MS CH 19 Nursing Care of Patients With Immune Disorders
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Questions and Answers

What is the primary function of IgE in hypersensitivity reactions?

  • To neutralize antigens directly
  • To trigger mast cells to release histamine (correct)
  • To stimulate the production of antibodies
  • To enhance vascular permeability only

Which of the following statements best describes a type I hypersensitivity reaction?

  • It is primarily caused by antibodies of the IgM class.
  • It is always mild and localized.
  • It does not involve any smooth muscle contraction.
  • It can result in severe systemic responses like anaphylaxis. (correct)

What happens to the body's blood vessels during a hypersensitivity reaction due to histamine release?

  • They constrict to reduce blood flow.
  • They undergo vasodilation and increased permeability. (correct)
  • They remain unchanged in size.
  • They become more resistant to antigen exposure.

Which category of hypersensitivity reactions includes conditions like rheumatoid arthritis and ulcerative colitis?

<p>Type III hypersensitivity reactions (D)</p> Signup and view all the answers

What is a common clinical test used to identify specific allergens in type I hypersensitivity?

<p>Skin scratch test (A)</p> Signup and view all the answers

In the event of a localized hypersensitivity reaction, what characteristic can be expected?

<p>Mild symptoms confined to the area (C)</p> Signup and view all the answers

What underlying condition is characterized as an immune deficiency in the context of hypersensitivity?

<p>Hypogammaglobulinemia (B)</p> Signup and view all the answers

Which of the following is NOT a listed form of a type I hypersensitivity reaction?

<p>Scleroderma (C)</p> Signup and view all the answers

Which treatment utilizes light waves to alleviate the hyper-immune response?

<p>Rhinophototherapy (B)</p> Signup and view all the answers

Anaphylaxis is related to which type of hypersensitivity reaction?

<p>Type I hypersensitivity reaction (A)</p> Signup and view all the answers

Immunotherapy for severe symptoms ceases when what condition is met?

<p>The patient has no symptoms with exposure to the allergen (C)</p> Signup and view all the answers

Atopic dermatitis is believed to be mediated by which type of antibody?

<p>IgE antibodies (C)</p> Signup and view all the answers

What is a common symptom associated with rhinophototherapy and allergic reactions?

<p>Sneezing (C)</p> Signup and view all the answers

What is the typical duration for rhinophototherapy treatment sessions?

<p>Three times a week for 3 weeks (C)</p> Signup and view all the answers

Atopic dermatitis is classified as what type of skin condition?

<p>Familial inflammatory skin response (C)</p> Signup and view all the answers

Which of the following substances is commonly linked to triggering anaphylactic reactions?

<p>Aminoglycosides (A)</p> Signup and view all the answers

What is the primary reason intravenous access is prioritized during an anaphylactic reaction?

<p>To administer IV epinephrine and vasopressors. (D)</p> Signup and view all the answers

Which of the following symptoms is indicative of neurological changes due to anaphylaxis?

<p>Profound restlessness. (A)</p> Signup and view all the answers

What immediate treatment is suggested for severe respiratory symptoms during anaphylaxis?

<p>Oxygen therapy or mechanical ventilation. (C)</p> Signup and view all the answers

What triggers urticaria in patients?

<p>Type I hypersensitivity reaction. (B)</p> Signup and view all the answers

Which of the following best describes the treatment approach for anaphylaxis after initial stabilization?

<p>Consider allergen testing for future prevention. (D)</p> Signup and view all the answers

During an anaphylactic reaction, which of the following diagnostic tests is typically unnecessary?

<p>Skin prick testing. (C)</p> Signup and view all the answers

What is a common patient manifestation of impaired gas exchange during anaphylaxis?

<p>Cyanosis. (A)</p> Signup and view all the answers

What role do antihistamines play in the treatment of anaphylaxis?

<p>They reduce inflammation and alleviate mild symptoms. (C)</p> Signup and view all the answers

What is the primary goal of the therapeutic measures for Mrs. Barnes' condition?

<p>To avoid the antigen triggering the reaction (C)</p> Signup and view all the answers

Which of the following medications is used for long-term treatment through allergen desensitization?

<p>Cinryze (C)</p> Signup and view all the answers

Which symptom is NOT associated with urticaria and angioedema?

<p>Scarring lesions (D)</p> Signup and view all the answers

What aspect of patient care is crucial in preventing skin integrity impairment related to allergic reactions?

<p>Educating about skin assessments and hygiene (B)</p> Signup and view all the answers

Which medication is classified as a selective bradykinin B2 receptor antagonist?

<p>Icatibant (C)</p> Signup and view all the answers

What is the recommended action for patients who may scratch their lesions?

<p>Keep fingernails short and clean (A)</p> Signup and view all the answers

Which of the following symptoms indicates a more serious physiological problem rather than anxiety or panic?

<p>Skin hypersensitivity reactions (D)</p> Signup and view all the answers

Which of the following tools can confirm the diagnosis related to Mrs. Barnes' symptoms?

<p>Comprehensive history and physical examination (C)</p> Signup and view all the answers

What is one of the main therapeutic measures for thyroid overstimulation?

<p>Corticosteroids (B)</p> Signup and view all the answers

Which subgroup of the population experiences thyroid gland issues more frequently?

<p>Both B and C (A)</p> Signup and view all the answers

What complication arises due to the appearance of autoantibodies in thyroid disorders?

<p>Destruction of thyroid cells (A)</p> Signup and view all the answers

What symptoms might initially indicate hyperthyroidism?

<p>Tremors and heat intolerance (B)</p> Signup and view all the answers

What is a critical aspect of nursing care for patients with potential anemia?

