Immunologic disorders
I. Functions of the Immune System
A. Provides protection against invasion by
microorganisms from outside the body
B. Protects the body from internal threats and
maintains the internal environment by removing
dead or damaged cells
II. Immune Response
A. T lymphocytes and B lymphocytes
1. Lymphocytes are produced in the bone
marrow and migrate to lymphoid tissue, where
they remain dormant until they need to form
sensitized lymphocytes for cellular immunity or
antibodies for humoral immunity.
2. Some B lymphocytes lie dormant until a
specific antigen enters the body, at which time
they greatly increase in number and are
available for defense.
3. Types of T lymphocytes include
helper/inducer, suppressor, and
cytotoxic/cytolytic.
4. T and B lymphocytes are necessary for a
normal immune response.
B. Humoral response
1. Humoral response is immediate.
2. This type of response provides protection
against acute, rapidly developing bacterial and viral
infections.
C. Cellular response
1. Cellular response is delayed; this is also called
delayed hypersensitivity.
2. This type of response is active against slowly
developing bacterial infections and is involve in
autoimmune responses, some allergic reactions, and
rejection of foreign cells.
III. Immunity
A. Innate immunity
1. Innate immunity is also called native or natural
immunity.
2. It is present at birth and includes biochemical,
physical, and mechanical barriers of defense, as
well as the inflammatory response.
B. Acquired immunity
1. Acquired or adaptive immunity is received
passively from the mother’s antibodies, animal
serum, or antibodies produced in response to a
disease.
2. Immunization produces active acquired
immunity.
V. Laboratory Studies
A. Antinuclear antibody (ANA) determination
1. The ANA determination is a blood test used
for the differential diagnosis of rheumatic
diseases and for the detection of antinucleon
protein factors and patterns associated with
certain autoimmune diseases.
2. The test is negative at a 1:40 dilution,
depending on the laboratory.
3. A positive result does not necessarily confirm
a disease.
4. The ANA is positive in most individuals
diagnosed with systemic lupus erythematosus
(SLE); it may also be positive in individuals with
systemic sclerosis (scleroderma) or rheumatoid
arthritis.
5. An ANA result can be false positive in some
individuals
B. Anti-dsDNA antibody test
1. The anti-dsDNA (double-stranded DNA)
antibody test is a blood test done specifically to
identify or differentiate DNA antibodies found in
SLE.
2. The test supports a diagnosis, monitors disease
activity and response to therapy, and establishes
a prognosis for SLE.
3. Values: negative, lower than 70 IU/mL by
enzyme-linked immunosorbent assay (ELISA)
C. Human immunodeficiency virus (HIV) testing
1. CD4 + T-cell count
a. Monitors the progression of HIV
b. As the disease progresses, usually the number
of CD4 + T cells decreases, with a resultant
decrease in immunity.
c. The normal CD4 + T-cell count is between 500
and 1600 cells/L.
d. In general, the immune system remains
healthy with CD4 + T-cell counts higher than
500 cells/L.
e. Immune system problems occur when the
CD4 + T-cell count is between 200 and 499
cells/L.
 f. Severe immune system problems occur when
the CD4 + T-cell count is lower than 200
cells/L.
2. CD4-to-CD8 ratio
a. Monitors progression of HIV
b. Normal ratio is approximately 2:1.
3. Viral culture involves placing the infected
client’s blood cells in a culture medium and
measuring the amount of reverse transcriptase
activity over a specified period of time.
4. Viral load testing measures the presence of
HIV
◦ viral genetic material (RNA) or another viral
◦ protein in the client’s blood.
5. The p24 antigen assay quantifies the amount
of
◦ HIV viral core protein in the client’s serum.
◦ 6. Oral testing for HIV
a. Uses a device that is placed against the gum
and cheek for 2 minutes
b. Fluid (not saliva) is drawn into an absorbable
pad, which, in an HIV-positive individual,
contains antibodies.
c. The pad is placed in a solution and a specified
observable change is noted if the test result is
positive.
d. If the result is positive, a blood test is needed
to confirm the results.
7. Home test kits for HIV
a. In one at-home test kit, a drop of blood is
placed on a test card with a special code number;
the card is mailed to a laboratory for testing for
HIV antibodies.
b. The individual receives the results bycalling a
special telephone number and entering the
special code number; test results are then given.
8. Nursing considerations
a. Maintain issues of confidentiality surrounding
HIV and acquired immunodeficiency Syndrome
(AIDS) testing.
b. Follow prescribed state regulations and
protocols related to reporting positive test
results.
D. Skin testing
1. Description
a. The administration of an allergen to the
surface of the skin or into the dermis
b. Administered by patch, scratch, or intradermal
techniques
2. Preprocedure interventions
a. Discontinue systemic corticosteroids or
antihistamine therapy 5 days before the test as
prescribed.
b. Ensure that informed consent was obtained
3. Postprocedure interventions
a. Record the site, date, and time of the test.
b. Record the date and time for follow-up
sitereading.
c. Have the client remain in the waiting room or
office for at least 30 minutes after the injections
to monitor for adverse effects.
d. Inspect the site for erythema, papules,
vesicles, edema, and wheal (Fig. 66-2).
e. Measure flare along with the wheal and
document the size and other findings.
f. Provide the client with a list of potential
allergens, if identified
NURSE ALERT:
 Have resuscitation equipment available if
skin testing is performed because the
allergen may induce an anaphylactic
reaction.
