Altered Immune Response - EXAM 5 Flashcards Preview

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What is bone marrow?

Bone marrow is the soft material that fills the central core of bones, especially long bones. It is the blood-forming tissue that produces the three major cell components of the blood.


What are the three major cell components of the blood?

  1. Erythrocytes (RBC)
  2. Leukocytes (WBC)
  3. Thrombocytes (platelets)


What is the absolute neutrophil count?

An important calculation which guides the care of a patient with bone marrow dysfunction. Once the ANC falls below 1500 cells/microliter, the risk for severe and potentially fatal infection rises dramatically.


What is considered mild neutropenia?

1000-1500 cells/microliter or 1-1.5


What is considered moderate neutropenia?

500-1000 cells/microliter or 0.5-1


What is considered severe neutropenia?

Fewer than 50 cells/microliter or <0.5


What are neutrophils?

Matrure WBCs


What are bands?

Immature WBCs


What happens without neutrophils?

Neutrophils are the primary phagocytes within the immune system. Without these cells, the host defenses are severely impaired. Even with vigilant hygiene and housekeeping measures, the neutropenic patient is at risk for fatal infections even from their own body flora.


What kind of virus is HIV?



What is HAART?

Highly active anti-retroviral therapy.

Since HIV is a retrovirus, medical therapy utilizing a combination of antiviral medications is known as HAART. The goal of HAART is optimization of the CD4 T lymphocytes and a biral load that is undetectable (fewer than 50 or 400 viral copies per mL of blood, depending upon the sensitivity of the test)


What are risk factors for thrombocytopenia (bone marrow dysfunction)?

  • Inherited platelet production (Fanconi's syndrome)
  • Acquired Immune (Idiopathic thrombocytopenia)
  • Acquired non Immune (HIT, drug induced)



What are risk factors of neutropenia (bone marrow dysfunction)?

  • Drug-Induced Causes (chemo, antiinflammatories, psychotropics)
  • Hematological Disorders (aplastic anemia, leukemia)
  • Autoimmune Disorders (SLE, RA)
  • Infections (Viral or Bacterial)
  • Miscellaneous (Sepsis, BM infiltration, nutritional deficiencies)


Given common causes/risk factors of these types of bone marrow dysfunction, what can the RN do to promote bone marrow health?

Medications are a common cause of bone marrow dysfunction. The RN needs to know which medications are myelotoxic or myelosuppresive and monitor laboratory reports carefully. Examples include many chemotherapeutic agents. Pt. education is necessary.


What is thrombocytopenia?

A decreased number of platelets. Coagulation studies may remain normal.


What is a normal platelet count?

150,000-400,000 per microliter.


What is the average lifespan of a platelet?

5-7 days


What would platelet counts be from prolonged bleeding from trauma or injury?

platelet counts below 50,000


At what lab value does life threatening spontaneous bleeding occur?

platelet counts below 20,000


What other lab values may be seen in thrombocytopenic individuals?

Decreased Hbg and Hct due to bleeding


What are some dermatologic manifestations of thrombocytopenia?

Pinpoint microhemorrhages called petichiae, larger bruises known as purpura, or hemorrhages called ecchymoses which may be tender


Where can bleeding occur in patients with thrombocytopenia?

  • Intraabdominal bleeding and overt hemorrhage
  • Brain
  • Eyes
  • Joints


What is the medical treatment of thrombocytopenia?

  • Corticosteroids
  • Immunoglobulin
  • Immunosuppresants
  • Transfusion of platelets


What is the surgical treatment of immune thrombocytopenia?

May consist of a splenectomy (the spleen sequesters platelets and coats them with antibodies that mark them for destruction by macrophages).


What medications are contraindicated in thrombocytopenic patients?

Aspirin and aspirin like products


What is a high priority nursing diagnosis for individuals with thrombocytopenia?

Risk for impaired tissue perfusion


What are the goals for individuals with thrombocytopenia?

The maintenance of vascular integrity and the absence of gross or occult bleeding


What is thrombocytopenia in children freqently caused by?

Viral infections such as:

  • Chicken pox
  • Rubella
  • Measles



What is thrombocytopenia most frequently cause by in adults?

Autoimmune disease


What could failure to take antiretroviral medications as prescribed result in?

