Chapter 14 Infection and Human Immunodeficiency Virus Infection and Chapter 13 Flashcards
1
Q
An antigen is a substance that elicits an?
A
immune response. Most antigens are composed of protein. All of the body’s cells have antigens on their surface that are unique to that person and enable the body to recognize itself.
2
Q
Immunity is classified as?
A
innate or acquired
3
Q
Innate immunity is?
A
present at birth, and its primary role is first-line defense against pathogens. This type of immunity involves a nonspecific response, and neutrophils and monocytes are the primary white blood cells (WBCs) involved. Innate immunity is not antigen specific, so it can respond within minutes to an invading microorganism without prior exposure to that organism.
4
Q
Acquired immunity is the?
A
development of immunity, either actively or passively
5
Q
Active acquired immunity results from the?
A
invasion of the body by foreign substances such as microorganisms and subsequent development of antibodies and sensitized lymphocytes. With each reinvasion of the microorganisms, the body responds more rapidly and vigorously to fight off the invader. Active acquired immunity may result naturally from a disease or artificially through immunization. Because antibodies are synthesized, immunity takes time to develop but is long lasting.
6
Q
Passive acquired immunity implies that the host?
A
- receives antibodies to an antigen rather than synthesizing them
- may take place naturally through transfer of immunoglobulins across placental membrane from mother to fetus
- Artificial passive acquired immunity occurs through injection with gamma globulin (serum antibodies). benefit of this immunity is its immediate effect
- passive immunity is short lived because person does not synthesize antibodies and does not retain memory cells for antigen
7
Q
Active: Natural and Artificial Immunity
A
1) Natural: contact with antigen through actual infection (e.g., chickenpox, measles, mumps)
2) Artificial: Immunization with antigen (e.g., vaccines for chickenpox, measles, mumps)
8
Q
Passive: Natural and Artificial Immunity
A
1) Natural: Transplacental and colostrum transfer from mother to child (e.g., maternal immunoglobulins passed to baby)
2) Artificial: Injection of serum with antibodies from one person (e.g., injection of hepatitis B immune globulin) to another person who does not have antibodies
9
Q
Antibodies
A
Immune globulins produced by lymphocytes in response to antigens
10
Q
Humoral immunity consists of antibody-mediated immunity. Since antibodies are produced by plasma cells (differentiated B cells) and found in plasma, the term humoral immunity is used. Production of antibodies is an essential component in a humoral immune response. Each of the five classes of immunoglobulins?
A
(IgG, IgA, IgM, IgG, IgE) have specific characteristics
11
Q
Humoral Immunity
1) Cells involved
2) Products
3) Memory cells
4) Protection
5) Examples
A
1) Cells involved: B lymphocytes
2) Products: Antibodies
3) Memory cells: Present
4) Protection: Bacteria, Viruses (extracellular), Respiratory and GI pathogens
5) Examples: Anaphylactic shock, Atopic diseases, Transfusion reaction, Bacterial infections
12
Q
Cell-Mediated Immunity
1) Cells involved
2) Products
3) Memory cells
4) Protection
5) Examples
A
1) Cells involved: T lymphocytes, macrophages
2) Products: Sensitized T cells, cytokines
3) Memory cells: Present
4) Protection: Fungus, Viruses (intracellular), Chronic infectious agents, Tumor cells
5) Examples: Tuberculosis, Fungal infections, Contact dermatitis, Graft rejection, Destruction of cancer cells
13
Q
Tumor Necrosis Factor (TNF)
A
- Proinflammatory mediator
- Activates macrophages and granulocytes
- Promotes immune and inflammatory responses
- Kills tumor cells
- Responsible for weight loss associated with chronic inflammation and cancer
14
Q
Cell-Mediated Immunity
Immune responses that are initiated through specific antigen recognition by T cells are termed cell-mediated immunity. Several cell types and factors are involved in cell-mediated immunity. The cell types involved include?
-Cell mediated immunity is of primary importance in?
A
T cells, macrophages, and NK cells.
Cell-mediated immunity is of primary importance in
(1) immunity against pathogens that survive inside of cells including viruses and some bacteria (e.g., mycobacteria) (2) fungal infections
(3) rejection of transplanted tissues
(4) contact hypersensitivity reactions
(5) tumor immunity
15
Q
The primary clinical evidence of immunosenescence is the high incidence of?
A
malignancies in older adults. Older people are also more susceptible to infections (e.g., influenza, pneumonia) from pathogens that they were relatively immunocompetent against earlier in life. Bacterial pneumonia is the leading cause of death from infections in older adults. The antibody response to immunizations (e.g., flu vaccine) in older adults is considerably lower than in younger adults
16
Q
A decline in immune function and immune response that occurs with aging
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Immunosenescene
17
Q
Researchers believe immunosenescence accounts for the increase in?
A
Cancer and infections
18
Q
Humoral protection
A
- Bacteria
- Viruses (extracellular)
- Respiratory pathogens
- Gastrointestinal pathogens
19
Q
Cellular protection
A
- Fungus
- Viruses (intracellular)
- Chronic infectious agents
- Tumor cells
20
Q
AIDS: Prevention of transmission in the healthcare setting
A
- Maintain standard precautions: hand washing/hygiene, protective barriers (gloves, mask, eye shield, gown)
- Do NOT recap needles and syringes
- Clean up spills of blood and body fluids immediately using germicidal solution
- Consider ALL body fluids to be contaminated
- Avoid contaminating the outside of specimen containers during collection
- Cleanse work surface ares with appropriate germicide (1:10 concentration of household bleach is effective)
21
Q
Human immunodeficiency virus (HIV) is a?
A
retrovirus that causes immunosuppression. People with HIV are more susceptible to infections that are normally controlled through immune responses.
22
Q
Transmission of HIV
A
HIV can be transmitted through contact with infected blood, semen, vaginal secretions, or breast milk. HIV transmission occurs through sexual intercourse with an infected partner; exposure to HIV-infected blood or blood products; and perinatal transmission during pregnancy, at delivery, or through breastfeeding. HIV is not spread casually
23
Q
Sexual Transmission.
A
- most common mode of transmission is unprotected sexual contact with an HIV-infected partner
- Sexual activity involves contact with semen, vaginal secretions, and/or blood, all of which have lymphocytes that may contain HIV.
- genital lesions from other sexually transmitted infections (e.g., herpes, syphilis) significantly increase likelihood of transmission
24
Q
Contact With Blood and Blood Products
A
- HIV can be transmitted from exposure to blood when sharing drug-using paraphernalia
- Needles, syringes, straws, and other equipment may be contaminated with HIV or other blood-borne organisms, and sharing this equipment can result in disease transmission
- Puncture wounds are the most common means of work-related HIV transmission. The risk of infection after a needle-stick exposure to HIV-infected blood is 0.3% to 0.4% (or 3 or 4 out of 1000)
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Perinatal Transmission of HIV
Perinatal transmission from an HIV-infected mother to her infant can occur during pregnancy, delivery, or breastfeeding
- On average, 25% of infants born to women with untreated HIV infection are born with HIV. Fortunately, the risk of transmission can be reduced to less than 2% in settings in which pregnant women are routinely tested for HIV infection and, if found to be infected, treated with antiretroviral therapy (ART), a combination of medication used to control and suppress HIV replication.
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Everyone who has AIDS has HIV infection. However, not everyone who has HIV has AIDS. The distinction rests with?
The number of CD4+ T cells the patient has and whether any opportunistic infections have occurred.
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Pathophysiology of HIV
- HIV is an RNA virus.
- RNA viruses are called retroviruses because they replicate in a “backward” manner (going from RNA to DNA)
- HIV cannot replicate unless it is inside a living cell
- The CD4+ T cell (CD4 cell), a type of lymphocyte, is the target cell for HIV. HIV enters the CD4+ T cell by binding to protein receptors on the outside of the cell (Fig. 14-1). This process is known as fusion
- Once HIV attached and fused with CD4+ T cell, HIV RNA enters CD4+ T cell and triggers release of reverse transcriptase (enzyme transforms HIV RNA into single strand of DNA). This strand copies itself, becoming double-stranded viral DNA
- enzyme, integrase, allows newly formed double-stranded DNA to integrate itself into host's genetic structure. This action has two consequences: (1) because all genetic material is replicated during cell division, all daughter cells are also infected and (2) viral DNA in the genome directs the cell to make new HIV
- Protease enzyme involved in replication process, cleaves newly formed strands of HIV genetic material into smaller pieces
- New HIV virions then formed and released. The CD4+ T cell is then destroyed after the HIV virions are released.
