NURS 304: ADULT NURSING

LECTURER: Ms. Mackey

Assessment of Immune
Function

The Immune System

Immunity: the bodys specific protective
response to invading foreign agent or
organism
Immunopathology
Immune disorders
Autoimmunity - normal protected immune
response
Hypersensitivity exaggerated response to antigen
Gammopathies over production of
immunoglobulins
Immune deficiencies: primary and secondary

Immune System
Antibody
An antibody is a protein substance developed by
the body in response to and interacting with a
specific antigen.

Antigen
A substance that induces the production of
antibody

Immunoglobulins
Antibodies (protein molecules IgA, E, G, M,
D)

Central and Peripheral Lymphoid

Organs

Development of Cells of the

Immune System

Immune Function
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 tars and saliva

Acquired immunity: specific against a foreign

antigen
Result of prior exposure to an antigen
Active or passive

Cellular Immune Response

B lymphocytes: humoral immunity
Produce antibodies or immunoglobulins

T lymphocytes: cellar immunity

Attack invaders directly, secrete cytokines, and

stimulate immune system responses
Helper T cells
Cytotoxic T cells
Memory cells
Suppressor T cells (suppress immune response

Variables That Effect Immune

System Function
Age and gender
Nutrition
Presence of conditions or disorders:
cancer/neoplasm, chronic illness, autoimmune
disorders, surgery/trauma
Allergies
History of infection or immunization
Genetic factors
Lifestyle
Medications and transfusions
Pyschoneuroimmunologic factors

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
Allergy
An inappropriate often harmful response of
the immune system to normally harmless
substances
Hypersensitive reaction to an allergen
initiated by immunological mechanisms
which is usually mediated by IgE antibodies

Allergen: the substance that causes

the allergic response
Atopy: refers to the allergic reactions
characterized by IgE antibody action
and a genetic predisposition

Immunoglobulins and Allergic

Response
Antibodies (IgE, IgD, IgG, IgM, and IgA) react
with other cells and molecules, to protect the
body
IgE antibodies are involved in allergic disorders
IgE molecules bind to an allergen and trigger
mast cells or basophils
These cells then release chemical mediators
such as histamine, serotonin, kinins, and
neutrophil
chemical substances cause the reactions seen in
allergic response

Hypersensitivity

A reflection of excessive immune response

Sensitization: initiates the buildup of antibodies
Types of hypersensitivity reactions:

Anaphylactic: Type I, e.g. asthma, allergic rhinitis

Cytotoxic: Type II, e.g. myasthenia gravis, Rh
isoimmunization
Immune complex: Type III, e.g. SLE, rheumatoid
arthritis
Delayed-type: Type IV, occurs 1-3/7 after exposure to
antigen, e.g. contact dermatitis

Management of Patients with

Allergic Disorders
History and manifestations;
comprehensive allergy history
Diagnostic tests
CBCeosinophil count
Total serum IgE
Skin tests

Medication
Oxygen, if respiratory need
Epinephrine used for anaphylactic
reactions
Antihistamines (benadryl, zrytec,
claratine)
Corticosteroids (prednasone)

Prevention and Treatment of

Anaphylaxis
Screen and prevent!
Treat respiratory problems, oxygen,
intubation, and cardiopulmonary
resuscitation as needed
Epinephrine 1:1,000 SQ
Auto injection system: epiPen
May follow with IV epinephrine
IV fluids

Other Allergic Disorders

Contact dermatitis
Atopic dermatitis
Drug reactions (dermatitis
medicamentosa)
Urticaria
Food allergy
Serum sickness
Latex allergy

Management of Patients
With Immunodeficiency

Immunodeficiency Disorders
Primary: genetic
Inborn errors of immune function
May effect phagocytic function, B cells and/or
T cells, or the complement system
E.g DiGeorge Syndrome, IgA deficiency,
Wiscot Aldrich Syndrome (thrombocytopenia),
phagocytic disorders

Secondary
Acquired
Related to underlying disorders, diseases,
toxic substances, or medications
HIV/AIDS, autoimmune disorders e.g SLE,

