Immunologic Nursing

8/11/2019 Immunologic Nursing

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3. 7eneral "unction$ able to distinguish body8s own cells "rom

"oreign cells and attach and remo%e "oreign cells or own body8s

damaged cells

6. 0easurement o" total WC

a. /art o" Complete lood Count (CC)

b. +ormal WC count$ 6955 : 15,555 mm3

c. -euocytosis$ WC ; 15,555

d. -eucopenia$ WC < 6955

9. Types o" WC

a. 0a*or groups are granulocytes, monocytes, lymphocytes

b. 0easurement$ WC #i""erential

1. Short name$ =di"">

2. Count o" 155 WC sorted into the di""erent types

3. Translates into percentage per type

6. Signi"icance

a. 'denti"ies portion o" total WC made up o" each

speci"ic type

b. 7i%es assessment data as to status o" immune

system and its response to an in*ury? clues as to

in"ection, in"lammation

c. Types o" WC listed in di""erential

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1. +eutrophils(also nows as polymorphonuclear

leuocytes (/0+s) or polys )

a. 99 @ 5B total circulating leuocytes

b. -i"e span is hours to days

c. /rotect against pathogens, speci"ically bacteria

d. Types o" neutrophils

1. Segmented (=segs>)$ mature, normally 99B

o" WC

2. ands$ immature neutrophils, normally 9B

o" WC

e. 'ncreased le%el$ acute in"lammation or in"ection

(bacterial)

2. osinophils

a. 1 @ 6B total circulating leuocytes

b. Dound in large amounts in respiratory and 7'

tract

c. /rotect against parasitic worms and in%ol%ed in

hypersensiti%ity

3. asophils

a. 5.9 @ 1B total circulating leuocytes

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b. Contain protein and chemicals including heparin

histamine, that are released during

hypersensiti%ity reactions, stress

6. 0onoctyes$ largest o" WC

a. 2 @3B total circulating leuocytes

b. 0igrate to tissues and can li%e "or years

c. 0ature into macrophages in tissue lungs,

connecti%e, li%er, etc.

d. /hagocytic against large "oreign particles and

cell debris

e. #e"ense against chronic in"ections such as

tuberculosis, %iral in"ections

9. -ymphocytes

a. 25 : 65B o" total circulating leuocytes

b. ""ectors and regulators o" speci"ic immune

responses

c. 'mmune sur%eillance$ monitor "or and destroy

cancerous cells

d. Circulate constantly, but concentrate in lymphoi

tissues including lymph nodes

e. #i""erential only loos at total lymphocyte

percentageoyce ammer

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". 3 di""erent types o" lymphocytes which wor

together$

1. T -ymphocytes (mature in thymus gland)

2. -ymphocytes (mature in bone marrow)

3. +! cells (natural iller cells)$ immune

sur%eillance

II. Nonspecific Inflammatory Response

A.arrier protection$body8s "irst line de"ense against in"ection include

1. 'ntact sin

2. 0ucus o" mucous membranes

3. actericidal action o" body "luids

.'n"lammation$nonspeci"ic immune response

1. +onspeci"ic$ localized, generally same with all types o" in*ury

2. Stages o" in"lammatory response$

a.Eascular response$ %asodilatation leading to redness,

warmth, swelling? three types o" eFudate$ "luid "rom

capillaries into tissue

1. Serous (plasma)

2. SanGuineous (mainly red blood cells)

3. Serosanguineous (miFture)

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b. Cellular response and phagocytosis$ margination and wbc8

to area

c. Tissue repair healing$ o%erlap o" in"lammation and healing

3. Cardinal signs o" in"lammation$ erythema (redness), warmth,

swelling, pain, loss o" "unction

6. Acute or Chronic

a. Acute

1. Short term, 1 : 2 wees

2. 'n*urious agent remo%ed

3. ealing occurs with tissue repair or scarring

b. Chronic

1. Slower onset, months : years

2. #ebilitating with se%ere tissue damage

C.Wound ealing

1. /hases

a. 'n"lammation$ debridement occurs, wound prepared "or

healing

b. &econstruction$ damaged tissue regenerates

1. &esolution$ original structure and "unction result

2. &epair$ replacement o" destroyed tissue by collagen

scar tissue

2. &eGuirementsoyce ammer

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a. AdeGuate nutrition

b. AdeGuate blood supply

c. AdeGuate oFygenation

3. Ither 'nter"ering Dactors

a. Chronic diseases, e. g. diabetes

b. #rug therapies, e.g. corticosteroids

c. 'n"ection

III. Immune Response

A.#e"inition o" 'mmunocompetent$client has immune system that

identi"ies antigen and destroys or remo%es it? healthy immune

response

.Characteristics o" healthy immune response

1. Sel"@recognition

2. Speci"ic

3. Systemic

6. as memory (with "irst eFposure, change in host occurs?

