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 (WC) or -eu.ocytes
1. /roduced in bone marrow
2. 0o%e through body %ia blood stream and through tissue spaces
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3. 7eneral "unction$ able to distinguish body8s own cells "rom
"oreign cells and attach and remo%e "oreign cells or own body8s
damaged cells
6. 0easurement o" total WC
a. /art o" Complete lood Count (CC)
b. +ormal WC count$ 6955 : 15,555 , mm
3

c. -eu.ocytosis$ WC ; 15,555
d. -eucopenia$ WC < 6955
9. Types o" WC
a. 0a*or groups are granulocytes, monocytes, lymphocytes
b. 0easurement$ WC #i""erential
1. Short name$ =di"">
2. Count o" 155 WC sorted into the di""erent types
3. Translates into percentage per type
6. Signi"icance
a. 'denti"ies portion o" total WC made up o" each
speci"ic type
b. 7i%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" WC listed in di""erential
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1. +eutrophils (also .nows as polymorphonuclear
leu.ocytes (/0+s) or polys )
a. 99 @ A5B 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 (=segs>)$ mature, normally 99B
o" WC
2. ands$ immature neutrophils, normally 9B
o" WC
e. 'ncreased le%el$ acute in"lammation or in"ection
(bacterial)
2. Cosinophils
a. 1 @ 6B total circulating leu.ocytes
b. Dound in large amounts in respiratory and 7'
tract
c. /rotect against parasitic worms and in%ol%ed in
hypersensiti%ity
3. asophils
a. 5.9 @ 1B total circulating leu.ocytes
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b. Contain protein and chemicals including heparin,
histamine, that are released during
hypersensiti%ity reactions, stress
6. 0onoctyes$ largest o" WC
a. 2 @3B total circulating leu.ocytes
b. 0igrate to tissues and can li%e "or years
c. 0ature into macrophages in tissue lungs,
connecti%e, li%er, etc.
d. /hagocytic against large "oreign particles and
cell debris
e. #e"ense against chronic in"ections such as
tuberculosis, %iral in"ections
9. -ymphocytes
a. 25 : 65B o" total circulating leu.ocytes
b. C""ectors and regulators o" speci"ic immune
responses
c. 'mmune sur%eillance$ monitor "or and destroy
cancerous cells
d. Circulate constantly, but concentrate in lymphoid
tissues including lymph nodes
e. #i""erential only loo.s at total lymphocyte
percentage
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". 3 di""erent types o" lymphocytes which wor.
together$
1. T -ymphocytes (mature in thymus gland)
2. -ymphocytes (mature in bone marrow)
3. +! cells (natural .iller cells)$ immune
sur%eillance
II. Nonspecific Inflammatory Response
A.arrier protection$ body8s "irst line de"ense against in"ection includes
1. 'ntact s.in
2. 0ucus o" mucous membranes
3. actericidal action o" body "luids
. 'n"lammation$ nonspeci"ic immune response
1. +onspeci"ic$ localized, generally same with all types o" in*ury
2. Stages o" in"lammatory response$
a. Eascular response$ %asodilatation leading to redness,
warmth, swelling? three types o" eFudate$ "luid "rom
capillaries into tissue
1. Serous (plasma)
2. SanGuineous (mainly red blood cells)
3. Serosanguineous (miFture)
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b. Cellular response and phagocytosis$ margination and wbc8s
to area
c. Tissue repair healing$ o%erlap o" in"lammation and healing
3. Cardinal signs o" in"lammation$ erythema (redness), warmth,
swelling, pain, loss o" "unction
6. Acute or Chronic
a. Acute
1. Short term, 1 : 2 wee.s
2. 'n*urious agent remo%ed
3. 2ealing occurs with tissue repair or scarring
b. Chronic
1. Slower onset, months : years
2. #ebilitating with se%ere tissue damage
C. Wound 2ealing
1. /hases
a. 'n"lammation$ debridement occurs, wound prepared "or
healing
b. &econstruction$ damaged tissue regenerates
1. &esolution$ original structure and "unction result
2. &epair$ replacement o" destroyed tissue by collagen
scar tissue
2. &eGuirements
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a. AdeGuate nutrition
b. AdeGuate blood supply
c. AdeGuate oFygenation
3. Ither 'nter"ering Dactors
a. Chronic diseases, e. g. diabetes
b. #rug therapies, e.g. corticosteroids
c. 'n"ection
III. Immune Response
A.#e"inition o" 'mmunocompetent$ client has immune system that
identi"ies antigen and destroys or remo%es it? healthy immune
response
. Characteristics o" healthy immune response
1. Sel"@recognition
2. Speci"ic
3. Systemic
6. 2as memory (with "irst eFposure, change in host occurs?
