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IMMUNOLOGIC

DISODERS
By:
Manuel L. Hermosa, EdD
Professor

I. STRUCTURES AND FUNCTION OF THE


IMMUNE SYSTEM

A. Functions of the Immune System

1. Defense against physical injury


and infection

2. Maintenance of homoeostasis, a
state of equilibrium of the internal
environment

B. Organs and Tissues of the Immune System include


the bone marrow and lymphoid tissue, which comprise
the thymus gland, lymph nodes, spleen, tonsils, and
adenoids.

1. Bone marrow is specialized soft tissue filling the


spaces in cancellous bone of the epiphyses. It is
responsible for:

a. releasing mature B lymphocytes into the blood


circulation

b. moving T lymphocytes from bone marrow to the


thymus

2. The thymus is a single unpaired gland that is


located in the mediastinum and is the primary central
gland of the lymphatic system. Its primary function is
allowing the T lymphocytes to develop before migrating
to the lymph nodes and spleen

3. Lymph nodes and vessels perform several important


function, such as:

a. transporting lymph

b. filtering and pathogocytizing (processing and


killing) antigens

c. generating lymphocytes and monocytes


4. Spleen functions include :

a. removing worn-out erythrocytes from blood

b. storing blood and platelets

c. filtering and purifying blood


5. The tonsils, adenoids, and other mucoid lymphatic
tissues defend the body against microorganisms
6. In the hematopoietic system, bone marrow and
lymphatic tissue produced blood cells including those
involved in immunologic defense (i.e. leukocytes)

C. Nonspecific Immunologic defense is


a type of immunity effective against
any harmful agent entering the body.
The bodys natural immunity can
discriminate friends from for or self
from nonself by cannot distinguish
between and pathogens.

Natural mechanism includes the following:

1. Physical barriers. Intact skin and mucous membrane prevent


pathogens from gaining access to the body. Cilia of the respiratory
tract filter and clear pathogens from the upper respiratory tract

2. Chemical barriers. Acidic gastric juices, enzymes in tears and


saliva, and sebaceous and sweat secretions attempt to destroy
invading bacteria and fungi.

3. Biologic response modifiers. Interferon, a viricidal substance,


counter viruses and activates other components of the immune
system

4. Action of white blood cells

a. Neutrophils are first to arrive at the inflammatory injury

b. Eosinophils and basophils are activated in response to allergic


reactions and stress

c. Granulocytes release cell mediators, such as histamine,


bradykinin, and prostaglandins and engulf the foreign toxins

d. Monocytes or macrophages function as phagotoc cells engulf,


ingest and destroy foreign toxins

5. Inflammatory response. This mechanism is elicited in response to tissue


injury or invading organisms. Most cells release chemical mediators, which
enhance the inflammatory response and produce the typical signs of infection
(i.e. redness, edema and itching). Vasoconstriction and vasodilation also play a
role in the inflammatory response.

6. Natural killer cells. These lymphocytes are responsible for immune


surveillance and host resistance to infection

7. Complements. This group of at least 20 circulating plasma proteins, made


in the liver, are subsequently activated in the presence of an antigen.

a. Functions of complement

- Cell lysis

- Opsonization, which involves making antigen more susceptible to


phagocytosis

- Chemotaxis, which involves inducing phagocytes to antigen

- Agglutination, which involves clumping of antigens

- Neutralization of viruses

b. Activation of complement can occur in one of two basic ways:

- Classical. Antigen antibody complex activates C1 (first of circulating


complement proteins)

- Alternate. No antigen-antibody complex is required; complement can be


initiated by the release of endotoxins and begins C3

D. Specific immunologic defense is a type of


immunity effective against specific harmful agents
entering the body. Immunity is a normal adaptive
response designed to protect the body against
potentially harmful antigens (i.e. any substance
recognized as foreign by the immune system)

1. Types of immunity

a. Inborn immunity is an inherited immunity of


species (e.g. human do not contract certain animal
diseases), races, and individuals to certain diseases.

b. Acquired immunity is immunity that develops


as an individual encounters specific harmful agents.
It may be natural (i.e. activated by the affected
individual) or as artificial (i.e. activated by vaccine)
and active or passive

- Active immunity involves production of antibodies


and

- Memory cells do not secrete antibodies, but on reexposure to the specific antigen, they develop into
antibody secreting plasma cells.

- Important vaccines include IM tetanus and


diphtheria booster injection which is required for adult
at least every 10 years, and the hepatitis B vaccine,
which is required for all health care workers

- Passive immunity is a temporary immunity


required by introduction of antibodies or sensitized
lymphocytes from another source (e.g. antibodies
through placental circulation to a fetus, gamma
globulin, anti serum from blood plasma of a person
with acquired immunity). The body dose not generate
memory cells.

2. The mechanism of specific immunity are of two


types : humoral (B lymphocytes) and cell mediated (T
lymphocytes) immunity. These two types of
immunologic responses discriminate self from nonself
and distinguish the formation of antibodies by plasma
cells in response to foreign proteins.

- Humoral immunity functions primarily in type I, type


II, and type III hypersensitivity reactions

- B lymphocytes ( so named because they were first


identified in the avian bursa) are involved in antibody
(i.e. immunoglobulin (Ig)) production

- Unsensitized B cells proliferate and mature into


plasma cells after exposure to antigen

- Plasma cells differentiate into memory cells (which


trigger a B-cell response on subsequent exposure to
same antigen) and antibodies

- Five types of antibodies are produced by the body:

- IgG activates complement, enhances phagocytosis,


crosses placenta (i.e. passive immunity), and is active in
a second response (reinfection)

- IgA is present in the body fluids (i.e. blood, saliva, and


tears, pulmonary, GI, prostatic, and vaginal secretions;
and breast milk), prevents absorption of antigens from
food, and protects against respiratory infections.

-IgM is the first antibody produced in the immune


response. It activates the complement system

-IgD may be required on B-cell surface for


transformation into plasma cells, but its exact role is
unclear

-IgE is associated with allergic and hypersensitivity


reactions and possibly helps in defense against parasites

b. Cell mediated immunity involves attack of microbes by


special killer T cells formed from lymphocytes

- Cellular immunity functions primarily delayed


hypersensitivity reactions; rejection of transplants; and
viral, fungal, and chronic infections

-T lympohocytes (cells are thymus derived), on


exposure to antigen, proliferate and differentiate into one
of several types of T cells.