 In some types of allergies, a reaction
occurs on a second and subsequent
contact with the allergen.
 Skin testing may be done to determine
the allergen.
B. Assessment
1. History of exposure to allergens
2. Itching, tearing, and burning of eyes and skin
3. Rashes
4. Nose twitching, nasal stuffiness
C. Interventions VII. Hypersensitivity and Allergy
1. Identification of the specific allergen A. Description
2. Management of the symptoms with 1. An abnormal, individual response to certain
antihistamines, antiinflammatory agents, and/or substances that normally do not trigger such an
corticosteroids exaggerated reaction.
3. Ointments, creams, wet compresses, and soothing 2. In some types of allergies, a reaction occurs on
baths for local reactions a second and subsequent contact with the
4. Desensitization programs may be recommended allergen.
3. Skin testing may be done to determine the
VI. Anaphylaxis allergen.
A. Description
1. A serious and immediate hypersensitivity reaction B. Assessment
that releases histamine from the damaged cells 1. History of exposure to allergens
2. Anaphylaxis can be systemic or cutaneous 2. Itching, tearing, and burning of eyes and skin
(localized). 3. Rashes
4. Nose twitching, nasal stuffiness
B. Assessment (Fig. 66-3)
C. Interventions (see Priority Nursing Actions) C. Interventions
1. Identification of the specific allergen
ANAPHYLACTIC REACTIONS 2. Management of the symptoms with
1. Quickly assess respiratory status and maintain antihistamines, antiinflammatory agents, and/or
a patent airway. corticosteroids
2. Call the health care provider (HCP) or Rapid 3. Ointments, creams, wet compresses, and
Response Team. soothing baths for local reactions
3. Administer oxygen. 4. Desensitization programs may be
4. Start an intravenous (IV) line and infuse recommended
normal saline.
5. Prepare to administer diphenhydramine and Products That May Contain Natural
epinephrine. Rubber Latex
6. Document the event, actions taken, and the ▪ ACE bandages (brown)
client’s response. ▪ Adhesive or elastic bandages
▪ Ambu bag
NURSE ALERT ▪ Balloons
◦ If the client experiences an anaphylactic reaction,
▪ Blood pressure cuff (tubing and bladder)
▪ Catheter leg bag straps
the quickly and maintain a patent airway. The
▪ Catheters
HCP or Rapid
▪ Condoms
◦ Response Team is called. In the meantime, the ▪ Diaphragms
nurse stays with the client and monitors the ▪ Elastic pressure stockings
client’s vital signs and for signs of shock. An IV ▪ Electrocardiographic pads
device is inserted if one is not already ▪ Feminine hygiene pads
◦ in place and normal saline is infused. The nurse ▪ Intravenous catheters, tubing, and rubber injection
ports
then prepares for the administration of
diphenhydramine and epinephrine and other ▪ Nasogastric tubes
medications as prescribed. The head of the bed is ▪ Pads for crutches
elevated if the client’s blood pressure is normal. ▪ Prepackaged enema kits
The client’s feet and legs may be raised if the ▪ Rubber stoppers on medication vials
blood pressureis low. The nurse documents the ▪ Stethoscopes
event, actions taken, and the client’s response. ▪ Syringes
 VIII. Latex Allergy
A. Description
1. Latex allergy is a hypersensitivity to latex.
2. The source of the allergic reaction is thought
to be the proteins in the natural rubber latex or
the various chemicals used in the manufacturing
process of latex gloves.
3. Symptoms of the allergy can range from mild
contact dermatitis to moderately severe
symptoms of rhinitis, conjunctivitis, urticaria,
and bronchospasm to severe life-threatening
anaphylaxis
B. Common routes of exposure
1. Cutaneous: Natural latex gloves and latex
balloons
2. Percutaneous and parenteral: Intravenous lines
and catheters; hemodialysis equipment
3. Mucosal: Use of latex condoms, catheters,
airways, and nipples
4. Aerosol: Aerosolization of powder from latex
gloves can occur when gloves are dispensed
from the box or when gloves are removed from
the hands.
C. At-risk individuals
1. Health care workers
2. Individuals who work in the rubber industry
3. Individuals having multiple surgeries
4. Individuals with spina bifida
5. Individuals who wear gloves frequently, such
as food handlers, hairdressers, and auto
mechanics
6. Individuals allergic to kiwis, bananas,
pineapples, tropical fruits, grapes, avocados,
potatoes, hazelnuts, and water chestnuts
D. Assessment
1. Anaphylaxis or type I hypersensitivity is a
response to natural rubber latex (
2. A delayed type IV hypersensitivity reaction
can occur; symptoms of contact dermatitis
include
pruritus, edema, erythema, vesicles, papules, and
crusting and thickening of the skin and can occur
within 6 to 48 hours following exposure.
