Caring for Clients with ImmuneMediated Disorders

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Caring for Clients with Immune-Mediated Disorders

• Chapter 40 Medical-Surgical

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Overview

• The immune system sometimes responds excessively
  to substances that are not potentially harmful.
• When this occurs, individuals manifest allergic
  and autoimmune disorders.

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Allergic Disorders

• An allergic disorder is characterized by a
  hyperimmune response to weak antigens that are
  usually harmless (table 40-1 pg. 610)
• The antingens that can cause an allergic response
  are called allergens.

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Allergic Disorders

• Allergies can occur at any age, and the pattern
  of allergic response can vary in the same person
  over the years.
• People may suddenly develop an allergic reaction
  to a substance with which they have had contact
  for years.

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Allergic Disorders

• On the other hand, allergic responses to one
  agent may gradually disappear, to be replaced by
  sensitivity to another substance. The reason for
  these changes is not clear.

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Types of Allergies

• Manifested in a variety of ways depending on the
  manner in which the allergen gains entry to the
  body and the intensity of the response.
• Organs and structures that are primarily involved
  in an allergic reaction include the skin,
  respiratory passageways, and GI tract.

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Types of Allergies

• Allergic rhinitistemporary, localized discomfort
  whereas Anaphylaxis and angioedema are
  life-threatening.
• See table 40-2 pg. 610.

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Pathophysiology

• 10 to 15 of the population develop.
• Can be inherited, although may not be sensitive
  to the same allergens.
• Can react to more than 1 type of antigen
• The first exposure to an allergen does not
  produce symptoms.
• However, T-cell lymphocytes process the antigen
  and present it to B-cell lymphocytes.
• B-cell lymphocytes promptly produce IgE
  antibodies that become attached to basophils or
  mast cells.

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Pathophysiology

• The first exposure to an allergen does not
  produce symptoms.
• However, T-cell lymphocytes process the antigen
  and present it to B-cell lymphocytes.
• B-cell lymphocytes promptly produce IgE
  antibodies that become attached to basophils or
  mast cells.

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Pathophysiology

• Mast cells are constituents of connective tissue
  that contain small amounts of heparin, serotonin,
  bradykinin, and histamine.
• With subsequent exposures to the allergen, mast
  cells and basophils release their vasoactive
  chemicals, increasing cell permeability.

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Pathophysiology

• Initially this produces localized reactions such
  as watery eyes, increased nasal and bronchial
  secretions, sneezing, vomiting, and diarrhea.
• Later, additional symptoms such as swelling,
  itching, and localized redness occur.

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Pathophysiology

• Histamine causes vasodilation that, if massive,
  causes hypotension and bronchoconstriction.

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Assessment Findings

• Respiratory nasal stuffiness, runny nose,
  sneezing, coughing, dyspnea, and wheezing.
• Skin hives, rash, and localized itching.
• Food Allergies cramping, vomiting, and diarrhea

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Assessment Findings

• Systemic potentially fatal effects include
  shock and airway obstruction caused by swelling.
• Clients exhibit the same reaction with each
  exposure to the allergen.

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Diagnostic Findings

• Diagnosis of an allergy may be simple and clear
  cut or may require multiple tests and an
  extensive history.
• Symptoms may vary with fatigue, emotional stress,
  or the seasons, complicates diagnosis.

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Diagnostic Findings

• Eosinophil count may be elevated.
• RAST (radioallergosorbent test)measures IgE. On
  a scale of 0 to 5, 2 or gt is a significant
  measurement.
• Skin testing---pollens, animal danders, food and
  dust

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Diagnostic Findings

• Three methods of skin testing are the
• 1. Intradermal injectiona dilute solution of an
  antigen is injected intradermally. A positive
  reaction is based on the size of a raised wheal
  and localized erythema that forms where the
  antigen was injected.

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Diagnostic Findings

• 2. Scratch or prick testinvolves making a
  scratch on the skin and applying a small amount
  of the liquid test antigen to the scratch.
• If a raised wheal or localized erythema appears,
  a positive reaction to the antigen has occurred.

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Diagnostic Findings

• 3. Patch testused for identifying the offending
  allergen in allergic contact dermatitis.
• A concentrated form of the substance is applied
  to the skin and covered with an occlusive
  dressing.
• After 48 hours, the dressing is removed the
  area examined for erythema, edema and vesicles.

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Diagnostic Findings

• Food allergens are identified by eliminating all
  food for several days and then monitoring for
  symptoms as a new food is added to the diet.

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Medical Management

• Desensitization is a form of immunotherapy in
  which the individual is given regular injections
  of dilute allergen. Re
• Repeated exposure to the weak antigen promotes
  the production of an antibody that blocks IgE.

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Medical Management

• Weekly injections until maximum dose is achieved.
• Maintenance injections are then administered at
  longer intervals usually every 2 to 4 weeks.
• It may take several years before a treated person
  experiences significant relief.

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Medical Management

• Following an injection, the client is observed
  for 30 minutes to assess for allergic symptoms.
• Epinephrine (adrenalin) is administered if a
  severe reaction occurs. (lateral thigh)
• Emergency kit that contains a pre-measured dose
  of injectable epinephrine should be carried by
  those with severe bee allergies.look at pg. 614.
  

