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68 Cards in this Set
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- Back
- 3rd side (hint)
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What is the immune system?
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Body's major defense mechanisms against infectious organisms and abnormal cells
A network of complex and spcialized cells, tissues, organs |
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What are immune cells?
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Seekout and destroy damaged cells/foreign tissue
Recognize and preseve host cells |
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What is a non-specific response?
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Same response/occur regardless of cause/invader
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Prevents/limits invaders
limits tissue damage |
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When does non-specific response occur?
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Occurs when 1st line defences breached (skin; mucous membranes; stomach/vaginal acidity
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When does a specific response occur?
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Occurs when inflammation unable to destroy invader
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What are the types of a specific response?
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antibody mediated (humoral)
cell mediated |
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what is an antibody mediated specific immune response?
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Involves B-lymphocytes
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What are the two phases of primary response?
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1. Primary response
2. Secondary response |
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What is the primary response?
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occurs with intital contact
Antibodies produced |
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What is a secondary response?
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Subsequent exposure
Memory cells remember antigens rapid response as antibodies called upon quickly |
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What is cell mediated specific immune response?
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Some antigens do not stimulate antibody response
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What kind of antigen does not stimulate and antibody response?
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viruses or bacteria that live inside cell and not detected by antibodies
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What kind lymphocytes doe the cell mediated immune response rely on?
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T lymphocytes
To inactivate the antigen since antibodies not activated |
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What is immunocompetence?
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good sufficent immune system
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What is immunoincompetence?
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Immune system not working well
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What is hypersensitivity?
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exaderated immune response
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What is autoimmune?
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attacks self
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What is immunodeficiency?
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Immune system can not have a sufficient immune response
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What are things to not for a focused assessment on the immune system?
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Gender
Family hx Have private environment Recent changes in health status Excessively fatigued |
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Describe hypersensitivity
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1. Altered immune response to antigen
2. Results in harm to client 3. Exaggrated response 4. Called "allergy" when allergen (antigen) is environmental |
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What is a type I response?
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Localized response
- more common - triggers = dust, dander, pullen - Hay fever, asthma |
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What is an example of a type I response?
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Anaphylaxis
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Is type 1 hypersensitivity systemic or localized?
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systemic
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What specific foods can trigger a type 1 response?
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eggs, seafood, grains, beans, cotton seed oil, chocolate
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What medications can cause a type 1 response?
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penicillin
cephaloyporines, |
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How soon after the antigen exposure does the resonse begin?
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within minuts of exposure
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What are the 4 pathophysiological responses to the release of histamines?
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1. Vasodilation
2. Increased capillary permability 3. Vasoconstriction 4. Smooth muscle contractions |
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What are the clinical manifestations of type I reaction?
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Lightheadedness
itching palms Wheezing air hunger stridor-- bronchiol constriction swollen eyelids and lips |
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what are two important nursing diagnosis for a person with type I hypersensitivity?
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Ineffective airway clearence
Decreased cardiac output |
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What is the drug of choice for immediate treatment for type I hypersensitvity?
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Epinephrine
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How does epinephrine work?
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vasoconstriction and bronchodilating
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How is epinephrine administered?
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subcutaneous
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How much epinephrine should be administered?
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0.3-0.5 ml
1:1,000 concentration |
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What nursing care measeure should be taken to maintain airway with type I hypersensitivity?
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1. Administer oxygen
2. Assess resp rate and pattern 3. Position high fowlers 4. Administer Epi |
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Why is cardiac output a concern with patients having a hypersensitivity?
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Peripheral vasodillation and increased capillary permeability from the release of histamine can significantly impair CO
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What measures can be taken to promote CO?
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Monitor VS
Assess skin color, temp, capillary refill, edema Monitor LOC Insert large cath IV Administer warm IV solutions Insert Foley |
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What are important points to teach a client with allergic reactions before discharge?
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1. Wear a medical alert tag
2. Lifestyle changes may need to take place to prevent reaction from occuring again 3. Instruct regarding the administartion of emergency drugs 4. Always ask about new medication 5. Pay close attention to ingredents for skin, eyes etc 6. Steroids are often used for short term |
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How should a person lay if they are in a shocky state?
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Flat with legs elevated
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What is a type II hypersensitivity reaction?
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Cytotoxic Reaction
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What is an example of a type II reaction/
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Transfusion of incompatible blood
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What is blood typing?
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determining the blood type of the person
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What is crossmatching?
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Crossmatching the blood of one individual with a another individual to see if they are compatible.
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What type of antigen and antibody does a person with type A blood have?
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A antigen
B antibodies |
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What type of antigen and antibody does a person with type B blood have?
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B antigen
A antibodies |
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What type of antigen and antibody does a person with type O blood have?
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neither antigens
both antibodies |
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What type of antigen and antibody does a person with type AB blood have?
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both antigens
neither antibodies |
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How many nurses need to check blood types when administering blood?
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two nurses
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How long does a unit of blood transfused?
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3-4 hours
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How much time does it take a tranfusion reaction to occur?
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15 minutes
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Can blood be transfused in the same site with other IV infusions?
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NO
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What is the importance to get a set of vital signs 15 minutes prior to initiating a transfusion?
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Provides a baseline for evalutating any changes related to the blood transfusions
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What is and autologous transfusion?
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Collection and re-infusion of pts own blood or blood componets
People who are having a planned procedure |
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What are risk factors for developing systemic lupus erythematosus (SLE)?
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Women
child bearing age African american Oral contraceptives Stress Exposure to UV light |
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What lab values are significant to the diagnosis of SLE?
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1. ESR is elevated greate then 100
2. CBC is moderate/severe anemia, thrombocytopenia 3. UA mild protein 4. Anti-DNA antibody testing -- usually rarely found |
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What are manifestations of SLE?
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Rheumatoid arthritis
weight loss anorexia rash on cheeks photosensitive GI symptoms |
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What symptom is experienced by 90% of those with SLE?
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Joint symptoms
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What is the most distinctive clinical manifestation of SLE?
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Butterfly rash
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What are the leading causes of death for people with SLE?
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Pneumonia
Septicemia |
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What drug can SLE be related to ?
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INH- TB drug
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What type of drug is Plaqeuenil?
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Reduces frequency of actue episodes of SLE in people with mild or active disease
Antimelarial |
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What side effects of the durge Plaquenil should clients be made aware of?
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Retinal toxicity and possible irrversible blindness
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What preventive intervention must be followed when taking this drug?
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Eye exams every 6 months
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What type of drug is Prednisone?
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Anti-inflamatory
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A priority nursing diagnosis for a client receiving immunosuppressive agents like Prednisone for the treatment of SLE?
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Increased risk for infection
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Why is a patient prescribed more than just Aspirin or other NSAIDS to manage her SLE?
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B/c of liver toxicity and hepitis
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What are two nursing diagnoses related to SLE?
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Ineffective protection
Impaired skin integrity |
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What are teaching points for ineffective protection?
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Use strict aseptic technique
Assess for frequently for infection Monitor lab values, CBC and organ function Ensure adequate nutrition |
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What are some teaching points for impaired skin integrity?
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Assess effects on the skin
Discuss the relationship btw sun exposure and disease activity Limit sun exposure Keep skin dry and clean |
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