Interventions for the Client with a Latex
Allergy
◦ Ask the client about a known allergy to latex
when performing the initial assessment.
◦ Identify risk factors for a latex allergy in the
client.
◦ Use nonlatex gloves and all latex-safe supplies.
◦ Keep a latex-safe supply cart near the client’s
room.
◦ Applya cloth barrierto the client’s arm undera
blood pressure cuff.
◦ Use latex-free syringes and medication
containers (glass ampules), and latex-safe
intravenous equipment.
◦ Instruct the client to wear a MedicAlert bracelet.
◦ Instruct the client about the importance of
informing healthcare providers and local and
paramedic ambulance companies about the
allergy
IX. Immunodeficiency
A. Description
1. Immunodeficiency is the absence or
inadequate production of immune bodies.
2. The disorder can be congenital (primary) or
acquired (secondary).
3. Treatment depends on the inadequacy of
immune bodies and its primary cause.
B. Assessment
1. Factors that decrease immune function
2. Frequent infections
The priority concern for a client with
immunodeficiency is infection.
C. Interventions
1. Protect the client from infection.
2. Promote a balanced diet with adequate
nutrition.
3. Use strict aseptic technique for all procedures.
4. Provide psychosocial care regarding lifestyle
changes and role changes.
5. Instruct the client in measures to prevent
infection.
6. Instruct the client to wear a MedicAlert
bracelet.
X. Autoimmune Disease
A. Description
1. Body is unable to recognize its own cells as a
part of itself.
 2. Autoimmune disease can affect collagenous
tissue.
B. Systemic lupus erythematosus (SLE)
1. Description
a. Chronic, progressive, systemic inflammatory
disease that can cause major organs and systems
to fail
b. Connective tissue and fibrin deposits collect in
blood vessels on collagen fibers and on organs.
c. The deposits lead to necrosis and
inflammation in blood vessels, lymph nodes,
gastrointestinal tract, and pleura.
d. No cure for the disease is known but
remissions are frequently experienced by clients
who manage their care well.
Causes
a. The cause of SLE is unknown, but is believed to
be a defect in immunological mechanisms, with a
genetic origin.
b. Precipitating factors include medications, stress,
genetic factors, sunlight or ultraviolet light, and
pregnancy.
c. Discoid lupus erythematosus is possible with
some medications but totally disappears after
the medication is stopped; the only manifestation is
the skin rash that occurs in lupus.
3. Assessment
a. Assess for precipitating factors.
b. Erythema of the face (malar rash; also called a
butterfly rash)
c. Dry, scaly, raised rash on the face or upper
body
d. Fever
e. Weakness, malaise, and fatigue
f. Anorexia
g. Weight loss
h. Photosensitivity
i. Joint pain
j. Erythema of the palms
k. Anemia
l. Positive ANA test and lupus erythematosus
preparation
m. Elevated erythrocyte sedimentation rate
(ESR) and C-reactive protein level
4. Interventions
a. Monitor skin integrity and provide frequent
oral care.
b. Instruct the client to clean the skin with a mild
soap, avoiding harsh and perfumed nsubstances.
c. Assist with the use of ointments and creams
for the rash as prescribed.
d. Identify factors contributing to fatigue.
e. Administer iron, folic acid, or vitamin
supplements as prescribed if anemia occurs.
f. Provide a high-vitamin and high-iron diet.
g. Provide a high-protein diet if there is no
evidence of kidney disease.
h. Instruct in measures to conserve energy, such
as pacing activities and balancing rest with
exercise.
i. Administer topical or systemic corticosteroids,
salicylates, and nonsteroidal anti-inflammatory
drugs as prescribed for pain and inflammation.
j. Administer medications to decrease the
inflammatory response as prescribed
k. Monitor intake and output, as well as daily
weight for signs of fluid overload if
corticosteroids are used.
l. Instruct the client to avoid exposure to sunlight
and ultraviolet light.
m. Monitor for proteinuria and red cell casts in
the urine.
n. Monitor for bruising, bleeding, and injury.
o. Assist with plasmapheresis as prescribed to
remove auto antibodies and immune complexes
from the blood before organ damage occurs.
p. Monitor for signs of organ involvement
such as pleuritis, nephritis, pericarditis, coronary
artery disease, hypertension, neuritis, anemia,
and peritonitis.
q. Note that lupus nephritis occurs early in
thedisease process.
r. Provide supportive therapy as major organs
become affected.
s. Provide emotional support and encourage the
client to verbalize feelings.
t. Provide information regarding support groups
and encourage the use of community resources.
NURSE ALERT
For the client with SLE, monitor the blood urea
nitrogen and creatinine levels frequently for
signs of renal
impairment.
C. Scleroderma (systemic sclerosis)
1. Description
 a. Scleroderma is a chronic connective tissue
disease, similar to SLE, that is characterized
by inflammation, fibrosis, and sclerosis.
b. This disorder affects the connective tissue
throughout the body.
c. It causes fibrotic changes involving the skin,
synovial membranes, esophagus, heart,
lungs, kidneys, and gastrointestinal tract.
d. Treatment is directed toward forcing the
disease into remission and slowing its progress.