repeated eFposures produces more rapid response)

C.Types o" 'mmune &esponses

1. Antibody@0ediated 'mmune &esponse (umoral &esponse)

a. Antigen is bacteria, bacterial toFin, or "ree %irus

b. @lymphocyte produces antibody to speci"ic antigenoyce ammer

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c. Antibody (immunoglobulin) binds with antigen to

inacti%ate it

d. 9 classes o" immunoglobulins are 'g7, 'gA, 'g0, 'g#, 'g

e. Antibody :medicated response occurs in 2 phases

1. 'nitial eFposure$ primary response de%elops

a. -ag time "rom eFposure to antibody

de%elopment

b. Antibodies de%elop, pea and person reco%ers

2. Secondary eFposure$ with repeat eFposure to antigen,

memory cells cause immediate rise in antibodies and

pre%ent disease "rom occurring again

2. Cell@0ediated 'mmune &esponse (Cellular &esponse)

a. Antigen is a %iral@in"ected cell, cancer cell, some bacteria,

or "oreign tissue

b. T@lymphocytes inacti%ate antigen without antibody

"ormation

1. ""ector T cell$ cytotoFic cell binds with sur"ace

antigen on "oreign cell or %irus@in"ected cell and

destroys it

2. &egulator T cells include$

a. elper T cell$ acti%ates cells "or antibodies?

assists cytoFic T cellsoyce ammer

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b. Suppressor T cell$ pro%ides negati%e "eedbac

and stops immune process

c. Cell@mediated has memory$ T cells respond to repeat

eFposure to antigen

IV. Immunity: Protection of body from disease

A.Types

1. Acti%e$ body produces antibodies or de%elops immune

lymphocytes against speci"ic antigens

2. /assi%e$ antibodies are administered to the client? e""ect

temporary

3. +atural$ client contacts antigen, de%elops the disease, reco%ers,

and is immune

6. AcGuired$ antigen introduced into client to stimulate immune

system to "orm antibodies and memory cells but not the actual

disease

9. Famples$

a. +atural Acti%e$ client had chicen poF, de%eloped

antibodies, is immune

b. AcGuired Acti%e$ Tetanus ToFoid gi%en to client? client

"orms antibodies against tetanus

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c. +atural /assi%e$ maternal antibodies passed to in"ant

through breast mil

d. AcGuired /assi%e$Tetanus Immune Globulin

(ypertet)$ antibodies gi%en to client who has not recei%ed

prior immunizations against tetanus

.Collaborati%e Care

1. Teaching and administration o" immunizations, %accines

2. Adherence with recommended schedules "or immunization

(&ecommendations sub*ect to change, eep current)

3. &ecommendations "or speci"ic groups, e.g. health care worers

at ris, epatitis %accine? elderly, chronically ill, in"luenza

%accine? tra%elers to "oreign countries, speci"ic disease (typhoid

"e%er) %accine

6. Administration o" immunizations$

a. Chec client allergies, no upper respiratory in"ection

b. +o li%e %irus %accines to immunosuppressed or those in

household

9. Dollow directions regarding administration (routes, sites), use

uneFpired %accines(label %ials when opened, document %ial

number)

V. Management of Client with Inflammationoyce ammer

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A.#iagnostic Testing$

1. White lood Cell Count with #i""erential

a. Total WC count$ increase (acute in"lammation or

in"ection) or decrease (consider immunosuppression)

b. #i""erential$ consider increases or decreases with speci"ic

cell type

2. rthrocyte Sedimentation &ate (S&)

a. +onspeci"ic

b. le%ated with in"lammation

3. C@reacti%e /rotein (C&/) Test

a. +ormal is negati%e

b. Tests "or presence o" protein "rom li%er

c. 'ndicati%e o" acute or chronic in"lammation

6. Serum /rotein

a. +ormal %alues

1. Total protein$ H : 4 gd-

2. Albumin$ 3.2 : 6.9 gd-

3. 7lobulin$ 2.3 : 3.6 gd-

b. #etermine whether there is adeGuate protein intae and

li%er "unctioning "or healing, immune system "unctioning

c. 7lobulin decreased with immunologic de"icienciesoyce ammer

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9. /rotein electrophoresis$ 0easurement o" immunoglobulins

'g7, 'gA, 'g0, 'g#, 'g (antibodies)

H. Antibody testing$ Titer le%els measured to determine whether

client has de%eloped antibodies to an in"ection or with an

immunization

. Sin testing$ assesses cell@mediated immunity

a. !nown antigen in*ected intradermally, e.g. tuberculin test

b. +ote induration indicating pre%ious eFposure and

sensitization to antigen

c. '" no reaction, depressed cellular immunity (anergy)

