Nursing Care for Immune Disorders: Chapter 19

• Chapter 19 explores the nursing care of patients with immune disorders

Immune Response

• Infections are caused by the invasion of harmful pathogens, including viruses, bacteria, fungi, and protozoa.
• The immune response involves defense mechanisms to maintain homeostasis
• The hypothalamus triggers fever to inactivate viruses
• Interferons prevent bacteria/virus multiplication
• Antibodies and WBCs work to target and eliminate pathogens

Virus

• Viruses consist of DNA or RNA enclosed by protein and lipids.
• Viruses reproduce by hijacking a cell's metabolic functions

Bacteria

• Bacteria multiply rapidly.
• Bacteria produces toxins that can kill cells or tissues.

Disorders of the Immune System

• Immune system disorders fall into three categories: hypersensitivity reactions, autoimmune disorders, and immune deficiencies

Type 1 Hypersensitivity Reaction

• Type 1 hypersensitivity reactions involve the release of histamine and other mediators.
• These reactions can cause urticaria, eczema, angioedema, conjunctivitis, allergic rhinitis, asthma, gastroenteritis, and anaphylaxis

Allergic Rhinitis

• Allergic rhinitis is the most common form of allergy.
• Symptoms include sneezing, nasal itching, runny nose, and itchy, red eyes

Atopic Dermatitis

• Atopic dermatitis, often called eczema, is an inflammatory skin response.
• It involves pruritus, edema, extremely dry skin, blisters, crusts, and scales

Urticaria (Hives)

• Urticaria, or hives, involves the release of histamine.
• Hives appear as raised, pruritic, nontender, erythematous wheals, or skin
• Therapeutic interventions include epinephrine, antihistamines, corticosteroids, and histamine H₂ blockers

Angioedema

• Angioedema is characterized by swelling in the submucosal/subcutaneous tissue due to vascular permeability.
• It can be caused by allergic reactions, angiotensin-converting enzyme inhibitors, or can be idiopathic, hereditary, or acquired.
• Angioedema manifests as painless, nonpruritic swelling
• It is an emergency if the airway is involved
• Treatment involves avoiding the allergen, antihistamines, corticosteroids, and fresh frozen plasma

Anaphylaxis

• Anaphylaxis is a severe systemic type 1 hypersensitivity reaction.
• It involves widespread histamine release
• It is characterized by bronchial narrowing, stridor, wheezing, and respiratory arrest, as well as hypotension, tachycardia, and cardiac arrest

Anaphylaxis: Treatment and Nursing Care

• Immediate treatment includes oxygen, epinephrine, antihistamines, corticosteroids, vasopressors, and mechanical ventilation, guided by the patient's symptoms.
• Nursing care focuses on early recognition, maintaining the airway, providing emotional support, and education

Type 1 Hypersensitivity Disorder: Nursing Care

• Nursing care for type 1 hypersensitivity disorders includes monitoring respiratory status and level of consciousness.
• Staying with the patient, noting and documenting skin and lesions is important.
• Education should involve avoidance of scratching, use of pressure or rubbing for itching, the need for medical alert identification, and methods of avoiding allergens

Type 2 Hypersensitivity Reaction

• In type 2 hypersensitivity, an antibody attaches to a foreign antigen on the cell membrane, resulting in cell lysis
• Hemolytic transfusion reactions, caused by ABO or Rh incompatibility, an example of this reaction

Hemolytic Transfusion Reaction

• Hemolytic transfusion reactions result in RBCs with foreign antigens being rapidly lysed.
• The lysed RBCs occlude blood vessels, causing clots, ischemia, and necrosis, and can be life-threatening
• Prevention includes administering RhoGAM to exposed Rho(D) negative patients and practicing careful blood transfusion administration
• Therapeutic interventions include antihistamines, corticosteroids, and sympathomimetics

Hemolytic Transfusion Reaction: Nursing Care

• Nursing focuses on monitoring the transfusion and immediately stopping the blood if reaction symptoms occur.
• Infuse normal saline with new tubing
• Follow agency transfusion reaction policy.
• Return unused blood and tubing to blood bank and educate the patient

Type 3 Hypersensitivity Reaction

• Type 3 hypersensitivity reactions involve initial sensitization to an antigen, followed by a reaction to later exposure
• These reactions result in a red edematous lesion, bleeding, and necrosis
• Immune complexes, comprising antigens and antibodies, form within blood vessels
• Enzymes released in this process lead to blood vessel damage

Serum Sickness

• Serum sickness is triggered by exposure to nonhuman proteins from anti-venoms, rabies vaccines, and immune modulating agents
• Serum sickness causes inflammation, tissue damage, and necrosis
• Symptoms appear within 7 to 21 days after exposure
• The condition is brief and self-limiting once antigen exposure is removed

