritated & reddened; left lower abdomen may be
tender on palpation.
 There is tendency for the patient experience remissions &
exacerbations.
 Increased risk of developing colorectal cancer.
 May inhibit extracolonic manifestations of eye (irritis), joint
(polyarthritis), & skin complaints (erythema nodosum, pyoderma
gangrenosum).

49. DIAGNOSTIC EVALUATION:-
Diagnosis is based on a combination of laboratory, radiologic,
endoscopic, & histologic findings.
Laboratory Tests:-
 Stool examination to rule out enteral pathogens; fecal analysis
positive for blood during active disease.
 Complete blood count- hemoglobin & hematocrit may be low due to
bleeding; WBC may be increased.
 Elevated erythrocyte sedimentation rate (ESR).
 Decreased serum levels of potassium, magnesium, & albumin may
be present.
 Barium enema to assess extent of disease & detect Pseudopolyps,
carcinoma, & strictures.

51.  Flexible proctosigmoidoscopy/colonoscopy findings reveal
mucosal erythema & edema, ulcers, inflammation that
begins distally in the rectum & spreads proximally for
variable distances.
 CT scan can identify complications such as toxic
megacolon.
 Rectal biopsy –
differentiates from other inflammatory
diseases or cancer.

52. General Measures:-
 Bed rest, I.V. fluid replacement, clear liquid diet.
 For patients with severe dehydration & excessive
diarrhea, fluid may be recommended to rest the intestinal
tract & restore nitrogen balance.
 Treatment of anemia- iron supplements for chronic
bleeding, blood replacement for massive bleeding.

53. Drug Therapy
 Sulfasalazine (Azulfidine)- mainstay drug for acute & maintenance
therapy. Given orally & is systemically absorbed.
 Oral salicylates, such as mesalamine (Pentasa), olsalazine
(Dipentum)
 Mesalamine enema available for protosigmoiditis; suppository for
proctitis.
 Corticosteroids- treated with 5-aminosalicylic acid preparations to
benefit from their potential steroid-sparing effects.
 Immunosuppressive drugs- purine analogues, 6-mercaptopurine,
azathioprine may be indicated when patient is refractory or
dependent on corticosteroids.
 Antidiarrheal medications may be prescribed to control diarrhea,
rectal urgency & cramping, abdominal pain; not routinely ordered-
treat with caution.

54. I. Noncurative approaches (possible curative, reconstructive procedure
at later date):
a)Temporary loop colostomy for decompression if toxic megacolon
present without perforation.
b)Subtotal colectomy, ileostomy, & Hartmann’s pouch.
c)Colectomy with ileorectal anastomosis.

55. II. Reconstructive procedures – curative:
 Total proctocolectomy with permanent end-ileostomy.
 Total proctocolectomy with continent ileostomy
 Total colectomy with ileal reservoir- anal (or ileal
reservoir-distal rectal) anastomosis – procedure of
choice. Multiple reservoir shapes can be surgically
created; however, the J-shaped pouch (reservoir) is the
easiest to construct.
 The ultimate surgical goal is to remove the
 entire colon & rectum to cure patient of ulcerative
colitis.

56. COMPLICATIONS
 Perforation, hemorrhage
 Toxic megacolon- fever, tachycardia, abdominal distention,
peritonitis, leukocytosis, dilated colon on abdominal X-ray – life-
threatening
 Abscess formation, stricture, anal fistula
 Malnutrition, anemia, electrolyte imbalance
 Skin lesions (erythema nodosum, pyoderma gangrenosum)
 Arthritis, ankylosing spondylitis
 Colon malignancy
 Liver disease (sclerosing colagitis)
 Eye lesions (conjunctivitis)
 Growth retardation in prepubertal children
 Possible infertility in females.

