2872_module 5_Laura.pptx

Module 5

NRSG 2872 Adult Health

This Week in Adult Health

Mon. 13 Oct.

Wed. 15 Oct.

Fri. 17 Oct.

Exam 2 – covering modules 3 & 4

Clinical #5 0630-1900

Lab #5 1000-1530 – Blood Administration

Module 5 – Hematologic & Immune System •Chapter 33: Assessment of Hematologic System•Chapter 34: Concepts of Care for Patients with Hematologic Systems

Finish Module 5 0830-1000•Chapter 16: Concepts of Inflammation & Immunity•Chapter 18: Concepts of Care for Patients with Hypersensitivity & Autoimmunity

All assignments due by midnight

Mon. 13 Oct.

Fri. 17 Oct.

Sun. 19 Oct.

Hematologic System & Immune System

Hematologic

•Brief review of hematologic system & its components •Brief review of hematologic assessment •Types of anemia including iron deficiency & sickle cell•Blood transfusion & reactions •Leukemia

Infection & Immunity

•Brief review of inflammation, infection, & immunity•Brief review of assessment •Types of allergic reactions, including anaphylaxis & angioedema •Systemic lupus erythematosus (SLE)

Module Objectives

Perform a focused assessment of a client with hematological concerns

Implement appropriate nursing care procedures for patients with hematological concerns

Assessment of the Hematologic System

Chapter 33

Physiology

• Components
• Plasma – no cellular elements
• Clear, straw-colored liquid
• About 90% water
• 6-8% protein
• Albumin most abundant
• Globulins
• Fibrinogen – needed for clot formation
• Prothrombin – needed for coagulation
• Normal body nutrients – carbs (glucose), proteins (amino acids), fat (lipids)
• Metabolic waste products
• Formed elements (cells)
• Erythrocytes (RBCs)
• Leukocytes (WBCs)
• Thrombocytes (platelets)

Erythrocytes (RBCs)

• Formed in the bone marrow  erythropoiesis
• Need vitamin B12 & folic acid
• Early childhood, all bones contain red marrow which is replaced with fatty, yellow marrow as child grows
• In adult, only specific bones contain red marrow (flat & irregular bones)
• Primary function is transport of O2 & CO2
• Hemoglobin is primary component of RBC
• Serves as buffer in acid-base balance
• Hemoglobin combines easily with O2 to form oxyhemoglobin
• Iron major component of hemoglobin & is necessary for O2 transport
• Hematocrit is percentage of the blood occupied by erythrocytes
• If exposed to hypotonic solutions, water enters RBC = cell wall rupture & destruction/hemolysis
• Hemolysis also occurs when membranes are damaged (trauma & burns)

• Primary work of WBCs is accomplished when cells leave circulating volume & enter body tissue to remove pathogens
• Types
• Granulocytes – originate in bone marrow
• Neutrophils, eosinophils, & basophils
• Primary function to destroy bacteria
• Agranular leukocytes – originate primarily in lymphatic tissue
• Consist of lymphocytes & monocytes
• Assist in removal of broken-down tissue cells
• Primarily involved in activating immune response

Leukocytes (WBCs)

• Primarily involved with hemostasis – when a vessel wall is damaged, platelets adhere to the area & eventually form a platelet plug to decrease bleeding
• Hemostasis – 3 phases
• 1st tissue injury causes release of platelet factor; thromboplastin formed
• 2nd prothrombin is converted to thrombin
• 3rd phase thrombin converts soluble fibrinogen to insoluble fibrin (looks like a fine network of thread like a mesh or web)
• Fibrinolysis – the process by which clots are formed

Thrombocytes (Platelets)

Blood Classification

• Blood types: A, B, AB, O
• Antigens on RBCs
• A type  A antigen
• B type  B antigen
• AB type  A&B antigens
• O type  No antigens (universal donor)
• Plasma antibodies
• A type  Anti-B
• B type  anti-A
• AB type  None (universal recipient)
• O type  Anti-A & Anti-B
• Transfusion risk – mismatched blood causes clumping (agglutination) & destruction (hemolysis)

• Rh+  D antigen present
• RH-  No D antigen
• RH- person can form antibodies if exposed to Rh+ blood

Rh System

Assessment

• History – any diseases of bone marrow or RBC-producing organs, treatments (chemo, radiation), family history, prior blood transfusions
• Bleeding problems during pregnancy/labor
• Presence of chronic disorders
• Effects of aging
• Nutritional status – especially iron, folic acid, protein
• Current blood values – complete blood count (CBC)
• Focused exam – skin, lymph nodes, liver & spleen enlargement
• Assess for pallor, jaundice, cyanosis – do not rely on skin alone
• Tongue changes with anemia
• Look for bleeding gums, bruising