Primary Immunodeficiency
Usually seen in infants and young children
Manifestations: vary according to type,
severe or recurrent infections, failure to
thrive or poor growth, positive family
history
Potential complications: recurrent, severe,
potentially fatal infections; related blood
dyscrasias or malignancies
Treatment: varies by type, treatment of
infection, immunoglobulin Rx, stem cell or
bone marrow transplant

Nursing Management
Monitor for signs and symptoms of
infections
Monitor lab values
Promote good nutrition
Address anxiety, stress, and coping
Strategies to reduce risk of infection
Handwashing and strict aseptic technique
Patient protection and hygiene measures: skin
care, promote normal bowel and bladder
function, pulmonary hygiene

Patient Teaching
Signs and symptoms of infection
Medication
Prevention of infection
Hand washing
Avoid crowds and persons with infections
Hygiene and cleaning

Nutrition and diet

Lifestyle modifications to reduce risk
Follow-up care

HIV/AIDS Infection
Human immunodeficiency virus is a
member of the retrovirus family that
causes AIDS.
Characterized by long incubation period
Carries genetic material in form of RNA

HIV infection is pandemic

Transmission of HIV
Transmitted by body fluids containing
HIV or infected CD4 lymphocytes
Blood, seminal fluid, vaginal secretions,
amniotic fluid, and breast milk
Most prenatal infections occur during
delivery

Casual contact does not cause

transmission
Breaks in skin or mucosa increase risk

High-Risk Behaviors
Sharing infected injection equipment
Having sexual relations with infected
individuals

Prevention
Standard precautions
Safer sex practices and safer
behaviors
Abstinence
Reduce the number of sexual
partners to one
Always use latex condoms; if allergic
to latex, use non-latex condoms

Do not share drug injection

equipment
Blood screening and treatment of
blood products

Standard Precautions
Standard precautions infection control
practices used to prevent transmission of
diseases that can be acquired by contact
with blood, body fluids, non-intact skin.
Hand hygiene
Personal Protective Equipment (PPE)
Respiratory hygiene
Proper disposal of soiled material
Environmental control
Disposal of sharps

Stages of HIV Disease

Primary infection
HIV asymptomatic
HIV symptomatic
AIDS

Primary Infection
AKA acute HIV infection/acute HIV
syndrome
Period from infection to development
of HIV antibodies
Symptoms: none to flu-like syndrome
Period of rapid viral replication and
dissemination through the body
CD4+ (500 1500 cells/mm3)

Viral set point: amount of virus in

body

HIV Asymptomatic
More than 500 CD4+ T
lymphpocytes/mm3
Chronic asymptomatic state
begins
Body has sufficient immune
response to defend against
pathogens
Individual is relatively well

HIV Symptomatic
200499 CD4+ lymphpocytes/mm3
CD4 T cells gradually fall
The patient develops symptoms or
conditions related to the HIV infection
Conditions are classified as category
B conditions

Oral candidiasis
Cervical dysplasia
Herpes zoster (shingles)
Fever, diarrhea x 1/12

AIDS
Less than 200 CD4+ lymphocytes/mm3
As levels drop below 100 cell/mm3 the
immune system is significantly
impaired
Development of category C conditions
Candidiasis of esophagus, lungs
Cervcal cancer
Kaposis sarcoma
Pneumoncystis pneumonia
Wasting syndrome

Diagnostic Tests
Enzyme immunoassay (ELISA) test to identify HIV
antibodies
Western Blot detects HIV antibodies & confirms
EIA
Viral Load Measures HIV RNA in plasma
CD4 / CD8 monitors the function of immune
systems and tracts the progression of the disease
Measures the ratio between the CD4 on helper T cells
and the CD8 on suppressor and cytotoxic T cells

Orasure (saliva)
OraQuick

Clinical Manifestations of
HIV/AIDS
Respiratory
1.Pneumocystic carini pneumonia (PCP):