57. NURSING MANAGEMENT

58. Assessment
 Review nursing history for patterns of fatigue & over-work,
tension, family problems that may exacerbate symptoms.
 Assess food habits & use of any dietary or herbal supplements used
as alternative therapies that may have a bearing on triggering
symptoms (milk intake may be a problem). Many patient use
vitamins, herbs & homeopathic remedies without realizing the
effect on bowel function.
 Determine number & consistency of bowel movements, any rectal
bleeding present.
 Listen for hyperactive bowel sounds; assess weight

59. Nursing Diagnoses
 Chronic pain r/t disease process
 Imbalanced Nutrition: less than body requirement r/t diarrhea, nausea
& vomiting
 Deficient fluid volume r/t diarrhea & loss of fluid & electrolytes
 Risk for infection r/t disease process, surgical procedures
 Ineffective coping r/t fatigue, felling of helplessness, & lack of
support system.

60. Nursing Intervention
 Promoting Comfort:-
 Follow prescribe treatment of reducing or eliminating food & fluid &
instituting parenteral feeding or low reside diets to the intestinal tract.
 Give sedatives & tranquilizers, as prescribed, not only to provide
general rest , but also to slow peristalsis.
 Be aware of skin breakdown around anus.
 Cleanse the skin gently after each bowel movement.
 Apply a protective emollient such as petroleum jelly etc.
 Relieve painful rectal spasms
 Report any evidence of sudden abdominal distention
 Reduce physical activity
 Provide commode or bathroom next to bed because urgency of
movement may be problem.

61. Diet plans for ulcerative colitis
 Foods to eat
Foods that you may be able to consume with UC include:
 Low fiber fruits such as bananas, honeydew melon, cooked or peeled
fruits, avocado, and mango
 Non-cruciferous vegetables such as potatoes, sweet potatoes,
cucumbers, and carrots
 Refined grain foods such as white pasta, white rice, oatmeal, and
certain breads
 Omega-3 fatty acid-rich foods such as salmon, mackerel, and
walnuts
 Low fat protein sources such as fish, chicken, lamb, turkey, and eggs

62.  Foods to avoid
 Insoluble fibers, which are found in raw cruciferous vegetables
and the skins and peels of fruits
 High fiber foods such as broccoli, cabbage, Brussels sprouts,
and cauliflower
 Some meats, including red meat and processed meats
 Lactose products such as cow’s milk, cheese, and ice cream
 Sugar alcohols, which might be found in sugar-free products
such as chewing gums and mints
 Acidic fruits such as oranges, grapefruits, grapes, and tomatoes
 High fat foods such as butter, creams, and fried and highly
processed foods
 Certain beverages such as alcohol, soda, coffee, and tea

63.  Maintain fluid Balance:-
 Maintain accurate intake & output records
 Check weight daily
 Monitor serum electrolytes, & report abnormalities.
 Observer for decrease skin turgor, dry skin, oliguria, decreased
temperature, weakness, increase hemoglobin, hematocrit, BUN, &
specific gravity, which all are signs of fluid loss leading to
dehydration.
 Minimizing Infection & Complications:-
 Give antibacterial drugs as prescribed.
 Administer corticosteroids as prescribed.
 Provide conscientious skin care after severe diarrhea.
 Administer prescribed therapy to correct existing anemia.
 Observe for signs of colonic perforation & hemorrhage – abdominal
rigidity, distention, hypotension, tachycardia.

64. Home Care Considerations:-
 Pouchitis:-
 Patient undergoing one of the continent restorative procedure (Kock,
or ileal reservoir & anal anastomosis) must be alert for a common
late postoperative complication called pouchitis.
 The symptoms include increased stool output, cramps & malaise.
 It is thought to be related to stasis within the pouch/ reservoir &
usually responds to metronidazole .
 Assess for these symptoms & notify health care provider.

65.  Food Blockage:-
 Patient with a temporary or permanent ileostomy must be alert for
signs & symptoms of a food blockage.
 This is a mechanical blockage of undigested foodstuffs at the level
of the fascia.
 It is most likely to occur in the first 6 weeks postoperatively when
the bowel is edematous.
 Symptoms may include spurty, watery stoolwith strong odor,
decreased or no stool output, abdominal discomfort, cramping or
bloating, & stomal swelling. Nausea & vomiting are late symptoms
& requires immediate attention.

