Immune
A 34-year-old patient comes to the clinic requesting HIV testing. He is a gay man with two significant others in his lifetime. His partner recently received a diagnosis of HIV infection. The patient asks the nurse how long it will take before the infection could show up in him. What would be the nurse's best response?
"Antibodies may be detected in the blood within 1 to 12 weeks of exposure."
The patient asks the nurse, "How does HIV cause AIDS?" What is the nurse's best response?
"HIV attacks the immune system, a system that protects the body from foreign invaders, and thus makes it unable to protect the body from organisms that cause diseases."
An 8-year-old boy receives a diagnosis of hemophilia. His mother is upset about his risk of acquiring HIV from blood products. What would be the nurse's best response?
"Many blood products are treated with heat or chemicals to inactivate the HIV virus."
The activation of T cells by antigens indicate which type of immunity is developing? (Select all that apply.)
**Adaptive immunity **Cellular immunity
Discuss immunosuppressive therapy and its use
**Administration of agents that interfere with the immune system's ability to respond to antigens. Infection is a threat to the immunosuppressed patient. **Example - meticulous aseptic technique is required when caring for these individuals.
The most common allergens that cause an anaphylactic reaction include: (Select all that apply.)
**Bees, wasps **Shellfish **Peanuts
Distinguish between HIV 1 and HIV 2.
**HIV 1 - Most virulent, profound immunodeficiency; high viral loads; Results in death **HIV 2 - Normal life expectancy, long-term nonprogresion; Less infectious during stage.
Discuss what happens to the body with an autoimmune disorder.
**Immune response to ones own tissue (no tolerance to self) **B&T cells produce autoantibodies **May be described as an immune attack on one self end result from the failure to distinguished foreign protein **Nursing process of prevent infections
Identify those at risk for developing Kaposi's sarcoma.
**Impaired immune system **Patient who have taken immunosuppressive agents **History of same sex partners **Those receiving antineoplastic medications.
Define opportunistic infections.
**Infections that occur as a result of immunocompromised **Yeast (candiditis) **Drug to treat candiditis: ketoconazole (Nizoral) **Avoid alcohol **Monitor hepatic function **Avoid sun exposure
Identify illnesses classified as autoimmune.
**Lupus erythematosus **Glomerulonephritis **Rheumatoid arthritis **Thrombocytopenic purpura
How does vertical transmission of HIV occur? (Select all that apply.)
**Mother to fetus during breast-feeding **Mother to fetus during pregnancy **Mother to fetus during delivery
Identify 6 factors that may alter the immune response.
1) Cytotoxic drugs 2) Stress 3) Young/old 4) Malnutrition 5) Surgical removal of lymph nodes: Thymus Spleen Hodgkins
Identify behaviors that pose the greatest risk of acquiring HIV.
1) Having a STD 2) Receiving blood transfusion 3) Sharing needle/syringes 4) Sexual experience in which sexual organ comes in contact with another person who practice risky sexual behaviors 5) Thinking that just because you are married with children and so you are not at risk
Identify modes of transmission of HIV specifically mother to infant.
1) Intrautero if mom is HIV positive 2) During the birth process if mom is HIV positive 3) Breastfeeding 4) Contaminated blood products during transfusion 5) Sharing of needles/syringes 6) Sexual experience with an infected person with HIV
Discuss the order of steps during plasmapheresis.
1) Needle stick 2) Removal of blood 3) Circulation of blood through cell separator (removal of undesirable components) 4) Remainder of plasma returned through vein in opposite arm 5) Replacement with lactate ringer
List the order of necessary steps to initiate a blood transfusion.
1) RN will start the blood 2) Hung only with 0.9 nacl and use inline filter 3) Blood can only be out 30 minutes, if not started needs to be returned to the lab 4) Blood can hang for only 4 hours 5) If reaction occurs need to stop transfusion, change out tubing and hang saline and new tubing. 6) Obtain vital signs 7) Notify doctor 8) Return blood and tubing to the lab for review.
Identify the time blood products must be infused once obtained from the lab.
4 hrs of removal from refrigerator and blood components within 6 hrs
Identify the average length of time it takes to convert from a diagnosis of HIV positive to AIDS.
8 to 14 years
Define seroconversion.