2. Assessment
a. Pain
b. Stiffness and muscle weakness
c. Pitting edema of the hands and fingers that
progresses to the rest of the body
d. Taut and shiny skin that is free from wrinkles
e. Skin tissue is tight, hard, and thick; loses its
elasticity; and adheres to underlying strucures.
f. Dysphagia
g. Decreased range of motion
h . Joint contractures
i. Inability to perform activities of daily living
3. Interventions
a. Encourage activity as tolerated.
b. Maintain a constant room temperature.
c. Provide small frequent meals, eliminating
foods that stimulate gastric secretions, such as
spicy foods, caffeine, and alcohol.
d. Monitor for esophageal involvement; if
present, advise the client to sit up for 1 to 2 hours
after meals. Using additional pillows and raising
the head of the bed on blocks may help to reduce
nocturnal reflux.
e. Provide supportive therapy as the major
organs become affected.
f. Administer corticosteroids as prescribed for
inflammation.
g. Provide emotional support and encourage the
use of resources as necessary
D. Polyarteritis nodosa
1. Description
a. Polyarteritis nodosa is a collagen disease; it is
a form of systemic vasculitis that causes
inflammation of the arteries in visceral organs,
brain, and skin.
b. Treatment is similar to the treatment for SLE.
c. Polyarteritis nodosa affects middle-aged men.
d. The cause is unknown and the prognosis is
poor.
e. Renal disorders and cardiac involvement are
the most frequent causes of death.
2. Assessment
a. Malaise and weakness
b. Low-grade fever
c. Severe abdominal pain
d. Bloody diarrhea
e. Weight loss
f. Elevated ESR
E. Pemphigus
1. Description
a. Pemphigus is a rare autoimmune disease that
occurs predominantly between middle
age and old age.
b. The cause is unknown, and the disorder is
potentially fatal.
c. Treatment is aimed at suppressing the immune
response and blister formation.
2. Assessment
a. Fragile, partial-thickness lesions bleed, weep,
and form crusts when bullae are
disrupted.
b. Debilitation, malaise, pain, and dysphagia
c. Nikolsky’s sign: Separation of the epidermis
caused by rubbing the skin
d. Leukocytosis, eosinophilia, foul-smelling
discharge from skin
3. Interventions
a. Provide supportive care.
b. Provide oral hygiene and increase fluid intake.
c. Soothe oral lesions.
d. Assist with soothing baths, as prescribed for
relief of symptoms.
e. Administer topical or systemic antibiotics as
prescribed for secondary infections.
f. Administer corticosteroids and cytotoxicagents
as prescribed to bring about remission.
XI. Goodpasture’s Syndrome
A. Description
1. An autoimmune disorder; autoantibodies are
made against the glomerular basement
membrane and alveolar basement membrane.
2. It is most common in males and young adults
who smoke; the exact cause is unknown.
3. The lungs and the kidneys are affected
primarily,and the disorder usually is not
diagnosed until significant pulmonary or renal
involvement occurs
B. Assessment
1. Clinical manifestations indicating pulmonary
and renal involvement
2. Shortness of breath
3. Hemoptysis
4. Decreased urine output
5. Edema and weight gain
6. Hypertension and tachycardia
. Interventions
1. Focus on suppressing the autoimmune
response with medications such as
corticosteroids, and on
2. plasmapheresis (filtration of the plasma
toremove some proteins and autoantibodies).
3. Provide supportive therapy for pulmonary and
renal involvement.
XII. Lyme Disease
A. Description
1. An infection caused by the spirochete Borrelia
burgdorferi, acquired from a tick bite (ticks live
in wooded areas and survive by attaching to a
host).
2. Infection with the spirochete stimulates
inflammatory cytokines and autoimmune
mechanisms.
B. Assessment
1. The typical ring-shaped rash of Lyme disease
does not occur in all clients. Many clients never
develop a rash. In addition, if a rash does occur,
it can occur anywhere on the body, not only at
the site of the bite.
Assessment and Stages of Lyme
Disease
Symptom
 First Stage can occur several days to
months following the bite.
 A small red pimple develops that may
spread into a ringshaped rash; it may
occur anywhere on the body.
 Ring-shaped rash may be large or small,
or may not occur at all.
 Flulike symptoms occur, such as
headaches, stiff neck,nmuscle aches, and
fatigue.
Second Stage
 This stage occurs several weeks
following the bite.
 Joint pain occurs.
 Neurological complications occur.
 Cardiac complications occur.
Third Stage
 Large joints become involved.
 Arthritis progresses.
C. Interventions
1. Gently remove the tick with tweezers, wash
the skin with antiseptic, and dispose of the tick
by flushing it down the toilet; the tick may also
be placed in a sealed jar so that the health care
provider can inspect it and determine its type.
2. Perform a blood test 4 to 6 weeks after a bite
to detect the presence of the disease (testing
before this time is not reliable).
