1

Nursing Care of Clients with Infection I. Immune System A. Composition Specialized cells, tissues, and organs located throughout body including 1. White blood cells 2. Thymus and bone marrow 3. Spleen, lymphoid tissues and lymph nodes, tonsils . !ey "unctions 1. #e"ends against pathogens$ bacteria, %iruses, "ungi, parasites 2. &emo%es and destroys dead or damaged cells 3. 'denti"ies and remo%es malignant cells (pre%ention o" tumors) C. Acti%ation$ &esponse to some type o" minor or ma*or in*ury 1. +onspeci"ic$ in"lammation that pre%ents or limits entry o" in%ader,in*ury (local) 2. Speci"ic$ immune response acts when in"lammation unable to destroy organisms (systemic) #. White lood Cells (W C) or -eu.ocytes 1. /roduced in bone marrow 2. 0o%e through body %ia blood stream and through tissue spaces 3. 1eneral "unction$ able to distinguish body2s own cells "rom "oreign cells and attach and remo%e "oreign cells or own body2s damaged cells 3. 0easurement o" total W C a. /art o" Complete lood Count (C C) b. +ormal W C count$ 3455 6 15,555 , mm3 c. -eu.ocytosis$ W C 7 15,555 d. -eucopenia$ W C 8 3455 4. Types o" W C a. 0a*or groups are granulocytes, monocytes, lymphocytes b. 0easurement$ W C #i""erential 1. Short name$ 9di"": 2. Count o" 155 W C sorted into the di""erent types 3. Translates into percentage per type 3. Signi"icance a. 'denti"ies portion o" total W C made up o" each speci"ic type b. 1i%es assessment data as to status o" immune system and its response to an in*ury; clues as to in"ection, in"lammation c. Types o" W C listed in di""erential 1. +eutrophils (also .nows as polymorphonuclear leu.ocytes (/0+s) or polys ) a. 44 < =5> total circulating leu.ocytes b. -i"e span is hours to days c. /rotect against pathogens, speci"ically bacteria d. Types o" neutrophils 1. Segmented (9segs:)$ mature, normally 44> o" W C 2. ands$ immature neutrophils, normally 4> o" W C e. 'ncreased le%el$ acute in"lammation or in"ection (bacterial) 2. ?osinophils a. 1 < 3> total circulating leu.ocytes b. @ound in large amounts in respiratory and 1' tract c. /rotect against parasitic worms and in%ol%ed in hypersensiti%ity 3. asophils a. 5.4 < 1> total circulating leu.ocytes b. Contain protein and chemicals including heparin, histamine, that are released during hypersensiti%ity reactions, stress 3. 0onoctyes$ largest o" W C a. 2 <3> total circulating leu.ocytes
Joyce Hammer 12/10/2013

2
b. 0igrate to tissues and can li%e "or years c. 0ature into macrophages in tissue lungs, connecti%e, li%er, etc. d. /hagocytic against large "oreign particles and cell debris e. #e"ense against chronic in"ections such as tuberculosis, %iral in"ections 4. -ymphocytes a. 25 6 35> o" total circulating leu.ocytes b. ?""ectors and regulators o" speci"ic immune responses c. 'mmune sur%eillance$ monitor "or and destroy cancerous cells d. Circulate constantly, but concentrate in lymphoid tissues including lymph nodes e. #i""erential only loo.s at total lymphocyte percentage ". 3 di""erent types o" lymphocytes which wor. together$ 1. T -ymphocytes (mature in thymus gland) 2. -ymphocytes (mature in bone marrow) 3. +! cells (natural .iller cells)$ immune sur%eillance II. Nonspecific Inflammatory Response A. arrier protection$ body2s "irst line de"ense against in"ection includes 1. 'ntact s.in 2. 0ucus o" mucous membranes 3. actericidal action o" body "luids . 'n"lammation$ nonspeci"ic immune response 1. +onspeci"ic$ localized, generally same with all types o" in*ury 2. Stages o" in"lammatory response$ a. Aascular response$ %asodilatation leading to redness, warmth, swelling; three types o" eBudate$ "luid "rom capillaries into tissue 1. Serous (plasma) 2. SanCuineous (mainly red blood cells) 3. Serosanguineous (miBture) b. Cellular response and phagocytosis$ margination and wbc2s to area c. Tissue repair healing$ o%erlap o" in"lammation and healing 3. Cardinal signs o" in"lammation$ erythema (redness), warmth, swelling, pain, loss o" "unction 3. Acute or Chronic a. Acute 1. Short term, 1 6 2 wee.s 2. 'n*urious agent remo%ed 3. Dealing occurs with tissue repair or scarring b. Chronic 1. Slower onset, months 6 years 2. #ebilitating with se%ere tissue damage C. Wound Dealing 1. /hases a. 'n"lammation$ debridement occurs, wound prepared "or healing b. &econstruction$ damaged tissue regenerates 1. &esolution$ original structure and "unction result 2. &epair$ replacement o" destroyed tissue by collagen scar tissue 2. &eCuirements a. AdeCuate nutrition b. AdeCuate blood supply c. AdeCuate oBygenation 3. Ether 'nter"ering @actors a. Chronic diseases, e. g. diabetes b. #rug therapies, e.g. corticosteroids c. 'n"ection
Joyce Hammer 12/10/2013

