___________________________________________________________ Chapter 34Immunologic Disorders 13
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 34.2
Instructor Preparation
Textbook Objectives Covered
5. Describe the pathophysiology, signs and symptoms, medical diagnosis, and medical treatment
for selected disorders of the immune system.
6. Assist in developing a nursing care plan for a patient with a disorder of the immune system.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speaker: rheumatology nurse
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying immunologic disorders, including:
• Anatomy and physiology of the immune system
• Age-related changes
• Nursing assessment of the immune system
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• acquired immunity (p. 645)
• antibody (p. 642)
• cell-mediated immunity
(p. 646)
• immunity (p. 644)
• immunoglobulin (p. 643)
Student Preparation
Assignments 2 hours
4
READ – Textbook (pp. 651-653)
REVIEW
• Box 34-3: Nursing Actions for the Patient at Risk for Injury from Infection: Compromised Host
Precautions (p. 652)
ANSWER – Text
• Review Questions for the NCLEX Examination: 7 (p. 661)
ANSWER – Study Guide
• Part IA: 7 (p. 205)
14 Chapter 34Immunologic Disorders ____________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 34.2
5
READ – Textbook (pp. 653-660)
ANSWER – Text
• Review Questions for the NCLEX Examination: 8 (p. 662)
ANSWER – Study Guide
• Part IH: 1-6 (p. 207)
6
• Review Questions for the NCLEX Examination: 9, 10 (p. 662)
READ – Textbook (pp. 653-660)
REVIEW
• Table 34-3: Drug Therapy: Drugs Used to Prevent Rejection of a Transplanted Organ (p.
660)
ANSWER – Text
50-Minute Lesson Plan
Lecture Outline 20 minutes
4
Slide 22
Nursing Actions for the Patient at Risk for Injury from Infection
• The lower a patient’s white blood cell count, in particular the lower the neutrophil count,
the greater the patient’s risk of infection
• See Box 34-2
Slide 23
Bone Marrow Transplant and Peripheral Blood Stem Cell Transplant
• Restore hematologic and immunologic systems in patients with malignancies who have
received extremely high doses of chemotherapy and radiation therapy
• Allogeneic bone marrow transplant
TALKING POINTS:
• Bone marrow transplantation is also used in patients with genetic bone marrow defects
and aplastic anemia in an attempt to repopulate the bone marrow with blood-producing
cells.
• How is a bone marrow transplant administered?
Slide 24
Complications of Bone Marrow Transplants
• Infection
• Thrombocytopenia
• Renal insufficiency
• Hepatic-venoocclusive disease
• Graft-versus-host disease
TALKING POINTS:
• Which complications have the most potential to be life-threatening?
___________________________________________________________ Chapter 34Immunologic Disorders 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 34.2
5
Slide 25
White Blood Cell Disorders of the Immune System: Neutropenia
• Total number of neutrophils abnormally low, increasing risk of infection
• Caused by decreased bone marrow production, chemotherapy, radiation therapy, certain
drugs or an autoimmune reaction
• Also by increased neutrophil utilization because of overwhelming infection
TALKING POINTS:
• Because these patients do not have adequate numbers of white blood cells to mount an
immunologic response, classic signs of infection (redness, swelling, and pain) may be
absent.
• What may be the only sign of infection in a patient who has had neutropenia for a long
period of time?
White Blood Cell Disorders of the Immune System: Neutropenia (cont.)
• Common sites of infection: lung, blood, skin, urinary tract, gastrointestinal tract
TALKING POINTS:
• Usually bacteria cause infections in neutropenic patients; however, fungi and viruses can
also infect these patients.
• What precautions should be taken when a patient is placed on compromised host
precautions?
