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Immune Disorders. Colleen Carter RN, MSN 2014. Nursing Management of Clients with Organ Transplants. Transplant success tied to matching tissue antigens, HLA (Human Leukocyte Antigens) Autograft Allograft Xenograft

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immune disorders

Immune Disorders

Colleen Carter RN, MSN

2014

nursing management of clients with organ transplants
Nursing Management of Clients with Organ Transplants
  • Transplant success tied to matching tissue antigens, HLA (Human Leukocyte Antigens)
  • Autograft
  • Allograft
  • Xenograft
  • Histocompatibility – ability of cells and tissues to survive transplantation without immunologic interference by the recipient
host versus graft transplant rejection
Host-versus-Graft Transplant Rejection
  • Complex process involving both antibody-mediated and cell mediated responses
  • Hyperacute Rejection – Begins immediately to 2-3 days after the transplant and can’t be stopped once it begins
  • Acute rejection – occurs 4 days to 3 mo post-transplant. Most common rejection and is treatable.
  • Chronic rejection – occurs from 4 mos to yrs post-transplant. No cure. Once organ cannot function, another transplant is only course.
treatment of transplant rejection
Treatment of Transplant rejection

Maintenance therapy – Ongoing immune suppressants Ex. cyclosporin, Imuran & a corticosteroid (prednisone)

Rescue therapy – treats acute rejection. Ex: ALG , murononab-CD3. Most effective during first course of treatment

system lupus erythematosus sle
System Lupus Erythematosus (SLE)
  • Chronic, multi-system, autoimmune disease
  • Affects more women than men
  • Affects more African American women than European American women
  • SLE thought to be a combination of environmental and genetic factors
  • Extremely variable in its course and no way to predict its progression
lupus signs and symptoms
Lupus: Signs and Symptoms
  • Skin: Butterfly rash
  • Raynaud’s Phenomenon
lupus signs symptoms
Lupus: Signs/Symptoms
  • Musculoskeletal System
  • Muscle and joint pain very common with exacerbations and remissions
  • Arthritis – affects primarily distal joints: hands, wrists, fingers, toes, ankles, knees, etc.
  • May have tendon involvement and rupture
  • Knees and hips can have treatment related osteonecrosis from steroid therapy
lupus signs symptoms1
Lupus: Signs/Symptoms
  • Cardiac System
  • Pericarditis - most common cardiac manifestation
  • Myocarditis
  • Anemia
  • Leukopenia
  • Thrombocytopenia
lupus signs symptoms2
Lupus: Signs/Symptoms
  • Respiratory System
  • Pleuritis – Inflammation of the pleura
  • Pleural Effusions – Fluid build-up between pleura and chest cavity
  • Pneumonia
lupus signs symptoms3
Lupus: Signs/Symptoms
  • Gastrointestinal/Hepatic Systems
  • Can affect any area of the GI system as well as pancreas, spleen, or liver
  • Ex: oral ulcers, peptic ulcers, abdominal pain/N/V/D, pancreatitis, hepatomegaly, GERD, ulcerative colitis
lupus signs symptoms4
Lupus: Signs/Symptoms
  • Renal System
  • Lupus Nephritis – leading cause of death among patients diagnosed with SLE (Lupus)
  • s/s to monitor for: fluid retention (edema, wt gain), hematuria, proteinuria, changes in urine output, hypertension
lupus signs symptoms5
Lupus: Signs/Symptoms
  • Neurologic System
  • Neuropathies
  • Psychoses, depression
  • Seizures, migraine headaches
  • CNS vasculitis
  • Peripheral neuropathies

CNS Vasculitis

lupus signs symptoms6
Lupus: Signs/Symptoms
  • Constitutional Symptoms
  • Fatigue
  • Weight changes/loss or gain
  • Fever
  • Arthralgias
lupus s s
Lupus: S/S
  • Psychosocial Issues
  • Altered body image/poor self-concept
  • Chronic fatigue/weakness may prevent being as socially active as previously
  • Fear and anxiety may occur due to the unpredictability of flares or the progression of the disease, necessity of life style changes, etc.
lupus diagnosis
Lupus: Diagnosis
  • Lab tests:

Antinuclear antibody

ESR (sed rate)

