1. immune disorder
1) hypersensitivity
- types of hypersensitivity reactions
| ① type 1: immediate, anaphylactic
• reaction: anaphylaxis, atopic disease, skin reaction |
• causative component: IgE
• mast cell degranulation |
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| ② type 2: cytolytic, cytotoxic
• reaction: ABO incompatibility, drug-induced hemolytic anemia |
• causative component: IgG, IgM, complement
• complement fixation |
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| ③ type 3: immune complex
• reaction: Arthus reaction, serum sickness, SLE, acute glomerulonephritis |
• causative component: antigen-antibody complexes
• deposition in vessels and tissue walls |
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| ④ type 4: cell-mediated, delayed
• reaction: tuberculosis, contact dermatitis, transplant rejection |
• causative component: sensitized T cells
• lymphokine release |
2) allergy
| • An allergy is an abnormal, individual response to certain substances that normally do not trigger such an exaggerated reaction. In some types of allergies, a reaction occurs on second and subsequent contact with the allergen. | • history or exposure to allergens
• rashes • itching, tearing and burning of the skin • nose twitching, nasal stuffiness • Skin testing may be done to determine the allergen. |
• identification of the specific allergen
• management of the symptoms with antihistamines, anti-inflammatory agents, or corticosteroids • ointments, creams, wet compresses, and soothing baths for local reactions • Desensitization programs may be recommended. |
(1) latex allergy
| • Latex allergy is a hypersensitivity to latex.
• at-risk individuals: health care workers, individuals who work in the rubber industry, individuals having multiple surgeries, individuals with spina bifida, individuals who wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, water chestnuts, apple, carrot, celery, papaya, tomato, and melon |
• Ask the client about a known allergy to latex when performing the initial assessment.
• Identify risk factors for a latex allergy in the client. • Keep a latex-safe supply cart near the client’s room. • Use non-latex gloves and all latex-safe supplies. Apply a cloth barrier to the client’s arm under a blood pressure cuff. Use latex-free syringes, medication containers (glass ampules), and latex-safe IV equipment. • Instruct the client to wear a Medic-Alert bracelet. |
- Products that may contain natural rubber latex: ace bandages (brown), adhesive or elastic bandages, Ambu bag, balloons, blood pressure cuff, catheter leg bag straps, catheters, condoms, diaphragms, elastic pressure stockings, electrocardiographic pads, feminine hygiene pads, gloves, IV catheters, tubing, and rubber injection ports, nasogastric tubes, pads for crutches, prepackaged enema kits, rubber stoppers on medication vials, stethoscopes, syringes
3) anaphylaxis
| • Anaphylaxis is a serious and immediate hypersensitivity reaction that releases histamine from the damaged cells. | • can be systemic or cutaneous | • Quickly assess the respiratory status and maintain a patent airway.
• The head of the bed is elevated if the client’s blood pressure is normal. The client’s feet and legs may be raised if the blood pressure is low. • Call the HCP or RRT. • Administer oxygen. • Start an IV line and infuse NS. • Prepare to administer diphenhydramine (Benadryl) and epinephrine (adrenaline). • Documents the event, actions taken, and the client’s response. |
4) immunodeficiency
| • Immunodeficiency is the absence or inadequate production of immune bodies. | • factors that decrease immune function
• frequent infections • medication history, such as the use of corticosteroids for long periods • nutritional status • history of alcohol or drug abuse |
• The priority concern for a client with immunodeficiency is infection. Protect the client from infection.
• Use strict aseptic technique for all procedures. • Instruct the client in measures to prevent infection. • Promote a balanced diet with adequate nutrition. • Provide psychosocial care regarding lifestyle changes and role changes. |
5) immunodeficiency syndrome: AIDS (Acquired Immunodeficiency Syndrome)
| • AIDS is a viral disease caused by HIV (Human Immunodeficiency Virus), which destroys T cells, thereby increasing susceptibility to infection and malignancy. The syndrome is manifested clinically by opportunistic infection and unusual neoplasms. (HIV infects CD4+ T cells.)
• high-risk groups: heterosexual or homosexual contact with high-risk individuals, IV drug abusers, persons receiving blood products, health care workers, babies born to infected mothers |
• Manifestations may not appear until late in the infection.
• fever, influenza-like symptoms • weight loss • protozoan infections: PJP (Pneumocystis Jiroveci Pneumonia) • neoplasms: Kaposi’s sarcoma (a slow-growing tumor that appears as raised, oblong, purplish, reddish-brown lesions) |
• Provide respiratory support. Administer oxygen and respiratory treatments as prescribed.