3
III. Immune Response A. #e"inition o" 'mmunocompetent$ client has immune system that identi"ies antigen and destroys or remo%es it; healthy immune response . Characteristics o" healthy immune response 1. Sel"<recognition 2. Speci"ic 3. Systemic 3. Das memory (with "irst eBposure, change in host occurs; repeated eBposures produces more rapid response) C. Types o" 'mmune &esponses 1. Antibody<0ediated 'mmune &esponse (Dumoral &esponse) a. Antigen is bacteria, bacterial toBin, or "ree %irus b. <lymphocyte produces antibody to speci"ic antigen c. Antibody (immunoglobulin) binds with antigen to inacti%ate it d. 4 classes o" immunoglobulins are 'g1, 'gA, 'g0, 'g#, 'g? e. Antibody 6medicated response occurs in 2 phases 1. 'nitial eBposure$ primary response de%elops a. -ag time "rom eBposure to antibody de%elopment b. Antibodies de%elop, pea. and person reco%ers 2. Secondary eBposure$ with repeat eBposure to antigen, memory cells cause immediate rise in antibodies and pre%ent disease "rom occurring again 2. Cell<0ediated 'mmune &esponse (Cellular &esponse) a. Antigen is a %iral<in"ected cell, cancer cell, some bacteria, or "oreign tissue b. T<lymphocytes inacti%ate antigen without antibody "ormation 1. ?""ector T cell$ cytotoBic cell binds with sur"ace antigen on "oreign cell or %irus< in"ected cell and destroys it 2. &egulator T cells include$ a. Delper T cell$ acti%ates cells "or antibodies; assists cytoBic T cells b. Suppressor T cell$ pro%ides negati%e "eedbac. and stops immune process c. Cell<mediated has memory$ T cells respond to repeat eBposure to antigen IV. Immunity: Protection of body from disease A. Types 1. Acti%e$ body produces antibodies or de%elops immune lymphocytes against speci"ic antigens 2. /assi%e$ antibodies are administered to the client; e""ect temporary 3. +atural$ client contacts antigen, de%elops the disease, reco%ers, and is immune 3. AcCuired$ antigen introduced into client to stimulate immune system to "orm antibodies and memory cells but not the actual disease 4. ?Bamples$ a. +atural Acti%e$ client had chic.en poB, de%eloped antibodies, is immune b. AcCuired Acti%e$ Tetanus ToBoid gi%en to client; client "orms antibodies against tetanus c. +atural /assi%e$ maternal antibodies passed to in"ant through breast mil. d. AcCuired /assi%e$ Tetanus 'mmune 1lobulin (Dypertet)$ antibodies gi%en to client who has not recei%ed prior immunizations against tetanus . Collaborati%e Care 1. Teaching and administration o" immunizations, %accines 2. Adherence with recommended schedules "or immunization (&ecommendations sub*ect to change, .eep current) 3. &ecommendations "or speci"ic groups, e.g. health care wor.ers at ris., Depatitis %accine; elderly, chronically ill, in"luenza %accine; tra%elers to "oreign countries, speci"ic disease (typhoid "e%er) %accine 3. Administration o" immunizations$
Joyce Hammer 12/10/2013