Most common infection

Initial symptoms may be nonspecific and
may include nonproductive cough, fever
chills, dyspnea, and chest pain
If untreated, progresses to pulmonary
impairment and respiratory failure
Treatment: pentamidine, TMP-SMZ (bactrim)

2.Mycobacterium avium complex (MAC)respiratory infection

3.Tuberculosis

Clinical Manifestations
Gastrointestinal
1.Oral candidiasis

May progress to esophagus and stomach

Treatment with nystatin, ketoconazole

2.Diarrhea related to HIV infection or enteric

pathogens
Octretide acetate for severe chronic diarrhea

3.Wasting syndrome

10% weight loss and chronic diarrhea or chronic

weakness and fever with absence of other cause
Anorexia, diarrhea, GI malabsorption, and lack of nutrition
may contribute

Clinical Manifestations
Kaposi's sarcoma
Cutaneous lesions, but may involve
multiple organ systems
Lesions cause discomfort, disfigurement,
ulceration, and potential for infection

B-cell lymphomas

Clinical Manifestations
Neurologic
1.HIV encephalopathy
Progressive cognitive, behavioral,
and motor decline

2.Cryptococcus neoformans
fungal infection that can cause
meningitis
3.Depression

Treatment
Treatment and protocols are continually evolving
Antiretroviral agents
Nucleoside reverse transcriptase inhibitors (NRTIs)
Non-nucleoside reverse transcriptase inhibitors
(NNRTIs)
Protease inhibitors (PIs)
Fusion inhibitors
Use of combination therapy
Management also focuses upon the treatment of
specific manifestations and conditions related to the
disease

Terminology
ART =
AntiRetroviral Therapy
ARV =
AntiRetroVirals
HAART =
Highly Active
AntiRetroviral
Therapy
Triple Therapy = Three Antiretrovirals
The Cocktail

Basic Facts about ARVs

ARVs are divided into
3 classes, each of
which attacks HIV in
a different way.
New classes

becoming available
through clinical trials.

Always use 3 or
more different ARV
medications for
therapy.
Regimen should be
selected by an
experienced HCW.
Other medications
interact with ARVs.

Advantages of ARV
Therapy
Improved
patient health
Reduced illness
Reduced
hospitalisations
Fewer deaths
from AIDS

CD4 Count

Viral Load

Time

How do ARVs control HIV?

ARVs reduce the ability of
the HIV virus to replicate
This increases the
functioning of the immune
system

How NRTIs Work

HIV

Nucleoside reverse transcriptase inhibitors

(NRTIs) latch onto the new strand of DNA that
reverse transcriptase is trying to build.

How NNRTIs Work

HIV

Non-nucleoside reverse transcriptase inhibitors

(NNRTIs) hook onto reverse transcriptase and stop
it from working

How PIs Work

HIV

Protease inhibitors (PIs) prevent final

assembly and completion of new HIV
viruses within the cell

Use of ARVs
The Stage of HIV depends upon:
Immunological markers (CD4 count)
Clinical symptoms (Opportunistic
infections)
It also depends on whether the patient is
READY to start

Bahamas - Adult ARV

Therapy
HIV infected adults and
adolescents should start ARV
therapy when they have:
CD4 count less than 250/mm3
Normal or not extreme lab values
Cr > 2mg/dl/l
Hgb < 6.5 g/dl
ALT > 175 IU/l (alanine
aminotransferase)

Goals of AVR Therapy

Decline in viral load from pre-treatment
levels by 6-8 weeks after initiating ARVs
Undetectable viral load = ultimate goal

ARVs

Require near perfect adherence

HIV resistance
Side effects
Toxicity

Basic Facts about Adherence and

ARV therapy
ARV blood concentrations must remain
constant; low concentrations allow HIV to
mutate.
HIV mutations cause drug resistance.
ARV medications must be taken every day
otherwise they will not work.
Things that can lower drug concentrations:
Missing 1 or 2 ARV medication doses regularly
Taking ARV medication late
Taking ARVs with certain foods or other medications