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HIV destroys about 1 billion CD4+ T cells every day. For many years the body can produce new CD4+ T cells to replace the destroyed cells. However, over time the ability of HIV to destroy CD4+ T cells exceeds the body's ability to replace the cells. The decline in the CD4+ T cell count impairs immune function. Generally, the immune system remains healthy with more than 500 CD4+ T cells/µL. Immune problems begin to occur when the count drops below?
500 CD4+ T cells/µL and Severe problems develop with fewer than 200 CD4+ T cells/µL
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With HIV, a point is eventually reached where so many CD4+ T cells have been destroyed that not enough are left to regulate immune responses. This allows?
opportunistic diseases (infections and cancers that occur in immunosuppressed patients) to develop. Opportunistic diseases are the main cause of disease, disability, and death in patients with HIV infection
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Clinical Manifestations and Complications for HIV
It is important to remember that (1) disease progression is highly individualized, (2) treatment can significantly alter this pattern, and (3) an individual's prognosis is unpredictable
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Acute HIV Infection
- Approximately 2 to 4 weeks after newly infected with HIV, individuals experience acute HIV infection, a period when people can have a mononucleosis-like syndrome of fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, and/or a diffuse rash.
- Some people also develop neurologic complications, such as aseptic meningitis, peripheral neuropathy, facial palsy, or Guillain-Barré syndrome
- Duringthis time high viral load (amount of HIV circulating in blood) is noted, and CD4+ T cell counts fall temporarily but quickly return to baseline or near-baseline levels - Many people, including HCPs, mistake acute HIV symptoms for a bad case of the flu
- Individuals are most infectious DURING the acute infection stage because of the high amounts of circulating HIV
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Chronic HIV Infection
| Explain Asymptomatic Infection
- interval between initial HIV infection and diagnosis of AIDS is about 10 years in untreated infection.
- During first several years after initial infection, individuals typically asymptomatic w/no symptoms or relatively limited signs of infection.
- Because most symptoms during early infection are vague and nonspecific for HIV, people may not be aware that they are infected. During this time, infected people continue their usual activities, and may include high-risk sexual and drug-using behaviors.
- This is a public health problem because infected individuals can transmit HIV to others even though they have no symptoms
- Personal health is also affected because people who do not know that they are infected have little reason to seek treatment and are less likely to make behavior changes that could improve the quality and length of their lives.
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Chronic HIV infection: Explain the symptomatic stage
- As CD4+ T cell count declines closer to 200 cells/µL and the viral load increases, HIV advances to a active stage. - Symptoms: persistent fever, frequent night sweats, chronic diarrhea, recurrent headaches, and severe fatigue may develop.
- common infections associated with this phase is oropharyngeal candidiasis (thrush)
- Other infections that can occur at this time include shingles (caused by the varicella-zoster virus); persistent vaginal candidal infections; outbreaks of oral or genital herpes; bacterial infections; and Kaposi sarcoma (KS), which is caused by human herpesvirus 8
- Oral hairy leukoplakia, an Epstein-Barr virus infection that causes painless, white, raised lesions on the lateral aspect of the tongue, is another indicator of disease progression
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A diagnosis of acquired immunodeficiency syndrome (AIDS) is made when an HIV-infected patient meets criteria established by the CDC. These criteria occur when the immune system becomes severely compromised. Opportunistic diseases generally do not occur in the presence of a functioning immune system. Many infections, a variety of malignancies, wasting, and HIV-related cognitive changes can occur in patients with immune impairment. Organisms that do not cause severe disease in people with functioning immune systems can cause debilitating, disseminated, and life-threatening infections during this stage. Several opportunistic diseases may occur at the same time, compounding the difficulties of diagnosis and treatment. Advances in HIV treatment have?
decreased the occurrence of opportunistic diseases
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Diagnostic Criteria for AIDS
| AIDS is diagnosed when an individual with HIV develops at least one of the following conditions:
1. CD4+ T cell count drops below 200 cells/µL.
2. One of the following opportunistic infections (OIs):
• Fungal: candidiasis of bronchi, trachea, lungs, or esophagus; Pneumocystis jiroveci pneumonia (PCP); disseminated or extrapulmonary coccidioidomycosis; disseminated or extrapulmonary histoplasmosis
• Viral: cytomegalovirus (CMV) disease other than liver, spleen, or nodes; CMV retinitis (with loss of vision); herpes simplex with chronic ulcer(s) or bronchitis, pneumonitis, or esophagitis; progressive multifocal leukoencephalopathy (PML); extrapulmonary cryptococcosis
• Protozoal: toxoplasmosis of the brain, chronic intestinal isosporiasis, chronic intestinal cryptosporidiosis
• Bacterial: Mycobacterium tuberculosis (any site); any disseminated or extrapulmonary mycobacteria, including Mycobacterium avium complex (MAC) or Mycobacterium kansasii; recurrent pneumonia; recurrent Salmonella septicemia
3. One of the following opportunistic cancers:
• Invasive cervical cancer
• Kaposi sarcoma (KS)
• Burkitt's lymphoma
• Immunoblastic lymphoma
• Primary lymphoma of the brain
4. Wasting syndrome. Wasting is defined as a loss of 10% or more of ideal body mass
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Diagnostic Studies: Diagnosis of HIV Infection
- Diagnosis of HIV infection is made by testing for HIV antibodies and/or antigens in the blood
- HIV screening tests detect HIV-specific antibodies or antigens, but typically it takes several weeks after initial infection before evidence of HIV can be detected on a screening test
- This delay is known as the window period
- HIV screening tests can be performed using blood or saliva
- Combination antibody and antigen tests (also known as fourth-generation tests) are able to detect HIV earlier than previous versions of HIV screening tests. The fourth-generation test decreases the window period to within 3 weeks following infection
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The progression of HIV is monitored by?
CD4+ T cell counts and viral load
- CD4+T cell counts provide a marker of immune function and decrease as the disease progresses
- The lower the viral load the less active the disease
* reported as real numbers or as undetectable
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Laboratory Studies in HIV Infection.
| Two laboratory tests are used for monitoring HIV progression:
CD4+ T cell count and viral load
1) CD4+ T cell count provides marker of immune function. As disease progresses, number of CD4+ T cells decreases (normal range for CD4+ T cells is 800 to 1200 cells/µL)
2) Laboratory tests that measure viral levels provide assessment of disease progression. lower the viral load, the less active the disease.
- viral loads reported as real numbers (e.g., 1260 copies/µL)
- goal of treatment is suppress viral load to lowest level possible (below level of detection on a commercial assay) - often referred to as “undetectable.” refers to amount of circulating HIV in the blood is below the level of detection of the test
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Laboratory studies for HIV infection
- Abnormal blood test results
- Decreased white blood cell (WBC) counts, below-normal numbers of lymphocytes (lymphopenia) and neutrophils (neutropenia), often seen
- Low platelet counts (thrombocytopenia) may be caused by HIV, antiplatelet antibodies, or drug therapy
- Anemia associated with chronic disease process and with adverse effects of ART
- Altered liver function, caused by HIV infection, drug therapy, or co-infection with a hepatitis virus, is common
- Early identification of co-infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) extremely important because these infections have a serious course in patients with HIV, may ultimately limit options for ART, and can cause liver-related morbidity and mortality
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Resistance tests can determine if a patient's HIV is resistant to drugs used for ART. Genotype and phenotype assays are used to help HCPs know which medications can be used to control a patient's infection. These tests are similar to culture and sensitivity testing used for antibiotic selection.
.
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Interprofessional care of the HIV-infected patient focuses on?
(1) monitoring HIV disease progression and immune function, (2) initiating and monitoring ART, (3) preventing the development of opportunistic diseases, (4) detecting and treating opportunistic diseases, (5) managing symptoms, (6) preventing or decreasing complications of treatment, and (7) preventing further transmission of HIV. To accomplish these goals, ongoing assessment, clinician-patient interactions, and patient teaching and support are required.
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Rapid HIV-Antibody Testing
1. Rapid testing is strongly recommended by the Centers for Disease Control and Prevention. Results are highly accurate, and it can be done in a variety of settings (mobile health units, HCPs' offices, or even in the privacy of an individual's home). Results are typically available within 20 minutes.
2. In-home HIV test kits are available. Testing is done on saliva.
3. Rapid tests are screening tests for antibodies, not for antigen.
4. Negative rapid tests should be followed by a risk assessment to determine the need for repeat tests.
5. Positive rapid tests can be disclosed to the patient but must be confirmed with a standard HIV assay. This step necessitates a blood draw and a return appointment to get results.
