Care of the Patient with an Immune Disorder

Care of the Patient with an Immune Disorder
Care of Patient with An Immune Disorder Chapter 15 – Adult Health Nursing Book Care of the Patient with an Immune Disorder Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Immunology The study of the immune system
Evolving science dealing with body’s ability to distinguish self from nonself Distinction is made through complex network of highly specialized cells and tissues Collectively called “the immune system” Also known as the “host defense system” Critical to our survival

Three Functions of the Immune System
Protect the body’s internal environment against invading organisms Maintain homeostasis by removing damaged cells from the circulation Serve as a surveillance network for recognizing and guarding against the development and growth of abnormal cells (Mutations constantly formed in body but recognized and destroyed) Immune is a word meaning “free from burden” in Latin. How does the definition correspond to our understanding of the functions of the immune system? A healthy functioning immune system is necessary for survival. It is this system that enables the body to protect itself. What body parts make up the immune system?

Immunocompetence When immune system responds appropriately to a foreign stimulus, body’s integrity is maintained Immune system mobilizes and uses its antibodies/other responses to stimulation by an antigen An appropriately functioning immune system reacts by a process known as immunocompetence. What are examples of exposures that will cause immunocompetence?

Immunoincompetence: weak or too vigorous immune system response causes disruption of homeostasis and malfunction in system When disruption of homeostatic balance in immune system occurs, diseases develop

Hyperactive response against environmental antigens (allergy)
Inappropriate responses of the immune system …4 categories of Immunoincompetence Hyperactive response against environmental antigens (allergy) Inability to protect the body, as in immunodeficiency disorders (AIDS) Failure to recognize the body as self, as in autoimmune disorders (systemic lupus erythematosus) Attacks on beneficial foreign tissue (organ transplant rejection or transfusion reaction) When the immune system does not work against potential pathogens, homeostasis is affected.

Immunity The quality of being insusceptible to or unaffected by a particular disease or condition 2 major subclassifications Innate immunity Adaptive immunity There are two subclassifications of immunity: innate and adaptive. Innate acts as a barrier between the body and the outside world. Its components act as soldiers against potentially invasive microorganisms. Does innate immunity always work? What will occur if it does not?

Innate Immunity (Non-specific)
First line of defense Provides physical and chemical barriers to invading pathogens and protects against the external environment Composed of the skin, mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestines and vagina

Adaptive (Acquired) Immunity
If first line fails: Second line of defense Provides a specific reaction to each invading antigen Unique ability to remember invading antigen Protects the internal environment Composed of thymus, spleen, bone marrow, blood, and lymph Includes both humoral and cell-mediated immunity Produces antibodies in the cells after an infection or vaccination In the event the body’s innate immunity does not effectively handle pathogens, adaptive immunity is the next line of defense. This type of immunity has the characteristic of specificity and memory. How do each of these concepts relate to the immune process?

When an Infectious Agent enters the Body…..
1 – encounters innate immune system 2 – if innate immune system cannot kill off- disease results and the 3 – adaptive immune system is activated 4 – the adaptive immune system helps patient to recover AND establishes a specific immunologic memory. 5 – If reinfected with same agent – no disease results…the patient has acquired immunity to the infectious agent

Organization of the Adaptive Immune System
The body organs identified assist in maintaining the lines of defense. Outline what role each of the listed parts does to aid in this function.

Cells of the Immune System
Macrophages and Lymphocytes Macrophages (phagocytes) When organisms pass epithelial barriers, macrophages activated Engulf and destroy microorganisms that pass the skin and mucous membrane Also carry antigens to the lymphocytes Antigen A substance recognized by the body as foreign that can trigger an immune response Adaptive immunity is assisted by helper cells. These cells include macrophages and lymphocytes. How are these cells similar? How do they differ? Discuss where these cells are produced. What determines their number?

