Med-Surg: Chapter 18 Assessment of the Immune System Flashcards by alexis susino

Comprehensive Patient History

Current Problem
Past Medical and Surgical History
Immunization Hx
Family History
Social History

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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

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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

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Comprehensive Patient Hx: Family History

malignancy
anemia
recent infections
TB hx
immune disorders
hemophilia

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Comprehensive Patient Hx: Social History

lifestyle factors
smoking status
alcohol intake
illicit drug use
recent foreign travel
employment history
environmental exposure history

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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

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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

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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

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Immune System Infection Risk Factors

Hepatic (Liver) Disease
Malnutrition
Pulmonary (Lung) Disease
Radiation Therapy
Renal (Kidney) Disease
Splenectomy
Surgery
Trauma

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Immune System Infection Risk Factors: Hepatic (Liver) Disease

Impact:

decreased neutrophil count
decreased phagocyte action
diminished immunoglobulin production

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Immune System Infection Risk Factors: Malnutrition

Impact:

decrease in WBC count
diminished neutrophil activity

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Immune System Infection Risk Factors: Pulmonary (lung) disease

Impact:

-decreased neutrophil activity

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Immune System Infection Risk Factors: Radiation Therapy

Impact:

decreased WBC production
damage to first-line barrier defenses

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Immune System Infection Risk Factors: Renal (Kidney) Disease

Impact:

decreased neutrophil action
decreased immunoglobulin activity

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Immune System Infection Risk Factors: Splenectomy

Impact:

-loss of recognition and encapsulation of bacteria

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Immune System Infection Risk Factors: Surgery

Impact:

disruption of normal flora
disruption of barrier defenses
reduced neutrophila action

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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