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HIV-Antibody/Antigen Testing (Fourth-Generation Testing)
A highly sensitive test detects antibodies and antigens associated with HIV. Blood samples that are negative for HIV infection are reported as negative. The new fourth-generation testing algorithm includes confirmatory testing with HIV viral load testing for any indeterminate results.
* If the patient has a negative fourth-generation test, but reports recent risky behaviors, encourage retesting in 4 to 6 weeks. Individuals at ongoing risk should be assessed or counseled for risk reduction interventions including preexposure prophylaxis (PrEP).
* If the results are positive and consistent with HIV infection, assist the patient in getting appropriate counseling, support, and follow-up HIV primary care.
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Drug Therapy for HIV Infection.
| The goals of drug therapy in HIV infection are to?
(1) decrease the viral load
(2) maintain or increase CD4+ T cell counts
(3) prevent HIV-related symptoms and opportunistic diseases
(4) delay disease progression
(5) prevent HIV transmission
- HIV cannot be cured, but ART can delay disease progression by decreasing viral replication
- When taken consistently and correctly, ART can reduce viral loads by 90% to 99%, which makes adherence to treatment regimens extremely important
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Drugs used to treat HIV work at various points in the HIV replication cycle. The major advantage of using drugs from different classes is that combination therapy can inhibit viral replication in several different ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance. A major problem with most drugs used in ART is that?
resistance develops rapidly when they are used alone (monotherapy) or taken in inadequate doses. For that reason, combinations of three or more drugs should be used.
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Interaction of ART With Other Drugs
* Many ARTs have interactions with other commonly used drugs and herbal therapies (e.g., St. John's wort).
* Significant interactions with ARTs also occur with over-the-counter drugs, including antacids, proton pump inhibitors, and certain supplements.
* Be sure to ask patients about prescribed and over-the-counter drugs as well as herbal products and supplements.
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Drug Therapy for Opportunistic Diseases.
Management of HIV is complicated by the many opportunistic diseases that can develop as the immune system deteriorates. Prevention is the preferred approach to opportunistic diseases. A number of opportunistic diseases associated with HIV can be delayed or prevented with adequate ART, vaccines (including hepatitis B, influenza, and pneumococcal), and disease-specific prevention measures. Although it is usually not possible to eradicate opportunistic diseases once they occur, prophylactic medications can significantly?
decrease morbidity and mortality rates. Advances in the prevention, diagnosis, and treatment of opportunistic diseases have contributed significantly to increased life expectancy.
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Preventing Transmission of HIV.
Preexposure prophylaxis (PrEP) is a comprehensive HIV prevention strategy to reduce the risk of sexually acquired HIV infection in adults at high risk. PrEP should be used in conjunction with other proven prevention interventions such as condoms, risk reduction counseling, and regular HIV testing.
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Tenofovir in combination with emtricitabine, also known as Truvada, is used to reduce the risk of HIV infection in uninfected individuals who are at significant risk of acquiring HIV. Tenofovir/emtricitabine is also currently used in combination with other antiretroviral agents for the treatment of HIV-infected people.
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Nursing Assessment
| Help individuals assess risk by asking some basic questions:
(1) Have you ever had a blood transfusion or used clotting factors? If so, was it before 1985?
(2) Have you ever shared drug-using equipment with another person?
(3) Have you ever had a sexual experience in which your penis, vagina, rectum, or mouth came into contact with another person's penis, vagina, rectum, or mouth?
(4) Have you ever had a sexually transmitted infection?
(5) Have you ever had sexual contact with someone known to have HIV?
- These questions provide the minimum information needed to initiate a risk assessment. Follow up a positive response to any of these questions with an in-depth exploration of issues related to the identified risk.
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Planning
| Nursing interventions can help the patient to?
(1) adhere to drug regimens
(2) adopt a healthy lifestyle that includes avoiding exposure to other sexually transmitted infections and blood-borne diseases
(3) protect others from HIV
(4) maintain or develop healthy and supportive relationships
(5) maintain activities and productivity
(6) explore spiritual issues
(7) come to terms with issues related to disease, disability, and death
(8) cope with symptoms caused by HIV and its treatments
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Healthy People
| Prevention and Early Detection of HIV
* Increase safer sexual practices, including condom use.
* Decrease equipment sharing among IV drug users.
* Increase clinician skills to assess for risk factors for HIV infection, recommend HIV testing, and provide counseling for behavior change.
* Make voluntary HIV testing a routine part of health care.
* Increase access to new HIV testing technologies, especially rapid testing.
* Increase access to HIV testing facilities in traditional health care settings, as well as in alternative sites such as drug and alcohol treatment facilities and community-based organizations.
* Increase risk assessment and individualized behavior change messages to people with HIV to prevent new infections.
* Decrease perinatal HIV infection by offering voluntary HIV testing as a part of routine prenatal care.
* Provide counseling and appropriate HIV therapy to those who are infected.
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A wide variety of activities can reduce the risk of HIV infection. Individuals choose the methods that best fit their needs and circumstances. Prevention techniques can be divided into?
safe sexual activities (those that eliminate risk) and risk-reducing sexual activities (those that decrease, but do not eliminate, risk).
- goal is to develop safer, healthier, and less risky behaviors. The more consistently and correctly prevention methods are used, the more effective they are in preventing HIV infection. It is also a good idea to use a combination of prevention methods (e.g., using condoms and decreasing the number of sex partners) to increase the prevention effect.
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Safe sexual activities eliminate the risk of exposure to HIV in semen and vaginal secretions. Abstaining from all sexual activity is an effective way to accomplish this goal, but there are safe options for those who cannot or do not wish to abstain. Limiting sexual behavior to activities in which the?
mouth, penis, vagina, or rectum does not come into contact with a partner's mouth, penis, vagina, or rectum eliminates contact with blood, semen, or vaginal secretions.
- Safe activities include masturbation, mutual masturbation (“hand job”), and other activities that meet the “no contact” requirements. Insertive sex between partners who are not infected with HIV and not at risk of becoming infected with HIV is also considered safe.
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Risk-reducing sexual activities decrease the risk of contact with HIV through the use of barriers. Barriers should be used when engaging in insertive sexual activity (oral, vaginal, or anal) with a partner who has HIV or whose HIV status is not known. The most commonly used barrier is the?
male condom. Male condoms can be used for protection during anal, vaginal, and oral intercourse. Female condoms provide an alternative to male condoms. Squares of latex (known as dental dams) can be used as a barrier during oral sexual activity.
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Decreasing risks related to drug use.
Drug use, including alcohol and tobacco, can cause immunosuppression, poor nutrition, and a host of psychosocial problems. However, drug use does not cause HIV infection. The major risk for HIV related to using drugs involves sharing equipment or having unsafe sexual experiences while under the influence of drugs. Basic risk reduction rules are?
(1) do not use drugs
(2) if you use drugs, do not share equipment
(3) do not have sexual intercourse when under the influence of any drug (including alcohol) that impairs decision making
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Decreasing risks related to drug use.
Safest method is to abstain from drugs, but this may not be a viable option for users who are not prepared to quit or have no access to drug treatment services. The risk of HIV for these individuals can be eliminated if they do not share equipment.
1) Injecting equipment (“works”) includes?
2) Equipment used to snort (straws) or smoke (pipes) drugs can also be contaminated with?
1) Injecting equipment (“works”) includes needles, syringes, cookers (spoons or bottle caps used to mix the drug), cotton, and rinse water
2) Equipment used to snort (straws) or smoke (pipes) drugs can also be contaminated with blood and should not be shared
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Decreasing risks related to drug use.
Access to sterile equipment is an important risk elimination tactic.
-Cleaning equipment before use can also reduce risk by?
decreasing the chance of blood contact
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Decreasing HIV risks of perinatal transmission
- best way to prevent HIV infection in infants is to prevent HIV infection in women
- Women already infected with HIV should be asked about their reproductive desires
- maintaining pregnancy and using ART to decrease the risk of transmission.
- If HIV-infected pregnant women are treated during pregnancy, the rate of perinatal transmission can be decreased from 25% to less than 2%
- ART has decreased risk for infants born to HIV-infected women
- current standard of care is for all women who are pregnant or contemplating pregnancy to be counseled about HIV, routinely offered access to voluntary HIV-antibody testing, and, if infected, offered optimal ART
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Decreasing risks at work.
The risk of infection from occupational exposure to HIV is small but real. OSHA requires employers to protect workers from exposure to blood and other potentially infectious materials. Precautions and safety devices decrease the risk of direct contact with blood and body fluids. Should exposure to HIV-infected fluids occur?
postexposure prophylaxis (PEP) with combination ART can significantly decrease the risk of infection. The need for timely treatment and counseling makes it even more critical for nurses to report all blood exposures.
