Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 3 Immune System
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Explain to the patient:
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That there is no cure for scleroderma, but it may go into remission and
then relapse.
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Schedule rest periods during activities.
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Avoid the cold.
Mononucleosis
A viral syndrome consisting of sore throat, enlarged lymph glands, and fevers.
Usually caused by the Epstein-Barr Virus, but sometimes other viruses are the
cause. Occasionally, a rash may be seen. The spleen is sometimes enlarged due to
sequestration of cells during the immune response.
WHAT WENT WRONG?
A virus was transmitted from contact to contact. Oftentimes, a secondary bacterial
infection, streptococcus, is found.
PROGNOSIS
Prognosis is good. Since it is a disease of young people, recovery is generally un-
complicated.
HALLMARK SIGN AND SYMPTOMS
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General malaise
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Fever
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Myalgias
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Headache
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Sore throat
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INTERPRETING TEST RESULTS
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Mono Spot or a positive heterophil antibody test is used to identify the
Epstein-Barr Virus.
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CBC, chemistry.
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Throat culture for strep.
TREATMENT
Treatment is supportive with rest and over-the-counter medications for symptom
resolution.
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Penicillin or erythromycin for the streptococcal throat.
NURSING DIAGNOSES
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Fatigue
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Activity intolerance
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Impaired physical mobility
NURSING INTERVENTIONS
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Encourage adequate rest.
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Assure fluids and nutritional intake.
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Monitor fever and vital signs.
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Throat culture, if indicated.
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Analgesics.
Epstein-Barr Virus/
Chronic Fatigue Syndrome
WHAT WENT WRONG?
Chronic Fatigue Syndrome (CFS) is a chronic, multisymptom, multisystem syn-
drome in a previously healthy adult. It results from any of five so far known
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viruses: Epstein-Barr, cytomegalovirus, coxsackievirus B, adenovirus type I, and
human herpes virus 6. In an unknown way, the viruses disturb the immune system
which is then unable to adequately fight off the virus.
PROGNOSIS
The prognosis varies as the disease waxes and wanes. Remissions and exacerba-
tions may be frequent. By adulthood, most of the population in the United States
will test positive for EB virus.
SIGNS AND SYMPTOMS
Persistent fatigue unrelieved by rest, impairment of memory and concentration,
myalgias, arthralgias, headache, change in sleep, malaise, depression, and labile
mood. Insomnia is a common occurrence.
INTERPRETING TEST RESULTS
Since CFS is a diagnosis of exclusion, testing is done to rule out other etiologies
for the symptoms. These may include CBC, metabolic panel, thyroid studies, HIV,
ESR, rheumatoid factor, Lyme, EBV, and CMV titers.
TREATMENT
Treatment is empirical and based on symptoms. Treating and eliminating other
diagnoses is imperative. Allowing for frequent rest periods, and adequate nutrition
are necessary. Pharmacological treatment may include NSAIDs and analgesics. As
there is a higher prevalence of past and present psychiatric diagnoses in patients
with CFS, an evaluation may be indicated. Psychotherapy may help. Physical ther-
apy is often indicated and routine exercising has been found to be helpful.
NURSING DIAGNOSES
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Activity intolerance
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Fatigue
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Chronic pain
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NURSING INTERVENTIONS
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Provide supportive care.
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Encourage fluids and adequate nutrition.
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Rest.
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Offer psychotherapy.
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Exercise regimen.
Lyme Disease
WHAT WENT WRONG?
A bite from a deer tick causes the bacteria (a spirochete) Borrelia burgdorferi, to
be transmitted into the human blood stream. The patient presents with fever, myal-
gias and the classic bull’s eye rash, erythema chronicum migrans up to three weeks
following the bite.
PROGNOSIS
Early treatment generally leads to a better outcome. Lingering constitutional symp-
toms occasionally occur.
HALLMARK SIGNS AND SYMPTOMS
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Fever
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Generalized aches
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Headache
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Rash at site of the bite (patient may not recall bite)
INTERPRETING TEST RESULTS
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IgM antibody is elevated.
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Lyme titers may be drawn.
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TREATMENT
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doxycycline, 100 mg bid (twice a day) × 14 to 21 days.
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aqueous penicillin G, 20 million units.
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ceftriaxone, 4 grams/day IM or IV.
NURSING DIAGNOSES
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Impaired skin integrity
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Impaired physical mobility
NURSING INTERVENTIONS
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Cover all exposed skin while outside.
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Use appropriate insect repellant.
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Inspect arms and legs for ticks when coming in from outside.
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Inspect pets.
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Educate on proper way to remove tick.
Septic Shock
WHAT WENT WRONG?
Septic shock starts with bacteremia, usually gram negative bacteria infecting the
blood. The sources are usually genito-urinary system, gastrointestinal tract, and
lungs. The infection may be underlying for some time before shock develops. Once
the cascade from bacteremia to septic shock starts, it may be difficult to halt the
process. Shock may occur more quickly in patients who are elderly, immune-
compromised, or with other comorbidities. In response to a bacterial infection,
TNF-alpha and other inflammatory chemicals are released into the blood, causing
an increase in the blood leaking from vessels into both the infected and non-
infected tissues (vascular permeability).
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PROGNOSIS
Prognosis depends on the general state of the patient, on the type of bacteria, how
quickly a definitive diagnosis is made, and the originating source(s) of the bac-
teremia. Mortality rates vary from 40 to 80 percent.
