Chapter 20: Care of Patients with Immune Functions Excess

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1

Hypersensitivity or Allergy

Is excessive inflammation occurring in response to the presence of an antigen to which the patient usually has been previously exposed.

2

Antigen

Foreign protein or allergen

3

Type I: Rapid Hypersensitivity Reactions; Atopic Allergy

This type results from the increased production of the immunoglobulin E (IgE) antibody class.

4

Inhaled Allergens

Plant pollens, fungal spores, animal dander, house dust, grass, ragweed

5

Ingested Allergens

Foods, food additives, drugs

6

Injected Allergens

Bee venom, drugs, biologic substances such as contrast dyes

7

Contacted Allergens

Latex, pollens, foods, environmental proteins

8

Anaphylaxis

Reactions that involve all blood vessels and bronchiolar smooth muscle causing widespread blood vessel dilation, decreased cardiac output, and bronchoconstriction.

9

Rhinorrhea

Some reactions occur just in the areas exposed to the antigen, such as the mucous membranes of the nose and eyes, causing symptoms of sneezing, and itchy, red, watery eyes.

10

Allergic Rhinitis or Hay Fever

Is triggered by immunity and inflammation reactions to airborne allergens, especially plant pollens, molds, dust, animal dander, wool, food, and air pollutants, may be "seasonal".

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Chronic Rhinitis or Perennial Rhinitis

Occurs intermittently (with no predictable seasonal pattern) or continuously when a person is exposed to certain allergens.

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Primary Phase

The allergen binds to two adjacent IgE molecules on the surface of a basophil or mast cell, which breaks the cell membrane.

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Secondary Phase

Results from the release of other cellular proteins.

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Histamine

A short-acting biochemical causes capillary leak, nasal and conjunctival mucus secretion, and itching (pruritus), often occurring with erythema (redness).

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History of Allergies

Ask the patient to describe the onset and duration of problems in relation to possible allergen exposure, work, school, and home environments and about possible exposures through hobbies, leisure time, or sports activities.

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Physical Assessment/Clinical Manifestations

The patient with allergic rhinitis has rhinorrhea (a “runny” nose), a “stuffy” nose, and itchy, watery eyes.

17

Laboratory Assessment

A white blood cell (WBC) count and differential indicate the presence of excess immunity with an allergic response by an increase in eosinophils.

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Allergy Testing

  • Skin testing
  • Patch testing
  • Scratch or prick test
19

Skin Testing

Is performed as scratch testing or intradermal testing.

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Patch Testing

Is often reserved for contact dermatitis.

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Scratch or Prick Test

Can show an immediate hypersensitivity reaction to an allergen and is used in routine allergy testing for type I reactions, cause a localized reaction (wheal) when the test result is positive.

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Patient Preparation to Allergy Testing

Systemic glucocorticoids and antihistamines are discontinued 2 weeks before the test to avoid suppressing the test response. Nasal sprays to reduce mucous membrane swelling are permitted, except for sprays that contain an antihistamine.

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Intradermal Testing

Is reserved for substances that are strongly suspected of causing allergy but did not test positive with scratch testing.

24

Oral Food Challenges

Is used to identify specific allergens if skin testing is not conclusive and if keeping a food diary has failed to determine the offending food items.

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Interventions

  • Avoidance therapy
  • Drug therapy
  • Complementary therapies
  • Desensitization therapy
26

Avoidance Therapy

Can be successful when specific allergens have been identified, educate to not have close contact with these agents.

27

Drug Therapy

This therapy involves the use of steroidal and nonsteroidal agents (to reduce inflammation), vasoconstrictors, antihistamines, and mast cell stabilizers, that inhibit the release or action of leukotrienes.

28

Decongestants

Are available as systemic oral drugs or nasal sprays, they work by causing vasoconstriction in the inflamed tissue, thereby reducing the edema.

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Antihistamines

Block histamine from binding to the receptor, this action prevents vasodilation and capillary leak.

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Corticosteroids

Decrease inflammation and excess immunity in many ways, one of which is by preventing the synthesis of mediators, can prevent the symptoms of rhinitis.

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Mast Cell Stabilizing Drugs

Include nasal sprays, such as cromolyn sodium (Nasalcrom), that prevent cell membranes from opening when an allergen binds to IgE.

32

Leukotriene Antagonists

May be used to manage and prevent allergic rhinitis.

33

Complementary and Alternative Therapies

Have helped some patients with rhinitis obtain relief, especially through the use of aromatherapy.

34

Desensitization Therapy

Commonly called “allergy shots,” may be needed when allergens are identified and cannot be avoided easily.

35

Anaphylaxis

Clinical Criteria 1

Onset within minutes to hours of skin or mucous membrane problems involving swollen lips, tongue, soft palate, uvula; widespread hives; pruritus; or flushing.

36

Anaphylaxis

Clinical Criteria 2

Onset within minutes to hours of two or more of these symptoms after a patient has been exposed to a potential allergen: skin or mucous membrane problems, respiratory distress or ineffectiveness, hypotension, or persistent GI problems.

37

Anaphylaxis

Clinical Criteria 3

Onset within minutes to hours of hypotension with systolic blood pressure lower than 90 mm Hg or 30% lower than the patient's baseline systolic pressure.

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Angioedema

Diffuse swelling of the eyes, lips, or tongue

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First-Line Drug

  • Epinephrine (Adrenalin)
  • Isoproterenol (Isuprel)
  • Ephedrine sulfate (Vatronol)
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Epinephrine (Adrenalin)

Rapidly stimulates alpha- and beta-adrenergic receptors of autonomic nervous system (alpha: vasoconstriction; beta: bronchodilation).