.0edications$

1. /urpose$ to pro%ide com"ort or decrease in"lammatory response

and damage

2. Types

a. Acetaminophen

a. Com"ort only

b. &educes pain and "e%er

c. +o anti@in"lammatory e""ect

b. Aspirin and salicylates

a. igher doses reGuired (H95 : 1555 mg J'#) "or anti

in"lammatory e""ect

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b. 'nhibits prostaglandin synthesis? anti pyretic? anti@

platelet e""ect

c. 'rritates gastrointestinal tract

c. +onsteroidal anti@in"lammatory drugs (+SA'#s)

a. 0ultiple types o" +SA'# medications? all ha%e

potential cross@sensiti%ity to aspirin, irritate

gastrointestinal tract

b. !etorolac (Toradol), only +SA'# that can be gi%en

parenterally

c. 'ndomethacin and phenylbutazone most toFic

d. Corticosteroids$ hormones produced by adrenal corteF

a. 'nhibit in"lammation? do not cure underlying

condition, but palliati%e

b. a%e serious side e""ects, can mas in"ections

c. 7uidelines "or use o" glucocorticoids

1. /re"er local acting such as topical or intra@

articular in*ection i" e""ecti%e

2. 7i%e smallest possible dose that will be e""ecti%e

3. '" oral, alternate@day dosing schedule to maintain

adrenal gland "unctioning

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6. With high@dose therapy, must taper dose? do not

stop abruptly to allow adrenal glands to resume

normal "unctioning

C./roper +utrition$essential "or healing

1. #e"initions

a. 'n"lammation$ catabolic state (tissue breadown)

b. ealing$ anabolic process (tissue build up)

2. #iet reGuirements

a. AdeGuate protein, calories, "at

b. Eitamins$ A, @compleF, !? mineral$ zinc,

c. AdeGuate "luids 29555 ml 26 hr

d. /re%ent weight loss, protein depletion

#.+ursing #iagnoses

1. /ain

2. 'mpaired Tissue 'ntegrity

3. &is "or 'n"ection

VI. Infection

A.Iccurrence$ when pathogen colonizes and multiplies within host

and host eFperiences in*ury, in"lammation or organ dys"unction in

response to in"ection or toFin

./athogen Dactorsoyce ammer

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1. Eirulence$ disease@causing potential

2. Chain o" in"ection (reser%oir, transmission, %ector)

3. Irganism resistance

6. #amage caused through toFin production

C.ost Dactors$ability to resist in"ection

1. /hysical barrier$ intact sin and mucous membranes

2. 'nternal en%ironment (body secretions, respiratory de"enses)

3. Speci"ic and nonspeci"ic immune responses

#.Stages o" 'n"ectious /rocess

1. 'ncubation

a. /athogen acti%e replication

b. +o symptoms

2. /rodromal

a. Symptoms begin to appear

b. +on@speci"ic

3. Acute

a. /athogen proli"erates, maFimum symptoms

b. De%er and chills? may be con"ined to speci"ic organsystem

c. Stress to body

1. Catabolic e""ects

2. 'n"lammatory process in response to toFins

3. /ossible trigger o" autoimmune disease processoyce ammer

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6. Con%alescent

a. Tissues repair

b. Symptoms resol%e

. /ossible Complications$Septicemia, septic shoc

D. +osocomial in"ections$'n"ections acGuired in health care setting (9B

in"ection rate)

1. &is "actors "or hospitalized clients

a. Compromised immune systems

b. 0edications including antibiotics, steroids

c. Treatments including in%asi%e procedures

d. 'ncreased incidence among elderly

2. /re%ention

a. ""ecti%e handwashing

b. n"orcement o" policies "or in%asi%e procedures

7.Antibiotic@&esistant 0icroorganisms

1. 'ncreasing due to inappropriate or prolonged antibiotic therapy

2. Current resistant strains

a. 0ethicillin@resistant Staphylococcus aureus (0&SA)

b. 0ulti@drug resistant tuberculosis (0#&@T)

c. /enicillin@resistant Streptococcus pneumoniae (/&S/)

d. Eancomycin@resistant nterococci (E&)

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e. Eancomycin 'ntermediate@resistant Staphylococcus aureus

(E'SA)

