Nursing Care of Patients with Immune Disorders Chapter 19

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Questions and Answers

What is the main categorization of immune disorders?

Infectious diseases, inflammatory reactions, and degenerative disorders

Hypersensitivity reactions, autoimmune disorders, and immune deficiencies (correct)

Neurological disorders, cardiovascular disorders, and musculoskeletal disorders

Cancer, genetic disorders, and hormonal imbalances

What is anaphylaxis classified as?

Infectious disease

Autoimmune disorder

Hypersensitivity reaction (correct)

Immune deficiency

What type of reaction involves immune complexes?

Cell-mediated reaction

Autoimmune reaction

Anaphylactic reaction (correct)

Delayed reaction

What is an example of an inhalant allergen?

Pollen Signup and view all the answers

What type of reaction occurs immediately after exposure to an antigen?

Anaphylactic reaction Signup and view all the answers

What is required for an anaphylactic reaction to occur?

Previous exposure to the antigen Signup and view all the answers

What is an example of an ingestant allergen?

Food Signup and view all the answers

How many categories of allergens are listed?

4 Signup and view all the answers

What is the preferred route for administering an Epi-pen?

Intramuscularly in the anterior thigh or deltoid Signup and view all the answers

What is the primary function of dopamine in the treatment of anaphylaxis?

Increase cardiac output and contractility Signup and view all the answers

What is the role of antihistamines in the treatment of anaphylaxis?

Relieve symptoms of an allergic reaction Signup and view all the answers

What is the primary goal of immediate treatment for anaphylaxis?

Guided by symptoms Signup and view all the answers

What should be done after using an Epi-pen?

Seek medical attention Signup and view all the answers

How often should the expiration dates of Epi-pens be checked?

Often Signup and view all the answers

What is the primary role of corticosteroids in anaphylaxis?

Decrease severity and recurrence of symptoms Signup and view all the answers

What patient statement demonstrates effective teaching on the use of an Epi-pen?

I will seek medical attention immediately after using the Epi-pen. Signup and view all the answers

What is the typical duration of a severe urticaria and angioedema condition?

Brief and self-limiting Signup and view all the answers

What is the type of immune response involved in Type IV reactions?

Cell-mediated immune response Signup and view all the answers

What happens during the first exposure to a chemical in contact dermatitis?

No symptoms occur, but memory cells are formed Signup and view all the answers

What is the purpose of topical immunomodulators in treating contact dermatitis?

To reduce the activity of T-lymphocytes Signup and view all the answers

Why do lymphocytes invade transplanted tissue in transplant rejection?

Because the transplanted tissue is sensed as foreign Signup and view all the answers

What is the purpose of immunosuppression therapy in transplant rejection?

To prevent rejection of the transplanted tissue Signup and view all the answers

What is the common symptom of severe urticaria and angioedema?

All of the above Signup and view all the answers

What is the recommended treatment for contact dermatitis?

Antihistamines, topical drying agents, and corticosteroids Signup and view all the answers

What is the primary concern for patients who have undergone a spleenectomy?

Increased risk of infection Signup and view all the answers

What is the primary cause of Multiple Organ Dysfunction Syndrome (MODS)?

Sepsis Signup and view all the answers

Which patient report requires immediate assessment and intervention by the nurse?

I noticed that I have developed tiny reddish-purple lesions all over my arms Signup and view all the answers

What is the term for bleeding under the skin?

Petechiae Signup and view all the answers

What lab result should the nurse review prior to the administration of etanercept to a patient with psoriatic arthritis?

Tuberculin skin test Signup and view all the answers

What is the primary reason for reviewing the white blood cell count before administering etanercept?

To monitor for infection Signup and view all the answers

What is the term for purple spots on the skin?

Purpura Signup and view all the answers

What is the primary purpose of educating patients who have undergone a spleenectomy?

To teach them how to prevent OPSS Signup and view all the answers

What is the result of infection in autoimmune disorders?

The immune system destroys healthy cells Signup and view all the answers

What is the purpose of checking WBC and platelets before giving immunosuppressants?

To report WBC < 4000 Signup and view all the answers

What is the cause of pernicious anemia?

Antibodies against gastric parietal cells Signup and view all the answers

What is the treatment for idiopathic autoimmune hemolytic anemia?

Immunosuppressive medications and corticosteroids Signup and view all the answers

What is the characteristic rash of lupus?

Butterfly rash on the face Signup and view all the answers

What is the goal of nursing care for patients with lupus?

To decrease inflammation and prevent organ damage Signup and view all the answers

What is the purpose of minimizing UV light in lupus treatment?

To prevent exacerbation of lupus symptoms Signup and view all the answers

What is the treatment for ankylosing spondylitis?

