Immune Disorders

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Immune Disorders
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2014-11-22 14:57:01
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Immune Disorders
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  1. Small organ located just behind the breastbone (where T-Cells Mature)
    Thymus
  2. Organs of the Immune System
    Tonsils/Adenoids

    Lymph Nodes and Lymphatic Vessels

    Thymus

    Spleen

    Appendix

    Peyer's Patches

    Bone marrow
  3. Small bean shaped structures that produce and store cells that fight infection and disease...they get larger with infections and feel sore
    Lymph Nodes
  4. Yellow tissue in center of bones that is responsible for making WBCs that are destined to become lymphocytes
    Bone Marrow
  5. Largest lymphatic organ in the body...contains WBCs that fight infection/disease...also helps control amount of blood in your body
    Spleen
  6. How does the Immune System work
    Germ enters body

    Macrophage devours germ, presents germ to T helper cells

    T-Helper cells recognize germs in macrophage and sends substance to activate B/T cells

    T-C (Cytotoxic) cells
    release cytotoxins and directly kill germ

    B cells prodoce antibodies which attach to the germ and help neutralize the germ and other cells kill the germ

    ....IF a germ enters the body again, B-Cells and T-Cells have a memory and they will recognize the germ and make antibodies and cytotoxic T-cells to destroy it
  7. Process of B-Cells responding to a germ entering the body:
    *B cell finds antigen that matches its receptors

    *It waits until it is activated by a helper T-cell

    *Then the B cell divides to produce plasma and memory cells

    *Plasma cells produce antibodies that attach to the current type of invader

    * "Eater Cells" prefer intruders marked with antibodies and eat loads of them

    *If the same intruder invades again, memory cells help the immune system to activate much faster
  8. Genetic Immunodeficiency Disorders
    Primary (may affect phagocytic function, B cells or T cells, of the complement system)

    Born with deficiencies
  9. Acquired Immunodeficiency Disorders
    Secondary (HIV/AIDS)

    *relating to underlying disorders, diseases, toxic substances or medications (what we pick up later in life)...

    • -IV drug abuse
    • -Malnutrition
    • -Chronic Disease (DM)
    • -Medications (corticosteroids)
  10. Primary Immunodeficiencies are usually seen in:
    Infants and young children
  11. Manifestations of Primary Immunodeficiencies:
    Severe or recurrent infections, failure to thrive or poor growth, positive family hx
  12. Potential complications of Primary Immunodeficiencies:
    • Recurrent, Severe, Potentially fatal infections;
    • Related blood dyscrasias or malignancies
  13. Treatment of Primary Immunodeficiencies:
    Pooled plasma or immunoglobulin

    Granulocyte-macrophage colony-stimulating factor (GM-CSF)

    Granulocyte colony-stimulating factor (GCSF)

    Thymus graft

    Stem cell/Bone marrow transplant
  14. 10 warning signs of primary immune deficiency:
    *4 or more new ear infections within 1 year

    *2 or more serious sinus infections within 1 year

    *2 or more months on antibiotics with little effect

    *2 or more pneumonias within 1 year

    *Failure of an infant to gain weight or grow normally

    *Recurrent, deep skin or organ abscesses

    *Persistent thrush in mouth or fungal infection on skin

    *Need for IV antibiotics to clear infections

    *2 or more deep-seated infections including septicemia

    *Family hx of PI (primary immunodeficiency)
  15. Most common primary immunodeficiency seen in adults
    Hypogammaglobulinemia

    CVID (common variable immunodeficiency)

    MG (medical management with IV immunoglobulin)
  16. Types of Gamma globulins (antibodies)
    IgG- mostly fight bacteria and viruses

    IgA- found in blood and secreted into tears, saliva, and mucous membranes

    IgM- formed first in response to an infection

    IgE- allergic reactions

    IgD- poorly understood function
  17. Preferred gamma globulin given to adults with PI
    IgG
  18. How is IV gamma globulin taken/given
    Blood is taken from screened donors

    Plasma is collected

    Plasma is held 60 days

    Plasma is pooled from up to 60,000 people

    IgG is separated from other components

    Solvent/Detergent is added to deactivate lipid-enveloped viruses

    Solvent is removed

    All remaining non IgG components are removed (strictly IgG)