3. Dollow recommended contact precautionsisolation techniGues

.Collaborati%e Care

1. #iagnostic Tests

a. WC Count and #i""erential

1. -euocytosis with in"ections

2. +eutrophilia increased segs? also shi"t to le"t

(increased band count)

b. Culture o" wound, blood, andor other body "luids

1. Ibtain specimen prior to starting antibiotic, i" not,

note antibiotic recei%ed on culture reGuest "orm

2. 7ram stain$ to identi"y probable pathogen

3. Culture$ organism incubated and grown? taes 26 : 6

hours

6. Sensiti%ity$ cultured organism sub*ected to di""erent

antibiotics to determine whether sensiti%e (antibiotic

will ill organism) or resistant (antibiotic will not ill

organism)

c. Serology$ detect antibodies to suspected organism

d. #irect antigen$ detect antigens in body specimens

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e. Antibiotic /eas and Troughs$ monitor therapeutic le%els

o" antibiotics to ensure proper dose "or optimum treatment

while a%oiding toFic le%els

1. /ea$ highest le%el o" antibiotic

2. Trough$ lowest le%el o" antibiotic

". Krays, ultrasound eFamination o" organs

g -umbar puncture to obtain cerebrospinal "luid "or

eFamination and culture

'. Administration o" anti@in"ecti%e therapy

1. Chec "or allergies, ris to "etus in child@bearing aged women

2. !now client renal, hepatic "unction? i" medication metabolized

through this system, monitor lab tests

3. est route to e""ecti%ely treat microorganism in in"ection site

6. Antibiotics

a. acteriostatic (inhibit growth) or bactericidal (ill

organism)

b. Speci"ic against di""erent categories o" microorganisms

that ha%e cell wall

1. 7ram positi%e

2. 7ram negati%e

3. oth (broad spectrum)

c. !nown toFicities to speci"ic organ systemsoyce ammer

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d .Superin"ection

1. 0a*or concern

2. Antibiotics change normal bacterial "lora in 7' tract,

mouth, %agina

3. I%ergrowth o" "ungus or bacteria

6. 0ay be treated with anti"ungal medications or eating

yogurt with li%e cultures

9. Anti%iral$ selecti%e since %irus is parasite within host8s cells

H. Anti"ungal$ treat "ungal in"ections

. Antiparasitic$ treat parasitic in"ections including protozoans

. Antibiotic Categories Speci"ics

1. /enicillins$ =cillins>

a. Stop immediately i" any sign o" hypersensiti%ity and be

ready to treat reaction

b. Cross sensiti%ity with cephalosporins

2. Cephalosporins

a. 6 generations

b. Cross sensiti%ity with penicillins

c. 0onitor "or idney and li%er toFicity

3. Aminoglycosides$ =mycins>

a. ItotoFic, nephrotoFicoyce ammer

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b. 0onitor weight, L+, creatinine

6. DluroGuinolones

a. Dluid intae 2 : 3 - daily to pre%ent crystaluria

b. 0onitor "or hepatotoFicity

9. Tetracyclines

a. Tae 1 hour be"ore or 2 hours a"ter meals

b. Can inter"ere with anticoagulants

H. 0acrolides (rythromycin)

a. Dor clients allergic to penicillin

b. 7' distress? tae on empty stomach or *ust be"ore meals

. Sul"onamides and Trimethoprim

a. Lsed "or urinary tract in"ections, otitis media,

/neumocystis carinii pneumonia

b. Chec "or any sul"a allergy

c. /rotect "rom photosensiti%ity

d. Tae on empty stomach

e. Dluid intae 2 - per day

4. 0etronidazole (Dlagyl)

a. +o alcohol intae (causes illness @@ Antabuse e""ect)

b. 0ay mae urine reddish brown

c. +eed adeGuate "luid intae 2.9 - daily

!.'solation TechniGuesoyce ammer

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According to Centers "or #isease Control and /re%ention (C#C)

7uidelines

1. Standard /recautions

a. arrier precautions with body "luids, especially blood

b. 7uidelines "or needles, sharp ob*ects disposal

2. Category@speci"ic /recautions

a. Airborne precautions

b. #roplet precautions

c. Contact precautions

-. +ursing #iagnoses

1. &is "or in"ections

2. AnFiety

3. yperthermia

a. Chills indicate rising temperature? monitor

b. -ower temperature cautiously to a%oid shi%ering which

raises temperature

c. &estore "luid balance? increased loss with "e%er

Nursing Care of Clients with ltered Immunity

I. !ac"ground

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A.A healthy immune system identi"ies antigens and e""ecti%ely

destroys or remo%es them

.Alterations that occur within immune system and result in illness

1. I%erreaction$ ypersensiti%ity, as with allergic reactions

2. 'ncompetency$ 'mmune de"iciency or malignancy as with

AcGuired 'mmune #e"iciency #isorder (A'#S)

3. -oss o" ability to recognize sel"$ Autoimmune disorders

C.'mmune responses

1. Antibody@mediated immune response$ action o"

lymphocytes (@cells)? acGuired immunity

2. Cell@mediated immune response$ T lymphocytes (T@cells) attac

antigens directly and acti%ate @cells

3. Types o" T@cells

a. ""ector cells$ CytotoFic (!iller T)