A change in serologic test results from negative to positive as antibodies develop in reaction to an infection.
Latex allergies Type I Etiology
A response to natural rubber latex proteins.
Diphenhydramine (Benadryl) Action/classification
ANTIHISTAMINE
The nurse is assisting with the administration of immunizations at a health care clinic. The nurse should understand that immunization provides which protection?
Acquired immunity from disease
Identify the body's second line of defense. Is it specific or nonspecific?
Adaptive immunity provides specific reaction to each invading antigen and has the unique ability to remember the antigen that caused the attack.
Anaphylactic reaction Etiology
An acute and potentially fatal hypersensitivity (allergic) reaction to an allergen. Results in a sudden severe vasodilation as a consequence of the release of certain chemical mediators from mast cells. Vasodilation causes an increase in capillary permeability, which causes fluid to seep into the interstitial space from the vascular space.
The client diagnosed with pemphigus is being seen in the clinic regularly. The nurse should plan care based on which description of this condition?
An autoimmune disease that causes blistering in the epidermis
Discuss Antiretroviral Therapy (ART).
An important component in the management of HIV infection. Six different classes of ART are used to prevent the viral replication process: integrase strand transfer inhibitors, fusion inhibitors, CCR5 antagonists (also referred to as entry inhibitors), nucleoside reverse transcriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PI). Each class of medication interrupts HIV at different stages of the infectious process.
Which individual is least at risk for the development of Kaposi's sarcoma?
An individual working in an environment where exposure to asbestos exists
Soluble factors Acquired (Active)
Antibodies, lymphokines
Discuss the role of each T lymphocyte.
Approximately 70 to 80% of the lymphocytes are T cell lymphocytes. When activated, T cells release compounds called lymphokines. Lymphokines attract macrophages to the site of infection or inflammation and prepares them for attack. T cells cooperate with the B cells to produce antibodies but do not produce antibodies themselves. T cells are responsible for cell-mediated immunity and protect the body against viruses, bacteria, fungi, and parasites. T cells also provide protection in allografts (transfer of tissue between two genetically dissimilar individuals of the same species) and against malignant cells. T-helper cells coordinate the immune response by activating phagocytes and other T cells, and by stimulating B cells to produce antibodies. T-suppressor cells maintain the humoral response at a level appropriate for the stimulus.
Discuss nursing care necessary for plasmapheresis.
Assess for low B/P due to vasovagal reaction or transient volume changes.
Anaphylactic reaction Nursing Interventions/Pt Teaching
Assessing respiratory status, including dyspnea, wheezing, and decreased breath sounds. Also assess circulatory status, including dysrhythmias, tachycardia, and hypotension. Monitor vital signs continually. Assess I&O, mental status, including anxiety, malaise, confusion, and coma; Skin status, including erythema, urticaria, cyanosis, and pallor; GI status, including nausea, vomiting, diarrhea, and incontinence.
The nurse is caring for a patient with a history of numerous allergies. What is the most important teaching concept?
Avoidance of the allergen
Humoral immunity is mediated by which type of cells?
B cells
Discuss the role of each B lymphocyte.
B cells make up approximately 20 to 30% of the lymphocyte population. B cells trigger the production of antibodies and proliferate (increase in number) in response to a particular antigen (a substance recognized by the body as foreign and that can trigger an immune response). An antigen is usually a protein that causes the formation of an antibody and reacts specifically with that antibody. B cells migrate to the peripheral circulation and tissues and eventually are filtered from the lymph and stored in the lymphoid tissue of the body. The initial formation of B cells does not require antigen stimulation or any other environmental stimulus. However, B cell proliferation depends on antigen stimulation. B cells are responsible for humoral immunity. B cells produce antibodies and protect against bacteria, viruses, and soluble antigens.
Identify food allergies that may indicate the potential for a latex allergy.
Bananas, avocados, kiwi fruit, tomatoes, apples, chestnuts, and melons
Isograft.
Between genetically identical individuals.
Allograft
Between two of the same species.
Flunisolide Action/classification
CORTICOSTEROID
Latex allergies Type IV Etiology
Caused by the chemical used in the manufacturing process of latex products.
Identify the body's second line of defense. Discuss Humoral Immunity.
