CHAPTER 36/28 NURSING 200

Patient education after anaphylaxis

- Avoid future exposure of antigens - How to administer emergency medications - Always keep epipen with you

Diagnostics of allergic rhinitis

- Blood counts - eosinophil count - Allergen testing - Nasal smears

Age related changes in Immunologic function

- Decrease in anti-body production - Skin thinner, less elasticity (physical barrier compromised) - Cilia action impaired d/t exposure of environmental toxins (smoking) - Decrease gastric secretion (chemical barrier compromised)

Clinical manifestations of atopic dermatitis

- EDEMA, CRUSTING AND SCALING OF SKIN - CAN HAVE CHRONICALLY IRRITATED SKIN - HAVE HARDENED LEATHERY APPEARANCE FROM CONSTANT SCRATCHING

Clinical manifestations for anaphylaxis

- Feeling of impending doom or fright. _ sweating, sneezing, SOB, pruritus, urticaria(hives), angioedema, nasal mucosal edema, profuse watery rhinorrhea, nasal congestion. - Hypotension, shock, cardiac arrhythmia. - Edema of upper respiratory tract - hoarseness, stridor, use of accessory muscles - severe stomach cramps, nausea, diarrhea, urinary urgency & incontinence

Substances that most commonly cause anaphylaxis

- Foods (peanuts, tree nut, shellfish) - Medications (ABT, allopurinol, radio-contrast agents, anesthetic agents such as lidocaine, vaccines, hormones such as insulin, NSAID's - Animal serums (tetanus antitoxin, snake venom antitoxin, rabies antitoxin) - Insect sings (bee, wasp, hornets, yellow jackets) - Latex

Possible Nursing Diagnoses for Atopic Dermatitis

- IMPAIRED BODY IMAGE - RISK FOR INFECTION - IMPAIRED SKIN INTEGRITY

Diagnostic testing for evaluating Immunologic Status

- Immune competence testing - CBC - ANC - HIV testing - Bone marrow biopsy - Skin testing - Specific antigen and antibody testing - Hypersensitivity Tests - HIV infection tests

active aquired immunity

- Immune defenses are being developed by the person's own body in response to an immunization or by contracting a disease (results from actual exposure to a pathogen)

Medical management of allergic rhinitis

- OTC medications - Encourage to see allergist, may need stronger than OTC medications - Treatment to relieve symptoms

Delayed type IV hypersensitivity reaction

- Occurs anyway from 24-72 hrs after exposure to an allergen - PPD

Anaphylaxis

- Severe allergic reaction the is rapid in onset and can cause various reactions, including death. Results from a rapid release of IgE-mediated chemicals inducing life threatening reactions. - A clinical response to an immediate (type I hypersensitivity) immunologic reaction between a specific antigen and an antibody - Occurs when the body's immune system produces antibodies toward a substance that is normally nontoxic

Allergy Testing

- Skin tests (Evaluate urticaria wheel and erythema) -Radioallergosorbent testing (RAST) (When blood drawn and specific allergen in blood evaluated o Example: not sure if truly allergic to eggs, RAST testing looks for allergen) - Provocative testing (Suspects peanut allergy, and skin testing didn't confirm, individual consumes small amount of suspected allergen to confirm allergy.)

CONTACT DERMATITIS

- Type IV DELAYED hypersensitivity reaction - Skin inflammation that results from direct skin contact with chemicals or allergens - Results from contact with a substance that is chemically or physically damaging to skin on nonimmunologic basis. Can occur after one exposure to irritant or after repeated exposure

Immune Complex (Type III) Hypersensitivity

- Working with immune system to say "we're having an unanticipated reaction - causing tissue injury - Involves immune complexes that are formed when antigens bind to antibodies - Associated with Systemic Lupus Erythematous

Nursing management in acute anaphylaxis

- assess airway, breathing pattern, other vital signs. - Observe for increasing edema, respiratory distress. - Prepare for initiation of emergency measures - establish IV line - Document interventions, vitals.

