Med-Surg: Chapter 18 Assessment of the Immune System Flashcards
Comprehensive Patient History
- Current Problem
- Past Medical and Surgical History
- Immunization Hx
- Family History
- Social History
Comprehensive Patient Hx: Current Problem
- constitutional: fevers, chills, night sweats, weight loss, fatigue, malaise, rashes
- dizziness; changes in mental status, memory, gait
- SOB, cough, wheezing
- chest pain; palpitations, presyncope, syncope
- loss of appetite, nausea, vomiting diarrhea, abdominal pain
- bleeding; site, characteristic, associated symptoms
- enlarged nodes: site characteristic, associated symptoms, predisposing factors
- joint pain, stiffness, swelling, muscle weakness, myalgias, arthralgias
- extremity swelling: unilateral/bilateral, characteristic, predisposing factors, associated symptoms, treatment
- medications: chemotherapy, immunosuppression, antibiotics/antivirals, interferon, leukotriene antagonists
- allergies and severity of reactions
- physical activity and tolerance
Comprehensive Patient Hx: Past Medical and Surgical History
- childhood illnesses
- medications: chemotherapy, antibiotics, immunosuppression, steroids
- malignancy
- recurrent infections
- surgery or trauma (Splenectomy; if spleen removed, increased risk of infection)
- chronic illnesses with or without risk factors
- blood transfusions
- tuberculosis (TB) or other infectious hx
Comprehensive Patient Hx: Family History
- malignancy
- anemia
- recent infections
- TB hx
- immune disorders
- hemophilia
Comprehensive Patient Hx: Social History
- lifestyle factors
- smoking status
- alcohol intake
- illicit drug use
- recent foreign travel
- employment history
- environmental exposure history
Physical Examination Includes What?
-vital signs
-inspection of skin and mucous membranes
-palpation of lymph nodes
-examination of neurological, respiratory, cardiovascular, gastrointestinal, genitourinary, and musculoskeletal system (head-to-toe)
>with an immune dysfunction, normal inflammatory responses may be blunted
Inspection for a Immune Disorder
Look for:
-hypo or hyperthermia
-enlarged lymph nodes
-edema
-changes in skin color and skin integrity
-rashes, dermatitis type lesions, hematomas, petechiae, or purpura
-changes in level of consciousness (LOC), cognition, gait, vision, and hearing
-changes in the respiratory system (tachypnea, air hunger, retractions, coughing, and nasal flaring)
>collect and examine the urine for sediment, odor, and blood
>stool samples assessed for blood, smell, and presence of diarrhea
Auscultation for a Immune Disorder
- listen to lungs for adventitious breath sounds (crackles, wheezing, rubs, or rhonchi)
- note a decrease in or absence of breath sounds
- listen to heart sounds; note if tachycardia, rubs, or irregularity of heart rhythm
- check for bowel sounds; note if hyperactive, hypoactive, or absent
Immune System Infection Risk Factors
- Hepatic (Liver) Disease
- Malnutrition
- Pulmonary (Lung) Disease
- Radiation Therapy
- Renal (Kidney) Disease
- Splenectomy
- Surgery
- Trauma
Immune System Infection Risk Factors: Hepatic (Liver) Disease
Impact:
- decreased neutrophil count
- decreased phagocyte action
- diminished immunoglobulin production
Immune System Infection Risk Factors: Malnutrition
Impact:
- decrease in WBC count
- diminished neutrophil activity
Immune System Infection Risk Factors: Pulmonary (lung) disease
Impact:
-decreased neutrophil activity
Immune System Infection Risk Factors: Radiation Therapy
Impact:
- decreased WBC production
- damage to first-line barrier defenses
Immune System Infection Risk Factors: Renal (Kidney) Disease
Impact:
- decreased neutrophil action
- decreased immunoglobulin activity
Immune System Infection Risk Factors: Splenectomy
Impact:
-loss of recognition and encapsulation of bacteria
Immune System Infection Risk Factors: Surgery
Impact:
- disruption of normal flora
- disruption of barrier defenses
- reduced neutrophila action
Immune System Infection Risk Factors: Trauma
Impact:
- disruption of barrier defenses
- contamination from soil, water, objects
Palpation and Percussion for a Patient with a Immune Disorder
-palpate skin to check temperature and whether clamminess is present
-examine lymph nodes for enlargement or tenderness; with light palpation, move the skin over the areas where nodes may be palpable; nodes not easily palpable in a healthy adult; if noted to be enlarged, tender, or fixed in position = concern
-explore the adjacent area and regions that are drained by the enlarged nodes for signs of infection or malignancy; cancerous nodes are not usually as tender as those from an infection or inflammatory process
-light and deep palpation with percussion on abdomen to assess for hepatosplenomegaly (enlargement of liver and spleen), palpable masses, and presence of abdominal fluid or abdominal pain
>liver and spleen may be enlarged b/c of infections, primary or metastatic cancer, or diseases of the blood or lymph system
-joints examined for mobility, pain, swelling, warmth, and erythema
Diagnostic Studies to Evaluate the state of an individual’s Immune Competence
- blood tests
- skin tests
- bone marrow aspiration and biopsy
- radiological imaging
Primary Immune Deficiencies
due to aberrant development of immune cells or tissues
Secondary Immune Deficiencies
due to outside interference of the normal immune system
>ex: AIDs (which is caused by HIV) is a secondary immune deficiency caused by a viral infection
Autoimmunity