66.  Treatment includes:
 Avoiding solid foods & drinking clear liquids when symptoms
occur. Patient with ileostomies must never take laxatives.
 Applying a pouching system with a larger opening to allow for
stomal swelling.
 Gently massaging the abdomen around the stoma & pulling the
knees to chest & rocking the body back & forth.
 A warm shower or bath may help with relaxation.
 If the blockage lasts for more than 2 to 3 hours or if
nausea/vomiting occurs, seek medical attention immediately

67.  If the blockage lasts for more than 2 to 3 hours or if
nausea/vomiting occurs, seek medical attention immediately
 It is best to instruct the patient how to prevent a food blockage by
limiting certain foods the first few months after surgery – Chinese
vegetables, skins & seeds, fatty meats, been hulls, popcorn & other
foods that do not digest well.
 Instruct the patient to avoid problem foods, chew food well, drink
plenty of fluids while eating, eat possible problem foods in small
amounts, & reintroduce problem foods slowly into the diet.

68.  Patient Education & Health Maintenance:-
 Teach patient about chronic aspect of ulcerative colitis & each
component of care prescribed.
 Encourage self-care in monitoring symptoms, seeking annual
checkup, & maintaining health.
 Alert patient to possible postoperative problems with skin care,
aesthetic difficulties, & surgical revisions.
 Encourage patient to share experiences with others undergoing
similar procedures.

69. AIDS
(Acquired Immunodeficiency syndrome)

70. Definition of HIV:-
• Human Immunodeficiency Virus, Thevirus compromises the
body’s ability to handle disease and causes AIDS.
• Acquired Immune Deficiency Syndrome, It is related to HIV, but
they are not one in the same. A person has AIDS only in the final
stages of HIV, after the immune system becomes unable to defend
itself against foreign invaders like bacteria, other viruses, and
allows the development of certaincancers

71.  The window period
• The window period is the period of time between initial infection of HIV
and development of a positive antibody test for HIV. Although antibodies
will usually be detected within 3 to 6 months, the window period can last
up to a year
 HIV Transmission
• HIV is transmitted in body fluids containing HIV and/or
infected Tlymphocytes. These fluids include
 Blood and blood product
 Seminal fluid
 Vaginal secretions
 Amniotic fluid
 Breast milk

72.  Pathophysiology:
 Viruses are intracellular parasites. HIV belongs to a group of
viruses known as retroviruses. These viruses carry their
genetic material in the form of ribonucleic acid (RNA) rather
than deoxyribonucleic acid (DNA). As can be seen in Figure
1, HIV consists of a viral core containing the viral RNA that
is surrounded by an envelope consisting of glycoproteins (gp)
that protrude.
 For HIV to enter the targeted cell, the membrane of the viral
envelope must be fused with the plasma membrane of the
cell, a process mediated by the envelope glycoproteins of
HIV

74.  The HIV life cycle is complex and consists of a number of
steps (Fig. 2). First, the HIV GP120 and GP41 attach to the
uninfected CD4 cell surface (receptor) and fuse with the cell
membrane. Second, the viral core contents are emptied into the
host cell, a process known as uncoating, Third, HIV enzyme
reverse transcriptase copies the viral genetic material from
RNA into double-stranded DNA. Fourth, double-stranded DNA
is spliced into the cellular DNA by the action of another HIV
enzyme integrase.

75.  Fifth, using the integrated DNA or provirus as a blueprint, the cell
makes new viral proteins and viral RNA. Sixth, HIV protease cleaves
the new proteins (polyproteins). Seventh, the new proteins join the
viral RNA into new viral particles. Finally, new viral particles bud
from the cell and start the process all over

76.  Stages of HIV Disease
 The stage of HIV disease is based on clinical history, physical
examination, laboratory evidence of immune dysfunction,
signs and symptoms, and infections and malignancies The
classification system groups clinical conditions into one of
three categories denoted as A, B, or C.