1. Carry C#4 antigen

2. Attac malignant cells

3. &esponsible "or transplanted organ re*ection and

gra"ted tissues

b. &egulator cells

1. elper T cells

a. Carry C#6 antigen

b. 'nitiate immune responseoyce ammer

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2. Suppressor T cells

a. Carry C#4 antigen

b. Stop immune response

6. 'mmune "unction declines with age

II. #ypersensiti$ity Reaction

A.#e"inition$ Altered immune response to antigen resulting in

harm to client, e.g. allergy

.Categories

1. &ange "rom irritating to li"e threatening (as with laryngospasm)

2. 'mmediate (e.g. anaphylaFis) %s. delayed (e.g. contact

dermatitis)

C./athophysiology

1. Antigen@antibody interaction$

1. Causes tissue damage

2. 'n%ol%es immediate reaction a"ter a prior sensitization

3. 'ncludes systemic reactions$ Types ', '', '''

a. Type '

1. Drom allergic reaction with 'g

2. 0ast cells and basophils "actors released, which

causes serious reactionoyce ammer

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3. 0ost serious reaction$ AnaphylaFis

a. Signs and symptoms$ hi%es, swelling,

di""iculty breathing, anaphylactic shoc

b. Client needs$ Air way protection? prompt

re%ersal (parenteral epinephrine)

b. Type ''

1. 'g7 or 'g0

2. Antibodies "ormed

3. Complement cascade acti%ated and destroys

cells, e.g. hemolytic trans"usion blood reaction

(AI, &h)

c. Type '''

1. 'g7 or 'g0

2. Antibody@antigen immune compleFes in

circulation and bloc tissues, e.g. reaction to

toFin post strep in"ection, glomerulonephritis

2. Antigen@lymphocyte reaction

a. Type 'E

b. #elayed 26 : 64 hours? contact dermatitis (e.g. lateF

allergy, positi%e tuberculin test)

#.Collaborati%e Care

1. I%erall Docusoyce ammer

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a. 0inimize eFposure to allergen

b. /re%ent hypersensiti%ity response

c. /er"orm prompt, e""ecti%e inter%entions "or allergic

responses

2. +ursing history and status be"ore any proceduremedication

a. #ocument allergies and reaction(s) that occurred with

e%ent

b. 0aintain record? allergy bracelet "or in@patient

c. As about anesthesia allergy "or local and general

preoperati%e clients

3. #iagnostic Tests

a. WC count with di""erential$ Type ' allergy$ eosinophilia

b. &adioallergosorbent test (&AST)$ detects 'g toward

speci"ic antigens

c. lood type and crossmatch$ pre%ents AI and &h

reactions

d. 'ndirect Coombs$ detects circulating antibodies (normal$

negati%e)

e. #irect Coombs$ detects antibodies on client8s &C8s

(normal$ negati%e)

". 'mmune compleF assays$ detects Antibodies Type '''

reactionsoyce ammer

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g. Complement assays$ detects amount o" a%ailable

complement? determines amount used

h. Sin tests$ detects allergens, includes intradermal testing

6. 0edications

a. Antihistamines

1. locs histamine receptors

2. &elie%es symptoms o" urticaria and angioedema

3. #iphenhydramine (enadryl)$ can be gi%en

parenterally or orally

b. pinepherine

1. 'mmediate treatment "or anaphylaFis

2. &elie%es the %asodilatation and bronchoconstriction

3. 7i%en subcutaneously or intra%enously

6. =ee sting it>$ carried by clients with nown serious

allergies

c. Cromolyn ('ntal)

1. locs histamine release

2. 7i%en by inhaler or nasal spray

d. 7lucocorticoids

1. oth topical and systemic e""ects

2. Anti@in"lammatory

9. /lasmapheresisoyce ammer

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a. +on@medication treatment

b. &emo%al o" harm"ul components in plasma by passing

blood through blood cell separator to remo%e immune

compleFes

H. +ursing #iagnoses

a. 'ne""ecti%e Airway Clearance (as with anaphylaFis)

b. #ecreased Cardiac Iutput (as with anaphylactic shoc)

c. &is "or 'n*ury (as with blood trans"usion reaction)

III. utoimmune %isorders

A.#e"inition$ 'mmune system8s ability to recognize sel" is

impaired, and immune de"enses are directed against person8s

own tissues

.Common autoimmune disorders

1. Tissueorgan speci"ic (ashimoto8s thyroiditis)

2. Systemic (rheumatoid arthritis, systemic lupus erythematosis

(S-))

C./athophysiology (not entirely certain but possibly)

1. idden antigens elicit immune response, de%elopment o"

autoantibodies

2. ody has changes "rom bacterial or %iral

in"ections, de"ecti%e immune systemoyce ammer

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#.Characteristics o" autoimmune disorders

