Transcript Ch 11 Care of Pts with Immune and Lymphatic DOs

Chapter 11
Care of Patients with Immune and Lymphatic
Disorders (with HIV and AIDS)
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Theory Objectives
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Discuss the key differences between primary
and acquired immune deficiency disorders.
Summarize the ideal actions of therapeutic
immunosuppressive drugs.
Illustrate the modes of transmission for HIV.
Discuss how pre-exposure prophylaxis reduces
the risk of contracting HIV.
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Theory Objectives (Cont.)
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List diagnostic tests for HIV and those used to
monitor the immune status of an HIV-positive
patient.
Determine opportunistic infections (viral,
bacterial, fungal, parasitic) that occur in HIV
patients.
Give examples of autoimmune disorders or
diseases within each of the three categories
of autoimmune disorders.
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Theory Objectives (Cont.)
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Compare and contrast the two types of
lymphoma, including how they are diagnosed.
Explain why the process of diagnosis and
treatment for fibromyalgia would be difficult or
frustrating for the patient.
Construct how an allergic reaction occurs
during an excessive immune response.
Relate the nurse’s role in helping the patient
to control allergies.
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Clinical Practice Objectives
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During a clinical rotation, review the facility's
policy for exposure to blood or body fluids
from an HIV-positive patient.
List nursing measures for the prevention of
infection for an immunocompromised patient.
Perform data collection on a patient in whom
an immune-suppressant disorder is
suspected.
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Clinical Practice Objectives (Cont.)
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Review a nursing care plan for a patient who
has low immunity.
Write nursing interventions for a patient with
fibromyalgia.
List the usual measures for treating an
anaphylactic reaction and locate the
necessary emergency equipment on your
clinical unit.
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Immune Function and Dysfunction
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Immunocompetence – threat stimulates
chemical, vascular – release of WBCs
Immune deficiency – abnormal response of
immune system due to infection, medical
therapy, exposure to toxins
Autoimmune disorders- overreaction or
hypersensitivity
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Immune Deficiency Disorders
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Two forms of immune deficiency
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Primary: an inherited genetic mutation (see Box
11-1 page 217)
Acquired:
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Immosuppressants used for organ
transplants/chemo reduces ability of the bone
marrow to produce WBC
human immunodeficiency syndrome (HIV) and
acquired immune deficiency syndrome (AIDS)
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What are examples of automimmune
disorders?
Lupus – antibodies assault healthy
cells
Type 1DM - body attacks pancreatic
cells that produce insulin
Immune Deficiency Disorders (Cont.)
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Diagnostic tests and treatment (Box 11-3 p.
218)
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CBC w/diff, RBC, creatine level, antinuclear
antibody, bone marrow studies, T-cell and B-cell
assays, Enzyme linked immunosorbent assays
(ELISA)
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What are some appropriate Nursing
diagnosis for these patients?
•
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•
Altered activity intolerance r/t
inflammatory nature of the disease
Chronic pain r/t inflammation from
the disease process
Potential for altered skin integrity r/t
sun sensitivity from the disease
process
Human Immunodeficiency Virus (HIV)
and Acquired Immunodeficiency
Syndrome (AIDS)
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HIV-1 and HIV-2
HIV1 – widespread
HIV 2- Western Africa, spreads at a lower
rate, lower plasma viral load takes longer to
incubate, lesser risk of developing AIDS
Pathophysiology
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Retrovirus- RNA replicates itself in host cell’s DNA
Reverse transcriptase – helps HIV replicate in
host cells- attached to CD4 T cell wall receptors
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HIV
Transmission of HIV
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The three highest risks for becoming infected
with HIV include:
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Having unprotected sex (oral, vaginal, or anal)
with an HIV-positive person
Sharing needles and syringes with an HIV-infected
person
Maternal–fetal exposure
Other possible risks are tattoos, body piercings,
and blood products
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Exposure Prophylaxis
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Pre-exposure
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Truvada (tenofovir disoproxil fumarate and
emtricitabine) = PreP
Safe sexual practices
Blood products – all screened 1 in 1.5million
chance to contract HIV
Vaccine development – difficult because
mutation rate- vaccine in development using
stem cells from people immune to HIV
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Signs and Symptoms
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No symptoms to flulike symptoms
Sentinel infections – opportunistic infections
that indicate immunosuppression (oral thrush,
night sweats, sig. unintended weight loss)
Variable clinical presentations and latent
periods without obvious symptoms
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Diagnosis
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HIV-1 Test System and OraQuick In-Home
HIV
Enzyme-linked immunosorbent assay
(ELISA) positive confirmed by Western Blot
Western blot HIV gene sequence test
25% of HIV infected patients are unaware
they have it, all sexually active persons
between 13 and 64 be HIV tested for their
physical exam.
