Chapter 11 Care of Patients with Immune and Lymphatic Disorders (with HIV and AIDS) - PowerPoint Presentation

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Chapter 11Care of Patients with Immune and Lymphatic Disorders (with HIV and AIDS)

Copyright © 2017, Elsevier Inc. All rights reserved.Slide2

Discuss the key differences between primary and acquired immune deficiency disorders.Summarize the ideal actions of therapeutic immunosuppressive drugs.Illustrate the modes of transmission for HIV.Discuss how pre-exposure prophylaxis reduces the risk of contracting HIV.

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Theory ObjectivesSlide3

List diagnostic tests for HIV and those used to monitor the immune status of an HIV-positive patient.Determine opportunistic infections (viral, bacterial, fungal, parasitic) that occur in HIV patients.Give examples of autoimmune disorders or diseases within each of the three categories of autoimmune disorders.

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Theory Objectives

(Cont.)Slide4

Compare and contrast the two types of lymphoma, including how they are diagnosed.Explain why the process of diagnosis and treatment for fibromyalgia would be difficult or frustrating for the patient.Construct how an allergic reaction occurs during an excessive immune response.Relate the nurse’s role in helping the patient to control allergies.

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Theory Objectives

(Cont.)Slide5

Clinical Practice ObjectivesDuring a clinical rotation, review the facility's policy for exposure to blood or body fluids from an HIV-positive patient.List nursing measures for the prevention of infection for an immunocompromised patient.Perform data collection on a patient

in whom an immune-suppressant disorder is suspected.

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Clinical Practice Objectives (Cont.)Review a nursing care plan for a patient who has low immunity.Write nursing interventions for a patient with fibromyalgia.List the usual measures for treating an anaphylactic reaction and locate the necessary emergency equipment on your clinical unit.

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Immune Function and DysfunctionImmunocompetence – threat stimulates chemical, vascular – release of WBCsImmune deficiency – abnormal response of immune system due to infection, medical therapy, exposure to toxins

Autoimmune disorders- overreaction or hypersensitivity

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Immune Deficiency DisordersTwo forms of immune deficiencyPrimary: an inherited genetic mutation (see Box 11-1 page 217)Acquired:

Immosuppressants used for organ transplants/chemo reduces ability of the bone marrow to produce WBChuman

immunodeficiency syndrome (HIV) and acquired immune deficiency syndrome (AIDS)

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What are examples of automimmune disorders?Lupus – antibodies assault healthy cellsType 1DM - body attacks pancreatic cells that produce insulinSlide10

Immune Deficiency Disorders (Cont.)Diagnostic tests and treatment (Box 11-3 p. 218) CBC w/diff, RBC,

creatine level, antinuclear antibody, bone marrow studies, T-cell and B-cell assays, Enzyme linked immunosorbent assays (ELISA)

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What are some appropriate Nursing diagnosis for these patients?Altered activity intolerance r/t inflammatory nature of the disease

Chronic pain r/t inflammation from the disease processPotential for altered skin integrity r/t sun sensitivity from the disease processSlide12

Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS)HIV-1 and

HIV-2HIV1 – widespreadHIV 2- Western Africa, spreads at a lower rate, lower plasma viral load takes longer to incubate, lesser risk of developing AIDSPathophysiology

Retrovirus- RNA replicates itself in host cell’s DNA

Reverse

transcriptase – helps HIV replicate in host cells- attached to CD4 T cell wall receptors

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HIV Slide14

Transmission of HIVThe three highest risks for becoming infected with HIV include:Having unprotected sex (oral, vaginal, or anal) with an HIV-positive personSharing needles and syringes with an HIV-infected person

Maternal–fetal exposureOther possible risks are tattoos, body piercings, and blood products

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Exposure ProphylaxisPre-exposureTruvada (tenofovir disoproxil fumarate and emtricitabine) = PreP

Safe sexual practicesBlood products – all screened 1 in 1.5million chance to contract HIV