Concepts of Care for Patients with Hematologic Conditions

Chapter 34

Anemias

• Low RBC count & decreased levels of hemoglobin & hematocrit
• Defect in bone marrow
• Loss of RBCs
• Hereditary disorders
• Inadequate nutritional intake of iron, folic acid
• The more rapid an anemia occurs, the more severe the symptoms
• Healthy term infants have adequate iron stores for first 5-6 months
• Common goal of treatment is to identify origin and correct underlying problem

• Pale skin, delayed wound healing
• Brittle, thinning hair
• Generalized lymphadenopathy
• SOA, dyspnea on exertion, tachypnea
• Tachycardia, palpitations, postural hypotension
• Chronic fatigue, weakness, apathy
• Anorexia, nausea, weight loss, constipation, diarrhea
• Beefy red tongue, stomatitis, hematemesis
• Headache, dizziness, tingling in extremities

General Clinical Manifestations

Iron Deficiency Anemia

• Inadequate intake of dietary iron or excessive loss of iron
• Risk factors
• Common in adolescent d/t rapid growth
• Vegetarians & lacto-ovo vegetarians
• Occurs in infants who primarily consume milk
• May occur in pregnancy
• Heavy menstrual bleeding
• Other blood loss states
• Older adults more prone d/t poor intake & decreased absorption
• Diagnostics – decreased iron, Hgb and Hct
• Manifestations – may be asymptomatic in early stages, then general symptoms of anemia
• Pallor, glossitis, cheilitis – most common findings
• Treatment
• Supplemental iron
• Dietary supplementation

• Inability to absorb vitamin B12 (cobalamin)
• May be associated with a loss of intrinsic factor (gastrectomy, gastric bypass) or an autoimmune problem
• Risk factors – typically not associated with diet; most common in adults older than 60
• Familial tendency
• May be precipitated by gastrectomy, gastritis, Crohn disease, or chronic alcoholism
• Long-term use of PPIs and H2 histamine receptor blockers prevent release of intrinsic factor
• Gastric atrophy
• Diagnostics
• Homocysteine, cobalamin, serum folate levels
• Reduced number of RBCs and presence of abnormal RBCs
• Gastric analysis for free hydrochloric acid
• Manifestations – general symptoms of anemia, confusion
• Paresthesia in the extremities, weakness, reduced vibratory sense
• Loss of balance, ataxia
• Smooth, beefy, red tongue (glossitis)
• Treatment – injections of vitamin B12 or intranasal may be required for life; maintain good nutrition

Pernicious Anemia

• Characterized by pancytopenia – decreased bone marrow production – RBCs, WBCs, platelets
• Risk factors – exposure to certain meds & chemicals can precipitate
• Chemotherapeutic agents, radiation
• Anticonvulsant meds
• Benzene, insecticides, arsenic
• Radiation therapy
• Up to 70% of cases are idiopathic, thought to be autoimmune
• Diagnostics – bone marrow biopsy
• Clinical manifestations – general symptoms of anemia, fever, infections associated with thrombocytopenia
• Treatment
• Remove causative agent
• Hematopoietic stem cell transplant
• Immunosuppressive therapy

Aplastic Anemia

• Associated with decreased dietary intake of folic acid
• Risk factors – origin very similar to that of B12
• Poor nutrition – decreased folic acid intake, alcoholism, anorexia
• Malabsorption syndromes
• Deficiency may occur with increased demands for folic acid – infancy, adolescence, pregnancy
• Drugs – anticonvulsants, methotrexate, oral contraceptives
• Hemodialysis
• Clinical manifestations
• Slow, insidious onset
• Weight loss, emaciated
• May appear ill with malnourishment
• Diagnostics – differentiate between folic acid and vitamin B12 deficiency
• Treatment – oral replacement, encourage increased dietary intake

Folic Acid Deficiency Anemia

• All patients with anemia
• Decrease body O2 needs
• Assess tolerance to activities
• Cluster care
• Supplemental O2 as needed
• Prevent infection
• Frequent hand hygiene
• Limit visitors
• Watch for signs & symptoms, elevated WBC, neutrophil
• Assess for complications
• Make sure heart can maintain adequate CO
• Evaluate for symptoms of hypoxia
• Teach implications of disease and how to maintain health
• Explain medical regimen; benefits & side effects
• Discuss importance of follow up
• Identify foods high in vitamin B12, iron, folic acid