4
a. Chec. client allergies, no upper respiratory in"ection b. +o li%e %irus %accines to immunosuppressed or those in household 4. @ollow directions regarding administration (routes, sites), use uneBpired %accines(label %ials when opened, document %ial number) V. Management of Client with Inflammation A. #iagnostic Testing$ 1. White lood Cell Count with #i""erential a. Total W C count$ increase (acute in"lammation or in"ection) or decrease (consider immunosuppression) b. #i""erential$ consider increases or decreases with speci"ic cell type 2. ?rthrocyte Sedimentation &ate (?S&) a. +onspeci"ic b. ?le%ated with in"lammation 3. C<reacti%e /rotein (C&/) Test a. +ormal is negati%e b. Tests "or presence o" protein "rom li%er c. 'ndicati%e o" acute or chronic in"lammation 3. Serum /rotein a. +ormal %alues 1. Total protein$ F 6 G g,d2. Albumin$ 3.2 6 3.4 g,d3. 1lobulin$ 2.3 6 3.3 g,db. #etermine whether there is adeCuate protein inta.e and li%er "unctioning "or healing, immune system "unctioning c. 1lobulin decreased with immunologic de"iciencies 4. /rotein electrophoresis$ 0easurement o" immunoglobulins 'g1, 'gA, 'g0, 'g#, 'g? (antibodies) F. Antibody testing$ Titer le%els measured to determine whether client has de%eloped antibodies to an in"ection or with an immunization =. S.in testing$ assesses cell<mediated immunity a. !nown antigen in*ected intradermally, e.g. tuberculin test b. +ote induration indicating pre%ious eBposure and sensitization to antigen c. '" no reaction, depressed cellular immunity (anergy) . 0edications$ 1. /urpose$ to pro%ide com"ort or decrease in"lammatory response and damage 2. Types a. Acetaminophen a. Com"ort only b. &educes pain and "e%er c. +o anti<in"lammatory e""ect b. Aspirin and salicylates a. Digher doses reCuired (F45 6 1555 mg H'#) "or anti in"lammatory e""ect b. 'nhibits prostaglandin synthesis; anti pyretic; anti<platelet e""ect c. 'rritates gastrointestinal tract c. +onsteroidal anti<in"lammatory drugs (+SA'#s) a. 0ultiple types o" +SA'# medications; all ha%e potential cross<sensiti%ity to aspirin, irritate gastrointestinal tract b. !etorolac (Toradol), only +SA'# that can be gi%en parenterally c. 'ndomethacin and phenylbutazone most toBic d. Corticosteroids$ hormones produced by adrenal corteB a. 'nhibit in"lammation; do not cure underlying condition, but palliati%e b. Da%e serious side e""ects, can mas. in"ections c. 1uidelines "or use o" glucocorticoids
Joyce Hammer 12/10/2013

5
1. /re"er local acting such as topical or intra<articular in*ection i" e""ecti%e 2. 1i%e smallest possible dose that will be e""ecti%e 3. '" oral, alternate<day dosing schedule to maintain adrenal gland "unctioning 3. With high<dose therapy, must taper dose; do not stop abruptly to allow adrenal glands to resume normal "unctioning C. /roper +utrition$ essential "or healing 1. #e"initions a. 'n"lammation$ catabolic state (tissue brea.down) b. Dealing$ anabolic process (tissue build up) 2. #iet reCuirements a. AdeCuate protein, calories, "at b. Aitamins$ A, <compleB, !; mineral$ zinc, c. AdeCuate "luids 24555 ml, 23 hr d. /re%ent weight loss, protein depletion #. +ursing #iagnoses 1. /ain 2. 'mpaired Tissue 'ntegrity 3. &is. "or 'n"ection VI. Infection A. Eccurrence$ when pathogen colonizes and multiplies within host and host eBperiences in*ury, in"lammation or organ dys"unction in response to in"ection or toBin . /athogen @actors 1. Airulence$ disease<causing potential 2. Chain o" in"ection (reser%oir, transmission, %ector) 3. Erganism resistance 3. #amage caused through toBin production C. Dost @actors$ ability to resist in"ection 1. /hysical barrier$ intact s.in and mucous membranes 2. 'nternal en%ironment (body secretions, respiratory de"enses) 3. Speci"ic and nonspeci"ic immune responses #. Stages o" 'n"ectious /rocess 1. 'ncubation a. /athogen acti%e replication b. +o symptoms 2. /rodromal a. Symptoms begin to appear b. +on<speci"ic 3. Acute a. /athogen proli"erates, maBimum symptoms b. @e%er and chills; may be con"ined to speci"ic organ,system c. Stress to body 1. Catabolic e""ects 2. 'n"lammatory process in response to toBins 3. /ossible trigger o" autoimmune disease process 3. Con%alescent a. Tissues repair b. Symptoms resol%e ?. /ossible Complications$ Septicemia, septic shoc. @. +osocomial in"ections$ 'n"ections acCuired in health care setting (4> in"ection rate) 1. &is. "actors "or hospitalized clients a. Compromised immune systems b. 0edications including antibiotics, steroids
Joyce Hammer 12/10/2013

