Nursing Care: Immune Disorders

• Chapter focuses on nursing care for patients experiencing immune disorders.
• Explain the factors that alter or influence the self-recognition portion of the immune system.
• Evaluate effectiveness of interventions.

Immune Response

• Infection results from the invasion of harmful pathogens and can be viral, bacterial, fungal, or parasitic.
• The immune response is a defense mechanism to maintain homeostasis.
• Interferons prevent bacteria or virus multiplication.
• Virus: DNA or RNA surrounded by protein and lipids, hijacks cells' metabolic function to reproduce.
• Bacteria: multiply quickly and produce toxins that can kill cells or tissues.

Disorders of the Immune System

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

Type 1 Hypersensitivity Reaction

• Type 1 involves histamine release, potentially causing urticaria, eczema, angioedema, conjunctivitis, allergic rhinitis, asthma, gastroenteritis, or anaphylaxis.

Allergic Rhinitis

• Most common form of allergy.
• Symptoms include sneezing, nasal itching, runny nose, itchy, and red eyes.

Atopic Dermatitis

• Often called Eczema.
• An inflammatory skin response presents as pruritus, edema, extremely dry skin, blisters, crusts, and scales.

Urticaria (Hives)

• Release of histamine that results in raised, pruritic, nontender, erythematous wheals on the skin.
• Therapeutic interventions include epinephrine, antihistamines, corticosteroids, and histamine H₂ blockers.

Angioedema

• Swelling occurs in submucosal/subcutaneous tissue resulting from vascular permeability.
• Causes include allergic reactions, angiotensin-converting enzyme inhibitors, idiopathic factors, and hereditary or acquired forms.
• Presents as painless, nonpruritic swelling, and is an emergency if the airway is involved.
• Treatments involve avoiding allergens, antihistamines, corticosteroids, and fresh frozen plasma.

Anaphylaxis

• Considered to be a severe systemic type 1 hypersensitivity reaction.
• Results in widespread histamine release, bronchial narrowing, stridor or wheezing, and respiratory or cardiac arrest.
• Treatment involves administering oxygen, epinephrine, antihistamines, corticosteroids, and vasopressors. May require mechanical ventilation.
• Nursing care focuses on early recognition and maintaining the airway.

Type 1 Hypersensitivity Disorder Nursing Care

• Includes monitoring respiratory status and level of consciousness.
• Explain to the patient the need to avoid scratching and to apply pressure or rub itching skin.
• Discuss methods of avoiding allergens with the patient.

Type 2 Hypersensitivity Reaction

• Occurs when an antigen is sensed as foreign, triggering antibody attachment on the cell membrane, which causes cell lysis.
• Hemolytic transfusion reaction is an example, due to ABO or Rh incompatibility.

Hemolytic Transfusion Reaction

• Involves the rapid lysis of RBCs with foreign antigens which can occlude blood vessels and cause clots.
• Results in ischemia and necrosis and is potentially life-threatening.
• Prevention is key by giving RhoGAM to exposed Rho(D) negative patients and carefully administering blood transfusions.
• Therapeutic interventions involve antihistamines, corticosteroids, and sympathomimetics.
• Nursing care involves monitoring the transfusion and patient while immediately stopping the blood if reaction symptoms occur.
• Normal saline should be infused with new tubing and all unused blood should be returned to the blood bank.

Type 3 Hypersensitivity Reaction

• Initial sensitization to an antigen followed by a secondary reaction to later exposure.
• Red edematous lesions, bleeding, and necrosis can result.
• Enzymes lead to blood vessel damage as antigen-antibody complexes form.

Serum Sickness

• Results from exposure to nonhuman proteins, such as anti-venoms, rabies vaccines, and immune modulating agents.
• Causes inflammation, tissue damage, and necrosis and symptoms appear between 7 to 21 days.
• Brief and self-limiting condition once antigen exposure is removed.
• Treatment based on symptoms: antipyretics, analgesics, anti-inflammatories, antihistamines, and corticosteroids.
• Nursing care involves monitoring symptoms, evaluating medication effects, and education.

Type 4 Hypersensitivity Reaction

• Involves a delayed reaction in which sensitized T lymphocytes contact an antigen, resulting in a cell-mediated immune response.
• Contact dermatitis and transplant rejection fall into this category.

Contact Dermatitis

• Occurs when a chemical comes in contact with the skin.
• On second exposure, T cells secrete chemicals, and may be caused by poison ivy, poison oak, or latex.
• Presents reddened, pruritic, and fragile vesicles.
• Therapeutic interventions includes antihistamines, topical drying agents, corticosteroids, and topical immunomodulators.
• Relief of itching can be achieved with tepid baking soda baths.

Transplant Rejection

• Transplanted living tissue sensed as foreign, causing lymphocytes to become sensitized immediately.
• Lymphocytes invade and destroy the transplanted tissue, which can result in failure of the tissue or organ.
• Prevention involves immunosuppression therapy, but infection can result in death.

Autoimmune disorders

• The immune system recognizes the body's own cells as foreign and triggers an immune response that destroys those cells.
• Pernicious anemia, idiopathic autoimmune hemolytic anemia, Hashimoto's, and lupus are examples of autoimmune disorders.

Pernicious Anemia

• Is caused by antibodies against gastric parietal cells of the small intestine.
• Results in Vitamin B12 deficiency and is acquired due to gastric or small bowel resections.
• Presents as weakness, anorexia, glossitis, pallor, and peripheral neuropathy.
• Therapeutic interventions include corticosteroids and lifelong Vitamin B12 supplementation.

Hashimoto's Thyroiditis

• Autoantibodies bind with the thyroid gland and stimulate it to secrete thyroid hormones.
• Gland enlarges as a result of overstimulation.
• Autoantibodies then destroy thyroid cells, and slows secretion activity, causing hypothyroidism.
• Lifelong thyroxine (thyroid replacement medication) is required.
• Nursing care: rest periods, compression stockings, daily weights, intake and output, and medication education.

Lupus Erythematosus

• The condition has three types: discoid lupus erythematosus (DLE) with skin lesions, drug-induced systemic lupus erythematosus (DILE) after certain medication use, and systemic lupus erythematosus (SLE) where there is chronic, inflammatory, multisystem symptoms.
• Multisystem inflammatory autoimmune disease that deposit circulating immune complexes with antibodies on capillary membranes 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
• Medical diagnoses include acute pain, disturbed body image, fatigue, and ineffective health self-maintenance.
• Clinical judgment: recognize cues(assessment), analyze cues, generate solutions(planning), take actions(implementation), and evaluate outcomes (evaluation).

Ankylosing Spondylitis

• Chronic progressive inflammatory disease affecting the sacroiliac, costovertebral, and large peripheral joints
• Symptoms include lower back stiffness, pain, lordosis or kyphosis, spasms, fatigue, and anorexia or weight loss.
• Medical management is only supportive care, and may indicate surgery as well.
• Nursing care includes education on posture, range-of-motion exercise, firm mattress, and thin pillow.

Immune Deficiencies

• The category refers to conditions when one or more components of the immune system is completely absent or deficient.
• Hypogammaglobulinemia is included in this category.

Hypogammaglobulinemia

• Refers to the absence or deficiency of one or more of five immunoglobulins from defective B cell function.
• Sufferers are prone to infections, but minimized with Ig G injections, fresh frozen plasma, and genetic counseling.