Characterized by a two-step immune process In the first step, exposure to an antigen occurs and B cells develop a memory for that antigen. When a second exposure occurs, B cells initiate a quick response to neutralize the invader.
Discuss the effects of aging on the immune system.
Decreased movement of respiratory secretions increases the risk of respiratory tract infections.
Discuss the effects of aging on the immune system.
Decreased production of saliva and gastric secretions increases the risk of gastrointestinal infections.
Discuss the effects of aging on the immune system.
Decreased tear production increases the risk of eye inflammation and infections.
primary immunodeficiency.
Defect in cells: phagocytes, B-cell deficiency, T-cell deficiency, Combined B and T-cell deficiency
Latex allergies Type IV Signs & Symptoms
Delayed response that usually occurs 24-48 hours after exposure. Dryness, pruritus, fissuring and cracking of the skin, followed by erythema and edema.
Discuss the effect of radiation on the immune system.
Destroys lymphocytes directly or through depletion of stem cells. As radiation increases, more bone marrow atrophies, leading to severe pancytopenia and severe suppression of immune function.
Once a person is diagnosed as HIV positive explain the use of confidentiality.
Diagnosis must be protected.
Diphenhydramine (Benadryl) side effects
Drowsiness, confusion, nasal stuffiness, dry mouth, photosensitivity, urine retention
secondary immunodeficiency.
Drug induced: To treat chronic diseases including neoplastic and autoimmune disorders
Why would testosterone be prescribed to the HIV/AIDS patient?
Effects of testosterone can be enhanced by a low-weight resistance-training program, which maintains muscle tone and improves appetite.
Discuss exercise and medication to help weight loss (wasting syndrome) often associated with AIDS.
Encourage nutritional supplementation and increase protein intake, provide enteral supplements, and assist with total parenteral nutrition when it is needed. Medications to stimulate appetite, such as dronabinol (Marinol), Testosterone to increase lean body mass and weight. Effects of testosterone can be enhanced by a low-weight resistance-training program, which maintains muscle tone and improves appetite.
After a bee sting, the patient's face becomes edematous and she begins to wheeze. Based on this assessment, the nurse would be prepared to administer which medication?
Epinephrine
Hypersensitivity reaction Etiology
Excessive reaction to a particular stimulus. An inappropriate and excessive response of the immune system to a sensitizing antigen. Arise when harmless substances, such as pollens, danders, food, and chemicals, are recognized as foreign. Believed to be caused by a genetic defect that allows increased production of immunoglobulin E (IgE) with release of histamine and other mediators from mast cells and basophils.
Identify factors influencing hypersensitivity.
Exposure amount: In general, the more allergen the individual is exposed to, the greater the chance of a severe reaction.
The client is diagnosed with stage I of Lyme disease. The nurse should check the client for which characteristic of this stage?
Flu-like symptoms
Enzyme linked immunoabsorben assay (ELISA)
For the presence of antibodies to the HIV infection, if positive, then the blood is tested using a more specific test - Western Blot
Identify side effects of immunosuppression as a result of cytotoxic drugs.
Generalized leukopenia results leading to decreased humor and cell mediated response. Allowing secondary infection.
Diphenhydramine (Benadryl)
Generic/ TRADE name
Fexofenadine (Allegra)
Generic/ TRADE name
Flunisolide
Generic/ TRADE name
Identify factors that may weaken the immune response.
Genetic factors, developmental defects, infection, malignancy, injury, drugs, or altered metabolic states.
Discuss protective equipment necessary when providing care for a patient with Kaposi's sarcoma.
Gown and gloves
The nurse is assessing a patient who has requested HIV testing. What would be considered to be the most risky behavior?
Having more than three sex partners in a year
Fexofenadine (Allegra) side effects
Headache, drowsiness, blurred vision, hypotension, bradycardia, tachycardia, dysrhythmias (rare), urinary retention
Flunisolide side effects
Headache, transient nasal burning, epistaxis, nausea, vomiting
Latex allergies Type I Nursing Interventions
Identification of patients and health care workers sensitive to latex is crucial in preventing adverse reactions. Collect a thorough health history and history of any allergies, especially for patients with any complaints of latex contact symptoms.