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Isoproterenol (Isuprel)

Stimulates beta-adrenergic receptors, relaxing bronchial smooth muscles and dilating vessels.

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Ephedrine sulfate (Vatronol)

Similar to isoproterenol but with longer duration of action.

43

Second-Line Drugs

  • Diphenhydramine HCl (Allerdryl, Benadryl)
  • Hydrocortisone sodium succinate (Solu-Cortef)
    • Dexamethasone (Decadron)
    • Methylprednisolone sodium succinate (Solu-Medrol)
    • Prednisone (orally)
44

Diphenhydramine HCl (Allerdryl, Benadryl)

Competes with histamine for H1 receptors on effector cells, thus blocking effects of histamine on bronchioles, gastrointestinal tract, and blood vessels.

45

Hydrocortisone sodium succinate (Solu-Cortef)

Dexamethasone (Decadron)

Methylprednisolone sodium succinate (Solu-Medrol)

Prednisone (orally)

Anti-inflammatory—inhibits production of many inflammatory mediators; inhibits mast cell degranulation.

46

Support Drugs

  • Norepinephrine (Levophed)
  • Dopamine (Intropin)
47

Norepinephrine (Levophed)

Raises blood pressure and cardiac output in severely decompensated states.

48

Dopamine (Intropin)

Raises blood pressure and cardiac output in severely decompensated states.

49

The client having an intravenous injection of radiocontrast material (dye) for an angiogram starts to have skin wheals at the injection site and difficulty breathing. What is the nurse's best first action?

Stop the infusion of the contrast material.

50

With which client is it most important for the nurse to use latex-free gloves?

28-year-old woman with spina bifida

51

Type II: Cytotoxic Reactions

The body makes autoantibodies directed against self cells that have some form of foreign protein attached to them.

52

Type III: Immune Complex Reactions

Excess antigens cause immune complexes to form in the blood.

53

Serum Sickness

A group of manifestations that occurs after receiving serum or certain drugs.

54

Type IV: Delayed Hypersensitivity Reactions

Sensitized T-cells (from a previous exposure) respond to an antigen by releasing chemical mediators and triggering macrophages to destroy the antigen.

55

Positive Purified Protein Derivative (PPD) Test for Tuberculosis (TB).

An intradermal injection of this agent causes sensitized T-cells to clump at the injection site, release lymphokines, and activate macrophages, usually see result in 24-72 hours.

56

Autoimmunity

In this response, antibodies or lymphocytes are directed against healthy normal cells and tissues.

57

Sjögren's Syndrome (SS)

A group of problems that often appear with other autoimmune disorders. Problems include dry eyes, dry mucous membranes of the nose and mouth (xerostomia), and vaginal dryness.

58

Goodpasture's Syndrome

An autoimmune disorder in which autoantibodies attack the glomerular basement membrane and neutrophils. The two organs with the most damage are the lungs and the kidneys.

59

A client recently admitted to the hospital with a UTI is to receive the first dose of an antibiotic intravenously. Before checking the five rights prior to administration, what is the nurse’s first action?

Review the clinical records and ask the client about any known allergies.

60

Assessment findings reveal that a client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client?

Communicate the need for avoidance therapy to the health care team.

61

The nurse is reviewing discharge teaching with a client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching?

"I am immune to bee stings now that I have had a reaction.”

62

A client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client’s discharge teaching plan?

Remove cloth drapes, carpeting, and upholstered furniture.

63

When preparing a client for allergy testing, the nurse provides the client with which instruction?

“Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response.”

64

The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity?

“The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation.”

65

The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. Zafirlukast works by which mechanism?

Blocking the leukotriene receptor

66

The nurse plans to assess a client with type I hypersensitivity for which clinical manifestation?

Allergic asthma

67

An alert, middle-aged client is admitted to the emergency department with wheezing, difficulty breathing, angioedema, blood pressure of 70/52 mm Hg, and apical pulse of 122 beats/min and irregular. The nurse makes an immediate assessment using the “ABCs” for any client experiencing anaphylaxis. What nursing intervention is the immediate priority?`

Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.

68

A client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation?

Epinephrine (Adrenalin)

69

The client with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed?

Zafirlukast (Accolate)

70

A client who is receiving an intravenous antibiotic begins to cough and states, “My throat feels like it is swelling.” Which action does the nurse take next?

Discontinue infusing the antibiotic.

71

Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant?

Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.

72

The nurse is reviewing the medical record of a client who is prescribed a decongestant. The nurse plans to contact the client’s health care provider if the client has which condition?

Hypertension

73

A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse?

Stridor

74

A client has been ordered norepinephrine (Levophed) for treatment of severe hypotension. The nurse plans to monitor the client for which adverse effect?

Headache

75

A client is admitted to the hospital with suspected Goodpasture’s syndrome. Which findings does the nurse expect to observe?

Hemoptysis

76

The nurse is assessing a client with suspected serum sickness. Which symptoms are consistent with serum sickness? (Select all that apply.)

  • Arthralgia
  • Lymphadenopathy
  • Malaise
77

A client is prescribed prednisone for treatment of a type I hypersensitivity reaction. The nurse plans to monitor the client for which adverse effects? (Select all that apply.)

  • Fluid retention
  • Gastric distress
  • Infection
  • Osteoporosis