    Purified IgG is preserved and stabalized

    Dispensed into vials and freeze dried

    Product is released
  19. Administration of Immunoglobulin Infusion:
    Dose determined by patient response (200-800 mg/kg of body weight)

    Administered every 3-4 weeks

    Pre-medicate with acetaminophen and benadryl 30 min prior to starting infusion

    Administer at a slow rate not to exceed 3 ml/min, usually at 100-200 ml/h

    • Stop infusion at first sign of reaction:
    •    -30-60 min usually occur
    •    -shaking, chills, flushing, dyspnea, n/v, rash, hives, etc
  20. Possible s/e of IV administration of immunoglobulin:
    • Back Pain
    • Fast HR
    • H/A
    • Joint/Muscle ache
    • N/V
    • Chest tightness, difficulty breathing, burning in head

    Dermatologic: rash, mild skin reaction at injection site

    Gastrointestinal: abdominal cramps, N/V

    Musculoskeletal: chest, back/hip pain, muscle pain, joint pain

    Neurologic: anxiety, chills, dizziness, fever, h/a
  21. Secondary Immunodeficiency is ___ common than primary immunodeficiency:
    MORE
  22. Common causes of secondary immunodeficiency:
    • stress
    • burns
    • uremia
    • diabetes
    • autoimmune disorders
    • viruses
    • exposure to immunotoxic medications
    • alcohol misuses
  23. Best known secondary immunodeficiency:
    HIV (human immunodeficiency virus)
  24. People with Secondary Immunodeficiency are considered:
    immunocompromised hosts
  25. Nursing Interventions of Secondary Immunodeficiency patients:
    Monitor Lab values

    Teach pts about infection prevention strategies

    Take medications

    Proper nutrition

    Wear masks

    Watch for s/s of infection (may be very subtle!)

    Clean off fresh fruits/veggies
  26. Group of chronic disorders characterized by diffuse inflammation and degeneration in the connective tissue
    Diffuse Connective Tissue Diseases
  27. Rheumatic Diseases are marked by:
    • Inflammation
    • Autoimmunity
    • Degeneration
  28. Most cases of SLE (systemic lupus erythematosus) occur in _____
    women of childbearing years

    African, Asian, Hispanic, and Native Americans (3x more likely than whites)
  29. SLE (Systemic Lupus Erythematosus) most commonly affects the:
    • Skin/Muscles
    • Linings of the Lungs
    • Heart
    • Nervous Tissue
    • Kidneys
  30. Causes of SLE (Lupus)
    ***Trigger in the body that makes the body turn on itself

    • Genetics
    • Virus
    • Stress
    • Diet
    • Certain Medications:
    • -Hydralazine
    • -Procainamide
    • -Isoniazid
    • -Thorazine
    • -Some antiseizure medications
  31. Systemic Effects of SLE
    Fever

    Fatigue

    Anemia

    Lymph Node Enlargement 

    Raynaud's Phenomenon and Sjogren's syndrome

    Any organ system may be involved

    Skin and mucosal manifestations
  32. SLE
  33. "Tell-Tale" Sign of Lupus:
    Butterfly-shaped rash across the cheeks and bridge of the nose.

    Other common skin problems include sensitivity to the sun with flaky, red spots or a scaly, purple rash on various parts of the body, including the face, neck, and arms. Some people also develop mouth sores

    Goes away and comes back in times of exacerbation
  34. Usual first sign of lupus:
    Joint/Muscle pain
  35. Difference between joint pain in Lupus and Rheumatoid Arthritis:
    Pain with Lupus comes and goes and does not cause permanent joint damage
  36. 12 Super Symptoms of Autoimmune Disorders:
    Brain Fog

    Persistent, low grade fever

    Swollen Glands

    Inflammation

    Itchy skin or rashes

    Hair loss

    Infections

    Changes in Weight

    Joint/Muscle Pain/Weakness

    Extreme Fatigue

    Tingling
  37. Criteria for Classifying Systemic Lupus
    ***4 of the 11 present serially or simultaneously

