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Nursing Management for Patients With Immunodeficiencies
Nursing management includes assessment, patient teaching, and supportive care. Assessment of the patient for infection and for response to treatment is important if it is to be effective. Nursing care of patients with primary and secondary immunodeficiencies depends on the underlying cause of the immunodeficiency, the type of immunodeficiency, and its severity. Because immuno-deficiencies result in a compromised immune system and high risk for infection, careful assessment of the patient’s immune status is essential. The assessment focuses on history of past infec-tions, particularly the type and frequency of infection; signs and symptoms of any current skin, respiratory, gastrointestinal, or genitourinary infection; and measures that prevent infection. The nurse monitors the patient for signs and symptoms of infection: fever; chills; cough with or without sputum; shortness of breath; difficulty breathing; difficulty swallowing; white patches in the oral cavity; swollen lymph nodes; nausea; vomiting; persistent diarrhea; frequency, urgency, or pain on urination; redness, swelling, or drainage from skin wounds; lesions on the face, lips, or perianal area; persistent vaginal discharge with or without perianal itching; and persistent abdominal pain.
Because the inflammatory response may be blunted, the pa-tient is monitored for subtle and unusual signs and changes in physical status. Vital signs and the development of pain, neuro-logic signs, cough, and skin lesions are monitored and reported. Pulse rate and respiratory rate should be counted for a full minute, as even subtle changes can signal deterioration in the patient’s clin-ical status. Thorough auscultation and assessment of the breath sounds are also key in detecting changes in respiratory status. Any unusual response to treatment and any significant change in the patient’s clinical condition are promptly reported to the physician.
The nurse also monitors laboratory values (ie, white blood cell count and differential cell count) for changes indicating infection. Culture and sensitivity reports from wound drainage, lesions, spu-tum, stool, urine, and blood are monitored to identify pathogenic organisms and appropriate antimicrobial therapy. Changes in laboratory results and subtle changes in clinical status must be re-ported to the physician because the immunocompromised pa-tient may not develop typical signs and symptoms of infection.
Assessment also focuses on nutritional status; stress level and coping skills; use of alcohol, drugs, or tobacco; and general hy-giene, all of which may affect immune function. Strategies the pa-tient has used to reduce risk for infection are identified.
Other aspects of nursing care are directed toward reducing the patient’s risk for infection, assisting with medical measures aimed at improving immune status and treating infection, improving the nutritional status, and maintaining bowel and bladder func-tion. These include careful hand hygiene, encouraging the patient to cough and perform deep-breathing exercises at regular inter-vals, and protecting the integrity of the skin and mucous mem-branes. All health care personnel must use strict aseptic technique when performing invasive procedures, such as dressing changes, venipunctures, and bladder catheterizations.
Other aspects of nursing care include assisting the patient in managing stress and in adopting a lifestyle that enhances immune system function.
If the patient is a candidate for any of the newer or experi-mental therapies (gene therapy, bone marrow transplantation, immunomodulators such as interferon gamma), the patient or parents (if the patient is a child) must be informed about the po-tential risks and benefits of the treatment regimen. A major role of the nurse is to assist the patient and family to understand the treatment options and to cope with the uncertainties of treatment outcomes.
The patient and the caregivers areinstructed about the signs and symptoms that indicate infection. The nurse explains that the immunosuppressed patient may also have atypical symptoms secondary to underlying immunosup-pression. Patients should be advised that they know themselves best; therefore, whenever they experience a symptom that is not typical for them, they should contact their health care provider. The health care provider will then determine and initiate indi-cated therapy. The patient and caregiver need instruction about any prophylactic medication regimen, including dosage, indica-tions, times, actions, and side effects. The patient is instructed about the importance of avoiding others with infections and avoiding crowds. The patient and family also need to learn about other ways to prevent infection (Chart 51-3).
The patient who is to receive IVIG at home will need infor-mation about the expected benefits and outcomes of the treat-ment as well as expected adverse reactions and their management (Chart 51-4). Patients who can perform self-infusion at home are instructed in sterile technique, medication dosages, administra-tion rate, and detection and management of adverse reactions.
The patient and family must be instructed to monitor for sub-tle changes in physical status and must be informed of the im-portance of seeking immediate health care if changes occur. Patients and their families are also instructed about the impor-tance of continuing the treatment regimen and assisted in incor-porating it into their lives.
The importance of follow-up appointments isemphasized to the patient and family. They are urged to notify the primary health care provider about early signs and symptoms of infection, including any subtle changes. The importance of continuing disease-prevention strategies is stressed because these strategies need to be followed lifelong. The patient should be en-couraged to have recommended health screening because of the increased susceptibility for cancer secondary to the immune suppression.
If the patient’s treatment includes IVIG and the patient or family cannot administer it, a referral for home care or an infu-sion service may be warranted.
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