Latex allergies Type IV Nursing Interventions
Identification of patients and health care workers sensitive to latex is crucial in preventing adverse reactions. Collect a thorough health history and history of any allergies, especially for patients with any complaints of latex contact symptoms.
Anaphylactic reaction Medical Management
Immediate aggressive treatment is the goal. At the first sign, the prescribed dose of epinephrine 1 : 1000 is given subq. For mild symptoms. Diphenhydramine may be given, IV therapy, and patient may be intubated. Place the patient in a recumbent position, elevate the legs, and keep the patient warm.
Identify ways to maintain the immune system of the HIV infected patient.
Immunizations, immunotherapy
The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate?
Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.
Discuss hypersensitivity reaction.
Is an inappropriate and excessive response of the immune system to a sensitizing agent. They arise when harmless substances, such as pollens, danders, foods, and chemicals, are recognized as foreign. The body mounts an immune response in much the same way it does to any foreign protein.
The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding this diagnosis?
It is an inflammatory disease of collagen contained in connective tissue.
Identify foods that may be beneficial to a patient experiencing diarrhea.
Lactose-free, low-fat, low-fiber, and high-potassium foods. Instruct patient to avoid dairy products, red meat, margarine, butter, eggs, dried beans, peas, and raw fruits and vegetables. Provide cooked or canned fruits and vegetables, which provide needed vitamins. Encourage patient to eat potassium-rich foods such as bananas and apricot nectar. Instruct patient to discontinue foods, nutritional supplements, and medications that may make diarrhea worse (ensure, antacids, stool softeners). Advise patient to avoid gas-producing foods. Serve warm, not hot, foods. Plan small, frequent meals. Encourage patient to drink plenty of fluids between meals.
The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?
Lyme disease is caused by a tick carried by deer.
Discuss why a CBS should be monitored during treatment with zidovudine.
Medication can cause anemia
Discuss the effects of aging on the immune system.
Medications commonly taken by the elderly such as antidepressants, statin drugs for elevated cholesterol, proton pump inhibitors for heartburn, and steroids also can reduce the immune system response.
Identify the signs and symptoms of mild
Mild: chills, dermatitis, diarrhea, fever urticaria, cough, and orthopnea
Identify the signs and symptoms of moderate
Moderate: fever, chills, urticaria, and wheezing occur after the first 30 minutes of administration.
Discuss ways to delay HIV disease progression.
Multidisciplinary approach can help ensure adherence to regimen.
Memory Acquired (Active)
NONE
Memory Innate (Passive)
NONE
Fexofenadine (Allegra) Action/classification
NONSEDATING ANTIHISTAMINE
The patient is concerned that he may be infected with HIV. Which sign or symptom is most commonly associated with an HIV infection?
Night sweats
Response mechanisms Innate (Passive)
Nonspecific: Mononuclear phagocytic system; inflammatory response
Flunisolide nursing implications
Not effective for acute episodes; use regularly; teach care and cleaning of inhaler; if symptoms do not improve in 3 wk, consult HCP.
Latex allergies Type I Signs & Symptoms
Occurs within minutes of contact with proteins. Urticaria, wheezing, or anaphylaxis
Discuss the effects of aging on the immune system.
Older adults are at increased risk for inflammation and infections resulting from changes in natural defense mechanisms.
Discuss the effects of aging on the immune system.
Older adults who have chronic illnesses are generally at increased risk for infection.
Autograft
One site to another on the same individual.
Discuss the effects of aging on the immune system.
Pathogens are able to enter through breaks in fragile, dry skin, increasing the risk of skin infections.
What are the most common opportunistic infection and malignant neoplasm in the patient with advanced HIV disease (AIDS)?
Pneumocystis jiroveci pneumonia, Kaposi's sarcoma
Identify the order of steps to be followed to ensure a safe blood transfusion.
Preventing transfusion reactions requires careful selection of blood donors, followed by careful typing and cross-matching of blood from donor to recipient. Proper storage of blood and adherence to the administration protocol are critical. Blood and blood components must be refrigerated at specific temperatures until a half hour before administration. Blood must be administered within 4 hours of removal from refrigeration, and blood components within 6 hours. Donor and recipient numbers are specific and must be checked thoroughly, and the patient must be identified with an armband. Administer all blood and blood products through microaggregate filters. Monitor for adverse effects.