Analgesics, anti-inflammatory, and physical therapy Signup and view all the answers

What is the purpose of administering IgG injections in immune deficiencies?

To replace deficient immunoglobulins Signup and view all the answers

What is a potential complication of spleen trauma?

All of the above Signup and view all the answers

What is a common symptom of GERD?

Weight loss Signup and view all the answers

What should a patient with GERD avoid consuming?

Alcohol, chocolate, and spicy foods Signup and view all the answers

What is the purpose of placing a T-tube in the common bile duct?

To drain bile Signup and view all the answers

What is the recommended time to take PPIs?

Late at night Signup and view all the answers

What is the purpose of fundoplication?

To prevent acid backup and hiatal hernia Signup and view all the answers

What is a potential complication of cirrhosis?

Ascites Signup and view all the answers

What is the purpose of giving vitamin K to a patient with esophageal varices?

To reduce bleeding Signup and view all the answers

What is the normal color of a stoma?

Pink to beefy red Signup and view all the answers

What is a characteristic of Asterixis?

Flapping of hands when arms are extended Signup and view all the answers

What is the recommended treatment for dumping syndrome?

Avoid fluids 1 hour before and 2 hours after eating Signup and view all the answers

What is the purpose of monitoring CBC and liver enzymes?

To detect any adverse effects of medications Signup and view all the answers

What is the purpose of giving cytoprotective drugs?

To protect the stomach lining Signup and view all the answers

What is the normal progression of a stoma over time?

It shrinks Signup and view all the answers

What is the primary assessment for GI perforation?

Hard rigid board-like abdomen Signup and view all the answers

What is the treatment for a ruptured appendix?

IV and antibiotic therapy for 8 hours, followed by surgery Signup and view all the answers

What is the characteristic of a healthy stoma in an ileostomy or colostomy?

Pink and moist Signup and view all the answers

What is the purpose of a t-tube in gallstone surgery?

To drain the bile duct Signup and view all the answers

What is the primary concern for patients with an ileostomy or colostomy?

All of the above Signup and view all the answers

What is the purpose of encouraging early ambulation in post-operative patients?

To prevent atelectasis Signup and view all the answers

What is a common symptom of peptic ulcer disease?

Heartburn Signup and view all the answers

What is the primary goal of treatment for peptic ulcer disease?

Reduce acid production Signup and view all the answers

What is the term for the inflammation of the GI tract?

Gastroenteritis Signup and view all the answers

What is the recommended dietary approach for managing peptic ulcer disease?

Eat small, frequent meals Signup and view all the answers

What is the cause of pernicious anemia?

Vitamin B12 deficiency Signup and view all the answers

What is the purpose of giving antacids with acute pain?

To neutralize stomach acid Signup and view all the answers

Study Notes

Disorders of Immune System

Three categories of immune disorders:
- Hypersensitivity reactions
- Autoimmune disorders
- Immune deficiencies

Hypersensitivity Reactions

Injury to body resulting from its exaggerated response
Classified by way tissue injured
Four types of hypersensitivity reactions:
- Anaphylactic reaction
- Destruction of cell that antigen attached to
- Involves immune complexes
- Delayed reaction

Categories of Allergens

Inhalants:
- Pollens
- Molds
- Spores
- Animal Dander
- House Dust
- Mites
Contactants:
- Plants
- Drugs
- Metals
- Cosmetics
- Dyes
- Fibers
- Chemicals
Ingestants:
- Food
- Food Additives
- Drugs
Injectables:
- Drugs/Dyes
- Vaccines
- Insect Stings

Anaphylaxis

Immediate treatment guided by symptoms
- IV access is priority
- Fluids to increase blood pressure
- Oxygen
- Epinephrine- IV
- Antihistamines
- Corticosteroids
- Vasopressors- dopamine- IV
- Mechanical ventilation- respiratory distress

EpiPen

Outer thigh at 90-degree angle at onset of symptoms
Hold in place for at least 10 seconds
Seek immediate medical attention after use
Repeat every 5-15 minutes until symptoms resolve
Store in dark place at room temperature
Check expiration dates often

Anaphylaxis Nursing Care

Early recognition
Emotional support
Education
- Insect repellent
- Medical alert bracelet
- Epinephrine pen- can be given SQ or IM

Type IV Delayed Reaction

Delayed reaction- ie. Poison ivy
Sensitized T lymphocyte contacts antigen
Cell-mediated immune response
Necrosis

Contact Dermatitis

Chemical comes in contact with skin
First exposure, no symptoms- memory cells formed
On second exposure, T cells secrete chemical reaction (histamine→cytokine) that causes itchy rash
Poison ivy, poison oak, latex rubber
Reddened, pruritic, fragile vesicles