77.  PRIMARY INFECTION (Clinical category A)
 During this period, there is intense viral replication and
widespread dissemination of HIV throughout the body resulting
in high levels of HIV in the blood and a dramatic drop in CD4 T
cell counts from the normal level of at least 800 cells/mm3 of
blood. Symptoms associated with the viremia range from none
to severe flu-like symptoms. Such as fever, enlarged lymph
nodes, rash, muscle aches, and headaches. Characterized by:
 Asymptomatic HIV infection
 Persistent generalized lymphadenopathy (PGL)
 Acute (primary) HIV infection

78.  HIV SYMPTOMATIC (Clinical category B)
 Category B consists of symptomatic conditions in HIV-infected
patients that are not included in the conditions listed in category C.
Examples of conditions in clinical category B include the following:
 Candidiasis, oropharyngeal (thrush) or vulvovaginal
 Cervical dysplasia (moderate or severe)/cervical carcinoma in situ
 Constitutional symptoms, such as fever (38.5C) or
diarrheaexceeding 1 month in duration
 Herpes zoster (shingles), involving at least two distinct episodes or
more than one dermatome
 Idiopathic thrombocytopenic purpura
 Pelvic inflammatory disease, particularly if complicated
bytuboovarian abscess
 Peripheral neuropathy

79.  AIDS (Category C)
 When CD4 T-cell levels drop below 200 cells/mm3 of blood,
patients are said to have AIDS. One complication of advanced
HIV infection is anemia, which may be caused by HIV,
opportunistic diseases, and medications such as:
 Candidiasis of bronchi, trachea, or lungs; esophagus
 Cervical cancer, invasive
 Coccidioidomycosis, disseminated or extrapulmonary
 Cryptosporidiosis, chronic intestinal (exceeding 1 month’s duration)
 Cytomegalovirus disease (other than liver, spleen, or lymph nodes)
 Cytomegalovirus retinitis (with loss of vision)

80.  Encephalopathy, HIV-related
 Herpes simplex: chronic ulcer(s) (exceeding 1 month’s duration);
 or bronchitis, pneumonitis, or esophagitis
 Isosporiasis, chronic intestinal (exceeding 1 month’s duration)
 Kaposi’s sarcoma
 Lymphoma, Burkitt’s immunoblastic primary, of brain
 Mycobacterium avium complex disseminated or extrapulmonary
 Mycobacterium tuberculosis, any site (pulmonaryor
extrapulmonary)
 Mycobacterium, other species or unidentified species,
disseminatedor extrapulmonary
 Pneumonia
 Progressive multifocal leukoencephalopathy
 Salmonella septicemia, recurrent
 Toxoplasmosis of brain
 Wasting syndrome due to HIV

81. Clinical Manifestations
RESPIRATORY MANIFESTATIONS
1. Shortness of breath
2. Dyspnea (labored breathing)
3. Cough
4. Chest pain
5. Fever
6. Pneumocystis carinii pneumonia (PCP), one of the first OIs
describedin association with AIDS.
7. Mycobacterium avium Complex (MAK) causes respiratory
infection but is also commonly found in the GI tract, lymph
nodes, and bone marrow.
8. Tuberculosis. Mycobacterium tuberculosis tends to occur in
injection drug users and other groups with a preexisting high
prevalence oftuberculosis (TB) infection.

82. GI MANIFESTATIONS
The GI manifestations of AIDS include
1. loss of appetite, nausea,
2. Vomiting
3. Oral and esophageal candidiasis
4. Chronic diarrhea.
5. Diarrhea is a problem in 50% to 90% of all AIDS patients.
Oral Candidiasis
A fungal infection, occurs in nearly all patients with AIDS and AIDS-
relatedconditions.
Wasting Syndrome
Wasting syndrome is part of the category C case definition for
AIDS. Diagnostic criteria include profound involuntary weight loss
exceeding 10% of baseline body weight and either chronic diarrhea
for more than 30 days or chronic weakness and documented
intermittent or constant fever in the absence of any concurrent
illness that could explain these findings.

83. ONCOLOGIC MANIFESTATIONS
1. Patients with AIDS have a higher than usual incidence of
cancer,
2. Kaposi’s sarcoma
3. certain types of B-cell lymphomas
4. invasive cervical carcinoma
5. Carcinomas of the skin, stomach, pancreas, rectum, and
bladder also occur more frequently than expected in
people with AIDS.

