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I. STRUCTURES AND FUNCTION OF THE IMMUNE SYSTEM A. Functions of the Immune System 1. Defense against physical injury and infection 2. Maintenance of homoeostasis, a state of equilibrium of the internal environment B. Organs and Tissues of the Immune System include the bone marrow and lymphoid tissue, which comprise the thymus gland, lymph nodes, spleen, tonsils, and adenoids. 1. Bone marrow is specialized soft tissue filling the spaces in cancellous bone of the epiphyses. It is responsible for: a. releasing mature B lymphocytes into the blood circulation b. moving T lymphocytes from bone marrow to the thymus 2. The thymus is a single unpaired gland that is located in the mediastinum and is the primary central gland of the lymphatic system. Its primary function is allowing the T lymphocytes to develop before migrating to the lymph nodes and spleen 3. Lymph nodes and vessels perform several important function, such as: a. transporting lymph b. filtering and pathogocytizing (processing and killing) antigens c. generating lymphocytes and monocytes 4. Spleen functions include : a. removing worn-out erythrocytes from blood b. storing blood and platelets c. filtering and purifying blood 5. The tonsils, adenoids, and other mucoid lymphatic tissues defend the body against microorganisms 6. In the hematopoietic system, bone marrow and lymphatic tissue produced blood cells including those involved in immunologic defense (i.e. leukocytes) C. Nonspecific Immunologic defense is a type of immunity effective against any harmful agent entering the body. The bodys natural immunity can discriminate friends from foe or self from nonself by cannot distinguish between and pathogens. Natural mechanism includes the following: 1. Physical barriers. Intact skin and mucous membrane prevent pathogens from gaining access to the body. Cilia of the respiratory tract filter and clear pathogens from the upper respiratory tract 2. Chemical barriers. Acidic gastric juices, enzymes in tears and saliva, and sebaceous and sweat secretions attempt to destroy invading bacteria and fungi. 3. Biologic response modifiers. Interferon, a viricidal substance, counter viruses and activates other components of the immune system 4. Action of white blood cells a. Neutrophils are first to arrive at the inflammatory injury b. Eosinophils and basophils are activated in response to allergic reactions and stress c. Granulocytes release cell mediators, such as histamine, bradykinin, and prostaglandins and engulf the foreign toxins d. Monocytes or macrophages function as phagotoc cells engulf, ingest and destroy foreign toxins 5. Inflammatory response. This mechanism is elicited in response to tissue injury or invading organisms. Most cells release chemical mediators, which enhance the inflammatory response and produce the typical signs of infection (i.e. redness, edema and itching). Vasoconstriction and vasodilation also play a role in the inflammatory response. 6. Natural killer cells. These lymphocytes are responsible for immune surveillance and host resistance to infection

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7. Complements. This group of at least 20 circulating plasma proteins, made in the liver, are subsequently activated in the presence of an antigen. a. Functions of complement - Cell lysis - Opsonization, which involves making antigen more susceptible to phagocytosis - Chemotaxis, which involves inducing phagocytes to antigen - Agglutination, which involves clumping of antigens - Neutralization of viruses b. Activation of complement can occur in one of two basic ways: - Classical. Antigen antibody complex activates C1 (first of circulating complement proteins) - Alternate. No antigen-antibody complex is required; complement can be initiated by the release of endotoxins and begins C3 D. Specific immunologic defense is a type of immunity effective against specific harmful agents entering the body. Immunity is a normal adaptive response designed to protect the body against potentially harmful antigens (i.e. any substance recognized as foreign by the immune system) 1. Types of immunity a. Inborn immunity is an inherited immunity of species (e.g. human do not contract certain animal diseases), races, and individuals to certain diseases. b. Acquired immunity is immunity that develops as an individual encounters specific harmful agents. It may be natural (i.e. activated by the affected individual) or as artificial (i.e. activated by vaccine) and active or passive - Active immunity involves production of antibodies and - Memory cells do not secrete antibodies, but on re-exposure to the specific antigen, they develop into antibody secreting plasma cells. - Important vaccines include IM tetanus and diphtheria booster injection which is required for adult at least every 10 years, and the hepatitis B vaccine, which is required for all health care workers - Passive immunity is a temporary immunity required by introduction of antibodies or sensitized lymphocytes from another source (e.g. antibodies through placental circulation to a fetus, gamma globulin, anti serum from blood plasma of a person with acquired immunity). The body dose not generate memory cells. 2. The mechanism of specific immunity are of two types : humoral (B lymphocytes) and cell mediated (T lymphocytes) immunity. These two types of immunologic responses discriminate self from nonself and distinguish the formation of antibodies by plasma cells in response to foreign proteins. - Humoral immunity functions primarily in type I, type II, and type III hypersensitivity reactions - B lymphocytes ( so named because they were first identified in the avian bursa) are involved in antibody (i.e. immunoglobulin (Ig)) production - Unsensitized B cells proliferate and mature into plasma cells after exposure to antigen - Plasma cells differentiate into memory cells (which trigger a B-cell response on subsequent exposure to same antigen) and antibodies - Five types of antibodies are produced by the body: - IgG activates complement, enhances phagocytosis, crosses placenta (i.e. passive immunity), and is active in a second response (reinfection) - IgA is present in the body fluids (i.e. blood, saliva, and tears, pulmonary, GI, prostatic, and vaginal secretions; and breast milk), prevents absorption of antigens from food, and protects against respiratory infections. -IgM is the first antibody produced in the immune response. It activates the complement system -IgD may be required on B-cell surface for transformation into plasma cells, but its exact role is unclear

