1. Description

a. The administration of an allergen to the surface of the skin or into the dermis

b. Administered by patch, scratch, or intradermal techniques

2. Preprocedure interventions

a. Discontinue systemic corticosteroids or antihistamine therapy 5 days before the test as prescribed.

b. Obtain informed consent.

3. Postprocedure interventions

a. Record the site, date, and time of the test.

b. Record the date and time for follow-up site reading.

c. Have client remain in waiting room or office for at least 30 minutes after the injection to monitor for adverse effects.

d. Inspect the site for erythema, papules, vesicles, edema, and wheal

e. Measure flare along with the wheal and document the size and other findings.

f. Provide the client with a list of potential allergens, if identified.

Have resuscitation equipment available if skin testing is performed because the allergen may induce an anaphylactic reaction.

A. Description

1. An allergy is an abnormal, individual response to certain substances that normally do not trigger such an exaggerated reaction.

2. In some types of allergies, a reaction occurs on a second and subsequent contact with the allergen.

3. Skin testing may be done to determine the allergen.

4. Types of hypersensitivity reactions

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B. Assessment

1. History of exposure to allergens

2. Itching, tearing, and burning of eyes and skin

3. Rashes

4. Nose twitching, nasal stuffiness

C. Interventions

1. Identification of the specific allergen

2. Management of the symptoms with antihistamines, antiinflammatory agents, or corticosteroids

3. Ointments, creams, wet compresses, and soothing baths for local reactions

4. Desensitization programs may be recommended.

A. Description

1. Anaphylaxis is a serious and immediate hypersensitivity reaction that releases histamine from

the damaged cells.

2. Anaphylaxis can be systemic or cutaneous (localized).

B. Assessment

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C. Interventions

1. Quickly assess respiratory status and maintain a patent airway.

2. Call the health care provider (HCP) or Rapid Response Team.

3. Administer oxygen.

4. Start an intravenous (IV) line and infuse normal saline.

5. Prepare to administer diphenhydramine (Benadryl) and epinephrine (adrenaline).

6. Document the event, actions taken, and the client’s response.

If the client experiences an anaphylactic reaction, the immediate action would be to assess the respiratory status quickly and maintain a patent airway. The HCP or Rapid Response Team is called. In the meantime, the nurse stays with the client and monitors the client’s vital signs and for signs of shock. An IV device is inserted if one is not already in place and normal saline is infused. The nurse then prepares for the administration of diphenhydramine and epinephrine and other medications as prescribed. The head of the bed is elevated if the client’s blood pressure is normal. The client’s feet and legs may be raised if the blood pressure is low. The nurse documents the event, actions taken, and the client’s response.

A. Description

1. Latex allergy is a hypersensitivity to latex.

2. The source of the allergic reaction is thought to be the proteins in the natural rubber latex or the various chemicals used in the manufacturing process of latex gloves.

3. Symptoms of the allergy can range from mild contact dermatitis to moderately severe symptoms of rhinitis, conjunctivitis, urticaria, and bronchospasm to severe life threatening anaphylaxis.

B. Common routes of exposure

1. Cutaneous: Natural latex gloves and latex balloons

2. Percutaneous and parenteral: Intravenous lines and catheters; hemodialysis equipment

3. Mucosal: Use of latex condoms, catheters, airways, and nipples

4. Aerosol: Aerosolization of powder from latex gloves can occur when gloves are dispensed from the box or when gloves are removed from the hands.

C. At-risk individuals

1. Health care workers

2. Individuals who work in the rubber industry

3. Individuals having multiple surgeries

4. Individuals with spina bifida

5. Individuals who wear gloves frequently, such as food handlers, hairdressers, and auto mechanics

6. Individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts

D. Assessment

1. Anaphylaxis or type I hypersensitivity is a response to natural rubber latex

2. A delayed type IV hypersensitivity reaction can occur; symptoms of contact dermatitis include pruritus, edema, erythema, vesicles, papules, and crusting and thickening of the skin and can occur within 6 to 48 hours following exposure.

E. Interventions

Ask the client about a known allergy to latex when performing the initial assessment.

Identify risk factors for a latex allergy in the client.

Use nonlatex gloves and all latex-safe supplies.

Keep a latex-safe supply cart near the client’s room.

Apply a cloth barrier to the client’s arm under a blood pressure cuff.

Use latex-free syringes, medication containers (glass ampules), and latex-safe intravenous equipment.

Instruct the client to wear a Medic-Alert bracelet.

Instruct the client about the importance of informing health care providers and local and paramedic ambulance companies about the allergy.