Adaptive Immunity Lymphoctyes Include T and B cells Also includes NK cells (natural killer) Large, granular lymphocytes 70%-80% of all lymphocytes are T-cell

Lymphoctyes - 70 – 80% are T cells – activated by an antigen
When activated by an antigen, T cells release substance called lymphokine Lymphokine attracts macrophages to the site of infection or inflammation and prepares them for attack T cells cooperate with B cells to produce antibodies but do not produce antibodies themselves T cells responsible for cell-mediated immunity Protect against viruses, fungi, and parasites Also provide protection in allografts and malignant cells

Origin and processing of B and T cells.
Figure 15-3 The process of adaptive immunity utilizes cells in defending the body. A specific type of white blood cell, known as a lymphocyte, is involved. Discuss the differences between T cells and B cells. Origin and processing of B and T cells.

Lymphocyte - 20-30% are B cells
Trigger production of antibodies and proliferate in response to a particular antigen B cells migrate to peripheral circulation/tissues and eventually filtered from lymph and stored in lymphoid tissue of body Initial formation of B cells does not require antigen stimulation However, B cell proliferation does require antigen stimulation B cells produce antibodies and protect against bacteria, viruses, and soluble antigens

Humoral immunity – B cells
One of the 2 forms of immunity Responds to antigens such as bacteria and foreign tissue; mediated by B cells (B cells produce antibodies) First exposure to antigen; primary humoral response initiated (response generally slow compared with subsequent exposures) When subsequent exposure occurs, memory B cells cause quick response, regardless of whether 1st exposure was to antigen or immunization Immunization-process by which resistance to infectious disease is induced or increased. In humoral immunity, the body produces B cells in response to a challenge by an antigen. The concept of memory is important to the success of humoral immunity.

Nature of Immunity Antigen is presented to T-helper cells by macrophages T lymphocytes categorized as: T-helper T-suppressor-maintain humoral response at appropriate level for stimulus Antigen is taken to B cells and with T-helper assistance, B cells begin antibody production

Active and Passive Immunity
Active immunity Antibodies are produced by one’s own body (vaccines) Passive immunity Antibodies are formed by another in response to a specific antigen and administered to an individual (newborn immunity)

Nature of Immunity Number and function of T-helper/suppressor cells determines strength and persistence of immune system. Normal ratio of helper to suppressor cells 2:1 When ratio is disrupted, autoimmune/autodeficient diseases occur. Factors affecting immunocompetence Aging Viruses Radiation Chemotherapeutic drugs

Immune Response Exposure to antigen and response with antibody will activate either Humoral complement system which results in breakdown of bacteria and release of lysosomes to destroy bacteria The antigen-antibody reaction, resulting in release of histamine thus producing symptoms of allergy Allergen-produces signs of allergy Immunogen-when immunity results from exposure to antigen

Cellular immunity – T cells
Also called cell-mediated immunity T cells activated by antigen T cells becomes sensitized; released into blood and body tissues and remain indefinitely On contact with antigen, attach to organism and destroy it Primary importance in: Immunity against pathogens that survive inside cells Fungal infections Rejection of transplanted tissues Contact hypersensitivity Tumor immunity Certain autoimmune diseases When potential pathogens are introduced into the body, T cells are activated. This process results in a full cellular response. What action is taken by the T cells once activated? Is there a specific type of pathogen targeted by the T cells?

Complement System Includes proteins that interact with one another and with other components of natural and acquired immune system. Normally inactive and blood and body fluids When antigen and antibody interact, system activated Step-by-step process similar to clotting The complement system can destroy the cell membrane of many bacterial species, and this action attracts phagocytes to the area The complement system is an organized series of enzymatic proteins. These enzymes are “awakened” when the body comes into contact with an antigen. What would you liken this process to? It is similar to a video game, such as Pac-Man.

Genetic Control of Immunity
There is a genetic link to both well- developed immune systems and poorly developed or compromised immune systems Develops at different rates and times in fetal and early life Theories of immunity support the impact of heredity. What influences can be attributed to immunity? Provide examples of genetics interacting with illness and disease

Effects of Aging on the Immune System
Aging causes a decline in the immune system Higher incidence of tumors Greater susceptibility to infections (flu and pneumonia) Aging does not affect the bone marrow Decrease in thymus function plays important role to immunosenescence causing reduction in T cells Aging also demonstrates delayed hypersensitivity response which is decline in cell-mediated immunity Reflected in increased mortality rates of cancers, etc. As the human body ages, there is a natural increase in disease process. What disorders increase with aging? What factors associated with growing older can encourage the onset of illness?

