Prevention:

NCM112  Strict avoidance of potential Prelims

allergens - GMJ
RLE - Module 2 III Disorder
 auto-injector system for epinephrine (3)
will be prescribed
to the pt
IMMUNOLOGIC DISORDERS  Screening for allergies before a medication is
Immunopathology prescribed
 refers to the study of diseases that result from  history of any sensitivity to suspected antigens must be
dysfunctions within the immune system obtained before administering any medication,
 excesses or deficiencies of immunocompetent cells, particularly in parenteral form, because this route is
alterations in the function of these cells, immunologic associated with the most severe anaphylaxis in pts
attack on self-antigens, or inappropriate or exaggerated  instruct pt to wear medical identification such as a
responses to specific antigens bracelet or necklace, which names allergies to
Hypersensitivity medications, food, and other substances
 is an excessive or aberrant immune response to any type  venom immunotherapy, which is used as a control
of stimulus measure and not a cure for people who are allergic to
 usually does not occur with the first exposure to an insect venom
allergen. Rather, the reaction follows a re-exposure after  Desensitization to insulin-allergic patients with
sensitization, or buildup of antibodies, in a predisposed diabetes and those who are allergic to penicillin
person Medical Management:
 Most allergic reactions are either type I or type IV  If the patient is in cardiac arrest, cardiopulmonary
hypersensitivity reactions resuscitation (CPR)
TYPES OF HYPERSENSITIVITY  if the patient is cyanotic, dyspneic, or wheezing.
a) Anaphylactic (Type I) Hypersensitivity Epinephrine
- an immediate reaction beginning within minutes of  Antihistamines and corticosteroids are given as adjunct
exposure to an antigen therapy
- most severe hypersensitivity reaction is anaphylaxis  Intravenous fluids (e.g., normal saline solution),
characterized by edema in many tissues, including the volume expanders, and vasopressor agents are given to
larynx, and is often accompanied by hypotension, maintain blood pressure and normal hemodynamic
bronchospasm, and cardiovascular collapse in severe status
cases Nursing Management:
- Antibiotics and radiocontrast agents cause the most  assesses the patient for signs and symptoms of
serious anaphylactic reactions anaphylaxis. Airway, breathing pattern, and vital signs
- Type I hypersensitivity reactions may include both local  observed for signs of increasing edema and respiratory
and systemic anaphylaxis distress
 Prompt notification of the rapid response team, the
provider, or both are required
 document the interventions used and the patient’s vital
signs and response to treatment
 instructed pt about antigens that should be avoided and
about other strategies to prevent recurrence of
anaphylaxis
 instructs the patient and family in the use of prescribed
Epi-pen and has the patient and family demonstrate
correct administration
b) Cytotoxic (Type II) Hypersensitivity
- occurs when the system mistakenly identifies a normal
constituent of the body as foreign
- reaction may be the result of a cross-reacting antibody,
possibly leading to cell and tissue damage
c) Immune Complex (Type III) Hypersensitivity
- - involves immune complexes that are formed when
Nursing Implications: antigens bind to antibodies
Assessment: - These complexes are cleared from the circulation by
 comprehensive allergy history and a thorough physical phagocytic action
examination - If these type III complexes are deposited in tissues or
 degree of difficulty and discomfort experienced by the vascular endothelium, two factors contribute to injury: the
patient because of allergic symptoms increased amount of circulating complexes and the
 degree of improvement in those symptoms with and presence of vasoactive amines. As a result, there is an
without treatment are assessed and documented increase in vascular permeability and tissue injury
Diagnostic Evaluation: d) Delayed-Type (Type IV) Hypersensitivity
 Complete Blood Count with Differential - WBC count - an immune reaction in which T-cell–dependent
is usually normal except with infection and macrophage activation and inflammation cause tissue
inflammation injury
 Eosinophil Count – greater than 5% to 10% IMMUNODEFICIENCY
 Total Serum Immunoglobulin E Levels - High total  In immune deficiency disorders, there is insufficient
serum IgE levels support the diagnosis of allergic production of antibodies, immune cells, or both making
disease the body unable to resist foreign microbes or toxins
 Skin testing - the intradermal injection of solutions  maybe congenital or acquired (chemotherapy or HIV)
several sites; Positive (wheal-and-flare) reactions are
clinically significant when correlated with the history, HIV Infection
physical findings, and results of other laboratory tests;  was a fatal disease, and the only treatments available were
Skin testing is considered the most accurate comfort measures and hospice care for several years
confirmation of allergy  There are two forms of HIV infection:
 a. HIV-1 - most common cause in the United States, - The patient is not immune to HIV (the antibodies do not
Europe, and Asia. indicate immunity).
b. HIV-2 - widespread in western Africa spreads at a Interpretation of Negative HIV Test Results:
lower rate has a lower plasma viral load and takes - Antibodies to HIV are not present in the blood at this
longer to incubate, and individuals with this strain time, which can mean that the patient has not been
have a lesser risk of developing AIDS infected with HIV or, if infected, the body has not yet
produced antibodies (stage 0).
PATHOPHYSIOLOGY OF HIV - The patient should continue taking precautions. The test
HIV-1 and HIV-2 are retroviruses that have only ribonucleic result does not mean that the patient is immune to the
