Title: Nursing Management of Clients with Stressors of Immune Function
1Nursing Management of Clients withStressors of
Immune Function
- NUR133 Lecture 7
- K. Burger, MSEd, MSN, RN, CNE
2Immune Response
- FUNCTIONS
- Defense against invading pathogens
- Removal of worn-out cells
- Immune surveillance
3Immune Response
- COMPONENTS
- LEUKOCYTES
- Neutrophils
- Eosinophils
- Basophils
- Lymphocytes B-lymphocytes/ T-lymphocytes
- Monocytes
4Immune Response
- COMPONENTS
- OTHER
- Bone marrow / stem cells
- Lymph nodes
- Spleen
- Thymus
- Tonsils/adenoids
- Appendix
- GALT
5Immune Response
- Innate
- Non-specific
- First line of defense
- Immediate
- Inflammatory process
- Adaptive
- Specific
- Sustained
- Antibody mediated
- or
- Cell mediated
6Adaptive Immune SystemAcquired Immunity
- Antibody Mediated
- B-Lymphocytes react to extracellular antigens
- Sensitization occurs
- Division into Plasma and Memory Cell
- Antibody response
- Immediate
- and
- Long-term
- Cell Mediated
- T-Lymphocytes react to intracellular antigens
- Sensitization occurs
- Proliferation of T-cell subsets
- Cytotoxic
- Helper
- Suppressor
7Classifications ofAdaptive Immunity
- Adaptive immunity
- Natural active most effective/ longest lasting
- Artificial active vaccination / immunization
- Natural passive maternal/fetus transmission
- Artificial passive injection of antibodies
8Immune Function Excess
- Auto-immune Disease
- Failure of body to recognize its own HLA
- Antibody production against self
- SLE, Rheumatoid arthritis, Scleroderma
- Hypersensitivity / Allergic Response
- Excessive response to an antigen
- Type I Type V
9Hypersensitivity / Allergic Response
- Type I Immediate atopic reaction
rhinitis/ anaphylaxis
- Type II Cytotoxic transfusion reaction
- Type III Mediated Immune complex
Rheumatoid arthritis - Type IV Delayed Poison ivy, PPD
- Type V Stimulated Graves disease
10Type I Immediate Hypersensitivity
- Triggered by allergens
- Pollen, mold, dust, certain foods or meds etc.
- B cells synthesize IgE antibodies to allergen
- IgE antibodies attach to mast cells/basophils
- Result retained sensitivity
- Localized and/or systemic (anaphylactic)
11HypersensitivityAssessment
- History family hx, exposures, symptoms
- Physical headache, rhinorrhea, tearing eyes
- Labs elevated eosinophils
- elevated ESR
- Skin testing scratch / intradermal
- Food challenge
12HypersensitivityNursing Diagnoses
- Ineffective health maintenance r/t deficient
knowledge regarding allergies - Latex allergy r/t hypersensitivity to natural
rubber latex - Risk for latex allergy r/t repeated exposure to
products containing latex
13HypersensitivityInterventions
- Avoidance therapy
- Desensitization therapy
- Drug therapy
- Decongestants
- Antihistamines
- Corticosteroids
- Mast Cell Stabilizers
- Leukotriene Antagonists
14Anaphylaxis Emergency Interventions
- Establish and maintain open airway
- O2 _at_ high flow ( 4-6 L/min)
- Establish IV access with NS or RL
- Epinephrine 11000 0.3 0.5 ml sc
- Benadryl 25-100 mg IV
- Suction prn
- Elevate HOB ( unless severe hypotension)
- Theophylline, Beta agonists, Corticosteroidsto
stabilize
15Immunodeficiency
- Absence or inadequate production of immune bodies
- Primary ( congenital )
- Secondary ( acquired)
- Induced ( related to external stressors )
16Acquired ImmunodeficiencyAIDS
- Pathophysiology
- HIV virus docks with CD4 (helper T-cells)
- Enters CD4 cells DNA
- Creates more virus
- Virus buds off original host CD4 to attack more
cells - CD4 cell no longer working as immune cell
17Acquired ImmunodeficiencyAIDS
- Classifications
- A HIV positive
- B - Infected with HIV
- C AIDs
- Progression
- Months Years
- Dependent on
- Means of acquisition
- Personal factors
18Acquired ImmunodeficiencyHIV / AIDSAssessment
- History
- Physical exam
- Testing
- ELISA
- Western Blot
- Viral load
- CBC with differential
- CD4 / CD8 count
19Additional ResourceTesting Guidelines
- NYS DEPARTMENT OF HEALTH
- HIV / AIDS Web Resource
- http//www.health.state.ny.us/diseases/aids/index.
htm
20Stages of HIV Infection
- Stage I 3wks-3mos prior to seroconversion.
Mild illness S/S or asymptomatic - Stage II 1-10 yrs after seroconversion Low
rate of replication CD4 normal - Stage III Persistent lymphadenopathy
- Stage IV Rapid replication of HIV virus
Multiple opportunistic infections
Very low CD4 counts - Stage V Full Blown AIDS CD4 very low
21HIV / AIDS Clinical Manifestations
- Opportunistic Infections
- Protozoal - Pneumocystis carinii (PCP)
- Fungal - Candida albicans
- Bacterial - Mycobacterium avium (MAC)
Mycobacterium tuberculosis - Viral - Cytomegalovirus (CMV)
Herpes simplex (HSV) - Malignancies
- Kaposis Sarcoma
22HIV / AIDsClinical Manifestations (cont)
- Endocrine complications
- Aids Dementia Complex
- Wasting Syndrome
- Skin Changes
23HIV / AIDSNursing Diagnoses
- Risk for infection
- Impaired skin integrity
- Diarrhea
- Imbalanced nutrition
- Acute/ Chronic pain
- Impaired gas exchange
- Disturbed thought processes
- Social isolation
24AIDS/ HIV Interventions
- Prevention and early detection of infection
- Maintenance of adequate respiratory function
- Pain management
- Maintenance of skin integrity
- Promotion of nutrition and IBW maintenance
- Maintenance of self-esteem
- Maintenance of orientation
25AIDS / HIV InterventionsDrug Therapy
- Anti-retroviral agents in cocktail
- HAART ( Highly active anti-retroviral therapy)
- Nucleoside Reverse Transcriptase Inhibitors
Retrovir AZT - Non-nucleoside RTI Viramune
- Protease Inhibitors Invirase
- Fusion Inhibitors Fuzeon
- Immune enhancers BRMs
- Antibiotics Bactrim, Pentam, Flagyl
- Antituberculars INH