    Malar Rash

    Discoid Rash

    Photosensitivity

    Oral Ulcers

    Arthritis

    Serositus

    Kidney Disease

    Neurologic Disease

    Immunologic Disease

    Positive Antinuclear antibody
  38. Lab to Dx Lupus:
    THERE IS NO SINGLE BLOOD TEST THAT CAN DETERMINE LUPUS!
  39. Diagnostics of Lupus: (very hard)
    No specific Test

    Patient Hx

    Physical Exam

    Lab Findings (+ana means something is wrong but not definitive of lupus)

    CBC

    Urinalysis

    X-ray of joints

    Chest X-ray

    ECG
  40. Collaborative Therapy for Systemic Lupus
    • NSAIDS for mild disease
    • Steroid-sparing drugs (methotrexate)
    • Antimalarials
    • Corticosteroids
    • Immunosuppresive drugs
  41. People that have SLE are at great risk for:
    CARDIOVASCULAR disease
  42. Goals for Treating a patient with Lupus:
    Reducing Tissue Inflammation caused by the Disease

    Suppressing the immune system abnormalities that are responsible for tissue inflammation

    Preventing flares and treating them when they do occur

    Easing symptoms such as joint pain and fatigue

    Minimizing complications of the disease
  43. Medications used for treating lupus
    *Always steroids bc of systematic inflammation (but they have s/e)

    *NSAIDS

    • *Antimalarials
    • (Plaquenil, Aralen)

    • *Corticosteroids
    • (Prednisone)

    • *Immunosuppressives
    • (Imuran, Cytoxan, Rheumatrex, Neoral, Cellcept, IVIGs)

    • *Thalidomide (for skin manifestations)
    • *DHEA (balance of hormones)
  44. 5 Things that can trigger LUPUS flare
    Infection (cold/flu)

    Stress (emotional/physical...)

    Pregnancy (directly after birth of baby)

    Sunlight

    Starting/Stopping new drug
  45. Chronic autoimmune disease in which a person's WBCs attack their moisture producing glands (4 million americans)
    Sjogren's Syndrome
  46. S/S of Sjogren's Syndrome
    Dry Eyes/ Dry Mouth
  47. A person with one autoimmune disease often has ____
    Several autoimmune diseases
  48. Medications given to treat Dry Mouth (Sjogrens Syndrome)
    • Salagen- 5-10mg TID
    • Evoxac- 30mg TID
    • Salivart- PRN
    • Biotene -PRN
    • Moi-Stir Solution- PRN
  49. Medications given to treat Dry Eye (Sjogren's Syndrome)
    • Lacrisert- 1 drop, BID
    • Restasis- 1 drop, BID
    • GenTeal- PRN
    • Refresh Plus- PRN
    • Visine Tears- PRN
    • Murine Tears- PRN
    • Refresh PM Ointment- Bedtime
  50. Treatment for Primary Raynaud's
    • Lifestyle Modifications:
    • -avoid cold exposure
    • -sufficient protection
    • -smoking cessation
    • -avoidance of sympathomimetic drug

    • Topical Nitrates
    • Long acting CCB
  51. Treatment for Secondary Raynaud's Phen.
    • Lifestyle Modification
    • -avoid cold exposure
    • -sufficient protection
    • -smoking cessation
    • -avoidance of sympathomimetic drug

    • Long Acting CCB
    • Nitrates
    • Additional Statin
    • Aspirin/Heparin
    • Prostaglandins
    • Bosentan (prevention of ulcers)
  52. Nursing Dx for Raynaud's
    Acute/Chronic Pain