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Antiretroviral therapy. ART can significantly slow the progression of HIV. However, treatment regimens can be complex, the drugs have side effects, ART does not work for everyone, and it is expensive. These factors can contribute to problems with adherence to treatment, a dangerous situation because of the high risk of developing drug resistance.
.
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Interventions for ART include teaching about?
(1) advantages and disadvantages of new treatments
(2) dangers of poor adherence to therapeutic regimens (3) how and when to take each drug
(4) drug interactions to avoid
(5) side effects that must be reported to the HCP
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Clinical guidelines provide information on initial drug regimens. However, one of the most important considerations for initiating therapy is?
patient readiness for treatment. Adherence to ART is a critical component of successful drug therapy for people with HIV infection
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ART: Taking drugs as prescribed (right dose and time) is important for all drug therapy, but with HIV infection, missing even a few doses can lead to drug resistance. Patients can be helped to adhere to difficult treatment regimens with?
electronic reminders, beepers, timers on pillboxes, and calendars. Group support and individual counseling can also help, but the best approach is to learn about the patient's life and assist with problem solving related to taking medications within the confines of that life.
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Delaying disease progression.image
HIV disease progression may be delayed by promoting a healthy immune system, whether the patient chooses to take ART or not. Useful interventions for HIV-infected patients include?
(1) getting nutritional support to maintain lean body mass and ensure appropriate levels of vitamins and micronutrients
(2) moderating or eliminating alcohol, tobacco, and drug use
(3) keeping up to date with recommended vaccines
(4) getting adequate rest and exercise
(5) reducing stress
(6) avoiding exposure to new infectious agents
(7) accessing counseling
(8) getting involved in support groups and community activities
(9) developing a consistent relationship with HCPs, including attendance at regular appointments
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HIV: Acute Exacerbations
Chronic diseases are characterized by acute exacerbations of recurring problems. This is especially true in HIV disease in which infections, cancers, debility, and psychosocial or economic issues may interact to overwhelm the patient's ability to cope. Nursing care becomes more complex as the patient's immune system deteriorates and new problems arise to compound existing difficulties. When opportunistic diseases or difficult treatment side effects develop what is needed?
symptom management, teaching, and emotional support are needed
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Nursing care can help prevent the many opportunistic diseases associated with HIV infection. The best way to prevent opportunistic disease is to ensure that the patient is adhering to an effective ART regimen and, if appropriate, taking prophylactic medications for opportunistic infections. Should an opportunistic disease occur, nursing care is an essential part of helping the patient adhere to medications and providing supportive care specific to the opportunistic disease. For example, if the patient has Pneumocystis jiroveci pneumonia (PCP), nursing interventions can ensure?
- If the patient has cryptococcal meningitis, an important nursing concern is?
-if the patient has Pneumocystis jiroveci pneumonia (PCP), nursing interventions can ensure adequate oxygenation.
If the patient has cryptococcal meningitis, an important nursing concern is maintaining a safe environment for a confused patient.
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Physical problems related to HIV or its treatment can interfere with the patient's ability to maintain a desired lifestyle. HIV-infected patients frequently experience anxiety, fear, depression, diarrhea, peripheral neuropathy, pain, nausea, vomiting, and fatigue. Nursing interventions for these symptoms are similar to what they would be for the patient who does not have HIV infection. For example, nursing management of diarrhea includes?
Nursing approaches for fatigue in HIV include teaching patients to assess?
- nursing management of diarrhea includes helping patients collect specimens, recommending dietary changes, encouraging fluid and electrolyte replacement, instructing the patient about skin care, and managing skin breakdown around the perianal area.
- Nursing approaches for fatigue: assess fatigue patterns; determine contributing factors; set activity priorities; conserve energy; schedule rest periods; exercise regularly; and avoid substances such as caffeine, nicotine, alcohol, and other drugs that may disturb sleep
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Some HIV-infected patients, especially those who have been infected and on ART for a long time, may develop a set of metabolic disorders. These include?
(1) lipodystrophy (changes in body shape caused by a redistribution of fat in the abdomen, upper back, and breasts along with fat loss in the arms, legs, and face)
(2) hyperlipidemia (elevated triglycerides, elevated low-density lipoproteins, and decreased high-density lipoproteins)
(3) insulin resistance
(4) hyperglycemia
(5) bone disease (osteoporosis, osteopenia, avascular necrosis)
(6) lactic acidosis
(7) renal disease
(8) cardiovascular disease
- Management of metabolic disorders focuses on detecting problems early, dealing with symptoms, and helping the patient cope with emerging problems and changes to treatment regimens. It is important to recognize and treat these problems early, especially because cardiovascular disease and lactic acidosis are potentially fatal complications
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The number of older adults who have HIV disease is increasing because?
(1) HIV treatment has been effective in reducing the number of deaths from HIV-related opportunistic infections
(2) people 60 and older are being infected at increasing rates. The number of people over the age of 60 living with HIV is expected to grow
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older people living with HIV are susceptible to the same diseases as non-HIV-infected older people. These include?
heart disease, cancer, diabetes, bone disease, arthritis, hypertension, kidney disease, and cognitive impairment. However, people with HIV infection may experience these diseases at an earlier age (compared with non-HIV-infected people) and may be at higher risk of co-morbidities related to the medications used to treat HIV
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Signs and Symptoms HIV-Infected Patients Need to Report
Teach the patient with HIV infection and the caregiver to report the following signs and symptoms.
Report Immediately
* Any change in level of consciousness: lethargic, hard to arouse, unable to be aroused, unresponsive, unconscious
* Headache accompanied by nausea and vomiting, changes in vision, changes in ability to perform coordinated activities, or after any head trauma
* Vision changes: blurry or black areas in vision field, new floaters, double vision
* Persistent shortness of breath related to activity and not relieved by a short rest period
* Nausea and vomiting accompanied by abdominal pain
* Vomiting blood
* Dehydration: unable to eat or drink because of nausea, diarrhea, or mouth lesions; severe diarrhea or vomiting; dizziness when standing
* Yellow discoloration of the skin
* Any bleeding from the rectum that is not related to hemorrhoids or trauma (e.g., from anal sexual intercourse)
* Pain in the flank with fever and inability to urinate for more than 6 hr
* Blood in the urine
* New onset of weakness in any part of the body, new onset of numbness that is not obviously related to pressure, new onset of difficulty speaking
* Chest pain not obviously related to cough
* Seizures
* New rash accompanied by fever
* New oral lesions accompanied by fever
* Severe depression, anxiety, hallucinations, delusions, or thoughts of causing danger to self or others
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Report the Following Signs and Symptoms Within 24 Hours
* New or different headache; constant headache not relieved by over-the-counter medication
* Headache accompanied by fever, nasal congestion, or cough
* Burning, itching, or discharge from the eyes
* New or productive cough
* Vomiting 2 or 3 times a day
* Vomiting accompanied by fever
* New, significant, or watery diarrhea (more than 6 times a day)
* Painful urination, bloody urine, urethral discharge
* Significant new rash (widespread; painful; or following a path down the leg or arm, around the chest, or on the face)
* Difficulty eating or drinking because of mouth lesions
* Vaginal discharge, pain, or itching
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Improving Adherence to Antiretroviral Therapy
| The following are strategies that you can use to improve a patient's adherence to using antiretroviral therapy:
1. Determine whether the patient understands the importance of adherence and is ready to start therapy.
2. Provide teaching on medication dosing.
3. Review potential side effects of drugs.
4. Assure the patient that side effects can be treated. If not, medication regimens can be changed.
5. Use teaching and memory aids, including pictures, pillboxes, and calendars.
6. Engage family and friends in the teaching process. Solicit their support to help the patient take treatment.
7. Simplify regimens, dosing, and food requirements as much as possible.
8. Use a team of nurses, HCPs, pharmacists, case managers, and mental health and peer counselors to support the patient.
9. Help the patient integrate the medication regimen into his or her typical life activities and work schedules
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Antiretroviral Drugs
Resistance to antiretroviral drugs is a major problem in treating HIV infection. Include the following instructions when teaching the patient and/or caregiver to decrease the risk of developing resistance.
1. Discuss options with your HCP to find the best regimen for you. Your provider should order at least three different antiretroviral drugs from at least two different drug groups.
2. Know the drugs you are taking and how to take them (some have to be taken with food, some must be taken on an empty stomach, some cannot be taken together). If you do not understand, ask. Have your nurse write the instructions clearly for you.
