COMMON AUTOIMMUNE DISORDERS AND ITS NURSING INTERVENTIONS

GRAVES DISEASE 1. Description a. Hyperthyroid state resulting from hypersecretion of thyroid hormones (T3 and T4) b. Characterized by an increased rate of body metabolism c. A common cause is Graves disease, also known as toxic diffuse goiter. d. Clinical manifestations are referred to as thyrotoxicosis. 2. Assessment for hyperthyroidism caused by Graves disease a. Enlarged thyroid gland (goiter) b. Palpitations, cardiac dysrhythmias, such as tachycardia or atrial fibrillation c. Protruding eyeballs (exophthalmos) d. Hypertension e. Heat intolerance f. Diaphoresis g. Weight loss h. Diarrhea i. Smooth, soft skin and hair j. Nervousness and fine tremors of the hands k. Personality changes such as irritability, agitation, and mood swings Nursing Interventions Provide adequate rest Rationale Sleep deprivation interferes with healing in many ways including its detrimental effect on our emotional health. Meditation and relaxation also offer benefits for immune system health. Reduces stimuli that may aggravate agitation, hyperactivity, and insomnia. Continued weight loss in face of adequate caloric intake may indicate failure of antithyroid therapy Aids in keeping caloric intake high enough to keep up with rapid expenditure of calories caused by hypermetablolic state Promotes rest, thereby reducing metabolic demands Stimulants can make symptoms worse, such as fast heartbeat, nervousness and problems focusing

Provide a cool and quiet environment Obtain weight daily

Provide a high calorie diet

Administer sedatives as prescribed Avoid administration of stimulants

SUBMITTED BY: DULFINA, IAN MIZZEL A. BSN-3 SUBMITTED TO: JOSEFINA S. BALOTE RN,MN

COMMON AUTOIMMUNE DISORDERS AND ITS NURSING INTERVENTIONS

Nursing Interventions Administer propranolol (inderal) as prescribed

Rationale Given to control thyrotoxic effects of tachycardia, tremors, and nervousness and is first drug of choice for acute storm. Decrease heart rate/cardiac work by blocking [betat]-adrenergic receptor sites and blocking conversion of T4 and T3. Note: if severe bradycardia develops, atropine may be required.

Administer antithyroid medications (propylthioracil, PTU) as prescribed

Blocks thyroid hormone synthesis and inhibits peripheral conversion of T4 to T3 may be definitive treatment or used to prepare patient for surgery; but effect is slow and so may not relieve thyroid storm. Note: Once PTU therapy is begun, abrupt withdrawal may precipitate thyroid crisis Acts to prevent release of thyroid hormone into circulation by increasing the amount thyroid hormone stored within the gland. May interfere with RAI treatment and may exacerbate the disease in some people. May be used as surgical preparation to decrease sized and vascularity of the gland or to treat thyroid storm. Note: should be started 1-3 after initiation of antithyroid drug therapy to minimize hormone formation from the iodine.

Administer iodine preparations as prescribed Provide a high calorie diet Aids in keeping caloric intake high enough to keep up with rapid expenditure of calories caused by hypermetablolic state Promotes rest, thereby reducing metabolic demands Stimulants can make symptoms worse, such as fast heartbeat, nervousness and problems focusing

Administer sedatives as prescribed Avoid administration of stimulants

SUBMITTED BY: DULFINA, IAN MIZZEL A. BSN-3 SUBMITTED TO: JOSEFINA S. BALOTE RN,MN

COMMON AUTOIMMUNE DISORDERS AND ITS NURSING INTERVENTIONS

Lupus
1. Description

a. Chronic, progressive, systemic inflammatory disease that can cause major organs and systems to fail b. Connective tissue and fibrin deposits collect in blood vessels on collagen fibers and on organs. c. The deposits lead to necrosis and inflammation in blood vessels, lymph nodes, gastrointestinal tract, and pleura. d. No cure for the disease is known but remissions are frequently experienced by clients who manage their care well. 2. Causes a. The cause of SLE is unknown, but is believed to be a defect in immunological mechanisms, with a genetic origin. b. Precipitating factors include medications, stress, genetic factors, sunlight or ultraviolet light, and pregnancy. c. Discoid lupus erythematosus is possible with some medications but totally disappears after the medication is stopped; the only manifestation is the skin rash that occurs in lupus. Assessment a. assess for precipitating factors
SUBMITTED BY: DULFINA, IAN MIZZEL A. BSN-3 SUBMITTED TO: JOSEFINA S. BALOTE RN,MN

