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Nursing of Adult Patients with Medical & Surgical Conditions Care of the Patient with an Immune Disorder Nature of Immunity • Three Main Functions – Protect the body’s internal environment against invading organisms – Maintain homeostasis by removing damaged cells from the circulation – Serve as a surveillance network for recognizing and guarding against the development and growth of abnormal cells Organization of the Immune System Nature of Immunity • Inappropriate Responses of the Immune System – Hyperactive responses against environmental antigens (allergy) – Inability to protect the body, as in immunodeficiency disorders (AIDS) – Failure to recognize the body as self, as in autoimmune disorders (systemic lupus erythmatosus) – Attacks on beneficial foreign tissue (organ transplant rejection or transfusion reaction) Nature of Immunity • Innate (Natural) Immunity – First line of defense – Provides physical and chemical barriers to invading pathogens and protects against the external environment – Composed of the skin, mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina – Non-specific immunity Nature of Immunity • Adaptive (Acquired) Immunity – Second line of defense – Provides a specific reaction to each invading antigen – Protects the internal environment – Composed of thymus, spleen, bone marrow, blood, and lymph – Produces antibodies in the cells after an infection or vaccination Nature of Immunity – Macrophages (phagocytes) • Engulf and destroy microorganisms that pass the skin and mucous membrane. • Carries antigen to the lymphocytes Nature of Immunity – Lymphocytes • T Cells – 70 - 80 % of lymphocytes – Releases lymphokine to attract macrophages to the site of infection or inflammation – Responsible for cell-mediated immunity – Provide the body with protection against viruses, fungi, and parasites. • B Cells – 20 - 30% of lymphocytes – Cause the production of antibodies – Provide protection against bacteria, viruses, and soluble antigens Types of Adaptive Immunity • Humoral Immunity – Responds to antigens such as bacteria and foreign tissue – Result of the development and continuing presence of circulating antibodies in the plasma – Active Immunity • antibodies are produced by one’s own body (vaccines) – Passive Immunity • antibodies formed by another in response to a specific antigen and administered to an individual (HBIG) • Cellular Immunity – Defense against intracellular organisms – Involved in resistance to infectious disease caused by viruses and some bacteria Immune Response • Immunization – A controlled exposure to a diseaseproducing pathogen which develops antibody production and prevents disease – Provides protection for months to years Immune Response • Immunotherapy – Treatment of allergic responses that administers increasingly large doses of the offending allergens to gradually develop immunity – Preseasonal, coseasonal, or perennial – Severe side effect: Anaphylaxis Hypersensitivity • Hypersensitivity – an abnormal condition characterized by an excessive reaction to a particular stimulus • Hypersensitivity Reaction – an inappropriate and excessive response of the immune system to a sensitizing antigen • Hypersensitivity Disorders – Harmless substances such as pollens, danders, foods, and chemicals are recognized as foreign Hypersensitivity • CAUSE: – Genetic defect that allows increased production of Immunoglobulin E (IgE) – Exposures may occur by inhalation, ingestion, injection, or touch Hypersensitivity • Diagnostic Tests – History • onset, nature, and progression of symptoms • aggravating and alleviating factors • frequency and duration of signs and symptoms – Physical Exam • Assessment of skin, middle ear, conjunctiva, nasooropharynx, and lungs – Laboratory Studies • CBC, skin testing, total serum IgE levels Hypersensitivity • Medical Management – Symptom management with medications • Antihistimines--pseudoephedrine(Actifed), diphenhydramine(Benadryl), chlorpheniramine(Chloir-Trimeton), brompheniramine(Dimetapp), cetirizine(Zyrtec), loratidine(Claritin), and fexofenadine(Allegra) – Environmental control • Avoidance of the offending allergen – Immunotherapy • Allergy specific injections Anaphylaxis • Etiology/Pathophysiology – System reaction to allergens • Venoms • Drugs - penicillin • Contrast media dyes • Insect stings • Foods Anaphylaxis • Signs and Symptoms – Feelings of uneasiness to impending death – Urticaria(hives) and pruritus – Cyanosis and pallor – Congestion and sneezing – Edema of the tongue and larynx with stidor – Bronchospasm, wheezing, and dyspnea – Nausea and vomiting – Diarrhea and involuntary stools – Tachycardia and hypotension – Coronary insufficiency, vascular collapse, dysrhythmias, shock, cardiac arrest, respiratory failure, and death Anaphylaxis • Treatment – Epinephrine 1:1000 0.5 ml SQ (may repeat at 15 minute intervals) – Benadryl 50 to 100mg IM or IV – IV access – Oxygen (as ordered by physician) – Aminophylline ( as ordered) Anaphylaxis • Nursing Interventions – Assessment: • Respiratory status • Circulatory status • Vital signs • Intake and output • Mental status • Skin status • GI status status – Teaching • Avoid allergen • Use Medic-Alert ID • Administration of epinephrine Transfusion Reactions • Etiology/Pathophysiology – Reactions that occur with mismatched blood Transfusion Reactions Signs and Symptoms – Mild • Dermatitis • Diarrhea • Fever • Chills • Urticaria • Cough • Orthopnea – Moderate • Fever • Chills • Urticaria • Wheezing – Severe • Fever • Extreme Chills • Severe Urticaria • Anaphylaxis Transfusion Reactions • Treatment – Mild • Stop transfusion • Administer saline • Administer steroids, diuretics, and antihistimines as ordered • Physician may order transfusion continued at a slower rate. Transfusion Reaction • Treatment – Moderate • Stop transfusion • Administer saline • Administer antihistamines and epinephrine as ordered Transfusion Reaction • Treatment – Severe • Stop transfusion • Administer saline • Administer antihistamines and epinephrine as ordered • Return blood or blood product to lab for testing • Obtain urine specimen Delayed Hypersensitivity • Reaction occurs 24 to 72 hours after exposure • Examples include: – Poison Ivy – Tissue transplant rejection Transplant Rejection • Autograft – Transplantation of tissue from one site to another on an individual • Isograft – Transfer of tissue between genetically identical individuals (identical twins) • Allograft (homograft) – Transplantation of tissue between members of the same species • Heterograft – Transplantation of tissue from another species such as a pig or cow Transplant Rejection • Antigenetic determinants on the cells lead to graft rejection via the immune process • 7-10 days after vascularization, lymphocytes appear in sufficient numbers for sloughing to occur Transplant Rejection • Immunosuppressives – Administration of agents that interfere with the ability of immune system to respond to antigenic stimulation • Corticosteroids • Cyclosporine (Neoral, Sandimmune) • Azathioprine (Imuran) Immunodeficiency • An abnormal condition of the immune system in which cellular or humoral immunity is inadequate and resistance to infection is decreased • May cause recurrent infections, chronic infections, severe infections, and/or incomplete clearing of infections • Can be induced (chemotherapy) Autoimmune Disorders • The development of an immune response to one’s own tissues • Body is unable to distinguish “self” protein from “foreign” protein • Examples of disorder: – pernicious anemia – Guillain-Barr’e – Scleroderma – Systemic lupus erthematosus