<p>Providing frequent rest periods (A)</p> Signup and view all the answers

What lifelong treatment might be required for a patient with thyroid issues?

<p>Vitamin B12 injections (A)</p> Signup and view all the answers

How should patients be educated regarding their treatment if they are prescribed vitamin B12 injections?

<p>They must understand the importance of not missing injections (B)</p> Signup and view all the answers

Which statement is true regarding the development of hypothyroidism from hyperthyroidism?

<p>Symptoms of hyperthyroidism may go unrecognized and lead to hypothyroidism. (C)</p> Signup and view all the answers

What is the primary rationale for teaching patients to keep their fingernails short and clean?

<p>It reduces the risk of damage or infection from scratching. (A)</p> Signup and view all the answers

Why is cotton recommended for clothing over affected areas in patients with contact dermatitis?

<p>Cotton is less irritating and allows for better airflow. (A)</p> Signup and view all the answers

Which method is suggested to alleviate itching instead of scratching?

<p>Gentle rubbing or applying pressure. (A)</p> Signup and view all the answers

What is an expected outcome when evaluating whether the patient's skin remains intact?

<p>Skin remains intact, and any lesions present are healing. (D)</p> Signup and view all the answers

What should the evaluation of health maintenance focus on regarding patient education?

<p>Patient's knowledge about their condition and treatment plan. (B)</p> Signup and view all the answers

Which intervention is intended to reduce itching in contact dermatitis patients?

<p>Advise tepid baking soda or colloidal oatmeal baths. (A)</p> Signup and view all the answers

What is the primary reason for using clean white cotton clothing for patients at night?

<p>To ensure a protective barrier that is less irritating. (A)</p> Signup and view all the answers

How should lesions be evaluated in patients diagnosed with contact dermatitis?

<p>Evaluate the healing process and the presence of lesions. (B)</p> Signup and view all the answers

What is the primary rationale for teaching patients to apply gentle rubbing or pressure instead of scratching?

<p>It minimizes skin trauma. (B)</p> Signup and view all the answers

Which intervention is specifically designed to prevent impaired skin integrity during sleep?

<p>Applying clean, white cotton clothing. (B)</p> Signup and view all the answers

What should be a key focus during the evaluation of whether the patient's skin remains intact?

<p>Checking for the presence of lesions. (D)</p> Signup and view all the answers

Which of the following is NOT an expected evaluation outcome for a patient with contact dermatitis?

<p>New lesions appearing during treatment. (B)</p> Signup and view all the answers

What is the primary goal when teaching a patient ways to reduce itching associated with contact dermatitis?

<p>To minimize pruritus and skin irritation. (A)</p> Signup and view all the answers

What rationale justifies the use of tepid baking soda baths for patients experiencing itching from contact dermatitis?

<p>They aid in drying up vesicles. (D)</p> Signup and view all the answers

Which of the following interventions is aimed at reducing the likelihood of infection due to scratching?

<p>Teaching the patient to use clean, short nails. (C)</p> Signup and view all the answers

When evaluating the results of applying interventions for contact dermatitis, which element is critical for assessing effectiveness?

<p>Rate of skin healing over time. (A)</p> Signup and view all the answers

What role does intrinsic factor play in the body?

<p>It aids in the absorption of vitamin B12 in the ileum. (D)</p> Signup and view all the answers

What complication is associated with long-term use of immunosuppressant medications?

<p>Higher risk of developing infections. (B)</p> Signup and view all the answers

What symptom should immunosuppressed patients be particularly vigilant about reporting?

<p>A low-grade fever. (A)</p> Signup and view all the answers

What is the effect of intrinsic factor antibodies on vitamin B12 absorption?

<p>They decrease the binding sites for vitamin B12. (B)</p> Signup and view all the answers

Which action is crucial for an immunosuppressed patient to reduce their risk of infection?

<p>Avoiding contact with sick individuals. (C)</p> Signup and view all the answers

Which of the following symptoms is NOT typically associated with vitamin B12 deficiency due to intrinsic factor issues?

<p>Impaired digestion. (A)</p> Signup and view all the answers

What is a potential outcome of a vitamin B12 deficiency?

<p>Decreased production of red blood cells. (B)</p> Signup and view all the answers

What familial link is commonly observed with the autoimmune form of pernicious anemia?

<p>There is a strong genetic predisposition. (A)</p> Signup and view all the answers

What are potential consequences of exposure to latex for health care workers?

<p>Fatal anaphylactic reactions (D)</p> Signup and view all the answers

What is essential for preventing recurrence in patients with contact dermatitis?

<p>Patient recognition of the causative agent (D)</p> Signup and view all the answers

What is a special measure that may be taken in medical facilities for patients with latex allergies?

<p>Preparing special latex-free kits (D)</p> Signup and view all the answers

What diagnostic test is primarily associated with transplant rejection?

<p>Biopsy (C)</p> Signup and view all the answers

What is the expected outcome for transplants if the immune response considers the tissue as foreign?

<p>Potential rejection of the transplant (A)</p> Signup and view all the answers

What is a therapeutic measure for minimizing the risk of transplant rejection?

<p>Preventive preoperative preparation with medications (A)</p> Signup and view all the answers

What is a potential consequence if latex allergy protocols are not followed?

<p>A possible development of life-threatening anaphylaxis (D)</p> Signup and view all the answers

What should be assessed during data collection for a patient with contact dermatitis?

<p>Symptoms and causative agent identification (A)</p> Signup and view all the answers

What is the primary characteristic of perennial allergic rhinitis compared to seasonal allergic rhinitis?

<p>Symptoms are constant throughout the year. (B)</p> Signup and view all the answers

Which symptom is not typically observed in patients with allergic rhinitis?

