Comprehensive Nclex -RN Immune Problems of the Adult Client 8th Ed PDF

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Summary reading notes in addition to questions and awnsers related to Immunity related health problems of the adult client. This is a guide to ace the NCLex exam for 2020/2021...

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UNIT XVII

Immune Problems of the Adult Client

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Introduction Pyramid to Success Pyramid Points focus on the effects of and complications associated with an immune deficiency. Specific focus relates to the nursing care related to the disorder, the impact of the treatment or disorder, and client adaptation. Human immunodeficiency virus and acquired immunodeficiency syndrome is a Pyramid focus, along with protecting the client from infection and preventing the transmission of infection to other individuals. Psychosocial issues relate to social isolation and the body image disturbances that can occur as a result of the immune disorder.

Client Needs: Learning Objectives Safe and Effective Care Environment Acting as an advocate related to the client’s decisions Addressing advance directives Consulting with the interprofessional health care team Ensuring that informed consent for treatments and procedures has been obtained Establishing priorities Handling hazardous and infectious materials safely Implementing standard and other precautions Maintaining asepsis Maintaining confidentiality regarding diagnosis Preventing infection Upholding client rights

Health Promotion and Maintenance Ensuring that the client receives recommended immunizations Implementing health screening measures Monitoring for expected body image changes Performing physical assessment techniques related to the immune system Preventing disease related to infection Providing health promotion programs Respecting client lifestyle choices

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Psychosocial Integrity Assisting in mobilizing appropriate support and resource systems Assisting the client and family to cope Assisting the client and family to adapt, and solve problems during illness or stressful events Considering religious, spiritual, and cultural preferences Discussing grief and loss related to death and the dying process Promoting a positive environment to maintain optimal quality of life

Physiological Integrity Managing medical emergencies Managing pain Monitoring for the expected and unexpected responses to treatments Optimizing pharmacological treatment Promoting nutrition Protecting the client from infection Providing basic care and comfort Reviewing diagnostic test and laboratory test results

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CHAPTER 62

Immune Problems http://evolve.elsevier.com/Silvestri/comprehensiveRN/

Priority Concepts Immunity; Infection I. Functions of the Immune System (Fig. 62-1) A. Provides protection against invasion by microorganisms from outside the body B. Protects the body from internal threats and maintains the internal environment by removing dead or damaged cells II. Immune Response A. T lymphocytes and B lymphocytes 1. Lymphocytes are produced in the bone marrow and migrate to lymphoid tissue, where they remain dormant until they need to form sensitized lymphocytes for cellular immunity or antibodies for humoral immunity. 2. Some B lymphocytes lie dormant until a specific antigen enters the body, at which time they greatly increase in number and are available for defense. 3. Types of T lymphocytes include helper/inducer, suppressor, and cytotoxic/cytolytic. 4. T and B lymphocytes are necessary for a normal immune response. B. Humoral response 1. Humoral response is immediate. 2. This type of response provides protection against acute, rapidly developing bacterial and viral infections. C. Cellular response 1. Cellular response is delayed; this is also called delayed hypersensitivity. 2. This type of response is active against slowly developing bacterial infections and is involved in autoimmune responses, some allergic reactions, and rejection of foreign cells.

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III. Immunity A. Innate immunity 1. Innate immunity is also called native or natural immunity. 2. It is present at birth and includes biochemical, physical, and mechanical barriers of defense, as well as the inflammatory response. B. Acquired immunity 1. Acquired or adaptive immunity is received passively from the mother’s antibodies, animal serum, or antibodies produced in response to a disease. 2. Immunization produces active acquired immunity. IV. Immunizations: See Chapter 18 for information about immunizations V. Laboratory Studies A. Antinuclear antibody (ANA) determination 1. The ANA determination is a blood test used for the differential diagnosis of rheumatic diseases and for the detection of antinucleoprotein factors and patterns associated with certain autoimmune diseases. 2. The test is negative at a 1:40 dilution, depending on the laboratory. 3. A positive result does not necessarily confirm a disease. 4. The ANA is positive in most individuals diagnosed with systemic lupus erythematosus (SLE); it may also be positive in individuals with systemic sclerosis (scleroderma) or rheumatoid arthritis. 5. An ANA result can be false positive in some individuals. B. Anti-dsDNA antibody test 1. The anti-dsDNA (double-stranded DNA) antibody test is a blood test done specifically to identify or differentiate DNA antibodies found in SLE. 2. The test supports a diagnosis, monitors disease activity and response to therapy, and establishes a prognosis for SLE. 3. Values: negative, lower than 70 U/mL by enzymelinked immunosorbent assay (ELISA) C. Human immunodeficiency virus (HIV) testing 1. CD4+ T cell count a. Monitors the progression of HIV b. As the disease progresses, usually the number of CD4+ T cells decreases, with a resultant decrease in immunity. c. The normal CD4+ T cell count is

