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Chapter 19 Nursing Care of Patients with Immune Disorders

Terms in this set (125)

Type 1 hypersensitivity involves ?
the release of histamine and other mediators from mast cells and basophils .
Histamine
Chemical stored in mast cells that triggers dilation and increased permeability of capillaries.
what may a type 1 hypersensitivity reaction lead to?
* urticaria
* eczema
* angioedema
* conjunctivitis
* allergic rhinitis
* asthma
* gastroenteritis
* anaphylaxis
Anaphylaxis reaction
reaction is an immediate reaction to that occurs from a specific antigen
for a reaction to occur the patient must have had what?
previous exposure (sensitization) to the antigen.
when the immune system over reacts what dose it make
immunoglobin E IgE antibodies that attach to mast cells through out the body.
what happens when subsequent exposure occurs ?
the antigen IgE trigger mast cells to release their contents.
what happens when histamine is released?
vasodilation
bronchoconstriction
mucus secretion's
vascular permeability
systematic exposure reaction is ?
wide spread and massive
local reaction
a hypersensitive reaction that occurs at the site of treatment (at the site on an injection, for example)
allergic rhinitis
an allergic reaction to airborne allergens that causes an increased flow of mucus
what is the most common form of allergy?
allergic rhinitis
perennial allergic rhinitis
year-round allergy to environmental allergens
hay fever (allergic rhinitis)
an annual recurring inflammation of the mucous membranes of the nose and eyes which is normally caused by pollen
seasonal allergies
antigens for allergic rhinitis are
environmental and air bourn
S/S of allergic rhinitis
sneezing
nasal itching
profuse watery rhinorrhea( runny nose)
itchy red eyes
mucosa is pale, cyanotic, edematous
allergic shiners
describe the mucosa when a pt has allergic rhinitis
pale
cyanotic
edematous
allergic shiners
Darkening of the lower eyelids as a result of venous congestion in the maxillary sinus
complications of allergic rhinitis
sinusitis, nasal polyps, asthma, and chronic bronchitis.
diagnostic test for allergic rhinitis
skin testing
in-vitro allergy test
radioallergosorbant test
how dose skin testing work
it identifies the specific offending allergens to allow avoidance of the allergens .
Treatment of allergic rhinitis
- eliminating the offending environmental stimuli
- severe symptoms use corticosteroids via inhalation or nasal spray.
- internasal saline spray
- rinophotothrapy
- immunotherapy
why should a nasal corticosteroid be used with caution in the eldrly?
dries out nares
rhinophototherapy uses what to do what?
uses light waves to reduce immune response .
treatment is 3 times a week and relives symptoms of sneezing, itching, and runny nose
immunotherapy also known as allergy shots
is reserved for patients with sever or debilitating symptoms.
therapy continues until the patient is no longer having symptoms when exposed to the environmental allergen.
Atopic Dermatitis (Eczema)
chronic inflammatory skin response
what are the two theories of cause of eczema?
1. allergic response is mediated by IgE antibodies, because they are found in pts with asthma or allergic rhinitis
2. defect in epithelial cells that damages the skins protective barrier
S/S of eczema
- pruritus
- edema
-extremely dry skin
FOLLOWED BY:
- red, weeping lesions that break open, crust over and scale off.
- skin eventually thickens in affected areas
Lichenification
Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)
diagnostic test for eczema
clinical exam
serum IgE levels will be elevated
if infection is present , culture and sensitivity test
treatment of eczema
- focus is on the symptoms of pruritus and dry inflamed skin
- antipruritic - reduces itching
- lukewarm soaks followed by application of emollients and oil in water lubricant's
- topical corticosteroids -anti-inflammatory
- topical calcineurin inhibitors- reduce inflammatory response , relives itching and rash when other steroids are not effective
- topical or systemic antibiotics are prescribed if skin lesions become infected
- diluted bleach soaks 2 times a week to reduce severity of symptoms especially those with infection
- identify and eliminate the triggers
- control environment and temp & humidity
What is anaphylaxis?
severe systemic type 1 hypersensitivity reaction.
Causes of anaphylaxis drugs :
- antibiotics : cephalosporins, penicillin, sulfonamides, anticonvulsants - such as (Dilantin) , NSAIDs - such as aspirin.