Discuss the treatment for mild, moderate, and severe reactions
Prevention of transfusion reactions is aimed at following protocol and ensuring proper crossmatching and typing.
The nurse is assisting with planning the care of a client with a diagnosis of immunodeficiency. The nurse should incorporate which intervention as a priority in the plan of care?
Protecting the client from infection
Discuss dietary guidelines for a patient with immunosuppression or HIV.
Provide instructions for high-calorie, high-protein, high-potassium, low-residue diet. Suggest foods easy to swallow. Provide oral care before and after, Advise to avoid foods that are spicy or acidic, rare meats, and raw fruits and vegetables
Identify nutritional needs of the HIV patient.
Provide instructions for high-calorie, high-protein, high-potassium, low-residue diet. Suggest foods easy to swallow. Provide oral care before and after, Advise to avoid foods that are spicy or acidic, rare meats, and raw fruits and vegetables
Describe Kaposi's sarcoma.
Rare cancer of the skin and mucous membranes; Blue, red or purple raised lesions
Identify the body's second line of defense. Identify negative effects of cell mediated immunity.
Rejection of transplanted tissues, contact hypersensitivity reactions, and certain autoimmune diseases.
Identify factors influencing hypersensitivity.
Repeated exposure: In general, the more often the individual is exposed to the allergen, the greater the response.
Identify factors influencing hypersensitivity.
Route of allergen entry: Most allergens enter the body via gastrointestinal and respiratory routes. Exposure to venoms through bites or stings and injectable medications present a more severe threat of allergic response.
Identify the signs and symptoms of severe reactions.
Severe: Fever, chills, pain in the lower back, tightness in the chest, tachycardia, drop in B/P, and blood in the urine
Response mechanisms
Specific immune response: Humoral immunity, cellular immunity
Discuss the precautions necessary when providing care for an HIV infected patient.
Standard Precautions. Personal protective equipment; gloves, double bag
A 38-year-old patient is receiving 2 units of packed red blood cells at 125 mL/h. Fifteen minutes after the start of the blood transfusion, the nurse notes the following vital signs: pulse 110 beats/minute, respirations 28 breaths/minute, blood pressure 98/58 mm Hg, and temperature 101°F. The patient is shivering. What is the nurse's initial action?
Stop the infusion.
Fexofenadine (Allegra) nursing implications
Store in tight container at room temp. Teach patient and family to avoid driving or other hazardous activities if drowsiness occurs.
Discuss the effects of aging on the immune system.
Structural changes in the urinary system that lead to urinary retention or stasis increase the risk of urinary tract infection.
Describe what happens, the sequence of events, during a hypersensitivity reaction.
Sudden severe vasodilation as a consequence of chemical mediators from mast cells. Vasodilation causes an increase in capillary permeability, which causes fluid to seep into the interstitial space from the vascular space.
Hypersensitivity reaction Medical Management
Symptom management with medications, Environmental control, and immunotherapy
Identify the body's second line of defense. Discuss Cellular Immunity (cell mediated immunity).
T cells are sensitized to a particular antigen On contact with the antigen to which they are sensitized, they attach to the organism and destroy it.
Cells Acquired (Active)
T cells, B cells
Identify ways to prevent transfusion reactions.
The best method of preventing reactions is an autologous transfusion (i.e., use one's own blood) for replacement therapy.
Identify the body's first line of defense. Is it specific or nonspecific?
The body's first line of defense, innate immunity, provides physical, mechanical, and chemical barriers to invading pathogens and protects against the external environment. The innate system includes intact skin and mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestine and vagina. These organs, tissue, and secretions provide biochemical and physical barriers to disease. The first line of defense provides nonspecific immunity to the individual.
Discuss wasting syndrome.
The loss of lean body mass as a result of illness - has been a common clinical manifestation of HIV disease since early in the epidemic. Caused by disturbances in metabolism, which interfere with the effective use of nutrients, resulting in the loss of lean (muscle) body mass, often without reductionof body fat. Evidence of loss of 10%of body mass. Episodes of diarrhea for 30 days
Hypersensitivity reaction Nursing Interventions/Pt Teaching
The most effective treatment is environmental control, which includes avoidance of the offending allergen. Patient teaching should revolve around the specific diagnosis. Advise patient with seasonal allergies to avoid offending allergens and ensure that he/she understands the therapeutic medication plan. Focus on health promotion and health teaching for self-care management.