Anemia Nursing Interventions

Sickle Cell Disorder

• Genetic disorder causes mutation in gene for hemoglobin
• Causes chronic anemia, pain, disability, organ damage, increased infection & early death due to poor blood perfusion
• RBCs become sickle shaped, rigid, clump together sticky and fragile RBCs
• Block blood flow & perfusion (vaso-occlusive event) – leads to further tissue hypoxia & more sickle-shaped cells
• Hypoxia is the most common trigger for RBCs to sickle
• Other triggers include dehydration, high altitudes, infection, smoking, stress, weather changes, strenuous exercise, blood loss
• Sickled cells usually go back to normal shape when trigger is removed, but some Hgb remains twisted
• Average lifespan of a sickle cell is 10-20 days compared with the 120-day lifespan of a normal RBC  hemolytic anemia

SCD Vaso-occlusive Crises (VOCs)

• Sudden onset
• Can occur as often as every few weeks or as seldom as once a year
• Many are in good health most of the time with crises only in response to triggers
• Repeated crises & impaired perfusion cause long-term damage to tissues & organs
• Development of small infarcted areas & scar tissue formation
• Eventually organ failure results
• Spleen, liver, heart, kidney, brain, joints, bones, & retina most often affected
• Average life expectancy of adults with SCD is 22 years less

SCD Etiology & Genetic Risk

• Autosomal recessive pattern of inheritance
• Specific mutation in the Hgb gene leads to formation of HbS instead of HbA
• Patient with SCD have two HbS gene alleles, one from each parent
• Sickle cell trait (SCT) when one abnormal gene is inherited
• Can pass to any children
• Can occur in all races & ethnicities
• More common in people from certain regions
• About 1 in 13 (8%) of African Americans have SCT
• Cannot be prevented, genetic counseling for family planning if desired

• SCT usually have no symptoms or abnormal findings other than presence of hemoglobin S
• Adult with SCD usually has long-standing diagnosis
• Ask about previous crises, factors that preceded, degree of severity, management
• Explore any recent sick contacts & assess for signs & symptoms of infection
• Review all activities & events in the past 24 hours including food & fluid intake, exposure to extreme temps, drugs taken, exercise, trauma, stress, etc.
• Assess perceived energy level by using a scale ranging from 0 to 10
• Ask about changes in sleep patterns & rest, ability to climb stairs, activity that induces SOA

SCD History

• Pain – most common
• Other symptoms vary depending on site of reduced perfusion & tissue damaged
• CV – look for SOA, general fatigue, weakness, murmurs, S3 heart sound, increased jugular venous distention
• Compare peripheral pulses, temp, cap refill in all extremities
• Extremities distal to blood vessel occlusion are usually cool to touch, have slow cap refill, may have reduced or absent pulses
• HR is usually rapid & BP may be low to normal
• Respiratory - pulmonary HTN over time; increased risk of pneumonia; acute chest syndrome
• \Skin changes – pallor/ash gray or cyanosis (look at conjunctivae, palms, soles, etc.); jaundice; ulcers on the legs
• Musculoskeletal – arms and legs often the site of blood vessel occlusion. Joints may be damaged. Inspect for swelling, temp, or color difference. Assess ROM.
• CNS – look for cognitive & behavioral changes as early signs of cerebral hypoxia

SCD Manifestations

• Lab
• High performance liquid chromatography (HPLC) detects hemoglobin variants
• Preferred method for diagnosis of SCD
• Part of newborn screening in some states
• Sickle cell screen
• Other labs indicate complications of disease, especially during crises
• WBC count usually high r/t chronic inflammation
• Imaging
• Bone changes d/t chronically stimulated marrow & low bone oxygen levels
• Joint x-rays may show necrosis & destruction
• Ultrasound, CT, PET, MRI may show soft tissue & organ changes
• Other
• ECG may show cardiac infarcts & tissue damage changes r/t area of heart damaged
• Echos may show cardiomyopathy and decreased CO

SCD Diagnostics

• Pain management
• IV opioids – morphine, hydromorphone
• Warm compresses, hydration, relaxation
• Hydration – oral fluids & IV
• Medications
• Hydroxyurea (increases fetal Hgb)
• L-glutamine (decreases sickling)
• Infection prevention
• Watch CBC, inspect mouth, lungs, urine
• VS q4h
• Oxygen & transfusion
• O2 during crises
• RBC transfusions to dilute HbS as necessary
• Monitor for side effects
• Hydroxyurea – teratogenic, bone marrow suppression

SCD Nursing

• Drink 3–4 L fluids daily
• Avoid cold, heat, high altitudes
• No cold packs
• Dress appropriately for weather
• Avoid overheating & overexposure to sun
• No smoking, alcohol, or drugs
• Mild exercise; avoid contact and/or strenuous sports
• Get vaccines & regular checkups
• Use auto-injector at first sign of crisis
• Notify providers of SCD diagnosis