Foods that can cause anaphylaxis are
eggs
nuts
shellfish
wheat
food additives: monosodium glutamate (MSG), bisulfites,
other causes:
latex, bites and stings
What can anaphylaxis cause?
respiratory arrest
cardiac arrest
S/S of anaphylaxis
GENERALIZED SMOOTH MUSCLE SPASMS:
- bronchial narrowing- stridor, wheezing, dyspnea, laryngeal edema
- abdominal cramping/ diarrhea
- nausea/ vomiting
INCREASED CAPPILARY PERMEABILITY:
- hypotension
- tachycardia
- increased respiratory symptoms
DILATION OF BLOOD VESSELS:
- further decreasing circulation volume
- increased skin temperature
- apprehension
- drowsiness
- profound restlessness
- headache
-seizure
what is increased capillary permeability?
fluid shifting from blood vessels to interstitium
interstitium
space containing interstitial fluid
diagnostic test for anaphylaxis
ABGS
ELETROCARDIOGRAM
history and physical exam
after recovery allergen testing for prevention
treatment for anaphylaxis
oxygen
iv access
epinephrine IM
vasodepressor drugs - dopamine
antihistamine drugs
corticosteroids
SEVER RESPITORY COMPERMISE:
- tracheotomy/ endotracheal intubation
- mechanical ventilation
urticaria
hives - type 1 hypersensitivity reaction
S/S of uticaria
raised lesions
pruritic, nontender and erythematous wheals on skin
concentrated on the trunk and proximal extremities
Treatment of Uticaria
oral antihistamines Benadryl
Avoid trigger in future
***severe cases:
- epinephrine
-corticosteroids
- antihistamines
*** chronic
- IgE monoclonal antibody therapy - Xolair
- acupuncture
Angioedema
swelling of the blood vessels
- is a result of vascular permeability that increases in the submucosal and subcutaneous layers.
- acquired by heredity
- caused by hypersenativity ,physical stimuli, autoimmune disease or infection, ACE INHIBITORS, NSAIDs, or C1 eserate inhibitor
S/S of angioedema
- acute localized swelling of the skin and mucosa and submucosa due to vascular leakage
*most commonly affects the face, eyes, lips
painless and non pruritic
Treatment of angioedema routine paraphyletic
C1 - INH
treatment for acute symptoms of angioedema
antihistamines
corticosteroids
Berinert
treats angioedema of the abdomen, face and throat
Haegarda
human plasma
what's used with angioedema caused by an ACE inhibitor ?
fresh frozen plasma
nursing diagnosis for type 1 hypersensitivity
impaired gas exchange
anxiety related to dyspnea
risk for impaired skin integrity related to allergic reaction
ineffective health maintenance r/t lack of knowledge to decrease inflammation and pruritus and reduce episodes of inflammation
anxiety when having anaphylactic symptoms is a sign of
airway compromise
Hemolytic transfusion reaction
IS A TYPE 2 HYPERSENSITIVITY REACTION IN WHICH INCOMPATIABLE SURFACE ANTIGENS ON RBCs ARE TRANSFUSED.
- destruction of red blood cells as a result of transfusion of incompatible blood
results of hemolytic transfusion reaction
massive amounts of cellular debris that blocks blood vessels throughout the body.
leading to ISCHEMIA AND NERCROSIS of the tissue and organs.
Life treating
What are the ABO blood types?
A, B, AB, O
Type O blood
no antigens, A and B antibodies
universal donor
- can only receive type O blood
Type AB blood
A and B antigens, no antibodies
universal recipients
Rh+
has the Rh antigen
what is the strongest antigen?
D antigen
people who are RH+ can or can not receive RH - blood ?
can receive
people with RH- blood ______ receive RH+ blood
can not
s/s of hemolytic reaction
low back or chest pain
hypotension
fever rising more than 1.8 degrees
tachycardia
tachypnea, wheezing, dyspnea
urticaria
anxiety
headache
nausea
diagnostic test for hemolytic reaction
DIRECT COOMBS TEST
- small amounts of the pts RBCs are washed
- antihuman globin is added
- if agglutination occurs (clumping) occurs an immune reaction is occurring
treatment of hemolytic reaction
antihistamines
corticosteroids
diuretics, to assist kidneys
priority nursing interventions for hemolytic reaction
- fear
- ineffective peripheral tissue perfusion
- risk for injury
prevention of hemolytic reaction steps
two nurses double check data
at bedside - double check pts name, id numbering medical record, unit of blood, pts identification bracelet, blood type in medical record on the unit of blood and on the paper work with the unit of blood.
nurses responsibilities during transfusion
vitals before transfusion, then in 15 after start, and when transfusion is complete
stay with pt the frist 15 min
if any symptoms noted - stop transfusion
- then normal saline infusion with new tubbing is started to keep vein paten.