- Helper T cells (T4) assist B-cells in humoral response


to form antibodies

- Suppressor T cells (T8) suppress B-cell synthesis of


antibody production through a feedback mechanism

- Memory T cells store future immune response to


some antigen

- Cytotoxic T cells direcly attack antigen, altering cell


membrane with resultant cell lysis

3. Stages of specific immune responses

a. Recognition. Circulating lymphocytes


and macrophages recognize foreign
maternal or antigens as nonself

b. Proliferation. Sensitized lymphocytes


proliferate, differentiate, and mature into
a respective T and B cells

c. Response. Antibody is produced with


specific T-cells action

d. Effector. Antigen is destroyed by


antibody, which is produced by B-cell or
cytotoxic T cell action

II. THE IMMUNE


SYSTEM

A. Assessment

1. Health history

a. Elicit a description of the clients present illness and


chief complaint, including onset, course, duration,
location and precipitating and alleviating factors. Elicit a
description of the clients overall health status, including
immunizations status usual childhood diseases, know
allergies, and a history of past and present medications.
Cardinal signs and symptoms indicating altered
immunity are subsequently described.

- General

- Recurrent infections

- Seasonal symptoms

- Weight loss

- Fever

- Head

- Itching, burning, watering eyes; vision problems; and eye infections

- Recurrent ear infections

- Rhinitis and sneezing

- Respiratory System

- Cough

- Dyspnea

- Recurrent infection

- Cardiovascular system

- Pain

- Reynauds phenomenon (i.e. extreme pallor and then cyanosis of


extremities brought on by cold exposure)

- GI System

- Nausea and vomiting

- Diarrhea

- Genitourinary System

- Recurrent infections

- dysuria and hematuria

- Musculoskeletal system

- Weakness and fatigue

- Inability to perform activities


of daily living (ADLs)

- Neurologic System

- Disorientation to name. date,


and place

- Altered level of
consciousness

- Paresthesias

b. Exposure the clients health history


for risk factors associated with
immune disorders, including not
keeping up to date immunizations,
exposure to infection disease, and
exposure to pollen, insects, and
allergens

2. Physical Examination

a. Inspection

- Inspect skin and mucous membranes fro rashes, lesions,


dermatitis, purpura (subcutaneous bleeding) and any type of
inflammation or drainage

- Assess the joints for tenderness, edema, and range of motion

- Inspect ears for drainage, inflammation, and scarring from ear


infections

b. Palpation

- Palpate the anterior and posterior cervical, axillary, and


inguinal lymph nodes fro enlargement

- Note the location, size, and consistency of lymph nodes.


Document complaints of tenderness if the node is palpable

c. Auscultation

- Auscultate lungs for abnormal lung sounds, such as wheezing,


crackles, and rhonchi

- Auscultate heart sounds for abnormalities, such as palpitations


and dysrhythmias

3. Laboratory and diagnostic studies

a. Multi-allergen allergy testing measures the increase and quantity of


allergen specific immunoglobulin (Ig) E antibodies and is done to identify
allergens to which the client has immediate hypersensitivity

b. T- and B-lymphocytes assays evaluate the number of lymphocytes in


the immune system

c. Ig assays (IgG, IgA, IgM) can detect and monitor immune deficiencies
d. Serum complement assays test for C3 and C4 complement when total
complement level is decreased
e. Autantibody tests

- Antinuclear antibody (ANA) test measures and differentiates ANAs


associated with certain autoimmune diseases such as systemic lupus
erythematosus

- Rheumatoid factor test measures for a macroglobulin type of antibody


found in rheumatoid arthritis
f. Radioallergosorbent test is radioimmunoassay that measures allergenspecific IgE.
g. The human immunodeficiency virus (HIV) test determines the presence
of HIV antibodies, which is the etiologic factor required immunodefiency
syndrome (AIDS)

B. Nursing Diagnoses

1. Ineffective airway clearance

2. Risk for infection

3. Acute or chronic pain

4. Impaired skin integrity

5. Deficient fluid volume

6. Deficient knowledge

7. Bathing or hygiene self-care deficit

8. Risk for injury

9. Ineffective coping

C. Planning and outcome identification.


The goal for a client diagnosed with
an immunologic disorder include
improved airway clearance,
prevention of infection, increased
comfort, improvement and
maintenance of skin integrity,
increased knowledge regarding
disease prevention and self-care,
absence of complications and injury,
and improved coping.

D. Implement

1. Assess respiratory status, including assessment of the


lungs, rate and depth of respirations, effort of breathing use
of accessory muscles, cyanosis, restlessness, anxiety, or
any change in level of consciousness

2. Minimize the risk of infection

a. Instruct the client on ways to avoid infection, including


the importance of personal hygiene and avoidance of
people with infections and large crowds

b. Instruct the client to wash the affected area with warm


water before applying topical creams; instruct him to wash
his hands before and after administering topical creams

3. Provide pain relief. Assess the clients pain, rule out any
complications, implement any nonpharmacologic
interventions (i.e. ice, cold, massage) to relieve pain,
administer pain medication, and evaluate the effectiveness
of interventions

4. Promote skin integrity

a. Assess the skin and mucous membranes for any rashes,


color changes, lesions, pallor, purpura, hydration and
inflammation

b. Keep skin clean and dry. Do not use harsh soaps

5. Maintain fluid balance. Monitor the clients intake and


output, and maintain 30 ml/hour urinary output; use a urometer
to ensure accurate output. Assess fro dehydration

6. Provide client and family teaching

a. Teach the client about the disease process and possible


triggers

b. Teach the client measures to minimize or prevent exposure


to the allergens

c. Discuss emergency measures (e.g. use of epinephrine) and


medication therapy, including the use of corticosteroids to reduce
inflammation

d. Teach the client danger signs and symptoms to report,


including respiratory distress and infection.

