Allergy and Immune Disorders

Med/Surg

Allergy and Immune Disorders

Allergy-hypersensitivity to one or more substances

Acquired through exposures to substancesAllergist-physician that specializes and treats allergiesImmunity is based on the ability of the body to

recognize foreign proteins and to destroy foreign matterAntigen is a foreign protein substance and the normal

reaction from the body is to produce antibodiesAntibodies release histamine (chemical mediators)

antigen-antibody responseThese mediators start a series of reactions in the bodyAllergic reactions do not form during the first exposure

to antigens, only during subsequent contactsAutoimmune disorders-body fails to recognize its own

cells and destroys themAllergies are responsible for symptoms that range from

rhinorrhea, skin rash to asthma or anaphylaxis

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:DyspneaSyncopeNasal edema and congestion

Skin TestsAntigens are injected intradermally or

applied to a scratch on the skinAfter 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)

Nursing ProcessData collectionObserve and assess (head to toe)Question client about pruritus, numbness, dyspnea,

tinglingExamine for rash, urticaria, rhinorrhea, sneezing,

wheezing Document and REPORT abnormal s/sA 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

Nursing Diagnosis for Allergy

DiarrheaRisk for InjuryImpaired Skin IntegrityDisturbed Sleep PatternFatigueDelayed Growth and DevelopmentDisturbed Self-esteem

Planning and ImplementationClient may require assistance with

Activities of daily living Dealing with emotional aspects of living with

chronic disorderTeach client, family about

Disorder and its prognosis, treatment

Nursing Process: EvaluationEvaluate outcomes of care

With client, family, other members of healthcare team

Short and long term goalsSymptom controlMedication compliance

Seriousness of disorder influences future planning for care, rehabilitation

AllergiesImmunogen-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

AllergiesAllergens can enter the body via:

inhalation-pollen, dust, moldingestion-meds, foods, eggs, nutsinjection-meds, insect bites/stings, immunizations with animal serum, blood transfusions

direct contact-poison ivy, dyes, latex rubber, wool

AllergiesManifestation of allergies r/t many factors

inheritedhormonal responsetype and concentration of allergenbody part involvedexposure to the allergenillnessallergy response can occur at any ageallergic reaction may include skin, respiratory, GI tract

edema-often r/t allergy and may occur on any body part: Monitor AIRWAY!!

Allergies with skin responseUrticaria-erythematous areas, burning

around swollen patches of skinItching (pruritis)Burning

These all appear suddenlyDisappear 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

AllergiesEczema

tiny, oozing, itchy blisters usually located on the neck, elbows and knees

Chronic eczema-scaly, thick skinContact Dermatitis

most common allergen is poison ivy, oak or sumac

causes itching, swelling, redness, blistersEncourage client to refrain from scratchingUse cool compresses or showersLight patting of the areaDistraction Avoid vigorous rubbing

soap, detergent, perfumes, cosmetics, metals in jewelry, wool, latex, and leather are other allergens

Allergies with a respiratory response

Allergic asthma-spasms of smooth muscles of the bronchiCauses edema, dyspnea, mucus accumulation and wheezingIf severe enough, death may occur

Bronchial asthma-commonMay 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

Allergic Rhinitis inflammed nasal passages caused by an

allergenS/S: edema, burning, itching, watery eyes and

rhinorrheaAllergens include pollen, molds, dust, dust

mites, perfumesSymptoms are seasonal or perennial

Food AllergyFood 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

Drug AllergiesAdverse reactions: result from the antigen-

antibody response, unintended response to a drugS/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 administeredS/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

Allergy with Multisystem Response

Symptoms occur in more than one body systemS/S: itching, edema, GI or respiratory symptomsEx: 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 substanceMay be difficult to identifyIf allergic to pollens, do not rake grass or mowIf allergic to pets, avoid themExercise is encouraged rather than discouraged.

Instruct clients to use their inhalers before exercise to avoid bronchospasm

ImmunotherapyDesensitization or hyposensitizationGive minute doses of allergens subq.Doses increased until client can tolerateMay eliminate the allergyIf receiving injections, must start them at

least 3 months prior to allergy season. Expensive and may last 1- 2 years or longer

Medication TherapyGiven 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

Medication TherapyDecongestants (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

AnaphylaxisSevere and may result in laryngoedema,

shock, vascular collapse, and deaths/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 absorptionOPEN AIRWAY!!!!SUPPORT CIRCULATION!ADMINISTER MEDS!!!

Immune DisordersImmunity-body’s adaptive state to protect itself

from disease, normalInfectious diseases-more virulent than immune

system antibodiesImmunosuppression-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

Autoimmune DisordersBody does not recognize itself, therefore, produces

antibodies against its own healthy cellsCalled autoimmunityCause 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

TypesOrgan-specific (localized autoimmune disease)-affects

one organExamples: DM-type 1, Hashimotos thyroiditis, Grave’s Disease, Addison’s disease, MS, Guillan BarreNon-organ specific (systemic autoimmune disease)-

affecting one or more organsExamples: Rheumatoid arthritis, SLE, scleroderma,

polymyalgia rheumatica

Autoimmune DisordersAt Risk

Genetic predispositionFemales (SLE)Abnormalities in immune cells

ExamplesRejection of transplanted organ-deemed foreign

object by the body and the normal immune system will reject this

Tissue typing performed prior to transplantUse immunosuppressive drugs for lifeS/S: chills, fever, HTN, diaphoresis, hypotension,

edema, and organ involvement

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 damageExacerbations caused by pregnancy and

BCP use are d/t increase in estrogenS/S-waxes and waning symptoms such as

fatigue, fever, weight loss, see pictureShift of WBC to left in a CBC-D (implies

infection d/t increased # of immature band cells)

SLEDiagnosis 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

SLEDrugs: 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

Rheumatoid ArthritisChronic and systemic diseaseInflammed joints

Swan neck deformity and ulnar deviationMay 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

Rheumatoid ArthritisProgresses in 3 stages:

Synovial lining swellingRapid division and growth of cells which causes

the synovium to thickenInflamed 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!!!)

RABiologic 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 RATakes several weeks to work, drug adjusted for

optimum effect at lowest dose

SclerodermaChronic connective tissue disease (autoimmune)-exact

cause unknownOrgan-specific disease!Not contagious or cancerous; most common in middle-

aged womenNot directly inherited, possibly a family hx of rheumatic

diseasesS/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

Latex AllergyCommonInitial 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