HALLMARK SIGNS AND SYMPTOMS
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Nausea and vomiting from the source of the infection
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Temperature over 101°F due to infection
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Hypotension due to fluid displacement, vasodilation
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Tachycardia from fever and infection
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Tachypnea from fever and infection
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Lactic acidosis results from poor oxygenation
INTERPRETING TEST RESULTS
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WBC 15,000 to 30,000—indicates infection.
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Decreased platelet count—blood coagulopathies are common in shock.
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Abnormal PT and PTT—blood coagulopathies.
TREATMENT
Treatment results depends on the individual. Varying responses are due to the vari-
able immune and inflammatory responses of each patient and their comorbidities.
Treatment depends on identifying the organism, the source of the bacteremia, the
appropriate antibiotic, and maintaining normal vital signs.
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Antibiotic specific for the type of bacteria present.
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Fluid resuscitation.
NURSING DIAGNOSES
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Decreased cardiac output
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Deficient fluid volume
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Skin integrity
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NURSING INTERVENTION
•
Monitor vital signs, especially fever.
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Monitor fluid intake and output to assess for fluid overload and hydration status.
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Monitor coagulation factors.
Systemic Lupus Erythematosus
(SLE)
WHAT WENT WRONG?
SLE is a chronic inflammatory immune disorder affecting the skin and other body
organs. Antibodies to DNA and RNA cause an autoimmune inflammatory response,
resulting in swelling and pain. It is most common in young women, and has a
strong genetic factor. The etiology is not known.
PROGNOSIS
Prognosis is good but is consistent with many remissions and exacerbations. Most
patients do quite well on a course of medications, but some progress rapidly with
severe organ involvement and subsequently, death. Certain medications may pro-
duce lupus-like symptoms in patients. A review of medications is indicated before
a diagnosis is made.
HALLMARK SIGNS AND SYMPTOMS
•
Butterfly rash on face due to deposition of immunoglobulin and comple-
ment in the skin.
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Fatigue may be due to anemia
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Anemia due to inflammation
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Fever, malaise
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Joint pain
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INTERPRETING TEST RESULTS
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Positive antinuclear antibody test—antibodies are present in the blood.
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Positive rheumatoid factor.
TREATMENT
Treatment of SLE is supportive. The drugs used should match the stage the
patient is in at the time. Treatment of systemic signs is dependent on the organ
system involved.
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Administer NSAIDs to decrease the inflammation and give analgesic
effects:
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ibuprofen
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flurbiprofen
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indomethacin
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sulindac
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naproxen
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diclofenac
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Antimalarials—used to treat joint manifestations and skin rashes.
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Administer immunosuppressants in patients who are unresponsive to corti-
costeroids:
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azathioprine
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cyclophosphamide
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Administer analgesic:
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NSAIDs
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aspirin
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acetaminophen
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tramadol
NURSING DIAGNOSES
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Impaired mobility
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Disturbed body image
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Ineffective protection
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Chronic pain
NURSING INTERVENTION
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Avoid sunlight.
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Cover butterfly rash with cosmetics.
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Reduce stress.
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Monitor for infections.
Crucial Diagnostic Tests
Immunologic Blood Studies
WHY IS IT GIVEN?
These tests are used to identify immunological factors in the blood:
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ANA. The antinuclear antibodies test is a screening test for the detection of
antibodies to nuclear antigens. Close to 100 percent of patients with SLE will
show positive evidence.
•
ESR. The erythrocyte sedimentation rate is useful in differentiating between
inflammatory and neoplastic disease. Serial values are helpful to track disease
severity.
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SS-A and SS-B. SS-A antibodies can be detected in about 30 percent of SLE
patients. SS-B antibodies have a high specificity for the sicca complex,
caused by diminished secretion from glands.
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Rheumatoid factor. Rheumatoid factor is an IgM antibody that is associated
with rheumatoid arthritis. Blood is drawn from a vein and a study is con-
ducted to determine if the blood contains this immunoglobulin antibody. 50
percent of the patients with rheumatoid arthritis have this antibody.
•
Scleroderma autoantibodies. The sclerodema antibody is found in venous
blood of patients who have scleroderma. The autoantibodies are positive in
about 25 to 40 percent of scleroderma patients.
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HOW DOES THE TEST WORK?
A small amount of blood is removed from the patient and is examined for
immunoglobulins, and their antibodies, antinuclear antibodies, rheumatoid factor,
and lupus erythematosus cell preparation. A positive finding indicates that the
patient has the corresponding immunologic disease, or has had some exposure.
WHAT TO DO?
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After the procedure:
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Make sure that the site of the venipuncture isn’t bleeding to ensure that
adequate clotting has occurred.
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Results should be available in several days.
Enzyme-Linked Immunosorbent Assay
(ELISA)
WHY IS IT GIVEN?
This determines if the patient’s blood contains antibodies for the human immuno-
deficiency virus (HIV) to determine if the patient is HIV-positive.
HOW DOES THE TEST WORK?
A small sample of blood is taken and examined for the presence of the HIV anti-
body. This is generally used for screening and confirmation is necessary with a
Western Blot test.
WHAT TO DO?
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Before the procedure:
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Obtain written informed consent due to legal requirements.
•
Explain the purpose of the test and how the test results are interpreted.