6
c. Treatments including in%asi%e procedures d. 'ncreased incidence among elderly 2. /re%ention a. ?""ecti%e handwashing b. ?n"orcement o" policies "or in%asi%e procedures 1. Antibiotic<&esistant 0icroorganisms 1. 'ncreasing due to inappropriate or prolonged antibiotic therapy 2. Current resistant strains a. 0ethicillin<resistant Staphylococcus aureus (0&SA) b. 0ulti<drug resistant tuberculosis (0#&<T ) c. /enicillin<resistant Streptococcus pneumoniae (/&S/) d. Aancomycin<resistant ?nterococci (A&?) e. Aancomycin 'ntermediate<resistant Staphylococcus aureus (A'SA) 3. @ollow recommended contact precautions,isolation techniCues D. Collaborati%e Care 1. #iagnostic Tests a. W C Count and #i""erential 1. -eu.ocytosis with in"ections 2. +eutrophilia increased segs; also shi"t to le"t (increased band count) b. Culture o" wound, blood, and,or other body "luids 1. Ebtain specimen prior to starting antibiotic, i" not, note antibiotic recei%ed on culture reCuest "orm 2. 1ram stain$ to identi"y probable pathogen 3. Culture$ organism incubated and grown; ta.es 23 6 3G hours 3. Sensiti%ity$ cultured organism sub*ected to di""erent antibiotics to determine whether sensiti%e (antibiotic will .ill organism) or resistant (antibiotic will not .ill organism) c. Serology$ detect antibodies to suspected organism d. #irect antigen$ detect antigens in body specimens e. Antibiotic /ea.s and Troughs$ monitor therapeutic le%els o" antibiotics to ensure proper dose "or optimum treatment while a%oiding toBic le%els 1. /ea.$ highest le%el o" antibiotic 2. Trough$ lowest le%el o" antibiotic ". Irays, ultrasound eBamination o" organs g -umbar puncture to obtain cerebrospinal "luid "or eBamination and culture '. Administration o" anti<in"ecti%e therapy 1. Chec. "or allergies, ris. to "etus in child<bearing aged women 2. !now client renal, hepatic "unction; i" medication metabolized through this system, monitor lab tests 3. est route to e""ecti%ely treat microorganism in in"ection site 3. Antibiotics a. acteriostatic (inhibit growth) or bactericidal (.ill organism) b. Speci"ic against di""erent categories o" microorganisms that ha%e cell wall 1. 1ram positi%e 2. 1ram negati%e 3. oth (broad spectrum) c. !nown toBicities to speci"ic organ systems .Superin"ection 1. 0a*or concern 2. Antibiotics change normal bacterial "lora in 1' tract, mouth, %agina 3. E%ergrowth o" "ungus or bacteria 3. 0ay be treated with anti"ungal medications or eating yogurt with li%e cultures 4. Anti%iral$ selecti%e since %irus is parasite within host2s cells
Joyce Hammer 12/10/2013

7
F. Anti"ungal$ treat "ungal in"ections =. Antiparasitic$ treat parasitic in"ections including protozoans J. Antibiotic Categories , Speci"ics 1. /enicillins$ 9cillins: a. Stop immediately i" any sign o" hypersensiti%ity and be ready to treat reaction b. Cross sensiti%ity with cephalosporins 2. Cephalosporins a. 3 generations b. Cross sensiti%ity with penicillins c. 0onitor "or .idney and li%er toBicity 3. Aminoglycosides$ 9mycins: a. EtotoBic, nephrotoBic b. 0onitor weight, K+, creatinine 3. @luroCuinolones a. @luid inta.e 2 6 3 - daily to pre%ent crystaluria b. 0onitor "or hepatotoBicity 4. Tetracyclines a. Ta.e 1 hour be"ore or 2 hours a"ter meals b. Can inter"ere with anticoagulants F. 0acrolides (?rythromycin) a. @or clients allergic to penicillin b. 1' distress; ta.e on empty stomach or *ust be"ore meals =. Sul"onamides and Trimethoprim a. Ksed "or urinary tract in"ections, otitis media, /neumocystis carinii pneumonia b. Chec. "or any sul"a allergy c. /rotect "rom photosensiti%ity d. Ta.e on empty stomach e. @luid inta.e 2 - per day G. 0etronidazole (@lagyl) a. +o alcohol inta.e (causes illness << Antabuse e""ect) b. 0ay ma.e urine reddish brown c. +eed adeCuate "luid inta.e 2.4 - daily !. 'solation TechniCues According to Centers "or #isease Control and /re%ention (C#C) 1uidelines 1. Standard /recautions a. arrier precautions with body "luids, especially blood b. 1uidelines "or needles, sharp ob*ects disposal 2. Category<speci"ic /recautions a. Airborne precautions b. #roplet precautions c. Contact precautions -. +ursing #iagnoses 1. &is. "or in"ections 2. AnBiety 3. Dyperthermia a. Chills indicate rising temperature; monitor b. -ower temperature cautiously to a%oid shi%ering which raises temperature c. &estore "luid balance; increased loss with "e%er Nursing Care of Clients with ltered Immunity I. !ac"ground A. A healthy immune system identi"ies antigens and e""ecti%ely destroys or remo%es them . Alterations that occur within immune system and result in illness
Joyce Hammer 12/10/2013