b. erythema butterfly or rash of the face c. Dry,scaly, raised rash on the face or upper body d. Fever e. Weakness, malaise, and fatigue f. Anorexia g. Weight loss h. Photosensitivity i. Joint pain j. Erythema of the palms k. Anemia l. Positive antinuclear antibody (ANA) test and lupus erythematosus (LE) preparation m. Elevated erythrocyte sedimentation rate (ESR) and Creactive protein level Nursing Interventions Monitor skin integrity and provide frequent oral care Instruct the client to clean the skin with a mild soap Assist with the use of ointments and creams as prescribed Identify factors contributing to fatigue. Administer iron, folic acid, or vitamin supplements as prescribed if anemia occurs Provide a high-vitamin and high-iron diet Provide a high-protein diet if Rationale To prevent ulceration avoiding harsh and perfume substance for the rashes treatment

To prevent fatigue To prevent anemia

To enhance nutritional need To enhance nutritional needs

COMMON AUTOIMMUNE DISORDERS AND ITS NURSING INTERVENTIONS

there is no evidence of kidney disease Instruct in measures to conserve energy, such as pacing activities and balancing rest with exercise Administer topical or systemic corticosteroids, salicylates, and nonsteroidal antiinflammatory drugs as prescribed for pain and inflammation Administer medications to decrease the inflammatory response as prescribed Instruct the client to avoid exposure to sunlight and ultraviolet light Monitor for proteinuria and red cell casts in the urine Monitor for bruising bleeding and injury Assist with plasmapheris as prescribed to remove autoantibodies and immune complexes from the blood before organ damage occurs. Monitor for signs of organ involvement such as pleuritis, nephritis, pericarditis, coronary artery disease, hypertension, neuritis, anemia, and peritonitis Note that lupus nephritis occurs early in the disease process Provide supportive therapy as major organs become affected Provide emotional support and encourage the client to verbalize feelings. Provide information regarding support groups and encourage the use of community resources.

to improve general health and help prevent infection

To enhance pain relief

To reduce inflammation

To reduce the chance of exacerbation

To prevent further complications

SUBMITTED BY: DULFINA, IAN MIZZEL A. BSN-3 SUBMITTED TO: JOSEFINA S. BALOTE RN,MN

COMMON AUTOIMMUNE DISORDERS AND ITS NURSING INTERVENTIONS

Multiple Sclerosis Description 1. Multiple sclerosis is a chronic, progressive, noncontagious, degenerative disease of the CNS characterized by demyelinization of the neurons 2. It usually occurs between the ages of 20 and 40 years and consists of periods of remissions and exacerbations. 3. The causes are unknown, but the disease is thought to be the result of an autoimmune response or viral infection. 4. Precipitating factors include pregnancy, fatigue, stress, infection, and trauma. 5. Electroencephalographic findings are abnormal. 6. Assessment of a lumbar puncture indicates an increased gamma globulin level, but the serum globulin level is normal. B. Assessment 1. Fatigue and weakness 2. Ataxia and vertigo 3. Tremors and spasticity of the lower extremities 4. Parasthesias 5. Blurred vision, diplopia, and transient blindness 6. Nystagmus 7. Dysphasia 8. Decreased perception to pain, touch, and temperature 9. Bladder and bowel disturbances, including
SUBMITTED BY: DULFINA, IAN MIZZEL A. BSN-3 SUBMITTED TO: JOSEFINA S. BALOTE RN,MN

urgency, frequency, retention, and incontinence 10. Abnormal reflexes, including hyperreflexia, absent reflexes, and a positive Babinski reflex 11. Emotional changes such as apathy, euphoria, irritability, and depression 12. Memory changes and confusion. Nursing Interventions Provide energy conservation measures during exacerbation Protect the client from injury by providing safety measures Place an eye patch on the eye for diplopia Monitor for potential complications such as urinary tract infections, calculi, pressure ulcers, respiratory tract infection, and contractures Promote regular elimination by bladder and bowel training Encourage independence Assist the client to establish a regular exercise and rest program Instruct the client to balance moderate activity with rest periods Assess the need for and Rationale to avoid fatigue