3. Take the full dose prescribed, and take it on schedule. If you cannot take the drug because of side effects or other problems, report it to your HCP immediately.
4. Take all of your medications as prescribed. Do not quit taking one drug while continuing the others. If you cannot tolerate even one of your drugs, talk to your HCP, who will recommend a way to deal with the side effects or a new set of drugs.
5. Many antiretroviral drugs interact with other drugs, including a number of common drugs you can buy without a prescription. Be sure your HCP and pharmacist know all of the drugs that you are taking, and do not take any new drugs without checking for possible interactions.
6. The goals of antiretroviral therapy are to decrease the amount of virus in your blood (your viral load) and to keep your CD4+ T cell count high. The best results reduce your viral load below detectable levels and keep your CD4+ T cell count high. Most HCPs do routine laboratory work every 3 to 6 months whether you are taking antiretroviral agents or not.
7. Two to 4 weeks after you start on drug therapy (or change your therapy), your HCP will test your viral load to find out how the drugs are working.
• Your viral load is reported in absolute numbers. All you need to know is that you want to see the viral load drop.
• Your CD4+ T cell count is reported in absolute numbers or percentages. It is best for your CD4+ T cell count to be above 500 to 600 cells/µL. If reported in percentages, you would like your CD4+ T cell value to be above 14%.
8. An undetectable viral load means that the amount of virus is extremely low and HIV cannot be found in the blood using current testing technology. It does not mean that the virus is gone because the virus can be in lymph nodes and organs that blood tests cannot detect. It also does not mean that you are no longer able to transmit HIV to others. You will need to continue protecting all of your sexual and drug-using partners from HIV.
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Health Promotion
1. Prevent HIV infection.
Risk factors: What behaviors or social, physical, emotional, pathogenic, or immune factors place the patient at risk?
• Education, including knowledge, attitudes, and behaviors, with emphasis on risk reduction to the following:
• General population: Cover general information
• Pregnant women: General information and information specific to HIV infection and pregnancy
• Individual patient: Specific to assessed need
• Empower patients to take control of prevention measures.
.
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A patient asks the nurse about rapid testing for human immunodeficiency virus (HIV) infection at home. What is the best response by the nurse?
"These tests are done on freshly voided urine."
"Positive rapid tests should be repeated for confirmation."
"Rapid tests are screening tests for antibodies, not for antigens."
"These tests are not recommended by the Centers for Disease Control and Prevention (CDC)."
"Positive rapid tests should be repeated for confirmation."
Rapid testing is recommended strongly by the CDC and can be done in a variety of settings. These tests are screening tests for antibodies, not antigens; testing is done on oral fluid samples. Positive rapid tests need to be confirmed with the more specific Western blot (WB) or immunofluorescence assay (IFA). This step necessitates a blood draw and a return appointment to get results.
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A patient with human immunodeficiency virus (HIV) taking antiretroviral therapy reports they are starting to feel like they did before starting the therapy. What test should the nurse prepare the patient for?
Phenotype assay
Western Blot test
Standard antibody test
White blood cell count lab test
```
Phenotype assay
The patient may have developed a resistance to the medications, and either a genotype or phenotype assay will let the nurse know if this is the reason why the antiretroviral therapy may not be working effectively. The Western Blot test is done to confirm that the patient has HIV. The standard antibody test is done to test for HIV antibodies. White blood cell count laboratory tests are done to test for possible infection.
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A woman infected with human immunodeficiency virus (HIV) delivers a baby with congenital anomalies. The patient was put on Atripla (tenofovir DF+emtricitabine+efavirenz) during pregnancy to control infection. The nurse recognizes that what is the probable cause for the fetal malformations?
Adverse effects of efavirenz
Adverse effects of tenofovir DF
Adverse effects of emtricitabine
Immune deficiency due to HIV
```
Adverse effects of efavirenz
The use of efavirenz in large doses in pregnant women may cause fetal anomalies. Tenofovir and emtricitabine are usually not associated with fetal malformations. Tenofovir and emtricitabine are used for preexposure prophylaxis. Immune deficiency due to HIV rarely causes fetal malformation.
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A nurse is assessing a patient's human immunodeficiency virus (HIV) risk. Which questions should the nurse ask to assess for an increased risk? Select all that apply.
"Have you ever had oral thrush?"
"Have you ever been hospitalized?"
"Have you ever had a blood transfusion?"
"Have you ever had unprotected sexual intercourse?"
"Have you ever had a sexually transmitted infection?"
"Have you ever had a blood transfusion?"
"Have you ever had unprotected sexual intercourse?"
"Have you ever had a sexually transmitted infection?"
To help a patient assess risk of HIV, the nurse should ask questions regarding history of blood transfusion, unprotected sexual intercourse, and sexually transmitted disease. These questions provide the minimum information needed to initiate a risk assessment. A positive response to any of these questions should be followed by an in-depth exploration of issues related to the identified risk. A history of oral thrush or hospitalization may not indicate risky behavior and may not contribute to risk assessment.
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A patient is diagnosed with acquired immunodeficiency syndrome (AIDS). Which opportunistic infections should the nurse monitor for in the patient? Select all that apply.
```
Legionnaires' disease
Candidiasis of bronchi
Ebola hemorrhagic fever
Toxoplasmosis of the brain
Mycobacterium avium (MAC) complex
```
Candidiasis of bronchi
Toxoplasmosis of the brain
Mycobacterium avium (MAC) complex
Candidiasis of bronchi, toxoplasmosis of the brain, and Mycobacterium avium complex are opportunistic infections in AIDS, because the immune system is too weak to fight back. Candidiasis of the bronchi is a fungal infection caused by Candida albicans. It rarely causes problems in healthy adults because they have strong immune systems, but is common in people with HIV due to weakened immunity. Toxoplasmosis of the brain is a protozoal infection, and Mycobacterium avium complex is a bacterial infection. Ebola hemorrhagic fever is caused by Ebola virus, and Legionnaires' disease is caused by Legionella pneumophila; these are not opportunistic diseases. They are emerging infections that have recently increased in incidence.
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A patient with chronic acquired immunodeficiency syndrome (AIDS) is taking antiretroviral therapy (ART) as well as medication for tuberculosis. What does the nurse anticipate observing when reviewing laboratory studies for this patient? Select all that apply.
```
Neutropenia
Lymphopenia
High platelet count
Normal hemoglobin levels
Abnormal liver function tests
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Neutropenia
Abnormal liver function tests
The patient may have abnormal liver function tests due to treatment with antitubercular drugs such as isoniazid (INH) and rifampin (RIF). These drugs are hepatotoxic and may derange the liver function tests. The patient is treated on ART, which may also cause neutropenia. A high platelet count, normal hemoglobin levels, and lymphopenia may not be significant findings when on therapy with ART and antitubercular drugs.
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An HIV patient is on long-term antiretroviral therapy (ART). Of what side effects of the antiretroviral therapy should the nurse instruct the patient to be aware?
Nausea
Vomiting
Diarrhea
Lipodystrophy
Lipodystrophy
HIV-infected patients on antiretroviral therapy may develop a metabolic disorder called lipodystrophy, which is the deposition of fat in the abdomen, upper back, and breasts. There may simultaneously be a loss of fat in the arms, legs, and face. Nausea, vomiting, and diarrhea are short-term side effects of ART and tend to subside with regular use.
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The nurse is caring for a patient newly diagnosed with human immunodeficiency virus (HIV). The patient asks what would determine the actual development of acquired immunodeficiency syndrome (AIDS). The nurse's response is based on the knowledge that what is a diagnostic criterion for AIDS?
Presence of HIV antibodies
CD4 +T cell count below 200/µL
Presence of oral hairy leukoplakia
White blood cell (WBC) count below 5000/µL
CD4 +T cell count below 200/µL
Diagnostic criteria for AIDS include a CD4 +T cell count below 200/µL or the development of specified opportunistic infections, cancers, wasting syndrome, or dementia. The presence of HIV antibodies or oral hairy leukoplakia or WBC count below 5000/µL may be found in patients with HIV disease, but do not define the advancement of HIV infection to AIDS.
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During an assessment, the nurse finds that a patient who is HIV-positive has whitish yellow patches in the mouth, GI tract, and esophagus. Which opportunistic infection is the patient likely experiencing?