Discuss anaphylaxis
The most severe allergic reaction. Acute and potentially fatal hypersensitivity reaction to an allergen. Sudden severe vasodilation as a consequence of chemical mediators from mast cells. Severe apprehension, fear of impending death, pruritsis, angioedema, cyanosis, pallor, bronchospasm, wheezing.
Discuss the effects of aging on the immune system.
The older adult's immune system continues to produce antibodies; therefore immunization for diseases such as pneumonia and influenza is recommended.
What is the expanded definition of AIDS?
The patient is HIV positive with a CD4 + lymphocyte count lower than 200/mm 3 or has an AIDS-related opportunistic infection.
Discuss how latex may become aerosolized resulting in anaphylaxis.
Through powder on gloves and can result in serious reactions when inhaled by sensitized individuals
Identify the lymph organs.
Thymus, spleen, bone marrow, blood, and lymph
Discuss transplant rejection.
Tissue rejection occurs several days after blood supply is established.
What is the purpose of performing a viral load study once every 3 to 4 months in an HIV-positive person?
To determine the effectiveness of the medication regimen
Identify the three functions of the immune system.
To maintain homeostasis by removing damaged cells from the circulation, thereby maintaining the body's various cell types in an unchanged and uniform form.
Identify the three functions of the immune system.
To protect the body's internal environment against invading microorganisms b destroying foreign antigens and pathogens, thus preventing the development of infections.
Use your drug handbook and discuss the use of ketoconazole (Nizoral) in the patient with Candidiasis.
Topical Antifungal
Discuss Transfusion Reactions.
Transfusion reactions are labeled mild, moderate, and severe. The most severe reactions occur within the first 15 minutes, moderate reactions occur within 30 to 90 minutes, and mild reactions may be delayed to late in the transfusion or hours to several days after transfusion.
Anaphylactic reaction Signs & Symptoms
Uneasiness that increases to a sense of severe apprehension, fear of impending death, urticarial, pruritus, angioedema, cyanosis, pallor, congestion and sneezing, edema of lips, tongue, and the larynx with stridor and occlusion of the upper airways. Lower respiratory S & S occur soon thereafter and include bronchospasm, wheezing, and severe dyspnea, GI S & S nausea, vomiting, diarrhea to dysphagia and involuntary stools. Tachycardia, hypotension. May worsen to coronary insufficiency, vascular collapse, dysrhythmias, shock, cardiac arrest, respiratory failure, and death.
Diphenhydramine (Benadryl) Nursing implications
Use cautiously with central nervous system depressants, including alcohol; tell patient to avoid driving or hazardous activity because of drowsiness.
Discuss measures that may reduce allergic reactions to aerosolized latex proteins.
Use of powder free gloves
Discuss the use of plasmapheresis.
Used to treat autoimmune disease such as lupus, glomerulonephritis, myasthenia gravis, thrombocytopenic purpura, rheumatoid arthritis, and guillain barre. To remove pathologic substance present in plasma.
Hypersensitivity reaction Signs & Symptoms
Vasodilation, edema, bronchoconstriction, mucus secretion, and pruritus.
The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse incorporate in the plan during the bathing of this client?
Wearing a gown and gloves
The nurse gave an intramuscular penicillin injection to a patient. What assessment finding would be most indicative of a systemic anaphylactic response?
Wheezing
Discuss the effects of the compliment system.
When an antigen and antibody interact, the compliment system is activated. It functions in a "step-by-step" series much like the clotting mechanism, but with a different purpose. The complement system can destroy the cell membrane of many bacterial species, and this action attracts phagocytes to the area.
Discuss the role of phagocytes.
When organisms pass the epithelial barriers phagocytes become active. Phagocytes also migrate through the blood stream to the tissues for the body's second defense against disease. Phagocytes engulf and destroy microorganisms that pass the skin and mucous membrane barriers. These cells also assist in the immune response by carrying antigens to the lymphocytes.
Discuss what is meant by immunocompetence.