hpc and blood bank notified
remain with the patient monitor symptoms and vitals
unused blood and tubing sent to lab
urine and blood specimens obtained and sent to lab
follow hcps orders to treat symptoms
don't discontinue iv site
Type 3 hypersensitivity
immune complexes formed by antigens and antibodies
serum sickness
type 3 hypersensitivity
reaction in which antigen antibody complexes form and lodge in small vessels
leads to inflammation , tissue damage and necrosis
*****occurs after administration of penicillin or sulfonamide
S/S of serum sickness
occur 7 to 3 weeks after exposure
**severe urticaria and angioedema***
fever
malaise
muscle soreness
arthralgia (joint pain)
splenomegaly (enlarged spelean)
nausea/vomiting/ diarrhea
lymphadenopathy (swollen lymph nodes)
diagnostic test for serum sickness
elevated WBC
elevated sedimentation rate
elevated c proteins
IgM and IgG increase
complement assay decreases
plasma cells are seen on peripheral blood smear
Treatment of serum sickness
- treat symptoms
antipyretics
analgesics
anti - inflammatory
antihistamines
epinephrine
corticosteroids
type 4 hypersensitivity
Delayed type hypersensitivity reactions.
T-cell and Macrophage mediated.
Ex: Tuberculosis
contact dermatitis
is when a substance or chemical comes into contact with skin, its absorbed and binds with skin proteins called HAPTENS
example: poison ivy , poison oak
s/s of contact dermatitis
red and pruritic with fragile vessels
infection can occur
diagnostic testing for contact dermatitis
patch testing allergens placed on patch then to skin gives indication of what pts are allergic too
biopsy
culture
Treatment of contact dermatitis
Removal of offending agent
oral/ topical antihistamines
topical drying agents
topical cortical steroids -most effective in bathing
if severe systemic corticosteroids or topical immunomodulators
transplant rejection
identification of transplanted tissue as foreign by the recipient's immune system, which responds by attacking the tissue
S/S of transplant rejection
depend on involved transplanted tissue or organ
severity of reaction, reflect the failure of the organ tissue
diagnostic tests for transplant rejection
biopsy
scans
blood tests
arteriography -dye injection used to see arteries on x ray
ultrasonography
complications of transplant rejection
total failure and loss of transplanted organ or tissue
****CAUSE OF DEATH***
is due to infection, with immunosuppression therapy asa contributing factor
priority nursing for transplant rejection
grieving
fear
deficient knowlege
autoimmune disorder
a condition in which the immune system produces antibodies against the body's own tissues
pernicious anemia (PA) pathophysiology
the body's immune system targets its own tissues . it then develops antibodies that destroy the parental cells and disrupt intrinsic factor and hydrochloric acid production.
- alters binding sites
- impairs the absorption of B12 in the ileum- deficiency results.
causing insuffient and deformed RBCs with poor oxygen carrying capacity
Causes of Pernicious Anemia
- Gastric mucosal atrophy; also causes lack of secretion of acid and digestive enzymes.
- Gastric resection and bypass: vitamin B12 not absorbed.
- Distal bowel resection or disease: impaired absorption of vitamin B12 intrinsic factor complex.
- May develop among middle-aged and elderly.
- Associated with autoantibodies against gastric mucosal cells and intrinsic factor.