84. NEUROLOGIC MANIFESTATIONS
1. Central peripheral and autonomic functions.
2. Metastatic neoplasms,
3. Cerebrovascular changes,
4. Metabolic encephalopathies,
5. Inflammation atrophy, demyelination, degeneration, and necrosis.
6. Cryptococcal meningitis is characterized by symptoms such as fever,
headache, malaise, stiff neck, nausea, vomiting, mental status changes,
and seizures.
7. Blindness aphasia, paresis (slightparalysis), and death.
8. Both central and peripheral neuropathies.
9. Vascular myelopathy is a degenerative disorder affecting the lateral and
posterior columns of the spinal cord, resulting in progressive spastic
paraparesis, ataxia, and incontinence.
10. Peripheral neuropathy with pain and numbness in the extremities,
weakness, diminished deep tendon reflexes, orthostatic hypotension, and
impotence.

85. DEPRESSIVE MANIFESTATIONS
Theprevalence of depression among people with HIV
infection isunknown.
INTEGUMENTARY MANIFESTATIONS
1. Herpes zoster and herpes simplex are associated with painful vesicles
that disrupt skin integrity.
2. Molluscum contagiosum is a viral infection characterized by deforming
plaque formation.
3. Seborrheic dermatitis is associated with an indurated, diffuse, scaly
rash involving the scalp and face.
4. Folliculitis associated with dry, flaking skin or atopic dermatitis, such as
eczema or psoriasis.
ENDOCRINE MANIFESTATIONS
At autopsy, endocrine glands show infiltration and destruction from
OIs or neoplasms. Endocrine function may also be affected by
therapeuticagents.

86. GYNECOLOGIC MANIFESTATIONS
1. Persistent, recurrent vaginal candidiasis may be the first sign of
HIVinfection in women.
2. Past or present genital ulcer disease is a risk factor for the
transmissionof HIV infection.
3. Women with HIV infection are more susceptible to and have
increasedrates and recurrence of genital ulcer disease and
venereal warts.
4. Women with HIV are 10 times more likely to develop cervical
intraepithelial neoplasia than are those not infected with HIV.

87. Diagnosis:
 Physical Exam evaluate for oral candidiasis, appearance of
retina, adenopathy, skin abnormalities, respiratory
symptoms, abdominal tenderness, and signs of dementia
 Chest X ray for pneumonia, tuberculosis.
 Brain imaging if neurological symptoms are present.

88. Laboratory Tests:
1. ELISA (Enzyme link immunosorbent assay) screening test/presumptivetest
produces false positive results in people who have been exposed to parasitic
diseases such as malaria
2. Western Blot analysis confirmatory test/positive result to confirmreactive
seropositive results obtained by ELISA test
3. Polymerase Chain Reaction test (PCR) - screen for viral RNA and therefore
allow detection of the virus after very recent exposure - viral load (measures
HIV RNA in the plasma) - better predictor of risk of HIV progression than CD4
count (CD4-CD8 Ratio) - significant lowering of CD4 over CD8.
4. Immunofluorescent test Particle Agglutination test HIV Antibody tests - negative
test (HIV antibodies not detectable in the blood at the time of test) - positive test
(HIV antibodies are present in blood, person is considered HIV positive)

89. Medical Treatment:
1. AIDS drugs are medicines used to treat but not cure HIV infection. These drugs
are sometimes referred to as “anteroviral drugs” work by reducing the
replication of the virus.
2. There are 2 groups of anteroviral drugs: Reverse transcriptase inhibitors -
inhibits the enzyme “reverse transcriptase” which is needed to “copy”
information for the virus to replicate. Zidovudine (ZDV) / Azidothymidine -
Retirvir (best known drug).
3. Protease inhibitors – inhibits the enzyme protease which are needed for the
assembly of viral particles. - Saquinavir - Invarase - Ratinovir - Norvir -
Indinavir – Crixivan
4. “ Cocktail or multi drugs” (combination of three to five drugs) – are used to
prolong the latent phase - as well as reduce the viral load during the final phase
HARRT (Highly Active Anti-Retrovirus Therapy) - very effective at controlling
the virus by reducing the viral load in the blood and returning CD4 cell counts
to near normal levels

90. Prevention of HIV &AIDS
HIV Prevention try to address the three main ways of transmission:
(1) Prevention the sexual transmission of HIV.
 Use condom include female condom.
 Safe sex education.
 Male circumcision
 Health teaching sexually transmitted infection.
(2) Preventing HIV transmission through blood.
 Screening blood product.
 Reducing needle sharing.
 Stopping needle stick accident.

