Care of the Immunologic Patient PDF

CARE OF THE IMMUNOLOGIC PATIENT OBJECTIVES Briefly review the anatomy and physiology of the immune system Assess the immune system function Describe management of patients with 1. Allergic reactions, 2. Rheumatic disorders, and 3. Autoimmune disorders THE IMMUNE SYSTEM Immunity: t...

CARE OF THE IMMUNOLOGIC PATIENT OBJECTIVES Briefly review the anatomy and physiology of the immune system Assess the immune system function Describe management of patients with 1. Allergic reactions, 2. Rheumatic disorders, and 3. Autoimmune disorders THE IMMUNE SYSTEM Immunity: the body’s specific protective response to invading foreign agent (antigen) or organism Immunopathology: the study of diseases that results from dysfunction of the immune system Components of immune system Bone marrow: T cells and B cells Lymphoid tissue: spleen, lymphocytes, and lymph nodes FUNCTION OF THE IMMUNE SYSTEM To remove foreign antigens such as viruses and bacteria to maintain homeostasis Phagocytosis: monocytes responsible for engulfing and destroying foreign bodies and toxins Inflammatory response: Response to injury or invading organisms Chemical mediators minimize blood loss, wall off invading organisms, activate phagocytes, promote formation of scar tissue and regeneration of injured tissue IMMUNITY Natural immunity: nonspecific response to any foreign invader White blood cell action: release cell mediators such as histamine, bradykinin, and prostaglandins and engulf (phagocytize) foreign substances Inflammatory response Physical barriers, such as intact skin, chemical barriers, and acidic gastric secretions or enzymes in tears and saliva Acquired immunity: specific against a foreign antigen Result of prior exposure to an antigen (immunization or contracting the disease) Active or passive ACTIVE AND PASSIVE IMMUNITY Active Immunologic defenses developed by person’s own body Lasts many years; may last a lifetime Examples: fighting a cold, allergic response to antigen Passive Temporary Results from transfer of a source outside of the body that has developed immunity through previous disease or immunization For example, transfer of antibodies from mother to infant through breast feeding; receiving immune globulin through injections FOUR STAGES IN IMMUNE RESPONSE Recognition Proliferation Response Effector RECOGNITION STAGE Recognition of antigens as foreign Use of lymph nodes and lymphocytes for surveillance Lymphocytes recirculate from the blood to lymph nodes and from the lymph nodes back into the bloodstream in a continuous circuit Macrophages play an important role in helping the circulating lymphocytes process antigens Both macrophages and neutrophils have receptors for antibodies and complement; as a result, they coat microorganisms with antibodies, complement, or both, thereby enhancing phagocytosis PROLIFERATION STAGE Circulating lymphocytes containing the antigenic message return to the nearest lymph node Stimulate some of the resident T and B lymphocytes to enlarge, divide, and proliferate T lymphocytes differentiate into cytotoxic (or killer) T cells B lymphocytes produce and release antibodies RESPONSE STAGE Begins with the production of antibodies by the B lymphocytes in response to a specific antigen Cellular response stimulates the resident lymphocytes to become cells that attack microbes; (killer) T cells Viral rather than bacterial antigens induce a cellular response Most immune responses to antigens involve both humoral and cellular responses, although one usually EFFECTOR STAGE Humoral Immunity Interplay of antibodies (B-cells) Cellular Immunity Action by cytotoxic T-cells IMMUNOLOGIC ASSESSMENT ASSESSMENT OF THE IMMUNE SYSTEM Health history Nutrition, infections, immunizations, allergies, history of autoimmune disorders, cancer, and chronic illness Physical exam Skin & mucous membranes Lesions, dermatitis, purpura, urticaria, inflammation, discharge, any s/s infection Lymph node assessment Enlarged: location, size, consistency, tenderness Other body systems (Chart 34-1) Respiratory, cardiovascular, genitourinary, gastrointestinal, and neurosensory systems MSK- joint tenderness, swelling, increased warmth, limited range of motion, pain Lab tests LAB TESTS TO EVALUATE IMMUNE FUNCTION WBC count and differential Bone marrow biopsy Humoral and cellular immunity tests Phagocytic cell function test Complement component tests Hypersensitivity tests Specific antigen–antibody tests HIV infection tests ALLERGIC REACTIONS ALLERGIC REACTION An inappropriate, often harmful response of the immune system to normally harmless substances (e.g., dust, ragweed, pollen) Allergic reaction: Manifestation of tissue injury resulting from interaction between an antigen and an antibody Body encounters allergens that are types of antigens Body's defenses recognize antigens as foreign Series of events occurs in an attempt to render the invaders harmless, destroy them, and remove them from the body TYPES OF IMMUNOGLOBULINS ALLERGIC REACTION Allergen triggers the B cell to make IgE antibody, which attaches