SCD Patient & Family Education

Blood Transfusions

• Whole blood or components of blood for replacement
• Packed RBCs (PRBCs)
• Excessive blood loss
• Anemia (Hgb <6 or 6-10)
• Kidney failure
• Fresh frozen plasma (FFP)
• Coagulation factor deficiencies (hemophilia)
• Albumin – burns, hypoproteinemia
• Clotting factors
• Cryoprecipitate – hemophilia A
• Platelets
• Platelets less than 20,000 or 50,000 & actively bleeding

Blood Transfusion – Preprocedural

• Verify labs & provider order
• Confirm blood type & Rh
• Get crossmatch sample
• Check past reactions
• Record baseline vitals
• Use 18–20G IV
• Prime tubing with NS
• Inspect blood
• Two RN check
• Start within 30 min
• Stay with patient 15–30 min

Blood Transfusion – During Procedure

• Remain with the patient for first 15-30 minutes
• Monitor VS & rate of infusion per facility policy
• Complications
• Acute hemolytic
• Febrile
• Allergic
• Bacterial
• Circulatory overload
• Alert provider immediately if any indications of reaction

Blood Transfusion - After

• Obtain VS upon completion
• Dispose of blood administration set according to facility policy
• Document patient’s response

Acute Hemolytic Reaction

• Occurs immediately or during subsequent transfusions
• Incompatible blood products
• Can occur following transfusion or with as few as 10 ml of blood
• Ranges from mild to life threatening
• Findings – fever, chills, low-back pain, tachycardia, flushing, hypotension, CP, tachypnea, nausea, anxiety, hemoglobinuria, impending sense of doom

• STOP the transfusion
• Remove blood tubing from IV access
• DO NOT CONTINUE INFUSING NS
• Change out the tubing down to the hub and start a new infusion of NS
• Monitor VS & fluid status
• Send blood bag & administration set to lab for testing

Febrile Reaction

• Occurs within 2 hours of starting transfusion
• Development of anti-WBC antibodies
• Seen when client has received multiple transfusions
• Findings include – chills, hypotension, tachycardia
• Increase of 1 degree F (0.5 degrees C) or greater from pretransfusion

• Use WBC filter for administration
• Stop transfusion to give antipyretics
• Initiate infusion of NS using new tubing

Allergic Reaction

• Occurs during or up to 24 hours after transfusion
• Sensitivity to a component
• Findings are usually mild – itching, urticaria, flushing
• May develop anaphylactic reaction

• Mild rection
• Stop transfusion
• Initiate NS using new tubing
• Give antihistamine (e.g. diphenhydramine) as ordered
• Restart transfusion slowly if prescriber orders
• Anaphylactic reaction
• Stop transfusion
• Give epi, O2, or CPR as indicated
• Remove blood tubing
• Start NS infusion with new tubing

Bacterial Reaction

• Occurs during or up to several hours after transfusion
• Contaminated blood products
• Findings include wheezing, dyspnea, chest tightness, cyanosis, hypotension, shock

• STOP the transfusion
• Give antibiotics & IV infusion of NS using new tubing
• Send blood culture specimen to lab for analysis

Circulatory Overload

• Can occur at any time during transfusion
• Transfusion rate too rapid for client
• Older clients or those with preexisting increased circulatory volume at increased risk
• Findings – crackles, dyspnea, cough, anxiety, JVD, tachycardia
• Can progress to pulmonary edema

• Slow or stop transfusion depending on severity of symptoms
• Position client upright – feet lower than heart level
• Give O2, diuretics, morphine as ordered

• Chronic disorder – proliferation of all red marrow cells owing to chromosomal mutation
• Risk factors – usually during middle age (median age 60), more common in males
• Diagnostics
• CBC – increased RBC, WBC, platelets, & hemoglobin
• Erythropoietin level
• Bone marrow biopsy
• Manifestations
• Early – HTN which can cause HA, vertigo, tinnitus, pruritus, visual disturbances
• Ruddy complexion
• Hepatosplenomegaly; peptic ulcer dyspepsia
• Complications – stroke secondary to thrombosis
• Treatment
• Phlebotomy
• Myelosuppressive agents
• Symptom management
• Nursing – help patient understand dietary implications and disease

Polycythemia Vera

Leukemia

• Uncontrolled proliferation of abnormal WBCs
• Eventual cellular destruction occurs because of the infiltration of the leukemic cells into the body tissue
• Highly vascular organs are primarily affected – spleen, liver, lymph nodes show marked infiltration, enlargement, fibrosis
• Invasion of bone marrow by the leukemic cells can precipitate pathologic fractures
• 3 primary consequences of leukemia
• Anemia from RBC destruction & bleeding
• Infection associated with neutropenia
• Bleeding tendencies caused by decreased platelets