acid (RNA) as their genetic material virus, nor does it mean the patient is not infected; it just
retrovirus has an enzyme called reverse transcriptase, which means that the body may not have produced antibodies
helps the virus replicate and place its genetic material in the yet.
DNA of the host cell - If a viral test is used, a negative result is more consistent
↓ with the conclusion that the patient is uninfected
The resulting new DNA continues the process of replication HIV STAGING
and produces as many as 2 billion viral particles a day that are Two markers are used routinely to assess immune function
released from the host cell into the circulatory system, and level of HIV viremia:
infecting other cells in the body 1. CD4+ T-cell count (CD4+ count)
↓  measured in all patients at entry into care
HIV primarily attaches to the CD4 cell (activate B cells,  Major laboratory indicator of immune function
natural killer cells, and phagocytes) wall receptors found on and prophylaxis for opportunistic infections, and
lymphocytes and some monocytes and go through several is the strongest predictor of subsequent disease
stages before it can effectively infect a host cell progression and survival
↓ 2. Plasma HIV RNA (viral load)
Once infected with HIV, the host cell, and the ability of the  better predictor of the risk of HIV disease
cell mediated immune response is seriously impaired progression than the CD4+ count
Once the infection occurs in the CD4 lymphocytes and HIV TREATMENT
produces HIV, the CD4 cell itself dies. If the CD4 lymphocyte count is less than 350 cells/mm3, it is
Detection in the infected person ' s blood takes around 10 days recommended that the patient initiate antiretroviral therapy
for HIVRNA and 25 days for HIV antibodies (ART) and prophylaxis for OIs. The goal of ART is to
↓ suppress HIV replication to a level below which drug resistant
An individual infected with HIV becomes more prone to mutations do not emerge and is now recommended for all HIV
opportunistic infections (OIs), including those derived from infected patients regardless of their viral load or CD4+ count
normal flora found in the body a. Reduce HIV-associated morbidity and prolong the
Suppression or inhibition of the immune response because of duration and quality of survival
HIV infection is the cause of AIDS. b. Restore and preserve immunologic function
The diagnosis of AIDS is usually made when an HIV-infected c. Maximally and durably suppress plasma HIV viral
patient' s CD4 T-lymphocyte count is less than 200 cells/mm3 load
or when a specific OI is diagnosed d. Prevent HIV transmission
FACTORS AFFECTING ADHERENCE TO ART
HIV TRANSMISSION - Poor adherence to the treatment plan.
- The only mode of transmission is by exposure to HIV- - Psychosocial barriers such as depression and other mental
infected blood, body fluids, or tissue illnesses
- Any break in the skin or mucous membranes is an entry - Neurocognitive impairment
portal for HIV - Low health literacy
- The highest risk for becoming infected with HIV are - Low levels of social support
having unprotected sex (oral, vaginal, or anal), sharing - Stressful life events
needles and syringes with an HIV-infected person, and - High levels of alcohol consumption and active substance
maternal-fetal exposure
use
- Receiving transfusion of HIV-infected blood or blood
- Homelessness
products
- Poverty
- Receiving an organ transplant from an HIV-infected
- Nondisclosure of HIV serostatus
donor
- Denial
- Stigma
Signs and Symptoms: Test:
fever, fatigue, diarrhea, Antibody tests - Inconsistent access to medications affects adherence
and loss of appetite Antigen/antibody tests (ELISA) NURSING ROLE IN HIV
oral thrush, recurrent Nucleic acid (RNA) Preventive Education
infections, skin *Blood tests can detect HIV 1) behavioral interventions have been effective in reducing
disorders, Night sweats, infection sooner after exposure the risk of acquiring or transmitting HIV by ensuring that
swollen lymph glands, than oral fluid tests because the people have the information, motivation, and skills
and significant level of antibody in blood is necessary to reduce their risk.
unintended weight loss higher than it is in oral fluid. 2) HIV testing because most people change behaviors to
protect their partners if they know they are infected with
HIV
Interpretation of Positive HIV Test Results 3) linkage to treatment and care, which enables individuals
with HIV to live longer, healthier lives and reduce their
- Antibodies to HIV are present in the blood (the patient
risk of transmitting HIV
has been infected with the virus, and the body has
AUTOIMMUNITY
produced antibodies).
Autoimmune disorders are caused by the immune system
- HIV is active in the body, and the patient can transmit the
reacting against the body’s own cells.
virus to others.
- Despite HIV infection, the patient does not necessarily
Systemic Lupus Erythematosus
have AIDS.
- The term erythematosus refers to the erythema (patchy o Immunosuppressant agents are given to suppress
congestion of capillaries of the skin with blood) that often the immune system, thereby reducing the risk of
accompanies the disease a systemic attack
- cause is unknown but genetics, hormones, immunologic NURSING MANAGEMENT FOR SLE
response, and environmental influences may play a role in - Assessment of the patient's ability to participate in
the development of this disease activities of daily living (ADLs) is important.
- body begins to produce abnormal antibodies that attack - Joint pain is also common; thus, management of pain and
the target tissues or cells instead of foreign agents and can assisting with mobility are priorities.
go on for years before the onset of symptoms become - Ongoing assessment of body systems is important to