Serum complement

Various antibody titers

CBC – looking for pancytopenia

Specific testing for body system involvement

Urinalysis/24 hr urine

Diagnostic Imaging: CXR, Hand x-rays, CT OR MRI

lupus treatment
Lupus: Treatment
  • Pharmacologic Management
    • NSAIDS
    • Antimalarials (Plaquenil)
    • Corticosteroid Therapy
    • Immunosuppressive agents (methotrexate or Imuran)
lupus treatment1
Lupus: Treatment
  • Non-pharmacologic Management
    • Avoid direct exposure to sunlight
    • Use sunscreen with SPF of 15 or higher
    • Wide brimmed hat when outside
    • Some physicians recommend avoiding use of oral contraceptives
    • Careful skin and hair care with mild soaps/shampoos
lupus important patient education
Lupus: Important Patient Education
  • Importance of skin care
  • Monitor body temp and other warning signs of a flare: increased fatigue, pain, abdominal discomfort, rash, headache, dizziness
  • Reproductive impact
  • Avoid exposure to infection
  • Need to follow treatment plan, including follow-up appointments and prompt reporting of a flare
  • Preventive health care
  • Medic Alert bracelet
rheumatoid arthritis ra
Rheumatoid Arthritis (RA)
  • Chronic, progressive, systemic, inflammatory, autoimmune disease that affects joints and other tissues or organ systems.
  • Most prevalent in European Americans
  • Affects 0.5% to 1% of the population worldwide; women more frequently than men
ra pathophysiology
RA Pathophysiology
  • Cause: believed to be genetic and environmental
  • Autoantibodies (rheumatoid factors) attack healthy tissue, especially synovial membranes, causing inflammation. Immune processes activated
  • Activation of the inflammatory and immune response damages the synovial membrane.
ra signs symptoms
RA Signs/Symptoms
  • Onset may be acute and severe (usually precipitated by a stressor such as surgery or an infection)
  • Or onset may be insidious
  • Joints primarily affected are hands, wrists, knees and feet
  • Joint involvement usually bilateral and symmetric.
  • Disease symptoms described as early or late and joint (articular) or systemic (extra-articular)
ra signs symptoms1
RA Signs/Symptoms
  • Early Disease Manifestations:
    • Joint stiffness, swelling, pain
    • Systemic:
      • Low-grade fever
      • Fatigue
      • Weakness
      • Anorexia
      • Paresthesias
ra signs symptoms2
RA Signs/Symptoms
  • Late Disease Manifestations
  • Joint deformities (swan neck and ulnar deviation)
  • Moderate to severe pain and morning stiffness

Swan neck deformity

Ulnar deviation

ra signs symptoms3
RA Signs/Symptoms
  • Late Disease Manifestations – Systemic
  • Osteoporosis
  • Anemia
  • Weight loss
  • Subcutaneous nodules
  • Peripheral neuropathy
  • Vasculitis
  • Pericarditis
  • Sjogren’s syndrome
  • Renal disease
ra diagnosis
RA Diagnosis
  • Based on patient’s hx, physical assessment, and diagnostic tests
  • Lab tests:
    • Rheumatoid factor
    • ANA
    • ESR and C-reactive protein
    • CBC
    • Synovial fluid exam
    • X-rays of affected joints
ra treatment
RA Treatment
  • Surgical Management:
  • A synovectomy to remove inflamed synovium may be necessary for knee or elbow
  • Total joint arthroplasty may be necessary for joint deformity and destruction
  • Arthrodesis (joint fusion) to stabilize joints such as cervical vertebrae, wrists, and ankles.
ra treatment1
RA Treatment
  • Pharmacological Management:
    • NSAIDS
    • Antimalarials
    • Corticosteroids, oral or intra-articular for temporary relief
    • Disease-Modifying Antirheumatic Drugs (DMARDS) to reduce disease activity: methotrexate, Imuran, Cytoxan or BMR’s: Humira, Enbrel, Remicade
ra treatment2
RA Treatment
  • Non-pharmacological treatment
  • Plasmapheresis
  • Balanced program of rest and exercise – energy conservation
  • Physical and Occupational therapy
  • Heat and cold
  • Assistive devices and splints
  • Balanced nutrition
scleroderma systemic sclerosis
Scleroderma (Systemic Sclerosis)
  • Autoimmune disorder of connective tissue
  • Characterized by hardening(sclero) and thickening of the skin (derma), blood vessels, synovium, skeletal muscles, and internal organs
  • Approximately 300,000 people in the US have Scleroderma
  • Affects women more than men by 3:1
  • Affects more African Americans than Caucasians
scleroderma pathophysiology
Scleroderma - Pathophysiology
  • Early stages very similar to SLE – often misdiagnosed
  • Can be limited or diffuse
  • May have CREST syndrome:
    • Calcinosis
    • Raynaud’s phenomenon
    • Esophageal dysmotility
    • Sclerodactyly
    • Telangiectasia
scleroderma signs symptoms
Scleroderma Signs/Symptoms
  • Musculoskeletal - Joint pain
  • GI: Dysphagia and reflux, esophagitis, diarrhea or constipation, abdominal cramping and malabsorption
  • Skin: Bilateral, symmetric swelling of hands and sometimes feet. After edematous phase, the skin becomes hard and thick.
  • Facial changes – skin tightening leads to loss of skin lines, appearance of disappearing lips
scleroderma signs symptoms1
Scleroderma Signs/Symptoms
  • Facial skin symptoms:
  • Tightening of the skin
  • Disappearing lips
  • Decreased mobility of eyelids
  • Evolving process