Types of Leukemia

Acute lymphocytic leukemia (ALL)

•Peak occurrence around 4; then again around 65 years •Favorable prognosis with chemo •Leukemic cell infiltrate the meninges, precipitating increased ICP; leukemic meningitis

Acute myelogenous leukemia (AML)

•Most common in older adults •Peak incidence age 60-70 years

Chronic myelogenous leukemia (CML)

•Uncommon before age of 20 years; peak incidence at age of 45 years •Onset generally slow •Symptoms less severe than those in acute stages of disease

Chronic lymphocytic leukemia (CLL)

•Common malignancy of older adults; rare before age 30 years•More common in men •Frequently asymptomatic; often diagnosed in a chronic fatigue workup

Leukemia Manifestations

• Anemia, fever, bleeding tendencies occurring together
• Anorexia, weight loss, cough
• CNS involvement – headache, confusion, increased irritability
• Fatigue, lethargy
• Petechiae, bruises easily, epistaxis
• Complaints of bone & joint pain
• Hepatomegaly & splenomegaly

Leukemia Diagnostics

• Bone marrow aspiration & biopsy
• CBC
• Studies to evaluate liver function
• ALT
• AST
• BUN
• Serum creatinine

• Medications
• Corticosteroids
• Antineoplastics
• Xanthine-oxidase inhibitor – allopurinol decreases uric acid levels in clients receiving antineoplastics
• Chemo – usually involves induction, consolidation, and maintenance phase
• Combo used to promote remission
• Hematopoietic stem cell transplantation
• Radiation therapy
• Remission characterized by absence of leukemic cells & disappearance of all symptoms

Leukemia Treatment

Leukemia – Nursing

• Prevent or limit
• Infection
• Bleeding episodes
• Renal complications associated with chemo
• Adverse effects of chemo
• Stomatitis
• Soft toothbrush
• Avoid lemon-glycerin swabs, sodium lauryl sulfate in toothpaste, mouthwash with alcohol
• Provide pain relief

• Use smallest needle possible
• Limit venipunctures & injections
• Soft toothbrush, no flossing
• Avoid alcohol-based mouthwash
• Electric razor only
• Prevent constipation
• Avoid aspirin & NSAIDs
• No catheters, enemas, or suppositories
• Monitor for bleeding signs
• Handle gently to prevent injury

Bleeding Precautions

• No aspirin or aspirin-containing products
• Caution with NSAIDs
• Discourage pets, fresh flowers, houseplants
• Teach how to stop bleeding
• Teach importance of good handwashing & other infection prevention measures
• Teach early signs of infection
• Community resources

Leukemia – Home Care

Concepts of Inflammation & Immunity

Chapter 16

• Functions
• Defense
• Homeostasis
• Surveillance
• Antigens
• Foreign to the body – think bacteria, viruses, or other pathogens
• Elicit an immune response
• Allergens are antigens that produce allergic response
• Antibodies
• Proteins produced by B Cells in response to antigens
• Help recognize & gi9ght off future infections by the same pathogen
• Active & passive immunity

Physiology of Immune System

Humoral & Cell-Mediated Response

• Humoral response
• Antibodies produced by plasma cells circulate through the blood
• Bind to & inactivate antigens or infectious agents
• Cell-mediated responses
• A response is initiated by recognition of antigens by T cells
• T cells then differentiate into specific cells that react directly with the antigen
• Provides cellular immunity, delayed hypersensitivity
• Humoral & cellular responses are not independent, but interdependent

Properties of Immunologic Response

• Specificity
• Formation of specific antibody for each antigen
• Does not protect against other antigens
• Memory
• Both responses are capable of “remembering” the antigen
• Responds more rapidly if exposed to the same antigen again
• Self-recognition
• IS has capability of distinguishing self or self-antigens from non-self or foreign antigens
• Self-antigens do not illicit an immune response

• Early response – self-limiting innate resistance or natural barrier
• Responds to site of tissue injury
• Results in redness, heat, swelling & pain d/t vasodilation, increased vascular permeability, WBC migration to injury
• Destroys injurious agents & removes them, confines agents to the area, stimulates immune response, promotes healing
• Chronic inflammation lasts 2 weeks or longer
• Frequently preceded by an unsuccessful acute response
• Infiltration of lymphocytes & macrophages occur in attempt to protect body
• Area may be walled off by a granuloma

Inflammatory Response

• Infants protected at birth by maternal antibodies that cross placenta
• Infants' immune system begins to function around 6 months
• With aging, diminished response of cell-mediated immunity and decline in efficiency of humoral immunity
• Older patients at increased risk for impaired inflammation & wound healing secondary to chronic diseases & meds that impair the inflammatory response