repeated eFposures produces more rapid response)
C. Types o" 'mmune &esponses
1. Antibody@0ediated 'mmune &esponse (2umoral &esponse)
a. Antigen is bacteria, bacterial toFin, or "ree %irus
b. @lymphocyte produces antibody to speci"ic antigen
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c. Antibody (immunoglobulin) binds with antigen to
inacti%ate it
d. 9 classes o" immunoglobulins are 'g7, 'gA, 'g0, 'g#, 'gC
e. Antibody :medicated response occurs in 2 phases
1. 'nitial eFposure$ primary response de%elops
a. -ag time "rom eFposure to antibody
de%elopment
b. Antibodies de%elop, pea. and person reco%ers
2. Secondary eFposure$ with repeat eFposure to antigen,
memory cells cause immediate rise in antibodies and
pre%ent disease "rom occurring again
2. Cell@0ediated 'mmune &esponse (Cellular &esponse)
a. Antigen is a %iral@in"ected cell, cancer cell, some bacteria,
or "oreign tissue
b. T@lymphocytes inacti%ate antigen without antibody
"ormation
1. C""ector T cell$ cytotoFic cell binds with sur"ace
antigen on "oreign cell or %irus@in"ected cell and
destroys it
2. &egulator T cells include$
a. 2elper T cell$ acti%ates cells "or antibodies?
assists cytoFic T cells
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b. Suppressor T cell$ pro%ides negati%e "eedbac.
and stops immune process
c. Cell@mediated has memory$ T cells respond to repeat
eFposure to antigen
IV. Immunity: Protection of body from disease
A.Types
1. Acti%e$ body produces antibodies or de%elops immune
lymphocytes against speci"ic antigens
2. /assi%e$ antibodies are administered to the client? e""ect
temporary
3. +atural$ client contacts antigen, de%elops the disease, reco%ers,
and is immune
6. AcGuired$ antigen introduced into client to stimulate immune
system to "orm antibodies and memory cells but not the actual
disease
9. CFamples$
a. +atural Acti%e$ client had chic.en poF, de%eloped
antibodies, is immune
b. AcGuired Acti%e$ Tetanus ToFoid gi%en to client? client
"orms antibodies against tetanus
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c. +atural /assi%e$ maternal antibodies passed to in"ant
through breast mil.
d. AcGuired /assi%e$ Tetanus Immune Globulin
(2ypertet)$ antibodies gi%en to client who has not recei%ed
prior immunizations against tetanus
. Collaborati%e Care
1. Teaching and administration o" immunizations, %accines
2. Adherence with recommended schedules "or immunization
(&ecommendations sub*ect to change, .eep current)
3. &ecommendations "or speci"ic groups, e.g. health care wor.ers
at ris., 2epatitis %accine? elderly, chronically ill, in"luenza
%accine? tra%elers to "oreign countries, speci"ic disease (typhoid
"e%er) %accine
6. Administration o" immunizations$
a. Chec. client allergies, no upper respiratory in"ection
b. +o li%e %irus %accines to immunosuppressed or those in
household
9. Dollow directions regarding administration (routes, sites), use
uneFpired %accines(label %ials when opened, document %ial
number)
V. Management of Client with Inflammation
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A.#iagnostic Testing$
1. White lood Cell Count with #i""erential
a. Total WC count$ increase (acute in"lammation or
in"ection) or decrease (consider immunosuppression)
b. #i""erential$ consider increases or decreases with speci"ic
cell type
2. Crthrocyte Sedimentation &ate (CS&)
a. +onspeci"ic
b. Cle%ated with in"lammation
3. C@reacti%e /rotein (C&/) Test
a. +ormal is negati%e
b. Tests "or presence o" protein "rom li%er
c. 'ndicati%e o" acute or chronic in"lammation
6. Serum /rotein
a. +ormal %alues
1. Total protein$ H : 4 g,d-
2. Albumin$ 3.2 : 6.9 g,d-
3. 7lobulin$ 2.3 : 3.6 g,d-
b. #etermine whether there is adeGuate protein inta.e and
li%er "unctioning "or healing, immune system "unctioning
c. 7lobulin decreased with immunologic de"iciencies
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9. /rotein electrophoresis$ 0easurement o" immunoglobulins
'g7, 'gA, 'g0, 'g#, 'gC (antibodies)
H. Antibody testing$ Titer le%els measured to determine whether
client has de%eloped antibodies to an in"ection or with an
immunization
A. S.in testing$ assesses cell@mediated immunity