<p>Sticky earwax (A)</p> Signup and view all the answers

What role do serum IgE levels play in the context of allergic rhinitis?

<p>They correlate with disease severity. (D)</p> Signup and view all the answers

Which therapeutic measure is essential in managing the itch-scratch cycle associated with allergic skin reactions?

<p>Antipruritics (B)</p> Signup and view all the answers

What physiological change occurs in the nasal mucosa during an allergic rhinitis reaction?

<p>Local tissue edema (A)</p> Signup and view all the answers

Which factor is most likely to be considered when assessing the presence of an infection in a patient with allergic rhinitis?

<p>Clinical culture and sensitivity tests (D)</p> Signup and view all the answers

Which of the following statements about the nasal mucosa in allergic rhinitis is accurate?

<p>It becomes pale and edematous. (D)</p> Signup and view all the answers

Which treatment option is specifically mentioned as being effective for skin dryness in allergic conditions?

<p>Alpha Keri oil as a lubricant (B)</p> Signup and view all the answers

What is a primary treatment option for managing long-term allergic reactions in patients like Mrs. Barnes?

<p>Immunotherapy for allergen desensitization (C)</p> Signup and view all the answers

Which of the following medications is used to build up a patient's C1-INH for managing symptoms?

<p>C1-esterase inhibitor ecallantide (Berinert) (B)</p> Signup and view all the answers

What is a key preventive measure for a patient with lesions due to allergic reactions?

<p>Keeping fingernails short and clean (D)</p> Signup and view all the answers

Which symptom is characteristic of angioedema compared to urticaria?

<p>Dermal swelling (A)</p> Signup and view all the answers

What role do antihistamines play in the management of allergic symptoms?

<p>They inhibit the action of histamines (B)</p> Signup and view all the answers

When assessing Mrs. Barnes, which vital sign indicates a potential concern related to her condition?

<p>Pulse rate of 102 beats per minute (C)</p> Signup and view all the answers

Which clinical test may be performed to confirm the diagnosis associated with Mrs. Barnes' symptoms?

<p>Skin testing for specific antigens (C)</p> Signup and view all the answers

What is an expected outcome for managing a patient's risk for impaired skin integrity related to allergic reactions?

<p>The patient's skin remains intact (D)</p> Signup and view all the answers

What is the role of mast cells in the process of type I hypersensitivity reactions?

<p>They release histamine and other mediators during the second exposure. (D)</p> Signup and view all the answers

What is a notable characteristic of the skin reaction observed during a type I hypersensitivity response?

<p>Presence of redness, vesicles, and eventual crusting. (D)</p> Signup and view all the answers

Which of the following accurately describes the initial immune response during the first exposure to an allergen?

<p>Helper T cells activate B cells to produce specific antibodies. (D)</p> Signup and view all the answers

What inflammatory mediators are primarily involved in the allergic response after re-exposure to an allergen?

<p>Histamine and prostaglandins. (D)</p> Signup and view all the answers

Which statement best describes the eventual progress of dermatitis associated with type I hypersensitivity?

<p>It can result in thickening of the skin known as lichenification. (C)</p> Signup and view all the answers

During a typical allergic skin test, what is the outcome indicating a positive reaction?

<p>Redness, vesicle formation, and pruritus. (C)</p> Signup and view all the answers

What is the significance of memory cells in type I hypersensitivity reactions?

<p>They store long-term immunological information for quicker reactivation upon re-exposure. (C)</p> Signup and view all the answers

What process occurs in the skin as a result of an allergic reaction, leading to a localized hypersensitivity response?

<p>Redness, edema, and the formation of crusting lesions. (B)</p> Signup and view all the answers

Which of the following statements describes perennial allergic rhinitis?

<p>It is characterized by symptoms present throughout the year. (B)</p> Signup and view all the answers

What physiological change occurs in the nasal mucosa during an allergic rhinitis episode?

<p>Vasodilation and local tissue edema occur. (D)</p> Signup and view all the answers

Which symptom is commonly associated with allergic rhinitis?

<p>Itchy, red eyes and profuse watery rhinorrhea. (B)</p> Signup and view all the answers

In patients with allergic rhinitis, elevated serum IgE levels correlate with which aspect of the condition?

<p>The severity of the allergic symptoms. (D)</p> Signup and view all the answers

Which of the following therapeutic measures is specifically aimed at reducing the itch-scratch cycle in allergic rhinitis?

<p>Antipruritics. (D)</p> Signup and view all the answers

The presence of 'allergic shiners' in patients with allergic rhinitis is primarily due to what mechanism?

<p>Vascular congestion in the maxillary sinuses. (D)</p> Signup and view all the answers

What primary cells are involved in the necrosis associated with a type IV hypersensitivity reaction?

<p>Macrophages (D)</p> Signup and view all the answers

Which treatment strategy is commonly employed for managing dry and inflamed skin in allergic rhinitis patients?

<p>Warm soaks followed by emollient application. (B)</p> Signup and view all the answers

Which of the following is the most common irritant responsible for causing contact dermatitis?

<p>Poison ivy (B)</p> Signup and view all the answers

What is the most immediate treatment required during an anaphylactic reaction to prevent respiratory and cardiac arrest?

<p>Epinephrine IV (B)</p> Signup and view all the answers

What diagnostic approach is utilized to rule out other conditions similar to allergic rhinitis?

<p>A detailed history and physical examination. (D)</p> Signup and view all the answers

In the context of contact dermatitis, T memory cells are formed after how many days of initial exposure to an allergen?