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Nursing Management

• History (family)
• All meds taken
• Latex (See box 40-1 on Pg 615)
• Closely observe a client each time a new drug is
  added. (Includes radiopaque dyes)
• If an allergic reaction is suspected, do not give
  the next dose of the drug until a MD sees the
  client.

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Nursing Management

• If an anaphylactic reaction occurs while a drug
  is being given by a parenteral route, stop
  administration of the drug and provide life
  support while the code team is summoned.
• See Nursing Careplan on pg. 615 617

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Nursing Process The Client With an Allergic
Disorder

• Assessment
• Thorough history Diet and family
• Record
• Allergic symptoms
• Factors that appear to increase or decrease
  symptoms
• Prescription or nonprescription drugs taken
• Skin rashes or eruptions
• Observation and monitoring each time a new drug
  is given

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Nursing Process The Client With an Allergic
Disorder

• Diagnosis, Planning, and Interventions
• Altered comfort Itching
• Impaired home maintenance
• PC Anaphylaxis and angioedema
• Evaluation of Expected Outcomes
• Relief of itching
• No evidence of rash
• Stable vital signs
• Effortless breathing
• Necessary changes made at home

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Autoimmune Disorders

• Autoimmune disorders are disorders in which
  natural cells are attacked or destroyed by Killer
  T cells and autoantibodies.
• Autoantibodies are immunoglobulins that target
  histocompatible cells, cell whose antigens match
  the individuals own genetic code.

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Autoimmune Disorders

• Disease are considered autoimmune disorders when
  they are characterized by unrelenting,
  progressive tissue damage without any verifiable
  etiology.

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Autoimmune Disorders

• Hemolytic anemia
• Multiple sclerosis
• pernicious anemia
• ulcerative colitis
• Hashimotos thyroiditis
• ankylosing spondylitis
• rheumatoid arthritis
• lupus

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Systemic Sclerosis of the Hands
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RA
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Autoimmune Disorders

• Assessment Usually associated with acute
  inflammatory response.
• Low-grade fever
• Malaise, or fatigue
• Weight loss may occur
• Periods of acute flare-ups alternate with
  asymptomatic periods

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Autoimmune Disorders

• Diagnostic Findings An elevation of circulating
  antibodies is the hallmark for these types of
  disorders.

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Autoimmune Disorders

• Medical Management immunosuppressive agents is
  mainstay for alleviating the symptoms (table 40-2
  pg. 619)
• Controlling or limiting side effects of the drugs
  is a major concern.

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Autoimmune Disorders

• Nursing Management Promote healthy lifestyle
  and stress reduction because stress and illness
  worsen many autoimmune diseases.
• Encourage good nutrition.
• See nursing process/care plan pg. 618

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Nursing Process The Client With an Autoimmune
Disorder

• Assessment
• Family history
• Vital signs
• Signs of localized inflammation and compromised
  body functions
• Clients level of energy
• Laboratory test findings
• Client teaching

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Nursing Process The Client With an Autoimmune
Disorder

• Diagnosis, Planning, and Interventions
• Activity intolerance
• Risk for infection
• Disturbed personal identity
• Evaluation of Expected Outcomes
• Participation in self-care and ADLs without
  overwhelming fatigue
• No evidence of iatrogenic infection
• Realistic self-perception

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Autoimmune Disorders

• Antigen is a substance that evokes the production
  of antibodies.
• If tissue injury results, the antigen is then
  called an allergen
• An allergen is a substance capable of causing an
  allergic response in tissues

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Angioedema

• Diffuse swelling of loose subq tissue dorsum of
  hands or feet, eyelids, lips, genitalia, mucous
  membranes
• edema of upper airway may produce respiratory
  distress and stridor may be mistaken for asthma

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Stridor

• http//www.merck.com/mmpe/sec05/ch045/ch045g.html?
  qtstridoraltsh

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Anaphylaxis

• Anaphylaxis is most serious drug allergy reaction
• If angioedema develops after giving a drug,
  insert an airway.must maintain a patent airway

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Chronic Fatigue Syndrome

• Pathophysiology and Etiology
• Low serum cortisol levels
• Neurally mediated hypotension
• Assessment Findings Signs and Symptoms
• Recent illness with flu-like symptoms
• Upper respiratory infection
• Ongoing fatigue
• Tender cervical and axillary lymph nodes
• Neurologic symptoms

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Chronic Fatigue Syndrome

• Assessment Findings Diagnostic Findings
• Medical history and physical examination
• Unremarkable findings
• Blood tests
• Exhaustive medical workup

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Chronic Fatigue Syndrome

• Medical Management
• Drug treatment
• Balanced activity and rest
• Hypotension Increased salt and water intake, if
  not contraindicated
• Several adjunct and alternative therapies
• Nursing Management
• Client education Disease process and the
  limitations it requires

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On Your Own!!

• Look at the general nutritional, pharmacologic
  gerontologic consideration in the back of each
  chapter.
• Look at the care plan pg. 623 624.