    Fatigue

    Impaired Physical Mobility

    Disturbed Body Image

    Ineffective Coping

    Complication secondary to effect of medications
  53. Mothers with HIV/AIDS _____ have babies when on medication and not pass it to their child
    CAN
  54. HIV attack the ___ cells and uses them to make copies of itself
    T-Cells
  55. HIV becomes AIDS when :
    A Good Majority of your cells have been destroyed.....a person can be HIV positive for long periods before developing AIDS (and may never develop AIDS)
  56. Ways HIV can be transmitted:
    • Sex
    • Pregnancy/Childbirth/Breast Feeding
    • Injection Drug Use
    • Occupational Exposure (MD/Nurse)
    • Blood Transfusion/Organ Transplant
  57. Many HIV people ____ have symptoms...often people only begin to feel sick when they progress toward AIDS
    Do Not
  58. As early as ___ weeks after exposure to HIV people, people can experience ARS (Worst Flu Ever)
    2-4 weeks
  59. After the initial HIV infection, the virus becomes less active in the body....this period can last ____
    Up to 10 Years
  60. Most severely affected people with HIV
    Gay/Bisexual Men (all races)
  61. _ in 5 living with HIV is unaware of their infection
    1
  62. The CDC recommends you get tested for HIV if you have more than 1 partner every ____
    3-6 months
  63. Risks associated with HIV infections:
    Sharing infected injection drug use equip.

    Having sex with infected people

    Infants born to mothers with HIV/breast-fed

    People who received organ transplants, HIV infected blood, or blood products (especially between 1978 and 1985)
  64. Prevention of HIV:
    • Standard Precautions
    • Safer Sex practices and safer behaviors
    • Do not share drug injection equip
    • Blood screening and treatment of blood products
  65. ___ can be used to treat people who may have been exposed to HIV by accident/in the healthcare field
    PEP
  66. Procedure for Occupational Exposure to HIV
    Alert Supervisor immediately

    ID patient

    Report to employee health as quickly as possible (emergency department if employee health is closed)

    Give consent for baseline testing (should be done within 72 hours)

    Start prophylaxis medication within 2 hours after exposure

    Practice safe sex until follow up appointment

    Take HIV medications for 4 weeks after exposure

    Follow up testing (1 month, 6 months, 1 year)

    Psychosocial Support
  67. Post Exposure Prophylaxis (PEP)
    Usually used for anyone who may have been exposed to HIV

    Healthcare workers have the greatest risk (needle sticks, body fluids, or open wounds/dermatitis)

    • *Taking anti-HIV drugs ASAP
    • *Must begin with 72 hours
    • *Consists of 2-3 anti-retroviral medication taken for 28 days
  68. Normal amount of T-Cells
    500-1,000
  69. HIV Life Cycle:
    • Attachment
    •  -GP120 and GP41 glycoproteins of IV bind with the host’s uninfected CD4 cells T cell membrane

    • Uncoating
    •  -HIV’s viral load is emptied into the CD4 T cell

    • DNA synthesis
    •  -Through reverse transcriptase HIV changes RNA to DNA that carries instructions for viral replication.

    • Integration
    •  -New viral DNA enters the CD4 T cells leading to lifelong infection

    • Transcription
    •  -When the CD4 T cell is activated , double stranded DNA forms single-strand RNA which
    • builds new virsues

    • Translation
    •  -The new messenger  RNA creates chains of
    • proteins and enzymes that contain components needed in the construction of the new viruses

    • Cleavage
    •  -The HIV enzyme protease cuts the polyprotein chain into the individual proteins that make up the new virus

    • Budding
    •  -New proteins and viral RNA migrate to the membrane of the infected CD4 T cell, exit
    • from the cell, and start the process all over
  70. Once you have HIV+, you are ____ +
    ALWAYS....but does not mean you have AIDS
  71. Stages of HIV disease
    Primary infection

    HIV asymptomatic

    HIV symptomatic

    AIDS
  72. Stage of HIV disease: 2 weeks- 6 months
    Infection
  73. IAcute phase of HIV infection
    Large amounts of virus are being produced in body

    Flu-Like Symptoms
  74. A person is dx as having AIDS when the CD4 falls below:
    200
  75. Without treatment, an HIV (AIDS) patient will typicall survive:
    3 years
  76. Large viral levels in the blood for 2-3 weeks
    • Viremia
    • (transmission is more likely when viral load is high)
  77. Primary HIV infection
    Viremia (large viral levels in the blood for 2-3 weeks)

    Followed by prolonged period (years) of low viral load (may last 10-12 years)
  78. Major consequence of rapid replication during HIV primary infection:
    Errors occur during the copying process causing mutations that contribute to treatment difficulties
  79. Clinical Manifestations of an ACUTE HIV infection
    • Flu-like symptoms
    • (fever, swollen lymph nodes, sore throat, h/a, malaise, nausea, muscle/joint pain, diarrhea, diffuse rash)