Serum Sickness: Treatment and Nursing Care

• Treatment focuses on symptom management
• Administer antipyretics, analgesics, anti-inflammatories, antihistamines, and corticosteroids
• Nursing focuses on monitoring symptoms, evaluating medication effects, and educating the patient

Type 4 Hypersensitivity Reaction

• Type 4 hypersensitivity reactions are delayed.
• Sensitized T lymphocytes contact an antigen, leading to a cell-mediated immune response
• Contact dermatitis and transplant rejection are examples

Contact Dermatitis

• Contact dermatitis results when a chemical comes in contact with skin, leading to T cells secreting chemicals upon subsequent exposures.
• Common causes include poison ivy, poison oak, and latex
• It is characterized by reddened, pruritic, fragile vesicles

Contact Dermatitis: Therapeutic Interventions and Nursing Diagnoses

• Therapeutic interventions using antihistamines, topical drying agents, corticosteroids, and topical immunomodulators
• Relieving itching include tepid baking soda or Aveeno baths, and washing with brown soap like Fels-Naptha
• Impaired Skin Integrity and Ineffective Health Self-Maintenance are common nursing diagnoses

Transplant Rejection

• Transplant rejection occurs when transplanted living tissue is recognized as foreign.
• Lymphocytes become sensitized immediately, invade the transplanted tissue, and destroy it, leading to failure of the tissue or organ
• Prevention involves immunosuppression therapy, being careful as infections can result in death.
• Education: Medications, rejection signs

Autoimmune Disorders

• Autoimmune disorders arise when the immune system recognizes the body’s own cells as foreign and launch an immune response that destroys these cells
• Examples include pernicious anemia, idiopathic autoimmune hemolytic anemia, Hashimoto’s, and lupus

Pernicious Anemia

• Pernicious anemia involves antibodies against gastric parietal cells of the small intestine, which causes Vitamin B12 deficiency

Pernicious Anemia Causes and Treatment

• Pernicious anemia is acquired from gastric bypass.
• Results in weakness, anorexia, glossitis, pallor, and peripheral neuropathy
• Therapeutic interventions include corticosteroids and lifelong vitamin B12 supplementation

Hashimoto’s Thyroiditis

• Hashimoto’s thyroiditis occurs when autoantibodies bind with the thyroid gland, stimulating it to secrete thyroid hormones
• The gland enlarges due to overstimulation
• Different autoantibodies appear, destroying thyroid cells, which slows secretion activity and causes hypothyroidism
• Lifelong thyroxine (thyroid replacement medication) is necessary

Hashimoto’s Thyroiditis: Nursing Care

• Nursing care for Hashimoto's thyroiditis involves rest periods, implementing compression stockings, monitoring daily weights, intake and output, and providing medication education

Lupus Erythematosus

• 3 types include
  • Discoid lupus erythematosus (DLE) - Skin lesions
  • Drug-induced systemic lupus erythematosus (DILE) - After certain medication use
  • Systemic lupus erythematosus (SLE) - Chronic, inflammatory, multisystem disorder

Lupus: Characteristics

• Lupus is a multisystem inflammatory autoimmune disease
• Circulating immune complexes with antibodies against DNA are deposited in the basement membranes of capillaries in the kidney, heart, skin, brain, and joints
• Overaggressive autoimmune responses are related to B and T cells
• 75% of patients with Lupus experience kidney damage

Lupus: Nursing Diagnoses

• Nursing diagnoses for lupus include acute pain, disturbed body image, fatigue, and ineffective health self-maintenance

Lupus: Clinical Judgment

• Assessment involves complete medical history, family history and physical examination
• Observe systemic inflammation, unexplained illness, inflammation
• Analyze the ability to cope with condition effects
• Treatment therapies should determine manifestations of SLE or DLE
• Implement medications and stress reduction techniques
• Evaluate medication side effects

Ankylosing Spondylitis

• Ankylosing Spondylitis - Chronic progressive inflammatory disease, that affects the sacroiliac, costovertebral, large peripheral joints
• Symptoms - Lower back stiffness, pain, lordosis, kyphosis, spasms, fatigue, anorexia, weight loss
• There is no cure, but supportive care and surgery available
• Nursing involves education about posture, range-of-motion, firm mattress, thin pillow

Immune Deficiencies

• Immune deficiencies occur when one or more components of the immune system is completely absent or deficient e.g. hypogammaglobulinemia

Hypogammaglobulinemia

• Hypogammaglobulinemia is the absence/deficiency of one or more of five immunoglobulins from defective B cell function.
• Patients with hypogammaglobulinemia are prone to infections.
• Minimizing infections, Ig G injections, fresh frozen plasma, and genetic counseling are therapeutic interventions

Chapter 19 covers nursing care for patients with immune disorders. It discusses the immune response, viruses, bacteria, and disorders of the immune system including hypersensitivity reactions, autoimmune disorders and immune deficiencies. Type 1 hypersensitivity reactions also involve the release of histamine and other mediators.