to the mast cell. When that allergen reappears, it binds to the IgE and triggers the mast cell to release its chemicals chemical substances cause reactions in allergic response symptoms ROLE OF B CELLS AND T CELLS IN ALLERGIC RESPONSE B-lymphocytes Programmed to produce one specific antibody (IgE from last example) Stimulates production of plasma cells (site of antibody production) Results in outpouring of antibodies T-lymphocytes Assist B cells Secrete substances that destroy target cells and stimulate macrophages Digest antigens and remove debris (killer T-cells) ASSESSMENT OF PATIENTS WITH ALLERGIC DISORDERS History and physical assessment of manifestations; comprehensive allergy history Diagnostic tests CBC: eosinophil count Total serum IgE Skin tests: prick (aka scratch) and intradermal INTRADERMAL TESTING AND INTERPRETATION INTRADERMAL TESTING MEDICATIONS TO TREAT ALLERGIC REACTIONS Oxygen, if respiratory assistance is needed Antihistamines (used in conjunction with decongestants for nasal congestion) Corticosteroids (more severe cases) Refer to Tables 33-2 (antihistamines) and 33- 3 (leukotriene modifiers) for a list of medications HYPERSENSITIVITY Abnormal heightened reaction to a stimulus of any kind Types of hypersensitivity reactions: Anaphylactic: type I; most severe Cytotoxic: type II Immune complex: type III Delayed type: type IV TYPE I: ANAPHYLACTIC REACTION Clinical syndrome that affects multiple organ systems, range from mild-severe Mild Peripheral tingling and a sensation of warmth, fullness in the mouth & throat Onset within 2 hours of exposure Moderate Flushing, warmth, anxiety, and itching in addition to any of the milder symptoms Bronchospasm, edema of airway or larynx, dyspnea, cough, wheezing Onset within 2 hours of exposure Severe (aka anaphylactic shock) Abrupt onset S/S of above progress rapidly to bronchospasm, laryngeal edema, cyanosis, hypotension. Cardiac arrest and coma may follow MANAGEMENT OF ANAPHYLAXIS Screen and prevent Treat respiratory problems, oxygen, intubation, and cardiopulmonary resuscitation as needed Epinephrine 1:1000 subcutaneously Auto injection system: EpiPen May follow with IV epinephrine IV fluids LATEX ALLERGY Allergic reaction to natural rubber proteins Rhinitis, conjunctivitis, contact dermatitis, urticaria, asthma, anaphylaxis Prevalence has been decreasing due to the use of nonlatex gloves 8% to 17% of healthcare workers affected, also food handlers, hair dressers, mechanics, and the police Cross reactions with allergies to kiwis, bananas, LATEX ALLERGY-NURSING MANAGEMENT Best treatment is avoidance of latex-based products Wear medical identification Educate on treatment of irritant contact dermatitis, allergic contact dermatitis that may result from latex exposure Educate about s/s of type 1 reaction, self-injection of epi pen and return demonstration Emergency care following use of epi pen, what products contain latex and safe alternatives, importance of preventing future reactions by avoiding latex RHEUMATIC DISORDERS RHEUMATIC DISEASES Encompass autoimmune, degenerative, inflammatory, and systemic conditions Affect the joints, muscles, and soft tissues of the body More than 100 types of rheumatic diseases Problems caused by rheumatic diseases include: Limitations in mobility and activities of daily living Pain and fatigue Altered self-image Sleep disturbances Systemic effects that can lead to organ failure and death PATHOPHYSIOLOGY OF RHEUMATOLOGIC DISORDERS Three distinct characteristics: Inflammation Complex process resulting in inflamed synovium Autoimmunity Hallmark of rheumatologic disease Body recognizes own tissue as foreign Degeneration Secondary process to inflammation COMMON SYMPTOMS OF RHEUMATIC DISEASE Pain Joint swelling Limited movement Stiffness Weakness Fatigue ASSESSMENT OF RHEUMATIC DISORDERS Health history: Include onset of and evolution of symptoms Family history Past health history Contributing factors Physical exam Functional assessment Combination of history and observation Gait, posture, general musculoskeletal size and structure Gross deformities and abnormalities in movement Symmetry, size, and contour of other connective tissues, such as the skin and adipose tissue ASSESSMENT OF RHEUMATIC DISORDERS Laboratory studies: (Table 34-1) Serum creatinine (assess metabolic waste), ESR (inflammation), RBCs (decreased in RA, SLE), Antinuclear antibody (ANA; positive in RA, SLE, scleroderma, etc.), etc. Imaging studies X-rays CT scan MRI Arthrography RHEUMATIC DISORDERS-PLANNING RHEUMATIC DISORDERS-IMPLEMENTATION Pain Self-care deficit Provide comfort measures Assist in identifying self-care Administer anti-inflammatory deficits analgesic Provide assistive devices Fatigue Consult with community agencies Explain energy conserving Disturbed body image techniques Assist to identify elements of Facilitate development of control over disease activity/rest schedule Encourage verbalization of Impaired physical mobility feelings Assess for need of PT/OT RHEUMATIC DISORDERS-IMPLEMENTATION Ineffective coping Identify areas of life