    • Occurs about 2-4 weeks after infection
    • Lasts 1-2 weeks
  80. Asymptomatic HIV is a CDC category:
    A

    (Public Health Problem!)
  81. Labs for Asymptomatic HIV
    >500 CD4 + T lymph
  82. Median interval between untreated HIV infection and dx of AIDS:
    11 years
  83. Clinical manifestations of intermediate/chronic HIV
    • CD4 + T cells 200-500 (viral load increases)
    • Symptoms from earlier stage becomes worse (persistent fevers, night sweats, diarrhea, h/a, fatigue)

    Localized infections, Lymphadenopathy, NS manifestations
  84. AIDS is classified as category:
    C
  85. Labs for AIDS
    <200 CD4 + Tcells
  86. 1/4 of people living with HIV are older than ___ years
    50
  87. Reasons for gerontology considerations for HIV patients:
    • Unprotected intercourse
    • Do not consider themselves at risk
    • Social bias toward homosexuality
    • May use IV drugs
    • May have received HIV infected blood before 1985
    • Reduction in immune system function
  88. Only sure method to determine HIV infection:
    • TESTING
    • (CDC recommends people 13-64 should be tested)
  89. Pre-HIV Test counseling sessions:
    Information about HIV test

    Information about HIV/ how it is spread and how to protect yourself

    Info about confidentiality of results

    Clear-easy to understand explanation of what the test results mean
  90. All HIV-pos test results must be reported to _____ for data tracking
    State Health Department

    (many states then report to CDC without any personal pt information)
  91. Post- HIV testing counseling:
    Clear communications about test results mean

    HIV prevention counseling

    Confirmatory test (Western blot test) if results were positive...results available within 2 weeks
  92. Lab tests for Dx and Tracking HIV
    EIA 

    Western Blot

    Viral Load (measures HIV RNA in plasma)

    CD4/CD8 

    OraQuick (in home)
  93. Antiretroviral Agents used for HIV
    NRTIs (nucleoside reverse transcriptase inhib)

    NNRTIs (Non-nucleoside reverse transcriptase inhibitors)

    Protease Inhibitors (PIs)

    Integrate Inhibitors

    Use of Combination Therapy

    Medications for AIDS
  94. Main goals of treatment for HIV:
    Decrease viral load

    Maintain/Raise CD4 counts (under 200 = AIDS)

    Delay HIV-related sx and opportunistic infections
  95. To avoid burnout and nonadherence, treatment for HIV is recommended when:
    Immune Suppression is great

    Any time pt has Hx of AIDS defining illness

    Asymptomatic < 350 cells

    HIV associated nephropathy

    Hep B co-infection when treatment of HBV is indicated
  96. Adherence to HIV drug regimens is critical to prevent:
    Disease Progression

    Opportunistic Disease

    Viral Drug Resistance
  97. Short Term S/E of HIV Drugs
    • Anemia
    • Diarrhea
    • Dizziness
    • Fatigue
    • H/A
    • Nausea and Vomiting
    • Pain and Nerve problems
    • Rash
  98. Common Long Term s/e of HIV drugs
    Lipdystrophy

    Insulin Resistance

    Lipid abrnomalities

    Decrease in bone density

    Lactic acidosis
  99. Problem in the way body produces, uses and stores fat...losing fat in the face/extremities and gaining fat in abdomen and back of neck
    Lipodystrophy
  100. Condition that can lead to abnormalities in your blood sugar levels and possibly diabetes...Lab tests which look at your sugar levels are usually the best indicators
    Insulin Resistance
  101. Increases in cholesterol or triglycerides...lab tests (cholesterol/triglycerides) are best indicators
    Lipid Abnormalities
  102. Build up of lactate (waste product)...can cause problems ranging from muscle aches to liver failure. ALERT IMMEDIATELY
    Lactic Acidosis
  103. Occurs when medicines being taken for HIV can't stop the virus from making more copies of itself (replication)
    RESISTANCE

    *antiretroviral drugs keep HIV from reproducing, making it CRUCIAL for pts to take HIV meds on time and consistently
  104. When viruses take advantage of the weakened immune system
    • opportunistic infections
    • (harmless viruses to "healthy" people)
  105. Opportunistic Infections common if people with HIV
    Candida Albicans