a. !nown antigen in*ected intradermally, e.g. tuberculin test
b. +ote induration indicating pre%ious eFposure and
sensitization to antigen
c. '" no reaction, depressed cellular immunity (anergy)
. 0edications$
1. /urpose$ to pro%ide com"ort or decrease in"lammatory response
and damage
2. Types
a. Acetaminophen
a. Com"ort only
b. &educes pain and "e%er
c. +o anti@in"lammatory e""ect
b. Aspirin and salicylates
a. 2igher doses reGuired (H95 : 1555 mg J'#) "or anti
in"lammatory e""ect
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b. 'nhibits prostaglandin synthesis? anti pyretic? anti@
platelet e""ect
c. 'rritates gastrointestinal tract
c. +onsteroidal anti@in"lammatory drugs (+SA'#s)
a. 0ultiple types o" +SA'# medications? all ha%e
potential cross@sensiti%ity to aspirin, irritate
gastrointestinal tract
b. !etorolac (Toradol), only +SA'# that can be gi%en
parenterally
c. 'ndomethacin and phenylbutazone most toFic
d. Corticosteroids$ hormones produced by adrenal corteF
a. 'nhibit in"lammation? do not cure underlying
condition, but palliati%e
b. 2a%e serious side e""ects, can mas. in"ections
c. 7uidelines "or use o" glucocorticoids
1. /re"er local acting such as topical or intra@
articular in*ection i" e""ecti%e
2. 7i%e smallest possible dose that will be e""ecti%e
3. '" oral, alternate@day dosing schedule to maintain
adrenal gland "unctioning
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6. With high@dose therapy, must taper dose? do not
stop abruptly to allow adrenal glands to resume
normal "unctioning
C. /roper +utrition$ essential "or healing
1. #e"initions
a. 'n"lammation$ catabolic state (tissue brea.down)
b. 2ealing$ anabolic process (tissue build up)
2. #iet reGuirements
a. AdeGuate protein, calories, "at
b. Eitamins$ A, @compleF, !? mineral$ zinc,
c. AdeGuate "luids 29555 ml, 26 hr
d. /re%ent weight loss, protein depletion
#.+ursing #iagnoses
1. /ain
2. 'mpaired Tissue 'ntegrity
3. &is. "or 'n"ection
VI. Infection
A.Iccurrence$ when pathogen colonizes and multiplies within host
and host eFperiences in*ury, in"lammation or organ dys"unction in
response to in"ection or toFin
. /athogen Dactors
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1. Eirulence$ disease@causing potential
2. Chain o" in"ection (reser%oir, transmission, %ector)
3. Irganism resistance
6. #amage caused through toFin production
C. 2ost Dactors$ ability to resist in"ection
1. /hysical barrier$ intact s.in and mucous membranes
2. 'nternal en%ironment (body secretions, respiratory de"enses)
3. Speci"ic and nonspeci"ic immune responses
#.Stages o" 'n"ectious /rocess
1. 'ncubation
a. /athogen acti%e replication
b. +o symptoms
2. /rodromal
a. Symptoms begin to appear
b. +on@speci"ic
3. Acute
a. /athogen proli"erates, maFimum symptoms
b. De%er and chills? may be con"ined to speci"ic organ,system
c. Stress to body
1. Catabolic e""ects
2. 'n"lammatory process in response to toFins
3. /ossible trigger o" autoimmune disease process
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6. Con%alescent
a. Tissues repair
b. Symptoms resol%e
C. /ossible Complications$ Septicemia, septic shoc.
D. +osocomial in"ections$ 'n"ections acGuired in health care setting (9B
in"ection rate)
1. &is. "actors "or hospitalized clients
a. Compromised immune systems
b. 0edications including antibiotics, steroids
c. Treatments including in%asi%e procedures
d. 'ncreased incidence among elderly
2. /re%ention
a. C""ecti%e handwashing
b. Cn"orcement o" policies "or in%asi%e procedures
7.Antibiotic@&esistant 0icroorganisms
1. 'ncreasing due to inappropriate or prolonged antibiotic therapy
2. Current resistant strains
a. 0ethicillin@resistant Staphylococcus aureus (0&SA)
b. 0ulti@drug resistant tuberculosis (0#&@T)
c. /enicillin@resistant Streptococcus pneumoniae (/&S/)
d. Eancomycin@resistant Cnterococci (E&C)
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e. Eancomycin 'ntermediate@resistant Staphylococcus aureus
(E'SA)
3. Dollow recommended contact precautions,isolation techniGues
2.Collaborati%e Care
1. #iagnostic Tests
a. WC Count and #i""erential
1. -eu.ocytosis with in"ections
2. +eutrophilia increased segs? also shi"t to le"t
(increased band count)