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-IgE is associated with allergic and hypersensitivity reactions and possibly helps in defense against parasites b. Cell mediated immunity involves attack of microbes by special killer T cells formed from lymphocytes - Cellular immunity functions primarily delayed hypersensitivity reactions; rejection of transplants; and viral, fungal, and chronic infections -T lympohocytes (cells are thymus derived), on exposure to antigen, proliferate and differentiate into one of several types of T cells. - Helper T cells (T4) assist B-cells in humoral response to form antibodies - Suppressor T cells (T8) suppress B-cell synthesis of antibody production through a feedback mechanism - Memory T cells store future immune response to some antigen - Cytotoxic T cells direcly attack antigen, altering cell membrane with resultant cell lysis 3. Stages of specific immune responses a. Recognition. Circulating lymphocytes and macrophages recognize foreign maternal or antigens as nonself b. Proliferation. Sensitized lymphocytes proliferate, differentiate, and mature into a respective T and B cells c. Response. Antibody is produced with specific T-cells action d. Effector. Antigen is destroyed by antibody, which is produced by B-cell or cytotoxic T cell action II. THE IMMUNE SYSTEM A. Assessment 1. Health history a. Elicit a description of the clients present illness and chief complaint, including onset, course, duration, location and precipitating and alleviating factors. Elicit a description of the clients overall health status, including immunizations status usual childhood diseases, know allergies, and a history of past and present medications. Cardinal signs and symptoms indicating altered immunity are subsequently described. - General - Recurrent infections - Seasonal symptoms - Weight loss - Fever - Head - Itching, burning, watering eyes; vision problems; and eye infections - Recurrent ear infections - Rhinitis and sneezing - Respiratory System - Cough - Dyspnea - Recurrent infection - Cardiovascular system - Pain - Reynauds phenomenon (i.e. extreme pallor and then cyanosis of extremities brought on by cold exposure) - GI System - Nausea and vomiting - Diarrhea - Genitourinary System

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- Recurrent infections - dysuria and hematuria - Musculoskeletal system - Weakness and fatigue - Inability to perform activities of daily living (ADLs) - Neurologic System - Disorientation to name. date, and place - Altered level of consciousness - Paresthesias b. Exposure the clients health history for risk factors associated with immune disorders, including not keeping up to date immunizations, exposure to infection disease, and exposure to pollen, insects, and allergens 2. Physical Examination a. Inspection - Inspect skin and mucous membranes fro rashes, lesions, dermatitis, purpura (subcutaneous bleeding) and any type of inflammation or drainage - Assess the joints for tenderness, edema, and range of motion - Inspect ears for drainage, inflammation, and scarring from ear infections b. Palpation - Palpate the anterior and posterior cervical, axillary, and inguinal lymph nodes fro enlargement - Note the location, size, and consistency of lymph nodes. Document complaints of tenderness if the node is palpable c. Auscultation - Auscultate lungs for abnormal lung sounds, such as wheezing, crackles, and rhonchi - Auscultate heart sounds for abnormalities, such as palpitations and dysrhythmias 3. Laboratory and diagnostic studies a. Multi-allergen allergy testing measures the increase and quantity of allergen specific immunoglobulin (Ig) E antibodies and is done to identify allergens to which the client has immediate hypersensitivity b. T- and B-lymphocytes assays evaluate the number of lymphocytes in the immune system c. Ig assays (IgG, IgA, IgM) can detect and monitor immune deficiencies d. Serum complement assays test for C3 and C4 complement when total complement level is decreased e. Autantibody tests - Antinuclear antibody (ANA) test measures and differentiates ANAs associated with certain autoimmune diseases such as systemic lupus erythematosus - Rheumatoid factor test measures for a macroglobulin type of antibody found in rheumatoid arthritis f. Radioallergosorbent test is radioimmunoassay that measures allergen-specific IgE. g. The human immunodeficiency virus (HIV) test determines the presence of HIV antibodies, which is the etiologic factor required immunodefiency syndrome (AIDS) B. Nursing Diagnoses 1. Ineffective airway clearance 2. Risk for infection 3. Acute or chronic pain 4. Impaired skin integrity 5. Deficient fluid volume 6. Deficient knowledge 7. Bathing or hygiene self-care deficit 8. Risk for injury 9. Ineffective coping

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C. Planning and outcome identification. The goal for a client diagnosed with an immunologic disorder include improved airway clearance, prevention of infection, increased comfort, improvement and maintenance of skin integrity, increased knowledge regarding disease prevention and self-care, absence of complications and injury, and improved coping. D. Implement 1. Assess respiratory status, including assessment of the lungs, rate and depth of respirations, effort of breathing use of accessory muscles, cyanosis, restlessness, anxiety, or any change in level of consciousness 2. Minimize the risk of infection a. Instruct the client on ways to avoid infection, including the importance of personal hygiene and avoidance of people with infections and large crowds b. Instruct the client to wash the affected area with warm water before applying topical creams; instruct him to wash his hands before and after administering topical creams 3. Provide pain relief. Assess the clients pain, rule out any complications, implement any nonpharmacologic interventions (i.e. ice, cold, massage) to relieve pain, administer pain medication, and evaluate the effectiveness of interventions 4. Promote skin integrity a. Assess the skin and mucous membranes for any rashes, color changes, lesions, pallor, purpura, hydration and inflammation b. Keep skin clean and dry. Do not use harsh soaps 5. Maintain fluid balance. Monitor the clients intake and output, and maintain 30 ml/hour urinary output; use a urometer to ensure accurate output. Assess fro dehydration 6. Provide client and family teaching a. Teach the client about the disease process and possible triggers b. Teach the client measures to minimize or prevent exposure to the allergens c. Discuss emergency measures (e.g. use of epinephrine) and medication therapy, including the use of corticosteroids to reduce inflammation d. Teach the client danger signs and symptoms to report, including respiratory distress and infection. 7. Promote self-care. Assist the client with ADLs as needed, but promote independence. Use any energysaving techniques available 8. Prevent injury. Instruct the client to wear identification tags or bracelets concerning allergies or disease 9. Promote client and family coping a. Teach the client and his family ways to cope with chronic illness, including verbalization of feelings and ways to prevent exacerbations b. Provide referrals E. Outcome evaluations 1. The client displays no respiratory distress, as evidenced by an absence of chest tightness, wheezing, cyanosis, cough, and exaggerated expiratory effort. 2. The client shows no symptoms of opportunistic infection, such as fatigue, fever, night sweats, weight loss and diarrhea 3. The client verbalizes relief of joint pain and discomfort 4. The client exhibits clean, dry skin that is free from rash, itching, burning, scaling, ulcerations and infection 5. The client has intact skin and oral mucosa 6. The client maintains adequate fluid and electrolyte balance and nutritional status