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Management
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CD4 lymphocyte count – if less than 350
patient begins antiretroviral therapy and
prophylaxis for opportunistic infections
World Health Organization (WHO) staging
handout
Highly active antiretroviral therapy (HAART)
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Cultural Considerations
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Factors that increase the incidence of HIV
infection and progression to AIDS among minority
groups
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Lack of culturally sensitive and high-quality information
about HIV risk and prevention
Socioeconomic status and limited access to health
care
Health beliefs concerning sexual practices, roles of
women, the value of children, and HIV treatment
The high cost of HAART
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Audience Response Question 1
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Which statement(s) regarding human
immunodeficiency virus transmission is/are true?
(Select all that apply.)
1.
2.
3.
4.
Breast milk can harbor the virus.
Proper use of personal protective equipment reduces
the risk of disease transmission.
Needle exchange programs facilitate the spread of
the virus.
Needle-stick injuries place health professionals at
risk.
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Opportunistic Infections (table 11-5 pg
226)
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Viral infections
Herpes simplex virus type 1 and type 2
Varicella zoster virus
Cytomegalovirus
Hepatitis
Bacterial infections
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Mycobacterium tuberculosis
Mycobacterium avium complex
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Opportunistic Infections (Cont.)
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Fungal infections
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Cryptococcosis
Histoplasmosis
Coccidiomycosis
Candidiasis
Pneumocystis jiroveci
Parasitic infections
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Toxoplasmosis
Cryptosporidiosis
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Other Complications
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Wasting syndrome >10% weight loss
Neoplasm (pg 226)
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Kaposi sarcoma
Lymphomas – Non-Hodgkins Lymphoma most
commom
Neurologic complications
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HIV encephalopathy and AIDS-dementia
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Kaposi Sarcoma
More common in men than women
infected with HIV
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Audience Response Question 2
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In determining the optimal therapy for a
patient infected with the human
immunodeficiency virus, the physician
considers which factor(s)? (Select all that
apply.)
1.
2.
3.
4.
5.
Clinical data
Compliance with therapy
Medication tolerance
Insurance coverage
Physician’s expectations
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Assessment (Data Collection)
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History and physical assessment
Focused assessment
Psychosocial history
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Planning
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Prevent secondary bacterial, viral, and fungal
infections.
Prevent wasting caused by malnutrition.
Maintain or improve the present level of immune
function.
Maintain adequate social functioning.
Maintain or improve current mental status.
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Implementation
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Standard Precautions
Patient teaching
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Compromised immunity
Infection control in the home
Wasting syndrome and nutrition
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Evaluation
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Data collection and analysis at regular
intervals
Include patient participation.
Patient and health care team expectations
Monitor tests to determine immune status,
viral load, blood cell status, and effects of
medications.
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Other Health Issues
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HIV risk in the over-50 population
Community education and care
HIV confidentiality and disclosure
When a nurse is HIV positive
Blood-borne pathogen exposure and health
care workers
Occupational exposure to HIV
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Autoimmune Disorders
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The immune system reacting against the
body’s own cells
Local, systemic, and mixed
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Signs and Symptoms
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More than 80 disease are thought to be
triggered by an alteration in immune function.
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Diagnosis
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Health history
Complete physical examination
Blood tests
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Treatment and Nursing Management
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Replacement or support of lost body function
Therapies targeted to halt destructive process
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Systemic Lupus Erythematosus
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Autoimmune disease
The body produces abnormal antibodies that
attack the target tissues instead of foreign
agents.