<p>7 to 10 days (B)</p> Signup and view all the answers

Which of the following symptoms is most closely associated with the hypotension caused by increased capillary permeability during anaphylaxis?

<p>Tachycardia (A)</p> Signup and view all the answers

Which physiological effect does the generalized smooth muscle spasm in anaphylaxis primarily contribute to?

<p>Bronchial narrowing (B)</p> Signup and view all the answers

What is the primary therapeutic measure used to treat symptoms of contact dermatitis?

<p>Topical corticosteroids (B)</p> Signup and view all the answers

In the context of anaphylaxis, which complication has the highest likelihood of directly resulting from airway obstruction?

<p>Cardiac arrest (D)</p> Signup and view all the answers

What is a serious health concern for healthcare workers related to latex exposure?

<p>Latex allergy (D)</p> Signup and view all the answers

What is a potential consequence of fluid shifting from vessels to the interstitium during anaphylaxis?

<p>Increased heart rate (B)</p> Signup and view all the answers

What type of immune response is primarily responsible for the symptoms observed in type IV hypersensitivity?

<p>Cell-mediated response (C)</p> Signup and view all the answers

Which of these treatments is indicated if severe respiratory compromise occurs during anaphylaxis?

<p>Mechanical ventilation (B)</p> Signup and view all the answers

Which of the following diagnostic tests is NOT typically used for contact dermatitis?

<p>Blood test (B)</p> Signup and view all the answers

When experiencing anaphylaxis, what mechanism leads to cramping, diarrhea, and nausea?

<p>Intestinal smooth muscle spasms (A)</p> Signup and view all the answers

What is the characteristic response at the site of contact with an allergen in contact dermatitis?

<p>Presence of red and pruritic vesicles (D)</p> Signup and view all the answers

What is the primary reason intravenous access is prioritized when treating anaphylaxis?

<p>To deliver epinephrine rapidly (A)</p> Signup and view all the answers

Which treatment specifically helps prevent the breakdown of any C1 inhibitor present in allergic reactions?

<p>Cinryze (C)</p> Signup and view all the answers

What is a key characteristic of the edema associated with urticaria and angioedema?

<p>It lasts longer than typical urticaria eruptions. (B)</p> Signup and view all the answers

Which medication is NOT classified as a treatment modality for acute symptoms of allergic reactions?

<p>Immunotherapy (B)</p> Signup and view all the answers

What type of skin care education is important to minimize the risk of infection from scratching lesions?

<p>Keep fingernails short and clean. (B)</p> Signup and view all the answers

Which of the following medications acts as a selective bradykinin B2 receptor antagonist?

<p>Icatibant (D)</p> Signup and view all the answers

What aspect of therapeutic measures is crucial for preventing impaired skin integrity during an allergic reaction?

<p>Assessing and documenting skin and lesions. (D)</p> Signup and view all the answers

Which class of medication is primarily used to relieve symptoms associated with allergic reactions?

<p>Antihistamines (D)</p> Signup and view all the answers

Which of the following statements accurately describes the diagnostic process for allergic conditions?

<p>Skin testing may be performed to identify specific antigens. (B)</p> Signup and view all the answers

What is the expected outcome when monitoring a patient's respiratory status during treatment for laryngeal edema?

<p>The patient will maintain clear lung fields without any respiratory distress. (B)</p> Signup and view all the answers

Which of the following practices is recommended to prevent allergen exposure for patients with allergies?

<p>Cover heat registers with filters and frequently vacuum. (D)</p> Signup and view all the answers

What action should be taken to relieve pruritus in patients with atopic dermatitis?

<p>Use humidification and apply cool soaks to affected areas. (D)</p> Signup and view all the answers

What is a critical teaching point regarding the use of an epinephrine autoinjector for patients with environmental allergies?

<p>Administer the autoinjector into the thigh when symptoms are severe. (A)</p> Signup and view all the answers

How should a nurse respond if a patient demonstrates changes in mentation while monitoring respiratory status?

<p>Assess for potential hypoxia or anxiety-related issues. (B)</p> Signup and view all the answers

What is the purpose of positioning a patient in a high-Fowler's or semi-Fowler's position?

<p>To improve ventilation and decrease upper airway edema. (A)</p> Signup and view all the answers

Which strategy should be emphasized for managing stress in patients with urticaria?

<p>Implementing relaxation techniques and stress management. (D)</p> Signup and view all the answers

What is the primary goal when monitoring a patient's vital signs in the context of fluid volume deficiency?

<p>To maintain blood pressure, pulse, and urine output within normal limits (D)</p> Signup and view all the answers

Which symptom is commonly monitored to identify early problems in patients experiencing dyspnea?

<p>Use of accessory muscles for breathing. (B)</p> Signup and view all the answers

Which symptom is most commonly associated with hypovolemia that should be reported to the healthcare provider?

<p>Irritability (B)</p> Signup and view all the answers

In managing deficient fluid volume, which intervention is least effective?

<p>Restricting all fluid intake (D)</p> Signup and view all the answers

What type of hypersensitivity reaction is illustrated by the potential adverse effects of latex gloves?

<p>Type IV hypersensitivity (B)</p> Signup and view all the answers

What is the recommended fluid replacement strategy in a patient experiencing gastrointestinal fluid loss?

<p>Administering hypotonic glucose-electrolyte solutions (B)</p> Signup and view all the answers

Which sign should a nurse monitor for potential signs of hypovolemia?

<p>Elevated heart rate (A), Muscle cramps (C)</p> Signup and view all the answers

What should be avoided when maintaining IV fluids in a patient suspected of fluid volume deficiency?

<p>Making unilateral decisions about fluid choices (C)</p> Signup and view all the answers

What common intervention is suggested to alleviate nausea in patients with fluid volume deficiency?

