Case Study 82

Name: Arnela Suhopoljac

12/12/15

Class/Group: RNSG-2363-51218

Date:

INSTRUCTIONS: All questions apply to this case study. Your responses should be
brief and to the point. When asked to provide several answers, list them in order of
priority or significance. Do not assume information that is not provided. Please print
or write clearly. If your response is not legible, it will be marked as ? and you will
need to rewrite it.

Scenario:
You are a nurse at a university student health clinic. T.Q. comes in to your clinic and
informs you of his immunodeficiency problem. He has just moved here to go to
school. He gives you a letter from his attending physician, hands you a vial of
gamma globulin, and asks you to give him his shot. The letter from T.Q.'s
physician states that he was diagnosed with primary immunodeficiency disease
18 years ago. He has an adequate number of B cells, but they fail to mature
properly and become plasma cells or immunoglobulin. T.Q. states he has a history of
chronic respiratory and gastrointestinal infections. He is maintained on 0.66 mL/kg
gamma globulin IM every 3 weeks and has tolerated this well. He has no known
drug allergies. His vital signs are stable.

1.Can you honor this patient's prescription? Why or why not? How could
you provide him with his injection?
If I was able to give it to him, I would have to first call his doctor and
verify that he was able to get it and that it was due, when his last dose
was, etc. I would have the clinic physician wait for orders.
2.What should you do while the physician is verifying information?
I would get his health history, previous illnesses, previous vaccinations,
and any other health issues that I would have to write down in his
health record.
I would also do an assessment on him

3.You note on T.Q.'s health record that he has not received his polio,
measles, mumps, or rubella vaccines. What explanation can be given for
the lack of these vaccinations?
Despite their proven efficacy in the population at large, vaccines can
be problematic for people with primary immunodeficiency diseases
(PI). Since some types of PI interfere with the bodys ability to make
antibodies in response to a vaccination, many would ask if it makes
any sense or does any good to give vaccines to patients with PI
Live vaccines, such as the chicken pox vaccine (Varivax), measles,
mumps, rubella (MMR), rotavirus, BCG, yellow fever, oral polio and the
influenza nasal spray, could actually cause the disease it is supposed
to prevent in individuals with these types of PI.
Those vaccines might not work while taking gamma globulin.
4.The clinic physician receives confirmation from T.Q.'s physician and
orders the gamma globulin. What questions would you ask T.Q. that would
reassure you that the medication he brought was safe to administer?
I would assess it and make sure that it is colorless or pale yellow. It
should not contain particles or the vial be damaged
I would ask how he stored it, if it was in the refrigerator , let it cool to
room temperature
5.Briefly describe the maturation cycle of the B cell.
B cell development occurs through several stages, each stage
representing a change in the genome content at the antibody loci. An
antibody is composed of two identical light (L) and two identical heavy
(H) chains, and the genes specifying them are found in the 'V'
(Variable) region and the 'C' (Constant) region. In the heavy-chain 'V'
region there are three segments; V, D, and J, that recombine randomly,
in a process called VDJ recombination, to produce a unique variable
domain in the immunoglobulin of each individual B cell. Similar
rearrangements occur for light-chain 'V' region except there are only
two segments involved; V and J.
6.Compare how primary immunodeficiencies differ from secondary
immunodeficiencies.
Distinction between primary versus secondary immunodeficiencies are
based on, respectively, whether the cause originates in the immune
system itself or is, in turn, due to insufficiency of a supporting
component of it or an external decreasing factor of it.
7.What is the most common primary immunodeficiency?

 The most common primary immunodeficiency types result in an

inability to make a very important type of protein called antibodies or
immunoglobulins, which help the body fight off infections from bacteria
or viruses
8.How do you know what type of immunoglobulin deficiency T.Q. has?
Because IgA deficiency is defined by primary immunodeficiency. Based
on that I know what kind of immunoglobulin deficiency he has.

9.Explain why T.Q. is at greater risk for developing infections than his
classmates.
Many people with primary immunodeficiency are born missing some of
the body's immune defenses, which leaves them more susceptible to
germs that can cause infection

10.Before T.Q. leaves, you assess his knowledge and give specific
precautions. What will you assess, and what precautions will you give?
I would assess his knowledge by making sure he keeps up with all his
future appointments like his routine blood work, his next dose, and to
call MD immediately if has side effects.
I would tell him to if he has any side effects to report them to his
doctor immediately. Those include: rash,itching,hives, which would
indicate anaphylactic shock.

Case Study Progress:

T.Q. returns in 3 weeks with complaints of a stuffy nose. He is also due for his next
injection of gamma globulin.

11.What will you assess to further evaluate his stuffy nose?

I would assess his vitals particularly temperature
I would then take a look at his nose and throat for redness or
swelling
I would ask him how long he has had a stuffy nose
If he has a headache or difficulty breathing

12.If T.Q. is developing a sinus infection, what signs are you likely to
encounter on examining him?

Inflammation
Pain
Headache
Congestion
Reduced smell or taste sometimes
Cough
Post-nasal drip

13.T.Q.'s nares do not appear swollen or red, although he does have some
clear mucus drainage. His temperature is normal at 98.4 F (36.9 C).
Should you give the medication or ask him to return when he is no longer
having nasal stuffiness? Why or why not?
I would go ahead and give it to him, and tell him to report if
there is any changes in his condition, I would also let his MD
know what is happening and obviously let the clinic MD know.
14.What do you need to teach T.Q. before leaving the clinic?
Strict hand washing, and to monitor for fever, pain or headache
with the stuffy nose.
Basically monitor for sings of any changes in his stuffy nose and
it worsening.

(Harding, 2013, pp. 367-371)

Harding, M., Snyder, J., Preusser, B. (2013). Winningham's Critical Thinking Cases in
Nursing: Medical-Surgical, Pediatric, Maternity, and Psychiatric, 5th Edition
[VitalSource Bookshelf version]. Retrieved from
https://bookshelf.vitalsource.com/books/978-0-323-08325-6