7. Promote self-care. Assist the client with


ADLs as needed, but promote independence.
Use any energy-saving techniques available

8. Prevent injury. Instruct the client to wear


identification tags or bracelets concerning
allergies or disease

9. Promote client and family coping

a. Teach the client and his family ways to


cope with chronic illness, including
verbalization of feelings and ways to prevent
exacerbations

b. Provide referrals

E. Outcome evaluations

1. The client displays no respiratory distress, as


evidenced by an absence of chest tightness,
wheezing, cyanosis, cough, and exaggerated
expiratory effort.

2. The client shows no symptoms of


opportunistic infection, such as fatigue, fever,
night sweats, weight loss and diarrhea

3. The client verbalizes relief of joint pain and


discomfort

4. The client exhibits clean, dry skin that is free


from rash, itching, burning, scaling, ulcerations
and infection

5. The client has intact skin and oral mucosa

6. The client maintains adequate fluid and


electrolyte balance and nutritional status

7. The client verbalize an understanding,


preventive measures, and treatment of the
disease process and the signs or symptoms
that should be reported to the health care
provider

8. The client is able to care for himself and


perform independent ADLs

9 The client remains free from injury

10. The client is able to verbalize


appropriate coping mechanisms to control
anxiety

CATEGORIES OF IMMUNE DISORDERS


A. Hypersensitivity reactions are immune responses to
allergens that result in tissue destruction

1. Type I (anaphylactic) reactions are mediated by the


immunoglobulin (Ig)E antibody, which promotes the release of
histamine and other reactive mediators. These basophil or
mast cells produce the characteristic symptoms of asthma or
hay fever.

2. Type II (cytotoxic) reactions (e.g. hemolytic anemia) are


mediated by IgG and IGM antibodies, which attach to cells
(usually circulating blood elements) and cause cell lysis

3. Type III (immune complex) reactions (e.g. rheumatoid


arthritis, serum sickness) are mediated by antigen-antibody
complexes that deposit in the lining of blood vessels or on
tissue surfaces

4. Type IV (delayed hypersensitivity) reactions (e.g. contact


dermatitis, transplant rejection) are mediated by lymphokines
released from sensitized T lymphocytes

B. Allergic disorders are hypersensitive


responses to an allergen to which the
organism has previously been exposed and
to which the organism has developed
antibodies

1. Interaction between antigen and


antibody typically results on one or more
manifestations of tissue injury

2. IgE antibodies are formed by persons


experiencing allergies who are genetically
predisposed. Histamine and other mediators
are released on reexposure to the allergen
to which the person is sensitized

C. Autoimmune disorders are


conditions in which the body no
longer differentiates self from nonself

1. Alterations in T cells or B cells


produce autoimmunebodies and
autosensitized T cells the cause
tissue injury. These changes may
involve one organ or many organ
systems

2. The cause of autoimmune


disorders remains unknown, but
many theories exist

D. Immune deficiency is defined as a congenital


or acquired deficit in the immune system that
makes the person susceptible to life-threatening
opportunistic infection

1. In congenital (primary) immunodeficiency,


the body produces inadequate amounts of one
or more immune cells. Deficits can be humoral
9B cell), cell- mediated (T-cell), or combined

2. Acquired (secondary) immunodefiuciency is


attributed to various etiologies, including:

a. immunosppressive therapy, such as


chemotherapeutic agents, corticosteroids,
nosteroidal anti-inflammatory agents and
irradiation

b. age-related factors, such as


deterioration in the thymus gland and T
cell functioning and a decreased number
of suppressor T cells and helper T cells

c. disruption of skin integrity, as occurs


with burns and trauma

d. nutritional deficits

e. malignant processes, such as


leukemia and lymphoma

f. infectious processes, such as sepsis


and acquired immunodeficiency
syndrome

TYPES OF LEUKOLCYTES
Cell Type

Normal Cell

Characteristic
s

Function

Granulocytes

Basophils

Eosinophils

Neutrophils

5,000 to
10,000/mm3

< 1% of all
leucocytes

2% to 4% of all
leukocytes
50% to 70% of
all leucocytes

* Formed in
bone marrow
* Granular
(under
microscope)
* Granules filled
with heparin,
histamine
* Contain
heparin,
histamine

* 12 hour
lifespan; 2 to 4
hour lifespan
with infection

* immediate
response to
cellular injury
* Play role in
inflammatory
* Play role in
hypersensitivity
* Phagotic
* First cell to
site of cellular
injury
* Contain
lysosomes

TYPES OF LEUKOLCYTES
Cell Type

Normal Cell

Characteristic
s

Agranilocytes

Lymphocytes

Monocytes

* Produced in

lymphatic
* 25% to 33% of system
all leukocytes
* Nongranular

(under

microscope)

* Classified as B
* 4% to 6% of
cells or T cells
all leukocytes

* Circulate in
blood but also
settle in tissue,
where they are
transformed in
macrophages

Function
* Fight infection

* Phagocytosis
* Release of
lymphokines
* Production of
gamma
globulins
* Cell mediated
reactions
* Phagocytosis
(can ingest
larger particles
that
neutrophils; five
times as many
in one
ingestion)

TYPES OF SPECIFIC IMMUNITY


(See page 7)

VACCINATION FOR ADULTS

HEPATITIS A

Recommended for travelers where


sanitation and hygiene are unsatisfactory
and foe people at high risk (i.e. homosexual
men, IV drug user, health care personnel).
Administered in two doses first dose, then
second dose 6 to 12 months after the first
dose

HEPATITIS B

Recommended for people at high risk (i.e. health


care personnel, hemodialysis clients).
Administered in three doses first dose, second
dose 1 month later, then third dose 5 months
after the second dose.

INFLUENZA Flu
shot

Recommended every fall for people age 65 or


older; residents in long term care facilities;
individual with heart or lung disease, diabetes,
kidney disease or a compromised immune
system; and for those who work with or live with
any of these individuals

VACCINATION FOR ADULTS

PNEUMOCOCC
AL

Recommended 1 time for people ages 65 or


older and for people younger than age 65
who have certain chronic illnesses. For
people with chronic respiratory disorders, a
one time revaccination dose after 5 years is
recommended

TETANUS
DIPTHERIA (Td)
tetanus shot

Must have booster every 10 years after childhood


immunizations. If none in childhood, must have
three shots first dose, then second dose 1
month later, then third dose 6 months after the
second dose

VACIRELLA

Recommended for people who have never had


chicken pox. Administered in two doses first
dose, then second dose 1 to 2 months after the
first dose.