<p>Administering antiemetics as ordered (D)</p> Signup and view all the answers

Flashcards

Hypersensitivity Reactions

Immune system response that causes injury to the body by overreacting.

Type I Reaction

Hypersensitivity reaction where a positive reaction occurs when exposed to an allergen.

Scratch Test

Used to identify specific allergens causing allergic reactions.

Histamine

Substance released by mast cells causing vasodilation, increased permeability, mucus, and smooth muscle contraction during an allergic response.

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Anaphylaxis

A severe form of Type I hypersensitivity reaction that can cause a widespread response.

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Allergic Rhinitis

A type of allergic reaction affecting the nasal passages, creating symptoms like allergies in the nose.

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Localized Reaction

Mild allergic reaction limited to the area of exposure.

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Systemic Reaction

A widespread allergic reaction affecting the entire body.

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Anaphylaxis

A severe, widespread allergic response

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Rhinophototherapy

Light waves treat symptoms of hyper-immune response.

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Atopic Dermatitis

Chronic inflammatory skin response; often called eczema.

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Type I Hypersensitivity

Allergic reaction mediated by IgE antibodies.

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Allergy Shots

Immunotherapy for severe allergic symptoms.

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Environmental Antigen

Substances in the environment that trigger allergies.

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Substances triggering anaphylaxis

Certain medications, anesthetics, and hormones.

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Symptoms of anaphylaxis

Symptoms include sneezing, itching, runny nose.

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Anaphylaxis Symptoms

Includes apprehension, drowsiness, profound restlessness, headache, and potential seizures, along with diffuse skin redness and warmth.

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Anaphylaxis Treatment Priority

Establishing intravenous access for epinephrine, vasopressors, fluids, and oxygen administration is crucial.

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Urticaria Cause

A Type I hypersensitivity reaction triggered by IgE antibodies reacting with antigens, causing mast cell release, especially histamine.

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Anaphylaxis Diagnosis

Based on physical assessment and patient/significant other history.

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IV Epinephrine Use

Used in anaphylaxis to treat symptoms like low blood pressure by increasing blood pressure.

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Diagnostic Tests During Anaphylaxis

Limited to tests needed to guide treatment, such as arterial blood gasses or ECG monitoring.

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LPN/LVN Role in Anaphylaxis

LPN/LVN should actively support symptom management, anticipate needed support members, and follow instructions, and monitor patient response to treatment.

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Respiratory Support in Anaphylaxis

Severe cases may need tracheostomy or intubation with mechanical ventilation.

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Mrs. Barnes' Symptoms

Symptoms include elevated temperature (99.2°F), low blood pressure (102/58 mm Hg), rapid pulse (102 beats per minute), and elevated respiratory rate (26 per minute). These may indicate an allergic reaction.

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Possible Causes

Potential causes of Mrs. Barnes' symptoms include allergic reactions (such as angioedema, urticaria) and other immune-system disorders.

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Additional Information Needed

Further details needed to diagnose Mrs. Barnes' condition include a comprehensive history, physical exam, and potentially skin tests, confirming the type of reaction.

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Allergic Reaction Treatment

Treatment typically involves avoiding the allergen, using antihistamines and corticosteroids, and potentially immunotherapy for long-term management.

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Angioedema

A type of allergic reaction, characterized by swelling of the skin and mucous membranes, lasting longer than typical urticaria.

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C1-INH

A protein that helps regulate the immune response, specifically involved in preventing inappropriate activation of immune factors.

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Cinryze

A medication used to increase levels of C1-INH, which can help reduce allergic inflammation by supporting the body's natural inhibitors.

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Impaired Skin Integrity

A potential risk posed when the skin doesn't maintain its integrity due to inflammatory reactions like allergic responses.

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Skin Integrity Risk

Risk of skin damage related to allergic reactions and itching.

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Skin Lesions

Physical skin changes or sores caused by an allergic reaction.

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Short Nails

Keeping fingernails short helps prevent skin damage from scratching.

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Cotton Clothing

Wearing cotton allows air to circulate, helps with itching and reduces irritation.

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Gentle Rubbing

Using gentle pressure instead of scratching to reduce skin trauma.

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Baking Soda Baths

Tepid baths containing baking soda, oatmeal baths, or cool washcloths/baths reduce itching.

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Health Maintenance

Following a plan to reduce inflammation and episodes related to the allergic reaction.

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Knowledge of Treatment

Understanding the cause, symptoms, and treatment plan of the allergy.

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Thyroid enlargement (goiter)

An enlarged thyroid gland, often a symptom of underlying conditions like autoimmune disorders or hyperthyroidism.

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Hyperthyroidism

A condition where the thyroid gland produces excessive hormones leading to symptoms like restlessness and weight loss.

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Autoimmune Cause of Hypothyroidism

Immune system attacks the thyroid gland, slowing its hormone production, causing hypothyroidism.

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Vitamin B12 Therapy

Treatment for certain conditions, often lifelong, to prevent symptoms.

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Hypothyroidism Symptom Progression

Initial signs might be missed as hyperthyroid symptoms; progresses into slow thyroid hormone production

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Initial Hyperthyroid Symptoms

Restlessness, tremors, chest pain, increased appetite, diarrhea, moist skin, heat intolerance, and weight loss.

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Idiopathic Autoimmune Hemolytic Anemia

A condition where the immune system destroys red blood cells.

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Eight Times More Common in Females

The likelihood of developing this condition is significantly higher in females than in males.

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Type I Hypersensitivity

An allergic reaction triggered by exposure to an allergen, resulting in an immediate immune response.