evident and health care is sought determine whether the disease process is affecting
PATHOPHYSIOLOGY OF SLE additional systems.
SLE occurs from an abnormal reaction of the body’s immune IMMUNOSUPPRESSION
system, especially against proteins found in the nucleus of  Suppression of the body’s immune system and its ability
body cells to fight infections and other diseases
↓  Immunosuppression may be deliberately induced with
Inflammation of the muscles, blood vessel abnormalities, and drugs, as in preparation for bone marrow or other organ
immune complex deposition in tissues occur throughout the transplantation, to prevent rejection of the donor tissue –
body  Drug-induced immunosuppression, often referred to as
↓ therapeutically induced immunosuppression requires a
Weakness (a hallmark of the SLE disease process); Neurologic delicate balance between the control of the body’s
symptoms; nephrotic syndrome or acute or chronic renal immune response and the side effects
failure; Coronary disease  Examples of immunosuppressive drugs:
Signs and Symptoms: a) An example of iatrogenic immune suppression
occurs with an organ transplant recipient
b) The patient must take multiple medications, such
as mycophenolate mofetil and cyclosporine for
the rest of his life
c) Lifelong immunosuppressive therapy does not
eliminate the danger of organ rejection or other
health complications, and the drugs need to be
adjusted according to the systemic and immune
response of each patient and to prevent toxicity
d) This treatment regimen must be strictly followed,
or the risk of organ rejection is increased from
activation of the patient' s own immune system
to destroy the “foreign” organ
NURSING MANAGEMENT IN SLE
Assessment:
- current physical status of the patient, such as his general
state of health, and the occurrence of infections
- Nutritional status should be assessed by measuring height
and weight and inspecting the skin, hair, and overall
appearance –
- Risk behaviors such as intravenous (IV) drug use,
multiple sexual partners, exposure to HIV,
immunosuppressive drug therapy, alcohol consumption,
and family history of genetic immune disorders
Diagnosis: Test:
- Physical assessment should include palpation of the
Currently, no single test can 1.Antinuclear antibody
lymph nodes and assessing the body systems involved in
confirm a diagnosis of SLE. (ANA) - detect
the patient's chief complaints
To confirm SLE, a patient must autoimmune disorder
have at least 4 of the 11 clinical 2. Antiphospholipid - Body temperature should be closely monitored for
presentations or laboratory test antibody (APA) - a significant changes, although immune-deficient patients
results performed for SLE syphilis test, positive may not have a temperature elevation even in the presence
showing evidence of a result is an indicator of of infection
multiorgan disorder SLE)
3. ESR and C-Reactive
Protein level - detects Diagnosis and Planning:
presence of inflammation - The primary nursing goals when caring for a patient who
has an immune deficiency are to
SLE TREATMENT a) protect the patient from infection
- There is no cure for SLE b) improve her health status
c) promote as high a degree of wellness as possible.
- Current treatments are targeted toward symptom control
Expected outcomes:
or management to prevent exacerbations, treat flare-ups
- Patient will remain free from infection.
when they occur, and minimize organ damage and long-
term complications - White blood cell counts are within normal limits
o Hydroxychloroquine, an antimalarial drug, aids - Isolation precautions for pts with severe
in long-term control of SLE. immunodeficiency
o Glucocorticoids, such as prednisone, are taken to - Preventive education
reduce symptoms experienced during major - Stress Reduction strategies
flare- ups. - Referrals to social workers
o Nonsteroidal anti-inflammatory drugs (NSAIDs) - Teach pt and fam s/s of infections
are used to reduce inflammation and control pain SPECIFIC DERMATOLOGIC DISORDERS
 Skin disorders may occur from immunologic and  Seborrhea is excessive production of sebum (secretion of
inflammatory disorders, proliferative and neoplastic sebaceous glands) in areas where sebaceous glands are
disorders, metabolic and endocrine disorders, and normally found in large numbers
nutritional problems.  Seborrheic dermatitis is a chronic inflammatory disease of
 Many patients with dermatologic disease are not the skin with a predilection for areas that are well
hospitalized and are seen only in providers ' offices and supplied with sebaceous glands or lie between skin folds,
outpatient clinics. where the bacterial count is high
 This can lead to delay in treatment and allows the disease  Two forms of seborrheic dermatoses can occur: an oily
to progress to a chronic and sometimes untreatable state form and a dry form and is a chronic condition that tends
to reappear
MALIGNANT CONDITIONS (SKIN CANCER)  Management: no known cure for seborrhea, the objectives
 Skin cancer is the most common cancer (Basal cell of therapy are to control the disorder and allow the skin to
Carcinoma - leading, Squamous cell carcinoma - second) repair itself, corticosteroid cream, which allays the
in the United States secondary inflammatory response, aeration of the skin to
 Since skin is easily inspected, skin cancer is readily seen avoid yeast infection, medicated shampoos for dandruff
and detected and is therefore believed to be amenable to treatment
early intervention
 Exposure to ultraviolet (UV)radiation, including the sun
and artificial UV rays (e.g., tanning booths) is the leading
preventable cause of skin cancer; incidence is related to
the total amount of exposure to the sun
 Management: excision
Squamous Cell Cancer is a malignant proliferation arising
from the epidermis and may arise from normal skin or from
pre-existing skin lesions