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7. The client verbalize an understanding, preventive measures, and treatment of the disease process and the signs or symptoms that should be reported to the health care provider 8. The client is able to care for himself and perform independent ADLs 9 The client remains free from injury 10. The client is able to verbalize appropriate coping mechanisms to control anxiety CATEGORIES OF IMMUNE DISORDERS A. Hypersensitivity reactions are immune responses to allergens that result in tissue destruction 1. Type I (anaphylactic) reactions are mediated by the immunoglobulin (Ig)E antibody, which promotes the release of histamine and other reactive mediators. These basophil or mast cells produce the characteristic symptoms of asthma or hay fever. 2. Type II (cytotoxic) reactions (e.g. hemolytic anemia) are mediated by IgG and IGM antibodies, which attach to cells (usually circulating blood elements) and cause cell lysis 3. Type III (immune complex) reactions (e.g. rheumatoid arthritis, serum sickness) are mediated by antigen-antibody complexes that deposit in the lining of blood vessels or on tissue surfaces 4. Type IV (delayed hypersensitivity) reactions (e.g. contact dermatitis, transplant rejection) are mediated by lymphokines released from sensitized T lymphocytes B. Allergic disorders are hypersensitive responses to an allergen to which the organism has previously been exposed and to which the organism has developed antibodies 1. Interaction between antigen and antibody typically results on one or more manifestations of tissue injury 2. IgE antibodies are formed by persons experiencing allergies who are genetically predisposed. Histamine and other mediators are released on reexposure to the allergen to which the person is sensitized C. Autoimmune disorders are conditions in which the body no longer differentiates self from nonself 1. Alterations in T cells or B cells produce autoimmunebodies and autosensitized T cells the cause tissue injury. These changes may involve one organ or many organ systems 2. The cause of autoimmune disorders remains unknown, but many theories exist D. Immune deficiency is defined as a congenital or acquired deficit in the immune system that makes the person susceptible to life-threatening opportunistic infection 1. In congenital (primary) immunodeficiency, the body produces inadequate amounts of one or more immune cells. Deficits can be humoral 9B cell), cell- mediated (T-cell), or combined 2. Acquired (secondary) immunodefiuciency is attributed to various etiologies, including: a. immunosppressive therapy, such as chemotherapeutic agents, corticosteroids, nosteroidal antiinflammatory agents and irradiation b. age-related factors, such as deterioration in the thymus gland and T cell functioning and a decreased number of suppressor T cells and helper T cells c. disruption of skin integrity, as occurs with burns and trauma d. nutritional deficits e. malignant processes, such as leukemia and lymphoma f. infectious processes, such as sepsis and acquired immunodeficiency syndrome TYPES OF LEUKOLCYTES Characteristics * Formed in bone marrow * Granular (under microscope) < 1% of all leucocytes * Granules filled with heparin, Normal Cell 3 5,000 to 10,000/mm

Cell Type Granulocytes Basophils

Function * immediate response to cellular injury * Play role in

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Eosinophils Neutrophils 2% to 4% of all leukocytes 50% to 70% of all leucocytes histamine * Contain heparin, histamine * 12 hour lifespan; 2 to 4 hour lifespan with infection inflammatory * Play role in hypersensitivity * Phagotic * First cell to site of cellular injury * Contain lysosomes * Fight infection * Phagocytosis * Release of lymphokines * Production of gamma globulins * Cell mediated reactions * Phagocytosis (can ingest larger particles that neutrophils; five times as many in one ingestion)

Agranilocytes Lymphocytes * 25% to 33% of all leukocytes

* Produced in lymphatic system * Nongranular (under microscope) * Classified as B cells or T cells

Monocytes

* 4% to 6% of all leukocytes

* Circulate in blood but also settle in tissue, where they are transformed in macrophages

TYPES OF SPECIFIC IMMUNITY

Specific immunity

Inborn species race individual natural

acquired

artificial

Active contact with the disease

Passive placenta mothers milk

Active Vaccine killed attenuated toxoid

Passive immune serum

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HEPATITIS A VACCINATION FOR ADULTS Recommended for travelers where sanitation and hygiene are unsatisfactory and foe people at high risk (i.e. homosexual men, IV drug user, health care personnel). Administered in two doses first dose, then second dose 6 to 12 months after the first dose Recommended for people at high risk (i.e. health care personnel, hemodialysis clients). Administered in three doses first dose, second dose 1 month later, then third dose 5 months after the second dose. Recommended every fall for people age 65 or older; residents in long term care facilities; individual with heart or lung disease, diabetes, kidney disease or a compromised immune system; and for those who work with or live with any of these individuals Recommended 1 time for people ages 65 or older and for people younger than age 65 who have certain chronic illnesses. For people with chronic respiratory disorders, a one time revaccination dose after 5 years is recommended Must have booster every 10 years after childhood immunizations. If none in childhood, must have three shots first dose, then second dose 1 month later, then third dose 6 months after the second dose Recommended for people who have never had chicken pox. Administered in two doses first dose, then second dose 1 to 2 months after the first dose.