Common products containing Latex:

- brown ace bandage - Adhesive bandages - Anesthesia equipment - BP Cuffs - Catheters & catheter supplies - Crutch pads - ECG Pads - Compression stockings - Gloves - IV catheters - Med vials - Penrose drains - Pulse Oximeters - Stethoscope tubing - Syringes - Thermometer probes - Tourniquets - Balloons - Diapers - Condoms - Feminine hygiene pads

Medications administered during anaphylaxis

- oxygen - epinephrine - Antihistamines - Corticosteroids - IV fluids, volume expanders, vasopressor agents - aminophylline & corticosteroids with COPD/Asthma - Glucogon if hypotensive & unresponsive to vassopressors -

Atopic Dermatitis is a Type ______ immediate sensitivity

1

Treatment of atopic dermatitis

1. Anti-histamines to reduce itching 2. Topical corticosteroids are mainstay of treatment (avoid systemic steroids) 3. Tacrolimus and pimecrolimus are topical calcineurin inhibitors approved for moderate to severe atopic dermatitis. Less atrophy than steroids BUT may be associated with increased risk of malignancy 4. Hydration and topical emollients are key to management. Soaps, vigorous rubbing, frequent bathing, and irritant clothing such as wool should be avoided 5. UVB phototherapy 6. Severe systemic cases may necessitate cyclosporine

Assessment of the Immune System/History

1. Health history (Do you have any allergies, what happens? Any autoimmune d/o? use of anti-neoplastic? Cancers? Chronic illness in health hx?) 2. Social History (Poor nutritional status, poor sleep habits, smoking, excessive ETOH consumption, illicit drug use, STI's, occupation and residential exposure to radiation and pollutants.) 3. Blood Transfusions and medications (Have you had any, when? *risk of HIV/Hepatitis transmission) 4. Nutrition (How is your appetite? · we need to feed the bones so they are able to produce cells we need to cells they need to) 5. Travel and occupation (Travel - What area have you traveled to, what diseases are present there? Do you need additional vaccinations to go to that site? Occupation (nurses) - exposure to disease (TB, C-Diff, COVID)

COMPONENTS OF NATURAL IMMUNITY

1. Physical barriers - (skin, mucous membranes, cilia of respiratory tract) 2. Chemical barriers - (Mucous, gastric acid, enzymes in tears and saliva) 3. Inflammatory response - (Elicited in response to tissue injury - cells sent to area of injury causing swelling) 4. Immune response - (Patients with CA, HIV/AIDS, receiving chemo, autoimmune patients, patients taking immunosuppressants, elderly may have compromised immune response)

Manifestations of serum sickness begin after ___________ days after anti-toxin

6-10 days

A patient has been brought to the emergency department in apparent anaphylaxis. The priority aspect of care is: A. Ensuring a patent airway B. Managing the patient's anxiety C. Assessing the patient's circulatory status D. Preventing complications of anaphylaxis

A

A patient is exhibiting anaphylaxis after eating shellfish. Which of the following reactions is the patient experiencing? A. Type I B. Type II C. Type III D. Type IV

A

A pt is being seen in the dermatology clinic to have allergy testing performed. Which of the following statements is accurate regarding this type of testing? A. A + reaction is evidenced by the appearance of an urticarial wheal B. The arms are the most suitable area of the body for skin testing C. A - response can be interpreted as an absence of sensitivity to an allergen D. There is no risk of a false negative result

A

When reviewing the chart of a pt diagnosed with allergic rhinitis, the nurse understands that this allergic disorder is caused by which type of hypersensitivity reaction? A. Type I B. Type II C. Type III D. Type IV

A

Allergic reaction

A manifestation of tissue injury resulting from interaction between an antigen and an antibody

allergic reaction

A manifestation of tissue injury resulting from interaction between an antigen and an antibody

SERUM SICKNESS

A type III hypersensitivity reaction. - Traditionally caused by the administration of therapeutic antisera (snake venom) of animal sources for the treatment or prevention of infectious diseases

The severity of anaphylaxis depends on the degree of allergy and the dose of the ________.

ALLERGEN

_______ is a clinical response to an immediate (type I hypersensitivity) immunologic reaction between a specific antigen and antibody.