Failure to take atiretroviral medications as prescribed results in HIV mutations which are resistant to medications. Since resistance is more likely to develop when fewer than three of these medications are used, patients should be taught never to stop one of the medications and continue the others. If some are stopped, they should all be stopped temporarily. When mutations of HIV which are resistant to meds a patient is taking develop, these meds will no longer be effective in that person. In addition, these meds will not be effective for other people who contract these strains of HIV from that person.


Why might patients with HIV not take all of their doses as prescribed?

  • They might not remember. Remembering is a constant reminder that the patient has an incurable illness
  • Some people do not sleep and eat meals on the same schedule each day. Some people sleep through a scheduled dose-time.
  • Patients may not be comfortable taking medications in public places if they fear other people will learn they have HIV/AIDS
  • People may not take meds as prescribed if they are feeling ill due to their disease or are experiencing unpleasant side effects from the med
  • HAART is very expensive
  • Some people fail to take their medications because they are depressed or suicidal


How can nurses help patients to be successful in their adhereance to HAART?

  1. Gather information about patients. Are they ready for rigorous treatment regimen? If their viral load is low, they may not need HAART immediately. If there is too much shock or emotional crisis they will not be focused enough to take the required 95% of their doses. Do they abuse substances? have a mental illness? homeless?


nystatin (Mycostatin)

Classification: Antifungal

Mechanism of Action: interferes with fungal DNA replication

Use: Oral and/or intestinal candida infections

Side/Adverse effects: allergic rash/urticaria

Nursing Implications:

  1. Little absorption, excreted in the feces
  2. Typically ordered orally to swish and swallow but may be used as a topical cream
  3. May swab mouth if patient cannot swish and swallow
  4. Shake before use
  5. Use after oral care and do not eat or use commercial mouthwash after nystatin to allow topical action to occur
  6. Vaginal preparations available as well


filgrastim (Neupogen) (G-CSF)

Classification: colony stimulating factors (CSFs)

Mechanism of action: Neulasta is long-acting. SC or IV routes for delivery

Use: To stimulate production, maturation, regulation, and activation of cells of the hematologic system.

Side/adverse effects: most commonly reported SE is bone pain

Nursing Implications:

  1. Indications that the factor is being effective: CBC, particularly the ANC
  2. Patients are candidates to recieve CSFs
    1. Myloid cell recovers after bone marrow transplant (BMT)
    2. Chemotherapy induced neutropenia


What reactions do occur from vaccinations?

  1. Local tenderness, erythema, and swelling at injection site
  2. Low grade fever
  3. Behavioral changes (drowsiness, fretfulness, eating less, prolonged unusual cry)


  1. Anaphylaxis
  2. Encephalopathy
  3. Guillain-Barre Syndrome (GBS)


What are isues of concern to the RN for the actual injection of a vaccination?

  1. Needle size
  2. Injection site
  3. Air bubble technique
  4. EMLA cream
  5. Distraction


What is a VIS and where can an RN obtain the appropriate ones to give to the parent of a child prior to the vaccine administration?


Vaccine info statement for all vaccines are available on the CDC website. Download 1 for each vaccine prior to administration and view contents with patient/parent.


What does AIDS stand for?

Aquired Immunodeficiency Syndrome


What tests monitor the disease progression of HIV?

  1. CD4+T cell counts
    1. Actual counts and percentages
    2. When CD4+ counts drop to 200-500 cells/ul, symptoms occur
  2. Viral load
    1. Detects number of copies of the virus/mL


At what CD4+ count do symptoms occur in HIV patients?

200-500 cells/ul


What are the symptoms of HIV infections?

  1. Mental status changes
  2. Persistent headaches
  3. High fever
  4. White patches on tongue
  5. Heavy night sweats
  6. Lymphadenopathy
  7. Loss of appetite/weight loss
  8. Chronic diarrhea
  9. Fatigue and muscle weakness


Early HIV T-cell count?

T-Cell greater than 500


Intermediate HIV T-Cell count?

Less than 200-500


Late HIV T-Cell count?

Less than 200


What are the typical complaints that may become diagnostic for progression from HIV to AIDS?

