Transcript Nursing of Adult Patients with Medical & Surgical Conditions

Nursing of Adult Patients
with
Medical & Surgical Conditions
Care of the Patient
with an
Immune Disorder
Nature of Immunity
• Three Main Functions
– Protect the body’s internal environment
against invading organisms
– Maintain homeostasis by removing
damaged cells from the circulation
– Serve as a surveillance network for
recognizing and guarding against the
development and growth of abnormal cells
Organization of the
Immune System
Nature of Immunity
• Inappropriate Responses of the
Immune System
– Hyperactive responses against
environmental antigens (allergy)
– Inability to protect the body, as in
immunodeficiency disorders (AIDS)
– Failure to recognize the body as self, as in
autoimmune disorders (systemic lupus
erythmatosus)
– Attacks on beneficial foreign tissue (organ
transplant rejection or transfusion reaction)
Nature of Immunity
• Innate (Natural) Immunity
– First line of defense
– Provides physical and chemical barriers to
invading pathogens and protects against
the external environment
– Composed of the skin, mucous
membranes, cilia, stomach acid, tears,
saliva, sebaceous glands, and secretions
and flora of the intestine and vagina
– Non-specific immunity
Nature of Immunity
• Adaptive (Acquired) Immunity
– Second line of defense
– Provides a specific reaction to each
invading antigen
– Protects the internal environment
– Composed of thymus, spleen, bone
marrow, blood, and lymph
– Produces antibodies in the cells after an
infection or vaccination
Nature of Immunity
– Macrophages (phagocytes)
• Engulf and destroy microorganisms that
pass the skin and mucous membrane.
• Carries antigen to the lymphocytes
Nature of Immunity
– Lymphocytes
• T Cells
– 70 - 80 % of lymphocytes
– Releases lymphokine to attract
macrophages to the site of infection or
inflammation
– Responsible for cell-mediated immunity
– Provide the body with protection against
viruses, fungi, and parasites.
• B Cells
– 20 - 30% of lymphocytes
– Cause the production of antibodies
– Provide protection against bacteria, viruses,
and soluble antigens
Types of Adaptive Immunity
• Humoral Immunity
– Responds to antigens such as bacteria and foreign
tissue
– Result of the development and continuing
presence of circulating antibodies in the plasma
– Active Immunity
• antibodies are produced by one’s own body (vaccines)
– Passive Immunity
• antibodies formed by another in response to a specific
antigen and administered to an individual (HBIG)
• Cellular Immunity
– Defense against intracellular organisms
– Involved in resistance to infectious disease caused
by viruses and some bacteria
Immune Response
• Immunization
– A controlled exposure to a diseaseproducing pathogen which develops
antibody production and prevents disease
– Provides protection for months to years
Immune Response
• Immunotherapy
– Treatment of allergic responses that
administers increasingly large doses of the
offending allergens to gradually develop
immunity
– Preseasonal, coseasonal, or perennial
– Severe side effect: Anaphylaxis
Hypersensitivity
• Hypersensitivity
– an abnormal condition characterized by an
excessive reaction to a particular stimulus
• Hypersensitivity Reaction
– an inappropriate and excessive response of
the immune system to a sensitizing antigen
• Hypersensitivity Disorders
– Harmless substances such as pollens,
danders, foods, and chemicals are
recognized as foreign
Hypersensitivity
• CAUSE:
– Genetic defect that allows increased
production of Immunoglobulin E (IgE)
– Exposures may occur by inhalation,
ingestion, injection, or touch
Hypersensitivity
• Diagnostic Tests
– History
• onset, nature, and progression of symptoms
• aggravating and alleviating factors
• frequency and duration of signs and symptoms
– Physical Exam
• Assessment of skin, middle ear, conjunctiva,
nasooropharynx, and lungs