HEALTH EDUCATION FOR ALLERGY SYMPTOM CONTROL


Maintain a dust free
environment

Reduce exposure to pollen

+ Reduce room contents to


the barest minimum by
removing drapes, curtains,
blinds (use pull shades
instead)
+ Wash wood work and
linoleum floors
+ Use wooden furniture,
which allows for easier
dusting
+ Use washable cotton
materials
+ Wear a mask when cleaning
+ Cover the mattress with a
hypoallergenic cover
+ Avoid wearing fabrics that
cause itching

+ Avoid barns, weed, dry


leaves, and grass
+ Avoid allergens and
irritants, including dusts,
fumes, odors, animals, and
tobacco smokes
+ Avoid sprays, powders, and
perfumes. Use hypoallergenic
cosmetics
+ Wear a mask at times of
increased exposures (e.g.
+windy days, mowing yard)
+ Be aware of high pollen
counts. Reduce exposure at
these times and stay in airconditioned areas
+ Ensure a smoke free

DISORDERS

ALLERGIC RHINITIS
A. Description. Allergic rhinitis (i.e.
hay fever) is an allergic reaction to
inhaled airborne allergens
characterized by seasonal
occurrences. It is the most common
form of respiratory allergy. Although
children and adolescents have an
especially high incidence, it occurs in
all age groups

B. Etiology. Allergic rhinitis is induced


by airborne pollens. Common
seasonal pollens include:

1. tree pollens (e.g. oak, maple,


and birch) in the spring

2. grass pollens (e.g. sheep sorrel,


and plantain) in the summer

3. weed pollens (e.g. ragweed) in


the fall

C. Pathophysiology. Allergic rhinitis


occurs when immunoglobulin (Ig)E
antibodies in the nasal mucosa
combine with inhaled allergens on
the mucosa surface. The nasal
mucosa reacts by slowing of ciliary
action, edema formation, and
leukocyte infiltration. Tissue edema
is a result of vasodilatation and
increased capillary permeability.

D. Assessment findings

1. Associated findings may be


include a family history of allergies

2. Clinical manifestations

a. Itching, burning nasal mucosa

b. Copious mucous secretions


causing runny nose

c. Red, burning tearing eyes

d. Sneezing

e. Pale, boggy nasal mucosa

3. Laboratory and diagnostic study findings

a. Nasal smears reveal eosinophils in nasal


secretions

b. Peripheral blood count reveal a


lymphocytes count above total 1,200/ml

c. Total serum IgE determination shows an


elevated serum level of IgE

d. Skin testing identifies the offending


allergens

e. Radioallergosorbent test measures


allergen-specific IgE. If antibodies are present,
they combine with the radiolabeled allergens,
which are compared with control values

E. Nursing Management

1. Administer prescribed medications, which


may include antihistamines, decongestants, and
topical cosrticosteroids

2. Encourage the client to use saline spray to


soothe mucous membranes. Advise the client to
blow his nose before administering nasal
medications

3. Prepare client for immunotherapy, which is


prescribed only when IgE hypersensitivity to
specific, unavoidable inhalant allergens (house
dust and pollens) is demonstrated

4. Minimize the risk of infection

5. Provide client and family teaching

ALLERGIC DERMATOSES
A. Description. Allergic dermatoses is
a group of inflammatory conditions
caused by skin reaction to irritating
or allergenic materials. They include
allergic contact dermatitis and atopic
dermatitis

B. Etiology
1. Allergic contact dermatitis is produced by
many substances. Common causes include
exposure to poison ivy, topical medications,
cosmetics, soaps, and industrial chemicals.
2. Although the cause of atopic dermatitis is
unknown, the condition appears to be
associated with a family history of allergic
respiratory disorders (e.g. allergic rhinitis,
asthma). Exacerbating factors amy include
irritants, infection, and certain allergens

C. Pathophysiology

1. Allergic contact dermatitis involves


delayed hypersensitivity and requires a latent
period ranging from several days ( for strong
sentisitizer such as poison ivy) to years

2. atopic dermatitis is type I immediate


hypersensitivity disorder resulting in large
amounts of histamine in the skin, changes in
lipid content of the skin, sebaceous gland
activity, and diaphoresis. It most commonly
begins in infancy or early childhood. It may
subside spontaneously to be followed by
unpredictable exacerbations throughout life.

D. Assessment findings

1. Associated findings. Client history may


known or suspected exposure to an
allergen

2. Clinical manifestations

a. Allergic contact dermatitis

- Burning, itching, edema, and erythema


of skin

- Crusting, weeping lesions

- Drying and feeling of the skin

- Hemorrhagic bullae, possibly with


severe responses

b. Atopic dermatitis

- Pruritus

-Hyperirritability of the skin

- Excessive dryness of the skin

- Redness for 15 to 30 seconds


after stroking followed by pallor
lasting 1 to 3 minutes

3. Laboratory and diagnostic study


findings

a. Allergic contact dermatitis.


Patch tests of the skin clarify
diagnosis with offending agents
being identified

b. Atopic dermatitis

- Serum immunoglobulin E levels


are frequently elevated

- Skin biopsy shows nonspecific


eczematous changes

E. Nursing Management

1. Administered prescribed medications, which may


include antihistamine, antipruritics, or steroidal creams

2. Minimize the risk of infection

3. Provide pain relief

4. Promote skin integrity

5. Promote client and family coping

6. Provide client and family teaching

a. Instruct the client to wear cotton fabrics and wash with


a mild detergent

b. Advise the client to take daily baths to hydrate the skin

c. Encourage the client to use topical skin moisturizer

d. Advise the client to humidify dry heat during winter.


Recommend that the client keep the room temperature at
680 to 700 F (200 to 21.0C)

ALLERGIC ASTHMA
A. Description. Allergic asthma is a
chronic reactive respiratory disorder
producing episodic, reversible airway
obstruction. The estimated incidence
is 3% to 8% of the population; more
than one half of cases found in
children younger than age 10

B. Etiology. Allergic asthma results


from an immunologically mediated
hypersensitivity to inhaled allergens,
such as airborne pollens and molds,
dust, and animal danders.

