Immunity Flashcards
the three functions of immunity
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
the three integrated responses of immune system are…
inflammation, cell mediated and antibody (humoral) response
the four types of immunity are…
innate/non-specific
cell-mediated
humoral
acquired/adaptive (there are two types passive and active)
what are some of the organs of the immune system?
lymph nodes
spleen
bone marrow
tonsils
skin
gut flora
thymus gland
describe the four types of hypersensitivity responses
-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
signs and symptoms of anaphylaxis?
rapid onset, loss of consciousness, hypotension, tachycardia, feelings of apprehension, tingling and swelling in mouth/face/throat/tongue, dyspnea, tight throat, bronchospasm, laryngeal edema
nursing interventions to treat anaphylaxis
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
what is agglutination?
clumping of blood cells
signs and symptoms of blood transfusion reaction include…
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
nursing interventions for a blood transfusion reaction include…
stop transfusion and notify provider, change IV tubing, recheck crossmatch record
latex allergies are which type of hypersensitivity?
can be type I or type IV. type I presents as skin redness, conjunctivitis, asthma, rhinitis, or anaphylaxis. type IV presents as contact dermatitis.
common food allergies related to latex allergies include….
banana, avocado, kiwi, chestnuts, tomato
immunocompromised considerations for allergies
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!
gerontological considerations for immunity
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
sepsis is…
a medical emergency
a life-threatening syndrome in response to an infection
characterized by fever, tachycardia, hypotension, tachypnea, altered mental status, and INFECTION
the biggest concern with sepsis is…
organ damage/failure which leads to death
sepsis criteria
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
sepsis interventions and times to complete interventions
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)
what is HIV?
human immunodeficiency virus. A retrovirus that causes immunosuppresion
what is AIDS?
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.
what are the stages of an HIV infection?
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)
what is the treatment for HIV?
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
what are some opportunistic infections (OI)?
Pneumocystis carinii pneumonia (PCP)
Kaposi’s Sarcoma (KS)
Tuberculosis (TB)
what kind of precautions should be taken by RN when caring for a pt with HIV?
standard precautions and extra caution to avoid needle sticks
nursing interventions for a pt with HIV
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
what is PrEP?
pre-exposure prevention (Truvada)
nursing care for HIV+ patients?
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