Stage 27
Non-Hodgkin’s Lymphoma
• Cancer of the lymph system, more common in older people
• Medical treatment: radiation therapy, chemotherapy, bone marrow transplant or peripheral
blood stem cell transplant
• Survival rate: 5 year 68%, depending on upon grade of the disease at diagnosis
Slide 28
Hodgkin’s Disease
• Lymphoma, characterized by Reed-Sternberg cells in the lymph nodes; incidence highest
for people in their 20s and 50s, males more likely
• Medical treatment: radiation therapy, chemotherapy, bone marrow transplant or peripheral
blood stem cell transplant
• Survival rate: 5 year 85%
Slide 29
Leukemia
• Cancer of the white blood cells: bone marrow produces too many immature white blood
cells
• Immature white blood cells leave patient at great risk for life–threatening infections
TALKING POINTS:
• The American Cancer Society statistics estimated that 30,800 cases of leukemia would be
diagnosed in 2002, accounting for 2% of all new cases of cancer diagnosed in that year.
• Which types of leukemia most commonly occur in adults?
16 Chapter 34Immunologic Disorders ____________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 34.2
Slide 30
Chronic leukemia
• Occurs most often in adults, WBC increases over months/years
• Usually treated with oral chemotherapy
• CML treated with Gleevec; life expectancy 3-8 years (or longer)
• CLL life expectancy 2-10 years
• Each may transform to acute leukemia
Slide 31
Leukemia (cont.)
• Signs and symptoms of acute leukemia
• Fevers and night sweats
• Fatigue, paleness, tachycardia, and tachypnea
TALKING POINTS:
• Concurrently, patients may have symptoms related to low platelet counts, such as
petechiae or purpura, epistaxis (nose bleeds), gingival bleeding (from the gums), melena
(blood in the stool), or menorrhagia (heavy menstrual bleeding).
• What may cause bone pain to occur in a patient with leukemia?
Slide 32
Leukemia (cont.)
• Medical diagnosis of acute leukemia
• CBC with extremely high white blood cell count
• Bone marrow biopsy
• Medical treatment of acute leukemia
• Chemotherapy
• Antibiotics and blood transfusions
TALKING POINTS:
• Acute leukemia is initially treated using high doses of chemotherapy to destroy the
5
&
6
Slide 33
Leukemia (cont.)
• Assessment
• Signs or symptoms of infection
• Complete vital signs every 4 hours
• If sputum, note the amount and color
• Skin for reddened, swollen, painful, or draining areas
TALKING POINTS:
• Fever is the hallmark of infection.
• Why is it possible that a patient with leukemia may have an infection with no production of
pus?
• Also note any side effects from the chemotherapy itself, such as nausea and vomiting or
stomatitis, so the appropriate interventions can be taken.
___________________________________________________________ Chapter 34Immunologic Disorders 17
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 34.2
Slide 34
Leukemia (cont.)
• Interventions
• Risk for injury
• Fatigue
• Impaired oral mucous membranes
Slide 35
Hypersensitivity Reactions
• Exaggerated immune responses that can be uncomfortable and harmful to the patient
• Four types of hypersensitivity reactions, classified according to the time between
exposure and reaction, immune mechanism involved, and site of reaction
Slide 36
Hypersensitivity Reactions (cont.)
• Type I
• Immediate hypersensitivity reactions are mediated by IgE reacting to common
allergens, such as dust, pollen, animal dander, insect stings, or various drugs
• Either local, resulting in local swelling and discomfort, or systemic, resulting in
anaphylaxis and possible death if not recognized and treated promptly
Slide 37
Hypersensitivity Reactions (cont.)
• Type II
• Immediate hypersensitivity reactions are mediated by antibody reactions
• Can occur with a mismatched blood transfusion or as response to various drugs
Slide 38
precipitation of antigen-antibody immune complexes
• Can occur with autoimmune reactions, some occupational diseases, or as response
to various drugs
Hypersensitivity Reactions (cont.)
• Type III
Slide 39
Hypersensitivity Reactions (cont.)