8
1. E%erreaction$ Dypersensiti%ity, as with allergic reactions 2. 'ncompetency$ 'mmune de"iciency or malignancy as with AcCuired 'mmune #e"iciency #isorder (A'#S) 3. -oss o" ability to recognize sel"$ Autoimmune disorders C. 'mmune responses 1. Antibody<mediated immune response$ action o" lymphocytes ( <cells); acCuired immunity 2. Cell<mediated immune response$ T lymphocytes (T<cells) attac. antigens directly and acti%ate <cells 3. Types o" T<cells a. ?""ector cells$ CytotoBic (!iller T) 1. Carry C#G antigen 2. Attac. malignant cells 3. &esponsible "or transplanted organ re*ection and gra"ted tissues b. &egulator cells 1. Delper T cells a. Carry C#3 antigen b. 'nitiate immune response 2. Suppressor T cells a. Carry C#G antigen b. Stop immune response 3. 'mmune "unction declines with age II. #ypersensiti$ity Reaction A. #e"inition$ Altered immune response to antigen resulting in harm to client, e.g. allergy . Categories 1. &ange "rom irritating to li"e threatening (as with laryngospasm) 2. 'mmediate (e.g. anaphylaBis) %s. delayed (e.g. contact dermatitis) C. /athophysiology 1. Antigen<antibody interaction$ 1. Causes tissue damage 2. 'n%ol%es immediate reaction a"ter a prior sensitization 3. 'ncludes systemic reactions$ Types ', '', ''' a. Type ' 1. @rom allergic reaction with 'g? 2. 0ast cells and basophils "actors released, which causes serious reaction 3. 0ost serious reaction$ AnaphylaBis a. Signs and symptoms$ hi%es, swelling, di""iculty breathing, anaphylactic shoc. b. Client needs$ Air way protection; prompt re%ersal (parenteral epinephrine) b. Type '' 1. 'g1 or 'g0 2. Antibodies "ormed 3. Complement cascade acti%ated and destroys cells, e.g. hemolytic trans"usion blood reaction (A E, &h) c. Type ''' 1. 'g1 or 'g0 2. Antibody<antigen immune compleBes in circulation and bloc. tissues, e.g. reaction to toBin post strep in"ection, glomerulonephritis 2. Antigen<lymphocyte reaction a. Type 'A b. #elayed 23 6 3G hours; contact dermatitis (e.g. lateB allergy, positi%e tuberculin test)
Joyce Hammer 12/10/2013

9
#. Collaborati%e Care 1. E%erall @ocus a. 0inimize eBposure to allergen b. /re%ent hypersensiti%ity response c. /er"orm prompt, e""ecti%e inter%entions "or allergic responses 2. +ursing history and status be"ore any procedure,medication a. #ocument allergies and reaction(s) that occurred with e%ent b. 0aintain record; allergy bracelet "or in<patient c. As. about anesthesia allergy "or local and general preoperati%e clients 3. #iagnostic Tests a. W C count with di""erential$ Type ' allergy$ eosinophilia b. &adioallergosorbent test (&AST)$ detects 'g? toward speci"ic antigens c. lood type and crossmatch$ pre%ents A E and &h reactions d. 'ndirect Coombs$ detects circulating antibodies (normal$ negati%e) e. #irect Coombs$ detects antibodies on client2s & C2s (normal$ negati%e) ". 'mmune compleB assays$ detects Antibodies Type ''' reactions g. Complement assays$ detects amount o" a%ailable complement; determines amount used h. S.in tests$ detects allergens, includes intradermal testing 3. 0edications a. Antihistamines 1. loc.s histamine receptors 2. &elie%es symptoms o" urticaria and angioedema 3. #iphenhydramine ( enadryl)$ can be gi%en parenterally or orally b. ?pinepherine 1. 'mmediate treatment "or anaphylaBis 2. &elie%es the %asodilatation and bronchoconstriction 3. 1i%en subcutaneously or intra%enously 3. 9 ee sting .it:$ carried by clients with .nown serious allergies c. Cromolyn ('ntal) 1. loc.s histamine release 2. 1i%en by inhaler or nasal spray d. 1lucocorticoids 1. oth topical and systemic e""ects 2. Anti<in"lammatory 4. /lasmapheresis a. +on<medication treatment b. &emo%al o" harm"ul components in plasma by passing blood through blood cell separator to remo%e immune compleBes F. +ursing #iagnoses a. 'ne""ecti%e Airway Clearance (as with anaphylaBis) b. #ecreased Cardiac Eutput (as with anaphylactic shoc.) c. &is. "or 'n*ury (as with blood trans"usion reaction) III. utoimmune %isorders A. #e"inition$ 'mmune system2s ability to recognize sel" is impaired, and immune de"enses are directed against person2s own tissues . Common autoimmune disorders 1. Tissue,organ speci"ic (Dashimoto2s thyroiditis) 2. Systemic (rheumatoid arthritis, systemic lupus erythematosis (S-?)) C. /athophysiology (not entirely certain but possibly) 1. Didden antigens elicit immune response, de%elopment o" autoantibodies 2. ody has changes "rom bacterial or %iral in"ections, de"ecti%e immune system
Joyce Hammer 12/10/2013