2 ways of helping the body to develop immunity
Immune Response 2 ways of helping the body to develop immunity Immunization Immunotherapy

Immune Response Immunization
A controlled exposure to a disease-producing pathogen that triggers antibody production and prevents disease Provides protection for months to years First vaccine: Edward Jenner and smallpox Administer a weakened or dead antigen of the disease Vaccine stimulates humoral immunity providing immunity for months/years. There are two ways to assist the body to develop immunity. They are immunization and immunotherapy. The concept of immunization dates back to the late 1790s. Vaccines and toxoids are weakened forms of disease-causing organisms, administered to provide protection from disease. Compare and contrast live and dead vaccines. For which diseases are vaccines routinely provided?

Immunotherapy - Desensitization
Treatment of allergic responses that involves administering increasingly large doses of the offending allergens to gradually develop immunity Preseasonal, coseasonal, or perennial Severe side effect: anaphylaxis Also called desensitization Immunotherapy is a long-term management option to treat allergies. In most cases this therapy is initiated in the physician’s office. When is home maintenance appropriate? If home maintenance is initiated, what are the responsibilities of the nurse? What supplies will be needed in the home if home therapy is ordered?

Immunotherapy Video

Immune Response - Immunotherapy
Nursing and Immunotherapy Observe patient for at least 20 minutes after administration because a hypersensitivity or anaphylaxis may occur Anaphylaxis treatment protocol with immunotheraphy is 02. – 0.5 ml of 1:1000 epinephrine hydrochloride subcutaneously every 20 minutes for three doses

Disorders of the Immune System
System failure can occur in several ways and express itself in mild to severe forms Believed that failures occur due to Genetic factors Developmental defects Infection Malignancy Injury Drugs Altered metabolic states

Altered immune response Hypersensitivity An abnormal condition characterized by an excessive reaction to a particular stimulus Hypersensitivity reaction An inappropriate and excessive response of the immune system to a sensitizing antigen Hypersensitivity disorders Arise when harmless substances such as pollens, danders, foods, and chemicals are recognized as foreign Immune responses result as the body tries to protect itself. What factors can be attributed to a failure in immune response?

Hypersensitivity disorders Etiology/pathophysiology Genetic defect that allows increased production of immunoglobulin E (IgE) (humoral antibody) Causes release of histamine and other mediators Humoral reactions occur immediatly Exposures may occur by inhalation, ingestion, injection, or touch Signs and symptoms caused by histamine release Reaction may be local (GI, resp, skin) or systemic (anaphylaxis) Several disorders result from hypersensitivity (asthma, uricaria) When hypersensitivity reactions result, what will determine the degree of reaction?

Hypersensitivity disorders Clinical manifestations/assessment Pruritus (itching) Nausea Sneezing Excessive nasal secretions and tearing Inflamed nasal membranes Skin rash Diarrhea Cough; wheezes; impaired breathing The types of clinical manifestations seen in a hypersensitivity reaction might vary between individuals.

Hypersensitivity disorders (continued) Diagnostic tests History Physical exam Laboratory studies: CBC, skin testing, total serum IgE levels Medical management/nursing interventions Symptom management: antihistamines Environmental control: avoidance of the allergen Immunotherapy What information should be collected from the patient concerning the events surrounding a hypersensitivity reaction?

Disorders of the Immune System Anaphylaxis
Etiology/pathophysiology System reaction to allergens Venoms Drugs—penicillin Contrast media dyes Insect stings Foods (eggs, shellfish, peanuts) Latex Vaccines Anaphylaxis is the most severe type of allergic reaction. It involves the systemic reaction to the allergen. Discuss the events that result in the anaphylactic response demonstrated.