Discord, systemic, and drug-induced forms
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Etiology and Pathophysiology
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Abnormal reaction against proteins found in
the nucleus of body cells
Prolonged exposure to sunlight
Exacerbation by drugs
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Signs and Symptoms
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All body systems can be affected.
Weakness is a hallmark of SLE.
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Diagnosis
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No single test that confirms a diagnosis of
SLE
Must have at least 4 or the 11 clinical
presentations or laboratory test results
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Treatment
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No cure
Targeted toward symptom control or
management to prevent exacerbations
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Nursing Management
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Caring for a patient with low immune
response
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Disorders of the Lymphatic System
Hodgkin Lymphoma
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Etiology
Pathophysiology
Signs and symptoms
Diagnosis, treatment, and nursing
management
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Remission—disease is under control
Relapse—reappearance of cancer or
abnormal cells
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Clinical Manifestations and
Pathophysiology
From Black JM, Hawks JH: Medical-surgical nursing: Clinical
management for positive outcomes, ed. 8, Philadelphia, 2009,
Elsevier Saunders.
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Staging
Adapted from Lewis SL, Heitkemper MM, Dirksen SR, et al.
Medical-surgical nursing: assessment and management of clinical
problems, 7th ed. St. Louis, 2007, Mosby.
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Non-Hodgkin’s Lymphoma
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Etiology and pathophysiology
Signs and symptoms
Diagnosis and treatment
Nursing management
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Primary Lymphedema
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Inherited form caused by a congenital
condition in which there is deficient growth of
the lymphatic system, especially in a lower
extremity
Chiefly affects females and most often
becomes apparent during the middle teens to
early 20s
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Secondary Lymphedema
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Acquired form caused by an obstruction caused
by trauma to the lymph vessels and nodes
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Mastectomy with lymph nodes removed
Extensive soft-tissue injury and scar formation
Parasites that enter lymph channels and block
them
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Secondary Lymphedema (Cont.)
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Patients may present with a variety of symptoms,
including restricted range of motion; heavy
feeling; aching discomfort; recurrent infections;
and thick, hard skin.
Regardless of the etiology, treatment goals are to
minimize the impact of the disease process on
the individual.
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Fibromyalgia
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Chronic systemic pain and multiple symptoms
that not caused by another source or disease
Affects women 10 times more than men and seen
in women ranging from 25 to 60 years of age
Stressors such as infection, trauma, drugs,
hormonal influences, and psychological distress
can trigger fibromyalgia and its related
symptoms.
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Fibromyalgia (Cont.)
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The most common feature of this disorder is
musculoskeletal pain.
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Hyperalgesia—heightened response to painful stimuli
Allodynia—pain response to nonpainful stimuli
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Tender Points in Fibromyalgia
From Freundlich B, Leventhal L: Diffuse pain syndromes. In Klippel
JH (Ed.): Primer on the rheumatic diseases, ed. 13, Atlanta, 2008,
Arthritis Foundation.
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Symptoms
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Tension or migraine headaches
Jaw and facial tenderness
Insomnia or waking up feeling just as tired as
when the person went to sleep
Vertigo
Difficulty with concentration, memory recall,
and performing simple mental tasks
Anxiety, depression
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Symptoms (Cont.)
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Numbness or tingling in the face, arms,
hands, legs, or feet
Sensation of swelling (without actual swelling)
in the hands and feet
Abdominal pain, bloating, nausea, and
constipation alternating with diarrhea (irritable
bowel syndrome)
Dysmenorrhea
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Symptoms (Cont.)
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Increase in urinary urgency or frequency
(irritable bladder)
Sensitivity to one or more of the following
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Odors
Noise
Bright lights
Medications
Certain foods
Cold
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Symptom Relief
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Antidepressants
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Narcotic pain relievers are not as effective.