to free from injury to protect the eye from any foreign bodies To prevent further complications

to facilitate elimination problems To promote self esteem To promote adequate exercise and rest To promote adequate rest

to assist in motor functioning

COMMON AUTOIMMUNE DISORDERS AND ITS NURSING INTERVENTIONS

provide assistive devices Initiate physical and speech therapy Instruct the client to avoid fatigue, stress, infection, overheating, and chilling Instruct the client to increase fluid intake and eat a balanced diet, including lowfat, high-fiber foods and foods high in potassium Instruct the client in safety measures related to sensory loss, such as regulating the temperature of bath water and avoiding heating pads Instruct the client in safety measures related to motor loss, such as avoiding the use of scatter rugs and using assistive devices Instruct the client in the selfadministration of prescribed medications. Provide information about the National multiple Sclerosis Society Rheumatoid Arthritis To address physical and speech problems to not aggravate condition Description 1. Rheumatoid arthritis is a chronic systemic inflammatory disease (immune complex disorder); the cause may be related to a combination of environmental and genetic factors. 2. Rheumatoid arthritis leads to destruction of connective tissue and synovial membrane within the joints. 3. Rheumatoid arthritis weakens the joint, leading to dislocation and permanent deformity of the joint. 4. Pannus forms at the junction of synovial tissue and articular cartilage and projects into the joint cavity, causing necrosis. 5. Exacerbations of disease manifestations occur during periods of physical or emotional stress and fatigue. 6. Vasculitis can impede blood flow, leading to organ or organ system malfunction and failure caused by tissue ischemia. B. Assessment 1. Inflammation, tenderness, and stiffness of the joints 2. Moderate to severe pain with morning stiffness lasting longer than 30 minutes 3. Joint deformities, muscle atrophy, and decreased range of motion in affected joints 4. Spongy, soft feeling in the joints 5. Low-grade temperature, fatigue, and weakness 6. Anorexia, weight loss, and anemia 7. Elevated ESR and positive rheumatoid factor 8. Radiographic study showing joint deterioration 9. Synovial tissue biopsy reveals inflammation

To have adequate nutrition and to promote healing

To promote safety and free from possible injury

To promote safety and free from possible injury

To alleviate pain

to address health conditions

SUBMITTED BY: DULFINA, IAN MIZZEL A. BSN-3 SUBMITTED TO: JOSEFINA S. BALOTE RN,MN

COMMON AUTOIMMUNE DISORDERS AND ITS NURSING INTERVENTIONS

Nursing Interventions Preserve join function Provide range-of-motion exercises Balance rest and activity Splints may be used during acute inflammation Prevent flexion contractures Apply heat or cold therapy as prescribed to joints Apply paraffin baths and massage as prescribed Encourage consistency with exercise program Use joint-protecting devices Avoid weight bearing on inflamed joints Self-care Assess the need for assistive devices such as raised toilet seats, self-rising chairs, wheelchairs, and scooters Work with an occupational therapist or healthcare provider Instruct the client in alternative strategies for providing activities of daily living Fatigue Identify factors that may contribute to fatigue Monitor for signs of anemia and administer iron, flock acid and vitamins as prescribed Monitor for medicationrelated blood loss by testing the stool for occult blood Instruct the client in measures to conserve energy, such as pacing activities and obtaining assistance when possible Disturbed body image Assess the clients reaction to the body change Encourage the client to verbalize feelings Assist the client with self-care activities and grooming

To maintain joint fuction to maintain joint motion and muscle strengthening Adequate rest may help in alleviating symptoms to prevent deformity To avoid deformity Cold may dull sensation causing less pain To relaxed the joint To improve the functioning of the joints To protect the joint to protect the joint

To prevent fatigue To prevent anemia

To prevent complications related to bleeding To improve general health and to prevent possible injury

To promote self esteem To promote self esteem To promote adequate hygiene

to facilitate mobility

to obtain assistive or adaptive devices To enhance body functions and to promote

SUBMITTED BY: DULFINA, IAN MIZZEL A. BSN-3 SUBMITTED TO: JOSEFINA S. BALOTE RN,MN