Anaphylaxis Assessment Feelings of uneasiness to impending death Urticaria (hives) and pruritus (itching) Cyanosis and pallor Congestion and sneezing Edema of the tongue and larynx with stridor Bronchospasm, wheezing, and dyspnea Nausea and vomiting The onset of symptoms from the time of exposure is rapid. Early intervention can often stop the onset of more severe reactions in the patient.

Anaphylaxis (continued) Clinical manifestations/assessment (continued) Diarrhea and involuntary stools Tachycardia and hypotension Coronary insufficiency, vascular collapse, dysrhythmias, shock, cardiac arrest, respiratory failure, and death

Anaphylaxis (continued) Nursing interventions Pharmacological management Epinephrine Benadryl Aminophylline IV access Oxygen Teaching: avoid allergen; use medical alert ID; administration of epinephrine Upon recognition of anaphylaxis, treatment must begin quickly to reduce complications and potential death. What are the actions of the recommended medications? How are the medications administered? Identify two nursing diagnoses for the patient diagnosed with anaphylaxis.

Disorders of the Immune System Latex allergies
Allergic reaction when exposed to latex products Type IV allergic contact dermatitis Caused by the chemicals used in the manufacturing process of latex gloves Type I allergic reactions Response to the natural rubber latex proteins Latex allergies are growing. What factors can be related to this increase in latex allergies?

Disorders of the Immune System Latex Allergies
Latex allergies (continued) Clinical manifestations/assessment Type IV contact dermatitis Dryness; pruritus; fissuring and cracking of the skin followed by erythema, edema, and crusting Type I allergic reaction Skin erythema, urticaria, rhinitis, conjunctivitis, or asthma to anaphylactic shock The identification of people at risk for the development of latex allergies is key in the prevention of allergic reactions. What risk factors are associated with the development of a latex allergy?

Disorders of the Immune System Latex Allergies
Latex allergies (continued) Medical management/nursing interventions Identification of patients and health care workers sensitive to latex is crucial in the prevention of adverse reactions Use nonlatex gloves when possible Use powder-free gloves Do not use oil-based hand creams Know the signs and symptoms of latex allergy Wear a medical alert bracelet and carry an epinephrine pen The development of a latex allergy in a health care worker is serious. What are the responsibilities of the workplace regarding the environment and work supplies? Ask if any of the students have latex sensitivities. Further, if there are affirmative responses, ask what the impact has been on their clinical experiences.

Disorders of the Immune System Transfusion Reactions
Etiology/pathophysiology Reactions that occur with mismatched blood Clinical manifestations/assessment Mild Diarrhea Fever and chills Urticaria Cough Orthopnea An allergic reaction due to a blood transfusion is serious. What steps can the nurse take to reduce the likelihood of this happening?

Disorders of the Immune System Transfusion Reactions
Transfusion reactions (continued) Clinical manifestations/assessment (continued) Moderate Fever and chills Urticaria Wheezing Severe Fever and extreme chills Severe urticaria Anaphylaxis When a transfusion reaction results, what data must be collected by the nurse?

Transfusion reactions (continued) Nursing interventions Mild Pharmacological management Corticosteroids Diuretics Antihistamines Stop transfusion Administer saline Physician may order transfusion continued at a slower rate

Transfusion reactions (continued) Nursing interventions (continued) Moderate Stop transfusion Administer saline Pharmacological management Administer antihistamines and epinephrine When a transfusion reaction results, the patient could have an antihistamine and epinephrine administered. How do these medications work? What nursing implications accompany their administration?

Transfusion reactions (continued) Nursing interventions (continued) Severe Stop transfusion Administer saline Pharmacological management Administer antihistamines and epinephrine Return blood or blood product to lab for testing Obtain urine specimen Care of the patient who has experienced a blood transfusion reaction has several steps. The physician must be notified, the transfusion stopped or slowed, and medications given. What nursing diagnoses are appropriate for this patient? What information should be documented in the patient’s medical record?