Additional treatment
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Exercise
Massage therapy
Guided imagery
Dietary changes
Referral to a mental health provider
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Nursing Responsibilities
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Detailed assessment of symptoms’ history
and documenting what the patient has
already tried to alleviate them
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Allergy
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Allergy is
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An abnormal response to certain substances
Considered a systemic immune disorder rather
than localized one
The reaction can be seen or expressed in
multiple body systems.
Allergens can enter the body in several ways
and can have either a local or a systemic
effect.
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Allergy (Cont.)
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Etiology and pathophysiology
Signs and symptoms
Diagnosis
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Radioallergosorbent test (RAST)
Skin test
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Allergy (Cont.)
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Drug allergies
Food allergies
Treatment
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Limit exposure to allergens
Drug therapy
Desensitization
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Hypersensitivity
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Hypersensitivity reactions, better known as
allergic reactions, are the body’s excessive
response to a normally harmless substance.
The severity of the condition can range from
a mild rash to life-threatening anaphylaxis.
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Etiology and Pathophysiology
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Type I hypersensitivity—immediate
hypersensitivity reactions that are mast cell–
mediated
Type II hypersensitivity—delayed-reaction
allergies involving T cells
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Diagnosis
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RAST
Skin testing—scratch test and patch test
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Primary Allergic Conditions
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Anaphylaxis
Angioedema
Asthma
Atopic dermatitis (eczema)
Food allergy or intolerance
Perennial allergic rhinitis or sinusitis
Seasonal allergic rhinoconjunctivitis (hay
fever)
Urticaria
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Four Broad Categories of Allergens
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Contactants
Ingestants
Inhalants
Injectables
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Assessment (Data Collection)
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General
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History of food intolerances, colic, abdominal
cramping, bloating or pain, vomiting, and diarrhea
in the absence of general illness
History of unusual reaction to any drug, insect
sting, odor, or fumes
History of recurrent respiratory problems or
seasonal flare-ups of any symptoms
History of fatigue, wheezing, or shortness of
breath upon exertion
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Assessment (Data Collection) (Cont.)
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Skin
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Eyes
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Itching, burning, dryness, scaling, irritations,
inflammations, rash (note symmetry and location),
scratches, or urticaria
Burning, itching, tearing, history of styes
Redness, discoloration below eyes (allergic
shiners), conjunctivitis, rubbing, or excessive
blinking
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Assessment (Data Collection) (Cont.)
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Nose
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History of nose twitching, stuffiness, recurring
nosebleeds, sudden episodes of sneezing or
snorting
Allergic salute (pushing nose upward and
backward with heel of hand), nasal polyps,
nasal voice
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Assessment (Data Collection) (Cont.)
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Mouth and throat
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Ears
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Open-mouth breathing, continual throat clearing,
mouth wrinkling with facial grimaces, redness of
throat, swollen lips or tongue
History of hearing loss, drainage from ears
Neck
Palpable, enlarged lymph nodes
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Nursing Implications
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Assist in the diagnosis of hypersensitivity.
Help the patient identify the particular
substance or substances that trigger an
allergic response.
Assist the patient in devising ways to avoid or
at least limit exposure to these allergens.
Relieve the symptoms of an allergy.
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Anaphylactic Reaction and
Anaphylactic Shock
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IgE-mediated immune responses
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Non-IgE allergen response
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If the mast cells depend on IgE to be activated,
they typically are triggered to produce only a
localized allergic response.
Examples of this are allergic conjunctivitis or
allergy-induced asthma.
Iodine-based dyes for select radiologic studies
Select narcotics such as morphine and
vancomycin, especially if administered too
rapidly
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Signs and Symptoms
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Urticaria (hives)
Angioedema
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Wheals
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Swelling beneath the skin
Small areas of swelling that itch and burn
May appear without subsequent anaphylaxis
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Effects of Anaphylaxis
From Van Meter KC, Hubert RJ: Gould’s pathophysiology for
health professions, ed. 5, Philadelphia, 2015, Elsevier Saunders.
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Treatment of Anaphylaxis
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Establish a patent airway.
Administer oxygen.
Administer intravenous epinephrine.
Administer antihistamine.
Institute measures to prevent or control
shock.
Provide psychological support during the
course of the syndrome and its treatment.
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