• Monitor for signs of infection. Provide protective isolation if the immune system is depressed. • Prevent the spread of infection. • Initiate standard and other necessary precautions. • Administer immunotherapy to stabilize the immune system. Combination therapy may be prescribed and includes the use of more than one antiretroviral medication. • Maintain fluid and electrolyte balance. • Provide meticulous skin care. • Provide psychosocial support as needed. • Provide adequate nutritional support as prescribed. |
- [Pediatric] immunizations and home care of children with HIV: Immunization against childhood disease is recommended for all children exposed to and infected with HIV. If a child has symptomatic HIV infection or has severe immunosuppression, only the inactivated influenza vaccine that is given IM should be used. Measles vaccine should not be given. Varicella-zoster virus vaccine should not be given. Do not share eating utensils with the child. Wash all eating utensils in the dishwasher. (식기로 전염되기 때문이 아님, 아이를 보호하기 위함) Wear gloves when caring for the child, especially when in contact with body fluids and changing diapers. Change the child’s diapers frequently, away from food areas. Clean up any of the child’s body fluid spills with a bleach solution (10:1 ratio of water to bleach).
6) t/p (transplantation) & post transplantation immunodeficiency
- KT (Kidney Transplantation): A human kidney from a compatible donor is implanted into a recipient. Kidney transplantation is performed for irreversible kidney failure.
- types of donors
| living related donors | • The most desirable source for t/p is living related donors who closely match the client.
• Donors are screened for ABO blood group, tissue-specific antigen, human leukocyte antigen suitability, and mixed lymphocyte culture index. Donors are also screened for the presence of any communicable diseases and undergo a complete medical evaluation. • Complete understanding of the donation process and outcome by the donor is necessary. |
| cadaver donors | • Cadaver donors must meet the institution’s criteria of brain death. |
- preoperative interventions: Verify the histocompatibility test of the donor, which will be done by organ bank personnel. Administer immunosuppressive medications to the recipient for 2 days before t/p, as prescribed. Maintain strict aseptic technique for the recipient. Ensure that the recipient is free of any infections. Encourage discussion of feelings of the donor and the recipient.
(KT) Verify that hemodialysis of the recipient was completed 24 hours before t/p. Assess renal function studies. - postoperative interventions: Maintain aseptic technique and monitor for infection. Monitor V/S, CVP for signs of complications. Monitor IV fluids closely; because for the first 12 to 24 hours, IV fluid replacement is based on hourly urine output. Encourage coughing and deep breathing exercise. Monitor for bowel sounds and for the passage of flatus; initiate a specific diet and oral fluids as prescribed when flatus and bowel sounds return. The client is usually ambulated after 24 hours. Administer medications as prescribed; immunosuppressive agents, corticosteroids, antibiotics. Assess for organ rejection by monitoring laboratory values closely. Avoid exposure to persons with infections. Ensure follow-up care.
(KT) Urine output usually begins immediately if the donor was a living donor. Hemodialysis may be performed until adequate kidney function is established. Monitor daily weight to evaluate fluid status. Monitor Foley catheter patency. Note that urine is pink and bloody initially but gradually returns to normal within several days to weeks. Remove the Foley catheter as soon as possible to prevent infection. Administer diuretics and osmotic agents. Avoid prolonged periods of sitting for life. Avoid contact sports. - graft rejection
| ① hyperacute rejection: Occurs at the time of anastomosis of the organ. | • removal of rejected kidney | |
| ② acute rejection: Occurs most frequently within 6 weeks postoperatively, but can occur any time post-transplantation. | • temperature higher than 100℉ (37.7℃)
• pain or tenderness over the grafted site • edema • rejection indicated by ultrasound or biopsy |
• Potentially reversible with increased immunosuppression and if treated early.
• High doses of corticosteroids or monoclonal antibodies may be prescribed if corticosteroids are ineffective. |
| ③ chronic rejection: Occurs slowly months to years after transplant and mimics CKD. | • Immunosuppressive medications and retransplantation if necessary. |
- post-transplantation immunodeficiency
| • The client must take immunosuppressive agents for the rest of his or her life post-transplantation to decrease rejection of the transplanted organ or tissue.
• high-risk clients: Clients with a history of malignancy or premalignancy have an increased susceptibility to malignancy if immunosuppressed. Clients with recent infection or exposure to tuberculosis, herpes zoster, or chickenpox have a high risk for severe generalized disease when on immunosuppressive agents. |
• the complete cell count with differential to determine signs of infection
• all body secretions periodically for blood • renal and hepatic function |
• Assess for signs of rejection. Signs will depend on the organ or tissue transplant.