3. Instruct the client in the administration of
antibiotics as prescribed; these are initiated
immediately (even before the blood testing
results are known)
4. Instruct the client to avoid areas that contain
ticks, such as wooded grassy areas, especially in
the summer months.
5. Instruct the client to wear long-sleeved tops,
long pants, closed shoes, and hats while outside.
6. Instruct the client to spray the body with tick
repellent before going outside.
7. Instruct the client to examine the body when
returning inside for the presence of ticks.
XIII. Immunodeficiency Syndrome
A. Acquired immunodeficiency syndrome
(AIDS)
1. AIDS is a viral disease caused by HIV, which
destroys T cells, thereby increasing susceptibility
to infection and malignancy.
2. The syndrome is manifested clinically by
opportunistic infections and unusual neoplasms.
3. AIDS is considered a chronic illness.
4. The disease has a long incubation period,
sometimes 10 years or longer.
Tests Used to Evaluate Progression of Human
Immunodeficiency Virus (HIV) Infection
◦ Complete Blood Cell Count
◦ ▪ WBC count (normal to decreased)
◦ ▪ Lymphopenia (< 30% of the normal number of
WBCs)
◦ ▪ Thrombocytopenia (decreased platelet count)
◦ Lymphocyte Screen
◦ ▪ Reduced CD4 +/ CD8+ T-cell ratio
◦ ▪ CD4+ (helper) lymphocytes decreased
◦ ▪ CD8+ lymphocytes increased
◦ Quantitative Immunoglobulin
◦ ▪ IgG level increased
◦ ▪ IgA level frequently increased
◦ Chemistry Panel
◦ ▪ Lactate dehydrogenase level increased (all
fractions)
◦ ▪ Serum albumin level decreased
◦ ▪ Total protein increased
◦ ▪ Cholesterol level decreased
◦ ▪ AST and ALT levels elevated
◦ Anergy Panel
◦ ▪ Nonreactive (anergic) or poorly reactive to
infectious agents or environmental materials
(e.g., pokeweed, phytohemagglutinin mitogens
and antigens, mumps, Candida)
◦ Hepatitis B Surface Antigen Testing
◦ ▪ To detect the presence of hepatitis B
◦ Blood Cultures
◦ ▪ To detect septicemia
◦ Chest Radiography
◦ ▪ To detect Pneumocystis jiroveci infection or
tuberculosis
Diagnostic Criteria for Acquired
Immunodeficiency Syndrome (AIDS)
◦ CD4 + T-cell count drops below 200 cells/ L
◦ Presence of a fungal, viral, protozoal, or bacterial
infection
◦ Candidiasis of bronchi, trachea, lungs, or
esophagus
◦ Pneumocystis jiroveci pneumonia
◦ Disseminated or extrapulmonary
coccidiomycosis
◦ Disseminated or extrapulmonary histoplasmosis
◦ Cytomegalovirus
◦ Herpes simplex
◦ Progressive multifocal leukoencephalopathy
◦ Toxoplasmosis
◦ Mycobacterium tuberculosis
◦ Recurrent pneumonia
◦ Recurrent salmonella septicemia
◦ Presence of an opportunistic cancer
◦ Invasive cervical cancer
◦ Kaposi’s sarcoma
◦ Burkitt’s lymphoma
◦ Immunoblastic lymphoma
◦ Primary lymphoma of the brain
◦ Wasting syndrome (10% or more of ideal body
mass)
◦ AIDS dementia complex
E. Interventions
1. Provide respiratory support.
2. Administer oxygen and respiratory treatments
as prescribed.
3. Provide psychosocial support and support
services as needed.
4. Maintain fluid and electrolyte balance.
5. Monitor for signs of infection and institute
protective isolation precautions as necessary.
6. Prevent the spread of infection.
7. Initiate standard and other necessary
precautions.
8. Provide comfort as necessary.
9. Provide meticulous skin care.
10. Provide adequate nutritional support as
prescribed.
F. Kaposi’s sarcoma
1. Description: Skin lesions that occur primarily
in individuals with a compromised immune
system
2. Assessment
a. Kaposi’s sarcoma is a slow-growing tumor
that appears as raised, oblong, purplish,
reddish-brown lesions; may be tender or
nontender.
b. Organ involvement includes the lymph nodes,
airways or lungs, or any part ofthe
gastrointestinal tract from the mouth to anus.
3. Interventions
a. Maintain standard precautions.
b. Provide protective isolation if the
immunsystem is depressed.
c. Prepare the client for radiation therapy or
chemotherapy as prescribed.
 d. Administer immunotherapy, as prescribed, to
stabilize the immune system.

XIV. Posttransplantation Immunodeficiency

A. Description
1. Secondary immunodeficiency is
immunosuppression caused by therapeutic
agents.
2. The client must take immunosuppressive
agents for the rest of his or her life
posttransplantation to decrease rejection of the
transplanted organ or tissue.

B. Diagnosis and monitoring of posttransplantation

clients
1. Check renal and hepatic function.
2. Monitor the complete cell count with
differential to determine signs of infection.