Determinants to Effective ARV

Therapy
Patient is not ready? he/she may be non-adherent
Patient doesnt understand the drugs? he/she may
take them incorrectly
Patient doesnt expect side effects? he/she may be
shocked and get put off ARVs or not report any
problems
Patient feels alone and unsupported? he/she may be
frightened, reluctant to take drugs or to report any
problems

Nurses Role in Monitoring

Verbal Reporting:
Nurses are often the first point of contact
Patients often feel more comfortable raising issues with
nurses
Nursing activities (e.g. vital signs) provides opportunity
for informal conversation re: problems/issues
Assessment: Is patient experiencing any side effects?
How
are they feeling? Any problems?
Follow up: Referral of concerns to Doctor; Recognising
urgent referrals; Good communication

Blood Samples
Correct clinical decisions depend on
meaningful clinical laboratory information
Nurses have a direct responsibility to
ensure that accurate results are obtained
which may inform appropriate clinical
decisions
This depends on proper specimen collection
Common blood tests:
CD4 Count
Viral Load
Monitoring Labs (FBC, LFTs)
Resistance Testing

Side Effects of NRTIs

AZT (Retrovir):

anaemia, headache,

neutropenia, fatigue

3TC (Epivir):

nausea, diarrhoea, headache,

fatigue, skin rash, abdominal pain, increase LFTs

d4T (Zerit):

headache, nausea, vomiting,

diarrhoea, rash, increase LFTs, peripheral
neuropathy, pancreatitis

ddI (Videx):

nausea, vomiting, diarrhoea,

abdominal pain, peripheral neuropathy,
increase LFTs, pancreatitis

Side Effects of NNRTIs

Efavirenz (Efavirenz):

rash,
sedative effects, headache, nausea,
diarrhoea, vivid dreams, insomnia,
increase LFTs, hepatitis,

Nevirapine (Viramune):

headache,
nausea, rash, diarrhoea, increase
LFTs, hepatitis, liver failure

Severe Side Effects or

Adverse Events
Some side effects may be severe
e.g. rash, hepatitis, lactic acidosis,
pancreatitis, hyperlipidaemia,
peripheral neuropathy

ARVs may need to be stopped/or

changed
Early identification and prompt,
appropriate management is
essential

Other toxicities..
Regular monitoring of blood
CBC/FBC
levels
is essential to
Liver function
identify ARV toxicities
Kidney function

Appropriate intervention
can then be made

Cholesterol
Glucose

Our Role
As nurses, we have a vital role to
play in ensuring side effects are

identified, managed and

treated
appropriately and effectively

How do we do this?........
Educating patients
Prompt recognition and reporting
Understanding lab tests and results
Explaining lab tests to patients
Therapeutic intervention
Providing support and counselling for
patient and family
Ensuring follow up of patients
Educating the general public

Collaborative Problems/Potentia
Complications
Opportunistic infections
Impaired breathing or respiratory
failure
Wasting syndrome
Fluid and electrolyte imbalance
Adverse reaction to medication

Opportunistic Infections
An opportunistic infection is an
infection caused by pathogens, particularly
opportunistic pathogens (bacterial, viral,
fungal or protozoan) that usually do not
cause disease in a healthy host.

Parasitic

Pneumocystis carinii

Fungal

Candida
Cryptococcus

Opportunistic Infections
Bacterial
Tuberculosis (TB)
Strep pneumonia

Viral
Kaposi Sarcoma
Herpes
Influenza (flu)

Toxoplasma gondii encephalitis

Cryptosporidium spp. infection

Aims & Collaborative Goals

Monitoring of disease progression

Prevent opportunistic infection
Monitoring antiretrovital treatment
Management of signs and symptoms
Prevent complications of treatments

Nursing Management:
Assessment
Assess physical and psychosocial status
Identify potential risk factors: IV drug
abuse, risky sexual practices
Immune system function
Nutritional status
Skin integrity
Respiratory & neurologic status
Fluid and electrolyte balance
Knowledge level