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Local Reaction

An allergic reaction confined to the area of contact with the allergen.

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Scratch Test

A method used to identify specific allergens by exposing a patient's skin to small amounts of different allergens.

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Anaphylactic Reaction

Severe, potentially life-threatening allergic reaction involving the whole body.

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Allergen

A substance that triggers an allergic reaction.

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Mast Cell

Cells that release histamine and other chemicals in response to allergens.

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Angioedema

Swelling of the blood vessels in the skin or mucous membranes.

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Histamine

Substance that causes inflammation and other allergy symptoms.

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Allergic Rhinitis

The most common allergy, characterized by symptoms like sneezing, runny nose, and itchy eyes.

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Perennial Allergic Rhinitis

Allergic rhinitis symptoms that occur throughout the year.

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Seasonal Allergic Rhinitis

Allergic rhinitis symptoms that occur during specific seasons.

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Causative Antigens

Environmental and airborne substances that trigger allergic reactions.

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Pathophysiology of Allergic Rhinitis

An antigen-antibody reaction; causing decreased ciliary action; increased mucous secretions; vasodilation, and local tissue edema.

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Signs and Symptoms of Allergic Rhinitis

Varying intensity; sneezing, nasal itching, runny nose, itchy eyes, pale/cyanotic/edematous nasal mucosa, "allergic shiners"

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Diagnostic Tests for Allergic Rhinitis

No specific tests for diagnosis; requires detailed history and physical exam.

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Therapeutic Measures for Allergic Rhinitis

Focus on symptom relief; antipruritics, luke warm soaks, emollients/lubricants, topical corticosteroids.

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Latex Allergy

An allergic reaction to natural rubber latex, a common material in healthcare.

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Anaphylactic Reactions

Severe, potentially fatal allergic reactions involving the entire body.

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Latex-Free Kits

Kits containing common supplies that are not made with latex.

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Transplant Rejection

Immune system response to transplanted tissue or organ, treating it as foreign material.

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Diagnostic Tests (Transplant)

Methods like biopsies, scans, and blood tests used to evaluate the success of organ transplants.

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Transplant Prevention

Measures like preoperative medication, transfusions, and radiation aimed at reducing the risk of rejection.

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Contact Dermatitis

Skin inflammation caused by direct contact with an irritant or allergen.

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Patient History (Dermatitis)

Important data collection in diagnosing dermatitis—identifying the causative agent and understanding the patient's awareness of the cause.

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Mrs. Barnes' Symptoms

Elevated temperature (99.2°F), low blood pressure (102/58 mm Hg), rapid pulse (102 bpm), and elevated respiratory rate (26 breaths/min).

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Possible Causes

Potential causes include allergic reactions (such as angioedema, urticaria) and other immune system disorders.

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Additional Information Needed

A complete history, physical exam, and possibly skin tests are needed to identify the specific cause of the reaction.

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Allergic Reaction Treatment

Treatment usually involves removing the allergen, using antihistamines and corticosteroids, and possibly immunotherapy.

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Angioedema

Swelling of the skin and mucous membranes, often due to an allergic reaction, lasting longer than urticaria.

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C1-INH

A protein that helps regulate the immune system and prevents inappropriate immune responses, specifically by preventing the breakdown of any C1 inhibitor.

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Cinryze

A medication that increases C1-INH levels, helping reduce allergic inflammation by supporting the body's natural inhibitors.

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Impaired Skin Integrity

Risk of the skin not maintaining its integrity due to inflammatory reactions and scratching, especially during allergic responses.

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Risk for Impaired Skin Integrity

The likelihood of a patient's skin not staying intact, potentially due to an allergic reaction and itching.

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Skin Lesions

Changes or sores on the skin caused by an allergic reaction.

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Short Nails

Keeping fingernails short to prevent scratching and skin damage.

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Cotton Clothing

Wearing cotton clothing over the affected area to allow air circulation and reduce itching and irritation.

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Gentle Rubbing

Using gentle pressure instead of scratching to minimize skin trauma.

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Baking Soda Baths

Tepid baths with baking soda, colloidal oatmeal, or cool washcloths to reduce itching.

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Ineffective Health Maintenance

Lack of understanding or following a plan to reduce inflammation and allergic reaction episodes.

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Knowledge of Treatment

Understanding the cause, symptoms, and treatment plan of the allergy.

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Intrinsic Factor Antibodies

Antibodies that target intrinsic factor, a protein crucial for vitamin B12 absorption.

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Vitamin B12 Deficiency

A condition resulting from impaired vitamin B12 absorption, affecting red blood cell production.

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Immunosuppressant Medications

Drugs that suppress the immune system, crucial for transplant patients.

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Infection Risk

Increased risk of infection in someone on immunosuppressant medications due to weakened immunity.

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Pernicious Anemia (Autoimmune)

A type of anemia where the body's immune system attacks intrinsic factor, impacting vitamin B12 absorption and leading to red blood cell shortage.

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Infection Signs/Symptoms

Important for immunosuppressed patients: low-grade fever, potential symptoms masked by steroids.

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Long-Term Transplant Success

Depends on strict adherence to immunosuppressant medication regimen.

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Avoiding Infection

Reduced risk for immunosuppressed patients by avoiding people with infections (like colds).

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Allergic Rhinitis

A common allergy affecting the nasal passages, causing symptoms like sneezing and runny nose.

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Perennial Allergic Rhinitis

Allergic rhinitis symptoms that occur year-round.

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Seasonal Allergic Rhinitis

Allergic rhinitis symptoms that occur during specific seasons.

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Causative Antigens (Allergic Rhinitis)

Environmental and airborne substances triggering allergic reactions.