1. 7enetic predisposition

2. Iccur in "emales more than males

3. Inset associated with stress

6. DreGuently are progressi%e, with periods o" eFacerbation and

remission

. Collaborati%e Care

1. #iagnostic Tests$

a. Serologic assays

1. Tests used to identi"y autoantibodies,

measured in titers, i.e. le%els in circulation

2. Iccur with autoimmune state

3. +ot speci"ic "or certain disease

b. Antinuclear antibody (A+A)

c. -upus erythematosus (-) prep

d. &heumatoid Dactor (&D)

e. Complement assay$ detects amount o" a%ailable

complement? determines amount used

2. 0edications

a. Anti@in"lammatory drugs$ aspirin, +SA'#s, corticosteroid

b. Antirheumatic drugs$ gold salts, hydroFychloroGuine

(/laGuenil)oyce ammer

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c. CytotoFic drugs

3. /lasmapheresis may be used

6. +ursing Care according to signs and symptoms o" speci"ic

disorder

9. Common +ursing #iagnoses

a. Acti%ity 'ntolerance

b. 'ne""ecti%e Coping (with chronic disease)

c. 'ne""ecti%e /rotection

d. &is "or 'ne""ecti%e Therapeutic &egimen 0anagement

e. 'nterrupted Damily /rocesses

IV. &issue &ransplants

A.acground

1. uman -euocyte Antigens (-A)

a. Speci"ic cell sur"ace marers uniGue to each indi%idual

person

b. Transplant success tied to obtaining organs with -A clos

to those o" recipient

2. Types o" Transplants

a. Autogra"t$ transplant o" client8s own tissue

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b. Allogra"t$ most common, gra"ts between member o" same

species, but di""erent genotypes and -A antigens?

cada%er donors are most common

c. Kenogra"t$ transplant "rom animal species to human, e.g.

pig %al%es

3. /reparation "or Allogra"t$ Tissue Typing

a. #etermine histocompatibility, i.e. identi"y recipient8s -A

type, blood type (AI, &h), and pre@"ormed antibodies

b. 0atch as closely as possible with the donor

6. Types o" &e*ections$ typically begin a"ter "irst 26 hours post

transplant$

a. yperacute Tissue &e*ection

1. Iccurs 2 : 3 days post transplant

2. #ue to pre@"ormed antibodies

3. 0ore common with pre%ious transplant or blood

trans"usion

b. Acute Tissue &e*ection

1. 0ost common and treatable

2. Iccurs between 3 days and 6 months post transplant

3. #ue to cellular immune response

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6. Signs and symptoms$ "e%er, redness, swelling and

tenderness o%er gra"t site? signs o" organ "ailure

(re"lected by lab %alues)

c. Chronic Tissue &e*ection

1. Iccurs 6 months to years post transplant

2. #ue to antibody@mediated immune response

3. -eads to ischemia and to organ and gradual

deterioration

6. 7ra"t@%ersus@ost #isease (7%#)$ "reGuent and

potentially "atal complication o" bone marrow

transplant? gra"ted tissue recognizes host tissue as

"oreign and mounts a cell@mediated response?

primarily a""ects sin, li%er, gastrointestinal tract

.Collaborati%e Care

1. I%erall goal o" pre and post transplant care is to reduce the ris

o" tissue re*ection or 7%#

2. #iagnostic testing : prior to transplant

a. lood type, &h "actor, crossmatch

b. -A histocompatibility$ used primarily with li%ing donors

"or idney or bone marrow transplants

c. 0iFed lymphocyte culture (0-C) assay test$

histocompatibility between donor and recipientoyce ammer

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3. #iagnostic testing @ post transplant

a. Lltrasound or 0agnetic resonance imaging (0&') o"

transplanted organ

b. Tissue biopsies o" transplanted organ? done routinely to

assess e%idence o" re*ection

6. 0edications

a. Antibiotics and anti%iral medications

1. Trimethoprim-sulfamethoxazole (Septra, Bactrim)$

protects against gram@negati%e bacteria in"ection

2.Acyclovir (Zovirax)$ protects "rom herpes simpleF

%irus (SE) in"ection

3. Ganciclovir (Cytovene)$ protects "rom de%elopment o

cytomegalo%irus (C0E) in"ection

b. 'mmunosuppressi%e agents$ Corticosteroids, also anti@

in"lammatory

1.Azathioprine (muran)

a. 0ainstay, inhibits both cell@mediated and

antibody@mediated immunity

b. 0etabolized by li%er? sa"e "or renal transplant

clients

c. 0a*or ad%erse e""ect$ bone marrow depression

(monitor CC)oyce ammer

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2. Cyclosporine

a. 'nhibits T@cell "unction and cell@mediated

immune responses

b. 0onitor blood le%els closely to chec "or

toFicity? nephrotoFic and hepatotoFic

c. Signs o" toFicity$ hypertension, C+S symptoms

3.!uromona"-C#$ (%&T$, %rthoclone)