BACTERIAL INFECTIONS
 Pus-forming bacterial infections of the skin are called
pyodermas and may be primary or secondary
 Primary skin infections originate in previously normal-
appearing skin and are usually caused by a single
organism
 Secondary skin infections arise from a preexisting skin
disorder or from disruption of the skin integrity from
injury or surgery
 Common primary bacterial skin infections are impetigo
and folliculitis
 Management: Antibiotic agents; contact precautions

VIRAL CONDITIONS
 Herpes zoster, also called shingles, is an infection caused
by the varicella-zoster virus
 After a case of chickenpox, it lies dormant inside nerve
cells near the brain and spinal cord
 When these latent viruses are reactivated because of
declining cellular immunity, they travel by way of the
peripheral nerves to the skin, where the viruses multiply
and create a red rash of small, fluid-filled blisters
 Management: Antiviral agents such as oral or IV
acyclovir, Analgesic, Anti-inflammatory agents,
diversionary and relaxation techniques

PEDICULOSIS: LICE INFESTATION

 affects people of all ages
 Lice are called ectoparasites because they live on the
outside of the host’ s body. They depend on the host for
their nourishment, feeding on human blood 5x a day.
They inject their digestive juices and excrement into the
skin, which causes severe itching
o Pediculosis capitis is an infestation of the scalp
by the head louse (head)
o Pediculosis corporis is an infestation of the body
by the body louse (pubic)
 Management: washing the hair with a shampoo containing
pyrethrin compounds with piperonyl butoxide, combed
hair with a fine-toothed comb dipped in vinegar to remove
any remaining nits or nit shells freed from the hair shafts,
bathe with soap and water for body lice, articles should be
washed in hot water to prevent reinfestation

SECRETORY DISORDERS: SEBORRHEIC

DERMATOSES