refers to the body’s attack against tissue that is self, causing organ or tissue dysfunction
Hypersensitivity
occurs when an exaggerated response to an antigen is present
Gammopathies
(caused by abnormal protein produced by plasma cells)
-caused by a overproduction of Igs from the plasma cell
Tests to Evaluate Immune Disorders
-obtained to identify antibody deficiencies, T-lymphocyte and neutrophil defects, and complement abnormalities
-specific tests based on assessment and related to the suspected deficiency or disorder
>ex: if patient has a hx of chronic bacterial infections, a CBC with differential to evaluate individual leukocyte counts
>ex: if fighting an infection, a CBC to evaluate WBC count and inflammatory markers such as C-reactive protein to evaluate responsiveness to a prescribed antibiotic
>if neutropenia (low neutrophil count) with a low absolute neutrophil count (ANC) is present, reverse isolation may be necessary to protect patient from infections
Complete Blood Count (CBC) with Differential
measures total leukocytes, with a breakdown of leukocyte types and percentage present
-increases in leukocytes with an increase in immature neutrophils (aka band neutrophils) indicates infection or inflammation; referred to as a left shift
Nursing Considerations When Patient Undergoing a Immunological Workup
- for all testing, provide patient teaching on what to expect, what the test is, and why it is being done
- adequate preparation, education, and counseling regarding studies ordered; teaching will allow patient to be prepared for the procedure
- patient should repeat back what is taught
Normal CBC with Differential Lab Values
-Leukocyte WBC count: 4.5-11.1 >Differential: Normal (%) -Neutrophils: 6,300 (40-70%) -Lymphocytes: 4,100 (20-40%) -Monocytes: 1,800 (2-8%) -Eosinophils: 250 (1-3%) -Basophils: 60 (less than 1%)
Absolute Neutrophil Count (ANC)
calculates number of neutrophils available for fighting bacterial infections
Absolute Lymphocyte Count (ALC)
calculates number of lymphocytes available to fight viral and opportunistic infections
Normal Leukocyte (WBC) count
4.5 to 11.1 10^3/mm3
Erythrocyte Sedimentation Rate
screening for presence of inflammatory process
C-reactive protein
detected if inflammatory process or tissue destruction is present
Total Immunoglobulin (Ig) levels: IgA, IgG, and IgM: Test Interpretation
presence of anti-body producing B cells
Levels of antibodies against vaccines: Test Interpretation
ability to produce IgM, IgG antibodies
Age-Related Changes
- competence may decrease as the immune system changes and weakens with age
- aging negatively affects innate and adaptive immune responses
- innate and adaptive immune responses provide defense against tumor cells; these responses decline with aging, creating increased incidence with cancers
- older adults have a decline in T-cell production and function and in antibody production when exposed to specific antigen challenges
- increase in production of autoantibodies; leading to autoimmune disorders
- decrease in B-cell production and function and antigen specific Ig activity; creating diminished immune memory and delayed hypersensitivity reactions
- malnutrition is a result of chewing and swallowing problems, blunted taste sensations, and chronic conditions that interfere with the absorption of food and nutrients
- economic factors, medication side effects, depressive moods, and decrease in social interaction may negatively impact oral intake and nutritional status in the aging population
Chapter Summary
-immune system is a network that remains in a continual mode of surveillance and on constant alert to defend the body against infection and disease
-lymphoid organs work in collaboration with specialized immunity and immune responses to afford this protection
-innate and adaptive immunity involves first-, second-, and third-line defenses that include physical and chemical barriers and inflammatory, cell-mediated, and antibody-mediated responses
-Innate Immunity provides the first two lines of defenses
>first-line is though anatomical, biochemical, genetic, or physiological barriers that include the skin and mucous membranes
>Second-line is the inflammatory responses with the assistance of IFN, complement, and phagocytosis
-Neutrophils are phagocytes and early responders to inflammation
-Monocytes and Macrophages respond later and stay longer to clean up debris at the site of inflammation
-Eosinophils defend against parasitic infiltration
-Natural Killer (NK) cells eliminate viruses and cancer cells
-Cytokines including Interferon (IFN), Interleukins (IL), and Tumor Necrosis Factor (TNF), are regulators of the inflammatory response
-local manifestations of inflammation: redness, heat, swelling, and pain
>Third-line defense through adaptive immunity which is acquired through natural or artificial exposure to an infection, antigen, or vaccine; protects through cell-mediated and antibody-mediated mechanisms by providing a specific antigen-antibody response with B- and T-cell activation; it can be active or passive immunity depending on if the immune response originated in the host or in a donor
When Immune Competence is Present
the immune system prevents the penetration of foreign microbes or antigens and the proliferation of abnormal or malignant cells
When Immune Incompetence is Present
lead to allergies, infection, cancer, and autoimmune and immunodeficiency disorders
What can Impact Immunity and Immune Responses
- age
- medications
- nutrition
- genetics
- physical or emotional stress
- illness