HEPATITIS B

INFLUENZA Flu shot

PNEUMOCOCCAL

TETANUS DIPTHERIA (Td) tetanus shot VACIRELLA

HEALTH EDUCATION FOR ALLERGY SYMPTOM CONTROL Maintain a dust free environment Reduce exposure to pollen + Reduce room contents to the barest minimum by + Avoid barns, weed, dry leaves, and grass removing drapes, curtains, blinds (use pull shades + Avoid allergens and irritants, including dusts, fumes, instead) odors, animals, and tobacco smokes + Wash wood work and linoleum floors + Avoid sprays, powders, and perfumes. Use + Use wooden furniture, which allows for easier dusting hypoallergenic cosmetics + Use washable cotton materials + Wear a mask at times of increased exposures (e.g. + Wear a mask when cleaning +windy days, mowing yard) + Cover the mattress with a hypoallergenic cover + Be aware of high pollen counts. Reduce exposure at + Avoid wearing fabrics that cause itching these times and stay in air-conditioned areas + Decrease dust in the environment by using air + Ensure a smoke free environment conditioning, air cleaners, humidifiers, and + Do not change detergents or soaps dehumidifiers ALLERGIC RHINITIS A. Description. Allergic rhinitis (i.e. hay fever) is an allergic reaction to inhaled airborne allergens characterized by seasonal occurrences. It is the most common form of respiratory allergy. Although children and adolescents have an especially high incidence, it occurs in all age groups B. Etiology. Allergic rhinitis is induced by airborne pollens. Common seasonal pollens include: 1. tree pollens (e.g. oak, maple, and birch) in the spring 2. grass pollens (e.g. sheep sorrel, and plantain) in the summer 3. weed pollens (e.g. ragweed) in the fall C. Pathophysiology. Allergic rhinitis occurs when immunoglobulin (Ig)E antibodies in the nasal mucosa combine with inhaled allergens on the mucosa surface. The nasal mucosa reacts by slowing of ciliary action, edema formation, and leukocyte infiltration. Tissue edema is a result of vasodilatation and increased capillary permeability.

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D. Assessment findings 1. Associated findings may be include a family history of allergies 2. Clinical manifestations a. Itching, burning nasal mucosa b. Copious mucous secretions causing runny nose c. Red, burning tearing eyes d. Sneezing e. Pale, boggy nasal mucosa 3. Laboratory and diagnostic study findings a. Nasal smears reveal eosinophils in nasal secretions b. Peripheral blood count reveal a lymphocytes count above total 1,200/ml c. Total serum IgE determination shows an elevated serum level of IgE d. Skin testing identifies the offending allergens e. Radioallergosorbent test measures allergen-specific IgE. If antibodies are present, they combine with the radiolabeled allergens, which are compared with control values E. Nursing Management 1. Administer prescribed medications, which may include antihistamines, decongestants, and topical cosrticosteroids 2. Encourage the client to use saline spray to soothe mucous membranes. Advise the client to blow his nose before administering nasal medications 3. Prepare client for immunotherapy, which is prescribed only when IgE hypersensitivity to specific, unavoidable inhalant allergens (house dust and pollens) is demonstrated 4. Minimize the risk of infection 5. Provide client and family teaching ALLERGIC DERMATOSES A. Description. Allergic dermatoses is a group of inflammatory conditions caused by skin reaction to irritating or allergenic materials. They include allergic contact dermatitis and atopic dermatitis B. Etiology 1. Allergic contact dermatitis is produced by many substances. Common causes include exposure to poison ivy, topical medications, cosmetics, soaps, and industrial chemicals. 2. Although the cause of atopic dermatitis is unknown, the condition appears to be associated with a family history of allergic respiratory disorders (e.g. allergic rhinitis, asthma). Exacerbating factors amy include irritants, infection, and certain allergens C. Pathophysiology 1. Allergic contact dermatitis involves delayed hypersensitivity and requires a latent period ranging from several days ( for strong sentisitizer such as poison ivy) to years 2. atopic dermatitis is type I immediate hypersensitivity disorder resulting in large amounts of histamine in the skin, changes in lipid content of the skin, sebaceous gland activity, and diaphoresis. It most commonly begins in infancy or early childhood. It may subside spontaneously to be followed by unpredictable exacerbations throughout life. D. Assessment findings 1. Associated findings. Client history may known or suspected exposure to an allergen 2. Clinical manifestations a. Allergic contact dermatitis

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- Burning, itching, edema, and erythema of skin - Crusting, weeping lesions - Drying and feeling of the skin - Hemorrhagic bullae, possibly with severe responses b. Atopic dermatitis - Pruritus -Hyperirritability of the skin - Excessive dryness of the skin - Redness for 15 to 30 seconds after stroking followed by pallor lasting 1 to 3 minutes 3. Laboratory and diagnostic study findings a. Allergic contact dermatitis. Patch tests of the skin clarify diagnosis with offending agents being identified b. Atopic dermatitis - Serum immunoglobulin E levels are frequently elevated - Skin biopsy shows nonspecific eczematous changes E. Nursing Management 1. Administered prescribed medications, which may include antihistamine, antipruritics, or steroidal creams 2. Minimize the risk of infection 3. Provide pain relief 4. Promote skin integrity 5. Promote client and family coping 6. Provide client and family teaching a. Instruct the client to wear cotton fabrics and wash with a mild detergent b. Advise the client to take daily baths to hydrate the skin c. Encourage the client to use topical skin moisturizer d. Advise the client to humidify dry heat during winter. Recommend that the client keep the 0 0 0 0 room temperature at 68 to 70 F (20 to 21. C)