Candida albicans
Coccidioides immitis
Cryptosporidium muris
Cryptococcus neoformans
Candida albicans
Opportunistic infections are caused by microorganisms that normally do not cause disease but which become pathogenic when the immune system is impaired and unable to fight off infection. AIDS patients are susceptible to opportunistic diseases. Whitish yellow patches in mouth, GI tract, and esophagus and the presence of thrush indicate Candida albicans. Infection by Coccidioides immitis manifests with symptoms like pneumonia, fever, weight loss, and cough. Cryptosporidium muris gastroenteritis is characterized by watery diarrhea, abdominal pain, and weight loss. Meningitis, cognitive impairment, motor dysfunction, fever, seizures, and headache are symptoms of Cryptococcus neoformans
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A patient who participates in high-risk activities has undergone an enzyme immunoassay (EIA) test for human immunodeficiency virus (HIV) infection. The nurse reviews the patient's lab results and notes a positive EIA result. What is likely to be included in the patient's plan of care? Select all that apply.
Repeat the EIA test.
Confirm with a Western blot test.
Confirm with an immunofluorescence assay.
Confirm with a rapid screening test for antigens.
Inform the patient that the patient is HIV-antibody positive.
Repeat the EIA test.
Confirm with a Western blot test.
Confirm with an immunofluorescence assay.
If the patient tests positive with the enzyme immunoassay (EIA) test, which is highly sensitive, the test has to be repeated. If the repeat test is positive, the patient should be subjected to a confirmatory Western blot or immunofluorescence assay. Rapid screening tests are helpful for detecting antibodies, not antigens. The patient should be informed that he is positive for HIV antibody only if the confirmatory Western blot or immunofluorescence assay is positive.
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The nurse is reviewing home medications with a patient diagnosed with human immunodeficiency virus (HIV). Which medications and over-the-counter pills may have interactions with HIV therapy? Select all that apply.
```
Antacids
St. John’s wort
Protease inhibitors
Integrase inhibitors
Proton pump inhibitors
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Antacids
St. John’s wort
Proton pump inhibitors
Antacids, proton pump inhibitors, and St. John’s wort all interact with HIV drug therapy. Protease inhibitors and integrase inhibitors are drugs used to treat HIV.
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Nursing diagnosis for HIV/AIDS
* Pain
* Imbalanced Nutrition: Less than body requirements
* Diarrhea
* Impaired skin integritly
* Disturbed though processess
* Chronic low self-esteem
* Social isolation
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Community based care for HIV/AIDS
* Home care management
* Health teaching
* Psychosocial preparation
* Health care resources
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Clinical manifestation of AIDS: Immunologic
* Low white cell counts CD4+ T cell <200/mm3
* Opportunistic infections
* Lymphadenopathy
* Fatigue
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Clinical manifestation of AIDS: Integumentary
* Poor wound healing
* Skin lesions
* Night sweats
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Clinical manifestation of AIDS: Respiratory
* Cough
| * SOB
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Clinical manifestation of AIDS: Gastrointestinal
* Diarrhea
* Weight Loss
* Nausea/vomiting
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Clinical manifestation of AIDS: CNS
* Confusion
* Dementia
* Headache
* Visual changes
* Personality changes
* Pain
* Seizures
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Clinical manifestation of AIDS: Opportunistic infections
```
Protozoal infections
* Pneumocystis Carinii Pneuonia
* Toxoplasmosis (Encephalitis)
* Cryptosporidiosis (GI)
Fungal infections
* Candidiasis-Stomatitis, Esophagitis, Vaginal
Bacterial Infections
* Mycobacterium Complex
* Tuberculosis
Viral Infections
* Cytomegalovirus
* Herpes Simplex Virus
* Varicella-Zoster Virus
```
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Malignancies associated with HIV/AIDS
* Kaposi's Sarcoma
* Non-Hodgkin's Lymphoma
* Hodgkin's Lymphoma
* Invasive Cervical Carcinoma
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AIDS Dementia Complex
Cognitive, Motor and Behavioral Impairments in 70% of AIDS clients
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You have suffered a needle stick injury after giving a patient an IM injection, but you have no information about the patient’s HIV status. What is the most appropriate method for obtaining this information
about the patient?
a. You should ask the patient to authorize HIV testing as soon as possible.
b. The nurse manager for the unit is responsible for obtaining the
information.
c. The occupational health nurse should discuss HIV status with the
patient.
d. HIV testing should be done the next time blood is drawn for other tests.
ANSWER C – The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and obtaining a patient’s HIV status and/or patient HIV testing is the occupational health nurse. Doing unauthorized HIV testing or asking the patient yourself would be unethical. The nurse manager is not responsible for obtaining this information (unless the manager is also in charge of occupational health)
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A diagnosis of AIDS can be made for a patient with HIV with
a CD4+ T-cell count <500/µL.
a WBC count <3000/µL (3 × 109/L).
development of oral candidiasis (thrush).
onset of Pneumocystis jiroveci pneumonia.
Answer: d
Rationale: The Centers for Disease Control (CDC) has established criteria for a patient to be diagnosed with AIDS. AIDS is diagnosed when an HIV-positive individual develops at least one of several criteria: examples are CD4+ T-cell count less than 200 cells/uL and fungal infection such as Pneumocystis jiroveci pneumonia (PCP). Candidiasis infection must be of the bronchi, trachea, lungs, or esophagus (not only the mouth).
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Active/Acquired Immunity
1) Body produces antibodies against specific antigens
2) Memory cells-produce immediate response on reexposure to antigen, long-term immunity
3) Acquired through exposure from disease or immunization
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Passive immunity
Maternal antibodies, injection of immune globulins
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Hypersensitivity Reactions
Sometimes the immune response is overreactive against foreign antigens or reacts against its own tissue, resulting in tissue damage. These responses are termed? Autoimmune diseases, a type of hypersensitivity response, occur when the body?
- responses are termed hypersensitivity reactions
- Autoimmune diseases, a type of hypersensitivity response, occur when the body fails to recognize self-proteins and reacts against self-antigens
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Hypersensitivity reactions can be classified according to the?
1) source of the antigen
2) time sequence (immediate or delayed)
3) immunologic mechanisms causing the injury
- Four types of hypersensitivity reactions exist. Types I, II, and III are immediate and are examples of humoral immunity. Type IV is a delayed hypersensitivity reaction and is related to cell-mediated immunity.
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Type I: IgE-Mediated Reactions.
Anaphylactic reactions are type I reactions that occur only in susceptible people who are highly sensitized to specific allergens. IgE antibodies, produced in response to the allergen, have a characteristic property of attaching to mast cells and basophils (Fig. 13-6; see Fig. 28-2). Within these cells are granules containing potent chemical mediators (histamine, serotonin, leukotrienes, eosinophil chemotactic factor of anaphylaxis [ECF-A], kinins, and bradykinin)
- Anaphylactic reactions are type I reactions that occur in susceptible people who are highly sensitized to specific allergens
- IgE antibodies, produced in response to the allergen, have characteristic property of attaching to mast cells and basophils. Within these cells are granules containing potent chemical mediators (histamine, serotonin, leukotrienes, eosinophil chemotactic factor of anaphylaxis [ECF-A], kinins, and bradykinin)
- On first exposure to allergen, IgE antibodies are produced and bind to mast cells and basophils
- any subsequent exposures, allergen links with IgE bound to mast cells or basophils and triggers degranulation of cells and release of chemical mediators from granules. In this process, the mediators that are released attack target tissues, causing clinical symptoms of an allergic response. These effects include smooth muscle contraction, increased vascular permeability, vasodilation, hypotension, increased secretion of mucus, and itching. mediators are short acting and effects are reversible
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Type 1: Hypersensitivities/Allergies
* Increased or excessive response to the presence of an antigen to which the patient has been exposed
* Degree of reaction ranging from uncomfortable to life threatening
105
IgG
Concentration
Location
Characteristics
Concentration: 76%
Location: Plasma, interstitial fluid
Characteristics: only immunoglobulin that crosses placenta,responsible for secondary immune response
106
IgA
Concentration
Location
Characteristics
Concentration: 15%
Location: Body secretions, including tears, saliva, breast milk, colostrum
Characteristics: Lines mucous membranes and protects body surfaces
107
IgM
Concentration
Location
Characteristics
Concentration: 8%
Location: Plasma
Characteristics: Is responsible for primary immune response, Forms antibodies to ABO blood antigens
108
IgD
Concentration
Location
Characteristics
Concentration: 1%
Location: Plasma
Characteristics: Is present on lymphocyte surface, Assists in the differentiation of B lymphocytes
109
IgE
Concentration
Location
Characteristics
Concentration: 0.002%
Location: Plasma, interstitial fluids
Characteristics: Causes symptoms of allergic reactions,
Fixes to mast cells and basophils, Assists in defense against parasitic infections
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Type II: Cytotoxic and Cytolytic Reactions.
| Cytotoxic and cytolytic reactions are type II hypersensitivity reactions involving the direct binding of?