ANAPHYLAXIS

The structural part of the invading or attacking organism that is responsible for stimulating antibody production is called an __________________.

ANTIGEN

In ______ therapy, every attempt is made to remove the allergens that act as precipitating factors.

AVOIDANCE

Four types of contact dermatitis

Allergic, irritant, phototoxic, and photoallergic

Hypersensitivity

An amplified or inappropriate response to an antigen leading to inflammation and destruction of healthy tissue May result from genetic, hormonal, and environmental factors

Hypersensitivity

An amplified or inappropriate response to an antigen leading to inflammation and destruction of healthy tissue. -May result from genetic, hormonal, and environmental factors

A pt is being seen in the dermatology clinic for urticaria. The nurse would expect which of the following medications to be prescribed for the pt? A. Sudafed B. Benadryl C. Decadron D. NasalCrom

B

During a clinical postconference, the instructor is discussing factors r/t the risk of anaphylaxis. Which of the following statements made by the instructor would be inconsistent with the risk of anaphylaxis? A. the severity depends on the degree of allergy B. the severity of previous reactions determines the severity of subsequent reactions C. the severity depends on the dose of the allergen D. the severity of previous reactions does not determine the severity of subsequent reactions

B

What teaching point should the nurse prioritize when providing health education to a patient with a newly diagnosed food allergy? A. Managing the GI symptoms of a food allergy B. Strategies for avoiding the offending food C. Techniques for ensuring adequate nutrition

B

_____ dermatitis is an acute or chronic skin inflammation that results from direct skin contact with chemicals or allergens.

CONTACT

Anaphylactic (Type I) Hypersensitivity

Can be mild-severe - Most severe form of hypersensitivity reaction or immune-mediated reaction is anaphylaxis. Often explosive in onset. - Characterized by edema in tissues (including larynx), accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. - Begins within minutes of exposure to an antigen.

atopic dermatitis

Characterized by inflammation and hyperactivity of the skin, often causing pruritis

A pt is concerned that he has an HIV infection. Which of the following tests might be performed on this pt? A. bone marrow biopsy B. agglutination C. scratch test D. ELISA

D

Which of the following is the most frequent source of exposure for a latex allergy? A. occasional use of latex condoms B. IV lines insertion C. use of hemodialysis equipment D. repeated donning of latex gloves

D

The protective effects of a vaccination are a result of what immune process? A. Passive acquired immunity B. Cellular immunity C. Natural immunity D. Active acquired immunity

D, ACTIVE AQUIRED IMMUNITY

aquired immunity

Develops as a result of exposure to an antigen. (Acquired during lifetime, not present at birth. Need exposure to antigen by contracting a disease, virus, or time period creating a protective immune response.)

Patients should be instructed to carry an emergency kit that contains _______________________.

Epinephrine - Epipen

A nurse who has a latex allergy should be advised to avoid wearing gloves while providing care.

FALSE A latex allergy does not remove the nurse's obligation to abide by standard precautions. The nurse should wear non-latex gloves.

TRUE OR FALSE: Most immune responses to antigens involve either humoral or cellular responses, not both

FALSE, BOTH

TRUE OR FALSE: Interferons modify the immune response by suppressing antibody production and humoral immunity

FALSE, CELLULAR

TRUE OR FALSE: Antihistamines prevent the release of histamine and protect surrounding tissue from the effects of the histamine release:

False, don't prevent but protect

Serum Sickness can cause __________________

Guillain Barre Syndrome - temporary paralysis starting in lower extremities moves up the body) - can cause paralysis of lungs requiring mechanical ventilation

_______ T cells are activated on recognition of antigens and stimulate the rest of the immune system

HELPER

Patients with ______________ should avoid the use of Sudafed

HTN

_______ involves the administration of gradually increasing quantities of specific allergens to the patient until a dose is reached that is effective in reducing disease severity from natural exposure.

