AUTOIMMUNE DISEASE NURSING CARE

Prof. Dr. H. Nursalam, M.Nurs (Hons)

Professor in Nursing Sciences
Universitas Airlangga

PENDIDIKAN TERAKHIR:
DOKTOR UNAIR 2005
GURU BESAR ILMU KEPERAWATAN: 01 OKTOBER 2013

JABATAN SEBELUMNYA:
DEKAN (2008-2010; 2015-2020), MANAJER KEPERAWATAN RS (2010-2015),
Wakil KAPRODI NERS FK UNAIR (1999-2008)

SAAT INI:
KPS S3 (2021-2025);
Ketua Komisi I Pendidikana SENAT AKADEMIK UNAIR

ORGANISASI:
1. KETUA PPNI JATIM
2. KETUA DEWAS AIPVIKI
3. PEMBINA AIPNI PUSAT
 Publication – Social Media

Akun Ilmiah ID/ Link Akun Ilmiah

Scopus 56660628500 (H-Index 9)
https://www.scopus.com/authid/detail.uri?authorId=56660628500

Orcid ID https://orcid.org/0000-0002-9052-6983

Sinta http://sinta.ristekbrin.go.id/authors/detail?id=5979800&view=overview

Google Scholar https://scholar.google.com/citations?hl=en&authuser=2&user=SflVStsAAAAJ

Academia.edu https://unair.academia.edu/nursalamnursalam

Linkedin https://www.linkedin.com/in/nursalam-nursalam-2753091b4/

Research Gate https://www.researchgate.net/profile/Nursalam_Nursalam4

 OUTLINES
1. THE CONCEPT OF IMMUNE DISEASES
2. MODEL OF NURSING CARE CLIENT
WITH IMMUNE DISEASES
3. EXAMPLES OF NURSING CARE
4. CONCLUSION
 1 THE CONCEPT OF AUTOIMMUNE
DISEASE

AUTOIMMUNITY: The presence of autoantibodies (antibodies against auto-

antigens) or autoreactive (self reactive) lymphocytes without the induction of any
pathological changes

Autoantibodies can be found in normal individuals, particularly in old animals

and in the female gender group

AUTOANTIBODIES may have a physiological role in:

1. Removal of senescent/ damaged cells
2. Idiotype anti-idiotypes negative feed back
AUTOIMMUNE DISEASES: happens when the body’s natural defense system can’t
tell the difference between your own cells and foreign cells, causing the body to
mistakenly attack normal cells.
 IMMUNE DISEASE
1. B cell or T cell deficiency: The immune system fails to defend the body from
bacterial or viral attacks

2. Autoimmune disease: The immune system mistakenly attacks the body's own
tissues that it no longer recognizes and tolerates.

3. Complex disease – immune: Excessive antigen-antibody complex activates a

deadly complement component that damages surrounding normal cells.

4. Allergy: The immune system inappropriately causes symptoms and damages

the body against allergens
 CRITERIA FOR AUTOIMMUNE DISEASE

1. The presence of
autoantibodies or autoreactive
lymphocytes (in association
with pathological changes)
2. Experimental reproduction of the
disease in laboratory animal
3. The features of the experimental
disease must closely match
with the clinical disease.
4. Ability to passively transfer the
disease by autoantibodies or
lymphocytes
 GENERAL CHARACTERISTICS
1) Autoimmunity results from a failure or breakdown of the mechanisms normally
responsible for maintaining self-tolerance in B cells, T cells, or both.
2) Although underlying molecular etiologies remain elusive for most autoimmune diseases, it is
thought that autoimmunity is multifactorial, resulting from a complex interplay
between genetic susceptibility, environmental triggers, and aberrant immune
regulation
3) Autoimmune diseases may be either systemic or organ specific.
4) Various effector mechanisms are responsible for tissue injury in different autoimmune
diseases.
5) It is not uncommon for a patient to have symptoms of more than one autoimmune
disease (known as ‘overlap’, or undifferentiated collagen vascular syndrome).
6) On contrary, a patient with one autoimmune disease may have serologic markers –
but no clinical manifestations – of another
What Causes Autoimmune Diseases?