• Type IV
• Delayed hypersensitivity reactions result from immune cells migrating to the site of
exposure days after the exposure to the antigen
• Can occur with contact dermatitis, measles rash, tuberculin skin testing, or various
drugs
Slide 40
Idiopathic Thrombocytopenic Purpura (ITP)
• IgG mistakenly helps destroy patient’s platelets
• Drugs that induce ITP: sulfonamides, thiazide diuretics, chlorpropamide, quinidine, and
gold. Patients with HIV are at increased risk for developing ITP
• Treatment: steroids and intravenous immune globulin (IVIG)
TALKING POINTS:
18 Chapter 34Immunologic Disorders ____________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 34.2
Slide 41
Thrombotic Thrombocytopenic Purpura (TTP)
• Exaggerated immunologic response to vessel injury that results in extensive clot formation
and decreased blood flow to the site
• Patients critically ill; develop fever, thrombocytopenia, hemolytic anemia, renal
impairment, and neurologic symptoms
• The main treatment is plasmapheresis
• Others: steroids, antiplatelet agents (e.g., aspirin, dipyridamole, Persantine), splenectomy,
or all three
TALKING POINTS:
• Plasmapheresis presumably removes the immunologic agent that triggered the TTP from
the plasma.
• Why are platelet transfusions contraindicated with TTP?
Systemic Lupus Erythematosus (SLE)
• Autoimmune disease: immune system unable to recognize itself; mounts an immune
response against its own proteins
TALKING POINTS:
• Ninety percent of cases occur in women, usually of childbearing age.
• In which ethnic groups is systemic lupus erythematosus (SLE) most common?
• Factors associated with a poor outcome include increased creatinine, hypertension, large
amounts of protein excreted in the urine, anemia, and low socioeconomic status.
Slide 43
Systemic Lupus Erythematosus (cont.)
• Signs and symptoms
• Fatigue, malaise, fever, anorexia, nausea, and weight loss
• Arthralgias and myalgias
Slide 44
Systemic Lupus Erythematosus (cont.)
• Diagnosis
• No one test confirms the diagnosis of SLE
• Based on constellation of symptoms
• If any four of the following symptoms:
• Characteristic rash
• Photosensitivity with exposure to sunlight
• Oral ulcers
___________________________________________________________ Chapter 34Immunologic Disorders 19
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 34.2
Slide 45
Systemic Lupus Erythematosus (cont.)
• Medical treatment
• There is no cure
• Treatment: symptomatic and aimed at minimizing symptoms, preventing organ
damage, and maintaining quality of life
Slide 46
Systemic Lupus Erythematosus (cont.)
• Assessment
• Thorough health history and physical examination
• Complete functional assessment: determine the effects of the symptoms on the
activities of daily living
Slide 47
Systemic Lupus Erythematosus (cont.)
• Interventions
• Fatigue
• Acute pain
Slide 48
Transplant Rejection
• Patients who undergo kidney, heart, liver, or other organ transplantation risk that their
healthy immune system will recognize the transplanted organ as foreign and try to destroy
it
Slide 49
Transplant Rejection (cont.)
• Rejections occur because
• T lymphocytes can directly attack the allograft, resulting in acute transplant rejection
within hours of the transplant
Slide 50
Transplant Rejection (cont.)
• Donor-recipient tissue matching minimizes recipient’s immune system attacking allograft
• Drug combinations suppress recipient’s immune system and minimize the immune
response to the allograft
• Drugs suppress the patient’s ability to fight bacteria, viruses, fungi, and parasites, putting
Slide 51
Transplant Rejection (cont.)
• Several newer drugs target the T cells while preserving B cell function and thus more of
the patient’s immune function
20 Chapter 34Immunologic Disorders ____________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 34.2
Activities
Classroom Choose from below to make 30 minutes
Online
4
DISCUSS
• Discuss colony-stimulating factors. Which
factors have been isolated for therapeutic
use?
• Discuss the types of patients who would
benefit from a bone marrow transplant. For
what disorders are blood stem cell
transplants useful?