a. 0onoclonal antibody, blocs T cell generation

and "unction

b. Lsed with steroid@resistant organ re*ections

6,Antilymphocyte 'lo"ulin (AG), antithymocyte

'lo"ulin (ATG)/olyclonal antilymphoctye antibodie

6. +ursing Care in%ol%es acute and chronic care "or client and

"amily

9. Common +ursing #iagnoses

a. 'ne""ecti%e /rotection

b. &is "or 'mpaired Tissue 'ntegrity

c. #ealing with psychologic conseGuences o" chronicity

1. /owerlessness

2. 'ne""ecti%e Coping

3. AnFiety

H. Common nursing inter%entionsoyce ammer

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a. Assessment "or signs o" in"ection, organ re*ection, ad%erse

e""ects o" medications, "reGuent laboratory testing

b. 0edications, handwashing and protecti%e isolation in

hospital and post discharge "or client and "amily

c. Stress@reduction, counseling, support group re"erral

V.Impaired Immune Response

A. Two types

1. Congenital$ rare

2. AcGuired$ acGuired immune de"iciency syndrome (A'#S)

.acground

1. Cases recognized in male homoseFual population in 141?

2. uman immunode"iciency %irus ('E) isolated in 146

3. &etro%irus transmitted by

a. #irect contact with in"ected blood and body "luids

b. Contaminated needles

c. 'n"ants born to 'E positi%e mothers (19 : 35 B)

C.&iss$ eha%orial

1. Lnprotected anal seF

2. 'n*ection drug use (sharing needles)

3. eteroseFual intercourse with in"ected persons

6. &ecei%ing blood trans"usions, blood productsoyce ammer

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9. Iccupational ris to health care worers, especially through

needle stics

#./athophysiology

1. &etro%irus

a. Carries genetic code in &+A

b. 'n"ects cells with C#6 antigen

c. Taes o%er cell8s #+A and then duplicates

d. 0ay remain dormant or become acti%e

e. Acti%e$ "orms %irons which destroys host cell

2. Serocon%ersion

a. H wees to H months post initial in"ection, antibodies to

'E are produced and will test positi%e

b. Actual %irus may remain inacti%e in cells "or years

c. Antibodies are ine""ecti%e against the %irus

3. Cells a""ected by 'E

a. elper T (C#6) cells

b. 0acrophages

c. Cells o" C+S

6. -oss o" helper T cells leads to typical

immunode"iciencies that result in multiple

opportunistic in"ections and cancers

. Typical Course o" 'E 'n"ectionoyce ammer

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1. Contraction o" %irus

a. Acute mononucleosis@type illness within days to wees

b. Symptoms include$ "e%er, sore throat, *oint and muscle

achiness, rash, lymphadenopathy

c. Asymptomatic period

1. 0ean period 4 to 15 years

2. Eirus can be transmitted to others through blood and

body "luids, e%en though client seems well

3. Some clients eFperience persistent lymphadenopathy

2. #e%elopment into A'#S

a. 0ani"estations include$ general malaise, "e%er, "atigue,

night sweats, in%oluntary weight loss, o"ten diarrhea, rash,

oral lesions and candidiasis

b. 0ultiple opportunistic in"ections, cancers

c. 65 : H5 B de%elop neurological symptoms

D. /ost@in"ection &elated 'ssues

1. A'#S #ementia CompleF

a. #irect e""ect o" %irus on brain

b. Starts with "luctuating memory loss? con"usion to apathy,

to se%ere dementia? tremor? spasticity? incontinence

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c. C+S in"ections and lesions including toFoplasmosis, non@

odgin8s lymphoma as space@occupying lesions,

cryptococcal meningitis, C0E in"ections

2. Ipportunistic 'n"ections

a. Iccur when C#6 count is less than 255 (normal greater

than 1555mm3)

b. /neumonia (*neumocystis carinii)

1. 0ost common opportunistic in"ection (9 :

45B)

2. +onspeci"ic mani"estations$ "e%er, cough, shortness o

breath, tachypnea, tachycardia

c. Tuberculosis

1. I"ten multidrug@resistant strains

2. &apid progressi%e, di""use pulmonary and

disseminated (other body organs)

d. Candidiasis (Can+i+a al"icans)

1. Eery common

2. Iral thrush, esophagitis, or %aginitis in women

e.!yco"acterium avium$ CompleF (0AC)