1) The exact etiology of autoimmune

diseases still remains unknown.
2) Several factors are presumed to
contribute to the emergence of an
autoimmune disease in a host, which
are:
a) the genetic predisposition,
b) the environmental triggers such as
bacterial (including the gut microbiota),
viral, fungal and parasitic infections;
physical and environmental agents;
hormonal factors, and
c) the hosts immune system dysregulation.
(Bellanti JA (Ed). Immunology IV: Clinical Applications in Health and Disease. I Care Press,
Bethesda, MD, 2012].)
Association of autoimmune diseases and MHC
 Mechanisms of Tissue damage
§ T cells are involved in almost all autoimmune diseases, particularly in organ specific
autoimmune disorders (probably due a lack of T regulatory cells or the participation of Th17
cells).
§ Macrophages, which are activated by T cells are also involved in tissue damage (release of
toxic enzymes and oxidative free-radicals; Type IV).
§ Most autoimmune diseases are characterized by the production of antibodies directed to
self antigens, known as auto-antibodies
§ The physical properties of an autoantibody that determines its pathogenicity include:
§ Its affinity to the antigen that plays a role in immune complexes formation, and
§ its charge that helps antibody attach to tissues, e.g. in SLE, positively charged auto-
antibodies (anti-double stranded DNA) associate with the negatively charged basement
membrane in the kidney, where they can form complexes in situ with DNA and lead to
local inflammation.
§ Most of the pathogenic auto-antibodies are of IgG isotype.
Examples of diseases caused by cell and tissue
specific antibodies
 Autoimmune Diseases
ORGAN SPECIFIC
AUTOIMMUNE THYROIDITIS NON-ORGAN SPECIFIC
AUTOIMMUNE SKIN DISEASES SLE
RHEUMATOIDARTHRITIS
AUTOIMMUNE REPRODUCTIVE
DISEASES POLYARTHRITIS
AUTOIMMUNE HEMOLYTIC ( NON-RA )
ANEMIA DERMATOMYOSITIS
MYESTHENIA GRAVIS MULTIPLE SCLEROSIS

POSSIBLE
AUTOIMMUNE OPTHALMIC DISEASES AUTOIMMUNE
• Alopecia atrea
INSULIN-DEPENDENT DIABETES
(TYPE 1 DM) • STEROID
RESPONSIVE
AUTOIMMUNE ADRENALITIS MENINGITIS
AUTOIMMUNE NEUROLOGICAL DISEASES
 2 MODEL OF NURSING CARE FOR CLIENT
WITH AUTOIIMUNE DISEASES

NURSING CARE
A form of professional service which
is an integral part of health services,
based on nursing knowledge and
tips in the form of comprehensive
Bio-Psycho-Socio-Spiritual services
aimed at individuals, families and
communities, both sick and healthy,
covering all processes of human
life.
 IMMUNE SYSTEM MECHANISM

Immunity:
Mechanism/ability of the body to withstand or eliminate foreign objects /
abnormal cells that are potentially harmful to the body

Immune system function:

Defends the body against foreign cell invasion and cancer cells; pave the way for
network repair.

Functions of the integumentary system/skin:

Prevents entry of external agents & loss of internal fluids by functioning as a
protective barrier between the external environment and other body parts
 Immune Responses:

1) Immune Specific: Destroys familiar foreign compounds

2) Non Specific Immune: First line against atypical cells (foreign cells,
injured mutants) Includes: Inflammation, interferons, NK cells and
the complement system.
Differences in the Nature of Specific and
Non-Specific Immune Response
Non Specific Specific
Resistance Unchanged by infection Improved by repeated
infections
Specify Generally effective Specific for pre-sensitized
against all microorganisms
microorganisms
Phagocyte Lymphocyte
Important Cells
Cell NK Antibody
Cell K

Lizosim Cytokine
Important
Molecules Komplemen
Interferon
 Specific Immune
Response

1. Antibody-mediated immunity à B. lymphocyte derivatives

2. Cell-mediated immunity à T. lymphocyte

B Lymphocytes
Antibodies based on biological activity are divided into:
1. Ig M B-cell surface receptors, to which antigens attach
2. IgG, produced: if the body is re-exposed to the same antigens IgG & IgM Bacteria
and some types of viruses
3. IgE, for allergic responses such as asthma, hives.
4. IgA, in the selection of digestive, respiratory, genitourinary, milk and tear systems.
5. IgD, on the surface of B cells, the function is not clear.
 Nursing Care to Service Excellent
Jean Watson (1999) à 10 caretive factor:
1. Humanistic-altruistic system of values
2. Faith-hope (= penuh harapan)
3. Sensitivity to self and others
4. Helping-trusting, human care relationship
5. Expressing positive and negative feelings
6. Creative problem-solving caring process
7. Transpersonal teaching-learning
8. Supportive, protective, and/or corrective mental, physical, societal
and spiritual environment
9. Human needs assistance
10.Existential-phenomenological-spiritual forces (mind – body – soul )
 Nursing Responsibilities in Patient-Centered
Approaches (Faye Abdellah)
1. Effective communication between patient and
caregiver. Information is accurate, timely and
appropriate.
2. Do everything possible to alleviate patients’
pain and make them feel comfortable.
3. We provide emotional support and alleviate fears and
anxiety.
4. We involve family and friends in every phase of our
patients’ care.
5. We ensure a smooth transition and continuity from
one focus of care to another.
6. We guarantee every member of our community has
access to our care (BPJS / poor / general)
Nursalam_Holistic_Unair_09
 HOLISTIC CARE