Contact Dermatitis Treatment

Antihistamines
Topical drying agents
Corticosteroids
Tacrolimus (Protopic) and pimecrolimus (Abreva)- topical immunomodulators
Tepid baking soda baths or Aveeno baths
Wash with brown soap (fels-naptha)
Avoid scratching skin

Transplant Rejection

Transplanted living tissue sensed as foreign
Lymphocytes sensitized immediately after transplant
Sensitized lymphocytes invade transplanted tissue and destroy it
Symptoms: Failure of organ or tissue
Prevention: Immunosuppression therapy

Autoimmune Disorders

Immune system recognizes body's own cells as foreign
Immune response destroys them

Immunosuppressants

Before giving: Check WBC and Platelets
Report WBC < 4000
Monitor for bleeding- teach soft toothbrush, razors
No pregnant patients
Use contraception
Educate to avoid crowds
While on drugs suppressing immunity- no live vaccines – MMR, nasal influenza, ZOSTAVAX--- not Shingrex (inactivated)
Flu and pneumovac are okay

Pernicious Anemia

Antibodies against gastric parietal cells lead to decreased production of intrinsic factor
Vitamin B12 deficiency
RBC production decreased, macrocytic RBC’s
Also caused by gastric or small bowel resections
DX: Schilling Test- radioactive B 12 given and 24 hour urine measurements done
Symptoms: numbness, tingling, weakness, glossitis
Treatment: Corticosteroids
Lifelong Vitamin B12 IM

Idiopathic Autoimmune Hemolytic Anemia

Autoantibodies attach to RBC’s lyse/clump
Unknown reason why it happens
Symptoms: Mild fatigue, pallor, severe hypotension, dyspnea, palpitations, jaundice
Treatment: Immunosuppressive medications, corticosteroids, folic acid, oxygen, blood transfusions, erythrocytapheresis (remove abnormal RBC- replace with normal RBC), spleenectomy
Nursing: Safety issues, cluster care, blood products

Hashimoto’s Thyroiditis

Autoantibodies for thyroid-stimulating hormone, thyroid gland overstimulation
Then autoantibodies destroy thyroid, hypothyroidism
Thyroid becomes filled with lymphocytes/phagocytes
Unknown cause
Symptoms: 1st hyper then hypothyroid Symptoms
Treatment: Lifelong thyroxine
Nursing: rest periods, daily weights, check fluid retention, medication education

Lupus (SLE)

Tend to occur in families, highest in child-bearing females
African Americans, Hispanics, Asians, Native Americans
Cause is unknown
Autoimmune disease- effects Connective Tissue
Spontaneous remissions and exacerbations
Mild to severe symptoms
Butterfly rash over bridge of nose and cheeks- worsens with sun
Joint or chest pain, anemia, fatigue, hematuria, etc
Can affect joints, skin, kidneys, blood, brain, heart, kidneys
Nursing: disturbed body image
Treatment focuses on decreasing inflammation and preventing organ damage
NSAIDS
Antimalarials
Corticosteroids
Immunosuppressants- hydroxychloroquine
Human Monoclonal Antibody- decrease B lymphocytes

Ankylosing Spondylitis

Chronic progressive inflammatory disease of sacroiliac, costovertebral, large peripheral joints
Lower back stiffness, pain, lordosis, kyphosis, spasms, fatigue, anorexia, weight loss
Treatment: No cure, analgesics, anti-inflammatory, physical therapy, surgery
Education: ROM frequently, position changes
Nursing: pain mgmt, rest periods, ADL assist

Immune Deficiencies

One or more components of immune system completely absent or deficient
Hypogammaglobulinemia
Absence or deficiency of one or more of 5 immunoglobulins r/t defective B cell function
Prone to infections
Treatment:
- Minimizing infections
- IgG injections
- Fresh frozen plasma

Spleen Trauma

Past - trauma to spleen- spleenectomy
Now - watch and attempt to let spleen heal - last resort
Spleenectomy
The spleen is a blood filter, so it is very bloody if traumatized

Side effects after total spleenectomy

Sepsis
Pulmonary Complications
Thrombocytosis
Excessive Bleeding during Surgery

Nursing Care/ Spleen Trauma

IV access, fluids, and vital signs
Monitor Blood loss- S/S Shock
Check for Peritonitis
Cullen’s Sign (ecchymosis around umbilicus)
Follow up CT Scans
Activity limitations
Teach how to assess for bleeding
After 6 months without complications, then the spleen is considered healed.