b. Culture o" wound, blood, and,or other body "luids
1. Ibtain specimen prior to starting antibiotic, i" not,
note antibiotic recei%ed on culture reGuest "orm
2. 7ram stain$ to identi"y probable pathogen
3. Culture$ organism incubated and grown? ta.es 26 : 64
hours
6. Sensiti%ity$ cultured organism sub*ected to di""erent
antibiotics to determine whether sensiti%e (antibiotic
will .ill organism) or resistant (antibiotic will not .ill
organism)
c. Serology$ detect antibodies to suspected organism
d. #irect antigen$ detect antigens in body specimens
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e. Antibiotic /ea.s and Troughs$ monitor therapeutic le%els
o" antibiotics to ensure proper dose "or optimum treatment
while a%oiding toFic le%els
1. /ea.$ highest le%el o" antibiotic
2. Trough$ lowest le%el o" antibiotic
". Krays, ultrasound eFamination o" organs
g -umbar puncture to obtain cerebrospinal "luid "or
eFamination and culture
'. Administration o" anti@in"ecti%e therapy
1. Chec. "or allergies, ris. to "etus in child@bearing aged women
2. !now client renal, hepatic "unction? i" medication metabolized
through this system, monitor lab tests
3. est route to e""ecti%ely treat microorganism in in"ection site
6. Antibiotics
a. acteriostatic (inhibit growth) or bactericidal (.ill
organism)
b. Speci"ic against di""erent categories o" microorganisms
that ha%e cell wall
1. 7ram positi%e
2. 7ram negati%e
3. oth (broad spectrum)
c. !nown toFicities to speci"ic organ systems
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d .Superin"ection
1. 0a*or concern
2. Antibiotics change normal bacterial "lora in 7' tract,
mouth, %agina
3. I%ergrowth o" "ungus or bacteria
6. 0ay be treated with anti"ungal medications or eating
yogurt with li%e cultures
9. Anti%iral$ selecti%e since %irus is parasite within host8s cells
H. Anti"ungal$ treat "ungal in"ections
A. Antiparasitic$ treat parasitic in"ections including protozoans
1. Antibiotic Categories , Speci"ics
1. /enicillins$ =cillins>
a. Stop immediately i" any sign o" hypersensiti%ity and be
ready to treat reaction
b. Cross sensiti%ity with cephalosporins
2. Cephalosporins
a. 6 generations
b. Cross sensiti%ity with penicillins
c. 0onitor "or .idney and li%er toFicity
3. Aminoglycosides$ =mycins>
a. ItotoFic, nephrotoFic
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b. 0onitor weight, L+, creatinine
6. DluroGuinolones
a. Dluid inta.e 2 : 3 - daily to pre%ent crystaluria
b. 0onitor "or hepatotoFicity
9. Tetracyclines
a. Ta.e 1 hour be"ore or 2 hours a"ter meals
b. Can inter"ere with anticoagulants
H. 0acrolides (Crythromycin)
a. Dor clients allergic to penicillin
b. 7' distress? ta.e on empty stomach or *ust be"ore meals
A. Sul"onamides and Trimethoprim
a. Lsed "or urinary tract in"ections, otitis media,
/neumocystis carinii pneumonia
b. Chec. "or any sul"a allergy
c. /rotect "rom photosensiti%ity
d. Ta.e on empty stomach
e. Dluid inta.e 2 - per day
4. 0etronidazole (Dlagyl)
a. +o alcohol inta.e (causes illness @@ Antabuse e""ect)
b. 0ay ma.e urine reddish brown
c. +eed adeGuate "luid inta.e 2.9 - daily
!.'solation TechniGues
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According to Centers "or #isease Control and /re%ention (C#C)
7uidelines
1. Standard /recautions
a. arrier precautions with body "luids, especially blood
b. 7uidelines "or needles, sharp ob*ects disposal
2. Category@speci"ic /recautions
a. Airborne precautions
b. #roplet precautions
c. Contact precautions
-. +ursing #iagnoses
1. &is. "or in"ections
2. AnFiety
3. 2yperthermia
a. Chills indicate rising temperature? monitor
b. -ower temperature cautiously to a%oid shi%ering which
raises temperature
c. &estore "luid balance? increased loss with "e%er
Nursing Care of Clients with ltered Immunity
I. !ac"ground
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A.A healthy immune system identi"ies antigens and e""ecti%ely
destroys or remo%es them
. Alterations that occur within immune system and result in illness
1. I%erreaction$ 2ypersensiti%ity, as with allergic reactions
2. 'ncompetency$ 'mmune de"iciency or malignancy as with
AcGuired 'mmune #e"iciency #isorder (A'#S)