10
#. Characteristics o" autoimmune disorders 1. 1enetic predisposition 2. Eccur in "emales more than males 3. Enset associated with stress 3. @reCuently are progressi%e, with periods o" eBacerbation and remission ?. Collaborati%e Care 1. #iagnostic Tests$ a. Serologic assays 1. Tests used to identi"y autoantibodies, measured in titers, i.e. le%els in circulation 2. Eccur with autoimmune state 3. +ot speci"ic "or certain disease b. Antinuclear antibody (A+A) c. -upus erythematosus (-?) prep d. &heumatoid @actor (&@) e. Complement assay$ detects amount o" a%ailable complement; determines amount used 2. 0edications a. Anti<in"lammatory drugs$ aspirin, +SA'#s, corticosteroids b. Antirheumatic drugs$ gold salts, hydroBychloroCuine (/laCuenil) c. CytotoBic drugs 3. /lasmapheresis may be used 3. +ursing Care according to signs and symptoms o" speci"ic disorder 4. Common +ursing #iagnoses a. Acti%ity 'ntolerance b. 'ne""ecti%e Coping (with chronic disease) c. 'ne""ecti%e /rotection d. &is. "or 'ne""ecti%e Therapeutic &egimen 0anagement e. 'nterrupted @amily /rocesses IV. &issue &ransplants A. ac.ground 1. Duman -eu.ocyte Antigens (D-A) a. Speci"ic cell sur"ace mar.ers uniCue to each indi%idual person b. Transplant success tied to obtaining organs with D-A close to those o" recipient 2. Types o" Transplants a. Autogra"t$ transplant o" client2s own tissue b. Allogra"t$ most common, gra"ts between member o" same species, but di""erent genotypes and D-A antigens; cada%er donors are most common c. Ienogra"t$ transplant "rom animal species to human, e.g. pig %al%es 3. /reparation "or Allogra"t$ Tissue Typing a. #etermine histocompatibility, i.e. identi"y recipient2s D-A type, blood type (A E, &h), and pre<"ormed antibodies b. 0atch as closely as possible with the donor 3. Types o" &e*ections$ typically begin a"ter "irst 23 hours post transplant$ a. Dyperacute Tissue &e*ection 1. Eccurs 2 6 3 days post transplant 2. #ue to pre<"ormed antibodies 3. 0ore common with pre%ious transplant or blood trans"usion b. Acute Tissue &e*ection 1. 0ost common and treatable 2. Eccurs between 3 days and 3 months post transplant 3. #ue to cellular immune response 3. Signs and symptoms$ "e%er, redness, swelling and tenderness o%er gra"t site; signs o" organ "ailure (re"lected by lab %alues)
Joyce Hammer 12/10/2013

11
c. Chronic Tissue &e*ection 1. Eccurs 3 months to years post transplant 2. #ue to antibody<mediated immune response 3. -eads to ischemia and to organ and gradual deterioration 3. 1ra"t<%ersus<Dost #isease (1%D#)$ "reCuent and potentially "atal complication o" bone marrow transplant; gra"ted tissue recognizes host tissue as "oreign and mounts a cell<mediated response; primarily a""ects s.in, li%er, gastrointestinal tract . Collaborati%e Care 1. E%erall goal o" pre and post transplant care is to reduce the ris. o" tissue re*ection or 1%D# 2. #iagnostic testing 6 prior to transplant a. lood type, &h "actor, crossmatch b. D-A histocompatibility$ used primarily with li%ing donors "or .idney or bone marrow transplants c. 0iBed lymphocyte culture (0-C) assay test$ histocompatibility between donor and recipient 3. #iagnostic testing < post transplant a. Kltrasound or 0agnetic resonance imaging (0&') o" transplanted organ b. Tissue biopsies o" transplanted organ; done routinely to assess e%idence o" re*ection 3. 0edications a. Antibiotics and anti%iral medications 1. Trimethoprim-sulfamethoxazole (Septra, Bactrim)$ protects against gram< negati%e bacteria in"ection 2. Acyclovir (Zovirax)$ protects "rom herpes simpleB %irus (DSA) in"ection 3. Ganciclovir (Cytovene)$ protects "rom de%elopment o" cytomegalo%irus (C0A) in"ection b. 'mmunosuppressi%e agents$ Corticosteroids, also anti<in"lammatory 1. Azathioprine ( muran) a. 0ainstay, inhibits both cell<mediated and antibody<mediated immunity b. 0etabolized by li%er; sa"e "or renal transplant clients c. 0a*or ad%erse e""ect$ bone marrow depression (monitor C C) 2. Cyclosporine a. 'nhibits T<cell "unction and cell<mediated immune responses b. 0onitor blood le%els closely to chec. "or toBicity; nephrotoBic and hepatotoBic c. Signs o" toBicity$ hypertension, C+S symptoms 3. !uromona"-C#$ (%&T$, %rthoclone) a. 0onoclonal antibody, bloc.s T cell generation and "unction b. Ksed with steroid<resistant organ re*ections 3, Antilymphocyte 'lo"ulin (A(G), antithymocyte 'lo"ulin (ATG)) /olyclonal antilymphoctye antibodies 3. +ursing Care in%ol%es acute and chronic care "or client and "amily 4. Common +ursing #iagnoses a. 'ne""ecti%e /rotection b. &is. "or 'mpaired Tissue 'ntegrity c. #ealing with psychologic conseCuences o" chronicity 1. /owerlessness 2. 'ne""ecti%e Coping 3. AnBiety F. Common nursing inter%entions a. Assessment "or signs o" in"ection, organ re*ection, ad%erse e""ects o" medications, "reCuent laboratory testing b. 0edications, handwashing and protecti%e isolation in hospital and post discharge "or client and "amily
Joyce Hammer 12/10/2013

