Allergy and Immune Disorders

1. Allergy and Immune Disorders Med/Surg

2. Allergy-hypersensitivity to one or more substances • Acquired through exposures to substances • Allergist-physician that specializes and treats allergies • Immunity is based on the ability of the body to recognize foreign proteins and to destroy foreign matter • Antigen is a foreign protein substance and the normal reaction from the body is to produce antibodies • Antibodies release histamine (chemical mediators) antigen-antibody response • These mediators start a series of reactions in the body • Allergic reactions do not form during the first exposure to antigens, only during subsequent contacts • Autoimmune disorders-body fails to recognize its own cells and destroys them • Allergies are responsible for symptoms that range from rhinorrhea, skin rash to asthma or anaphylaxis

3. Allergy-hypersensitivity to one or more substances • Dx tests: detailed medical history and physical exam, laboratory and skin tests, allergy-antibody response varies with seasons, fatigue, and hormones • Lab tests: CBCD, eosonophil count, eosinophil smear of secretions, blood levels of IgE (immunoglobulin E) • *Skin tests: done to confirm disorders or determine the cause of allergic reactions intradermally. The needle is held flat against the skin and the bevel up. • *Physical examination information: • Dyspnea • Syncope • Nasal edema and congestion

4. Skin Tests • Antigens are injected intradermally or applied to a scratch on the skin • After 20-30 minutes, the skin test is read, redness (erythema), or an induration (lump, wheal, or edema) represent a positive test • Degree of edema (measured in mm’s) indicates the severity of the reaction • Physician may premedicate with antihistamines prior to these tests • Monitor the client closely because they could have a severe allergic reaction (anaphylactic reaction)

6. Nursing Process • Data collection • Observe and assess (head to toe) • Question client about pruritus, numbness, dyspnea, tingling • Examine for rash, urticaria, rhinorrhea, sneezing, wheezing • Document and REPORT abnormal s/s • A person can have an allergic reaction to any medication • *the reaction is more dramatic if the medication is administered parenterally • Check allergies prior to administering meds • *Immune disorders often present with fatigue, dyspnea, recurrent infections, joint pain, rashes, slow wound healing or visual disturbances • Ask about family Hx

7. Nursing Diagnosis for Allergy • Diarrhea • Risk for Injury • Impaired Skin Integrity • Disturbed Sleep Pattern • Fatigue • Delayed Growth and Development • Disturbed Self-esteem

8. Planning and Implementation • Client may require assistance with • Activities of daily living • Dealing with emotional aspects of living with chronic disorder • Teach client, family about • Disorder and its prognosis, treatment

9. Nursing Process: Evaluation • Evaluate outcomes of care • With client, family, other members of healthcare team • Short and long term goals • Symptom control • Medication compliance • Seriousness of disorder influences future planning for care, rehabilitation

10. Allergies • Immunogen-antigens that cause an immune response in the body • Allergens-antigens that cause a tissue reaction to occur • Sensitive or allergic reaction occurs when a person has a tissue reaction to a specific substance

11. Allergies • Allergens can enter the body via: • inhalation-pollen, dust, mold • ingestion-meds, foods, eggs, nuts • injection-meds, insect bites/stings, immunizations with animal serum, blood transfusions • direct contact-poison ivy, dyes, latex rubber, wool

12. Allergies • Manifestation of allergies r/t many factors • inherited • hormonal response • type and concentration of allergen • body part involved • exposure to the allergen • illness • allergy response can occur at any age • allergic reaction may include skin, respiratory, GI tract • edema-often r/t allergy and may occur on any body part: Monitor AIRWAY!!

13. Allergies with skin response • Urticaria-erythematous areas, burning around swollen patches of skin • Itching (pruritis) • Burning • These all appear suddenly • Disappear in a few hours or last days, weeks • Result from food, additives, meds, infections, stress • Tx: identify cause and give meds: antihistamines, epinephrine or steroids

14. Allergies • Eczema • tiny, oozing, itchy blisters • usually located on the neck, elbows and knees • Chronic eczema-scaly, thick skin • Contact Dermatitis • most common allergen is poison ivy, oak or sumac • causes itching, swelling, redness, blisters • Encourage client to refrain from scratching • Use cool compresses or showers • Light patting of the area • Distraction • Avoid vigorous rubbing • soap, detergent, perfumes, cosmetics, metals in jewelry, wool, latex, and leather are other allergens