91. (1) Prevention mother to child transmission
 Testing the mother HIV at their third trimester and
afterdelivery their body.
 Treatment should be offered if the mother test positive.
 The baby should be tested when it is born and also
offeredtreatment if positive.

92. Nursing management
Nursing diagnosis;-
1. Diarrhea related to enteric pathogens or HIV infection
Intervention
1. Assess patient’s normal bowel habits.
2. Assess for diarrhea: frequent, loose stools; abdominal pain or cramping, volume
of liquid stools, and exacerbating and alleviating factors.
3. Obtain stool cultures and administer antimicrobial therapy asprescribed.
4. Initiate measures to reduce hyperactivity of bowel:
a. Maintain food and fluid restrictions as prescribed. SuggestBRAT diet
(bananas, rice, applesauce, tea and toast).
b. Discourage smoking.
c. Avoid bowel irritants such as fatty or fried foods, rawvegetables, and
nuts.
d. Offer small, frequent meals.
5. Administer anticholinergic antispasmodics and opioids or other
medications as prescribed.
6. Maintain fluid intake of at least 3 Lunless contraindicated.

93. 2. Ineffective airway clearance related to Pneumocystis carinii pneumonia, increased
bronchial secretions, and decreased ability tocough related to weakness and fatigue
Intervention
1. Assess and report signs and symptoms of altered respiratorystatus, tachypnea, use of
accessory muscles, cough, color and amount of sputum, abnormal breath sounds,
dusky or cyanotic skin color, restlessness, confusion, or somnolence.
2. Obtain sputum sample for culture prescribed. Administer antimicrobial therapy as
prescribed.
3. Provide pulmonary care (cough, deep breathing, postural drainage, and vibration)
every 2 to 4 hours.
4. Assist patient in attaining semi- or high Fowler’s position.
5. Encourage adequate rest periods.
6. Initiate measures to decrease viscosity of secretions:
i. Maintain fluid intake of at least 3 L per day unless
contraindicated.
ii. Humidify inspired air as prescribed.
iii. Consult with physician concerning use of mucolytic
agentsdelivered through nebulizer or IPPB treatment.
7. Perform tracheal suctioning as needed.
8. Administer oxygen therapy as prescribed.
9. Assist with endotracheal intubation; maintain ventilator settingsas prescribed.

94. 3. Imbalanced Nutrition: Less than Body Requirements
May be related to: Inability or altered ability to ingest, digest, and/or metabolize
nutrients—nausea, vomiting, increased metabolic rate and nutritional needs (fever,
infection)
Possibly evidenced by
Weight loss, decreased subcutaneous fat and muscle mass (wasting)Lack of interest
in food, aversion to eating, altered taste sensation Desired Outcomes—Client Will
Maintain weight or display weight gain toward desired goal.
INTERVENTIONS
1. Identify factors that are contributing to inability to eat, such assevere dyspnea, pain,
nausea and vomiting, copious sputum, or respiratory treatments
2. Assist with and encourage oral hygiene after emesis, after aerosol and postural
drainage treatments, and before meals.
3. Schedule respiratory treatments at least 1 hour before meals
4. Auscultate for bowel sounds. Observe and palpate for abdominal distention.
5. Provide small, frequent meals, including dry foods, such as toast or crackers, and
foods that are appealing to client

95. 4. Fatigue
May be related to: Decreased metabolic energy production,
increased energy requirements (hyper metabolic state) or Altered
body chemistry—side effects of medication, chemotherapy
Possibly evidenced by: Unremitting, overwhelming lack of
energy; inability to maintain usual routines, tiredness, Decreased
performance,impaired ability to concentrate,
Desired Outcomes/Evaluation Criteria—Client Will
- Report improved sense of energy.
- Perform ADLs, with assistance as necessary.
- Participate in desired activities at level of ability.