3. -oss o" ability to recognize sel"$ Autoimmune disorders
C. 'mmune responses
1. Antibody@mediated immune response$ action o"
lymphocytes (@cells)? acGuired immunity
2. Cell@mediated immune response$ T lymphocytes (T@cells) attac.
antigens directly and acti%ate @cells
3. Types o" T@cells
a. C""ector cells$ CytotoFic (!iller T)
1. Carry C#4 antigen
2. Attac. malignant cells
3. &esponsible "or transplanted organ re*ection and
gra"ted tissues
b. &egulator cells
1. 2elper T cells
a. Carry C#6 antigen
b. 'nitiate immune response
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2. Suppressor T cells
a. Carry C#4 antigen
b. Stop immune response
6. 'mmune "unction declines with age
II. #ypersensiti$ity Reaction
A.#e"inition$ Altered immune response to antigen resulting in
harm to client, e.g. allergy
. Categories
1. &ange "rom irritating to li"e threatening (as with laryngospasm)
2. 'mmediate (e.g. anaphylaFis) %s. delayed (e.g. contact
dermatitis)
C. /athophysiology
1. Antigen@antibody interaction$
1. Causes tissue damage
2. 'n%ol%es immediate reaction a"ter a prior sensitization
3. 'ncludes systemic reactions$ Types ', '', '''
a. Type '
1. Drom allergic reaction with 'gC
2. 0ast cells and basophils "actors released, which
causes serious reaction
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3. 0ost serious reaction$ AnaphylaFis
a. Signs and symptoms$ hi%es, swelling,
di""iculty breathing, anaphylactic shoc.
b. Client needs$ Air way protection? prompt
re%ersal (parenteral epinephrine)
b. Type ''
1. 'g7 or 'g0
2. Antibodies "ormed
3. Complement cascade acti%ated and destroys
cells, e.g. hemolytic trans"usion blood reaction
(AI, &h)
c. Type '''
1. 'g7 or 'g0
2. Antibody@antigen immune compleFes in
circulation and bloc. tissues, e.g. reaction to
toFin post strep in"ection, glomerulonephritis
2. Antigen@lymphocyte reaction
a. Type 'E
b. #elayed 26 : 64 hours? contact dermatitis (e.g. lateF
allergy, positi%e tuberculin test)
#.Collaborati%e Care
1. I%erall Docus
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a. 0inimize eFposure to allergen
b. /re%ent hypersensiti%ity response
c. /er"orm prompt, e""ecti%e inter%entions "or allergic
responses
2. +ursing history and status be"ore any procedure,medication
a. #ocument allergies and reaction(s) that occurred with
e%ent
b. 0aintain record? allergy bracelet "or in@patient
c. As. about anesthesia allergy "or local and general
preoperati%e clients
3. #iagnostic Tests
a. WC count with di""erential$ Type ' allergy$ eosinophilia
b. &adioallergosorbent test (&AST)$ detects 'gC toward
speci"ic antigens
c. lood type and crossmatch$ pre%ents AI and &h
reactions
d. 'ndirect Coombs$ detects circulating antibodies (normal$
negati%e)
e. #irect Coombs$ detects antibodies on client8s &C8s
(normal$ negati%e)
". 'mmune compleF assays$ detects Antibodies Type '''
reactions
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g. Complement assays$ detects amount o" a%ailable
complement? determines amount used
h. S.in tests$ detects allergens, includes intradermal testing
6. 0edications
a. Antihistamines
1. loc.s histamine receptors
2. &elie%es symptoms o" urticaria and angioedema
3. #iphenhydramine (enadryl)$ can be gi%en
parenterally or orally
b. Cpinepherine
1. 'mmediate treatment "or anaphylaFis
2. &elie%es the %asodilatation and bronchoconstriction
3. 7i%en subcutaneously or intra%enously
6. =ee sting .it>$ carried by clients with .nown serious
allergies
c. Cromolyn ('ntal)
1. loc.s histamine release
2. 7i%en by inhaler or nasal spray
d. 7lucocorticoids
1. oth topical and systemic e""ects
2. Anti@in"lammatory
9. /lasmapheresis
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a. +on@medication treatment
b. &emo%al o" harm"ul components in plasma by passing
blood through blood cell separator to remo%e immune
compleFes
H. +ursing #iagnoses
a. 'ne""ecti%e Airway Clearance (as with anaphylaFis)
b. #ecreased Cardiac Iutput (as with anaphylactic shoc.)