Transfusion Blood products
Blood should be properly typed and cross- matched Should be properly refrigerated until 30 minutes prior to adminstration Administer blood within 4 hours of removal from refrigerator Blood products within 6 hours Best prevention is use of autologous blood-can be frozen and store for up to 3 years

Transfusion Blood Products
Donor numbers and recipients must be thoroughly checked by two nurses that the number match according to policy

Disorders of the Immune System Delayed Hypersensitivity
Reaction occurs 24 to 72 hours after exposure Examples include: Poison ivy Tissue transplant rejection

Disorders of the Immune System Transplant Rejection
Types of grafts Autograft Isograft (identical twins) Allograft (homograft; members of same species; most common) Heterograft Antigenic determinants on the cells lead to graft rejection via the immune process To avoid, antigenic determinants matched as close as possible. 7 to 10 days after vascularization occurs, sensitized lymphocytes appear in sufficient numbers for sloughing to occur The introduction of tissue into the body might be done for a variety of reasons. What treatment plans utilize tissue transplantation? Define each of the tissue types used in transplantation.

Disorders of the Immune System Transplant Rejection
Transplant rejection (continued) Immunosuppressive therapy Agents that significantly interfere with the ability of the immune system to respond to antigenic stimulation by inhibiting cellular and humoral immunity agents include Corticosteroids Cyclosporine (Neoral, Sandimmune) Azathioprine (Imuran) Pharmacological agents are administered to reduce the risk of tissue rejection. What classification of agents can be used?

Immunosuppressive Therapy
Nursing tip : When a transplant patient is receiving immunosuppressive therapy (Imuran, cyclosporine), remember that the purpose of these drugs is to suppress the immune reponse, so the critical nursing goal is to minimize the risk for infection for these patients

Disorders of the Immune System Immunodeficiency
An abnormal condition of the immune system in which cellular or humoral immunity is inadequate and resistance to infection is decreased May cause recurrent infections, chronic infections, severe infections, and/or incomplete clearing of infections Defects in genes leading to immunodeficiency provide hereditary link to disease Can be induced (chemotherapy) Associated with many diseases including AIDS, multiple myeloma, etc. A healthy, functioning immune system provides the body with protection against pathogens. When the immune system fails to adequately provide protection, illness and disease will result. What are examples of immunodeficiency diseases?

Disorders of the Immune System Immunodeficiency Disorders
Disorders involve an impairment of one or more immune mechanisms Primary immunodeficiency disorders Immune cells are improperly developed or absent Phagocytic defects B-cell deficiency T-cell deficiency Combined B-cell and T-cell deficiency

Disorders of the Immune System – Secondary Immunodeficiency DO
Secondary immunodeficiency disorders Drug-induced immunosuppression Cytotoxic drugs in chemo, transplant rejection prevention, etc. Stress-Effects interrelationships between nervous, endocrine, and immune systems Malnutrition-Extended protein deficiency results in thymus gland atrophy & lymphoid tissue decreases; infection raised Radiation-destroys lymphocytes, BM atrophies, and pancytopenia occurs Surgical removal of lymph nodes, thymus, or spleen Hodgkin’s lymphoma-impairs immune response and places demand on immune system resulting in impaired response to 2nd infect How do each of the factors listed contribute to immunodeficiency disorders?

Autoimmune Disorders Autoimmune
The development of an immune response to one’s own tissues Body is unable to distinguish “self” protein from “foreign” protein Tend to cluster so patient may have more than one or same/related disease found in other members of family Possible genetic predisposition to autoimmune disease Examples of disorder: rheumatoid arthritis, pernicious anemia; Guillain-Barré syndrome; scleroderma; systemic lupus erythematosus, Crohn’s disease

Autoimmune Disorders treatment
Plasmapheresis Removal of plasma that contains components causing/though to cause disease Replaced with fluid such as saline, albumin, fresh frozen plasma Also called “plasma exchange” Used to treat autoimmune disease Rationale to remove pathogenic substances in plasma May also remove inflammatory mediators that cause tissue damage

Autoimmune Disorders Plasmapheresis
Whole blood removed through needle inserted in one arm and circulation of the blood through cell separator Separator divides the blood into plasma and its cellular components through centrifugation Plasma, platelets, WBC, RBCs separated selectively Undesirable component removed and remainder of blood returned to patient via needle in opposite arm Plasma typically replaced with saline, LR, FFP, albumin May only remove 500mL a time Observe for s/s hypotension and citrate toxicity (anticoagulant); HA, paresthesias, dizziness

