Immunity

Question 1

the three functions of immunity

Answer 1

Defense: Our body attacks the foreign antigen and pathogens

Homeostasis: the removal or digestions of damaged cellular substances allowing the regular cells to remain unchanged/unharmed

Surveillance: Our body continually recognizes mutations and destroys them

Question 2

the three integrated responses of immune system are…

Answer 2

inflammation, cell mediated and antibody (humoral) response

Question 3

the four types of immunity are…

Answer 3

innate/non-specific
cell-mediated
humoral
acquired/adaptive (there are two types passive and active)

Question 4

what are some of the organs of the immune system?

Answer 4

lymph nodes
spleen
bone marrow
tonsils
skin
gut flora
thymus gland

Question 5

describe the four types of hypersensitivity responses

Answer 5

-type I/IgE mediated
Anaphylaxis reaction from antigens such as pollen, food, drugs, dust. also includes allergic rhinitis.

-type II/cytotoxic
blood transfusion reaction, caused by Rh incompatibility

-type III/immune complex
tissue damage. can be systemic, local, immediate or delayed

-type IV/delayed
cell mediated response. such as in contact dermatitis or transplant rejections

Question 6

signs and symptoms of anaphylaxis?

Answer 6

rapid onset, loss of consciousness, hypotension, tachycardia, feelings of apprehension, tingling and swelling in mouth/face/throat/tongue, dyspnea, tight throat, bronchospasm, laryngeal edema

Question 7

nursing interventions to treat anaphylaxis

Answer 7

Establish/maintain/Ensure a patent airway
COULD mean giving epinephrine 1st
Administer oxygen

Establish IV access

Epinephrine (antihistamines will not stop shock

Oxygen: high flow

Maintain blood pressure

Review table 14.11 (p. 225)

Ongoing, frequent monitoring/assessing

Patient teaching re: prevention, epi-pen

Question 8

what is agglutination?

Answer 8

clumping of blood cells

Question 9

signs and symptoms of blood transfusion reaction include…

Answer 9

chills, fever, tachycardia, increased anxiety, flushing, headache. can also include: chest pain, hypotension, tachypnea, low back pain.

mild reactions include: hives, facial flushing and pruritis. severe reactions include: bronchospasm, anxiety, and severe SOB

Question 10

nursing interventions for a blood transfusion reaction include…

Answer 10

stop transfusion and notify provider, change IV tubing, recheck crossmatch record

Question 11

latex allergies are which type of hypersensitivity?

Answer 11

can be type I or type IV. type I presents as skin redness, conjunctivitis, asthma, rhinitis, or anaphylaxis. type IV presents as contact dermatitis.

Question 12

common food allergies related to latex allergies include….

Answer 12

banana, avocado, kiwi, chestnuts, tomato

Question 13

immunocompromised considerations for allergies

Answer 13

Nurse should:
Masks, gowns, gloves
LIMIT invasive ‘lines’
Limit visitors; no ill visitors
Single patient use items

Educate pt:
No raw/uncooked veggies; no buffets; filter and/or boil water; use dishwasher
No sharing→ razors, toothbrush, deodorant; practice SAFE SEX!

Question 14

gerontological considerations for immunity

Answer 14

Decline in function of immune system
Increased susceptibility to infection
Response to immunizations is lower
Thymus shrinks
T-cells production diminishes
Diminished or lack of hypersensitivity reaction/overall decreased immune response

Question 15

sepsis is…

Answer 15

a medical emergency
a life-threatening syndrome in response to an infection
characterized by fever, tachycardia, hypotension, tachypnea, altered mental status, and INFECTION

Question 16

the biggest concern with sepsis is…

Answer 16

organ damage/failure which leads to death

Question 17

sepsis criteria

Answer 17

infection, PLUS at least 2 of the following:
altered mental status
temp > 38.3C
HR > 90 bpm
hyperglycemia w/o DM dx >140
hypothermia, core temp < 36C
SBP <100
tachypnea/ RR > 22
edema/positive fluid balance >20 ml/kg in 24 hr period

Question 18

sepsis interventions and times to complete interventions

Answer 18

1-2 L fluid to help lower pulse, and raise BP
Labs including lactate will tell if pt is acidotic (within 15 mins)
Blood cultures to see whats actually in pt system (within 15 mins)
Start broad spectrum abx like vanco (within 30 mins)

Question 19

what is HIV?

Answer 19

human immunodeficiency virus. A retrovirus that causes immunosuppresion

Question 20

what is AIDS?

Answer 20

acquired immunodeficiency syndrome. A point on the continuum of HIV infection where a person in severely immunocompromised. Some criteria for dx AIDS are wasting syndrome, malignancies, cognitive changes, opportunistic infections, and/or lab values.

Question 21

what are the stages of an HIV infection?

Answer 21

Initial asymptomatic period: Some individuals may have flu-like symptoms
Latent period while the virus is contained
Late stage where immune system begins to fail (AIDS)

Question 22

what is the treatment for HIV?

Answer 22

ART (antiretroviral therapy). Educate pt that these are taken lifelong and it is not a cure. Also educate pt that he/she can still transmit the virus while on meds

Question 23

what are some opportunistic infections (OI)?

Answer 23

Pneumocystis carinii pneumonia (PCP)
Kaposi’s Sarcoma (KS)
Tuberculosis (TB)

Question 24

what kind of precautions should be taken by RN when caring for a pt with HIV?

Answer 24

standard precautions and extra caution to avoid needle sticks

Question 25

nursing interventions for a pt with HIV

Answer 25

monitor closely for s/s of infection, only use indwelling catheters and venipuncture if truly necessary
educate, educate, educate!
to prevent further infection pt should practice hand hygiene, receive adequate nutrition, no unprotected sex even with other HIV+ individs, avoid people w infections, decrease smoking and alcohol use

Question 26

what is PrEP?

Answer 26

pre-exposure prevention (Truvada)

Question 27

nursing care for HIV+ patients?

Answer 27

Monitor progression and immune function
Educate importance of medication compliance
Infection prevention
Managing symptoms
Preventing complications
Risk reduction counseling-changing behaviors
Limit partners/ practice abstinence
Address myths re: certain barriers
USE of barriers
Testing
Address drug use
No needle sharing
Info about needle exchange programs/ clean equipment