3. Assess all body secretions periodically for
blood.

C. High-risk clients
1. Clients with a history of malignancy or
premalignancy have an increased susceptibility
to malignancy if immunosuppressed.
2. Clients with recent infection or exposure to
tuberculosis, herpes zoster, or chickenpox have
a high risk for severe generalized disease when
on immunosuppressive agents.

D. Assessment
1. Assess for signs of opportunistic infections.
2. Assess nutritional status.
3. Assess for signs of rejection (signs will
depend on the organ or tissue transplant).

E. Interventions
1. Strict aseptic technique is necessary.
2. Provide teaching regarding asepsis and the
signs of infection and rejection.
3. Institute protective isolation precautions as
necessary.
4. Provide psychosocial support as needed.
5. Provide client teaching about
immunosuppressants.
I. Human Immunodeficiency Virus (HIV) and
Acquired IMMUNOLOGIC MEDICATIONS
Immunodeficiency Syndrome (AIDS)
A. Medications include nucleoside-nucleotide
reverse transcriptase inhibitors (NRTIs),
nonnucleoside reverse transcriptase inhibitors
(NNRTIs), protease inhibitors (PIs), and fusion
inhibitors
B. NRTIs and NNRTIs work by inhibiting the
activity of reverse transcriptase.
C. PIs work by interfering with the activity of the
enzyme protease.
D. Fusion inhibitors work by inhibiting the binding
of HIV to cells.
E. Standard treatment consists of using 3 or 4
medications in regimens known as highly active
antiretroviral therapy (HAART); this therapy is not
curative but can delay or reverse loss of immune
function, preserve health, and prolong life.
F. Other medications include those that are used to
treat complications or opportunistic infections that
develop
G. Nucleoside-nucleotide reverse transcriptase
inhibitors (NRTIs)
1. Abacavir: Can cause nausea; monitor for
hypersensitivity reaction, including fever, nausea,
vomiting, diarrhea, lethargy, malaise, sore throat,
shortness of breath, cough, and rash.
2. Abacavir/lamivudine: In addition to the
effects that can occur from abacavir and lamivudine,
hypersensitivity reactions, lactic acidosis, and severe
hepatomegaly can occur.
3. Didanosine: Can cause nausea, diarrhea,
peripheral neuropathy, hepatotoxicity, and
pancreatitis
4. Emtricitabine: Can cause headache, diarrhea,
nausea, rash, hyperpigmentation of the palms
and soles, lactic acidosis, and severe hepatomegaly
5. Emtricitabine/tenofovir: In addition to the
effects that can occur from emtricitabine and
tenofovir (see below), lactic acidosis and
severe hepatomegaly can occur.
6. Lamivudine: Causes nausea and nasal congestion
7. Lamivudine/zidovudine: Can cause anemia
and neutropenia and lactic acidosis with
hepatomegaly
8. Lamivudine/zidovudine/abacavir: In addition
to the effects that can occur from lamivudine,
zidovudine, and abacavir, hypersensitivity reactions,
anemia, neutropenia, lactic
acidosis, and severe hepatomegaly can occur.
9. Stavudine: Can cause peripheral neuropathy
and pancreatitis
10. Tenofovir: Can cause nausea and vomiting
11. Zidovudine: Can cause nausea, vomiting, anemia,
leukopenia, myopathy, fatigue, and
headache
H. Nonnucleoside reverse transcriptase inhibitors
(NNRTIs)
1. Delavirdine: Can cause rash, liver function
changes, and pruritus
2. Efavirenz: Can cause rash, dizziness, confusion,
difficulty concentrating, dreams, and
encephalopathy
3. Etravirine: Can cause rash, gastrointestinal
disturbances, headache, hypertension, and peripheral
neuropathy
4. Nevirapine: Can cause rash, Stevens-Johnson
syndrome, hepatitis, and increased transaminase
levels
I. Protease inhibitors (PIs)
1. Atazanavir: Can cause nausea, headache,
infection, vomiting, diarrhea, drowsiness, insomnia,
fever, hyperglycemia, hyperlipidemia, and
increased bleeding in clients with hemophilia
2. Fosamprenavir: Can cause nausea, vomiting,
headache, altered taste sensations, perioral
paresthesia, rashes, and altered liver function
3. Indinavir: Can cause nausea, diarrhea,
hyperbilirubinemia, nephritis, and kidney stones
4. Lopinavir/ritonavir Can cause nausea, diarrhea,
altered taste sensations, circumoral paresthesia,
and hepatitis
5. Nelfinavir: Can cause nausea, flatulence, and
diarrhea
6. Ritonavir: Can cause nausea, vomiting, diarrhea,
altered taste sensations, circumoral paresthesia,
hepatitis, and increased triglyceride
levels
7. Saquinavir: Can cause nausea, diarrhea,
photosensitivity, and headache
8. Tipranavir: Hepatotoxicity (liver damage); can
also cause nausea, vomiting, diarrhea, headache, and
fatigue
J. Integrase inhibitor: Raltegravir
1. Stops HIV replication and is used in combination
with other antiretroviral medications
2. Common side and adverse effects include nausea,
diarrhea, fatigue, headache, and itching.