affected by disease Develop plan for managing symptoms and enlisting support of family and friends to promote daily function Complications secondary to medications Perform periodic clinical assessment and laboratory evaluation Provide education about correct self-administration, potential side effects, and importance of monitoring Counsel regarding methods to reduce side effects and manage symptoms Administer medications in modified doses as prescribed if complications occur EDUCATION PLAN FOR NEWLY DIAGNOSED RHEUMATIC DISEASE Explain the disease and principles of disease management Medication teaching and safe self-administration (Table 34-2) E.g., meds to take with meals, schedule of meds, self-monitor for visual changes, GI upset, tinnitus, or other adverse effects and to notify a provider, etc. Pain management techniques Cope with stress Dietary plan Identify need for health promotion, prevention, and screening Community resources  AUTOIMMUNE DISEASES-RHEUMATOID ARTHRITIS (RA) Autoimmune disease of unknown origin, autoimmune reaction originates in synovial tissue 1% of worldwide population, most commonly between 3rd and 6th decade of life Risk factors Females 2.5x greater incidence than males Environmental-pollution, smoking Family history Bacterial and viral illnesses Characterized by chronic, painful, joint inflammation, worse in the AM, exacerbations & remissions RHEUMATOID ARTHRITIS RHEUMATOID ARTHRITIS-ASSESSMENT History and physical Insidious onset Fatigue Malaise Joint pain, warmth, edema, tenderness Joint pain after inactivity especially in the AM Joint deformity Lab and diagnostics: rheumatoid factor (RF), ANA, ESR, CRP, CBC, x-rays, synovial fluid analysis RHEUMATOID ARTHRITIS-PLANNING & IMPLEMENTATION Administer medications ASA, NSAIDS, DMARDS (antirheumatics), immunosuppressants, corticosteroids, etc. (Table 34-2) Encourage frequent rest periods Encourage ROM activities, cane/crutches/assistive devices Encourage cold compresses to acutely inflamed joints Provide emotional support Education about disease, medication, and self care Avoid complications RHEUMATOID ARTHRITIS-COMPLICATIONS Joint deformity Impaired self-care and nutrition Cardiovascular disease (secondary to inflammation from disease) Medication side effects E.g., gastric irritation, gastric ulcer, skin rash, headaches, bone marrow depression, hyperglycemia, etc. (see Table 34-2) AUTOIMMUNE DISEASES-SYSTEMIC LUPUS ERYTHEMATOUS (SLE) 1.6-7.8 individuals per 100,000 affected 6-10x more frequent in females 3x more frequent in African American than Caucasians Characterized by remissions and exacerbations Diagnosed with presence of 4 of 11 symptoms: Malar rash, discoid rash, photosensitivity, oral ulcers, non- erosive arthritis, pleuritis or pericarditis, kidney disease, neurologic disease, hematologic disorder, immunologic disorder, positive antinuclear antibody SYSTEMIC LUPUS ERYTHEMATOUS SYSTEMIC LUPUS ERYTHEMATOUS- ASSESSMENT History and physical Fever, malaise, weight loss, anorexia ”Butterfly” rash, oral ulcers, alopecia Joint tenderness, swelling, and pain (early symptoms in 90%) Photosensitivity Depression Labs and diagnostics: ANA, ESR, CBC, LE (lupus erythematosus) cell prep test SYSTEMIC LUPUS ERYTHEMATOUS- PLANNING & IMPLEMENTATION Assess/monitor Use sunscreen Skin breakdown Maintain medication schedule Signs of infection Signs/symptoms of infection Lung sounds Signs/symptoms of complications (edema, decreased urine output, acute shortness of Nutritional status breath, chest pain, etc.) Mobility Signs of depression Encourage close follow up care Blood pressure, cardiac function Visual changes Avoid complications Educate Keep skin lesions clean/dry Avoid direct sunlight/ultraviolet light SYSTEMIC LUPUS ERYTHEMATOUS- COMPLICATIONS Anemia Nephritis Pericarditis* Pleuritis* Retinopathy CNS involvement Psychosis, cognitive impairment, seizures, peripheral and cranial neuropathies Stroke and heart attack secondary to atherosclerosis AUTOIMMUNE DISEASES-SJÖGREN’S SYNDROME Systemic, autoimmune disease progressively affects lacrimal and salivary glands > 90% affected are females between 35-50 years old 1 of 1000 affected in US = 2-4 million people Co-occurs with RA or SLE Manifestations in other systems AUTOIMMUNE DISEASES-SJÖGREN’S SYNDROME Signs/symptoms: Eyes: dry eyes, redness, feel “gritty”, lack of tearing Mouth: dry mouth, dry and sticky oral mucous membranes, complaints of difficulty swallowing (lack of saliva) Skin: vasculitis with palpable purpura, skin lesions may ulcerate and cause pain Other: optic neuritis, trigeminal neuralgia, sensory neuropathy (burning pain in extremities), numbness, AUTOIMMUNE DISEASES-SJÖGREN’S SYNDROME Nursing management Administer artificial tears, ocular ointments for dry eyes Cholinergic drugs for dry mouth, Biotene mouth wash recommended Recommend small, frequent meals, omitting spicy, salty, and irritating food Avoiding smoking, excessive alcohol use, and drugs with anticholinergic side effects DMARDS, only for severe cases Education on disease and self-care, encourage follow up care