ALLERGIC ASTHMA A. Description. Allergic asthma is a chronic reactive respiratory disorder producing episodic, reversible airway obstruction. The estimated incidence is 3% to 8% of the population; more than one half of cases found in children younger than age 10 B. Etiology. Allergic asthma results from an immunologically mediated hypersensitivity to inhaled allergens, such as airborne pollens and molds, dust, and animal danders. C. Pathophysiology. Although the pathologic mechanisms of allergic asthma remain somewhat unclear, the fundamental process presumably involves a reaction of sensitized immunoglobulin E antibodies to an inhaled allergen, with subsequent release of chemical mediators, such as histamine, slow-reacting substance of anaphylaxis, and eosinophils chemotactic factor of anaphylaxis. Obstruction results from constriction of bronchial smooth muscles, swelling of bronchial membranes, and hyper secretion of mucus D. Assessment findings 1. Associated findings. The clients health history may reveal a family history of allergic asthma and exposure to a known or suspected precipitating substances 2. Clinical manifestations

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a. Chest tightness b. Prolonged, strenuous expirations c. Wheezing on expirations d. Buccal and peripheral cyanosis e. Cough, non productive at first, followed by violent coughing that produces thin, gelatinous mucus and is relieved by a bronchodilator f. Nausea and vomiting g. Anxiety 3. Laboratory and diagnostic study findings a. Pulmonary function studies reveal airway obstruction and decreased peak expiratory flow rate b. Radiologic or bronchoscopic examination may show hyperinflation and flattened diaphragm c. Arterial blood gas (ABG) analysis typically reveals the following: - Decreased partial pressure of arterial oxygen - Initially, decreased partial pressure of arterial carbon dioxide (PaCO 2) and increased pH (respiratory alkalosis) - Later increased PaCO2 and decreased pH (respiratory acidosis) E. Nursing Management 1. Administer prescribed medications, which include adrenergics, bronchodilators, leukotriene receptor antagonist, mast cell inhibitors, and oral corstocosteroids 2. Provide nursing care during an acute attck a. Administer adrenergics , which are the initial medications because they dilate bronchial smooth muscles, increase ciliary movements, and decrease the chemical mediators of anaphylaxis b. Collaborate with respiratory therapy and administer oxygen as prescribed c. Elevate the head of the bed, and lean the client forward to provide maximum lung expansion and esae respiratory effort d. Monitor respiratory rate and depth and auscultate lung sounds e. Monitor ABGs for changes from baseline f. Administer fluids because clients are usually dehydrated from diaphoresis g. Provide reassurance to help relieve anxiety 3. Monitor for and take precautions to prevent complications, such as pneumothorax, pulmonary hypertension, right heart failure, and respiratory failure 4. Provide client and family teaching a. Encourage the client to undergo testing to identify the cause of asthma attacks b. Convey the importance of strict compliance with the therapeutic regimen c. Discuss the need for increased fluid intake to thin bronchial secretions d. Review stress reduction methods e. Provide additional teaching 5. Provide referrals ANAPHYLAXIS A. Description. Anaphylaxis is an acute, life threatening allergic reaction marked by rapid progressively urticaria and respiratory distress that may result in anaphylactic shock. B. Etiology. Anaphylaxis results from ingesting ( or other system exposure) to allergenic substances. Possible causative substances include: 1. Drugs (e.g. penicillin and other antibiotics, vaccines, hormones, salicylates, and local anesthetics) 2. Foods (e.g. legumes, nuts, berries, seafoods, and egg albumin) 3. Sulfite containing food additives

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4. Insect venom (e.g. wasp, hornets, honeybee, certain spiders) C. Pathophysiology 1. Anaphylactic reaction requires previous sensitazations to the triggering allergen, with production of specific immunoglobulin (Ig)E antibodies that bind to mast cells and basophils 2. On exposure, IgE recats immediately with the allergen and triggers release of potent chemical mediators (e.g. histamine, eosinophil chemotactic factor of anaphylaxis) from basophils and mast cells. Concurrently, IgG or IgM activates release of complement fractions, and two other chemical mediators (i.e. bradykinin and leukotrienes) trigger profound vascular changes that can lead to vascular collapse (i.e. anaphylactic shock) 3. Anaphylaxis is a medical emergency because of the possibility of respiratory obstruction and vascular collapse. In severe cases, death may occur within 5 to 10 minutes of onset. B. Assessment findings 1. Clinical manifestations depend on whether mediators remain local or are systemic a. Local effects include wheals with surrounding red flares and urticaria. Usually, local effects are not dangerous b. Systemic manifestations - Intense urticaria and edema at the site of injection or injury, rapidly spreading to the face, hands, and other body areas - Respiratory distress from bronchospasm, coughing, sneezing, or wheezing - Arrhythmias, tachycardia or bradycardia, hypotension, and signs of circulatory collapse - Nausea and vomiting, abdominal pain, and diarrhea 2. Laboratory and diagnostic study findings a. Serum and urine histamine is elevated for a short time b. Serum tryptase, a mast cell enzyme marker for allergic and anaphylactic reactions, elevated 30 to 90 minutes after reactions onset E. Nursing Management 1. Provide nursing care during an anaphylactic attack a. Establish a patent airway b. Administer epinephrine, IM or subcutaneously, to constrict dilated blood vessels, a tuberculin syringe to ensure the exact dosage and monitor the client closely after administration c. Establish a patent IV line for drug and fluid administration d. Administer a high concentration of oxygen. Have a tracheostomy set at the bedside e. Monitor vital functions, evaluating blood pressure, pulse, respirations, arterial blood gas values, electrocardiogram and urinary output f. Administer prescribed medications, which may include anthistaminse, bronchodilators, vasopressors, and corcosteroids 2. Teach preventive measures a. Encourage the client to avoid or eliminate any offending allergens b. Advise the client, who is sensitive to insect bites, to carry anti-sting kits c. Instruct the client to wear identification tags or bracelets 3. Maintain safety precautions a. Always keep the client in the office for 30 minutes after administering any new medication to determine if allergic reaction occurs b. Always check for known allergies before administering any prescribed or over the counter medication 4. Provide referrals

