19 WH Immune revised (3) (8) (1) (1) (1) (1).ppt
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Chapter 19 Nursing Care of Patients with Immune Disorders 11790 Disorders of Immune System Three categories: I. Hypersensitivity reactions Anaphylaxis, hemolytic transfusion reactions, measles, transplant rejections 11790 Disord...
Chapter 19 Nursing Care of Patients with Immune Disorders 11790 Disorders of Immune System Three categories: I. Hypersensitivity reactions Anaphylaxis, hemolytic transfusion reactions, measles, transplant rejections 11790 Disorders of Immune System (cont.) II. Autoimmune disorders Rheumatoid arthritis, ulcerative colitis, multiple sclerosis III. Immune deficiencies Hypogammaglobulinemia, acquired immunodeficiency syndrome 11790 I. 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 11790 Categories of Allergens Inhalants Pollens Molds Spores Animal Dander House Dust Mites 11790 Categories of Allergens Contactants Plants Drugs Metals Cosmetics Dyes Fibers Chemicals 11790 Categories of Allergens Ingestants Food Food Additives Drugs 11790 Categories of Allergens Injectables Drugs/Dyes Vaccines Insect Stings 11790 Type I Anaphylactic reaction Immediate occurring reaction Mild to severe to life threatening Patient must have had previous exposure (sensitization) to antigen. During 1st exposure IgE are made and attach to mast cells. 2nd exposure releases histamine If second exposure local- rxn small If second exposure systemic= rxn massive 11790 Atopic Dermatitis Eczema Inflammatory skin response Pruritus, edema, extremely dry skin, blisters-- break open & crust, scales then lichenification Tx. Luke warm soaks then oil-in-water lubricants, topical steroids, antipruritics, dilute bleach soaks twice weekely 11790 Allergic Rhinitis Most common form of allergy Antigen-antibody reaction Sneezing, nasal itching, runny nose, itchy red eyes Repeated rhinitis= sinus infection Dx tests: skin testing Try to eliminate cause, antihistamines, immunotherapy if severe (allergy shots), nasal corticosteriods Nsg. If forget to take allergy injection-call MD—do not double up, may need to decrease dose and slowly increase again. Nursing-Environmental allergens Rhinophototherapy 11790 Rhinophototherapy Rhinophototherapy-light waves to reduce hypersensitivity Before treatment blow nose properly and if necessary, they can use a vasoconstrictor spray to reduce the edema of the nasal mucosa Takes 2-3 minutes per nostril. Two to three times/week for 3 weeks No tissue-damaging effect, can be applied very safely for the long-term treatment of allergy patients. Decreases symptoms: runny nose, itchy eyes, etc. 11790 Anaphylaxis Severe systemic hypersensitivity reaction Widespread histamine release Bronchial narrowing: Stridor, wheezing, respiratory arrest Hypotension, tachycardia, cardiac arrest Tx. IV epinephrine and vasopressor (dopamine), intubation, antihistamines and corticosteroids. Epi-pen—preferred route is IM anterior thigh or deltoid, can be given SQ 11790 Pharmacology Review Epinephrine Alpha and Beta agonist Improve breathing, increase Bp, decrease swelling Dopamine Inotropic agent Increases cardiac output, dilates blood vessels, increase contractility, circulation improved Benadryl H1 receptor blocker/antihistamine Does not stop reaction but relieves the symptoms Corticosteroids Help decrease severity and recurrence of symptoms 11790 11790 11790 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 11790 Epi-Pen Outer thigh at 90 degree at onset s/s 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 11790 Anaphylaxis Nursing care Early recognition Emotional support Education Insect repellent Medical alert bracelet Epinephrine pen- can be given SQ or IM 11790 The nurse is instructing a patient with sever allergy to was stings on the proper use of epinephrine auto-injector. Which patient statement BEST demonstrates the teaching has been effective? I will keep my epi-pen stored in my refrigerator at all times I will inject the medication iinto my outer thigh at the first sign of an allergic reaction I will seek follow-up treatment within 24 hours of injecting the medication I will hold the epipen firmly in place for at least 5 seconds to ensure full delivery of the medication. 