Skin Integrity
Frequent routine assessment of skin
and mucosa
Reposition at least every 2 hours and
as needed
Pressure reduction devices
Instruct patient to avoid scratching
Use gentle, nondrying soaps or
cleansers
Avoid adhesive tape
Perianal skin care

Promoting Usual Bowel Pattern

Assess bowel pattern and factors
that may exacerbate diarrhea
Avoid foods that act as bowel
irritants, such as raw fruits and
vegetables, carbonated beverages,
spicy foods, and foods of extreme
temperatures
Small, frequent meals
Administer medications as prescribed
Assess and promote self-care
strategies to control diarrhea

Activity Intolerance
Maintain balance between
activity and rest
Instruction regarding energy
conservation techniques
Relaxation measures
Strengthening muscles

Maintaining Thought Processes

Assess mental and neurologic status
Use clear, simple language if mental
status is altered
Establish and maintain a daily
routine
Orientation techniques
Ensure patient safety and protect
from injury
Instruct and involve family in
communication and care

Nutrition
Monitor weight, I&O, dietary intake,
and factors that interfere with
nutrition
Dietary consult
Control of nausea with antiemetics
Oral hygiene
Treatment of oral discomfort
Dietary supplements
May require enteral feedings or
parenteral nutrition

Decreasing Isolation
Promote an atmosphere of
acceptance and understanding
Assess social interactions and
monitor behaviors
Allow patient to express feelings
Address psychosocial issues
Provide information related to the
spread of infection
Educate ancillary personnel, family,
and partners

Other Interventions
Improving airway clearance
Position in semi-Fowler's or high
Fowlers
Pulmonary therapy; coughing and
deep breathing, postural drainage,
percussion, and vibration
Ensure adequate rest

Pain
Medications as prescribed
Skin and perianal care

Prevention of Infection
Hand Hygiene
Proper washing of hands

Reverse barrier nursing for

patients whos decrease WBC
(neutropenia)
Proper use of protective barriers

Monitor blood investigations

(WBC) for early intervention,
report abnormal readings
Monitoring of V/S

Prevention of Infection
Minimize visitors with infections
because of pts. Immune response
Use strict asepsis for all invasive
procedures

Prevention of Infection
Ensure pts. environment is kept clean
to prevent transfer of organisms
Educate pt. on importance of hand
washing, clean environment to
prevent transmission of organisms
Ensuring pt. receives a nutritionally
balanced diet for maintenance of
immune system
Administration of anti infectives if
prescribed

Objectives
By the end of this session you should be
able to:
Define the term SLE
Identify the etiology of SLE
Explain the pathiphysiology of SLE;
Discuss the signs and symptoms of SLE;
and
Discuss the medical and nusring
management of SLE.

Systemic Lupus
Erythematosus (SLE)

Chronic multisystem inflammatory

disease
Occurs more frequently in women
More common in black women

Associated with abnormalities of

immune system
Results from interactions among
genetic, hormonal, environmental,
and immunologic factors

Incidence
SLE affects 2 to 8 persons per 100,000 in
United States
Most cases occur in women of
childbearing years
Peak incidence occurs between 15
40yrs.
Female to male ratio of 9:1
African, Asian, Hispanic, and Native
Americans three times more likely to
develop than whites

Etiology
Etiology is unknown
Most probable causes
Genetic influence
Hormones
Environmental factors (ultra violet light)
Certain medications
Hydralazine, procainanmide
Quinidine, methyldopa, isoniazid, phenytoin

SLE: Pathophysiology
There is a disturbed immune
regulation that causes an over
production of autoantibodies
This disturbance is caused by a
combination of factors:
Genetic
Hormonal
Environmental
Medication

Pathophysiology contd.
Abnormal suppressor T cell function
causes the increase in autoantibody
production
The autoantibodies combine with
antigens to form immune complexes
The immune complexes are
deposited in vascular and tissue
surfaces which triggers an
inflammatory response
The inflammatory process leads to
tissue damage

Clinical Manifestations
Onset may be acute (sudden) or
insidious (gradual)
Ranges from a relatively mild disorder to
rapidly progressing
Can affect any body system
Most commonly affects the skin/muscles,
lining of lungs, heart, nervous tissue,
and kidneys
Characterized by exacerbations and
remission