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between 500 and 1600 cells/L. d. In general, the immune system remains healthy with CD4+ T cell counts higher than 500 cells/L. e. Immune system problems occur when the CD4+ T cell count is between 200 and 499 cells/L. f. Severe immune system problems occur when the CD4+ T cell count is lower than 200 cells/L. 2. CD4-to-CD8 ratio a. Monitors progression of HIV b. Normal ratio is approximately 2:1. 3. Viral culture involves placing the infected client’s blood cells in a culture medium and measuring the amount of reverse transcriptase activity over a specified period of time. 4. Viral load testing measures the presence of HIV viral genetic material (RNA) or another viral protein in the client’s blood. 5. The p24 antigen assay quantifies the amount of HIV viral core protein in the client’s serum. 6. Oral testing for HIV a. Uses a device that is placed against the gum and cheek for 2 minutes b. Fluid (not saliva) is drawn into an absorbable pad, which, in an HIVpositive individual, contains antibodies. c. The pad is placed in a solution, and a specified observable change is noted if the test result is positive. d. If the result is positive, a blood test is needed to confirm the results. 7. Home test kits for HIV a. In one at-home test kit, a drop of blood is placed on a test card with a special code number; the card is mailed to a laboratory for testing for HIV antibodies. b. The individual receives the results by calling a special telephone number and entering the special code number; test results are then given. 8. Nursing considerations a. Maintain issues of confidentiality surrounding HIV and acquired immunodeficiency syndrome (AIDS)

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testing. b. Follow prescribed state regulations and protocols related to reporting positive test results. D. Skin testing 1. Description a. The administration of an allergen to the surface of the skin or into the dermis b. Administered by patch, scratch, or intradermal techniques 2. Preprocedure interventions a. Discontinue systemic corticosteroids or antihistamine therapy 5 days before the test as prescribed. b. Ensure that informed consent was obtained. 3. Postprocedure interventions a. Record the site, date, and time of the test. b. Record the date and time for follow-up site reading. c. Have the client remain in the waiting room or office for at least 30 minutes after the injections to monitor for adverse effects. d. Inspect the site for erythema, papules, vesicles, edema, and wheal (Fig. 62-2). e. Measure flare along with the wheal, and document the size and other findings. f. Provide the client with a list of potential allergens, if identified.

Have resuscitation equipment available if skin testing is performed, because the allergen may induce an anaphylactic reaction.

VI.

Hypersensitivity and Allergy A. Description 1. An abnormal, individual response to certain substances that normally do not trigger such an exaggerated reaction. 2. In some types of allergies, a reaction occurs on a second and subsequent contact with the allergen. 3. Skin testing may be done to determine the allergen.

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B. Assessment 1. History of exposure to allergens 2. Itching, tearing, and burning of eyes and skin 3. Rashes 4. Nose twitching, nasal stuffiness C. Interventions 1. Identification of the specific allergen 2. Management of the symptoms with antihistamines, antiinflammatory agents, and/or corticosteroids 3. Ointments, creams, wet compresses, and soothing baths for local reactions 4. Desensitization programs may be recommended. VII. Anaphylaxis A. Description 1. A serious and immediate hypersensitivity reaction that releases histamine from the damaged cells 2. Anaphylaxis can be systemic or cutaneous (localized). B. Assessment (Fig. 62-3) C. Interventions (see Priority Nursing Actions)

Pr io r ity Nur sing Actio ns Anaphylactic Reaction 1. Quickly assess respiratory status and maintain a patent airway. 2. Call the primary health care provider (PHCP) and Rapid Response Team. 3. Administer oxygen. 4. Start an intravenous (IV) line and infuse normal saline. 5. Prepare to administer diphenhydramine and epinephrine. 6. Document the event, actions taken, and the client’s response.

Reference Ignatavicius. Workman, Rebar. 2018;364–365.