– Laboratory Studies
• CBC, skin testing, total serum IgE levels
Hypersensitivity
• Medical Management
– Symptom management with medications
• Antihistimines--pseudoephedrine(Actifed),
diphenhydramine(Benadryl),
chlorpheniramine(Chloir-Trimeton),
brompheniramine(Dimetapp), cetirizine(Zyrtec),
loratidine(Claritin), and fexofenadine(Allegra)
– Environmental control
• Avoidance of the offending allergen
– Immunotherapy
• Allergy specific injections
Anaphylaxis
• Etiology/Pathophysiology
– System reaction to allergens
• Venoms
• Drugs - penicillin
• Contrast media dyes
• Insect stings
• Foods
Anaphylaxis
• Signs and Symptoms
– Feelings of uneasiness to impending death
– Urticaria(hives) and pruritus
– Cyanosis and pallor
– Congestion and sneezing
– Edema of the tongue and larynx with stidor
– Bronchospasm, wheezing, and dyspnea
– Nausea and vomiting
– Diarrhea and involuntary stools
– Tachycardia and hypotension
– Coronary insufficiency, vascular collapse,
dysrhythmias, shock, cardiac arrest,
respiratory failure, and death
Anaphylaxis
• Treatment
– Epinephrine 1:1000 0.5 ml SQ
(may repeat at 15 minute intervals)
– Benadryl 50 to 100mg IM or IV
– IV access
– Oxygen (as ordered by physician)
– Aminophylline ( as ordered)
Anaphylaxis
• Nursing Interventions
– Assessment:
• Respiratory status
• Circulatory status
• Vital signs
• Intake and output
• Mental status
• Skin status
• GI status status
– Teaching
• Avoid allergen
• Use Medic-Alert ID
• Administration of epinephrine
Transfusion Reactions
• Etiology/Pathophysiology
– Reactions that occur with mismatched
blood
Transfusion Reactions
Signs and Symptoms
– Mild
• Dermatitis
• Diarrhea
• Fever
• Chills
• Urticaria
• Cough
• Orthopnea
– Moderate
• Fever
• Chills
• Urticaria
• Wheezing
– Severe
• Fever
• Extreme Chills
• Severe Urticaria
• Anaphylaxis
Transfusion Reactions
• Treatment
– Mild
• Stop transfusion
• Administer saline
• Administer steroids, diuretics, and
antihistimines as ordered
• Physician may order transfusion continued at a
slower rate.
Transfusion Reaction
• Treatment
– Moderate
• Stop transfusion
• Administer saline
• Administer antihistamines and epinephrine as
ordered
Transfusion Reaction
• Treatment
– Severe
• Stop transfusion
• Administer saline
• Administer antihistamines and epinephrine as
ordered
• Return blood or blood product to lab for testing
• Obtain urine specimen
Delayed Hypersensitivity
• Reaction occurs 24 to 72 hours after
exposure
• Examples include:
– Poison Ivy
– Tissue transplant rejection
Transplant Rejection
• Autograft
– Transplantation of tissue from one site to
another on an individual
• Isograft
– Transfer of tissue between genetically
identical individuals (identical twins)
• Allograft (homograft)
– Transplantation of tissue between
members of the same species
• Heterograft
– Transplantation of tissue from another
species such as a pig or cow
Transplant Rejection
• Antigenetic determinants on the cells
lead to graft rejection via the immune
process
• 7-10 days after vascularization,
lymphocytes appear in sufficient
numbers for sloughing to occur
Transplant Rejection
• Immunosuppressives
– Administration of agents that interfere with
the ability of immune system to respond to
antigenic stimulation
• Corticosteroids
• Cyclosporine (Neoral, Sandimmune)
• Azathioprine (Imuran)
Immunodeficiency
• An abnormal condition of the immune
system in which cellular or humoral
immunity is inadequate and resistance
to infection is decreased
• May cause recurrent infections, chronic
infections, severe infections, and/or
incomplete clearing of infections
• Can be induced (chemotherapy)
Autoimmune Disorders
• The development of an immune
response to one’s own tissues
• Body is unable to distinguish “self”
protein from “foreign” protein
• Examples of disorder:
– pernicious anemia
– Guillain-Barr’e
– Scleroderma
– Systemic lupus erthematosus