Clinical Manifestations

Fig 65-9

Clinical Manifestations
Dermatologic
Cutaneous vascular lesions
Discoid LE (chronic rash)
Butterfly rash
Oral/nasopharyngeal ulcers
Alopecia

Clinical Manifestations
Musculoskeletal
Polyarthralgia with morning stiffness
Arthritis
Swan neck fingers
Ulnar deviation
Subluxation with hyperlaxity of joints

Clinical Manifestations
Renal
Lupus nephritis
Ranging from mild proteinuria to
glomerulonephritis
Primary goal in treatment is slowing the
progression

Serum creatinine and urinanalysis is

done to screen for renal involvement

Clinical Manifestations
Nervous system
Generalized/focal seizures
Peripheral neuropathy
Cognitive dysfunction
Disorientation
Memory deficits
Psychiatric symptoms

Diagnostic Studies
No specific test
SLE is diagnosed primarily on criteria
relating to patient history, physical
examination, and laboratory findings

Diagnostic Tests

CBC for hematologic problems

UA for lupus nephritis
X-rays of affected joints
Chest x-ray for pulmonary problems
ECG for cardiac problems
Antinuclear antibody test (ANA)

Collaborative Care
Goals:
Early diagnosis
Preventing loss of organ fucntions
Minimize disease related disabilities
Preventing complicaitons from therapy

SLE: Drug therapy

NSAIDs
Reduce inflammation

Antimalarial drugs
Controls disease by decreasing
bodies production of antigens

SLE: Drug therapy cont.

Corticosteroids (prednisone)
Used to stabilize cells reducing the
inflammatory process
Block chemical pathways & decrease #
of circulating lymphocytes

Immunosuppressive and Steroidsparing drugs

Nursing Management
Nursing Diagnoses

Fatigue
Acute pain
Impaired skin integrity
Ineffective therapeutic regimen
management
Body image disturbance

Nursing Management
Planning
Overall goals
Have satisfactory pain relief
Comply with therapeutic regimen to
achieve maximum symptom management
Demonstrate awareness of, and avoid
activities that cause disease exacerbation
(triggers)
Maintain optimal role function and a
positive self-image

Nursing Management
Nursing Implementation
Acute intervention
During exacerbation, patient will
become abruptly, dramatically ill
Record severity of symptoms and
response to therapy

Nursing Management
Nursing Implementation
Acute intervention (contd)
Observe for

Fever pattern
Joint inflammation
Limitation of motion
Location and degree of discomfort
Fatigability

Nursing Management
Nursing Implementation
Acute intervention (contd)
Monitor weight and I&O
Collect 24-hour urine sample
Assess neurological status
Explain nature of disease
Provide support

Nursing Management
Nursing Implementation
Ambulatory and home care (Discharge)
Reiterate that adherence to treatment
does not necessarily halt progression
Minimize exposure to precipitating factors
fatigue, sun, stress, infection, drugs
Teach energy conservation and relaxation
exercises
For joint problems, all the teaching for RA
related to joint protection, ROM, and
positioning to prevent contractures

Nursing Management

Nursing Management
Lupus and pregnancy
Infertility can result from SLE treatment
regimen
SLE is associated with complications of
pregnancy
Pregnancy & post partum can cause
exacerbations of SLE
Women with serious SLE should be
counseled against pregnancy

Nursing Management
Psychosocial issues
Counsel patient and family that SLE has
good prognosis
Physical effects can lead to isolation,
self-esteem, and body image
disturbances
Assist patient in developing goals

Nursing Management
Evaluation
Expected outcomes
Performance of activities of daily
living without pain
Limitation of direct exposure to sun
and use of sunscreen
No open skin lesions

Nursing Management
Evaluation
Expected outcomes (contd)
Expression of satisfaction with
activity level
Pacing of activities to match level of
tolerance
Expression of confidence in ability to
manage SLE over time and in home
environment