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Pathophysiology (Allergic Rhinitis)

An antigen-antibody reaction leading to decreased ciliary action, increased mucus, vasodilation, and tissue swelling.

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Signs and Symptoms (Allergic Rhinitis)

Varying intensity; include sneezing, nasal itching, runny nose, itchy eyes, pale/cyanotic/swollen nasal mucosa, and "allergic shiners".

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Diagnostic Tests (Allergic Rhinitis)

No specific tests; Diagnosis relies on a detailed history and physical examination.

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Therapeutic Measures (Allergic Rhinitis)

Focus on symptom relief; including antipruritics, lukewarm soaks, emollients/lubricants, and topical corticosteroids.

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Anaphylactic Reaction

A severe, life-threatening allergic reaction affecting the whole body.

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Signs and Symptoms of Anaphylaxis

Sudden, life-threatening signs like smooth muscle spasms (causing respiratory issues), and capillary permeability increase (leading to hypotension and tachycardia).

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Immediate Treatment for Anaphylaxis

Establishing IV access for epinephrine, vasopressors, fluids, and administering oxygen is crucial for treating anaphylaxis.

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Profound Complications of Anaphylaxis

Respiratory and cardiac arrest are the most severe consequences of an anaphylactic reaction.

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Systemic Release of Histamine

Introduction of an allergen at a systemic level triggers mast cells to release histamine and other mediators, leading to widespread effects.

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Mast Cells and IgE

IgE antibodies, produced from prior sensitization, attach to mast cells throughout the body, making them sensitive to allergens.

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Bronchial Narrowing in Anaphylaxis

Smooth muscle spasms during anaphylaxis cause bronchial narrowing, leading to respiratory symptoms such as stridor, wheezing, and dyspnea.

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Treatment Measures for Respiratory Compromise

Severe respiratory compromise during anaphylaxis may require interventions like tracheostomy or endotracheal intubation and mechanical ventilation.

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Mrs. Barnes' symptoms

Elevated temperature (99.2°F), low blood pressure (102/58 mm Hg), rapid pulse (102 bpm), and elevated respiratory rate (26 breaths/min).

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Possible causes of symptoms

Allergic reactions (angioedema, urticaria) or other immune system issues.

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Additional info needed

Detailed medical history, physical exam, and potentially skin tests to identify the specific trigger.

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Allergic reaction treatment

Avoiding the trigger, using antihistamines and corticosteroids, possibly immunotherapy for long-term management.

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Angioedema

Swelling of skin/mucous membranes, lasting longer than typical hives (urticaria).

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C1-INH

A protein regulating the immune system, preventing improper immune responses, specifically stopping the breakdown of C1 inhibitor.

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Cinryze

Medication increasing C1-INH levels, helping reduce allergic inflammation by supporting the body's natural inhibitors.

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Impaired skin integrity

Risk of skin damage/broken skin related to allergic reactions and itching.

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Impaired Gas Exchange

A nursing diagnosis related to breathing problems, such as swelling in the voice box (laryngeal edema).

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Expected Outcome (Impaired Gas Exchange)

Patient maintains clear lungs and free of trouble breathing.

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Monitor Respiratory Effort

Check breathing rate, depth, and how hard the patient is working to breathe to find issues early.

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Patient Positioning (Impaired Gas Exchange)

Position the patient sitting up in a chair or slightly angled to improve breathing and reduce throat swelling.

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Anxiety related to dyspnea

Anxiety caused by shortness of breath or difficulty breathing.

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Epinephrine Autoinjector

A medicine used for severe allergic reactions and is given to help manage a reaction.

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Environmental Antigen

Substance in the environment that might cause an allergic reaction.

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Teaching Plan (Atopic Dermatitis)

Instructions to help manage skin inflammation, including preventing infections, moisturizing skin, and managing itchiness.

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Type IV Hypersensitivity

A delayed allergic reaction where sensitized T lymphocytes react with an antigen, causing tissue damage.

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Contact Dermatitis

Skin inflammation caused by direct contact with an irritant or allergen, later triggering a reaction by T-cells.

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Haptens

Small chemicals that bind to skin proteins and trigger an immune response later.

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T Memory Cells

Immune cells that form after initial contact with an allergen, enabling quicker reactions in subsequent exposures.

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Latex Allergy

Allergic reaction to natural rubber latex; common for healthcare workers.

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Diagnostic Tests (Dermatitis)

Methods used to identify contact dermatitis cause, including skin biopsy, patch testing, and patient history.

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Therapeutic Measures (Dermatitis)

Treatment focusing on symptom relief, including antihistamines, topical corticosteroids, and systemic corticosteroids for severe cases.

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Common Irritants (Dermatitis)

Poison ivy, poison oak, and latex are common triggers for contact dermatitis.

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T cell types

T cells are a type of white blood cell that plays a crucial role in the immune response. Three main types are T-helper cells, cytotoxic T cells, and T-suppressor cells.

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Type IV Hypersensitivity

A delayed hypersensitivity reaction that occurs typically 24-72 hours after exposure to an antigen. This response involves different T-cells.

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Fluid Volume Deficit

A condition where the body loses more fluids than it takes in, leading to dehydration and potentially harmful effects.

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Pain Rating Scale

A scale from 0 to 10 used to measure the intensity and severity of pain, to guide decisions on pain management.

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Hypovolemia

Low blood volume, often characterized by signs such as restlessness, weakness, and postural hypotension (low blood pressure when standing).

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Fluid Imbalance

An issue when the amount of fluids entering and leaving the body are not equal, leading to potential health problems.

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Analgesics

Pain relievers, sometimes prescribed to help manage pain symptoms. Often used in combination with other treatments.