5/13/22 Magister of Nursing - Airlangga University (JONI)

 CAR
ING

5/13/22 Magister of Nursing - Airlangga University

 Contoh - rational for the theory choosen:
(1) Adaptation Model
ANTECEDENT: BEHAVIOR
Input Control Effectors CONSEQUENCY Output
processes

Stimuli
Adaptation Coping Physiological function Adaptive
Level mechanisms Self-concept and ineffective
l FOCAL § Regulator Role function response
l CONTEXTUAL § Cognator Interdependence
l RESIDUAL
Feedback

Person as adaptive system. (From Roy, C. [1984]. Introduction to nursing: An adaptation model [2 nd ed.,
p. 30]. Englewood Cliffs, NJ: Prentice Hall.)
FRAMEWORK (p.403– ADAPTATION & PNI)
A Counseling for patient
(contextual) with Stress – pre op

Learning process
(cognator)
Perception Coping (+)
(+)
B Cognition -
Emotion
(Behavior –
coping)
Stress A
D
A
Hypotalamus
H (CRF)
P
Adrenal medulla T
P (Catecolamines A
Pituitary
(ACTH) - endorphin T
C A
(Conequency) I
Adrenal Cortex Vital signs O
AXIS (Cortisol ) (T, P, R, PB) N

IMMUNE RESPONSE MODULATION

(CD4; cytokin; IgG)
nursalam-MASALAH
 MODEL OF NURSING CARE
INPUT
Coping Strategy Social Support

Biologis; psikologis; social;

spiritual
COGNITIVE /
COGNATOR KOGNISI (LEARNING
RESPONSE PROCESS)
PROCESS
Cerebral Cortex LIMBIG SYSTEM
(Cognition: (Emotion: .Amigdala) Emotion (+)
Perception (+)
Astrocyte)

Learning (+) Anxiety(-)

Judgment(+) COPING STYLE (+) Social Interaction

-Rationalizations (+)
-Utilizing Social Support
Emotion (+) -Looking for Silver Lining
 HPA-AXIS
PROCESS
Hypothalamus
(CRF )
BIOLOGICAL
REGULATOR Pituitary
RESPONSE (ACTH)

Cortex Adrenal:
Fasciculate Zone
(Cortical)
OUTPUT
IMMUNE RESPONSE MODULATION

Th
IL-2, IL-10,
Th-1 (CD4 ) IFN-g
Th-2 (CD8 )

NKcell & CTL

Anti-HIV
Nursalam_Holistic_Unair_09
CLIENT CONDITION & QoL
PENGARUH SLEEP HYGIENE
MODIFIKASI BRAINGYM THD
ENDORPIN DAN KUALITAS
TIDUR PADA LANSIA
(Nursalam dkk, 2018)

Teori:
Kolcaba + PNI + Kualitas TIdur

en
r im
pe
ks
E
 INTERVENTION
A. BIOLOGY
B. PSYCHOLOGICAL
C. SOCIAL
D. SPIRITUAL
A

Nursalam_Holistic_Unair_09
 B
PSYCHOLOGICAL INTERVENTION

• SELF POTENTION EMPOWERMENT

• COGNITION TECHNIQUE (LEARNING PROCESS)

• BEHAVIOR (ACT – HEALTH CONDITION)

 Indicator adaptive psychological
response (psychology)
Psychological response
progress (Acceptance
response)
Psychology 1. Denial
- Kubler – Ross 2. Anger
(Sign. Anger & 3. Bargaining
Bargaining) 4. Depression
5. Acceptance
 C
SOCIAL APPROACH
We’ll do this together

• Emotional
• Reward
• Instrumental
• Information

37
 Indicator adaptive social response

Social adaptation progress

1. Emotional need
2. Self definition(-)
3. Interpersonal relationship (+)
Social (Emotional)
 D
SPIRITUAL

1) Pray
2) Self control
SPIRITUAL INTERVENTION
v Spiritual : values & religiosity