When the immune system responds appropriately to a foreign stimulus, the body's integrity is maintained; this is called immunocompetence. Immunocompetence is the immune system's ability to mobilize and use its antibodies and other responses to stimulation by an antigen.
According to the CDC's specific diagnostic criteria identify the changes that occur during the progression from HIV infection to AIDS.
a. WBC - Decreases b. Viral load (virus detectable in blood) - Increases c. CD8 count - Increases d. CD4 count - Decreases (less than 200)
Which immune disorder results from a failure to tolerate "self"?
autoimmune disorders.
Western blot test
confirmatory test for HIV
The nurse advises a friend who asks the nurse to administer his allergy injections that:
immunotherapy should be administered only in a setting where emergency equipment and drugs are available.
Which is another term for desensitization?
immunotherapy.
Identify the progression of HIV to AIDS in a timeline.
· The early symptomatic phase of HIV infection occurs when the CD4+ cell count drops below 500 cells/mm3 · Early symptoms include constitutional problems such as persistent, unexplained fevers, recurrent, drenching night sweats, chronic diarrhea, headaches, and fatigue · A physical exam may reveal persistent generalized lymphadenopathy · One of the most common infections seen in individuals with early symptomatic disease is oral candidiasis. · Neurologic manifestations of HIV disease occur in more than 90% of individuals who are infected. · AIDS is the acronym used to describe the end stage of the spectrum of HIV infection · CD4+ count decreases · The number of viruses detectable in the blood increases rapidly · Without treatment, the median time from an AIDS diagnosis to death average 1 to 3 years.
Identify ways to gain acquired immunity
Cellular immunity, also called cell-mediated immunity, is the mechanism of acquired immunity characterized by the dominant role of T cells. Cell-mediated immunity results when T-cells are activated by an antigen. Whole cells become sensitized in a process similar to that which stimulates the B cells to form antibodies. Once these T cells have been sensitized, they are released into the blood and body tissues, where they remain indefinitely. On contact with the antigen to which they are sensitized, they attach to the organism and destroy it. Cellular immunity is involved in resistance to infectious diseases caused by viruses and some bacteria.
Soluble factors Innate (Passive)
Chemical defense: Lysozyme, complement, acute-phase proteins, interferon
A patient receives a diagnosis of HIV disease. She visits the physician today for her prescriptions. What medication does the nurse expect the physician to order for the patient?
Combination of these drugs
A patient comes to the clinic for his weekly allergy injection. He missed his appointment the week before because of a family emergency. Which action is appropriate in administering the patient's injection?
Consult with the health care provider about decreasing the dose for this injection.
What diet should the patient with HIV follow?
High calorie, high protein, low residue
Identify factors influencing hypersensitivity.
Host response to allergen: The more sensitive the individual, the greater the allergic response.
What is responsible for causing the majority of HIV disease and AIDS?
Human immunodeficiency virus type 1
Discuss the effects of aging on the immune system.
Immune system functioning declines with advanced age. Research is continuing.
Identify ways to gain passive immunity
Immunity is provided by antibodies that are formed by one person in response to a specific antigen and administered to another person. Passive immunity can occur as antibodies pass through the placenta or through breast milk. Other examples of passive immunity include antivenom given after a snake bite and immunoglobulin administered after exposure to prevent infection.
Compare and contrast immunization and immunotherapy.
Immunization: Controlled exposure to develop antibodies Immunotherapy: Inject very diluted antigen (allergen) which increases weekly. To assist in building tolerance to the allergen (desensitization) Perennial therapy: is most widely accepted, because it allows for a higher cumulative dose, which produce a better effect up to 18 weeks or more.
The patient tells the nurse he is overwhelmed. There is so much he must do to keep his new kidney functioning, and then rejection may still occur. Which patient problem statement is appropriate?
Impaired Coping
The client brought to the emergency department is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action?
Maintaining a patent airway
The nurse is caring for a patient who has had a kidney transplant. What should be included in the care of a patient with a suppressed immune system?
Meticulous aseptic technique
Physical Barriers Acquired (Active)
NONE
Specificity Acquired (Active)
NONE
Specificity Innate (Passive)
NONE
Identify factors influencing hypersensitivity.
Nature of the allergen: Most allergic reactions are precipitated by complex, high-molecular-weight protein substances.