12
c. Stress<reduction, counseling, support group re"erral V. Impaired Immune Response A. Two types 1. Congenital$ rare 2. AcCuired$ acCuired immune de"iciency syndrome (A'#S) . ac.ground 1. Cases recognized in male homoseBual population in 1LG1; 2. Duman immunode"iciency %irus (D'A) isolated in 1LG3 3. &etro%irus transmitted by a. #irect contact with in"ected blood and body "luids b. Contaminated needles c. 'n"ants born to D'A positi%e mothers (14 6 35 >) C. &is.s$ eha%orial 1. Knprotected anal seB 2. 'n*ection drug use (sharing needles) 3. DeteroseBual intercourse with in"ected persons 3. &ecei%ing blood trans"usions, blood products 4. Eccupational ris. to health care wor.ers, especially through needle stic.s #. /athophysiology 1. &etro%irus a. Carries genetic code in &+A b. 'n"ects cells with C#3 antigen c. Ta.es o%er cell2s #+A and then duplicates d. 0ay remain dormant or become acti%e e. Acti%e$ "orms %irons which destroys host cell 2. Serocon%ersion a. F wee.s to F months post initial in"ection, antibodies to D'A are produced and will test positi%e b. Actual %irus may remain inacti%e in cells "or years c. Antibodies are ine""ecti%e against the %irus 3. Cells a""ected by D'A a. Delper T (C#3) cells b. 0acrophages c. Cells o" C+S 3. -oss o" helper T cells leads to typical immunode"iciencies that result in multiple opportunistic in"ections and cancers ?. Typical Course o" D'A 'n"ection 1. Contraction o" %irus a. Acute mononucleosis<type illness within days to wee.s b. Symptoms include$ "e%er, sore throat, *oint and muscle achiness, rash, lymphadenopathy c. Asymptomatic period 1. 0ean period G to 15 years 2. Airus can be transmitted to others through blood and body "luids, e%en though client seems well 3. Some clients eBperience persistent lymphadenopathy 2. #e%elopment into A'#S a. 0ani"estations include$ general malaise, "e%er, "atigue, night sweats, in%oluntary weight loss, o"ten diarrhea, rash, oral lesions and candidiasis b. 0ultiple opportunistic in"ections, cancers c. 35 6 F5 > de%elop neurological symptoms @. /ost<in"ection &elated 'ssues 1. A'#S #ementia CompleB
Joyce Hammer 12/10/2013