Oral candidiasis "thrush": use mycostatin (nystatin) swish and swallow for prevention and treatment

Oral hairy leukoplakia


What are some AIDS related illnesses?

  1. Infections:
    1. Cryptococcal meingitis
    2. Toxoplasmosis encephalitis
    3. Cytomegalovirus retinitis
    4. Herpes simplex virus
    5. Oral candidiasis
    6. Candida encephalitis
    7. Pneumocystitis carnii
    8. Pulmonary tuberculosis
  2. Cancers:
    1. Kaposi's sarcoma
    2. Malignant lymphoma


What is the nursing management of HIV/AIDs?

  1. Adhere to drug regimens
  2. Promote healthy lifestyle
  3. Prevent opportunistic infections
  4. Prevent transmission to others
  5. Have supportive relationships
  6. Maintain productive activity
  7. Come to terms with issues related to living with disease, death, and spirtuality


Why is it critical to adhere to HIV drug regimens?

  1. Prevent disease progression
  2. Prevent opportunistic disease
  3. Prevent viral drug resistance


What is AIDS wasting syndrome?

Metabolic disorder. Cardiovascular risk almost doubles. Hyperlipedemia. Insulin resistance. Renal dysfunction.

Also there is AIDS-dementai complex


What is SLE?

Systemic lupus erythematosus

Chronic multisystem inflammatory autoimmune disease


What systems does SLE affect?

Circulating immune companies containing antibodies against DNA are deposited in the capillary basement membrane. It typically affects the skin, joints, serous membranes along with renal, hematologic and neurologic systems.


Why is SLE considered a disorder of immunoregulation?

  • Antibodies directed against own cells (DNA) autoimmune reactions are altered against constituents of the cell nucleus, particularly DNA. The over agreesive antibody response is r/t B and T cell hyperactivity cell membrane is damaged and DNA is released into circulation and viewed as non self. Antibody attacks foreign antigen (DNA)


What is it about SLE that causes such different clinical manifestations?

No two people will present exactly the same. When autoantibodies bind to their specific antigens, immune complexes are deposited in the basement membranes of capillaries in many body tissues. The specific manifestations of SLE depend on which cell types or organs are involved.


What are some common triggers of autoimmune disease?

Genetic susceptibility PLUS:

Infectious agents




What does pregnancy do to SLE?

Temporarily clears up


What is plasmapheresis for SLE?

Removal of plasma containing components causing or thought to cause disease. Washes out antibodies. Major SE is hypotension. Rationale for therapeutic plasmaphersis in autoimmune disorders is to remove pathologic substances present in plasma (circulating autoantibodies)


What lifestyle habits can support a healthy immune system?

  1. Balanced diet
  2. Healthy sleep patterns
  3. Health exercise routine
  4. Good hand washing


What are the benefits and risks of central access, esepcially for neutropenic patients?

Benefits: Access to vascular system (draw blood, med, fluids)

Risks: infections (IV sites, potential site for hospital acquired infection.


Someone with low platelets and risk for bleeding you should not do repeated blood draws on.


What medical and nursing measures can be taken for a person with bone marrow suppresion until the patient's WBC returns to normal?


  • Prophylactic, empiric, and therapeutic antibiotics
  • Antibacterial, antifungal and antiviral medication
  • Hematopoietic growth factors
    • filgrastim (Neupogen)
    • erythropoietin (Epogen)
  • Granulocyte transfusions for overwhelming infection and/or septic shock


  • Institute protective (reverse) isolation
  • Strict handwashing
  • Visitor restrictions
  • Private room
  • LAF (laminar air flow) if available
  • Avoid uncooked meat and unwashed fruit and veggies
  • Positive pressure room
  • HEPA filtration
  • Monitor and early ID
    • WBC, ANC
    • Serial blood cultures
    • Other cultures ("Pan")
    • Treat fevers immediately
    • VS frequently
  • Maintain IV access for antibiotics and monitor for side effects
  • Reinforce that patient may be on triple antibiotics, antivirals, antifungals as well as transfusions and electrolyte replacements
  • Discuss implications for nursing


What are good teaching points for a ptient with bone marrow suppression?