    Coccidoides Immitis (penumonia/fever, weight loss)

    CNS lymphoma

    Crytococcosus neoformans

    Cryptosporidium Muris

    CMV

    Hep B

    Hep C

    Herpes Simplex

    Histoplasma capsulatum

    Infuenza virus

    JC papovavirus

    Kaposi sarcoma

    Mycobacterium avium complex

    Mycobacterium tuberculosis

    Pneumocytis Pneumonia

    Toxoplasma Gondi

    Varicella-zoster virus
  106. Type of Resp Infections common in HIV patients
    Pneumocystis Pneumonia

    Mycobacterium Avium Complex

    TB
  107. GI Opportunistic Infection from HIV/AIDS
    Oral Candidiasis (treat with Mycelex, Nystatin, Ketoconazole)

    Diarrhea (octreotide acetate)

    Wasting Syndrome
  108. Cutaneous lesions involving multiple organ systems, causing discomfort, disfigurement, ulceration, and infection....
    Kaposi's Sarcoma (opportunistic infection that comes with AIDS)

    (also B-cell lymphomas)
  109. Manifestation of HIV/AIDS: Neuro
    Peripheral neuropathy

    HIV encephalopathy

    Cryptococcus Neoformans

    Progressive multifocal leukoencephalopathy

    Depression
  110. Nursing Dx for AIDS
    Risk for Infection (r/t immunodeficiency)

    Deficient Knowledge (r/t means of preventing HIV transmission)

    Social Isolation (r/t stigma of disease, withdrawal of support systems, isolation procedures, fear of infecting others)
  111. Main Goals of AIDS
    Keep viral load low

    Maintain immune function

    Improve QOL

    Prevent opportunistic disease and new infections

    Reduce disability

    Prevent new infections
  112. Interventions for AIDS
    Adhere to drug regimen

    Promote healthy lifestyles

    Prevent transmission

    Have supportive relationships
  113. Blood Types
    • A (A antigen, B antibody)
    • B (B antigen, A antibody)
    • AB (AB antigens, NO antibodies)
    • O (No antigens, AB antibodies)
  114. Universal Donor
    O
  115. Universal Recipient
    AB
  116. Test to evaluate Rh status
    Coombs test
  117. An RH- can give to either ___ or ___ patients
    + or -
  118. An RH+ can only give to ____ patients
    RH +
  119. Acute blood transfusion reactions
    • Acute hemolytic reactions
    • Febrile reactions
    • Allergic reactions
    • Circulatory overload
    • Sepsis
    • Delayed transfusion reactions
  120. Delayed blood transfusion reactions:
    Infection
  121. Nursing practice steps for giving blood and managing adverse reactions:
    Verify correct blood and patient by 2 RNs

    Start blood on time, End blood on time

    Vital Signs prior to giving

    Remain with patient 15 mins/Observe for signs of a transfusion reaction

    Stop blood for fever or other sx of reaction

    ****Pt temp and BP are priority (documented prior to transfusion, beginning of transfusion, and 15 min after!)
  122. IF blood transfusion reaction occurs:
    Stop!!!

    Maintain patent IV line with saline

    Notify the blood bank and physician

    Recheck ID tags

    Monitor v/s and UO

    Treat sx, Follow MD orders

    Save blood bag and tubing and send to blood bank

    Collect required blood and urine specimens to evaluate for hemolysis

    DOCUMENT
  123. What adverse reactions can occur with Blood Transfusions:
    • Febrile (MOST COMMON)
    • -sudden fever, chills, anxiety, flushing, muscle pain)

    • Acute Hemolytic (RBCs burst)
    • -chills, fever, flushing, tachycardia, tachypnea, hypotension, shock, cardiac arrest, low back pain, dark urine, plasmapheresis, renal failure, jaundice)

    Mild Allergy

    Anaphylactic and Severe Alllergy

    • Sepsis
    • -RAPID fever, chills, vomiting, diarrhea, shock

    • Circulatory Overload
    • -HTN, H/A, Tachycardia, pulmonary edema, cough, dyspnea

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