-
Small organ located just behind the breastbone (where T-Cells Mature)
Thymus
-
Organs of the Immune System
Tonsils/Adenoids
Lymph Nodes and Lymphatic Vessels
Thymus
Spleen
Appendix
Peyer's Patches
Bone marrow
-
Small bean shaped structures that produce and store cells that fight infection and disease...they get larger with infections and feel sore
Lymph Nodes
-
Yellow tissue in center of bones that is responsible for making WBCs that are destined to become lymphocytes
Bone Marrow
-
Largest lymphatic organ in the body...contains WBCs that fight infection/disease...also helps control amount of blood in your body
Spleen
-
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
-
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
-
Genetic Immunodeficiency Disorders
Primary (may affect phagocytic function, B cells or T cells, of the complement system)
Born with deficiencies
-
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)
-
Primary Immunodeficiencies are usually seen in:
Infants and young children
-
Manifestations of Primary Immunodeficiencies:
Severe or recurrent infections, failure to thrive or poor growth, positive family hx
-
Potential complications of Primary Immunodeficiencies:
- Recurrent, Severe, Potentially fatal infections;
- Related blood dyscrasias or malignancies
-
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
-
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)
-
Most common primary immunodeficiency seen in adults
Hypogammaglobulinemia
CVID (common variable immunodeficiency)
MG (medical management with IV immunoglobulin)
-
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
-
Preferred gamma globulin given to adults with PI
IgG
-
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
-
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
-
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
-
Secondary Immunodeficiency is ___ common than primary immunodeficiency:
MORE
-
Common causes of secondary immunodeficiency:
- stress
- burns
- uremia
- diabetes
- autoimmune disorders
- viruses
- exposure to immunotoxic medications
- alcohol misuses
-
Best known secondary immunodeficiency:
HIV (human immunodeficiency virus)
-
People with Secondary Immunodeficiency are considered:
immunocompromised hosts
-
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
-
Group of chronic disorders characterized by diffuse inflammation and degeneration in the connective tissue
Diffuse Connective Tissue Diseases
-
Rheumatic Diseases are marked by:
- Inflammation
- Autoimmunity
- Degeneration
-
Most cases of SLE (systemic lupus erythematosus) occur in _____
women of childbearing years
African, Asian, Hispanic, and Native Americans (3x more likely than whites)
-
SLE (Systemic Lupus Erythematosus) most commonly affects the:
- Skin/Muscles
- Linings of the Lungs
- Heart
- Nervous Tissue
- Kidneys
-
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
-
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
-
-
"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
-
Usual first sign of lupus:
Joint/Muscle pain
-
Difference between joint pain in Lupus and Rheumatoid Arthritis:
Pain with Lupus comes and goes and does not cause permanent joint damage
-
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
-
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
-
Lab to Dx Lupus:
THERE IS NO SINGLE BLOOD TEST THAT CAN DETERMINE LUPUS!
-
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
-
Collaborative Therapy for Systemic Lupus
- NSAIDS for mild disease
- Steroid-sparing drugs (methotrexate)
- Antimalarials
- Corticosteroids
- Immunosuppresive drugs
-
People that have SLE are at great risk for:
CARDIOVASCULAR disease
-
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
-
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)
-
5 Things that can trigger LUPUS flare
Infection (cold/flu)
Stress (emotional/physical...)
Pregnancy (directly after birth of baby)
Sunlight
Starting/Stopping new drug
-
Chronic autoimmune disease in which a person's WBCs attack their moisture producing glands (4 million americans)
Sjogren's Syndrome
-
S/S of Sjogren's Syndrome
Dry Eyes/ Dry Mouth
-
A person with one autoimmune disease often has ____
Several autoimmune diseases
-
Medications given to treat Dry Mouth (Sjogrens Syndrome)
- Salagen- 5-10mg TID
- Evoxac- 30mg TID
- Salivart- PRN
- Biotene -PRN
- Moi-Stir Solution- PRN
-
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
-
Treatment for Primary Raynaud's
- Lifestyle Modifications:
- -avoid cold exposure
- -sufficient protection
- -smoking cessation
- -avoidance of sympathomimetic drug
- Topical Nitrates
- Long acting CCB
-
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)
-
Nursing Dx for Raynaud's
Acute/Chronic Pain
Fatigue
Impaired Physical Mobility
Disturbed Body Image
Ineffective Coping
Complication secondary to effect of medications
-
Mothers with HIV/AIDS _____ have babies when on medication and not pass it to their child
CAN
-
HIV attack the ___ cells and uses them to make copies of itself
T-Cells
-
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)
-
Ways HIV can be transmitted:
- Sex
- Pregnancy/Childbirth/Breast Feeding
- Injection Drug Use
- Occupational Exposure (MD/Nurse)
- Blood Transfusion/Organ Transplant
-
Many HIV people ____ have symptoms...often people only begin to feel sick when they progress toward AIDS
Do Not
-