96. Nursing intervention:-
1. Recommend scheduling activities for periods when client has mostenergy.
2. Plan care to allow for rest periods. Involve client and SO in schedule
planning.
3. Encourage client to do whatever possible, such as perform self-care,sit in
chair, or take short walks. Provide assistance, as needed. Increase activity
level, as indicated.
4. Monitor physiological response to activity, such as changes in BP, respiratory
rate, or heart rate.
Collaborative
1. Refer to physical and/or occupational therapy.
2. Refer to community resources, such as grocery delivery, Meals
3. on Wheels, house cleaning or home maintenance services, orhome-care agency.
4. Provide supplemental oxygen, as indicated.

97. 5. Social Isolation
May be related to: Altered state of wellness, changes in physical
appearance, alterations in mental status, Perceptions of unacceptable social or
sexual behavior or values, inadequate personal resources or support systems
or Physical isolation
Possibly evidenced by
Expressed feeling of aloneness imposed by others, feelings of rejection
Absence of supportive SO—partners, family, acquaintances or friends
Desired Outcomes/Evaluation Criteria—Client Will
Social Support
1. Identify supportive individual(s).
2. Use resources for assistance.
3. Participate in activities and programs at level of ability and desire

98. Nursing Intervention:
1. Ascertain client’s perception of situation.
2.
Spend time talking with client during and between care activities.
3. Be supportive, allowing for verbalization. Treat with dignity andregard for client’s
feelings.
4. Limit or avoid use of mask, gown, and gloves when possible, such aswhen talking to
client.
5. Identify support systems available to client, including presenceof,relationship with,
immediate and extended family.
6. Explain isolation precautions and procedures to client and SO.
7. Encourage open visitation, as appropriate, telephone contacts, andsocial activities within
level of tolerance.
8. Encourage active role of contact with SO.
9. Develop a plan of action with client that looks at available resources and supports healthy
behaviors. Help client problem-solve solution to short-term or imposed isolation.
10. Be alert to verbal and nonverbal cues including withdrawal, statements of despair, and
sense of aloneness. Ask client if thoughtsof suicide are being entertained.

99. 6. Risk for Infection
May be related to: Inadequate primary defenses—broken skin, traumatized
tissue, stasis of body fluids or Depression of the immune system,
Desired Outcomes/ Patient Will:
Infection Status
- Achieve timely healing of wounds/lesions.
- Be febrile and free of purulent drainage/secretions and other signs of infectious
conditions.

100. Interventions:
1. Assess patient knowledge and ability to maintain opportunistic infection
prophylactic regimen.
2. Assess the patient’s current medications, particularly those that promote
susceptibility to infection such as corticosteroids and immune suppressive
Wash hands before and after all care contacts. Instruct patient/ to wash
hands as indicated.
3. Provide a clean, well-ventilated environment.
4. Monitor vital signs, including temperature during a lupus flare.
5. Teach the patient to look for signs and symptoms of infection, particularly
urinary and respiratory infections. (Note: The cardinal signs of infection
may be masked because of corticosteroids and antipyretic medications.
Assess respiratory rate/depth; note dry spasmodic cough on deep
inspiration, changes in characteristics of sputum, and presence of
wheezes/rhonchi.

101. 1. Examine skin/oral mucous membranes for white patches or lesions
2. Clean patient’s nails frequently.
3. Encourage the patient to eat a balanced diet with adequate calories
to help preserve the immune system.
4. Teach the patient to minimize exposure to crowds and people with
Infections or contagious illnesses.
5. Educate the patient about immunizations.
6. Check the patient’s current immunization status.
7. Teach the patient that infections can be minimized with
immunizations.
8. Encourage the patient to consult her or his doctor before considering
allergy shots or flu or pneumococcal vaccines; these medications
may induce a lupus flare.