• Assess for signs of opportunistic infections. • Assess nutritional status. • Strict aseptic technique is necessary. • Provide teaching regarding asepsis and the signs of infection and rejection. |
2. autoimmune disease
1) SLE (Systemic Lupus Erythematosus)
| • It is a chronic, progressive, systemic inflammatory disease that can cause major organs and systems to fail. Connective tissue and fibrin deposits collect in blood vessels on collagen fibers and on organs. The deposits lead to necrosis and inflammation in blood vessels, lymph nodes, gastrointestinal tract, and pleura. | • erythema of the face also called a butterfly rash
• fever • weakness, fatigue • anorexia, weight loss • joint pain • positive ANA (Anti Nuclear Antibody) test and LE (Lupus Erythematosus) preparation • elevated ESR (Erythrocyte Sedimentation Rate) and CRP (C-Reactive Protein) level • signs of organ involvement such as pleuritis, nephritis, pericarditis, coronary artery disease, hypertension, neuritis, anemia, and peritonitis |
• Monitor skin integrity and provide frequent oral care. Instruct the client to clean the skin with a mild soap, avoiding harsh and perfumed substances. Assist with the use of ointments and creams for the rash as prescribed. Instruct the client to avoid exposure to sunlight and ultraviolet light.
• Identify factors contributing to fatigue. Instruct in measures to conserve energy, such as pacing activities and balancing rest with exercise. • Provide a high-protein diet if there is no evidence of kidney disease. Provide a high-vitamin and high-iron diet. Administer iron, folic acid, or vitamin supplements as prescribed if anemia occurs. • Monitor I/O, as well as daily weight for signs of fluid overload if corticosteroids are used. Monitor for proteinuria and red cell casts in the urine. Monitor the BUN and Cr levels frequently. • Administer topical or systemic corticosteroids, salicylates, and non-steroidal anti-inflammatory drugs as prescribed for pain and inflammation. Administer medications to decrease the inflammatory response as prescribed. • Assist with plasmapheresis as prescribed to remove autoantibodies and immune complexes from the blood before organ damage occurs. |
2) scleroderma (systemic sclerosis)
| • Scleroderma is a chronic connective tissue disease that is characterized by inflammation, fibrosis, and sclerosis. | • pain, stiffness and muscle weakness, decreased range of motion
• pitting edema of the hands and fingers • tight, hard, and thick skin tissue
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• Encourage activity as tolerated. Maintain a constant room temperature.
• Monitor for esophageal involvement; if present, advise the client to sit up for 1 to 2 hours after meals. • Provide small frequent meals, eliminating foods that stimulate gastric secretions, such as spicy foods, caffeine, and alcohol. • Administer corticosteroids as prescribed for inflammation. |
3) polyarteritis nodosa
| • Polyarteritis nodosa is a collagen disease; it is a form of systemic vasculitis that causes inflammation of the arteries in visceral organs, brain, and skin. | • similar to the intervention for SLE |
4) pemphigus
| • Pemphigus is a rare autoimmune disease that occurs predominantly between middle and old age. | • Fragile, partial-thickness lesions bleed, weep, and form crusts when bullae are disrupted.
• Nikolsky’s sign (separation of the epidermis caused by rubbing the skin) • debilitation • leukocytosis |
• Provide oral hygiene. Soothe oral lesions.
• Assist with soothing baths for relief of symptoms, as prescribed. • Administer corticosteroids and cytotoxic agents. Administer topical or systemic antibiotics as prescribed. |
5) Goodpasture’s syndrome
| • Goodpasture’s syndrome is an autoimmune disorder. Autoantibodies are made against the glomerular basement membrane and alveolar basement membrane. The lungs and the kidneys are affected primarily. | • clinical manifestations indicating pulmonary and renal involvement | • Administer corticosteroids as prescribed.
• Assist with plasmapheresis as prescribed. |
6) Lyme disease
| • Lyme disease is an infection caused by the spirochete Borrelia burgdorferi, acquired from a tick bite. Infection with the spirochete stimulates inflammatory cytokines and autoimmune mechanisms. | • ring-shaped rash
• flulike symptoms • joint pain, arthritis • neurological complications, |
• Gently remove the tick with tweezers, wash the skin with antiseptic, and dispose of the tick by flushing it down the toilet. Perform a blood test 4 to 6 weeks after a bite to detect the presence of the disease.
• Administer antibiotics as prescribed. • Instruct the client to avoid areas that contain thick, such as wooded grassy areas, especially in the summer months. Instruct the client to wear long-sleeved tops, long pants, closed shoes, and hats while outside. Instruct the client to spray the body with tick repellent before going outside. |