c. &is. "or 'n*ury (as with blood trans"usion reaction)
III. utoimmune %isorders
A.#e"inition$ 'mmune system8s ability to recognize sel" is
impaired, and immune de"enses are directed against person8s
own tissues
. Common autoimmune disorders
1. Tissue,organ speci"ic (2ashimoto8s thyroiditis)
2. Systemic (rheumatoid arthritis, systemic lupus erythematosis
(S-C))
C. /athophysiology (not entirely certain but possibly)
1. 2idden antigens elicit immune response, de%elopment o"
autoantibodies
2. ody has changes "rom bacterial or %iral
in"ections, de"ecti%e immune system
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#.Characteristics o" autoimmune disorders
1. 7enetic predisposition
2. Iccur in "emales more than males
3. Inset associated with stress
6. DreGuently are progressi%e, with periods o" eFacerbation and
remission
C. Collaborati%e Care
1. #iagnostic Tests$
a. Serologic assays
1. Tests used to identi"y autoantibodies,
measured in titers, i.e. le%els in circulation
2. Iccur with autoimmune state
3. +ot speci"ic "or certain disease
b. Antinuclear antibody (A+A)
c. -upus erythematosus (-C) prep
d. &heumatoid Dactor (&D)
e. Complement assay$ detects amount o" a%ailable
complement? determines amount used
2. 0edications
a. Anti@in"lammatory drugs$ aspirin, +SA'#s, corticosteroids
b. Antirheumatic drugs$ gold salts, hydroFychloroGuine
(/laGuenil)
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c. CytotoFic drugs
3. /lasmapheresis may be used
6. +ursing Care according to signs and symptoms o" speci"ic
disorder
9. Common +ursing #iagnoses
a. Acti%ity 'ntolerance
b. 'ne""ecti%e Coping (with chronic disease)
c. 'ne""ecti%e /rotection
d. &is. "or 'ne""ecti%e Therapeutic &egimen 0anagement
e. 'nterrupted Damily /rocesses
IV. &issue &ransplants
A.ac.ground
1. 2uman -eu.ocyte Antigens (2-A)
a. Speci"ic cell sur"ace mar.ers uniGue to each indi%idual
person
b. Transplant success tied to obtaining organs with 2-A close
to those o" recipient
2. Types o" Transplants
a. Autogra"t$ transplant o" client8s own tissue
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b. Allogra"t$ most common, gra"ts between member o" same
species, but di""erent genotypes and 2-A antigens?
cada%er donors are most common
c. Kenogra"t$ transplant "rom animal species to human, e.g.
pig %al%es
3. /reparation "or Allogra"t$ Tissue Typing
a. #etermine histocompatibility, i.e. identi"y recipient8s 2-A
type, blood type (AI, &h), and pre@"ormed antibodies
b. 0atch as closely as possible with the donor
6. Types o" &e*ections$ typically begin a"ter "irst 26 hours post
transplant$
a. 2yperacute Tissue &e*ection
1. Iccurs 2 : 3 days post transplant
2. #ue to pre@"ormed antibodies
3. 0ore common with pre%ious transplant or blood
trans"usion
b. Acute Tissue &e*ection
1. 0ost common and treatable
2. Iccurs between 3 days and 6 months post transplant
3. #ue to cellular immune response
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6. Signs and symptoms$ "e%er, redness, swelling and
tenderness o%er gra"t site? signs o" organ "ailure
(re"lected by lab %alues)
c. Chronic Tissue &e*ection
1. Iccurs 6 months to years post transplant
2. #ue to antibody@mediated immune response
3. -eads to ischemia and to organ and gradual
deterioration
6. 7ra"t@%ersus@2ost #isease (7%2#)$ "reGuent and
potentially "atal complication o" bone marrow
transplant? gra"ted tissue recognizes host tissue as
"oreign and mounts a cell@mediated response?
primarily a""ects s.in, li%er, gastrointestinal tract
. Collaborati%e Care
1. I%erall goal o" pre and post transplant care is to reduce the ris.
o" tissue re*ection or 7%2#
2. #iagnostic testing : prior to transplant
a. lood type, &h "actor, crossmatch
b. 2-A histocompatibility$ used primarily with li%ing donors
"or .idney or bone marrow transplants
c. 0iFed lymphocyte culture (0-C) assay test$
histocompatibility between donor and recipient
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3. #iagnostic testing @ post transplant
a. Lltrasound or 0agnetic resonance imaging (0&') o"
transplanted organ
b. Tissue biopsies o" transplanted organ? done routinely to
assess e%idence o" re*ection
6. 0edications
a. Antibiotics and anti%iral medications
1. Trimethoprim-sulfamethoxazole (Septra, Bactrim)$
protects against gram@negati%e bacteria in"ection
2. Acyclovir (Zovirax)$ protects "rom herpes simpleF
%irus (2SE) in"ection
3. Ganciclovir (Cytovene)$ protects "rom de%elopment o"
cytomegalo%irus (C0E) in"ection
b. 'mmunosuppressi%e agents$ Corticosteroids, also anti@
in"lammatory
1. Azathioprine (muran)
a. 0ainstay, inhibits both cell@mediated and
antibody@mediated immunity
b. 0etabolized by li%er? sa"e "or renal transplant
clients
c. 0a*or ad%erse e""ect$ bone marrow depression
(monitor CC)
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2. Cyclosporine
a. 'nhibits T@cell "unction and cell@mediated
immune responses
b. 0onitor blood le%els closely to chec. "or
toFicity? nephrotoFic and hepatotoFic
c. Signs o" toFicity$ hypertension, C+S symptoms
3. !uromona"-C#$ (%&T$, %rthoclone)
a. 0onoclonal antibody, bloc.s T cell generation
and "unction
b. Lsed with steroid@resistant organ re*ections
6, Antilymphocyte 'lo"ulin (A(G), antithymocyte
'lo"ulin (ATG)) /olyclonal antilymphoctye antibodies
6. +ursing Care in%ol%es acute and chronic care "or client and
"amily
9. Common +ursing #iagnoses
a. 'ne""ecti%e /rotection
b. &is. "or 'mpaired Tissue 'ntegrity
c. #ealing with psychologic conseGuences o" chronicity
1. /owerlessness
2. 'ne""ecti%e Coping
3. AnFiety
H. Common nursing inter%entions
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a. Assessment "or signs o" in"ection, organ re*ection, ad%erse