IMMUNOTHERAPY

Medical management of Dermatitis Medicanmentosa

Identify and discontinue causative medication

____________ immunity provides a nonspecific response to any foreign pathogen, regardless of the pathogen's composition.

NATRUAL

___________ Immunity is dependent on the ability to distinguish self vs non-self (Tom Cruise example)

Natural

Cytotoxic (Type II) Hypersensitivity

Occurs when the system mistakenly identifies a normal substance of the body as foreign. - Can occur with blood transfusions - Several conditions associated with this: Myasthenia gravis, Goodpasture syndrome, Rh-hemolytic disease of newborn.

Agglutination helps clear the body of the pathogens by facilitating _________.

PHAGOCYTOSIS

Most common adverse reaction with Dermatitis medicamentosa

Rashes Can be accompanied by systemic or generalized sx such as bronchospasm, urticaria, and angioedema

Treatment of contact dermatitis

Removal of offending agent and topical glucocorticoids if needed

Physical assessment of immune system

Respiratory - what's RR, POX, cough dry/productive? SBAR MD with frequent congested, productive cough Cardiovascular - hypotension? Tachy? Anemia? Arrythmias? Gastrointestinal - N/V/D? C-Diff? Genitourinary - UTI? Burning, urgency, frequency, vaginal discharge? Musculoskeletal - joint edema? Pain? Redness? Skin - is skin intact? Wounds? Multiple IV sites? Frequent holes in skin d/t venipuncture? Lesions? Rashes? Urticaria (HIVES)? Neurosensory - visual changes? HA's? Hearing loss-could be ear infection?

Common antihistamine medications & patient teaching

SEDATING: Benadryl, Chlor-Trimeton, Atarax - (May cause Drosiness, confusion, dizziness, dry mouth, urinary retention) - educate patient NO driving, avoid alcohol NON-SEDATING: Zyrtex, Clarinex, Alavert, Claritin - Claritin may cause depression & needs to be taken on an empty stomach. Zyrtec and Clarinex can be taken without regard to food.

___________ cells are potentially immortal cells that are capable of self-renewal and differentiation.

STEM

allergic rhinitis

Seasonal allergies AKA Hay Fever - The most common chronic respiratory allergic disease mediated by an immediate (type I hypersensitivity) reaction

passive acquired immunity

TEMPORARY immunity. A form of immunity where the fetus receives antibodies made by the mother through breast milk

TRUE OR FALSE The most commonly used oral adrenergic agent is pseudoephedrine hydrochloride (Sudafed)

TRUE

TRUE OR FALSE: Lymph nodes are the centers for immune cell proliferation.

TRUE

TRUE OR FALSE: Natural Immunity provides a nonspecific response to any foreign pathogen, regardless of the pathogen's composition

TRUE

TRUE OR FALSE: Supressor T-cells have the ability to decrease B-cell production

TRUE

TRUE OR FALSE: Systemic symptoms occur with contact dermatitis

TRUE

TRUE OR FALSE: The primary goal in serum sickness therapy is to treat the clinical syndrome prophylactically

TRUE

TRUE OR FALSE: The risk of anaphylaxis is determined by prick and intradermal skin testing

TRUE

natural immunity

This type of immunity provides a nonspecific response to any foreign pathogen, regardless of the pathogen's composition. An immunity that is presence at birth, provides immunity against infectious agent without ever having encountered it before. "Broad spectrum defense, resistance to infection"

Dermatitis Medicamentosa

Type 1 Hypersensitivity reaction to a medication

LATEX ALLERGY

Type 1 hypersensitivity - allergic reaction to natural rubber proteins

food allergy

Type 1 hypersensitivity reaction in which the body's immune system reacts to substances in some foods

Urticaria and Angioneurotic Edema

Urticaria (hives) is a type I hypersensitive allergic reaction of the skin characterized by the sudden appearance of pinkish, edematous elevations

Types of acquired immunity

active and passive

Angioneurotic edema

acute swelling of the face, neck, lips, larynx, hands, feet, genitals, and internal organs (involves the deeper layers of the skin, resulting in more diffuse swelling)

Immunotherapy (allergy desensitization) is done when:

allergen is indentified

Manifestations of allergic rhinitis

sneezing and nasal congestion; clear, watery nasal discharge; itchy eyes and nose; postnasal drip, dry cough, headache, and lacrimation (teary eyes)