K. Chemokine receptor 5 (CCR5) antagonist:
Maraviroc
1. Binds with CCR5 and blocks viral entry
2. Most common side and adverse effects are
cough, dizziness, pyrexia, rash, abdominal pain,
musculoskeletal symptoms, and upper respiratory ▪ Tipranavir
tract infections; liver injury and cardiovascular Integrase Inhibitor
events have occurred in some clients. ▪ Raltegravir
L. Fusion inhibitor: Enfuvirtide can cause skin ▪ Dolutegravir
irritation at injection site, fatigue, nausea, insomnia, ▪ Elvitegravir
and peripheral neuropathy. Fusion Inhibitor
M. Antiinfective and antiinflammatory ▪ Enfuvirtide
medications: Chemokine Receptor 5 (CCR5) Antagonist
Used to treat opportunistic infections such as ▪ Maraviroc
Pneumocystis jiroveci pneumonia; Toxoplasma Antiinflammatory Medication
encephalitis is treated with ▪ Sulfasalazine
sulfamethoxazole/trimethoprim Antiinfective Medications
N. Antifungal medications: Used to treat ▪ Atovaquone
candidiasis ▪ Metronidazole
and cryptococcal meningitis (see Box 67-1) ▪ Pentamidine isethionate
O. Antiviral medications: Used to treat ▪ Sulfamethoxazole/ trimethoprim
cytomegalovirus retinitis, herpes simplex, and Antifungal Medications
varicella-zoster virus ▪ Amphotericin B
▪ Fluconazole
Medications for Human Immunodeficiency Virus ▪ Itraconazole
(HIV) and Acquired Immunodeficiency ▪ Ketoconazole
Syndrome (AIDS) ▪ Voriconazole
Nucleoside-Nucleotide Reverse Transcriptase Antiviral Medications
Inhibitors ▪ Acyclovir
(NRTIs) ▪ Foscarnet
▪ Abacavir ▪ Ganciclovir
▪ Abacavir/ lamivudine ▪ Valacyclovir
▪ Didanosine
▪ Emtricitabine II. Immunosuppressants
▪ Emtricitabine/ tenofovir A. Description: Immunosuppressants are used for
▪ Emtricitabine/ tenofovir/efavirenz transplant recipients to prevent organ or tissue
▪ Lamivudine rejection and to treat autoimmune disorders such as
▪ Lamivudine/ zidovudine systemic lupus erythematosus.
▪ Lamivudine/ zidovudine/ abacavir B. Cyclosporine
▪ Stavudine 1. Used for prevention of rejection following
▪ Tenofovir allogeneic organ transplantation
▪ Zidovudine 2. Usually administered with a glucocorticoid and
Nonnucleoside Reverse Transcriptase Inhibitors another immunosuppressant
(NNRTIs) 3. The most common adverse effects are
▪ Delavirdine nephrotoxicity, infection, hypertension, and
▪ Efavirenz hirsutism.
▪ Etravirine C. Tacrolimus
▪ Nevirapine 1. Used for prevention of rejection following liver
Protease Inhibitors (PIs) or kidney transplantation
▪ Atazanavir 2. Adverse effects include nephrotoxicity,
▪ Darunavir neurotoxicity, gastrointestinal effects, hypertension,
▪ Fosamprenavir hyperkalemia, hyperglycemia, hirsutism, and
▪ Indinavir gum hyperplasia.
▪ Lopinavir/ ritonavir D. Azathioprine
▪ Nelfinavir 1. Generally used with renal transplant recipients
▪ Ritonavir 2. Can cause neutropenia and thrombocytopenia
▪ Saquinavir E. Cyclophosphamide
1. Used for its immunosuppressant action to treat ▪ Muromonab-CD3
autoimmune disorders ▪ Rho(D) immune globulin
2. Can cause neutropenia and hemorrhagic cystitis Other
F. Methotrexate ▪ Sirolimus
1. Used for its immunosuppressant action to treat ▪ Everolimus
autoimmune disorders
2. Can cause hepatic fibrosis and cirrhosis, bone IV. Antibiotics
marrow suppression, ulcerative stomatitis, and A. Inhibit the growth of bacteria
renal damage B. Include medication classifications of
G. Mycophenolate mofetil and mycophenolic acid aminoglycosides, cephalosporins, fluoroquinolones,
1. Used to prevent rejection following kidney, macrolides, lincosamides, monobactams, penicillins
heart, and liver transplantation and
2. Can cause diarrhea, vomiting, neutropenia, and penicillinase-resistant penicillins, sulfonamides,
sepsis; increases the risk of infection and tetracyclines, antimycobacterials, and others
malignancies, especially lymphomas C. Adverse effects (Table 67-1)
H. Basiliximab D. Nursing considerations
1. Used to prevent rejection following kidney 1. Assess for allergies.
transplantation 2. Monitor appropriate laboratory values before
2. Can cause severe acute hypersensitivity reactions, therapy as appropriate and during therapy to
including anaphylaxis assess for adverse effects.