Effects of Aging on Immune Response

Concepts of Care for Patients with Hypersensitivity & Autoimmunity

Chapter 17

• Inflammation & immunity are protective when directed against appropriate targets with time-limited response
• When response is excessive, widespread, or directed against normal body tissue = damage
• Excessive responses underlie problems with hypersensitivity (aka allergy)
• Allergen = an antigen that triggers excessive inflammation or immunity overreactions
• Inhaled
• Ingested
• Injected
• Contacted via skin or mucous membranes
• Can cause minor inconvenience (itchy, watery eyes, sneezing) to life-threatening reactions
• Classified into 4 basic types depending on timing, pathophysiology, and symptoms
• Predisposition to allergies is genetic, but specific allergies are NOT inherited

Hypersensitivities/Allergies

• Occurs when a person has previously been sensitized to a specific antigen
• Results from increased production of IgE antibody which causes release of histamine
• Smooth muscle contraction (spasms of bronchial muscles & airway obstruction)
• Capillary vasodilation & increased capillary permeability leading to vascular collapse (decreased BP)
• Increased nasal stuffiness & bronchial secretions
• Usually occurs minutes after exposure
• Conditions associated with type I
• Anaphylaxis (most severe)
• Latex allergy (within minutes)
• Atopic reactions (most common)

Hypersensitivity Type I

• Antibodies destroy the cell on which the antigen is bound = tissue injury
• Normal process of phagocytosis accelerated & begins to damage healthy tissue
• Conditions associated with Type II
• Hemolytic disease of newborn (Rh factor)
• Leukopenia & thrombocytopenia
• ABO blood incompatibility (hemolytic reaction)
• Goodpasture syndrome

Hypersensitivity Type II

Hypersensitivity Type III

• Cause: Immune complexes deposit in tissues
• Affected Areas: Kidneys, skin, joints, lungs, blood vessels
• Symptoms: Inflammation & tissue damage
• Examples:
• Persistent infections (strep)
• Systemic Lupus Erythematosus (SLE)
• Rheumatoid Arthritis (RA)

• T cells are sensitized to an antigen from a previous exposure; occurs 24-48 hours after exposure
• May take 72 hours to reach max intensity
• Sensitized T cells initiate inflammatory response, leads to cellular damage & damage to surrounding tissue
• Conditions associated with type IV
• TB, skin testing
• Contact dermatitis (poison ivy)
• Transplant rejection
• Latex allergy

Hypersensitivity Type IV

• Occurs in clients highly sensitized to a specific allergen
• Antigen-antibody response causes release of histamine
• Histamine causes allergic reaction  hives & itching
• Causes vasodilation & increased capillary permeability
• Risk factors
• History of exposure to allergen
• Amount of allergen
• Absorption of ingested allergen
• Antibody levels from previous exposure
• Occupational, social, environmental factors
• The more rapid the onset of symptoms, more severe the reaction

Anaphylactic Reaction

Manifestations

• Depends on level of prior sensitivity & amount of allergen
• Mild to moderate
• Peripheral tingling
• Pruritus, urticaria
• Sensation of warmth
• Edema of lips & tongue
• Nasal congestion
• Flushing
• Anxiety
• May rapidly progress to
• Acute anxiety
• Difficulty breathing (bronchospasm, laryngeal edema), GI cramping, cyanosis, hypotension

Anaphylaxis Treatment

• Type I hypersensitivity reaction
• involves all blood vessels & bronchiolar smooth muscle
• Causes widespread blood vessel dilation, decreased CO, bronchoconstriction within seconds to minutes after exposure
• Occurs rapidly & systemically and can be fatal
• Major factor in fatal outcomes is delay in giving epinephrine!
• Can be fatal even with appropriate intervention – prevention is KEY
• Epi – first line of treatment for severe reactions – repeat q5-15 minutes
• O2 high concentrations
• IV fluids, vasopressors, volume expanders to maintain circulatory status
• Maintain patent airway – intubation or trach may be needed
• Corticosteroids to reduce inflammation
• In hospital – drugs & injectable imaging contrast media (dyes); food & insect stings or bites in community settings

• ID clients with predisposition to a reaction
• Evaluate all client history regarding reactions to meds, foods, insect bites, vaccines (esp. egg-cultured), blood products, diagnostic agents)
• If a hypersensitivity is suspected, a localized skin test may be done
• Prevention is priority
• Maintain adequate ventilation
• Bed rest, low Fowler position with legs elevated
• High O2 concentration as needed
• Use of airway adjuncts as needed
• Medications to reverse bronchospasm (albuterol, corticosteroid, epinephrine)
• Restore adequate circulation
• IV fluids (NS or LR), carefully titrate with VS
• Vasopressors & volume expanders
• Closely monitor all patients for early signs
• If you suspect anaphylaxis, immediately notify rapid response team
• Give epi as soon as possible