C. Pathophysiology. Although the pathologic


mechanisms of allergic asthma remain
somewhat unclear, the fundamental process
presumably involves a reaction of sensitized
immunoglobulin E antibodies to an inhaled
allergen, with subsequent release of chemical
mediators, such as histamine, slow-reacting
substance of anaphylaxis, and eosinophils
chemotactic factor of anaphylaxis. Obstruction
results from constriction of bronchial smooth
muscles, swelling of bronchial membranes,
and hyper secretion of mucus

D. Assessment findings

1. Associated findings. The clients health history


may reveal a family history of allergic asthma and
exposure to a known or suspected precipitating
substances

2. Clinical manifestations

a. Chest tightness

b. Prolonged, strenuous expirations

c. Wheezing on expirations

d. Buccal and peripheral cyanosis

e. Cough, non productive at first, followed by violent


coughing that produces thin, gelatinous mucus and is
relieved by a bronchodilator

f. Nausea and vomiting

g. Anxiety

3. Laboratory and diagnostic study findings

a. Pulmonary function studies reveal airway


obstruction and decreased peak expiratory flow
rate

b. Radiologic or bronchoscopic examination may


show hyperinflation and flattened diaphragm

c. Arterial blood gas (ABG) analysis typically


reveals the following:

- Decreased partial pressure of arterial oxygen

- Initially, decreased partial pressure of arterial


carbon dioxide (PaCO2) and increased pH
(respiratory alkalosis)

- Later increased PaCO2 and decreased pH


(respiratory acidosis)

E. Nursing Management

1. Administer prescribed medications, which include


adrenergics, bronchodilators, leukotriene receptor antagonist,
mast cell inhibitors, and oral corstocosteroids

2. Provide nursing care during an acute attck

a. Administer adrenergics , which are the initial medications


because they dilate bronchial smooth muscles, increase ciliary
movements, and decrease the chemical mediators of anaphylaxis

b. Collaborate with respiratory therapy and administer oxygen


as prescribed

c. Elevate the head of the bed, and lean the client forward to
provide maximum lung expansion and esae respiratory effort

d. Monitor respiratory rate and depth and auscultate lung


sounds

e. Monitor ABGs for changes from baseline

f. Administer fluids because clients are usually dehydrated from


diaphoresis

g. Provide reassurance to help relieve anxiety

3. Monitor for and take precautions to prevent


complications, such as pneumothorax, pulmonary
hypertension, right heart failure, and respiratory
failure

4. Provide client and family teaching

a. Encourage the client to undergo testing to


identify the cause of asthma attacks

b. Convey the importance of strict compliance


with the therapeutic regimen

c. Discuss the need for increased fluid intake to


thin bronchial secretions

d. Review stress reduction methods

e. Provide additional teaching

5. Provide referrals

ANAPHYLAXIS
A. Description. Anaphylaxis is an
acute, life threatening allergic
reaction marked by rapid
progressively urticaria and
respiratory distress that may result in
anaphylactic shock.

B. Etiology. Anaphylaxis results from


ingesting ( or other system exposure) to
allergenic substances. Possible causative
substances include:

1. Drugs (e.g. penicillin and other


antibiotics, vaccines, hormones,
salicylates, and local anesthetics)

2. Foods (e.g. legumes, nuts, berries,


seafoods, and egg albumin)

3. Sulfite containing food additives

4. Insect venom (e.g. wasp, hornets,


honeybee, certain spiders)

C. Pathophysiology

1. Anaphylactic reaction requires previous


sensitazations to the triggering allergen, with production
of specific immunoglobulin (Ig)E antibodies that bind to
mast cells and basophils

2. On exposure, IgE recats immediately with the


allergen and triggers release of potent chemical mediators
(e.g. histamine, eosinophil chemotactic factor of
anaphylaxis) from basophils and mast cells. Concurrently,
IgG or IgM activates release of complement fractions, and
two other chemical mediators (i.e. bradykinin and
leukotrienes) trigger profound vascular changes that can
lead to vascular collapse (i.e. anaphylactic shock)

3. Anaphylaxis is a medical emergency because of the


possibility of respiratory obstruction and vascular
collapse. In severe cases, death may occur within 5 to 10
minutes of onset.

B. Assessment findings

1. Clinical manifestations depend on whether


mediators remain local or are systemic

a. Local effects include wheals with surrounding red


flares and urticaria. Usually, local effects are not
dangerous

b. Systemic manifestations

- Intense urticaria and edema at the site of injection


or injury, rapidly spreading to the face, hands, and
other body areas

- Respiratory distress from bronchospasm, coughing,


sneezing, or wheezing

- Arrhythmias, tachycardia or bradycardia,


hypotension, and signs of circulatory collapse

- Nausea and vomiting, abdominal pain, and diarrhea

2. Laboratory and diagnostic study


findings

a. Serum and urine histamine is


elevated for a short time

b. Serum tryptase, a mast cell


enzyme marker for allergic and
anaphylactic reactions, elevated 30
to 90 minutes after reactions onset

E. Nursing Management

1. Provide nursing care during an anaphylactic attack

a. Establish a patent airway

b. Administer epinephrine, IM or subcutaneously, to


constrict dilated blood vessels, a tuberculin syringe to ensure
the exact dosage and monitor the client closely after
administration

c. Establish a patent IV line for drug and fluid


administration

d. Administer a high concentration of oxygen. Have a


tracheostomy set at the bedside

e. Monitor vital functions, evaluating blood pressure, pulse,


respirations, arterial blood gas values, electrocardiogram and
urinary output

f. Administer prescribed medications, which may include


anthistaminse, bronchodilators, vasopressors, and
corcosteroids

2. Teach preventive measures

a. Encourage the client to avoid or eliminate any


offending allergens

b. Advise the client, who is sensitive to insect bites,


to carry anti-sting kits

c. Instruct the client to wear identification tags or


bracelets

3. Maintain safety precautions

a. Always keep the client in the office for 30


minutes after administering any new medication to
determine if allergic reaction occurs

b. Always check for known allergies before


administering any prescribed or over the counter
medication

4. Provide referrals

RHEUMATOID ARTHRITIS
A Description. Rheumatoid arthritis is
a chronic, progressive disease
involving inflammation of ten
synovial joints. The incidence is three
times greater in women that in men.
Peak age of onset is between age 30
and 60, but the disease can develop
in any age.