1. 29B o" A'#S cases

2. 0a*or cause o" =wasting syndrome>

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3. Signs and symptoms include$ chills, "e%er, weaness,

night sweats, abdominal pain, diarrhea, weight loss

". Ither 'n"ections

1. Eiral$ erpes simpleF or zoster %irus, C0E

o" retina, 7' tract, lungs

2. /arasitic$ ToFoplasma gondii, Cryptococcus

neo"ormans, Cryptosporidium

3. Secondary Cancers

a. !aposi8s Sarcoma

1. I"ten presenting symptom

2. Sin lesions with %ascular macules, papules, %iolet

lesions on sin and %iscera? o"ten on "ace,

gastrointestinal tract, lungs

3. 'nitially painless, but become pain"ul

6. 'ndicator o" late@stage disease

b. -ymphomas

1. +on@odgin8s lymphoma and primary

lymphoma o" brain

2. Aggressi%e and rapid spread

c. 'n%asi%e Cer%ical Carcinoma$ Woman with 'E usually

die o" cer%ical cancer, not A'#S

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7.Collaborati%e Care

1. Treatment

a. +o cure "or 'E in"ection and A'#S

b. Current research "or treatment and cure

c. Still uni%ersally "atal nature o" disease

d. /re%ention is %ital strategy

2. 7oals o" care

a. arly identi"ication o" in"ection

b. /romote health@maintenance acti%ities

c. /re%ent opportunistic in"ections

d. Treatment o" disease complications (cancers)

e. /ro%ide emotional and psychosocial support

3. #iagnostic Testing

a. nzyme@lined immunosorbent assay (-'SA)

1. Widely used as screening test "or 'E in"ection?

detects 'E antibodies, not %irus

2. Could be negati%e in early course o" in"ection be"ore

detectable antibodies de%elop

3. &esults .9B positi%e

a. Dalse positi%es can occur

b. '" positi%e, always repeat test and con"irm by

another method, such as Western blotoyce ammer

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b. Western blot antibody testing$ combined with -'SA

greater speci"icity (;.B)

c. 'E %iral load tests$ measure amount o" acti%ity

replicating 'E %irus

d. CC$ detect anemia, leucopenia, thrombocytopenia

e. C#6 cell count$ used to monitor progress o" disease and

guide therapy

". Tests to detect secondary cancers and opportunistic

in"ections

1. Tuberculin sin testing

2. rain 0agnetic resonance imaging (0&')

3. Speci"ic cultures and serology "or in"ections

6. /ap smears e%ery H months to detect cer%ical cancer

3. 0edications

a. /urposes

1. Suppress the 'E in"ection and prolong client8s li"e

2. Treat opportunistic in"ections and cancers

b. ""ecti%eness measured by

1. Eiral load and C#6 cell counts (abo%e 955 mm3)

2. I"ten used in combinations according to e""ecti%enes

c. Classes o" medications used to Suppress 'E in"ection

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1. +ucleoside &e%erse Transcriptase 'nhibitor

(+&T's)

a. Wors at le%el o" #+A

b. Mido%udine (&etro%ir, AMT) widespread use? als

used prophylactically post parenteral eFposure to

'E

2./rotease 'nhibitors$ locs %iral enzymes

3.+onnucleoside &e%erse Transcriptase 'nhibitors

6. Ither agents$ 'nter"erons

d. 0edications against Ipportunistic 'n"ectionsCancers

1. Antibiotics, anti%irals, anti@cancer agents

2. Eaccines "or pneumococcal, in"luenza, hepatitis

, aemophilus in"luenzae serotype b

3. 'soniazid ('+) prophylactically "or positi%e

tuberculin test

6. /rophylactic trimethoprim@sul"amethoFazole

(actrim) i" C#6 cell count is below 255 to

pre%ent*neumocystis carinii/neumonia (/C/)

6. +ursing Care

a. /re%ention o" in"ection

1. Sa"e seFual practices

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2. +o sharing or needles and drug paraphernalia (drug

users)

3. Screening o" donated blood and use o" autologous

6. Lse o" standard precautions by health care worers

b. Care o" the client with 'E

1. 0aintain health and pre%ent de%elopment o"

opportunistic in"ections, cancers? physical needs

change o%er course o" illness

2. Still a stigma associated with illness? assist client,

"amily to deal with it

3. 'ntense medical care, client de%elopment o" support

systems, use o" psychosocial support

c. +ursing #iagnoses (many and change with course o"

illness)

1. 'ne""ecti%e Coping$ #ealing with stigma, contagious

disease chronic illness, terminal illness

2. 'mpaired Sin 'ntegrity

3. 'mbalanced +utrition less than ody &eGuirements$

Control nausea, diarrhea

6.'ne""ecti%e SeFual /atterns$ /ractice sa"e seFual practices, in"orming

partners o" 'E status

6

Documents

Immunologic Nursing