Vaccine

development – difficult because mutation rate- vaccine in development using stem cells from people immune to HIV

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Signs and SymptomsNo symptoms to flulike symptomsSentinel infections – opportunistic infections that indicate immunosuppression (oral thrush, night sweats, sig. unintended weight loss)Variable clinical presentations and latent periods without obvious symptoms

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DiagnosisHIV-1 Test System and OraQuick In-Home HIVEnzyme-linked immunosorbent assay (ELISA) positive confirmed by Western Blot

Western blot HIV gene sequence test25% of HIV infected patients are unaware they have it, all sexually active persons between 13 and 64 be HIV tested for their physical exam.

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ManagementCD4 lymphocyte count – if less than 350 patient begins antiretroviral therapy and prophylaxis for opportunistic infectionsWorld Health Organization (WHO) staging handout

Highly active antiretroviral therapy (HAART)

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Cultural ConsiderationsFactors that increase the incidence of HIV infection and progression to AIDS among minority groupsLack of culturally sensitive and high-quality information about HIV risk and prevention

Socioeconomic status and limited access to health careHealth beliefs concerning sexual practices, roles of women, the value of children, and HIV treatmentThe high cost of HAART

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Audience Response Question 1Which statement(s) regarding human immunodeficiency virus transmission is/are true? (Select all that apply.)

Breast milk can harbor the virus.Proper use of personal protective equipment reduces the

risk of disease transmission.

Needle

exchange programs facilitate the spread of

the

virus.

Needle-stick

injuries place health professionals at

risk

.

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Viral infectionsHerpes simplex virus type 1 and type 2Varicella zoster virusCytomegalovirusHepatitisBacterial infections

Mycobacterium tuberculosisMycobacterium avium complex

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Opportunistic

Infections (table 11-5

pg

226)Slide26

Opportunistic Infections (Cont.)Fungal infectionsCryptococcosisHistoplasmosis

CoccidiomycosisCandidiasisPneumocystis

jiroveci

Parasitic infections

Toxoplasmosis

Cryptosporidiosis

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Other ComplicationsWasting syndrome >10% weight lossNeoplasm (pg 226)

Kaposi sarcomaLymphomas – Non-Hodgkins Lymphoma most

commom

Neurologic

complications

HIV encephalopathy and AIDS-dementia

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Kaposi Sarcoma 28

More common in men than women infected with HIVSlide29

Audience Response Question 2In determining the optimal therapy for a patient infected with the human immunodeficiency virus, the physician considers which factor(s)? (Select all that apply.)

Clinical dataCompliance with therapy

Medication

tolerance

Insurance

coverage

Physician’s

expectations

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Assessment (Data Collection)History and physical assessmentFocused assessmentPsychosocial history

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PlanningPrevent secondary bacterial, viral, and fungal infections.Prevent wasting caused by malnutrition.Maintain or improve the present level of immune function.Maintain adequate social functioning.

Maintain or improve current mental status.

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ImplementationStandard PrecautionsPatient teachingCompromised immunity

Infection control in the homeWasting syndrome and nutrition

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EvaluationData collection and analysis at regular intervalsInclude patient participation.Patient and health care team expectations

Monitor tests to determine immune status, viral load, blood cell status, and effects of medications.

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Other Health IssuesHIV risk in the over-50 populationCommunity education and careHIV confidentiality and disclosureWhen a nurse is HIV positive

Blood-borne pathogen exposure and health care workersOccupational exposure to HIV

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Autoimmune DisordersThe immune system reacting against the body’s own cellsLocal, systemic, and mixed

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Signs and SymptomsMore than 80 disease are thought to be triggered by an alteration in immune function.

