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

arrier protection$ body2s "irst line de"ense against in"ection includes 1. 'n"lammation$ nonspeci"ic immune response 1. li%er. AdeCuate nutrition b. corticosteroids c. 25 6 35> o" total circulating leu. /hases a. Dealing occurs with tissue repair or scarring b. &epair$ replacement o" destroyed tissue by collagen scar tissue 2. 'n"ection Joyce Hammer 12/10/2013 . &esolution$ original structure and "unction result 2. -ymphocytes (mature in bone marrow) 3. Slower onset. -ymphocytes a. warmth. /hagocytic against large "oreign particles and cell debris e. Aascular response$ %asodilatation leading to redness. Chronic diseases. 'n"lammation$ debridement occurs. months 6 years 2. swelling. 1 6 2 wee. diabetes b. Stages o" in"lammatory response$ a. 0ature into macrophages in tissue lungs.in 2. 0igrate to tissues and can li%e "or years c. etc. #ebilitating with se%ere tissue damage C. Serous (plasma) 2.ocytes b. wound prepared "or healing b. Acute 1. AdeCuate blood supply c. d. ?""ectors and regulators o" speci"ic immune responses c.iller cells)$ immune sur%eillance II. 3 di""erent types o" lymphocytes which wor. connecti%e. Nonspecific Inflammatory Response A. loss o" "unction 3. Ether 'nter"ering @actors a. Short term. 'n*urious agent remo%ed 3. Circulate constantly. Wound Dealing 1. 'mmune sur%eillance$ monitor "or and destroy cancerous cells d. Serosanguineous (miBture) b. Tissue repair healing$ o%erlap o" in"lammation and healing 3. #e"ense against chronic in"ections such as tuberculosis. g. 0ucus o" mucous membranes 3. &eCuirements a. &econstruction$ damaged tissue regenerates 1. 'ntact s. +onspeci"ic$ localized. Acute or Chronic a. warmth. Cardinal signs o" in"lammation$ erythema (redness). +! cells (natural . pain. together$ 1. SanCuineous (mainly red blood cells) 3. %iral in"ections 4. #i""erential only loo.s at total lymphocyte percentage ". e.g. T -ymphocytes (mature in thymus gland) 2. actericidal action o" body "luids . AdeCuate oBygenation 3. e. Cellular response and phagocytosis$ margination and wbc2s to area c. three types o" eBudate$ "luid "rom capillaries into tissue 1. #rug therapies. generally same with all types o" in*ury 2.2 b.s 2. but concentrate in lymphoid tissues including lymph nodes e. Chronic 1. swelling.

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

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

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

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

&estore "luid balance. Cross sensiti%ity with penicillins c. Antiparasitic$ treat parasitic in"ections including protozoans J. sharp ob*ects disposal 2. 'solation TechniCues According to Centers "or #isease Control and /re%ention (C#C) 1uidelines 1. +o alcohol inta. creatinine 3. Alterations that occur within immune system and result in illness Joyce Hammer 12/10/2013 . 0acrolides (?rythromycin) a. K+. 0onitor "or . 3 generations b. Antibiotic Categories . 0ay ma. EtotoBic.e on empty stomach or *ust be"ore meals =. Cross sensiti%ity with cephalosporins 2.e 2 .daily !. nephrotoBic b. !ac"ground A. A healthy immune system identi"ies antigens and e""ecti%ely destroys or remo%es them . &is. ta. Aminoglycosides$ 9mycins: a. Chills indicate rising temperature.e on empty stomach e. Category<speci"ic /recautions a.e 2. @luid inta. Cephalosporins a. especially blood b.4 . /neumocystis carinii pneumonia b. 1uidelines "or needles. arrier precautions with body "luids. Standard /recautions a. Speci"ics 1. Tetracyclines a. +eed adeCuate "luid inta. /enicillins$ 9cillins: a.e 2 6 3 . #roplet precautions c. -ower temperature cautiously to a%oid shi%ering which raises temperature c. 0onitor "or hepatotoBicity 4. 0etronidazole (@lagyl) a. Can inter"ere with anticoagulants F.per day G. 1' distress. Airborne precautions b.idney and li%er toBicity 3. Dyperthermia a.daily to pre%ent crystaluria b. increased loss with "e%er Nursing Care of Clients with ltered Immunity I. Anti"ungal$ treat "ungal in"ections =. Ta. Ksed "or urinary tract in"ections. @luroCuinolones a. Chec. Contact precautions -. @or clients allergic to penicillin b.e (causes illness << Antabuse e""ect) b. Stop immediately i" any sign o" hypersensiti%ity and be ready to treat reaction b. +ursing #iagnoses 1. Sul"onamides and Trimethoprim a. monitor b. Ta. "or in"ections 2.7 F.e 1 hour be"ore or 2 hours a"ter meals b. /rotect "rom photosensiti%ity d. AnBiety 3. @luid inta. otitis media. 0onitor weight. "or any sul"a allergy c.e urine reddish brown c.