s/s of pernicious anemia
increasing weakness
loss of appetite
glossitis- inflammation or infection of the tongue
pallor
irritability
confusion
numbness or tingling in the extremities
diagnostic tests for pernicious anemia
microscopic examination of RBC's
low b12
intrinsic factor antibodies and parietal cell test
methylmalonic acid levels elevated
serum cobalamin decreased
gastric secretion analysis - measures level of hydrochloric acid - low or absent indicated anemia
shilling test - 24 hr urine
enzyme linked immunosorbent assay - identifies antibody
treatment of pernicious anemia
corticosteroids
vitamin B12 therapy for life
nursing care for pernicious anemia
administer b12 as ordered
ambulation and frequent rest periods
safety
assistance with activities
Pt edu for pernicious anemia
understand b12 injections are life long
don't miss injections
periodic b12 testing / follow up appointments
Hashimoto's thyroiditis
an autoimmune disease in which the body's own antibodies attack and destroy the cells of the thyroid gland
causes of hashimoto's thyroiditis
unknown
occurs more in females ages 30- 50
and seen more with pts who have downs or turners syndromes
S&S HASHIMOTOS DISEASE initial signs
(same as hyperthyroidism)
- restlessness
- tremors
- chest pain
- increased apatite
- diarrhea
- moist skin
- heat intolerance
- weight loss
S/S of Hashimoto's thyroiditis as it progresses
enlarged thyroid gland
fatigue
bradycardia
hypotension
dyspnea
anorexia
constipation
dry skin
weight gain
sensitivity to cold
facial puffiness
slowing of mental processes
diagnostic test for hashimotos
immunofluorescent assay
serum TSH levels elevated
T3 and thyroxine levels are low
thyroid scan
Treatment of Hashimoto Thyroiditis
life long treatment of thyroxine -hormone therapy
nursing care for hashimotos
if goiter - soft diet
frequent rest periods
ted hoses
daily wt
I and o
monitor for fluid retention
Hashimoto's thyroiditis pt edu
avoid foods with iodine
diet high in fiber
during hyperthyroid phase diet should be high in protein and carbs
how long should you wait before taking levothyroxine if taking meds that interfere with the absorption
4 hrs after taking other meds that interfere
medications associated with triggering Lupus Erythematosus
diazepam
etanercept
hydralazine
rifampin
among others
Common Lupus Erythematosus Flare triggers
sunlight, fluorescent/halogen lights, stress, emotional crisis, overworked, lack of rest, infection, surgery, hormones, pregnancy/ post partum, stopping meds suddenly, allergies, immunizations, certain prescription drugs, some OTC drug:cough syrups
whats the difference between lupus and RA ?
SLE has more body organ involvement earlier in the disease
S/S of SLE
1) Fever S/S
2) Butterfly rash
3) Periungal erythema
4) Vasculitis / nephritis / peritonitis
diagnostic testing for SLE
cbc
ANA
anti - smith
anti- nDNA
anti - Ro
anti - La
ESR/CRP
24hr urine creitine clearance
uranalysis
serum creatine
kidney biopsy
Treatment of SLE
symptom management
NSAIDs
immunosuppressants
corticosteroids
antimalarial
iv immunoglobins
complications of SLE
emboli
mesenteric /intestinal vasculitis leading to obstruction, perforation, infarction
myocarditis
osteonecrosis
renal failure
sepsis
thrombocytopenia
vasculitis
priority nursing SLE
acute pain
disturbed body image
fatigue
ineffective health maintenance
Nursing care SLE
prevention of exacerbations(flare ups)
minimize sun/ uv exposure- protective clothing sunscreen sppf 70
min 8 hrs of sleep with naps during the day
range of motion exercise
warm baths in the am
heat/cold therapies
assistive devices/braces
diet
immunizations
education on coping
Discoid lupus
limited to the skin
s/s associated with lupus for pts to report
facial puffiness
foamy or Coca-Cola colored urine
ankylosing spondylitis
is a chronic progressive inflammation of the spine and sacroiliac area
can affect large limb joints
inflammatory process begins in lower region going upward
what antigen is associated with ankylosing spondylitis
human leukocyte antigen (HLA) B27
what results from ankylosing spondylitis ?
fusion of the spine
"Bamboo spine" on x-ray
Ankylosing spondylitis (chronic inflammatory arthritis: HLA-B27)
ankylosing spondylitis affects who
men late teens to age 40
s/s of ankylosing spondylitis
lower back pain/ stiffness -worse in the am
back spasms
curvature of back flattens in lower back
curvature in upper back increases
fatigue
anorexia
wt loss
positive HLA-B27
indicates ankylosing spondylitis
treatment for ankylosing spondylitis
1. Exercise program and NSAIDs
2. If NSAIDS don't work : give anti-TNF drug (infliximab / etanercept)
nursing care for ankylosing spondylitis
focuses on administration and evaluation of medications and pt edu to help reduce pain, stiffness
teach proper posture, range of motion, changing positions every 2 hrs
sleep on firm mattress with no pillow/ tin pillow
pain management - rest periods, help with ADLs , exercise
Hypogammaglobulinemia
Absence/Deficiency of One or More of Five Immunoglobulins from Defective B Cell Function
makes pt prone to infections
affecting mostly males
S&S of hypogammaglobulinemia
recurrent infections mainly strepylococcus
diagnosis of hypogammagbulina
immunoelectrophoresis
treatment of hypogammaglobulinema
aimed at minimizing infection while increasing the immune sytem function through subcutaneous injections or IV infusions of immunoglobin - fresh frozen plasma
IgA can not b replaced putting pt at risk for
pulmonary infections
nursing care for hypogammaglobulinemia
moitor for infection
any break in skin washed imeadiatly and monitored
edu on s/s
avoid crowds
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