Body image and psychosocial issues

scleroderma signs and symptoms
Scleroderma Signs and Symptoms
  • Cardiovascular: Raynaud’s Syndrome, Myocardial fibrosis, Pericarditis and dysrhythmias
  • Pulmonary: Lung fibrosis, pulmonary hypertension, exertional dyspnea
  • Renal – proteinuria, hematuria, hypertension, and renal failure
scleroderma diagnosis
Scleroderma Diagnosis
  • ANA: of at least 1:40
  • Lab tests/results similar to SLE: ESR – elevated; CBC- may show anemia, RF – elevated in about 30%
  • Barium swallow – may show esophageal dysmotility
  • X-ray of hands & wrists – muscle atrophy, osteopenia
  • No single diagnostic test – overlap with other autoimmune diseases so diagnosis may initially be difficult
scleroderma treatment
Scleroderma Treatment
  • Corticosteroids & immunosuppressants – tried to slow the progression
  • Protect hands from the cold
  • Report fever to the
  • Skin protection, moisturizer and careful ongoing assessments
  • Gastric secretion blockers for esophagitis/reflux. Avoid spicy foods, caffeine, alcohol
  • NSAIDS for joint pain
  • Be aware that the side effects from many of the pharmacological treatments can worsen symptoms of the disease
slide36
Gout
  • Metabolic d/o characterized by an acute inflammatory arthritis triggered by crystallization of urate within the joints.
  • May be caused by an inborn error of metabolism or as the result of another disease process or factor; i.e. crash diets, renal insufficiency
  • Affects approximately 3 million Americans each year, and over twice that man have been affected at some time.
  • Occurs more often in men. More common in women who are post-menopausal or taking diuretics
slide37
Gout
  • 3 clinical stages
  • Asymptomatic – not detected unless a uric acid level is checked.
  • Acute - Extremely painful joint inflammation, usually in the great toe, called podagra
  • Chronic – After repeated episodes of acute gout, urates are deposited in various other connective tissues: synovial fluids (gouty arthritis); subcutaneous tissue (tophi) and kidneys(can form kidney stones and result in kidney failure)
gout treatment
Gout treatment
  • Pharmacological Management
  • Acute Gout: NSAID (Indocin) or ibuprofen; and colchicine. Taken until symptoms subside
  • Chronic gout: Prevention is key. Zyloprim (allopurinol) lowers uric acid levels. Benemid(probenecid) promotes excretion of uric acid. May be given one or the other or a combination.
gout treatment1
Gout treatment
  • Non-pharmacological Management
  • Dietary restrictions on high-purine meats (red and organ meats) and seafood (shellfish and oily fish with bones) may be recommended
  • No alcohol
  • Avoid aspirin and diuretics
  • Drink enough fluid to maintain daily urine output of 2000 mL or more
lyme disease
Lyme Disease
  • Most common tick-borne illness in North America
  • Carried by the infected deer tick (black-legged tick)
  • Occurs most often in children and young adults living in rural areas
  • Risk factors:

Spending time in wooded or grassy areas

Having exposed skin

Not removing ticks promptly or properly

lyme disease pathophysiology
Lyme Disease: Pathophysiology
  • After an incubation period of 3-30 days after the bite, the spirochete migrates outward into the skin
  • Forms a characteristic erythema migrans (bull’s eye rash)
  • May spread to other skin sites, organs, or nodes
lyme disease signs symptoms
Lyme Disease: Signs/Symptoms
  • Stage I:
  • Skin: Bull’s eye rash
  • Musculoskeletal: pain and stiffness in muscles and joints
  • Constitutional: flu-like symptoms, fever, chills, fatigue, body aches
  • If not treated or treatment is unsuccessful, progresses to Stage II
lyme disease signs symptoms1
Lyme Disease Signs/Symptoms
  • Stage II:
  • Migratory musculoskeletal pain and swelling; especially in the knees
  • Carditis with dysrhythmias, dyspnea, palpitations
  • CNS disorders: meningitis, Bell’s palsy, numbness or weakness in limbs, impaired muscle movement
  • If not diagnosed and treated can progress to Stage III
lyme disease signs symptoms2
Lyme Disease Signs/Symptoms
  • Stage III (months to years after the tick bite)
  • Chronic recurrent arthritis
  • Chronic fatigue
  • Cardiac complications
  • Thinking/memory issues
lyme disease treatment
Lyme Disease: Treatment
  • Antibiotic therapy: doxycycline, tetracycline, amoxicillin, cefuroxime, erythromycin. May be given for 3-4 weeks
  • Aspirin or another NSAID for relief of arthritic symptoms
  • May need assistive devices (splints/crutches)
  • Prevention is the Key
preventing lyme disease
Preventing Lyme Disease
  • When walking in wooded or grassy areas:
  • Wear long pants tucked into socks, long sleeves, hat, gloves, shoes
  • Use insect repellents (10-30% DEET)
  • Check yourself, your children and your pets for ticks
  • Remove a tick with tweezers by

pulling straight out. Clean with

alcohol other antiseptic.

fibromyalgia
Fibromyalgia
  • Common rheumatic pain syndrome with wide-spread musculoskeletal pain, stiffness, and tenderness
  • Women affected 9 times more often than men
  • Genetic and environmental factors are thought to contribute
  • Requires a hx of widespread pain in all 4 quadrants of the body for a minimum duration of 3 months and pain in at least 11 of 18 trigger points
fibromyalgia signs symptoms
Fibromyalgia Signs/Symptoms
  • Fatigue, moderate to severe
  • Sleep disorders
  • Problems with cognitive function (Fibro Fog)
  • Irritable Bowel Syndrome
  • Headaches and migraines
  • Anxiety and depression
  • Environmental sensitivities
fibromyalgia treatment
Fibromyalgia Treatment
  • Pharmacological Management is symptomatic:
  • 3 drugs approved as of 2009 to reduce pain levels and improve sleep: Lyrica, Cymbalta, and Savella
  • Tricyclic antidepressants such as amitryptyline may help with pain and sleep as well
  • SSRI’s - treat depression and anxiety
fibromyalgia treatment1
Fibromyalgia Treatment
  • Non-pharmacological Management
  • Physical therapy
  • Regular exercise routine
  • Alternative therapies: Massage, acupuncture, chiropractic, yoga
  • Stress management
  • Therapy to assist with depression/anxiety
chronic fatigue syndrome or chronic fatigue and immune dysfunction syndrome cfids
Chronic Fatigue Syndrome or Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS)
  • Complicated disorder characterized by extreme fatigue unexplained by any underlying medical condition
  • May worsen with activity, but doesn’t improve with rest
  • No single test to confirm a diagnosis
  • Risk factors: Age (40’s and 50’s), female, overweight and inactive, stress
chronic fatigue syndrome signs symptoms
Chronic Fatigue Syndrome Signs/Symptoms
  • Fatigue
  • Loss of memory or concentration
  • Sore throat
  • Enlarged lymph nodes in neck or axilla
  • Unexplained muscle pain
  • Multiple joint pain
  • Headache of a new type, pattern or severity
  • Unrefreshing sleep
  • Extreme exhaustion lasting more than 24 hrs after physical or mental exercise
chronic fatigue syndrome treatment
Chronic Fatigue Syndrome Treatment
  • Pharmacological Management is symptom focused
  • Antidepressants
  • NSAIDS may help with body aches and pain
  • Non-pharmacological Management:
  • Gentle exercise program
  • Psychological counseling
  • Lifestyle changes: reduce stress, improve sleep habits, pacing
  • Alternative medicine: acupuncture, massage, yoga, or tai chi
  • Support groups may be helpful