Immunity Types of Immunity
Naturally acquired active immunity: person has had the disease and made antibodies; antibodies remain for life Artificially acquired active immunity: person is given a live or weakened (attenuated) antigen in a vaccine to stimulate antibody production to prevent specific diseases for an extended time; “boosters” may be necessary There are different types of immunity. A person who has had chickenpox is said to have naturally acquired active immunity to that particular disease. The person who has had the disease has made lifelong antibodies against the disease to prevent its recurrence. The purpose of artificially acquired active immunity is to prevent the person from contracting dangerous diseases throughout his or her life. Rubeola (measles) is one of the vaccines given. Live vaccines are treated so the risk of developing a full infection in an otherwise healthy person is minimal. The rubeola vaccine does cause the person to develop a mild case of measles, which then initiates the antigen-antibody response in the body to prevent the person from getting a full infection from measles. Some diseases may require periodic booster injections of vaccine to maintain high enough antibody levels to protect the person from disease. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 64 64

Immunity Types of Immunity (cont.) Passive immunity
Naturally acquired passive immunity Antibodies pass from mother to infant through breast milk Artificially acquired passive immunity Immunoglobulins are injected into a person who does not have immunity to the antigen After the antigen-antibody response has occurred, the antibodies are stored in the body. Immunoglobulins are specific types of protein antibodies that are stored in blood serum and plasma. Concentrated immunoglobulins are also called antisera and may be collected from humans or animal sources. Administration of hepatitis B immune globulin to someone exposed to, but not immunized against, the disease is an example of artificially acquired passive immunity. Passive immunity is temporary. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 65 65

Immunization Schedule
The following vaccines are recommended: Hepatitis B Diphtheria, tetanus, pertussis Haemophilus influenzae type b Inactivated poliovirus Measles, mumps, rubella Varicella Pneumococcal Influenza Hepatitis A (for selected populations) Although most children in this country have received their immunizations before entering school, the United States lags behind many other countries in the percentage of children immunized at an early age. We now know that some of the early immunizations require “boosters” to provide lifelong immunity. The “MMR” booster for measles, mumps, and rubella is an example of this. The American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians collaborate on immunization guidelines that are updated every January. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 66 66

Vaccines = attenuated or killed antigens in a formula that produces an antigen-antibody response in the body Hepatitis B Toxoids = attenuated or weakened toxins that produce an antitoxin response, causing immunity in the body Tetanus Some disease-causing proteins that come from invading bacteria are called toxins. Toxins, like antigens, stimulate the immune system to produce antitoxins, which act to neutralize antigens. The body is unable to distinguish between a toxin and toxoid. What does the term endemic mean? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 67 67

Produce immunity in the body Uses Routine schedule of active immunizations for adults and children Specific biologic agents for endemic disease areas Specific biologic agents to people at high risk Screening for disease exposure Modify disease process in previously unimmunized persons There are many uses for immunologic medications. In addition to the routine administration of immunizations for specific diseases, immunizations are recommended for persons who live in areas where there is a high risk of exposure to diseases such as yellow fever, cholera, and typhoid. People at high risk for serious complications of pneumococcal infections and influenza (e.g., elderly, chronically ill, health care workers) are encouraged to obtain these immunizations. An additional group of biologic agents (purified protein derivative [PPD], histoplasmin, coccidioidin) is used in screening procedures to identify persons who have been exposed to a certain disease or who may have the active disease (e.g., tuberculosis). In special circumstances, biologic agents such as gamma globulins may be useful for modifying a disease process in previously unimmunized persons. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 68 68