15. Allergies with a respiratory response • Allergic asthma-spasms of smooth muscles of the bronchi Causes edema, dyspnea, mucus accumulation and wheezing • If severe enough, death may occur • Bronchial asthma-common • May be induced by exercise, meds, stress, etc. • Sx: recurring paroxysms of dyspnea with wheezing, dyspnea, tight chest, cough, wheezing, thick sputum, cyanosis, diaphoresis, tachycardia, tachypnea, death in extreme situations • Cause-narrowing of the lumen of the smaller bronchi and bronchioles • Tx: corticosteroids, bronchodilators, antihistamines, anticholinergics

16. Allergic Rhinitis • inflammed nasal passages caused by an allergen • S/S: edema, burning, itching, watery eyes and rhinorrhea • Allergens include pollen, molds, dust, dust mites, perfumes • Symptoms are seasonal or perennial

17. Food Allergy • Food allergens include: eggs, wheat, soybeans, fish, shellfish, chocolate, seeds, nuts, beer, corn, citrus fruits, and some dairy products • S/S: n/v/d, abd. pain, tenderness; swelling of the lips and throat, rhinoconjunctivitis, sneezing, wheezing, urticaria, migraines • Tx: avoid those food allergens that cause these sx’s • Latex allergies are noted in people who have hypersensitivities to bananas, avocados, kiwis, chestnuts

18. Drug Allergies • Adverse reactions: result from the antigen-antibody response, unintended response to a drug • S/S: depend on the drug, obtain a thorough H&P • Serum Sickness or Serum Reaction-antiserum used for rabies may cause a severe reaction • Body’s immune system attacks the serum or med administered • S/S: occur 7-14 days after receiving a drug, body has not developed antibodies; itching at injection site, skin rash, enlarged lymph nodes, general weakness, elevated temp • Tx: antihistamines, corticosteroids

19. Allergy with Multisystem Response • Symptoms occur in more than one body system • S/S: itching, edema, GI or respiratory symptoms • Ex: latex allergy which produces itching, erythema, edema, respiratory, cardiac and GI symptoms may occur, wheezing, dyspnea, laryngeal edema, bronchial spasm, tachycardia, and cardiac arrest, anaphylaxis may occur • Tx: Avoid substance • May be difficult to identify • If allergic to pollens, do not rake grass or mow • If allergic to pets, avoid them • Exercise is encouraged rather than discouraged. Instruct clients to use their inhalers before exercise to avoid bronchospasm

20. Immunotherapy • Desensitization or hyposensitization • Give minute doses of allergens subq. • Doses increased until client can tolerate • May eliminate the allergy • If receiving injections, must start them at least 3 months prior to allergy season. Expensive and may last 1- 2 years or longer

21. Medication Therapy • Given to counteract an allergy or to relieve symptoms. • Antihistamines-inhibit the action of histamine (mediator in allergic response) Provide temporary relief and must be used freq. • Meds may cause drowsiness and should not be used long term. • Antihistamines may dry secretions and may make it difficult to swallow or expectorate

22. Medication Therapy • Decongestants (nasal congestion) bronchodilators and expectorants (relieve respiratory symptoms) cortisone (relieve itching and inflammation) epinephrine (used in emergencies to neutralize adverse effects of histamine) • Antihistamine inhibit the action of histamine, a major chemical mediator involved in the allergic response. • These medications may cause drowsiness, in clients who have asthma, antihistamines may dry up the secretions so much that clients cannot swallow or expectorate Leukotrienes are chemical mediators that are 100-1000 times more potent than histamine in causing bronchospasm

23. Anaphylaxis • Severe and may result in laryngoedema, shock, vascular collapse, and death • s/s: see box 84-1 • Causes include: ASA, vaccines, foods, x-ray contrast medium with iodine, antibiotics, insect venom • Tx: IMMEDIATE d/t airway obstruction, remove cause, administer antihistamines, if d/t injection or insect bite, apply tourniquet and use ice to slow absorption • OPEN AIRWAY!!!! • SUPPORT CIRCULATION! • ADMINISTER MEDS!!!

24. Immune Disorders • Immunity-body’s adaptive state to protect itself from disease, normal • Infectious diseases-more virulent than immune system antibodies • Immunosuppression-immune system is depressed d/t disease, shock, injury, drugs,or radiation, may be congenital (agammaglobulinemia) • Overproduction of gamma globulins-alignant blood diseases or infection present • Severe immune response to an antigen that is invading (anaphylaxis) • Rejection response-foreign substance in the body is rejected; organs, skin grafts

25. Autoimmune Disorders • Body does not recognize itself, therefore, produces antibodies against its own healthy cells • Called autoimmunity • Cause unknown, believe that genetic predisposition, interaction with physical, chemical, and biologic agents trigger abnormal immune responses, and abnormal immune cells that lead to abnormal immune responses • Types • Organ-specific (localized autoimmune disease)-affects one organ • Examples: DM-type 1, Hashimotos thyroiditis, Grave’s • Disease, Addison’s disease, MS, Guillan Barre • Non-organ specific (systemic autoimmune disease)-affecting one or more organs • Examples: Rheumatoid arthritis, SLE, scleroderma, polymyalgia rheumatica