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Oral Replacement Therapy

Using beverages or solutions that contain electrolytes to replace lost fluids such as water and sports drinks.

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Study Notes

Learning Outcomes

  • Explain the immunological mechanism for the four types of hypersensitivities.
  • Explain the pathophysiology of disorders of the immune system.
  • Identify the etiologies, signs, and symptoms of immune system disorders.
  • Plan nursing care for patients undergoing tests for immune system disorders.
  • Describe current medical treatment for immune system disorders.
  • List data collected when caring for patients with disorders of the immune system.
  • Explain factors that alter or influence the self-recognition portion of the immune system.
  • Plan nursing care for patients with disorders of the immune system.
  • Evaluate effectiveness of nursing interventions.

Key Terms

  • anaphylaxis
  • angioedema
  • ankylosing spondylitis
  • histamine
  • urticaria

Hypersensitivity Reactions (Type I)

  • Anaphylactic reaction is an immediate reaction to a specific antigen.
  • Previous exposure (sensitization) is required.
  • IgE antibodies attach to mast cells throughout the body.
  • Subsequent exposure triggers mast cells to release histamine.
  • Histamine causes vasodilation, increased vascular permeability, mucous production, and smooth muscle contraction.
  • Localized reactions are mild and remain local.
  • Systemic reactions are massive and widespread.

Allergic Rhinitis

  • Allergic rhinitis is a result of an antigen-antibody reaction.
  • Ciliary action decreases, and mucous secretions increase.
  • Vasodilation and local tissue edema occur.
  • Signs and symptoms include sneezing, nasal itching, runny nose, and itchy red eyes.

Atopic Dermatitis (Eczema)

  • A familial, chronic inflammatory skin response.
  • Not typical for a type I hypersensitivity reaction.
  • Specific antigen is not usually identified.
  • Symptoms include pruritus, edema, and extremely dry skin, followed by eruptions of vesicles.

Anaphylaxis

  • Severe systemic type I hypersensitivity reaction.
  • Triggers include various antibiotics, anesthetics, hormones, and other substances (listed in Table 19.1).
  • Table 19.2 lists signs and symptoms of anaphylaxis.

Type II Hypersensitivity Reaction

  • Involves the destruction of a cell or substance with attached antigen, recognized by IgG or IgM as foreign.
  • Antigen attachment causes cell lysis or accelerated phagocytosis.
  • Hemolytic transfusion reaction examples of Type II hypersensitivity.
  • Incompatible RBC surface antigens are transfused.
  • Recipient's antibodies attach to the foreign antigens, causing rapid RBC destruction.

Type III Hypersensitivity Reaction

  • Involves immune complexes formed by IgG or IgM and antigens lodged in blood vessels.
  • Leads to inflammation, tissue damage, and necrosis.
  • Serum sickness is an example of Type III hypersensitivity.
  • Usually occurs 7-21 days after exposure.
  • Characterized by urticaria, angioedema, fever, and malaise.

Type IV Hypersensitivity Reaction (Delayed Reaction)

  • Occurs when a sensitized T lymphocyte encounters the specific antigen.
  • Macrophages and T lymphocytes cause tissue necrosis.
  • Contact dermatitis is an example of Type IV hypersensitivity.
  • Itchiness, redness and vesicles develop at exposure site.
  • Triggers include latex, poison ivy/oak, and certain chemicals.

Urticaria (Hives)

  • Type I hypersensitivity reaction triggered by antigen-stimulated IgE antibodies.
  • Raised, pruritic, and erythematous wheals on the skin., mostly on the trunk and proximal extremities.
  • Treatment depends on severity, with epinephrine in severe cases., oral or topical corticosteroids, antihistamines, or histamine blockers.

Angioedema

  • Acquired or hereditary disorders.
  • Often involves the subcutaneous layers of the skin and mucous membranes.
  • Mostly non-pruritic.
  • Caused by the buildup of bradykinin.

Transplant Rejection

  • Transplanted living tissue is seen as foreign material by the immune system.
  • Lifelong immunosuppression is needed to prevent rejection.
  • Rejection can occur at any time after transplantation.
  • Causes varying degrees of transplant rejection (signs or symptoms depend on tissue or organ).

Pernicious Anemia

  • Antibodies that destroy gastric parietal cells lead to decreased intrinsic factor production.
  • Decreased absorption of vitamin B12.
  • Weakness, loss of appetite, glossitis, and pallor often reported.
  • Macrocytic anemia is diagnosed with a blood microscopic exam.

Lupus Erythematosus (SLE)

  • Chronic inflammatory disease.
  • Genetic and environmental factors may play a role.
  • Characterized by periods of remission and exacerbation.
  • Common symptoms include butterfly rash, photosensitivity, fatigue, fever, joint pain, and kidney involvement.

Ankylosing Spondylitis

  • Chronic progressive, inflammatory disease primarily of the spine.
  • Often affects men more than women.
  • Insidious onset of lower back stiffness and pain.
  • Curvature of the lower back may flatten and upper back curve increase.
  • Positive HLA-B27 test and radiographic evidence needed for diagnosis.

Immune Deficiencies

  • Characterized by a complete or partial absence or deficiency of immune system components, resulting in increased susceptibility to infections.
  • Acquired or hereditary disorders.
  • Examples include hypogammaglobulinemia.

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Nursing Care of Patients With Immune Disorders PDF

Description

This quiz covers the immunological mechanisms of hypersensitivity reactions, including their pathophysiology and management. It focuses on nursing care, patient assessment, and treatment of immune system disorders. Test your knowledge on key terms and the nursing interventions essential for effective patient care.

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