e""ects o" medications, "reGuent laboratory testing
b. 0edications, handwashing and protecti%e isolation in
hospital and post discharge "or client and "amily
c. Stress@reduction, counseling, support group re"erral
V. Impaired Immune Response
A. Two types
1. Congenital$ rare
2. AcGuired$ acGuired immune de"iciency syndrome (A'#S)
. ac.ground
1. Cases recognized in male homoseFual population in 1341?
2. 2uman immunode"iciency %irus (2'E) isolated in 1346
3. &etro%irus transmitted by
a. #irect contact with in"ected blood and body "luids
b. Contaminated needles
c. 'n"ants born to 2'E positi%e mothers (19 : 35 B)
C. &is.s$ eha%orial
1. Lnprotected anal seF
2. 'n*ection drug use (sharing needles)
3. 2eteroseFual intercourse with in"ected persons
6. &ecei%ing blood trans"usions, blood products
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9. Iccupational ris. to health care wor.ers, especially through
needle stic.s
#./athophysiology
1. &etro%irus
a. Carries genetic code in &+A
b. 'n"ects cells with C#6 antigen
c. Ta.es o%er cell8s #+A and then duplicates
d. 0ay remain dormant or become acti%e
e. Acti%e$ "orms %irons which destroys host cell
2. Serocon%ersion
a. H wee.s to H months post initial in"ection, antibodies to
2'E are produced and will test positi%e
b. Actual %irus may remain inacti%e in cells "or years
c. Antibodies are ine""ecti%e against the %irus
3. Cells a""ected by 2'E
a. 2elper T (C#6) cells
b. 0acrophages
c. Cells o" C+S
6. -oss o" helper T cells leads to typical
immunode"iciencies that result in multiple
opportunistic in"ections and cancers
C. Typical Course o" 2'E 'n"ection
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1. Contraction o" %irus
a. Acute mononucleosis@type illness within days to wee.s
b. Symptoms include$ "e%er, sore throat, *oint and muscle
achiness, rash, lymphadenopathy
c. Asymptomatic period
1. 0ean period 4 to 15 years
2. Eirus can be transmitted to others through blood and
body "luids, e%en though client seems well
3. Some clients eFperience persistent lymphadenopathy
2. #e%elopment into A'#S
a. 0ani"estations include$ general malaise, "e%er, "atigue,
night sweats, in%oluntary weight loss, o"ten diarrhea, rash,
oral lesions and candidiasis
b. 0ultiple opportunistic in"ections, cancers
c. 65 : H5 B de%elop neurological symptoms
D. /ost@in"ection &elated 'ssues
1. A'#S #ementia CompleF
a. #irect e""ect o" %irus on brain
b. Starts with "luctuating memory loss? con"usion to apathy,
to se%ere dementia? tremor? spasticity? incontinence
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c. C+S in"ections and lesions including toFoplasmosis, non@
2odg.in8s lymphoma as space@occupying lesions,
cryptococcal meningitis, C0E in"ections
2. Ipportunistic 'n"ections
a. Iccur when C#6 count is less than 255 (normal greater
than 1555,mm
3
)
b. /neumonia (*neumocystis carinii)
1. 0ost common opportunistic in"ection (A9 :
45B)
2. +onspeci"ic mani"estations$ "e%er, cough, shortness o"
breath, tachypnea, tachycardia
c. Tuberculosis
1. I"ten multidrug@resistant strains
2. &apid progressi%e, di""use pulmonary and
disseminated (other body organs)
d. Candidiasis (Can+i+a al"icans)
1. Eery common
2. Iral thrush, esophagitis, or %aginitis in women
e. !yco"acterium avium$ CompleF (0AC)
1. 29B o" A'#S cases
2. 0a*or cause o" =wasting syndrome>
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3. Signs and symptoms include$ chills, "e%er, wea.ness,
night sweats, abdominal pain, diarrhea, weight loss
". Ither 'n"ections
1. Eiral$ 2erpes simpleF or zoster %irus, C0E
o" retina, 7' tract, lungs
2. /arasitic$ ToFoplasma gondii, Cryptococcus
neo"ormans, Cryptosporidium
3. Secondary Cancers
a. !aposi8s Sarcoma
1. I"ten presenting symptom
2. S.in lesions with %ascular macules, papules, %iolet
lesions on s.in and %iscera? o"ten on "ace,