B. Etiology. Rheumatoid arthritis is


apparently an autoimmune disorder;
its cause is unknown. Exacerbations
may be associated with increased
physical or emotional stress.

C. Pathophysiology. Pathologic changes


begin as inflammation and progress
to destruction of joints, producing
deformity and loss of motion. The
disease may affect only joints or may
extend to body organs and blood
vessels.

D. Assessment findings

1. Clinical manifestations

a. Edematous, warm, tender joints

b. Limited range of motion in affected joints

c. Generalized edema or nodules around


affected joints

d. Impaired mobility and ability to perform


activities of daily living (ADLs)

e. Fatigue, weakness, and anorexia

f. In later stages, weight loss, fever, anemia,


muscle atrophy, and Sjogrens syndrome

2. Laboratory and diagnostic study


findings

a. Radiographic studies reveal


abnormalities such as progressive
joint damage

b. Rheumatoid factor is present


in more 80% of the clients

c. Erythrocyte sedimentation
rate is significantly elevated

d. Red blood cell count and C4


complement are decreased

E. Nursing Management

1. Administer prescribed medications, which may include


nonsteroidal anti inflammatory drugs, aspirin, slow acting
antirhematic medications, and corticosteroids

2. Provide pain relief. Provide comfort measures, including


massage and position changes. Apply hot or cold therapy to
affected joints according to the clients needs

3. Promote self-care

4. Promote client and family coping

5. Promote adequate rest and sleep to prevent fatigue;


provide comfort measures, including a foam mattress and
supportive pillows; and discuss energy conservation techniques

6. Encourage proper body alignment to prevent contractures

7. Collaborate with the physical therapist to design and


provide the client with physical therapy program, which begins
after the acute phase resolves. Encourage a muscle activity
program for self-care. Water exercises are excellent because
water promotes buoyancy, which eases joint movement

8. Recommend a weight reduction program,


if appropriate

9. Collaborate with the occupational


therapist and promote the use of braces,
splints and assistive mobility devices, if
appropriate

10. Discuss relaxation techniques, such as


imagery, elf hypnosis, biofeedback,
diversionary activities,a nd distraction for
pain management

11. Discuss maintaining optimal nutritional


status

12. Provide a referral

SYSTEMIC LUPUS ERYTHEMATOSUS


A. Description. Systemic lupus
eryhtematous (SLE) is a chronic
systemic inflammatory disease
affecting multiple body systems.
Women are affected at least eight
times more often than men, and
women of childbearing age are
particularly susceptible

B. Etiology. SLE is thought to be


autoimmune disorder

C. Pathophysiology
1. SLE involves markedly increased B-cell
hypergammaglobulinemia, autoantibody
production, and decreased T cell functions.
Symptoms result from immune complex
invasion of body systems. Disease progression,
which is characterized by recurring remissions
and exacerbations, is widely variable
2. Prognosis is good with early detection and
treatment however, SLR can lead to potentially
serous complications, including cardiovascular,
renal, and neurologic problems and serve
bacterial infections

D. Assessment findings

1. Clinical manifestations may be insidious or a acute;


the client may remain under diagnosed for many years;
clinical manifestations involve multiple body systems

a. Musculoskeletal system

- Arthralgias and arthritis (synovitis)

- Joint edema and tenderness

- Pain on movement and morning stiffness

b. Integumentary system

- Subacute cutaneous lupus erythamatous results in a


butterfly rash across the bridge of the nose and cheeks

- Discoid lupus erythematosus results in skin


involvement that may b eprovoked by sunlight or artificial
ultraviolet light

- Oral ulcers of the buccal mucosa and hard palate


occur in crops and may accompany skin lesions

c. Cardiovascular system

- Pericarditis

- Popular, eryhtematous, and purpuric lesions on


finger tips, elbows, toes, forearms, and hands

d. Respiratory sytem

- Pleural effusion

- Pleuritis

e. Neurologic system

- Subtle changes in personality and cognitive ability

- Commonly, depression and psychosis

f. Other systems

- Lymphadenopathy

- With renal involvement, the glomeruli of kidney


are usually affected

2. Laboratory and diagnostic study


findings

a. Antinuclear antibody test result is


positive

b. Red and white blood cell counts may


be decreased, revealing
thrombocytopenia, severe anemia,
leukocytosis, and leucopenia

c. Anti-deoxyribonuclic acid cell test


reveals a high titer

d. Urine testing reveals proteinuria and


cellular casts in urine

E. Nursing Management

1. Administer prescribed medications, which may


include corticosteroids, nonsteroidal, anti-inflammatory
drugs, and salyclates to help control the joint pain and
oral or topical corticosteroids to help with the rash. Anti
malarial agents are used in some clients

2. Maintain skin integrity, which includes keeping the


skin clean and dry, using mild soaps and lotions, and
inspecting the skin for vasculitic lesions

3. Perform cardiovascular, respiratory, neurologic and


musculoskeletal assessment to identify and described
any systemic problems

4. Provide meticulous mouth care

5. Arrange for a dietary consult to ensure optimal


nutrition while meeting the clients need for soft, easily
tolerated foods

6. Apply warm packs as needed to relieve joint pain and


stiffness

7. Collaborate with the physical therapy department and


encourage an appropriate exercise program to help
maintain mobility and strength

8. Provide client and family teaching

a. Encourage protection from the sun and ultraviolet light.


Advise the client to avoid going out between 10:00 am and
4:00 pm, use sunscreen with a sun protection factor of at
least 30, wear a large hat and tight weave clothing, and
refrain from using a tanning bed

b. Advise the client to consult a health care provider


before receiving immunizations or taking birth control pills
or over the counter drugs

c. Advise the client to avoid persons with contagious


infections

9. Provide a referral

ACQUIRED IMMUNODEFICIENCY SYNDROME


A. Description. Acquired immunodeficiency
syndrome (AIDS) is a severe
immunodeficiency caused by the human
immunodeficiency virus (HIV), which allows
normally benign organisms to flourish and
cause disease. The virus cause cell death
and a decline in immune function resulting in
opportunistic infections, malignancies, and
neurologic problems. These opportunistic
conditions define the syndrome.