- IgG or IgM antibodies to an antigen on the cell surface.
- Antigen-antibody complexes activate the complement system, which mediates the reaction. Cellular tissue is destroyed in one of two ways: (1) activation of the complement system resulting in cytolysis or (2) enhanced phagocytosis.
111
Target cells frequently destroyed in type II reactions are?
erythrocytes, platelets, and leukocytes. The tissue damage usually occurs rapidly. Some of the antigens involved are the ABO blood group, Rh factor, and drugs. Pathophysiologic disorders characteristic of type II reactions include ABO incompatibility transfusion reaction, Rh incompatibility transfusion reaction, autoimmune and drug-related hemolytic anemias, leukopenias, thrombocytopenias, erythroblastosis fetalis (hemolytic disease of the newborn), and Goodpasture syndrome.
112
The body makes special autoantibodies directed against self cells that have some form of foreign protein attached to them.
Occur when IgG or IgM antibodies attack the patients own tissue
Type II Cytotoxic Reactions
113
Excess antigens cause immune complexes to form in the blood. These circulating complexes usually lodge in small blood vessels
Type III Immune Complex Reactions
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Type III: Immune-Complex Reactions.
Tissue damage in immune-complex reactions, which are type III reactions, occurs secondary to antigen-antibody complexes. Soluble antigens combine with immunoglobulins of the IgG and IgM classes to form complexes that are too small to be effectively removed by the mononuclear phagocyte system. Therefore the complexes deposit in?
tissue or small blood vessels. They cause activation of the complement system and release of chemotactic factors that lead to inflammation and destruction of the involved tissue
115
Type III reactions may be local or systemic and immediate or delayed. The clinical manifestations depend on the number of complexes and the location in the body. Common sites for deposit are the?
kidneys, skin, joints, blood vessels, and lungs. Severe type III reactions are associated with autoimmune disorders such as systemic lupus erythematosus, acute glomerulonephritis, and rheumatoid arthritis
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Type IV: Delayed Hypersensitivity Reactions.
A delayed hypersensitivity reaction—a type IV reaction—is a cell-mediated immune response. Although cell-mediated responses are usually protective mechanisms, tissue damage occurs in delayed hypersensitivity reactions. The tissue damage in a type IV reaction does not occur in the presence of antibodies or complement. Rather?
sensitized T cells attack antigens or release cytokines. Some of these cytokines attract macrophages into the area. The macrophages and enzymes released by them are responsible for most of the tissue destruction. In the delayed hypersensitivity reaction, it takes 24 to 48 hours for a response to occur.
117
Clinical examples of a delayed hypersensitivity reaction include?
contact dermatitis; hypersensitivity reactions to bacterial, fungal, and viral infections; and transplant rejections. Some drug sensitivity reactions also fit this category.
118
* In this type of reaction, the reactive cell is the T-lymphocyte (T-cell)
* Antibodies and complement are not involved
* Local collection of lymphocytes and macrophages causes edema, induration, ischemia, and tissue damage at the site
Type IV Delayed hypersensitivity Reactions
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Type V: Stimulatory Reaction
* Excess stimulation of a normal cell surface receptor by an autoantibody, resulting in a continuous "turned-on" state for the cell
* Graves disease (caused by a generalized overactivity of the entire thyroid gland (hyperthyroidism)
120
Drug Therapy.
| The major categories of drugs used for symptomatic relief of chronic allergic disorders include?
antihistamines, sympathomimetic/decongestant drugs, corticosteroids, antipruritic drugs, and mast cell–stabilizing drugs. Many of these drugs can be obtained over the counter and are often misused by patients.
121
Antihistamines are the best drugs for treatment of?
They are less effective for?
They act by?
- treatment of allergic rhinitis and urticaria
- They are less effective for severe allergic reactions. They act by competing with histamine for H1-receptor sites and thus blocking the effect of histamine. Best results are achieved if they are taken as soon as allergy symptoms appear. Antihistamines can be used effectively to treat edema and pruritus but are relatively ineffective in preventing bronchoconstriction. With seasonal rhinitis, antihistamines should be taken during peak pollen seasons
122
Sympathomimetic/Decongestant Drugs.
- major sympathomimetic drug is epinephrine (Adrenalin), for anaphylactic reaction
- Epinephrine produced by adrenal medulla and stimulates α- and β-adrenergic receptors
- Stimulation of the α-adrenergic receptors causes vasoconstriction of peripheral blood vessels. β-Receptor stimulation relaxes bronchial smooth muscles. - Epinephrine acts directly on mast cells to stabilize against further degranulation
- action of epinephrine lasts a few minutes
- For the treatment of anaphylaxis, the drug must be given parenterally (IM, IV)
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Corticosteroids.
| Nasal corticosteroid sprays are effective in relieving the symptoms of?
allergic rhinitis
-Occasionally patients have such severe manifestations of allergies that they are truly incapacitated. In these situations, a brief course of oral corticosteroids can be used.
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Mast Cell–Stabilizing Drugs.
| Cromolyn (NasalCrom) is a mast cell–stabilizing agent that inhibits the?
release of histamines, leukotrienes, and other agents from the mast cell after antigen-IgE interaction. It is available as an inhalant nebulizer solution or a nasal spray. Cromolyn is used in the management of allergic rhinitis
125
Autoimmunity is an immune response against self in which the immune system no longer differentiates self from nonself. For some unknown reason, immune cells that are normally unresponsive (tolerant to self-antigens) are activated. In autoimmunity, what causes tissue damage?
autoantibodies and autosensitized T cells cause pathophysiologic tissue damage
126
The cause of autoimmune diseases is still unknown. Age is thought to play some role because the number of circulating autoantibodies increases in people over age 50. However, the principal factors in the development of autoimmunity are?
(1) the inheritance of susceptibility genes, which may contribute to the failure of self-tolerance
(2) initiation of autoreactivity by triggers, such as infections, which may activate self-reactive lymphocytes
127
Autoimmune diseases tend to cluster, so that a given person may have more than one autoimmune disease (e.g., rheumatoid arthritis, Addison's disease), or the same or related autoimmune diseases may be found in other members of the same family. This observation has led to the concept of genetic predisposition to autoimmune disease. Most of the genetic research in this area correlates certain?
human leukocyte antigen (HLA) types with an autoimmune condition
128
Even in a genetically predisposed person, some trigger is required for the initiation of autoreactivity. This may include infectious agents such as a virus. Viral infections can cause an alteration of cells or tissues that are not normally antigenic. The virally induced changes can make the cells or tissues antigenic. Viruses may be involved in the development of diseases such as type 1 diabetes mellitus. Rheumatic fever and rheumatic heart disease are autoimmune responses triggered by?
streptococcal infection and mediated by antibodies against group A β-hemolytic streptococci that cross-react with heart muscles and valves and synovial membranes
129
Gender and hormones also have a role in autoimmune disease.
More women than men have autoimmune disease. During pregnancy, many autoimmune diseases get better. After delivery, the woman with an autoimmune disease frequently has an exacerbation
130
Main points for autoimmunity
* Autoimmunity is the process whereby a person develops an inappropriate immune respone
* Antibodies and/or lymphocytes are directed against healthy normal cells and tissues
* For unknown reasons, the immune system fails to recognize certain body cells or tissues as self and triggers immune reactions
131
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?
Enzyme immunoassay
Immunofluorescence assay
Rapid HIV antibody testing
Viral load testing
Viral load testing
132
Inflammation (HIPER)
```
H: heat
I: induration
P: pain
E: edema
R: redness
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A nurse is assessing a patient who has developed eczematous skin lesions due to ingestion of nail polish remover today as well as several days ago. Which type of immunity reaction does the nurse suspect?
IgE-mediated reaction
Immune-complex reaction
Cytotoxic and cytolytic reaction
Delayed hypersensitivity reaction
Delayed hypersensitivity reaction
A delayed hypersensitivity reaction is a type of inflammatory reaction that is initiated by mononuclear leukocytes. The term "delayed" is used because a secondary cellular response appears 24 to 48 hours after the antigen exposure. The patient developed eczematous skin lesions on the second exposure, indicating the formation of memory cells to the antigen. The reaction between the memory cells and the antigens sensitizes the patient and results in skin lesions within 48 hours. This indicates a delayed hypersensitivity reaction. IgE-mediated reactions, immune-complex reactions, and cytotoxic and cytolytic reactions are immediate types of hypersensitivity reactions in which a response is seen within 12 minutes of an antigen challenge.