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DiagnosisHealth historyComplete physical examinationBlood tests

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Treatment and Nursing ManagementReplacement or support of lost body functionTherapies targeted to halt destructive process

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Systemic Lupus ErythematosusAutoimmune diseaseThe body produces abnormal antibodies that attack the target tissues instead of foreign agents.Discord, systemic, and drug-induced forms

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Etiology and PathophysiologyAbnormal reaction against proteins found in the nucleus of body cellsProlonged exposure to sunlightExacerbation by drugs

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Signs and SymptomsAll body systems can be affected.Weakness is a hallmark of SLE.

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DiagnosisNo single test that confirms a diagnosis of SLEMust have at least 4 or the 11 clinical presentations or laboratory test results

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TreatmentNo cureTargeted toward symptom control or management to prevent exacerbations

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Nursing Management 45

Caring for a patient with low

immune responseSlide46

Disorders of the Lymphatic SystemSlide47

Hodgkin LymphomaEtiologyPathophysiologySigns and symptoms

Diagnosis, treatment, and nursing managementRemission—disease is under controlRelapse—reappearance of cancer or abnormal cells

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Clinical Manifestations and Pathophysiology 48

From Black JM, Hawks JH: Medical-surgical nursing: Clinical management for positive outcomes, ed. 8, Philadelphia, 2009, Elsevier Saunders.Slide49

Staging 49

Adapted from Lewis SL,

Heitkemper

MM, Dirksen SR, et al. Medical-surgical nursing: assessment and management of clinical problems, 7th ed. St. Louis, 2007, Mosby.Slide50

Non-Hodgkin’s LymphomaEtiology and pathophysiologySigns and symptomsDiagnosis and treatmentNursing management

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Primary LymphedemaInherited form caused by a congenital condition in which there is deficient growth of the lymphatic system, especially in a lower extremityChiefly affects females and most often becomes apparent during the middle teens to early 20s

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Secondary LymphedemaAcquired form caused by an obstruction caused by trauma to the lymph vessels and nodesMastectomy with lymph nodes removedExtensive soft-tissue injury and scar formation

Parasites that enter lymph channels and block them

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Secondary Lymphedema (Cont.)Patients may present with a variety of symptoms, including restricted range of motion; heavy feeling; aching discomfort; recurrent infections; and thick, hard skin.Regardless of the etiology, treatment goals are to minimize the impact of the disease process on the individual.

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FibromyalgiaChronic systemic pain and multiple symptoms that not caused by another source or diseaseAffects women 10 times more than men and seen in women ranging from 25 to 60 years of ageStressors such as infection, trauma, drugs, hormonal influences, and psychological distress can trigger fibromyalgia and its related symptoms.

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The most common feature of this disorder is musculoskeletal pain.Hyperalgesia—heightened response to painful stimuliAllodynia—pain response to nonpainful stimuli

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Fibromyalgia

(Cont.)Slide56

Tender Points in Fibromyalgia 56

From

Freundlich

B,

Leventhal

L: Diffuse pain syndromes. In

Klippel

JH (Ed.): Primer on the rheumatic diseases, ed. 13, Atlanta, 2008, Arthritis Foundation.Slide57

SymptomsTension or migraine headachesJaw and facial tendernessInsomnia or waking up feeling just as tired as when the person went to sleepVertigo

Difficulty with concentration, memory recall, and performing simple mental tasksAnxiety, depression

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Symptoms (Cont.)Numbness or tingling in the face, arms, hands, legs, or feetSensation of swelling (without actual swelling) in the hands and feetAbdominal pain, bloating, nausea, and constipation alternating with diarrhea (irritable bowel syndrome)

Dysmenorrhea

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Symptoms (Cont.)Increase in urinary urgency or frequency (irritable bladder)Sensitivity to one or more of the following

OdorsNoiseBright lightsMedications

Certain foods

Cold

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Symptom ReliefAntidepressantsNonsteroidal anti-inflammatory drugs (NSAIDs)Narcotic pain relievers are not as effective.