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RHEUMATOID ARTHRITIS A Description. Rheumatoid arthritis is a chronic, progressive disease involving inflammation of ten synovial joints. The incidence is three times greater in women that in men. Peak age of onset is between age 30 and 60, but the disease can develop in any age. B. Etiology. Rheumatoid arthritis is apparently an autoimmune disorder; its cause is unknown. Exacerbations may be associated with increased physical or emotional stress. C. Pathophysiology. Pathologic changes begin as inflammation and progress to destruction of joints, producing deformity and loss of motion. The disease may affect only joints or may extend to body organs and blood vessels. D. Assessment findings 1. Clinical manifestations a. Edematous, warm, tender joints b. Limited range of motion in affected joints c. Generalized edema or nodules around affected joints d. Impaired mobility and ability to perform activities of daily living (ADLs) e. Fatigue, weakness, and anorexia f. In later stages, weight loss, fever, anemia, muscle atrophy, and Sjogrens syndrome 2. Laboratory and diagnostic study findings a. Radiographic studies reveal abnormalities such as progressive joint damage b. Rheumatoid factor is present in more 80% of the clients c. Erythrocyte sedimentation rate is significantly elevated d. Red blood cell count and C4 complement are decreased E. Nursing Management 1. Administer prescribed medications, which may include nonsteroidal anti inflammatory drugs, aspirin, slow acting antirhematic medications, and corticosteroids 2. Provide pain relief. Provide comfort measures, including massage and position changes. Apply hot or cold therapy to affected joints according to the clients needs 3. Promote self-care 4. Promote client and family coping 5. Promote adequate rest and sleep to prevent fatigue; provide comfort measures, including a foam mattress and supportive pillows; and discuss energy conservation techniques 6. Encourage proper body alignment to prevent contractures 7. Collaborate with the physical therapist to design and provide the client with physical therapy program, which begins after the acute phase resolves. Encourage a muscle activity program for self-care. Water exercises are excellent because water promotes buoyancy, which eases joint movement 8. Recommend a weight reduction program, if appropriate 9. Collaborate with the occupational therapist and promote the use of braces, splints and assistive mobility devices, if appropriate 10. Discuss relaxation techniques, such as imagery, elf hypnosis, biofeedback, diversionary activities,a nd distraction for pain management 11. Discuss maintaining optimal nutritional status 12. Provide a referral SYSTEMIC LUPUS ERYTHEMATOSUS

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A. Description. Systemic lupus eryhtematous (SLE) is a chronic systemic inflammatory disease affecting multiple body systems. Women are affected at least eight times more often than mmen, and women of childbearing age are particularly susceptible B. Etiology. SLE is thought to be autoimmune disorder C. Pathophysiology 1. SLE involves markedly increased B-cell hypergammaglobulinemia, autoantibody production, and decreased T cell functions. Symptoms result from immune complex invasion of body systems. Disease progression, which is characterized by recurring remissions and exacerbations, is widely variable 2. Prognosis is good with early detection and treatment however, SLR can lead to potentially serous complications, including cardiovascular, renal, and neurologic problems and serve bacterial infections D. Assessment findings 1. Clinical manifestations may be insidious or a acute; the client may remain under diagnosed for many years; clinical manifestations involve multiple body systems a. Musculoskeletal system - Arthralgias and arthritis (synovitis) - Joint edema and tenderness - Pain on movement and morning stiffness b. Integumentary system - Subacute cutaneous lupus erythamatous results in a butterfly rash across the bridge of the nose and cheeks - Discoid lupus erythematosus results in skin involvement that may b eprovoked by sunlight or artificial ultraviolet light - Oral ulcers of the buccal mucosa and hard palate occur in crops and may accompany skin lesions c. Cardiovascular system - Pericarditis - Popular, eryhtematous, and purpuric lesions on finger tips, elbows, toes, forearms, and hands d. Respiratory sytem - Pleural effusion - Pleuritis e. Neurologic system - Subtle changes in personality and cognitive ability - Commonly, depression and psychosis f. Other systems - Lymphadenopathy - With renal involvement, the glomeruli of kidney are usually affected 2. Laboratory and diagnostic study findings a. Antinuclear antibody test result is positive b. Red and white blood cell counts may be decreased, revealing thrombocytopenia, severe anemia, leukocytosis, and leucopenia c. Anti-deoxyribonuclic acid cell test reveals a high titer d. Urine testing reveals proteinuria and cellular casts in urine E. Nursing Management