11790 Urticaria (Hives) Release of histamine from mast cells Caused by stress, meds or foods Raised, pruritic, nontender, erythematous wheals on skin Treatment Stress management, cool soaks Epinephrine Corticosteroids Antihistamines Histamine H2 blockers (cimetidine) 11790 URTICARIA/HIVES 11790 Angioedema Form of urticaria Affects submucosal/subcutaneous tissue rather than skin- vascular leakage Lasts longer than urticaria-hives Painless, dermal erythematous/subcutaneous eruptions, skin/mucous membrane edema Tx. Symptomatic relief w/ antihistamines and corticosteroids Long-term tx. = immunotherapy for desensitization Nursing: Airway major concern 11790 Steps in an Allergic Reaction 11790 Type II Destruction of substance that has antigen attached to cell membrane Usually sensed by immunoglobulin IgG or IgM If cell is foreign (bacteria), it is beneficial Not beneficial when RBC sensed as foreign 11790 Hemolytic Transfusion Reaction RBCs with antigens foreign to person rapidly lysed Rapid lysis of RBC’s= vessels to occlude from debris Ischemia, necrosis Life threatening Prevention Rhogam: Rho (D) negative patients Careful blood transfusion administration RN need to be careful with proper ID protocol 11790 Blood Compatibilities Type A Type B Type AB Type O Can receive Can receive Universal Universal type A or O type B or O Recipients Donors blood types blood types Do not make A Can receive or B antibodies only O blood type Those who are Rh + can receive Rh-, but those who are Rh – CANNOT receive Rh + 11790 Rh Sensitivity Maternal and fetal Rh factors are different— then mother becomes sensitized by fetal Rh type This will affect future fetuses Rh - mom gets sensitized by Rh + fetus Also if Rh - patient given Rh + blood accidentally Tx= Give Rhogam to prevent hemolytic rxn. 11790 If hemolytic rxn occurs S/S Sudden onset of back or chest pain Fever, chills, wheezing, tachy, hives Tx Treatment depends on severity Antihistamines, corticosteroids, epinephrine Diuretics to help kidneys w/ excretion if they have become occluded w/ cellular debris 11790 Nursing Prevention crucial Follow strict guidelines for blood tx Double-checking patient I.D. Frequent vital signs during blood Documentation Quick, critical thinking if rxn occurs-will occur during 1st 15 minutes Turn off Blood, call MD, NSS with new line 11790 Nursing--Blood transfusions Blood released from blood bank 2 nurses double check specified data At bedside check double check patient’s name, ID number, unit of blood, pt’s ID bracelet, blood type on chart, on unit of blood and paperwork Vital signs with start of transfusions Before start of blood, 15 minutes x2 , then 30 minutes x2, then hourly and when transfusion completed—check institution’s policy Should stay with pt during first 15 minutes of blood starting 11790 Blood Reaction Occurs Turn off blood Vital signs/ Assess patient Report to MD STAT Start IV new line Administer Normal Saline and follow specific orders from physician 11790 Type III-Hypersensitivity Rxn Involves immune complexes formed by antigens and antibodies (IgG) Pt sensitized 1st time exposed to antigen and with 2nd exposure rxn occurs Antigen-antibody complexes within blood vessels as antigen absorbed thru vessel wall Neutrophils attracted & release enzymes that lead to blood vessel damage Red, edematous skin lesion, hemorrhage, necrosis 11790 Serum Sickness Antigen-antibody complexes cause symptoms of inflammation 7 to 10 days after exposure (ie. Med rxn) Severe urticaria and angioedema S/S= fever, malaise, muscle soreness, n/v/d, splenomegaly, angioedema Brief and self-limiting condition Supportive care and education Antipyretics, antihistamines, epinephrine 11790 Type IV Delayed reaction- ie. Poison ivy Sensitized T lymphocyte contacts antigen Cell-mediated immune response Necrosis 11790 Contact Dermatitis Chemical comes in contact with skin First exposure, no symptoms-memory cells formed On second exposure, T cells secrete chemical reaction (histaminecytokine) that causes itchy rash Poison ivy, poison oak, latex rubber Reddened, pruritic, fragile vesicles 11790 Contact Dermatitis Treatment Antihistamines, topical drying agents, corticosteroids Tacrolimus (Protopic) and pimecrolimus (Abreva)—topical immunomodulators Reduce the activity of T-lymphocytes in the immune system so, T-cells fail to release their cytokines which cause inflammation, redness and itching). Tepid baking soda baths or Aveeno baths Wash with brown soap (fels-naptha) Avoid scratching skin 11790 Transplant Rejection Transplanted living tissue sensed as foreign Lymphocytes sensitized immediately after transplant Sensitized lymphocytes invade transplanted tissue and destroy it S/S= Failure of organ or tissue Prevention Immunosuppression therapy Educate family rejection can happen even years later. Infection can result in death 11790 Autoimmune Disorders Immune system recognizes body’s own cells as foreign Immune response destroys them 11790 Immunosuppressants Before Giving Check WBC and Platelets Report WBC < 4000 Monitor for bleeding- teach soft toothbrush, razors No pregnant patients And do not get