26. Autoimmune Disorders • At Risk • Genetic predisposition • Females (SLE) • Abnormalities in immune cells • Examples • Rejection of transplanted organ-deemed foreign object by the body and the normal immune system will reject this • Tissue typing performed prior to transplant • Use immunosuppressive drugs for life • S/S: chills, fever, HTN, diaphoresis, hypotension, edema, and organ involvement

27. SLE (Systemic Lupus Erythematosus) • Chronic systemic disorder (widespread damage to connective tissue) • Believed to be caused by antibodies that fight the body’s own cells and tissues that it normally protects leading to inflammation and tissue/organ damage • Exacerbations caused by pregnancy and BCP use are d/t increase in estrogen • S/S-waxes and waning symptoms such as fatigue, fever, weight loss, see picture • Shift of WBC to left in a CBC-D (implies infection d/t increased # of immature band cells)

28. SLE • Diagnosis is made by 4 of 11 criteria: malar rash, discoid rash, photosensitivity, oral ulcers, arthritis, serositis, renal disorder, neurologic disorder, hematologic disorder (hemolytic anemia or leukopenia), immunologic disorder (+LE cell prep) , antinuclear antibody (+ titer) • Damage to hematologic system, skin, heart, kidneys, brain, connective tissue • Note a false + syphilis test may occur in client’s with SLE d/t the phospholipid used in the assay; chronically false + veneral disease research laboratory or RPR tests may indicated a client has SLE • Tx-NOT CURABLE; managed with meds and lifestyle modification such as rest, stress management, use anti-inflammatory agents and corticosteroids, goals of tx: decrease inflammation, suppress overactive immune system, prevent symptom flares

29. SLE • Drugs: NSAIDS, antimalarials (control rash, fatigue, fever), corticosteroids, cytotoxic drugs (suppress the hyperactive immune response) • Nsg care: tx to prevent flare-ups: limit sun exposure, eat healthy, get adequate rest, exercise, and learn to recognize signs of impending flare-ups

30. Rheumatoid Arthritis • Chronic and systemic disease • Inflammed joints • Swan neck deformity and ulnar deviation • May have systemic manifestations • Morning stiffness lasting over 1 hour, fatigue, wt. loss • Autoimmune disorder of the musculoskeletal system • S/S: fatigue, stiffness in am, weakness, muscle pain, loss of appetitie, most commonly begins in the smaller joints of the fingers, hands and wrists, joint involvement is symmetrical

31. Rheumatoid Arthritis • Progresses in 3 stages: • Synovial lining swelling • Rapid division and growth of cells which causes the synovium to thicken • Inflamed cells release enzymes that digest bone, cartilage, which often causes the joint to lose its shape, alignment and movement • Tx: symptomatic use analgesics, corticosteroids (prednisone-take same time every day), radiation to suppress normal antigen-antibody responses, heat and cold tx., gold salts (MONITOR for ANAPHYLAXIS!!!)

32. RA • Biologic Response Modifiers-etanercept, infliximab • Drugs modify immune system by inhibiting proteins called cytokines which contribute to inflammation • Protein-A Immunoadsorption Therapy-therapy that filters blood to remove antibodies and immune complexes that promote inflammation • Disease Modifying Antirheumatic Drugs (DMARDS)-methotrexate-standard use of tx of RA • Takes several weeks to work, drug adjusted for optimum effect at lowest dose

33. Scleroderma • Chronic connective tissue disease (autoimmune)-exact cause unknown • Organ-specific disease! • Not contagious or cancerous; most common in middle-aged women • Not directly inherited, possibly a family hx of rheumatic diseases • S/S: chronic hardening and thickening of the skin caused by new collagen formation, skin changes include edema and pallor, then firmness of the skin; systemic scleroderma is due to injury to blood vessels and to fibrosis or scarring and the • Blood vessel injury leads to Raynauds, kidney disease, pulmonary HTN or other manifestations • TX: Localized scleroderma (drugs not proven in clinical trials), Plaquenil, methotrexate (suppress immune function), prednisone, Dilantin (action unclear), phototherapy; treatment aimed at symptoms

34. Latex Allergy • Common • Initial sx are mild but become worse after repeated exposure-likely to be allergic to latex if you have other allergies • S/S-pruritis, hives, watery eyes, scratchy throat, dyspnea, lips and/or throat edema-this can lead to DEATH!!! • TX-avoid contact with latex-even condoms, keep epi-pen closeby