gastrointestinal tract, lungs
3. 'nitially painless, but become pain"ul
6. 'ndicator o" late@stage disease
b. -ymphomas
1. +on@2odg.in8s lymphoma and primary
lymphoma o" brain
2. Aggressi%e and rapid spread
c. 'n%asi%e Cer%ical Carcinoma$ Woman with 2'E usually
die o" cer%ical cancer, not A'#S
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7.Collaborati%e Care
1. Treatment
a. +o cure "or 2'E in"ection and A'#S
b. Current research "or treatment and cure
c. Still uni%ersally "atal nature o" disease
d. /re%ention is %ital strategy
2. 7oals o" care
a. Carly identi"ication o" in"ection
b. /romote health@maintenance acti%ities
c. /re%ent opportunistic in"ections
d. Treatment o" disease complications (cancers)
e. /ro%ide emotional and psychosocial support
3. #iagnostic Testing
a. Cnzyme@lin.ed immunosorbent assay (C-'SA)
1. Widely used as screening test "or 2'E in"ection?
detects 2'E antibodies, not %irus
2. Could be negati%e in early course o" in"ection be"ore
detectable antibodies de%elop
3. &esults 33.9B positi%e
a. Dalse positi%es can occur
b. '" positi%e, always repeat test and con"irm by
another method, such as Western blot
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b. Western blot antibody testing$ combined with C-'SA
greater speci"icity (;33.3B)
c. 2'E %iral load tests$ measure amount o" acti%ity
replicating 2'E %irus
d. CC$ detect anemia, leucopenia, thrombocytopenia
e. C#6 cell count$ used to monitor progress o" disease and
guide therapy
". Tests to detect secondary cancers and opportunistic
in"ections
1. Tuberculin s.in testing
2. rain 0agnetic resonance imaging (0&')
3. Speci"ic cultures and serology "or in"ections
6. /ap smears e%ery H months to detect cer%ical cancer
3. 0edications
a. /urposes
1. Suppress the 2'E in"ection and prolong client8s li"e
2. Treat opportunistic in"ections and cancers
b. C""ecti%eness measured by
1. Eiral load and C#6 cell counts (abo%e 955 mm
3
)
2. I"ten used in combinations according to e""ecti%eness
c. Classes o" medications used to Suppress 2'E in"ection
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1. +ucleoside &e%erse Transcriptase 'nhibitors
(+&T's)
a. Wor.s at le%el o" #+A
b. Mido%udine (&etro%ir, AMT) widespread use? also
used prophylactically post parenteral eFposure to
2'E
2./rotease 'nhibitors$ loc.s %iral enzymes
3.+onnucleoside &e%erse Transcriptase 'nhibitors
6. Ither agents$ 'nter"erons
d. 0edications against Ipportunistic 'n"ections,Cancers
1. Antibiotics, anti%irals, anti@cancer agents
2. Eaccines "or pneumococcal, in"luenza, hepatitis
, 2aemophilus in"luenzae serotype b
3. 'soniazid ('+2) prophylactically "or positi%e
tuberculin test
6. /rophylactic trimethoprim@sul"amethoFazole
(actrim) i" C#6 cell count is below 255 to
pre%ent *neumocystis carinii /neumonia (/C/)
6. +ursing Care
a. /re%ention o" in"ection
1. Sa"e seFual practices
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2. +o sharing or needles and drug paraphernalia (drug
users)
3. Screening o" donated blood and use o" autologous
6. Lse o" standard precautions by health care wor.ers
b. Care o" the client with 2'E
1. 0aintain health and pre%ent de%elopment o"
opportunistic in"ections, cancers? physical needs
change o%er course o" illness
2. Still a stigma associated with illness? assist client,
"amily to deal with it
3. 'ntense medical care, client de%elopment o" support
systems, use o" psychosocial support
c. +ursing #iagnoses (many and change with course o"
illness)
1. 'ne""ecti%e Coping$ #ealing with stigma, contagious
disease chronic illness, terminal illness
2. 'mpaired S.in 'ntegrity
3. 'mbalanced +utrition less than ody &eGuirements$
Control nausea, diarrhea
6.'ne""ecti%e SeFual /atterns$ /ractice sa"e seFual practices, in"orming
partners o" 2'E status
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