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Nursing 271 > Med-Surg: Chapter 18 Assessment of the Immune System > Flashcards

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

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1
Q

Comprehensive Patient History

A
  • Current Problem
  • Past Medical and Surgical History
  • Immunization Hx
  • Family History
  • Social History
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2
Q

Comprehensive Patient Hx: Current Problem

A
  • 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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3
Q

Comprehensive Patient Hx: Past Medical and Surgical History

A
  • 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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4
Q

Comprehensive Patient Hx: Family History

A
  • malignancy
  • anemia
  • recent infections
  • TB hx
  • immune disorders
  • hemophilia
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5
Q

Comprehensive Patient Hx: Social History

A
  • lifestyle factors
  • smoking status
  • alcohol intake
  • illicit drug use
  • recent foreign travel
  • employment history
  • environmental exposure history
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6
Q

Physical Examination Includes What?

A

-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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7
Q

Inspection for a Immune Disorder

A

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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8
Q

Auscultation for a Immune Disorder

A
  • 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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9
Q

Immune System Infection Risk Factors

A
  • Hepatic (Liver) Disease
  • Malnutrition
  • Pulmonary (Lung) Disease
  • Radiation Therapy
  • Renal (Kidney) Disease
  • Splenectomy
  • Surgery
  • Trauma
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10
Q

Immune System Infection Risk Factors: Hepatic (Liver) Disease

A

Impact:

  • decreased neutrophil count
  • decreased phagocyte action
  • diminished immunoglobulin production
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11
Q

Immune System Infection Risk Factors: Malnutrition

A

Impact:

  • decrease in WBC count
  • diminished neutrophil activity
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12
Q

Immune System Infection Risk Factors: Pulmonary (lung) disease

A

Impact:

-decreased neutrophil activity

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13
Q

Immune System Infection Risk Factors: Radiation Therapy

A

Impact:

  • decreased WBC production
  • damage to first-line barrier defenses
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14
Q

Immune System Infection Risk Factors: Renal (Kidney) Disease

A

Impact:

  • decreased neutrophil action
  • decreased immunoglobulin activity
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15
Q

Immune System Infection Risk Factors: Splenectomy

A

Impact:

-loss of recognition and encapsulation of bacteria

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16
Q

Immune System Infection Risk Factors: Surgery

A

Impact:

  • disruption of normal flora
  • disruption of barrier defenses
  • reduced neutrophila action
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17
Q

Immune System Infection Risk Factors: Trauma

A

Impact:

  • disruption of barrier defenses
  • contamination from soil, water, objects
18
Q

Palpation and Percussion for a Patient with a Immune Disorder

A

-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

19
Q

Diagnostic Studies to Evaluate the state of an individual’s Immune Competence

A
  • blood tests
  • skin tests
  • bone marrow aspiration and biopsy
  • radiological imaging
20
Q

Primary Immune Deficiencies

A

due to aberrant development of immune cells or tissues

21
Q

Secondary Immune Deficiencies

A

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

22
Q

Autoimmunity

A

refers to the body’s attack against tissue that is self, causing organ or tissue dysfunction

23
Q

Hypersensitivity

A

occurs when an exaggerated response to an antigen is present

24
Q

Gammopathies

A

(caused by abnormal protein produced by plasma cells)

-caused by a overproduction of Igs from the plasma cell

25
Q

Tests to Evaluate Immune Disorders

A

-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

26
Q

Complete Blood Count (CBC) with Differential

A

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

27
Q

Nursing Considerations When Patient Undergoing a Immunological Workup

A
  • 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
28
Q

Normal CBC with Differential Lab Values

A 
-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%)
29
Q

Absolute Neutrophil Count (ANC)

A

calculates number of neutrophils available for fighting bacterial infections

30
Q

Absolute Lymphocyte Count (ALC)

A

calculates number of lymphocytes available to fight viral and opportunistic infections

31
Q

Normal Leukocyte (WBC) count

A

4.5 to 11.1 10^3/mm3

32
Q

Erythrocyte Sedimentation Rate

A

screening for presence of inflammatory process

33
Q

C-reactive protein

A

detected if inflammatory process or tissue destruction is present

34
Q

Total Immunoglobulin (Ig) levels: IgA, IgG, and IgM: Test Interpretation

A

presence of anti-body producing B cells

35
Q

Levels of antibodies against vaccines: Test Interpretation

A

ability to produce IgM, IgG antibodies

36
Q

Age-Related Changes

A
  • 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
37
Q

Chapter Summary

A

-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

38
Q

When Immune Competence is Present

A

the immune system prevents the penetration of foreign microbes or antigens and the proliferation of abnormal or malignant cells

39
Q

When Immune Incompetence is Present

A

lead to allergies, infection, cancer, and autoimmune and immunodeficiency disorders

40
Q

What can Impact Immunity and Immune Responses

A
  • age
  • medications
  • nutrition
  • genetics
  • physical or emotional stress
  • illness

Nursing 271 (208 decks)

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