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The nurse is comparing cell-mediated immunity and humoral immunity. Which of these are characteristics of humoral immunity? Select all that apply.
Antibodies are produced.
Involves B lymphocyte cells.
Involves T lymphocyte cells and macrophages.
Examples include anaphylactic shock and transfusion reaction.
Examples include destruction of cancer cells and graft rejection.
Antibodies are produced.
Involves B lymphocyte cells.
Examples include anaphylactic shock and transfusion reaction.
Humoral immunity involves B lymphocyte cells and produces antibodies. Examples include anaphylactic shock, atopic diseases, transfusion reaction, and bacterial infections. The other responses reflect cell-mediated immunity. Humoral immunity does not involve T lymphocytes and macrophages (cell-mediated immunity does). Cancer cell destruction and graft rejection are examples of cell-mediated immunity.
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A nurse is assessing a patient with a diagnosis of Graves’ disease. Which hypersensitivity reaction does the nurse determine will occur in this patient?
IgE-mediated reaction
Immune-complex reaction
Cytotoxic and cytolytic reaction
Delayed hypersensitivity reaction
Cytotoxic and cytolytic reaction
In cytotoxic reaction, the antibodies produced by the immune response bind to the antigens on the patient’s own cell surfaces. In Graves’ disease, antibodies are produced that bind to the thyroid-stimulating hormone receptor, causing excessive stimulation of the receptor. This excessive stimulation causes excessive production of thyroid hormone. Therefore a cytotoxic reaction is suspected in a patient who shows symptoms of Graves' disease. IgE-mediated reaction may be suspected in patients with asthma. Immune-complex reaction may be suspected in patients with rheumatoid arthritis. Delayed hypersensitivity reaction may be suspected in patients with contact dermatitis caused by poison ivy.
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Type I: IgE Mediated
Antigen
Antibody involved
Complement involved
Mediators of injury
Examples
Skin test
```
Antigen: pollen, food, drugs, dust
Antibody involved: IgE
Complement involved: No
Mediators of injury: Histamine, Mast cells, Leukotrienes, prostaglandins
Examples: Allergic rhinitis, asthma, atopic dermatitis, urticaria, angioedema
Skin test: wheal and flare
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Type II: Cytotoxic
Antigen
Antibody involved
Complement involved
Mediators of injury
Examples
Skin test
```
Antigen: Cell surface of RBCs, cell basement membrane
Antibody involved: IgG, IgM
Complement involved: Yes
Mediators of injury: Complement lysis, Macrophages in tissues
Examples: Transfusion reaction, Goodpasture syndrome, Immune thrombocytopenic purpura, Grave's disease
Skin test: None
138
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Type III Immune Complex
Antigen
Antibody involved
Complement involved
Mediators of injury
Examples
Skin test
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Antigen: Extracellular fungal, viral, bacteria
Antibody involved: IgG, IgM
Complement involved: Yes
Mediators of injury: Neutrophils, complement lysis, monocytes, macrophages, lysosomal enzymes
Examples: systemic lupus erythmatosus, Rheumatoid arthritis, acute glomerulonephritis
Skin test: Erythema and edema in 3-8 hours
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Type IV Delayed hypersensitivity
Antigen
Antibody involved
Complement involved
Mediators of injury
Examples
Skin test
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Antigen: intracellular or extracellular
Antibody involved: None
Complement involved: No
Mediators of injury: Cytokins, T-cytotoxic cells
Examples: contact dermatitis (to poison ivy)
Skin test: Erythema and edema in 24-48 hours (TB test)
140
A nurse is administering epinephrine to a patient who has developed an anaphylactic reaction after the injection of an antibiotic. What should the nurse tell the patient regarding epinephrine? Select all that apply.
Its effect lasts for 6 hours.
It relaxes bronchial smooth muscles.
It can be given orally or parenterally.
Nasal sprays of epinephrine are very effective.
It causes vasoconstriction of peripheral blood vessels.
It relaxes bronchial smooth muscles.
It causes vasoconstriction of peripheral blood vessels.
Epinephrine is a hormone produced by adrenal medulla that causes vasoconstriction of peripheral blood vessels and relaxes bronchial smooth muscles. These effects are due to activation of beta-adrenergic receptors. Its action lasts for a few minutes, and it can be given only parenterally (IM or IV). The drug cannot be given through nasal sprays.
141
An instructor is teaching about wheal-and-flare reactions. Which statement made by the student nurse indicates that further education is required?
"A wheal-and-flare reaction is very dangerous."
"A wheal-and-flare reaction can serve a diagnostic purpose."
"A mosquito bite is an example of a wheal-and-flare reaction."
"A wheal-and-flare reaction is characterized by a pale wheal containing edematous fluid."
"A wheal-and-flare reaction is very dangerous."
a wheal and flare reaction is a reaction that occurs in response to an allergen. The reaction occurs in minutes or hours and is usually not dangerous. This reaction serves a diagnostic purpose as a means of demonstrating allergic reactions to specific allergens during skin tests. The classic example of a wheal-and-flare reaction is a mosquito bite. Wheal-and-flare reactions are characterized by a pale wheal containing edematous fluid.
142
Which immunoglobulin has the highest total serum concentration?
IgA
IgD
IgE
IgG
IgG
The serum concentration of IgG is 78%, which is the highest of these immunoglobulins. IgA has a serum concentration of 15%. IgD has a serum concentration of 1%. IgE has a serum concentration of 0.002%.
143
Which type of immunity occurs when a patient receives a hepatitis B immune globulin injection?
Active-natural
Passive-active
Active-artificial
Passive-artificial
Passive-artificial
The patient receives passive-artificial immunity when given an immune globulin, because exposure via blood products is considered passive-artificial. Passive and active immunity are two types of immunity, not one type. Active-natural immunity occurs when a patient has natural contact with the antigen. Active-artificial immunity occurs when a patient is immunized with an antigen, for instance via vaccine.
144
The nurse recognizes that a patient is demonstrating signs of a transplant rejection after a renal transplant. Which phenomenon is responsible for the rejection of donor organs and tissue?
Innate immunity
Passive immunity
Humoral immunity
Cell-mediated immunity
Cell-mediated immunity
Cell-mediated immunity involves various cells, including natural killer cells. The natural killer cells are responsible for identifying "self" and "nonself" tissues, which sometimes results in rejection of grafts and transplants. Innate immunity is present after birth. It involves a nonspecific response through neutrophils and monocytes and is not responsible for graft rejections. Passive immunity results when antibodies are acquired by the body and not produced within. Humoral immunity involves immunoglobulin production and is responsible for allergic reactions.
145
The nurse differentiates between the types of hypersensitivity reactions and recognizes that which type is related to cell-mediated immunity?
Type I
Type II
Type III
Type IV
Type IV
Type IV is related to cell-mediated immunity. It is a delayed hypersensitivity reaction. Tissue damage occurs in delayed hypersensitivity reactions. It requires 24 to 48 hours for a response to occur. Type I, Type II, and Type III are immediate reactions and are a part of humoral immunity.
146
The nurse is providing education to a client with an IgE-mediated hypersensitivity reaction. What statement made by the patient indicates that further education is required?
"Asthma is an example of an IgE-mediated hypersensitivity reaction."
"Complement system is involved in IgE-mediated hypersensitivity reactions."
"Histamine and mast cells are the mediators of injury in IgE-mediated hypersensitivity reactions."
"Exogenous pollen, food, and dust are the antigens associated with IgE-mediated hypersensitivity reactions."
"Complement system is involved in IgE-mediated hypersensitivity reactions."
IgE-mediated hypersensitivity reaction is a type I hypersensitivity reaction that is provoked by reexposure to a specific type of antigen called an allergen. Asthma is an example of an IgE-mediated hypersensitivity reaction because it is caused by repeated exposure to an allergen. Complement system is not involved in IgE-mediated hypersensitivity reactions. Histamine and mast cells are the mediators of injury in IgE-mediated hypersensitivity reactions. Exogenous pollen, food, and dust are the antigens associated with IgE-mediated hypersensitivity reactions.
147
The nurse is caring for a patient who had an exposure to poison ivy, which initiated a cell-mediated immune response. The production of what type of cell is increased as a result of this response?
IgE
Bacteria
Cytokines
Macrophages
Cytokines
A cell-mediated immune response triggers the differentiation of T helper cells into T cytotoxic cells, which produce cytokines. IgE is an immunoglobulin and is produced during humoral immunity. Cell-mediated response does not affect the number of bacteria in the body. Macrophages are types of white blood cells (WBC) that identify and ingest antigens containing foreign material.