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1. Administer prescribed medications, which may include corticosteroids, nonsteroidal, anti-inflammatory drugs, and salyclates to help control the joint pain and oral or topical corticosteroids to help with the rash. Anti malarial agents are used in some clients 2. Maintain skin integrity, which includes keeping the skin clean and dry, using mild soaps and lotions, and inspecting the skin for vasculitic lesions 3. Perform cardiovascular, respiratory, neurologic and musculoskeletal assessment to identify and described any systemic problems 4. Provide meticulous mouth care 5. Arrange for a dietary consult to ensure optimal nutrition while meeting the clients need fo r soft, easily tolerated foods 6. Apply warm packs as needed to relieve joint pain and stiffness 7. Collaborate with the physical therapy department and encourage an appropriate exercise program to help maintain mobility and strength 8. Provide client and family teaching a. Encourage protection from the sun and ultraviolet light. Advise the client to avoid going out between 10:00 am and 4:00 pm, use sunscreen with a sun protection factor of at least 30, wear a large hat and tight weave clothing, and refrain from using a tanning bed b. Advise the client to consult a health care provider before receiving immunizations or taking birth control pills or over the counter drugs c. Advise the client to avoid persons with contagious infections 9. Provide a referral ACQUIRED IMMUNODEFICIENCY SYNDROME A. Description. Acquired immunodeficiency syndrome (AIDS) is a severe immunodeficiency caused by the human immunodeficiency virus (HIV), which allows normally benign organisms to flourish and cause disease. The virus cause cell death and a decline in immune function resulting in opportunistic infections, malignancies, and neurologic problems. These opportunistic conditions define the syndrome. B. Etiology 1. HIV is transmitted sexually, through direct contact with blood or blood products and some body secretions 2. Persons at risk for contracting HIV a. Anyone who engages in unprotected sexual activity with an infected partner. b. Recipients of transfused blood or blood components (uncommon since 1985, when blood screening was instituted) c. IV drug abusers d. Children (perinatally) of mothers with HIV e. Health care workers exposed to HIV needle stick ( The incidence ofr health care workers exposed to HIV by needle stick is estimated to be less than 1%) C. Pathophysiology. HIV is a part of a group of viruses known as retroviruses, which carry genetics material in ribonucleic acid rather than deoxyribonucleic acid. HIV infects cells with CD4 lymphocytes (also called T4 or helper T cells). This infection causes cell death and a decrease in the immune function, resulting in opportunistic infections and neurologic problems. HIV can be isolated from blood, semen, saliva, tears, breast milk, and cerebrospinal fluid. After a variable course of about 10 years from the time of infection, 50% of infected persons develop AIDS. The incubation period of HIV varies, ranging from 6 months to 5 years, with an average of 2 years D. Assessment findings 1. Associated findings. The Client may report recurring viral and bacterial infections

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2. Clinical manifestations a. Fatigue b. Fever and night sweat c. Weight loss d. Generalized lymphadenopathy e. Nonproductive cough and shortness of breath f. Skin lesions, dry skin, and pallor g. GI upset and chronic diarrhea h. Edema i. Visual impairment j. Painful oral lesions k. Bruising and bleeding tendencies l. Joint pain m. Opportunistic infections, such as Pneumocystis carini pneumonia, mycobacterial infections, cryptococcal infection, toxoplasmosis, histoplasmosis and cytomegalovirus infection n. Kaposis sarcoma and AIDS dementia complex p. HIV wasting syndrome 3. Laboratory and diagnostic findings a. Enzyme linked immunosorbent assay (ELISA) indicates exposure to or infection with HIV but does not diagnose AIDS b. Western blot assay identifies HIV antibodies c. SUDS screening test is only 95% accurate but the results are available in 30 to 60 minutes. This test is only useful when a health care worker sustains a needle stick injury, if the cli ents test comes back positive, the health care workers is started on prophylactic anti-retroviral medications d. AIDS is diagnosed on clinical history, risk factors, physical examination. Laboratory evidence of immune dysfunction and positive ELISA or Western blot assay. E. Nursing Management. No cure or vaccine has been found, and treatment focuses on maintaining health and improving survival time. 1. Administer prescribed medication, which may include drug therapy for AIDS related opportunistic infections, antiretroviral therapy, antidiarrheals, and antiemetics 2. Promote preventive measures related to the transmission of HIV. This is a prime concern until a vaccine is found; researchers have reported that a vaccine is being investigated and tested for prevention of HIV transmission a. Promote public education regarding HIV and AIDS. Teach client and families to practice safe sex, avoiding sharing needles, and avoid touching anothers body fluid without protection b. Inform HIV infected clients that even though HIV is undetectable, the clients may be infectious and should practice safe sex c. Promote standard precautions to protect health care pr ovider from exposure to the clients blood or body fluids and to protect the client from cross contamination 3. Maintain skin integrity by instructing the client to avoid scratching strong perfumed , soaps, and adhesive tapes; follow routine oral care; keep anal area as clean as possible. wear white socks to prevent foot problems; keep linens dry and clean; and apply protective barriers to the skin as necessary 4. Instruct the client about the promotion of normal bowel movements and prevention of diarrhea. Instruct the client to monitor the quantity and volume of liquid stools and avoid bowel irritants, such as raw fruits, vegetables, spicy foods, and hot and cold foods. 5. Promote infection prevention. Discuss the importance of maintaining personal hygiene, keeping bathrooms and kitchens clean, and getting adequate rest activity and well balance diet

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6. Teach energy conservation technique such as sitting while doing morning care, using a shower chair and arranging the home in a way save time from walking or standing. In the hospital, put all necessary items within easy reach 7. Discuss ways the client and family can assist with mental status problems. These includes putting notes on the refrigerator or note boards, using calendars and clocks to orient the clients to time and place, and assisting the client with paying bills, shopping and other households activities 8. Teach methods for airway clearance. These include turning, coughing, and deep breathing; increasing fluid intake to thin secretions; maintaining semi-Fowlers position; and using humidified oxygen if necessary. 9 Help maintain nutritional status by controlling nausea and vomiting encouraging foods that are easy to swallow; encouraging oral hygiene before and after meals; promoting a high protein, high calorie diet; monitoring weight, intake and output, monitoring fluids and electrolyte balance; and administering appetite stimulants 10. Monitor and manage complications of opportunistic infections. Opportunistic infections protozoans, fungal, bacterial and viral occur because of immune suppression; they account for most of the clinical manifestations observed in AIDS . Pneumocystis carini pneumonia is the most common. 11. Teach ways to cope with chronic illness to the client and his family. Always include the family in teaching and care, and provide family members with grief counseling. Discuss advanced directives and durable power of attorney for health care 12. Provide referrals MEDICATIONS FOR IMMUNE DISORDERS Indications Selected Interventions Relax smooth bronchial muscle * Instruct the client to inhale twice as follows; and dilate airways inhale once, wait 1 minute, and inhale once more

Classifications Adrenergic Albuterol Epinephrine Isoetharine Isoproterenol Metaproterenol terbutaline Antibiotics Aminogycosides (gentamicin, tobramycin) Amoxicillin Erythromycin Penicillin tetracycline