Teach patient and family"

  1. How to take temperature
  2. That temperature peaks at 4-6pm
  3. To notify physician of increased temperature, even in the absence of other signs of infection
  4. Call for greater than 38C
  5. Avoid crowds and contact with people with infection
  6. Precautions to decrease infection, mask in public areas
  7. Good nutrition
  8. Avoid stress
  9. Adequate rest to maintain immune system function


Why is the presence of fever and chill so important to note for a neutropenic patient?

  1. Pus is rate due to neutropenia
  2. Fever may be the only indication of infection and septic shock
  3. Prompt initiation of antibiotics is essential
  4. Lethal effects if infection develops


Why is teaching the patient personal hygiene techniques such an essential therapeutic nursing intervention for bone marrow suppression?

The patient's normal flora is the most common source of microbial colonization and infection


What are potential sites for bleeding with someone with bone marrow suppresion?

  1. Oral mucous membranes
    1. Inspect oral mucosa daily
    2. Gentle mouthcare with soft toothbrush
    3. Do not floss
  2. Venipuncture, IM, and SC sites
    1. Avoid if possible
  3. Skin
    1. Electric razor use only
  4. Emesis, sputum, feces, urine, NG secretions and wound secretions
    1. Check for occult blood
    2. Avoid aspirin
    3. Prevent valsalva constipation
  5. Platelet transfusions can be administered for low count of active bleeding
  6. Low dose anticoagulant therapy (lovenox, heparin SC) usually hold if platelet count is less than 50K
  7. A helmet may be required when the profoundly thrombocytopenic patient is ambulatory


What teaching points are important for someone with bone marrow suppression in regards to bleeding?

  1. Wear medic alert bracelet and notify all health care personnel of bleeding disorder
  2. Teach patient and family signs of bleeding, precautions to prevent bleeding and action to take if bleeding
  3. Caution to avoid OTC meds without approval of PCP
  4. Avoid physical activity that might cause trauma (no shaving with straight razor)
  5. Avoid straining stool


What if the neutropenic patient is a menstruating female?

Use pads instead of tampons. Self monitor frequency saturation of pad. Medical interventions can be implemented to stop menses when appropriate because prevention of bleeding is vital


What therapies help restore RBCs in anemia?

  1. FeSO4 + vitamin therapy
  2. PRBC transfusion
  3. Erythropoietin (Epogen) or darbopoeitin


Under what circumstances would a bone marrow suppressed patient require treatment of anemia?

  1. When they have symptoms
  2. Hct is less than prescribed individualized parameter


What is aplastic anemia?

It is also called hypostatic or pancytopenic anemia. It is a life-threatening stem cell disorder characterized by hypoplastic, fatty bone marrow and results in pancytopenia.


What is leukemia?

Cancer of the blood-forming tissues. Most common form of childhood cancer. It is a broad term given to a group of malignant disorders affecting the blood and blood-forming tissues of the bone marrow, lymph system, and spleen.


What is lymphoma?

Malignant neoplasms originating in the bone marrow and lymphatic structures resulting in the proliferation of lymphocytes. A group of neoplastic diseases that arise from lymphoid and hemopoietic systems. It is divided into two major groups: hodgkin disease and non-hodgkin lymphoma


What is myelodysplastic syndrome (MDS)?

A group of related hemtologic disorders characterized by a change in the quantity and quality of bone marrow elements. Other terms used to describe this hemtologic disorder include preleukemia, hematopoietic dysplasia, refractory anemia with excessive myloblasts, subacute myeloid leukemia, oligoplastic leukemia, and smoldering leukemia


What is nadir?

The lowest point in some series of measurements, such as white blood cell, hemoglobin, or platelet levels.


What is pancytopenia?

Refers to the triad of profound anemia, leukopenia, and thrombocytopenia


What is a toxoid?

a toxin that has been treated with chemicals or heat to decrease its toxic effect but that retains its antigenic power. It is given to produce immunity by stimulating the creation of antibodies.


What is a booster?

An additional dose of an immunizing agent, such as a vaccine or toxoid, given at a time after the initial dose to sustain the immune response elicited by the previous dose of the same agent.


What is an immunoglobulin?

any of a class of proteins present in the serum and cells of the immune system, that function as antibodies.


What is an autoimmune disease?

A disease in which the body produces antibodies that attack its own tissues, leading to the deterioration and in some cases to the destruction of such tissue.


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