Discuss what happens when B cells encounter an antigen.
On first exposure to a given antigen, a primary humoral response is initiated. This response is generally slow compared with subsequent antigen exposures. When a second exposure occurs, memory B cells cause a quick response, regardless of whether the first exposure was to an antigen or to immunization.
Identify the origination of lymphocytes.
Originate from stem cells in the bone marrow and are initially similar in appearance. Some lymphocytes migrate to the thymus, where they mutate into T cells; others remain in the bone marrow, where - in humans- they develop into B cells.
Cells Innate (Passive)
Phagocytes, natural killer (NK) cells
Physical Barriers Innate (Passive)
Physical defense: Skin and mucous membranes. Mucous membranes line body cavities such as the mouth and stomach. These cavities secrete chemicals (saliva and hydrochloric acid) that destroy bacteria. Cilia, tears, and flora of the intestine and vagina also provide natural protection.
The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should determine that this has been confirmed by which finding?
Punch biopsy of the cutaneous lesions
The client is suspected of having systemic lupus erythematous (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of SLE?
Rash on the face across the nose and on the cheeks
A 72-year-old patient is admitted to the hospital with a diagnosis of immunodeficiency disease. What is the primary nursing goal?
Reduce the risk of the patient developing an infection.
Type I allergic reaction to latex is a response to the __________ __________ __________.
Rubber, Latex, Proteins
For most people who are HIV positive, marker antibodies are usually present 10 to 12 weeks after exposure. What is the development of these antibodies called?
Seroconversion
The health care provider asks the nurse to talk with a patient about how HIV is transmitted. Which routes of transmission are most important for the nurse to discuss with the patient?
Sexual intercourse, sharing needles, mother-to-child transmission
Discuss the effects of aging on the immune system.
Signs and symptoms of infection tend to be more subtle than those in younger individuals. Because older adults have decreased body temperature, fever may be more difficult to detect. Changes in behavior such as lethargy, fatigue, disorientation, irritability, and loss of appetite may be early signs of infection.
Discuss nursing interventions during immunotherapy.
The patient should be observed for at least 20 minutes after administration because a hypersensitivity reaction or anaphylaxis may occur. In the event of anaphylaxis during immunotherapy, the treatment protocol includes the administration of epinephrine chloride given subcutaneously.
Identify the three functions of the immune system.
To serve as a surveillance network for recognizing and guarding against the development and growth of abnormal cells. Abnormal cells (mutations) are being formed constantly in the body but are recognized as abnormal cells and are destroyed.
A patient experienced an anaphylactic reaction to an antibiotic. What are the correct nursing interventions for anaphylaxis? (Select all that apply.)
**Assess respiratory status frequently. **Maintain patent airway. **Administer epinephrine as ordered. **Monitor vital signs frequently.
A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse correctly recognizes which statement about the procedure? (Select all that apply.)
**Plasmapharesis will replace the plasma that contains antinuclear antibodies with a substitute fluid. **Plasma removed during the procedure will be replaced by normal saline.
Which illnesses are believed to be caused by an autoimmune disorder? (Select all that apply.)
**Rheumatoid arthritis **Systemic lupus erythematosus **Guillain-Barré syndrome
The student nurse is giving a presentation on the transmission of HIV to his class. The student is correct by sharing which information? (Select all that apply.)
**Risk for transmission of HIV is higher with anal intercourse than with other types of sexual intercourse. **People who use injection drugs and share needles have an elevated risk for being infected with HIV. **The leading mode of transmission of HIV worldwide is sexual intercourse, despite sexual preference.
Which statements describe innate, or natural, immunity? (Select all that apply.)
**The body's first line of defense against disease, which protects locally against the external environment **Includes stomach acid, saliva, and secretions/flora of the intestine and vagina **Responds with neutrophils, macrophages, and lymphocytes
Which interventions should be implemented in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.
**Use nonlatex gloves. **Use medications from glass ampules. **Do not puncture rubber stoppers with needles. **Keep a latex-safe supply cart available in the client's area.
The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which should be the appropriate nursing action?
Ask the client if they ever sustained a bee sting in the past.
The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching ?
"I should not use insect repellent because it will attract the ticks."