B. Etiology

1. HIV is transmitted sexually, through direct


contact with blood or blood products and some body
secretions

2. Persons at risk for contracting HIV

a. Anyone who engages in unprotected sexual


activity with an infected partner.

b. Recipients of transfused blood or blood


components (uncommon since 1985, when blood
screening was instituted)

c. IV drug abusers

d. Children (perinatally) of mothers with HIV

e. Health care workers exposed to HIV needle stick


( The incidence ofr health care workers exposed to
HIV by needle stick is estimated to be less than 1%)

C. Pathophysiology. HIV is a part of a group of


viruses known as retroviruses, which carry
genetics material in ribonucleic acid rather than
deoxyribonucleic acid. HIV infects cells with CD4
lymphocytes (also called T4 or helper T cells).
This infection causes cell death and a decrease in
the immune function, resulting in opportunistic
infections and neurologic problems. HIV can be
isolated from blood, semen, saliva, tears, breast
milk, and cerebrospinal fluid. After a variable
course of about 10 years from the time of
infection, 50% of infected persons develop AIDS.
The incubation period of HIV varies, ranging from
6 months to 5 years, with an average of 2 years

D. Assessment findings

1. Associated findings. The Client may report recurring viral and bacterial
infections

2. Clinical manifestations

a. Fatigue

b. Fever and night sweat

c. Weight loss

d. Generalized lymphadenopathy

e. Nonproductive cough and shortness of breath

f. Skin lesions, dry skin, and pallor

g. GI upset and chronic diarrhea

h. Edema

i. Visual impairment

j. Painful oral lesions

k. Bruising and bleeding tendencies

l. Joint pain

m. Opportunistic infections, such as Pneumocystis carini pneumonia,


mycobacterial infections, cryptococcal infection, toxoplasmosis, histoplasmosis
and cytomegalovirus infection

n. Kaposis sarcoma and AIDS dementia complex

p. HIV wasting syndrome

3. Laboratory and diagnostic findings

a. Enzyme linked immunosorbent assay (ELISA)


indicates exposure to or infection with HIV but does
not diagnose AIDS

b. Western blot assay identifies HIV antibodies

c. SUDS screening test is only 95% accurate but


the results are available in 30 to 60 minutes. This
test is only useful when a health care worker
sustains a needle stick injury, if the clients test
comes back positive, the health care workers is
started on prophylactic anti-retroviral medications

d. AIDS is diagnosed on clinical history, risk


factors, physical examination. Laboratory evidence
of immune dysfunction and positive ELISA or
Western blot assay.

E. Nursing Management. No cure or vaccine has been found, and


treatment focuses on maintaining health and improving survival
time.

1. Administer prescribed medication, which may include drug


therapy for AIDS related opportunistic infections, antiretroviral
therapy, antidiarrheals, and antiemetics

2. Promote preventive measures related to the transmission of


HIV. This is a prime concern until a vaccine is found; researchers
have reported that a vaccine is being investigated and tested for
prevention of HIV transmission

a. Promote public education regarding HIV and AIDS. Teach


client and families to practice safe sex, avoiding sharing needles,
and avoid touching anothers body fluid without protection

b. Inform HIV infected clients that even though HIV is


undetectable, the clients may be infectious and should practice
safe sex

c. Promote standard precautions to protect health care provider


from exposure to the clients blood or body fluids and to protect
the client from cross contamination

3. Maintain skin integrity by instructing the client to avoid


scratching strong perfumed , soaps, and adhesive tapes; follow
routine oral care; keep anal area as clean as possible. wear
white socks to prevent foot problems; keep linens dry and
clean; and apply protective barriers to the skin as necessary

4. Instruct the client about the promotion of normal bowel


movements and prevention of diarrhea. Instruct the client to
monitor the quantity and volume of liquid stools and avoid
bowel irritants, such as raw fruits, vegetables, spicy foods, and
hot and cold foods.

5. Promote infection prevention. Discuss the importance of


maintaining personal hygiene, keeping bathrooms and kitchens
clean, and getting adequate rest activity and well balance diet

6. Teach energy conservation technique such as sitting while


doing morning care, using a shower chair and arranging the
home in a way save time from walking or standing. In the
hospital, put all necessary items within easy reach

7. Discuss ways the client and family can assist with mental status problems.
These includes putting notes on the refrigerator or note boards, using
calendars and clocks to orient the clients to time and place, and assisting the
client with paying bills, shopping and other households activities

8. Teach methods for airway clearance. These include turning, coughing,


and deep breathing; increasing fluid intake to thin secretions; maintaining
semi-Fowlers position; and using humidified oxygen if necessary.

9 Help maintain nutritional status by controlling nausea and vomiting


encouraging foods that are easy to swallow; encouraging oral hygiene before
and after meals; promoting a high protein, high calorie diet; monitoring
weight, intake and output, monitoring fluids and electrolyte balance; and
administering appetite stimulants

10. Monitor and manage complications of opportunistic infections.


Opportunistic infections protozoans, fungal, bacterial and viral occur
because of immune suppression; they account for most of the clinical
manifestations observed in AIDS . Pneumocystis carini pneumonia is the most
common.

11. Teach ways to cope with chronic illness to the client and his family.
Always include the family in teaching and care, and provide family members
with grief counseling. Discuss advanced directives and durable power of
attorney for health care

12. Provide referrals

MEDICATIONS FOR IMMUNE DISORDERS


Classificatio
ns

Indicatio
ns

Selected Interventions

Adrenergic
Albuterol
Epinephrine
Isoetharine
Isoproterenol
Metaproteren
ol
terbutaline

Relax
smooth
bronchial
muscle
and dilate
airways

* Instruct the client to inhale twice as


follows; inhale once, wait 1 minute, and
inhale once more

Antibiotics
Aminogycosid
es
(gentamicin,
tobramycin)
Amoxicillin
Erythromycin
Penicillin
tetracycline

Prevent
or
treat
infections
caused by
pathogeni
c
microorga
nisms

* Before administering the first dose,


assess the client for allergies and
determine whether culture has been
obtained
* After multiple doses, assess the client
for super infection (thrush, yeast
infection, diarrhea); notify the health
care provider if these occur
* Assess the insertion site for phlebitis if
antibiotics are being administered IV
* To assess the effectiveness of