VIII. Latex Allergy A. Description 1. Latex allergy is a hypersensitivity to latex. 2. The source of the allergic reaction is thought to be the proteins in the natural rubber latex or the various chemicals used in the manufacturing process of latex gloves. 3. Symptoms of the allergy can range from mild contact dermatitis to moderately severe symptoms of rhinitis, conjunctivitis, urticaria, and bronchospasm to severe life-threatening anaphylaxis. B. Common routes of exposure (Box 62-1)

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1. Cutaneous: Natural latex gloves and latex balloons 2. Percutaneous and parenteral: Intravenous lines and catheters; hemodialysis equipment 3. Mucosal: Use of latex condoms, catheters, airways, and nipples 4. Aerosol: Aerosolization of powder from latex gloves can occur when gloves are dispensed from the box or when gloves are removed from the hands. C. At-risk individuals 1. Health care workers 2. Individuals who work in the rubber industry 3. Individuals having multiple surgeries 4. Individuals with spina bifida 5. Individuals who wear gloves frequently, such as food handlers, hairdressers, and auto mechanics 6. Individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts D. Assessment 1. Anaphylaxis or type 1 hypersensitivity is a response to natural rubber latex (Fig. 62-4; also see Fig. 62-3). 2. A delayed type 4 hypersensitivity reaction can occur; symptoms of contact dermatitis include pruritus, edema, erythema, vesicles, papules, and crusting and thickening of the skin and can occur within 6 to 48 hours following exposure. E. Interventions (Box 62-2) IX. Immunodeficiency A. Description 1. Immunodeficiency is the absence or inadequate production of immune bodies. 2. The disorder can be congenital (primary) or acquired (secondary). 3. Treatment depends on the inadequacy of immune bodies and its primary cause. B. Assessment 1. Factors that decrease immune function 2. Frequent infections 3. Nutritional status 4. Medication history, such as use of corticosteroids for long periods 5. History of alcohol or drug abuse

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C. Interventions 1. Protect the client from infection. 2. Promote a balanced diet with adequate nutrition. 3. Use strict aseptic technique for all procedures. 4. Provide psychosocial care regarding lifestyle changes and role changes. 5. Instruct the client in measures to prevent infection. 6. Instruct the client to wear a MedicAlert bracelet.

The priority concern for a client with immunodeficiency is infection.

X. Autoimmune Disease A. Description 1. Body is unable to recognize its own cells as a part of itself. 2. Autoimmune disease can affect collagenous tissue. B. Systemic lupus erythematosus (SLE) 1. Description a. Chronic, progressive, systemic inflammatory disease that can cause major organs and systems to fail b. Connective tissue and fibrin deposits collect in blood vessels on collagen fibers and on organs. c. The deposits lead to necrosis and inflammation in blood vessels, lymph nodes, gastrointestinal tract, and pleura. d. No cure for the disease is known, but remissions are frequently experienced by clients who manage their care well. 2. Causes a. The cause of SLE is unknown but is believed to be a defect in immunological mechanisms, with a genetic origin. b. Precipitating factors include medications, stress, genetic factors, sunlight or ultraviolet light, and pregnancy. c. Discoid lupus erythematosus is possible with some medications but totally disappears after the medication is stopped; the only manifestation is the

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skin rash that occurs in lupus. 3. Assessment a. Assess for precipitating factors. b. Erythema of the face (malar rash; also called a butterfly rash) c. Dry, scaly, raised rash on the face or upper body d. Fever e. Weakness, malaise, and fatigue f. Anorexia g. Weight loss h. Photosensitivity i. Joint pain j. Erythema of the palms k. Anemia l. Positive ANA test and lupus erythematosus preparation m. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level 4. Interventions a. Monitor skin integrity and provide frequent oral care. b. Instruct the client to clean the skin with a mild soap, avoiding harsh and perfumed substances. c. Assist with the use of ointments and creams for the rash as prescribed. d. Identify factors contributing to fatigue. e. Administer iron, folic acid, or vitamin supplements as prescribed if anemia occurs. f. Provide a high-vitamin and high-iron diet. g. Provide a high-protein diet if there is no evidence of kidney disease. h. Instruct in measures to conserve energy, such as pacing activities and balancing rest with exercise. i. Administer topical or systemic corticosteroids, salicylates, and nonsteroidal anti-inflammatory drugs as prescribed for pain and inflammation. j. Administer medications to decrease the inflammatory response as prescribed.

