Immune and Lymphatic Disorders - Chapter 11

• Chapter 11 addresses the care of patients with immune and lymphatic disorders.

Theory Objectives

• Identify the differences between primary and acquired immune deficiency disorders.
• Summarize the ideal actions of therapeutic immunosuppressive drugs.
• Learn treatments for HIV-positive individuals.
• Explain how pre-exposure prophylaxis reduces the risk of contracting HIV.
• Compare diagnostic tests for HIV and those used to monitor the immune status.
• Explain opportunistic infections in HIV patients, including viral, bacterial, fungal, and parasitic types.

Immune Function and Dysfunction

• Immunocompetence refers to the ability of the immune system to respond appropriately to an antigen.
• Immune deficiency occurs when the immune system is unable to respond adequately to antigens.
• Autoimmune disorders arise when the immune system attacks the body's own tissues.

Immune Deficiency Conditions

• Primary immune deficiency is an inherited genetic mutation.
• Acquired immune deficiency includes human immunodeficiency syndrome (HIV) and acquired immune deficiency syndrome (AIDS).

Therapeutic Immunosuppression

• Drug-induced immunosuppression requires a delicate balance between controlling the body's immune response and managing side effects.
• Immunosuppression is used with organ transplant recipients.
• It helps in the management of autoimmune disorders.
• It helps with non-Hodgkin lymphoma, rheumatoid arthritis, and neoplastic growths.

Diagnostic Tests and Treatment of Immune Deficiencies

• Diagnostic tests involve health history, current complaints or symptoms, and physical examination findings.
• Treatments include immune globulin (Ig), bone marrow transplant, granulocyte colony-stimulating factor (filgrastim [Neupogen]), and antimicrobial agents.

Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS)

• HIV-1 and HIV-2 are retroviruses that utilize reverse transcriptase in their pathophysiology.

HIV Transmission

• The three highest risks for becoming infected with HIV include having unprotected sex with an HIV-positive person.
• Sharing needles and syringes with an HIV-infected person is also a high risk.
• Maternal-fetal exposure can transmit HIV.

HIV Exposure Prophylaxis

• Truvada (tenofovir disoproxil fumarate and emtricitabine) is combined with safer sexual practices as pre-exposure prophylaxis (PrEP).
• Postexposure prophylaxis (PEP) is more effective when the exposure is a single episode with an HIV-positive partner.
• PEP should be initiated less than 72 hours after exposure.

HIV Prevention

• Safe sexual practices include barrier protection as well as touch and various forms of intimacy.
• The current risk of contracting HIV from a blood transfusion, blood products, or a donated organ or tissue is extremely small, about 1 in 2 million.
• Clinical trials are showing promise for a vaccine for HIV.
• Obtain accurate facts and educate others.

HIV: Signs and Symptoms

• No symptoms or flu-like symptoms may present at the start.
• Oral thrush, recurrent infections, skin disorders, night sweats, swollen lymph glands, and significant unintended weight loss are sentinel infections.

HIV Diagnosis

• Diagnosis can be confirmed using the HIV-1 Test System and OraQuick In-Home HIV test.
• Enzyme-linked immunosorbent assay (ELISA) and HIV-1 nucleic acid (NAT) tests can also be used.

Management of HIV Infection

• Initiate antiretroviral therapy (ART) if CD4 lymphocyte count is less than 350 cell/mm³.
• The World Health Organization (WHO) staging system is used.
• Antiretroviral drugs are used in treatment.

HIV Stages

• The first stage (acute HIV infection) develops within 2 to 4 weeks with flu-like symptoms, high HIV level, can be transmitted, and antibody testing is negative for about 1 1/2 months.
• The second stage (chronic HIV infection) is asymptomatic, transmittable, and usually advances to AIDS without treatment.
• The third stage (AIDS: terminal stage) severely damages the immune system, opportunistic infections and cancer occur, and without treatment life expectancy is about 3 years.

Opportunistic Infections

• Viral infections include herpes simplex virus types 1 and 2, varicella-zoster virus, cytomegalovirus, and hepatitis.
• Bacterial infections include Mycobacterium tuberculosis and Mycobacterium avium complex.
• Fungal infections include cryptococcosis, histoplasmosis, coccidiomycosis, candidiasis, and Pneumocystis jiroveci.
• Parasitic infections include toxoplasmosis and cryptosporidiosis.

Other Complications

• Wasting syndrome
• Neoplasms, including Kaposi sarcoma and lymphomas
• Neurologic complications

Other Health Issues

• There is an HIV risk in the over 50 population.
• Community education and care is important.
• HIV confidentiality and disclosure must be considered.
• Management of when a nurse is HIV positive.
• Protocols for bloodborne pathogen exposure and healthcare workers.

Autoimmune and Autoinflammatory Disorders

• The immune system reacts against the body's own cells.
• autoimmune disorders can be local, systemic, or mixed.
• General signs and symptoms usually include fever, fatigue, abdominal pain or digestive issues, swollen glands, joint pain, and swelling.
• Diagnosis includes health history, complete physical examination, and blood tests.
• Treatment and nursing management involves replacement or support of lost body function as well as therapies targeted to halt the destructive process.