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

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

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

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

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

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

anti%irals. Care o" the client with D'A 1. in"luenza. Classes o" medications used to Suppress D'A in"ection 1. 'ntense medical care. +ursing Care a. Airal load and C#3 cell counts (abo%e 455 mm3) 2. physical needs change o%er course o" illness 2. 0aintain health and pre%ent de%elopment o" opportunistic in"ections. thrombocytopenia e. 'soniazid ('+D) prophylactically "or positi%e tuberculin test 3.4> positi%e a. assist client. anti<cancer agents 2. Sa"e seBual practices 2. Mido%udine (&etro%ir. AMT) widespread use. 0edications against Epportunistic 'n"ections. C#3 cell count$ used to monitor progress o" disease and guide therapy ". contagious disease chronic illness. Kse o" standard precautions by health care wor. 0edications a. cancers. &esults LL. /urposes 1. Daemophilus in"luenzae serotype b 3. /rophylactic trimethoprim<sul"amethoBazole ( actrim) i" C#3 cell count is below 255 to pre%ent *neumocystis carinii /neumonia (/C/) 3.in 'ntegrity 3. client de%elopment o" support systems. E"ten used in combinations according to e""ecti%eness c.Cancers 1. Wor. C C$ detect anemia. Screening o" donated blood and use o" autologous 3.14 2. Western blot antibody testing$ combined with ?-'SA greater speci"icity (7LL. such as Western blot b.L>) c. D'A %iral load tests$ measure amount o" acti%ity replicating D'A %irus d. /ap smears e%ery F months to detect cer%ical cancer 3. @alse positi%es can occur b. Tests to detect secondary cancers and opportunistic in"ections 1.s at le%el o" #+A b. Speci"ic cultures and serology "or in"ections 3. 'mpaired S. Tuberculin s. use o" psychosocial support c. always repeat test and con"irm by another method. +onnucleoside &e%erse Transcriptase 'nhibitors 3.s %iral enzymes 3. Treat opportunistic in"ections and cancers b. "amily to deal with it 3. hepatitis .in testing 2. Still a stigma associated with illness. 'mbalanced +utrition less than ody &eCuirements$ Control nausea. leucopenia. ?""ecti%eness measured by 1. 'ne""ecti%e Coping$ #ealing with stigma. Aaccines "or pneumococcal. terminal illness 2. /rotease 'nhibitors$ loc. rain 0agnetic resonance imaging (0&') 3. diarrhea Joyce Hammer 12/10/2013 . Ether agents$ 'nter"erons d. /re%ention o" in"ection 1. Antibiotics. +o sharing or needles and drug paraphernalia (drug users) 3. Suppress the D'A in"ection and prolong client2s li"e 2.ers b. +ursing #iagnoses (many and change with course o" illness) 1. also used prophylactically post parenteral eBposure to D'A 2. '" positi%e. +ucleoside &e%erse Transcriptase 'nhibitors (+&T's) a. Could be negati%e in early course o" in"ection be"ore detectable antibodies de%elop 3.

'ne""ecti%e SeBual /atterns$ /ractice sa"e seBual practices. in"orming partners o" D'A status Joyce Hammer 12/10/2013 .15 3.

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