OPSS

Overwhelming Post spleenectomy Sepsis Syndrome
High risk for infection after having spleen removed
Life-long risk of infection, especially in children
Risk for infection the highest in the first year after spleenectomy
Patients need lots of teaching in order to prevent OPSS
Flu/Pneumonia shots
Limit exposure to large crowds, etc…

MODS

Multiple Organ Dysfunction Syndrome
Cascade of events that leads to organ failure
Many times due to
- Sepsis
- Trauma

GERD (Gastroesophageal Reflux Disease)

Symptoms: dyspepsia (burning/heartburn), worsened pain while lying down, weight loss, regurgitation, dysphagia, bleeding, and loss of tooth enamel
Patient teaching: avoid bedtime snacks, eat small frequent meals, avoid caffeine, milk products, spicy foods, and citrus
Treatment: antacids, H2 blockers (e.g. tidine), and PPI (Prazole)
Lifestyle modifications: drink fluids between meals, avoid lying down after eating, and elevate the head of the bed (HOB) 4-6 inches

Cholecystectomy (Gallbladder Removal)

Surgical procedure: laparoscopy and T-tube placement in the common bile duct
Post-operative care: monitor drainage (yellowish-brown color), keep tube under the surgical site, and turn off suction to assess bowel sounds
Patient teaching: avoid atelectasis by taking deep breaths and coughing only when medicated, and encourage early ambulation
Complications: impaired gas exchange and fluid deficit

Cirrhosis

Symptoms: RUQ pain, fatigue, and ascites (fluid accumulation in the abdomen)
Patient teaching: limit activity, rest, and decrease fluid intake
Treatment: diuretics (e.g. Lasix) to reduce abdominal swelling, and paracentesis for ascites
Complications: encephalopathy ( Asterixis, confusion, and increased ammonia levels)

Liver Biopsy

Procedure: left side lying position during biopsy, and right side lying position post-operatively
Complications: bleeding and encephalopathy

Esophageal Varices

Treatment: vasoconstrictors (e.g. Propranolol) to decrease varices, and vitamin K for clotting
Patient care: protect airway, monitor vital signs, and maintain a side-lying position

GI Perforation

Assessment: hard, rigid board-like abdomen, abdominal pain radiating to the shoulder, restlessness, and apprehension
Treatment: avoid applying heat, and consider surgical intervention

Appendicitis

Symptoms: located in the RLQ, positive McBurney's point (pain in RLQ when touched), Rovsig's point (pain in LLQ when RLQ palpated), rebound tenderness, and radiating pain
Treatment: IV and antibiotic therapy, and surgical intervention
Complications: perforation and peritonitis

Gallstones

Symptoms: same as cholecystectomy
Treatment: laparoscopy and T-tube placement in the common bile duct
Patient teaching: same as cholecystectomy

Ileal Conduit/Colostomy

Procedure: removal of the colon, and creation of an ileostomy or colostomy
Stoma care: monitor for pink, moist, and healthy stoma, and check for discoloration and abnormalities every 8 hours
Diet: eat small, frequent meals, and avoid fatty foods, seeds, and broccoli
Complications: impaired gas exchange and fluid deficit

Gastroenteritis

Definition: inflammation of the GI tract
Types: autoimmune (Chronic Type A) and PUD (Chronic Type B)
Symptoms: heartburn, belching, sour taste, nausea, and vomiting
Treatment: PPI and 2 antibiotics

Peptic Ulcer Disease (PUD)

Symptoms: gut pain 1-2 hours after meals, radiating to the shoulder area, and weight loss
Treatment: PPI and 2 antibiotics
Complications: perforation, hard, rigid abdomen, and bleeding

Medication Classification and Patient Teaching

Antacids: neutralize stomach acid, take 1 hour before or after meals, and not with other medications
H2 blockers (e.g. tidine): decrease acid production, take 30 minutes before meals, and can cause confusion
PPI (e.g. Prazole): prevents final transportation of hydrogen ions, take in the morning, and can cause bone breakdown
Cytoprotective drugs (e.g. pepto-bismol, sucralfate): used as a bandaid, take on an empty stomach, and can cause constipation and abdominal discomfort

Ostomy Assessments

Vital signs: monitor for pink, moist, and healthy stoma
Skin around the stomach: monitor for irritation
Stoma shrinks over time, which is normal

Dumping Syndrome

Definition: rapid entry of food into the jejunum
Symptoms: dizziness, increased heart rate, sweating, nausea, abdominal cramps, and diarrhea
Treatment: avoid fluids 1 hour before and 2 hours after eating

Fundoplication

Procedure: wraps the upper part of the stomach around the esophagus to form a collar-like structure
Goal: prevent acid back-up and air hiatal hernia
Post-operative care: elevate the head of the bed (HOB) 6-10 days, and monitor for dysphagia

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This quiz covers the nursing care of patients with immune disorders, including hypersensitivity reactions, autoimmune disorders, and immune deficiencies.