Systemic Lupus Erythematosus (SLE)

• SLE is an autoimmune disease that produces abnormal antibodies that attack target tissues instead of foreign agents.
• Forms include discoid, systemic, and drug-induced.
• SLE etiology includes an abnormal reaction against proteins in the nucleus of body cells.
• Prolonged exposure to sunlight and exacerbation by drugs may cause symptoms.
• Signs and symptoms include painful or swollen joints and muscle pain, extreme fatigue, unexplained fever, and red rash usually on the face (malar or butterfly rash).
• Other symptoms are loss of hair, sensitivity to the sun, weakness and profound fatigue, mouth ulcers, poor appetite, weight loss, abnormal menses, and edema and swollen glands.
• No single test confirms a diagnosis of SLE; must have at least four of the 11 clinical presentations or laboratory test results.
• There is no cure, treatment is targeted toward symptom control or management to prevent exacerbations.
• Nursing Management requires caring for a patient with low immune response.
• Assess ability to participate in ADLs, provide pain management and assist with mobility.
• Educate the patient about the disease, and review the appropriate skin care.

Hodgkin Lymphoma

• Hodgkin Lymphoma's etiology is genetic, environmental, or a combination.
• The pathophysiology involves Reed-Sternberg cells.
• Signs and symptoms include lymphadenopathy, abdominal fullness, fatigue, night sweats, weight loss, and pruritus.
• Diagnosis, treatment, and nursing management is important.
• Definitive diagnosis is presence of Reed-Sternberg cells.
• Treatment depends on the stage and chemotherapy can be used in all stages.
• Radiation: Involved-node radiotherapy (INRT)
• Remission—disease is under control
• Nursing care should focus on symptoms the patient is currently experiencing and the side effects of the prescribed therapies.

Non-Hodgkin's Lymphoma (NHL)

• NHL is the seventh most common cancer in men and women.
• Incidence is higher in men than women.
• It is less predictable and spreads to other body sites much more rapidly than HL.
• Symptoms include unilateral, painless enlargement of a lymph node that may progress to generalized, painless lymphadenopathy, high fevers, chills, night sweats, weight loss, cough, dyspnea, chest pain, nausea, vomiting, a sense of fullness in the abdomen, and constipation.
• Hepatomegaly or splenomegaly may also occur.
• To aid in staging, CT, magnetic resonance imaging (MRI), PET, or ultrasound can be used.
• A biopsy of various body tissues may also be performed to determine the type of NHL.
• Treatment includes chemotherapy, radiation, bone marrow transplant, and surgery.

Primary Lymphedema

• It is an inherited form caused by a congenital condition in which there is deficient growth of the lymphatic system, especially in a lower extremity.
• Chiefly affects females and most often becomes apparent during the middle teens to early 20s.

Secondary Lymphedema

• Acquired form caused by an obstruction caused by trauma to the lymph vessels and nodes.
• May be caused by a mastectomy with lymph nodes removed. or extensive soft-tissue injury and scar formation.
• Parasites that enter lymph channels and block them may also cause this.
• Secondary Lymphedema Symptoms includes patients presenting with a variety of symptoms, including restricted range of motion, heavy feeling, aching discomfort, recurrent infections, and thick, hard skin.
• Regardless of the etiology, treatment goals are to minimize the impact of the disease process on the individual.

Fibromyalgia

• Fibromyalgia is a chronic systemic pain and multiple symptoms that are not caused by another source or disease.
• It affects women 10 times more than men and is seen in women ranging from 25 to 60 years of age.
• Stressors such as infection, trauma, drugs, hormonal influences, and psychological distress can trigger fibromyalgia and its related symptoms.
• Hyperalgesia—heightened response to painful stimuli
• Allodynia-pain response to nonpainful stimuli

Allergy

• Allergy is an abnormal response to certain substances and is considered a systemic immune disorder rather than a localized one.
• Hypersensitivity reaction is the body’s excessive response to a normally harmless substance.
• Allergens can enter the body in several ways and can have either a local or a systemic effect.
• Signs and Symptoms: Itchy, red, watery eyes, Soft palate pruritus, Clear rhinorrhea, Sneezing, Erythema, Edema, Dyspnea and wheezing
• Diagnosis: Patient history of reactions, Radioallergosorbent test(RAST), Skin scratch test, Patch test

Anaphylactic Reaction and Anaphylactic Shock

• IgE-mediated immune responses occur if the mast cells depend on IgE to be activated, this is triggered to produce only a localized allergic response. Examples are allergic conjunctivitis or allergy-induced asthma.
• Non-IgE allergen response: Iodine-based dyes for select radiologic studies.
• Anaphylactic Reaction and Anaphylactic Shock Signs and Symptoms: urticaria (hives), angioedema, wheals, tachycardia, decreased pulses, and a rapid drop in blood pressure, dyspnea, accumulation of mucus, and wheezing.
• The treatment of Anaphylaxis is:
  • Establish a patent airway
  • Administer oxygen
  • Administer intravenous epinephrine
  • Administer antihistamine
  • Institute measures to prevent or control shock. -Provide psychological support during the course of the syndrome and treatment.