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k. Monitor intake and output, as well as daily weight for signs of fluid overload if corticosteroids are used. l. Instruct the client to avoid exposure to sunlight and ultraviolet light. m. Monitor for proteinuria and red cell casts in the urine. n. Monitor for bruising, bleeding, and injury. o. Assist with plasmapheresis as prescribed to remove autoantibodies and immune complexes from the blood before organ damage occurs. p. Monitor for signs of organ involvement such as pleuritis, nephritis, pericarditis, coronary artery disease, hypertension, neuritis, anemia, and peritonitis. q. Note that lupus nephritis occurs early in the disease process. r. Provide supportive therapy as major organs become affected. s. Provide emotional support and encourage the client to verbalize feelings. t. Provide information regarding support groups and encourage the use of community resources.

For the client with SLE, monitor the blood urea nitrogen and creatinine levels frequently for signs of renal impairment.

C. Scleroderma (systemic sclerosis) 1. Description a. Scleroderma is a chronic connective tissue disease, similar to SLE, that is characterized by inflammation, fibrosis, and sclerosis. b. This disorder affects the connective tissue throughout the body. c. It causes fibrotic changes involving the skin, synovial membranes, esophagus, heart, lungs, kidneys, and gastrointestinal tract. d. Treatment is directed toward forcing the disease into remission and slowing its progress.

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2. Assessment a. Pain b. Stiffness and muscle weakness c. Pitting edema of the hands and fingers that progresses to the rest of the body d. Taut and shiny skin that is free from wrinkles e. Skin tissue is tight, hard, and thick; loses its elasticity; and adheres to underlying structures. f. Dysphagia g. Decreased range of motion h. Joint contractures i. Inability to perform activities of daily living 3. Interventions a. Encourage activity as tolerated. b. Maintain a constant room temperature. c. Provide small frequent meals, eliminating foods that stimulate gastric secretions, such as spicy foods, caffeine, and alcohol. d. Monitor for esophageal involvement; if present, advise the client to sit up for 1 to 2 hours after meals. Using additional pillows and raising the head of the bed on blocks may help reduce nocturnal reflux. e. Provide supportive therapy as the major organs become affected. f. Administer corticosteroids as prescribed for inflammation. g. Provide emotional support and encourage the use of resources as necessary. D. Polyarteritis nodosa 1. Description a. 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. b. Treatment is similar to the treatment for SLE. c. Polyarteritis nodosa affects middle-aged

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men. d. The cause is unknown and the prognosis is poor. e. Renal disorders and cardiac involvement are the most frequent causes of death. 2. Assessment a. Malaise and weakness b. Low-grade fever c. Severe abdominal pain d. Bloody diarrhea e. Weight loss f. Elevated ESR 3. Interventions: Refer to interventions for SLE. E. Pemphigus 1. Description a. Pemphigus is a rare autoimmune disease that occurs predominantly between middle age and old age. b. The cause is unknown, and the disorder is potentially fatal. c. Treatment is aimed at suppressing the immune response and blister formation. 2. Assessment a. Fragile, partial-thickness lesions bleed, weep, and form crusts when bullae are disrupted. b. Debilitation, malaise, pain, and dysphagia c. Nikolsky’s sign: Separation of the epidermis caused by rubbing the skin d. Leukocytosis, eosinophilia, foulsmelling discharge from skin 3. Interventions a. Provide supportive care. b. Provide oral hygiene and increase fluid intake. c. Soothe oral lesions. d. Assist with soothing baths, as prescribed for relief of symptoms. e. Administer topical or systemic antibiotics as prescribed for secondary

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infections. f. Administer corticosteroids and cytotoxic agents as prescribed to bring about remission. XI. Goodpasture’s Syndrome A. Description 1. An autoimmune disorder; autoantibodies are made against the glomerular basement membrane and alveolar basement membrane. 2. It is most common in males and young adults who smoke; the exact cause is unknown. 3. The lungs and the kidneys are affected primarily, and the disorder usually is not diagnosed until significant pulmonary or renal involvement occurs. B. Assessment 1. Clinical manifestations indicating pulmonary and renal involvement 2. Shortness of breath 3. Hemoptysis 4. Decreased urine output 5. Edema and weight gain 6. Hypertension and tachycardia C. Interventions 1. Focus on suppressing the autoimmune response with medications such as corticosteroids and on plasmapheresis (filtration of the plasma to remove some proteins and autoantibodies). 2. Provide supportive therapy for pulmonary and renal involvement. XII. Lyme Disease A. Description 1. An infection caused by the spirochete Borrelia burgdorferi, acquired from a tick bite (ticks live in wooded areas and survive by attaching to a host) 2. Infection with the spirochete stimulates inflammatory cytokines and autoimmune mechanisms. B. Assessment (Box 62-3; Fig. 62-5) 1. The typical ring-shaped ...