As early as ___ weeks after exposure to HIV people, people can experience ARS (Worst Flu Ever)
2-4 weeks
-
After the initial HIV infection, the virus becomes less active in the body....this period can last ____
Up to 10 Years
-
Most severely affected people with HIV
Gay/Bisexual Men (all races)
-
_ in 5 living with HIV is unaware of their infection
1
-
The CDC recommends you get tested for HIV if you have more than 1 partner every ____
3-6 months
-
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)
-
Prevention of HIV:
- Standard Precautions
- Safer Sex practices and safer behaviors
- Do not share drug injection equip
- Blood screening and treatment of blood products
-
___ can be used to treat people who may have been exposed to HIV by accident/in the healthcare field
PEP
-
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
-
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
-
Normal amount of T-Cells
500-1,000
-
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
-
-
Once you have HIV+, you are ____ +
ALWAYS....but does not mean you have AIDS
-
Stages of HIV disease
Primary infection
HIV asymptomatic
HIV symptomatic
AIDS
-
Stage of HIV disease: 2 weeks- 6 months
Infection
-
IAcute phase of HIV infection
Large amounts of virus are being produced in body
Flu-Like Symptoms
-
A person is dx as having AIDS when the CD4 falls below:
200
-
Without treatment, an HIV (AIDS) patient will typicall survive:
3 years
-
Large viral levels in the blood for 2-3 weeks
- Viremia
- (transmission is more likely when viral load is high)
-
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)
-
Major consequence of rapid replication during HIV primary infection:
Errors occur during the copying process causing mutations that contribute to treatment difficulties
-
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
-
Asymptomatic HIV is a CDC category:
A
(Public Health Problem!)
-
Labs for Asymptomatic HIV
>500 CD4 + T lymph
-
Median interval between untreated HIV infection and dx of AIDS:
11 years
-
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
-
AIDS is classified as category:
C
-
Labs for AIDS
<200 CD4 + Tcells
-
1/4 of people living with HIV are older than ___ years
50
-
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
-
Only sure method to determine HIV infection:
- TESTING
- (CDC recommends people 13-64 should be tested)
-
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
-
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)
-
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
-
Lab tests for Dx and Tracking HIV
EIA
Western Blot
Viral Load (measures HIV RNA in plasma)
CD4/CD8
OraQuick (in home)
-
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
-
Main goals of treatment for HIV:
Decrease viral load
Maintain/Raise CD4 counts (under 200 = AIDS)
Delay HIV-related sx and opportunistic infections
-
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
-
Adherence to HIV drug regimens is critical to prevent:
Disease Progression
Opportunistic Disease
Viral Drug Resistance
-
Short Term S/E of HIV Drugs
- Anemia
- Diarrhea
- Dizziness
- Fatigue
- H/A
- Nausea and Vomiting
- Pain and Nerve problems
- Rash
-
Common Long Term s/e of HIV drugs
Lipdystrophy
Insulin Resistance
Lipid abrnomalities
Decrease in bone density
Lactic acidosis
-
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
-
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
-
Increases in cholesterol or triglycerides...lab tests (cholesterol/triglycerides) are best indicators
Lipid Abnormalities
-
Build up of lactate (waste product)...can cause problems ranging from muscle aches to liver failure. ALERT IMMEDIATELY
Lactic Acidosis
-
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
-
When viruses take advantage of the weakened immune system
- opportunistic infections
- (harmless viruses to "healthy" people)
-
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
-
Type of Resp Infections common in HIV patients
Pneumocystis Pneumonia
Mycobacterium Avium Complex
TB
-
GI Opportunistic Infection from HIV/AIDS
Oral Candidiasis (treat with Mycelex, Nystatin, Ketoconazole)
Diarrhea (octreotide acetate)
Wasting Syndrome
-
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)
-
Manifestation of HIV/AIDS: Neuro
Peripheral neuropathy
HIV encephalopathy
Cryptococcus Neoformans
Progressive multifocal leukoencephalopathy
Depression
-
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)
-
Main Goals of AIDS
Keep viral load low
Maintain immune function
Improve QOL
Prevent opportunistic disease and new infections
Reduce disability
Prevent new infections
-
Interventions for AIDS
Adhere to drug regimen
Promote healthy lifestyles
Prevent transmission
Have supportive relationships
-
Blood Types
- A (A antigen, B antibody)
- B (B antigen, A antibody)
- AB (AB antigens, NO antibodies)
- O (No antigens, AB antibodies)
-
-
-
Test to evaluate Rh status
Coombs test
-
An RH- can give to either ___ or ___ patients
+ or -
-
An RH+ can only give to ____ patients
RH +
-
Acute blood transfusion reactions
- Acute hemolytic reactions
- Febrile reactions
- Allergic reactions
- Circulatory overload
- Sepsis
- Delayed transfusion reactions
-
Delayed blood transfusion reactions:
Infection
-
-
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!)
-
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
-
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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