Adverse Reactions Mild reactions common: mild local pain and swelling at site Occasional effects include altered levels of consciousness, headache, lethargy, rash, urticaria, vesiculation, diarrhea, increased respiratory rate, arthralgia, dyspnea, fever, lymphadenopathy, and malaise. There are rare instances of these medications being linked to other health problems. Statistically, the risk of complications from getting a disease outweighs the risk of adverse effects of the immunization. Occasional effects are treated symptomatically, and many physicians recommend premedication before receiving scheduled vaccines. Most states have laws that require infants and children to be properly immunized before starting school. To reduce the liability pharmaceutical companies face, a special fund has been established by the federal government that pays for medical costs incurred if a patient has a serious adverse effect from required immunizations. A certain percentage of the fees patients pay go toward this fund, called the National Vaccine Injury Compensation Program. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 69 69

Drug Interactions Nursing Implications and Patient Teaching Assess health history, immunization status, allergies to eggs or feathers, presence of infection, use of immunosuppressants, pregnancy Some vaccines are contraindicated in persons with an allergy to eggs or feathers, because they are prepared with animal serum or in chick embryos. Immunizations are not given to patients with active infection, severe febrile illness, or a history of serious side effects from previous vaccinations. Live, attenuated virus vaccines should not be given if there is a recent history of acquired passive antibodies (immune globulins). Patients who are immunocompromised should not be given immunologic agents, and all vaccines should be used with caution in women who are pregnant or breastfeeding. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 70 70

Antihistamines Action
Compete with histamine for H1 receptor sites to limit its effectiveness Limits capillary permeability, and swelling Limits acetylcholine release, which dries secretions in the bronchioles and gastrointestinal system Sedative effect on the CNS Histamine is released (by mast cells and basophils) when the body is injured. Histamine dilates the capillaries of the smooth muscle and vascular system. Antihistamines relieve the effects of histamine on body organs and structures. The six major groups of antihistamines are found in Table These groups vary in characteristics and action. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 71 71

Antihistamines Relieve symptoms of allergic disorders Uses
Seasonal allergic rhinitis (SAR) Perennial allergic rhinitis (PAR) Perennial nonallergic rhinitis (PNAR) Relieve symptoms of allergic disorders Adjunctive therapy for anaphylaxis Sedation Allergic rhinitis is a condition in which a person has a reaction to outdoor allergens (SAR) or indoor allergens (PAR). Perennial nonallergic rhinitis (PNAR) is a condition in which inflammatory symptoms are caused by problems other than allergens. Histamine plays a role in producing the inflammatory symptoms in these conditions: watery eyes, nasal stuffiness, postnasal drip, and sneezing. Antihistamines are used for hives, angioneurotic edema, serum sickness, and blood-product reactions and are a common ingredient in cold remedies because they decrease mucus secretion and cause drowsiness at bedtime. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 72 72

Antihistamines Adverse Reactions
Most due to anticholinergic activity of drug Changes in blood pressure, blurred vision Tachycardia, insomnia, dry mouth, nausea Restlessness, excitability, sedation, tinnitus Constipation, urinary retention Overdose is potentially fatal, especially in children Some patients might experience CNS overstimulation and others CNS sedation from antihypertensives. Antihistamine overdosage is potentially fatal, particularly in children, because the CNS is stimulated and depressed at the same time. What drugs increase the effect of antihistamines? (CNS depressants such as hypnotics, sedatives, tranquilizers, depressant analgesics, alcohol) Antihypertensives strengthen the action of other drugs such as anticholinergics and may mask ototoxicity from drug therapy. These medications also can interfere with the effect of anticholinesterase drugs and may decrease the effect of corticosteroids and hormones. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 73 73

Antihistamines Drug Interactions
Sedative effect increased with other CNS depressants (sedatives, hypnotics, ETOH) Can strengthen anticholinergic effects When used with ototoxic drugs (ASA, streptomycin), can mask ototoxic effects May decrease effects of corticosteroids and other hormones loratadine, diphenhydramine, fexofenadine Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antihistamines Life span considerations Pediatrics:
Infants and young children often have anticholinergic side/adverse effects Paradoxical reactions may occur: increased nervousness, confusion, or hyperexcitability Elderly More likely to develop side effects such as dizziness, syncope (fainting), confusion, and extrapyramidal reactions Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 75 75

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