Additional treatmentExerciseMassage therapy

Guided imagery

Dietary changes

Referral to a mental health provider

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Nursing ResponsibilitiesDetailed assessment of symptoms’ history and documenting what the patient has already tried to alleviate them

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AllergyAllergy isAn abnormal response to certain substancesConsidered a systemic immune disorder rather than localized oneThe reaction can be seen or expressed in multiple body systems.

Allergens can enter the body in several ways and can have either a local or a systemic effect.

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Allergy (Cont.)Etiology and pathophysiologySigns and symptomsDiagnosis

Radioallergosorbent test (RAST)Skin test

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Allergy (Cont.)Drug allergiesFood allergiesTreatment

Limit exposure to allergensDrug therapyDesensitization

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HypersensitivityHypersensitivity reactions, better known as allergic reactions, are the body’s excessive response to a normally harmless substance.The severity of the condition can range from a mild rash to life-threatening anaphylaxis.

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Etiology and PathophysiologyType I hypersensitivity—immediate hypersensitivity reactions that are mast cell–mediatedType II hypersensitivity—delayed-reaction allergies involving T cells

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DiagnosisRASTSkin testing—scratch test and patch test

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Primary Allergic ConditionsAnaphylaxisAngioedemaAsthmaAtopic dermatitis (eczema)Food allergy or intolerance

Perennial allergic rhinitis or sinusitisSeasonal allergic rhinoconjunctivitis (hay fever)Urticaria

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Four Broad Categories of AllergensContactantsIngestantsInhalantsInjectables

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Assessment (Data Collection)GeneralHistory of food intolerances, colic, abdominal cramping, bloating or pain, vomiting, and diarrhea in the absence of general illnessHistory of unusual reaction to any drug, insect sting, odor, or fumes

History of recurrent respiratory problems or seasonal flare-ups of any symptomsHistory of fatigue, wheezing, or shortness of breath upon exertion

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Assessment (Data Collection) (Cont.)SkinItching, burning, dryness, scaling, irritations, inflammations, rash (note symmetry and location), scratches, or

urticariaEyesBurning, itching, tearing, history of styes

Redness, discoloration below eyes (allergic shiners), conjunctivitis, rubbing, or excessive blinking

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Assessment (Data Collection) (Cont.)NoseHistory of nose twitching, stuffiness, recurring nosebleeds, sudden episodes of sneezing or snorting

Allergic salute (pushing nose upward and backward with heel of hand), nasal polyps, nasal voice

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Assessment (Data Collection) (Cont.)Mouth and throatOpen-mouth breathing, continual throat clearing, mouth wrinkling with facial grimaces, redness of throat, swollen lips or tongue

EarsHistory of hearing loss, drainage from earsNeck

Palpable, enlarged lymph nodes

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Nursing ImplicationsAssist in the diagnosis of hypersensitivity.Help the patient identify the particular substance or substances that trigger an allergic response.Assist the patient in devising ways to avoid or at least limit exposure to these allergens.

Relieve the symptoms of an allergy.

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Anaphylactic Reaction and Anaphylactic ShockIgE-mediated immune responsesIf the mast cells depend on IgE to be activated, they typically are triggered to produce only a localized allergic response.

Examples of this are allergic conjunctivitis or allergy-induced asthma.Non-IgE

allergen response

Iodine-based dyes for select radiologic studies

Select narcotics such as morphine and

vancomycin

, especially if administered too rapidly

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Signs and SymptomsUrticaria (hives)AngioedemaSwelling beneath the skin

WhealsSmall areas of swelling that itch and burnMay appear without subsequent anaphylaxis

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Effects of Anaphylaxis 77

From Van Meter KC, Hubert RJ: Gould’s

pathophysiology

for health professions, ed. 5, Philadelphia, 2015, Elsevier Saunders.Slide78

Treatment of AnaphylaxisEstablish a patent airway.Administer oxygen.Administer intravenous epinephrine.Administer antihistamine.

Institute measures to prevent or control shock.Provide psychological support during the course of the syndrome and its treatment.

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