NC of Pt. with Immune Disorders

In autoimmune disorders, the immune system no longer recognizes the body’s normal cells as self.

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Autoimmune disorders include pernicious anemia, idiopathic autoimmune hemolytic anemia, Hashimoto’s thyroiditis, systemic lupus erythematosus, and ankylosing spondylitis.

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Type I hypersensitivity reactions involve the release of epinephrine and other mediators from mast cells and basophils.

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A hemolytic transfusion reaction is an example of a type II hypersensitivity reaction.

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Several factors either cause or influence this breakdown of self-recognition, including viral infections, drugs, and cross reactive antibodies.

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A patient asks the nurse how an allergy can develop to a medication that has been taken before without problems. Which of the following is the most appropriate response?

• “It probably is due to your age, because as we age, the body becomes more sensitive to environmental stimuli, which leads to hypersensitivities.”

• “What have you eaten in the last 24 hours? Most medications are altered by food, thereby producing different effects in the body.”

• “Viral illnesses and exposure to various chemicals and environmental substances can alter the immune system and its response to previously benign stimuli.”

• “Patients who have autoimmune disorders such as lupus or arthritis tend to develop sensitivities to common medications.”

The nurse is collecting data on a patient with suspected pernicious anemia. Which of these signs or symptoms would the nurse expect to find for this patient? Select all that apply.

• Pallor

• Glossitis

• Itching

• Kyphosis

• Weakness

The nurse is collecting data from a patient with contact dermatitis. Which data is essential for the nurse to obtain?

• Date of gastric surgery

• Appearance of skin lesions

• Weight gain

• Appetite

The nurse is caring for a patient who asks what ankylosing spondylitis is. Which of the following responses from the nurse is appropriate?

• “It is a chronic progressive inflammatory disease of the spine and large limb joints.”

• “Autoantibodies lyse red blood cells.”

• “There is formation of antigen–antibody complexes leading to inflammation.”

• “Production of immunoglobulin E antibodies occurs.”

A patient is receiving cefuroxime (Zinacef) intravenously. Fifteen minutes after the cefuroxime is started, the patient reports an uneasy feeling as well as feeling very warm. Which actions would the nurse take now? Select all that apply.

• Call for assistance.

• Stay with the patient.

• Turn off the intravenous infusion.

• Offer the patient ice water.

• Monitor vital signs.