13
a. #irect e""ect o" %irus on brain b. Starts with "luctuating memory loss; con"usion to apathy, to se%ere dementia; tremor; spasticity; incontinence c. C+S in"ections and lesions including toBoplasmosis, non<Dodg.in2s lymphoma as space<occupying lesions, cryptococcal meningitis, C0A in"ections 2. Epportunistic 'n"ections a. Eccur when C#3 count is less than 255 (normal greater than 1555,mm3) b. /neumonia (*neumocystis carinii) 1. 0ost common opportunistic in"ection (=4 6 G5>) 2. +onspeci"ic mani"estations$ "e%er, cough, shortness o" breath, tachypnea, tachycardia c. Tuberculosis 1. E"ten multidrug<resistant strains 2. &apid progressi%e, di""use pulmonary and disseminated (other body organs) d. Candidiasis (Can+i+a al"icans) 1. Aery common 2. Eral thrush, esophagitis, or %aginitis in women e. !yco"acterium avium$ CompleB (0AC) 1. 24> o" A'#S cases 2. 0a*or cause o" 9wasting syndrome: 3. Signs and symptoms include$ chills, "e%er, wea.ness, night sweats, abdominal pain, diarrhea, weight loss ". Ether 'n"ections 1. Airal$ Derpes simpleB or zoster %irus, C0A o" retina, 1' tract, lungs 2. /arasitic$ ToBoplasma gondii, Cryptococcus neo"ormans, Cryptosporidium 3. Secondary Cancers a. !aposi2s Sarcoma 1. E"ten presenting symptom 2. S.in lesions with %ascular macules, papules, %iolet lesions on s.in and %iscera; o"ten on "ace, gastrointestinal tract, lungs 3. 'nitially painless, but become pain"ul 3. 'ndicator o" late<stage disease b. -ymphomas 1. +on<Dodg.in2s lymphoma and primary lymphoma o" brain 2. Aggressi%e and rapid spread c. 'n%asi%e Cer%ical Carcinoma$ Woman with D'A usually die o" cer%ical cancer, not A'#S 1. Collaborati%e Care 1. Treatment a. +o cure "or D'A in"ection and A'#S b. Current research "or treatment and cure c. Still uni%ersally "atal nature o" disease d. /re%ention is %ital strategy 2. 1oals o" care a. ?arly identi"ication o" in"ection b. /romote health<maintenance acti%ities c. /re%ent opportunistic in"ections d. Treatment o" disease complications (cancers) e. /ro%ide emotional and psychosocial support 3. #iagnostic Testing a. ?nzyme<lin.ed immunosorbent assay (?-'SA) 1. Widely used as screening test "or D'A in"ection; detects D'A antibodies, not %irus
Joyce Hammer 12/10/2013

14
2. Could be negati%e in early course o" in"ection be"ore detectable antibodies de%elop 3. &esults LL.4> positi%e a. @alse positi%es can occur b. '" positi%e, always repeat test and con"irm by another method, such as Western blot b. Western blot antibody testing$ combined with ?-'SA greater speci"icity (7LL.L>) c. D'A %iral load tests$ measure amount o" acti%ity replicating D'A %irus d. C C$ detect anemia, leucopenia, thrombocytopenia e. C#3 cell count$ used to monitor progress o" disease and guide therapy ". Tests to detect secondary cancers and opportunistic in"ections 1. Tuberculin s.in testing 2. rain 0agnetic resonance imaging (0&') 3. Speci"ic cultures and serology "or in"ections 3. /ap smears e%ery F months to detect cer%ical cancer 3. 0edications a. /urposes 1. Suppress the D'A in"ection and prolong client2s li"e 2. Treat opportunistic in"ections and cancers b. ?""ecti%eness measured by 1. Airal load and C#3 cell counts (abo%e 455 mm3) 2. E"ten used in combinations according to e""ecti%eness c. Classes o" medications used to Suppress D'A in"ection 1. +ucleoside &e%erse Transcriptase 'nhibitors (+&T's) a. Wor.s at le%el o" #+A b. Mido%udine (&etro%ir, AMT) widespread use; also used prophylactically post parenteral eBposure to D'A 2. /rotease 'nhibitors$ loc.s %iral enzymes 3. +onnucleoside &e%erse Transcriptase 'nhibitors 3. Ether agents$ 'nter"erons d. 0edications against Epportunistic 'n"ections,Cancers 1. Antibiotics, anti%irals, anti<cancer agents 2. Aaccines "or pneumococcal, in"luenza, hepatitis , Daemophilus in"luenzae serotype b 3. 'soniazid ('+D) prophylactically "or positi%e tuberculin test 3. /rophylactic trimethoprim<sul"amethoBazole ( actrim) i" C#3 cell count is below 255 to pre%ent *neumocystis carinii /neumonia (/C/) 3. +ursing Care a. /re%ention o" in"ection 1. Sa"e seBual practices 2. +o sharing or needles and drug paraphernalia (drug users) 3. Screening o" donated blood and use o" autologous 3. Kse o" standard precautions by health care wor.ers b. Care o" the client with D'A 1. 0aintain health and pre%ent de%elopment o" opportunistic in"ections, cancers; physical needs change o%er course o" illness 2. Still a stigma associated with illness; assist client, "amily to deal with it 3. 'ntense medical care, client de%elopment o" support systems, use o" psychosocial support c. +ursing #iagnoses (many and change with course o" illness) 1. 'ne""ecti%e Coping$ #ealing with stigma, contagious disease chronic illness, terminal illness 2. 'mpaired S.in 'ntegrity 3. 'mbalanced +utrition less than ody &eCuirements$ Control nausea, diarrhea
Joyce Hammer 12/10/2013

15
3. 'ne""ecti%e SeBual /atterns$ /ractice sa"e seBual practices, in"orming partners o" D'A status

Joyce Hammer 12/10/2013