Anaphylaxis Nursing

Patient Education – Auto Epinephrine Injectors

• Practice with trainer device
• Carry 2 injectors at all times
• Store in case, avoid heat/light
• Use at first sign of reaction
• Inject into outer thigh at 90°
• Hold for 3 seconds, then massage
• Call 911 immediately

Angioedema

• Severe type I hypersensitivity reaction - emergency
• Sudden localized swelling of the deeper layers of the skin
• Can occur in any part of the body – arms, hands, legs, feet, genitals
• Most often seen in lips, face, tongue, larynx, & neck
• Intestinal angioedema can also occur
• Drugs most associated include ACE inhibitors & NSAIDs including aspirin
• Greatest risk from ACEIs within the first 24 hours after starting

Angioedema Manifestations

• Swelling of lips – can also include face, throat, or extremities
• Itching also common
• Difficulty breathing & muscle weakness in severe cases – requires medical attention

Angioedema – Nursing

• Obtain history – need to know all drugs taken on a regular basis, especially for BP
• No specific test can diagnose
• Interventions focus on maintaining airway & stopping reaction
• O2 by NC
• Administer epinephrine & corticosteroids as ordered
• Indications for intubation – stridor & inability to swallow
• If intubation not possible, emergency trach needed (must be below level of edema)

• Autoimmune condition occurs when IS no longer recognizes normal tissue
• Reacts against self-antigens & begins to destroy host tissue
• Autoimmune response & disease occurrence
• Direct action of the antibody on the cell surface
• Causes cell destruction & may activate inflammatory response
• An alteration of both B cells and/or T cells can produce auto-sensitized T cells & cause tissue damage
• Definitive genetic component to autoimmune diseases
• Affect women 3x more often than men

Autoimmune Conditions

Autoimmune Response

• Systemic
• Connective tissue disorders – SLE
• Rheumatic disorders – RA
• Chronic pain & progressive immobility
• Organ specific
• Myasthenia gravis, MS, Guillain-Barre
• Hyperthyroid, celiac
• Addison
• T1DM, pernicious anemia

• Multisystem inflammatory autoimmune disorder
• Affects multiple organs
• Characterized by diffuse production of auto-antibodies that attack & cause damage to body organs & tissue
• Tissue injury caused by deposition of immune complexes through the body – activates immune response
• Severity varies greatly; periods of remission & exacerbation
• Risk factors
• Women 20-40 years of age
• Familial tendency
• More prevalent in Black Americans, Asian Americans, Hispanics, Native Americans
• Maybe triggered by environmental stimulus, infections, & meds – sun exposure most common

Systemic Lupus Erythematosus

SLE Manifestations

• General: Fatigue, fever, weight loss
• Skin: Butterfly rash, sun sensitivity, mouth ulcers, hair loss
• Joints: Pain, swelling, arthritis
• Kidneys: Proteinuria, nephritis
• Heart/Lungs: HTN, pericarditis, pleurisy
• Neuro: Seizures, confusion
• Blood: Anemia, low WBC/platelets
• Other: Raynaud’s, emotional changes

SLE Diagnostics

• No specific test is diagnostic – assess symptoms
• Presence of antinuclear antibody (ANA), high levels of anti-DNA, and presence of anti-Smith (Sm)
• C-reactive protein (CRP), ESR – monitor inflammation & therapy effectiveness

• Most important problems – persistent pain, chronic inflammation, fatigue, possible loss of tissue integrity, decreased self-esteem
• NSAIDs
• Corticosteroids for exacerbations
• Immunosuppressants
• Antimalarial agents (hydroxychloroquine)
• Steroid-sparing drugs (methotrexate)

SLE – Treatment

• Prevent exacerbations
• Maintain good nutrition; low-cholesterol diet
• Avoid exposure to infections
• Teach about skin problems – discoid lesions, hair loss
• Avoid exposure to sunlight – SPF 30 minimum
• Maintain adequate perfusion
• Assess for numbness, tingling, weakness of hands & feet
• Prevent injury to extremities, especially fingers
• Watch fluid status – cardiac status, fluid retention, weight gain
• Pain control
• Establish schedule to conserve energy, still maintain activity
• NSAIDs
• Non-pharmacologic therapy to supplement analgesics
• Maintain renal function
• Watch for peripheral edema, HTN, hematuria, decreased output
• Monitor BUN and creatinine
• Watch for UTI & teach good hygiene to prevent UTI
• Maintain psychological equilibrium