PRACTICE
• Divide the class into small groups. Have
members in the groups role-play a patient,
the patient’s family member(s), and the
nurse who should explain the purpose of
three of the following:
• Neutropenic precautions
POST AND COMMENT
• Ask students to post an online video
explaining one of the following precautions
to a patient/family.
• Neutropenic precautions
• Thrombocytopenic precautions
Ask students to post constructive comments
on each other’s videos.
5
DISCUSS
• Discuss the pathophysiology and signs and
symptoms of neutropenia and leukemia.
• Discuss the genetic predisposition to
systemic lupus erythematosus (SLE).
• Invite a nurse working in a rheumatology
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss the
earliest signs of neutropenia.
• Post the following discussion topic online
and have students comment. Discuss how
___________________________________________________________ Chapter 34Immunologic Disorders 21
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 34.2
6
DISCUSS
• Divide the class into groups. Have each
group discuss a nursing care plan based on
one of the following nursing diagnoses:
• Risk for injury related to infection
• Impaired oral mucous membranes
RESEARCH
• Ask students to conduct an online search of
the cost of at least three medications
intended to prevent transplant rejection.
Critical Thinking Question
A 10-year-old boy is hospitalized with idiopathic thrombocytopenic purpura (ITP), currently
referred to as immune thrombocytopenic purpura. He had recently recovered from the
mumps and has developed a fever, thrombocytopenia, and is confused as to time and place.
His symptoms include ecchymosis of his arms and legs. He is undergoing plasmapheresis
on a daily basis and his father questions the nurse: “If his blood is the problem, why do they
give most of it back to him? I don’t understand why they can’t give him more platelets.”
What is the nurse’s best response?
Discussion Guidelines: The nurse should first explain that ITP is an autoimmune disorder, which
means that the patient’s own body mistakenly destroys its own platelets. Platelets are responsible
Instructor Notes/Student Feedback
22 Chapter 34Immunologic Disorders ____________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
34
Assessments for
Immunologic Disorders
CHAPTER OBJECTIVES
Lesson 34.1:
2. List the data to be collected when assessing a patient with a disorder of the immune system.
3. Describe the tests and procedures used to diagnose disorders of the immune system and nursing
considerations for each.
Lesson 34.2:
5. Describe the pathophysiology, signs and symptoms, medical diagnosis, and medical treatment for
selected disorders of the immune system.
6. Assist in developing a nursing care plan for a patient with a disorder of the immune system.
Assessments by Lesson & Objective
Lesson 34.1
1
Study Guide
• Part IA: 1-8 (p. 205)
• Part IB: 1-5 (p. 206)
• Part IC: 1-7 (p. 206)
Evolve Instructor Resources
• Test Bank: 1, 2, 3, 19, 26, 28, 30, 31
• Open Book Quiz: 1, 2
Evolve Student Resources
• NCLEX Review: 1, 2, 3, 4, 8, 9
2
Evolve Instructor Resources
• Test Bank: 14, 18
Evolve Student Resources
• NCLEX Review: 6
3
Study Guide
• Part IF: 1-5 (p. 206)
Evolve Instructor Resources
• Test Bank: 4, 10, 12, 20, 25, 27
• Open Book Quiz: 3
Evolve Student Resources
• NCLEX Review 4, 7, 10
• Prioritization: 1, 4, 5
___________________________________________________________ Chapter 34Immunologic Disorders 23
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
Lesson 34.2
4
Study Guide
• Part IA: 7 (p. 205)
Evolve Instructor Resources
• Test Bank: 6, 7, 17, 25
• Open Book Quiz: 4, 5, 9
Evolve Student Resources
• Prioritization: 2, 3
5
Study Guide
• Part IH: 1-6 (p. 207)
Evolve Instructor Resources
• Test Bank: 5, 15, 16, 21, 22, 29
6
Study Guide
• Part IIIL: 1-3 (p. 210)
Evolve Instructor Resources
• Test Bank: 8, 9, 11, 13, 23
Instructor’s Notes/Student Feedback