Hope

Reality

v Life value : Meaningful Life

v Religiosity : Improve
 Indicator of Adaptive spiritual
response

Response
1. Realistic expectation
2. Patience
Spiritual 3. Looking for silver
lining (-)
 3 EXAMPLES OF NURSING CARE
IN AUTOIMMUNE DISEASE

5 COMMON AUTOIMMUNE DISEASES INCLUDE:

1) Rheumatoid Arthritis (RA)
2) Multiple Sclerosis (MS),
3) Systemic Lupus Erythematosus (SLE),
4) Thyroid Disease (Graves disease),
5) Type 1 Diabetes,
COMMON AUTOIMMUNE DISEASE
1) NURSING CARE IN RHEUMATOID ARTHRITIS
Cause: Diffuse connective tissue
diseases have unknown causes, but
they are also thought to be the
result of immunologic
abnormalities.

Clinical Manifestation:
Joint pain, swelling, warmth,
erythema, lack of function,
deformities

Nursing care of the patient with RA

should follow a basic plan of care.
 CONT…1) NURSING MANAGEMENT OF RA
Nursing Assessment:
1. History and physical exam. The history and physical examination address manifestations such as
bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints.
2. Extra-articular changes. The patient is also assessed for extra-articular changes and these include
weight loss, sensory changes, lymph node enlargement, and fatigue.

Nursing Diagnosis:
1. Acute and chronic pain related to inflammation and increased disease activity, tissue damage,
fatigue, or lowered tolerance level.
2. Fatigue related to increased disease activity, pain, inadequate sleep/rest, deconditioning,
inadequate nutrition, and emotional stress/depression
3. Impaired physical mobility related to decreased range of motion, muscle weakness, pain on
movement, limited endurance, lack or improper use of ambulatory devices.
4. Self-care deficit related to contractures, fatigue, or loss of motion.
5. Disturbed body image related to physical and psychological changes and dependency imposed by
chronic illness.
6. Ineffective coping related to actual or perceived lifestyle or role changes.
 CONT…1) NURSING MANAGEMENT IN RA
The major goals for a patient with RA are:
1. Improvement in comfort level.
2. Incorporation of pain management techniques into daily life.
3. Incorporation of strategies necessary to modify fatigue as part of the daily activities.
4. Attain and maintain optimal functional mobility.
5. Adapt to physical and psychological changes imposed by the rheumatic disease.
6. Use of effective coping behaviors for dealing with actual or perceived limitations and role changes.

Nursing Interventions (eg. Relieving Pain and Discomfort):

1. Provide a variety of comfort measures (eg, application of heat or cold; massage, position changes, rest;
foam mattress, supportive pillow, splints; relaxation techniques, diversional activities).
2. Administer anti-inflammatory, analgesic, and slow-acting antirheumatic medications as prescribed.
3. Individualize medication schedule to meet patient’s need for pain management.
4. Encourage verbalization of feelings about pain and chronicity of disease.
5. Teach pathophysiology of pain and rheumatic disease, and assist patient to recognize that pain often
leads to unproven treatment methods.
6. Assist in identification of pain that leads to use of unproven methods of treatment.
7. Assess for subjective changes in pain.
2) NURSING CARE IN MULTIPLE SCLEROSIS

Nursing main problem: Fatigue

May be related to:

1. Decreased energy production,
increased energy requirements to
perform activities
2. Psychological/emotional demands
3. Pain/discomfort
4. Medication side effects
 CONT…2) NURSING MANAGEMENT IN MS
The major goals for a patient with MS are:
1. Patient will identify risk factors and individual actions affecting fatigue.
2. Patient will identify alternatives to help maintain desired activity level.
3. Patient will participate in recommended treatment program.
4. Patient will report improved sense of energy.

Nursing Interventions:
1. Note and accept the presence of fatigue.
2. Identify and review factors affecting the ability to be active: temperature extremes, inadequate food
intake, insomnia, use of medications, time of day.
3. Accept when the patient is unable to do activities.
4. Determine the need for walking aids. Provide braces, walkers, or wheelchairs. Review safety
considerations.
5. Schedule ADLs in the morning if appropriate. Investigate the use of cooling vest.
6. Plan care consistent rest periods between activities. Encourage afternoon nap.
7. Assist with physical therapy. Increase patient comfort with massages and relaxing baths.
8. Stress need for stopping exercise or activity just short of fatigue.
3) NURSING CARE IN SYSTEMIC LUPUS
ERYTHEMATOSUS

Nursing main problem: Impaired

Skin Integrity

May be related to:

1. Exacerbation of disease process
2. High-dose corticosteroid use
3. Inflammation
4. Use of immunosuppressant drugs
5. Vasoconstriction
 CONT…3) NURSING MANAGEMENT IN SLE
The major goals for a patient with SLE are:
1. Client will verbalize ability to cope with hair loss.
2. Client will identify measures to cover scalp loss as required by personal preference.
3. Client will maintain optimal skin integrity, as evidenced by an absence of rashes and skin
lesions.