SLE – Nursing

Human Immunodeficiency Virus (HIV)

• Caused by a retrovirus that causes immunosuppression
• Infection causes increased susceptibility to infection d/t diminished response of the IS
• Transmission
• Blood
• Sexual
• Perinatal
• CD4 T helper cells are regulating cells in the IS; level of CD4 T cell sis used to monitor stages & progression of virus
• Normal T cell count at least 800 cells
• Higher viral load = greater risk of transmission

Stage I – Acute HIV

• Intense viral replication & dissemination of HIV throughout the body
• Symptoms are mild, ranging from no symptoms to flulike symptoms
• Window of seroconversion – period from when person is infected until HIV antibodies can be detected (average 1-3 weeks)
• May have vague, nonspecific symptoms for years
• High viral load and CD4 count falls, but only temporarily

Stage II – Chronic HIV

• Asymptomatic - CD4 count greater than 500 & low viral load
• Chronic vague symptoms persist – fever, fatigue, headache, night sweats
• Persistent generalized lymphadenopathy
• Symptomatic – CD4 count between 200 & 500 & increased viral load
• Exacerbation of symptoms
• Localized infections, increased lymphadenopathy, and neurologic manifestations
• Candida is a common problem
• Hairy oral leukoplakia – may be indication of progression of disease
• Shingles, oral, or genital herpes lesions
• Kaposi sarcoma
• Cutaneous skin lesion – looks like a bruise; later will turn dark violet or black
• Invades body organs, extremities, skin, torso
• May become painful

Stage III – Acquired Immunodeficiency Syndrome (AIDS)

• CD4 T-cell count less than 200 & viral load increased
• Diagnosis made when HIV-positive client develops at least one of the following disease
• AIDS dementia complex
• At least one opportunistic cancer
• Invasive cervical cancer
• Kaposi sarcoma
• Burkitt lymphoma
• Immunoblastic lymphoma
• Primary lymphoma of the brain
• At least one opportunistic infection – viral (cytomegalovirus), fungal, bacterial, or protozoal infection

• Diseases & infections that occur in clients with AIDS
• Take advantage of suppressed immune system
• Type of infection & extent varies with each client, depending on extent of immunosuppression
• Single opportunistic infections are rare
• May be delayed or prevented with antiretroviral therapy, vaccines, and disease-specific prevention
• Specific strains of pneumonia, TB, fungal infections, Kaposi sarcoma, candidiasis, etc.

HIV – Opportunistic Diseases

HIV Testing

• Antibody/antigen testing – highly sensitive test
• 4th generation testing algorithm includes confirmatory testing with HIV viral load testing for any indeterminate results
• If negative testing but continued risky behavior, should retest in 4-6 weeks
• If positive, assist in finding follow-up care
• Rapid tests – ready within 20 minutes
• Results preliminary & must be confirmed
• Must return for standard assay if positive
• In-home testing kids available
• Serum monitoring after diagnosis
• CD4 count & plasma assays
• Evaluation for drug resistance

HIV Treatment

• Meds – antiretroviral therapy (ART)
• Prescribed according to viral load & CD4 count
• Combo of at least 3 or more ART drugs
• Women should begin ART even if pregnant
• Combo drug therapy attacks virus at different stages
• OTC drugs & herbals may cause reactions (especially St. John wort)
• Meds don’t cure, but decrease viral replication & slow disease process
• Adherence to drug schedule is critical
• Nonadherence can lead to mutations of the virus & increased resistance

• Educate regarding transmission
• Safe sex
• Don’t share needles
• Monitor for & prevent opportunistic infection
• Antimicrobials given in high doses for extended period, may cause neutropenia
• Protect from iatrogenic infections or HAIs
• Teach client symptoms
• Persistent unexplained fever, night sweats
• Thrush
• Persistent diarrhea & weight loss
• Maintain adequate nutrition
• Teach regarding nutrition & calories – high calorie, protein to correct deficiencies
• Encourage several small meals
• Avoid foods that cause irritation
• Maintain fluid & electrolyte status
• Evaluate for weight gain & loss
• Assess for chronic diarrhea
• Encourage fluids

HIV Nursing

• Home care for immunocompromised
• Maintain personal hygiene & practice standard precautions
• Do not share personal items (toothbrushes, razors.)
• Teach how to prevent infection
• Cook all veggies & meats
• Peel fruits before eating
• Avoid contact with animal waste (litter boxes, bird cages, fish)
• Avoid crowds & people with respiratory tract infections
• Do not get pregnant

HIV – Teaching