Prevent or treat infections caused by pathogenic microorganisms

Antidiarrheal Attapulgite Bismuth subsalicylate Diphenoxylate and atropine loperamide Antiemetics Benzquinamide Dimenhydrinate Trimethobenzamide

Absorb excess water from stool

* Before administering the first dose, assess the client for allergies and determine whether culture has been obtained * After multiple doses, assess the client for super infection (thrush, yeast infection, diarrhea); notify the health care provider if these occur * Assess the insertion site for phlebitis if antibiotics are being administered IV * To assess the effectiveness of antibiotic therapy, monitor the white blood cell count * Monitor peaks and troughs for aminoglycosides * To assess the effectiveness of the medication, record the number and consistency of stools * Monitor intake and output, daily weight, and serum electrolyte levels

Relieve nausea and vomiting by inhibiting medullary chemoreceptor triggers; drug choice depends on the cause of

* Advise the client that this medication may cause drowsiness * Because the medication may cause chemical irritation, administer by deep IM injection into a

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Hydrochloride Promethazine scopolamine Antihistamines Cetirizine Cholorpheniramine maleate Descloratadine Diphenhydramine Fexofenadine Loratidine terfenadine Antipruritic agents Topical steroids Desoximetasone Hydrocosrtisone Triamcinolone Topical anesthetics Benzocaine dibucaine Antiretrovirals Nucleoside inhibitors Didanosine Zidovudine vomiting large muscle mass, if appropriate * Measure emesis and maintain accurate intake and output; monitor for dehydration * Teach the client to avoid alcohol, driving, or engaging in hazardous activities because the medication may cause drowsiness. (Some antihistamines are nonsedating. Make sure the client is knowledgeable of the medications adverse effects) * Encourage sucking on hard candy or ice chips fro relief of dry mouth * Advise the client to wash his hands before and after application * Instruct the client to clean the affected area with warm water before application

Inhibit histamine release by binding selectively to H, receptors

Relieve or prevent itching (may be topical steroids or anesthetics)

Nonnucleoside reverse Transcriptase inhibitors Delavirdine Nevirapine Protease inhibitors Indinavir ritonavir

Suppress synthesis of viral deoxyrisbonucleic acid reverse transcriptase); first drug used against human immunodeficiency virus (HIV) infection; remains a mainstay of treatment Cause direct inhibition of HIV by binding to active center of reverse transcriptase

* The client must adhere closely to the prescribed dosing schedule * All medications are oral. Except IV zidovudine which must be administered slowly

* Instruct the client to take the medication 1 hour before or after food or antacids * Inform the client to notify his health care provider if a rash occur * Instruct the client to follow proper instructions when taking the medication, some must be taken on an empty stomach, and others must be taken with food * Inform the client that all protease inhibitors may cause diabetes, (Inform the client of the signs and symptoms of diabetes and to notify his health care provider if these occur) * Monitor serum level of theophylline (therapeutic level, 10 to 20 ug/ml) * Provide the medication at regular intervals, before meals, and with a full glass of water * Instruct the client to notify his health care provider of irritability, restlessness, headache, insomnia, dizziness, tachycardia, palpitations, or seizures * Do not crush sustained release medication

Bronchodilators (xanthine derivatives) theophylline

Bind to the active site of HIV protease, thereby preventing the enzyme form cleaving HIV polyprotiens; the virus remains immature and noninfectious when used in combination with reverse transcriptase inhibitors, viral load reduced to a level undetectable by current assays Relax bronchial smooth muscle

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Corticosteroids Inhaledfluticasone; beclomethasone Oral hydrocortisolone, prednisone) Topical Ensure a potent, local acting antiinflammatory and immune modifier effect; also used to strengthen the biologic membrane, which inhibits capillary permeability, and prevent leakage of fluid into the injured area and development of edema; exact mechanism unknown * Caution the client not to exceed the maximum daily dose of 4 sprays/nostril * Instruct the client to rinse his mouth after each use to prevent nasal candidiasis * Instruct the client to take the medication exactly as directed and to taper it rather than stop it abruptly, which could cause serious withdrawal symptoms leading to adrenal insufficiency, shock, and death * Forewarn the client that the medication may cause reportable cushingolid effects (weight gain, moon face, buffalo hump, and hirsutism) and may mask signs and symptoms of infection * Instruct the client to wash the exposed area with warm water and to dry it thoroughly before applying the medication * Instruct client to take medication in the evening without food * Explain that the medication is not for acute asthma attacks

Corticosteroids

COX-2 inhibitors Celecoxib rofecoxid Leukotriene antagonist montelukast receptor

Inhibit the formation of substances that can cause joint and connective tissue problems Reduce inflammation in air- ways; used for prophylactic and maintenance drug therapy for chronic asthma Inhibit mast cell, thereby releasing chemical mediators that result in bronchodilation and a decrease in airway inflammation

Mast cell inhibitor Cromolyn sodium

Nonopiod analgesics Nonsteroidal Anti-inflammatory drugs Acetylsalicylate acid ibuprofen Vasopressors Metaraminol norepinephrine

Relieve pain, inflammation

edema,

and

Rapidly restore blood pressure in anaphylaxis by producing vasoconstriction and stimulating the heart

* Teach the client to insert the capsule in a nebulizer device, exhale completely, place the mouth piece between the lips, inhale deeply, hold the breath for 10 seconds, and then exhale * Tell the client that an inhaler is used prophylactically before exercise, not in acute asthma attack * Instruct the client to take with food to decrease GI upset * Instruct the client to report signs and symptoms of GI distress (i.e. nausea, vomiting, bleeding) to his health care provider * Monitor the clients vital signs, intake and output, mental status, peripheral pulses, and skin color. * The client should be on telemetry and monitored continuously

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