MEDICAL SURGICAL NURSING II
VNRS B85
NURSING CARE OF CLIENTS WITH ALTERED IMMUNITY
Introduction:
The immune system functions to protect the body from invasion from foreign antigens, to
destroy potentially harmful cells, and to remove cellular debris. Over the years there has
been an emergence of new diseases affecting the immune system. It is vital that the nurse
today understand the foundations of the immune system and the immune response. This
chapter focuses on the components of the immune system and specific immune responses
to these diseases.
Learning Outcomes:
Upon completion of this chapter, the student will be able to:
A.
Theory
1.
Review the normal anatomy and physiology of the immune system and the
immune response.
2.
Describe the four types of hypersensitive reactions.
3.
Discuss the Pathophysiology of Autoimmune disorders and tissue
transplant rejection.
4.
Discuss the characteristics of immunodeficiencies.
5.
Identify laboratory and diagnostic tests used to diagnose and monitor
immune response.
6.
Describe pharmacologic and other collaborative therapies used in treating
clients with altered immunity.
7.
Correlate the pathophysiological alterations with the manifestations of
HIV/AIDS infection.
8.
Use the nursing process as a framework to provide individualized care to
clients with altered immune responses.
Assignment:
LeMone-Burke Chapter 13
Chapter 13
Lecture Outline
Nursing Care of Clients with Altered Immunity
Anatomy and Physiology of the Immune System
•Contains lymphocytes and lymphatic tissue
•properties
Effectiveness depends on systems ability to differentiate between “self” and “non self”
•Autoimmune disorders occur when immune system fails to recognize itself
•Antibody-mediated immune response
•Cell-mediated immunity
•Declines with aging
Four Types of Hypersensitivity Reactions
•
Type I: IgE-Mediated Hypersensitivity
–Allergic asthma
–Allergic rhinitis (hay fever)
–Anaphylactic shock
•
Type II: Cytotoxic Hypersensitivity
–Blood transfusion reaction
•
Type III: Immune Complex-mediated Hypersensitivity
–IgG or IgM antibody-antigen immune complexes
–Histamine release
•
Type IV: Delayed Hypersensitivity
–Cell-mediated, not antibody-mediated
–Reactions are delayed-developing 24-48 hours later
Autoimmune Disorders and Tissue Transplant Rejection
•
Factors that may cause Autoimmune Disorders
–Release of “hidden” antigens
–Chemical, physical, or biologic changes in host tissue
–An antigen whose properties closely resemble those of host tissue
–Defect in normal cellular immune functions
–Slow growing mycobacteria
Autoimmune Disorders and Tissue Transplant Rejection
•
Tissue Match Terminology
–Autograft: transplant of the client’s own tissue
–Isograft: tissue from identical twin
–Allograft: graft between members of the same species
–Xenograft: transplant from a different species
Autoimmune Disorders and tissue Transplant Rejection
•
Tissue Rejection
–Hyperacute tissue rejection
–Active tissue rejection
–Chronic tissue rejection
–Graft-versus-host disease (GVHD)
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May be congenital or acquired
Unusual susceptibility to infection
Most severe when the antibody-mediated and cell-mediated responses are impaired
Genetically determined and rare
Affecting children more than adults
Laboratory and DiagnostTests for Immune Response
•WBC count with differential
•Radioallergosorbent test (RAST)
•Blood type and crossmatch
•Indirect Coombs’ test
•Direct Coombs’ test
•Immune complex assays
•Complement assays
•Skin tests
–Prick (epicutaneous or puncture test)
–Intradermal
–Patch
–Food allergy
Collaborative Therapies for Altered Immunity
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Immunotherapy: desensitization
Antihistamines: used in type 1 responses
Epinephrine: anaphylaxis
Corticosteroids: used for anti inflammatory effects
Plasmapheresis: removes harmful components from the plasma
Teaching Points for the Client with Altered Immune Responses
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Anaphylaxis kit
When to seek medical attention
Use of medications
Adverse reactions to medications
Skin care
Avoiding contact
Manifestations of HIV/AIDS
•
Early Clinical Manifestations of HIV/AIDS
–Flu and mononucleosis type symptoms
–Persistent generalized lymphadenopathy
–General malaise, fever, fatigue, night sweats, involuntary weight loss
•
Later Clinical Manifestations of HIV/AIDS
–Dementia and neurologic effects
–Opportunistic infections
–Pneumocystis carinii pneumonia
–Tuberculosis
–Candidiasis
–Wasting syndrome
–Kaposi’s sarcoma
–Lymphoma
Nursing Process for Care of Client with Altered Immune Responses
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Goal to prevent opportunistic infections
Assess coping mechanisms
Monitor nutritional status
Assess family and community support