I. Lymphocyte immune globulin, antithymocyte 3. Monitor for adverse effects and report to the
globulin health care provider if any occur.
1. Used to prevent rejection following kidney, 4. Determine the appropriate method of
heart, liver, and bone marrow transplantation administration and provide instructions to the client.
2. Side and adverse effects include fever, chills, 5. Monitor intake and output.
leukopenia, and skin reactions. 6. Encourage fluid intake (unless contraindicated).
3. Can cause anaphylactoid reactions 7. Initiate safety precautions because of possible
J. Sirolimus central nervous system effects.
1. Used to prevent renal transplant rejection 8. Teach the client about the medication and how
2. Increases the risk of infection; raises to take it; emphasize the importance of completing
cholesterol and triglyceride levels; can cause the full prescribed course.
renal injury
3. Other side and adverse effects include rash, ANTIBIOTICS
acne, anemia, thrombocytopenia, joint pain, Aminoglycosides
diarrhea, and hypokalemia. ▪ Amikacin
▪ Gentamicin
Immunosuppressants ▪ Neomycin
Calcineurin Inhibitors ▪ Streptomycin
▪ Cyclosporine ▪ Tobramycin
▪ Tacrolimus Cephalosporins
▪ Cefaclor
Cytotoxic Medications ▪ Cefadroxil
▪ Azathioprine ▪ Cefazolin
▪ Cyclophosphamide ▪ Cefdinir
▪ Methotrexate ▪ Cefditoren
▪ Mycophenolate mofetil ▪ Cefepime
▪ Mycophenolic acid ▪ Cefotaxime
▪ Cefotetan
Antibodies ▪ Cefoxitin
▪ Basiliximab ▪ Cefpodoxime
▪ Lymphocyte immune globulin, antithymocyte ▪ Cefprozil
globulin ▪ Ceftazidime
▪ Ceftibuten ▪ Ketoconazole
▪ Ceftriaxone ▪ Voriconazole
▪ Cefuroxime Antiviral Medications
▪ Cephalexin ▪ Acyclovir
Fluoroquinolones ▪ Foscarnet
▪ Ciprofloxacin ▪ Ganciclovir
▪ Gemifloxacin ▪ Valacyclovir
▪ Levofloxacin
▪ Moxifloxacin
▪ Norfloxacin Classification and Adverse Effects
▪ Ofloxacin Aminoglycosides Ototoxicity Confusion,
Macrolides disorientation, Renal toxicity, Gastrointestinal
▪ Azithromycin irritation, Palpitations, blood pressure changes,
▪ Clarithromycin Hypersensitivity reactions
▪ Erythromycin Cephalosporins Gastrointestinal disturbances
Lincosamides Pseudomembranous colitis, Headache, dizziness,
▪ Clindamycin lethargy, paresthesias, Nephrotoxicity,
▪ Lincomycin Superinfections
Fluoroquinolones Headache, dizziness, insomnia,
Monobactam Depression, Gastrointestinal effects, Bone marrow
▪ Aztreonam depression, Fever, rash, photosensitivity
Penicillins Macrolides Gastrointestinal effects,
▪ Amoxicillin Pseudomembranous colitis, Confusion, abnormal
▪ Ampicillin thinking, Superinfections, Hypersensitivity reactions
▪ Penicillin G Lincosamides Gastrointestinal effects,
▪ Penicillin V Pseudomembranous colitis, Bone marrow depression
▪ Piperacillin Monobactams Gastrointestinal effects,
Penicillinase-Resistant Hepatotoxicity
Penicillins Allergic reactions
▪ Dicloxacillin Penicillins and penicillinase-resistant
▪ Nafcillin Penicillins Gastrointestinal effects, including sore
▪ Oxacillin mouth and furry tongue, Superinfections
Sulfonamides Hypersensitivity reactions, including
▪ Sulfamethoxazole anaphylaxis
▪ Sulfadiazine Sulfonamides Gastrointestinal effects
▪ Sulfasalazine Hepatotoxicity, Nephrotoxicity
▪ Sulfisoxazole Bone marrow depression
▪ Trimethoprim/ Dermatological effects, including
sulfamethoxazole hypersensitivity and photosensitivity
Tetracyclines Headache, dizziness, vertigo, ataxia,
▪ Demeclocycline depression, seizures
▪ Doxycycline Tetracyclines Gastrointestinal effects
▪ Minocycline Hepatotoxicity, Teeth (staining) and bone damage
▪ Tetracycline Superinfections, Dermatological reactions, including
Antimycobacterials rash and photosensitivity, Hypersensitivity reactions
▪ Antituberculosis agents Antimycobacterials, leprostatics, Gastrointestinal
▪ Leprostatics:Clofazimine, effects, Neuritis, dizziness, headache, malaise,
Thalidomide drowsiness, hallucinations
Antifungal Medications Antifungals Gastrointestinal effects
▪ Amphotericin B Headache, rash, anemia, hepatotoxicity
▪ Fluconazole Hearing loss, peripheral neuritis
▪ Itraconazole