Nursing Interventions:
1. Assess the skin for integrity.
2. Assess the client’s description of pain.
3. Assess for an erythematous rash, which may be present on the face, neck, or extremities.
4. Assess for photosensitivity.
5. Assess the degree to which symptoms interfere with the client’s lifestyle and body image.
6. Encourage adequate nutrition and hydration.
7. Instruct the client to clean, dry, and moisturize intact skin; use warm (not hot) water, especially over
bony prominences; use unscented lotion. Use a mild shampoo.
8. Instruct the client to avoid contact with harsh chemicals and to wear appropriate protective gloves, as
needed. Avoid hair dye, permanent solution, and curl relaxers.
9. Recommended prophylactic pressure-relieving devices (e.g., special mattress, elbow pads).
4) NURSING CARE IN GRAVES DISEASE

Nursing main problem: Risk for

Decreased Cardiac Output

May be related to:

1. Uncontrolled hyperthyroidism,
hypermetabolic state
2. Increasing cardiac workload
3. Changes in venous return and
systemic vascular resistance
4. Alterations in rate, rhythm,
conduction
 CONT…4) NURSING MANAGEMENT IN GD
The major goals for a patient with GD are:
Maintain adequate cardiac output for tissue needs as evidenced by stable vital signs, palpable
peripheral pulses, good capillary refill, usual mentation, and absence of dysrhythmias.

Nursing Interventions:
1. Monitor BP lying, sitting, and standing, if able. Note widened pulse pressure.
2. Monitor central venous pressure (CVP), if available.
3. Investigate reports of chest pain or angina.
4. Assess pulse and heart rate while patient is sleeping.
5. Auscultate heart sounds, note extra heart sounds, development of gallops and systolic
murmurs.
6. Monitor ECG, noting rate and rhythm. Document dysrhythmias.
7. Monitor temperature; provide cool environment, limit bed linens or clothes, administer tepid
sponge baths.
8. Observe signs and symptoms of severe thirst, dry mucous membranes, weak or thready pulse,
poor capillary refill, decreased urinary output, and hypotension.
9. Record I&O. Note urine specific gravity.
5) NURSING CARE IN TYPE 1 DIABETES

Nursing main problem: Risk for

Unstable Blood Glucose Level

May be related to:

1. Deficient knowledge of diabetes
management
2. Developmental level
3. Inadequate blood glucose
monitoring
4. Lack of adherence to diabetes
management
 CONT…5) NURSING MANAGEMENT IN T1DM

The major goals for a patient with GD are:

Client will maintain a blood glucose reading of less than 180 mg/dL; fasting blood glucose levels of
less than <140 mg/dL; hemoglobin A1C level <7%.

Nursing Interventions:
1. Monitor for signs of hyperglycemia such as fatigue, blurred vision, dry mouth.
2. Monitor for signs of hypoglycemia such as sweating, lightheadedness, weakness, nausea,
tachycardia.
3. Assess feet for temperature, pulses, color, and sensation.
4. Monitor blood glucose level prior meals and at bedtime.
5. Review client’s HbA1c-glycosylated hemoglobin.
6. Assess child’s and parent’s current knowledge and understanding about the prescribed diet.
7. Assess the pattern of physical activity.
7 CONCLUSION
1. Nursing care plays an important role in the process of treatment of
autoimmune disease. It helps patients to cope with the disease in their
everyday lives, teaches how to deal with, and prevents periods of the
disease.
2. The nurse supports the patient, and mobilizes the patient’s family to
give him or her the necessary help so that they do not feel lonely in
their fight against the disease.
3. Moreover, by undertaking educational actions connected with lifestyle
and rehabilitation, Nurse can contribute to improving their quality of
life.
 A N

G U A T K
) GI THANKS
E N E N B A
M T H E R )
N G N G B IN G
L I R E I & IV
SA (ST B E R ,G
N )
M N G KA RS
E VI A E
G M LO D O T H
I N G , E N H O
A L IN M C
S R G E A
(CA ALIN FOR
S G
Y IN
RA
(P