pregnant till 3 months after treatment— men wear condoms for 3 months 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 11790 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 Pernious anemia- higher B 12 in urine **S/S: numbness, tingling, weakness, glossitis Corticosteroids Lifelong Vitamin B12 IM 11790 Idiopathic Autoimmune Hemolytic Anemia Autoantibodies attach to RBC’s lyse/clump Unknown reason why it happens S/S: Mild fatigue, pallor, severe hypotension, dyspnea, palpitations, jaundice Tx: Immunosuppressive medications, corticosteroids, folic acid, oxygen, blood transfusions, erythrocytapheresis (remove abnormal RBC-replace with normal RBC), spleenectomy Nsg: Safety issues, cluster care, blood products 11790 Hashimoto’s Thyroiditis Autoantibodies for thyroid-stimulating hormone, thyroid gland overstimulation Then autoantibodies destroy thyroid, hypothyroidism Thyroid becomes filled with lymphocytes/phagocytes Unknown cause S/S: 1st hyper then hypothyroid S/S Lifelong thyroxine Nsg: rest periods, daily weights, check fluid retention, medication education 11790 Lupus (SLE) Tend to occur in families, highest child-bearing females African Americans, Hispanics, Asians, Native Americans Cause is unknown Autoimmmune 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 effect joints, skin, kidneys, blood, brain, heart, kidneys 11790 Lupus Nursing: disturbed body image Help verbalize but goal is to help return to previous social involvement Treatment focuses on decreasing inflammation and preventing organ damage NSAIDS Antimalarials Corticosteroids Immunosuppressants- hydroxychloroquine Human Monoclonal Antibody- decrease B lymphocytes 11790 Lupus treatments Nursing Minimize UV light, sleep for fatigue, ROM to maintain joints, warm baths, splints, PT, good nutrition Medication teaching- Hydroxychloroquine Every 6-12 eye checks-report changes Should see improvement of energy Takes a few weeks to become effective 11790 Ankylosing Spondylitis Chronic progressive inflammatory disease of sacroiliac, costovertebral, large peripheral joints Lower back stiffness, pain, lordosis, kyphosis, spasms, fatigue, anorexia, weight loss Tx: No cure, analgesics, anti-inflammatory, physical therapy, surgery Education: ROM frequently, position changes Nsg: pain mgmt, rest periods, ADL assist 11790 Normal Lordosi Kyphosis s 11790 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 11790 11790 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 11790 Side effects after total spleenectomy Sepsis Usually on 2 year regimen of antibiotics Pulmonary Complications Thrombocytosis Spleen holds approx 1/3 blood platelets so if no spleen increase in circulating platelets Excessive Bleeding during Surgery 11790 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. 11790 OPSS Overwhelming Post spleenectomy Sepsis Syndrome High risk for infection after having spleen removed 11790 OPSS 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… 11790 MODS Multiple Organ Dysfunction Syndrome Cascade of events that leads to organ failure. Many times due to Sepsis Trauma 11790 11790 A patient is prescribed methotrexate for treatment of an autoimmune disorder. Which patient report requires immediate assessment and intervention by the nurse? “I will consult with my I before discontinuing birth control” “I noticed that I have developed tiny reddish-purple lesions all over my arms “I have not had a normal bowel movement in 2 days” “I seem to be losing an excessive amount of hair since starting this medication” 11790 Answer Tiny reddish-purple lesions Medication causes thrombocytopenia Report: Petechiae- bleeding under skin Purpura- purple spots on skin Melena- black tarry stools Hematemesis- vomiting blood Bleeding gums 11790 Which lab results should the nurse review prior to the administration of etanercept to a patient with psoriatic arthritis? SATA Tuberculin skin test aPTT (partial thromboplastin time) White blood cell count Total cholesterol panel Red blood cell count 11790 Answer TB test- will need to be treated first White blood cell count Red blood cell count- anemia?? Meds have an effect on bone marrow Elevated CRP expected since have inflammatory disease 11790 Math problem—rounding rule Medication order: Heparin 6500 units subcutaneously every morning. Supplied: Heparin 10,000 units/ mL. How much should the nurse administer? 11790 Simple Nursing/Nurse Mike Class work or at Home Work Have students watch and complete Simple Nursing/Nurse Mike Immune System Medications Worksheet with youtube (Shared Folder) 11790 11790 Test Review For test review refer to: ATI Custom Assessment Builder Immune ATI Learning systems Immune & Infectious 11790