MEDICATIONS FOR IMMUNE DISORDERS


Classifications

Indications

Selected Interventions

Antidiarrheal
Attapulgite
Bismuth
subsalicylate
Diphenoxylate
and atropine
loperamide

Absorb excess
water from stool

* To assess the effectiveness


of the medication, record the
number and consistency of
stools
* Monitor intake and output,
daily weight, and serum
electrolyte levels

Antiemetics
Benzquinamide
Dimenhydrinate
Trimethobenza
mide
Hydrochloride
Promethazine
scopolamine

Relieve nausea and


vomiting by
inhibiting
medullary
chemoreceptor
triggers; drug
choice depends on
the cause of
vomiting

* Advise the client that this


medication may cause
drowsiness
* Because the medication
may cause chemical
irritation, administer by deep
IM injection into a large
muscle mass, if appropriate
* Measure emesis and
maintain accurate intake and
output; monitor for
dehydration

MEDICATIONS FOR IMMUNE DISORDERS


Classification
s

Indications

Selected Interventions

Antihistamines
Cetirizine
Cholorphenira
mine maleate
Descloratadin
e
Diphenhydram
ine
Fexofenadine
Loratidine
terfenadine

Inhibit
histamine
release by binding
selectively to H,
receptors

Antipruritic
agents
Topical
steroids
Desoximetaso
ne
Hydrocosrtison

Relieve or prevent
itching (may be
topical steroids or
anesthetics)

* Teach the client to avoid


alcohol, driving, or engaging in
hazardous activities because
the medication may cause
drowsiness. (Some
antihistamines are nonsedating.
Make sure the client is
knowledgeable of the
medications adverse effects)
* Encourage sucking on hard
candy or ice chips fro relief of
dry mouth
* Advise the client to wash his
hands
before
and
after
application
* Instruct the client to clean the
affected area with warm water
before application

MEDICATIONS FOR IMMUNE DISORDERS


Classification
s

Indications

Selected Interventions

Antiretrovirals
Nucleoside
inhibitors
Didanosine
Zidovudine

Nonnucleoside
reverse
Transcriptase
inhibitors
Delavirdine
Nevirapine

Protease
inhibitors
Indinavir
ritonavir

Suppress synthesis of viral


deoxyrisbonucleic acid
reverse transcriptase);
first drug used against
human immunodeficiency
virus (HIV) infection;
remains a mainstay of
treatment
Cause direct inhibition of
HIV by binding to active
center of reverse
transcriptase

Bind to the active site of


HIV protease, thereby
preventing the enzyme
form cleaving HIV
polyprotiens; the virus
remains immature and
noninfectious when used
in combination with

* The client must adhere


closely to the prescribed
dosing schedule
* All medications are oral.
Except IV zidovudine which
must be administered slowly

* Instruct the client to take the


medication 1 hour before or
after food or antacids
* Inform the client to notify his
health care provider if a rash
occur

* Instruct the client to follow


proper instructions when
taking the medication, some
must be taken on an empty
stomach, and others must be
taken with food
* Inform the client that all

MEDICATIONS FOR IMMUNE DISORDERS


Classification
Indications
s
Bronchodilator Relax
bronchial
s
(xanthine smooth muscle
derivatives)
theophylline

Corticosteroids
Inhaledfluticasone;
beclomethason
e
Oral

hydrocortisolo
ne,
prednisone)
Topical

Ensure a potent,
local acting antiinflammatory and
immune modifier
effect; also used
to strengthen the
biologic
membrane, which
inhibits capillary
permeability, and

Selected Interventions
* Monitor serum level of theophylline
(therapeutic level, 10 to 20 ug/ml)
* Provide the medication at regular
intervals, before meals, and with a full
glass of water
* Instruct the client to notify his health
care provider of irritability, restlessness,
headache,
insomnia,
dizziness,
tachycardia, palpitations, or seizures
* Do not crush sustained release
medication
* Caution the client not to exceed the
maximum daily dose of 4 sprays/nostril
* Instruct the client to rinse his mouth
after each use to prevent nasal
candidiasis
* Instruct the client to take the
medication exactly as directed and to
taper it rather than stop it abruptly,
which could cause serious withdrawal
symptoms
leading
to
adrenal
insufficiency, shock, and death

MEDICATIONS FOR IMMUNE DISORDERS


Classifications

COX-2 inhibitors
Celecoxib
rofecoxid

Indications

Inhibit the
formation of
substances that
can cause joint and
connective tissue
problems

Leukotriene
Reduce
receptor antagonist inflammation in airmontelukast
ways; used for
prophylactic and
maintenance drug
therapy for chronic
asthma

Selected
Interventions

* Instruct client to
take medication in
the evening
without food
* Explain that the
medication is not
for acute asthma
attacks

MEDICATIONS FOR IMMUNE DISORDERS


Classifications
Mast cell inhibitor
Cromolyn sodium

Indications

Selected
Interventions

Inhibit
mast
cell,
thereby
releasing
chemical
mediators
that
result
in
bronchodilation and a
decrease in airway
inflammation

* Teach the client to


insert the capsule in
a nebulizer device,
exhale completely,
place the mouth
piece between the
lips, inhale deeply,
hold the breath for 10
seconds, and then
exhale
* Tell the client that
an inhaler is used
prophylactically
before exercise, not
in acute asthma
attack

MEDICATIONS FOR IMMUNE DISORDERS


Classifications

Indications

Selected
Interventions

Nonopiod analgesics
Nonsteroidal
Anti-inflammatory
drugs
Acetylsalicylate acid
ibuprofen

Relieve pain, edema,


and inflammation

* Instruct the client to


take with food to
decrease GI upset
* Instruct the client to
report signs and
symptoms of GI
distress (i.e. nausea,
vomiting, bleeding) to
his health care
provider

Vasopressors
Metaraminol
norepinephrine

Rapidly restore blood


pressure in
anaphylaxis by
producing
vasoconstriction and
stimulating the heart

* Monitor the clients


vital signs, intake and
output, mental
status, peripheral
pulses, and skin color.
* The client should be
on telemetry and
monitored
continuously