■ Ace bandages (brown)

■ Adhesive or elastic bandages

■ Ambu bag

■ Balloons

■ Blood pressure cuff (tubing and bladder)

■ Catheter leg bag straps

■ Catheters

■ Condoms

■ Diaphragms

■ Elastic pressure stockings

■ Electrocardiographic pads

■ Feminine hygiene pads

■ Gloves

■ Intravenous catheters, tubing, and rubber injection ports

■ Nasogastric tubes

■ Pads for crutches

■ Prepackaged enema kits

■ Rubber stoppers on medication vials

■ Stethoscopes

■ Syringes 

A. Description

1. Immunodeficiency is the absence or inadequate production of immune bodies.

2. The disorder can be congenital (primary) or acquired (secondary).

3. Treatment depends on the inadequacy of immune bodies and its primary cause.

B. Assessment

1. Factors that decrease immune function

2. Frequent infections

3. Nutritional status

4. Medication history, such as use of corticosteroids for long periods

5. History of alcohol or drug abuse

C. Interventions

1. Protect the client from infection.

2. Promote a balanced diet with adequate nutrition.

3. Use strict aseptic technique for all procedures.

4. Provide psychosocial care regarding lifestyle changes and role changes.

5. Instruct the client in measures to prevent infection.

6. Instruct the client to wear a Medic-Alert bracelet.

The priority concern for a client with immunodeficiency is infection. 

1. Description

a. Chronic, progressive, systemic inflammatory disease that can cause major organs and systems to fail

b. Connective tissue and fibrin deposits collect in blood vessels on collagen fibers and on organs.

c. The deposits lead to necrosis and inflammation in blood vessels, lymph nodes, gastrointestinal tract, and pleura.

d. No cure for the disease is known but remissions are frequently experienced by clients who manage their care well.

2. Causes

a. The cause of SLE is unknown, but is believed to be a defect in immunological mechanisms, with a genetic origin.

b. Precipitating factors include medications, stress, genetic factors, sunlight or ultraviolet light, and pregnancy.

c. Discoid lupus erythematosus is possible with some medications but totally disappears after the medication is stopped; the only manifestation is the skin rash that occurs in lupus.

3. Assessment

a. Assess for precipitating factors.

b. Erythema of the face (malar rash; also called a butterfly rash)

c. Dry, scaly, raised rash on the face or upper body

d. Fever

e. Weakness, malaise, and fatigue

f. Anorexia

g. Weight loss

h. Photosensitivity

i. Joint pain

j. Erythema of the palms

k. Anemia

l. Positive anti-nuclear antibody (ANA) test and lupus erythematosus (LE) preparation

m. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein level

4. Interventions

a. Monitor skin integrity and provide frequent oral care.

b. Instruct the client to clean the skin with a mild soap, avoiding harsh and perfumed substances.

c. Assist with the use of ointments and creams for the rash as prescribed.

d. Identify factors contributing to fatigue.

e. Administer iron, folic acid, or vitamin supplements as prescribed if anemia occurs.

f. Provide a high-vitamin and high-iron diet.

g. Provide a high-protein diet if there is no evidence of kidney disease.

h. Instruct in measures to conserve energy, such as pacing activities and balancing rest with exercise.

i. Administer topical or systemic corticosteroids, salicylates, and nonsteroidal antiinflammatory drugs as prescribed for pain and inflammation.

j. Administer medications to decrease the inflammatory response as prescribed.

k. Monitor intake and output, as well as daily weight for signs of fluid overload if corticosteroids are used.

l. Instruct the client to avoid exposure to sunlight and ultraviolet light.

m. Monitor for proteinuria and red cell casts in the urine.

n. Monitor for bruising, bleeding, and injury.

o. Assist with plasmapheresis as prescribed to remove autoantibodies and immune complexes from the blood before organ damage occurs.

p. Monitor for signs of organ involvement such as pleuritis, nephritis, pericarditis, coronary artery disease, hypertension, neuritis, anemia, and peritonitis.

q. Note that lupus nephritis occurs early in the disease process.

r. Provide supportive therapy as major organs become affected.

s. Provide emotional support and encourage the client to verbalize feelings.

t. Provide information regarding support groups and encourage the use of community resources.

For the client with SLE, monitor the blood urea nitrogen and creatinine levels frequently for signs of renal impairment.

1. Description

a. Scleroderma is a chronic connective tissue disease, similar to SLE, that is characterized by inflammation, fibrosis, and sclerosis.

b. This disorder affects the connective tissue throughout the body.

c. It causes fibrotic changes involving the skin, synovial membranes, esophagus, heart, lungs, kidneys, and gastrointestinal tract.

d. Treatment is directed toward forcing the disease into remission and slowing its progress.

2. Assessment

a. Pain

b. Stiffness and muscle weakness

c. Pitting edema of the hands and fingers that progresses to the rest of the body

d. Taut and shiny skin that is free from wrinkles

e. Skin tissue is tight, hard, and thick, loses its elasticity, and adheres to underlying structures.

f. Dysphagia

g. Decreased range of motion

h. Joint contractures

i. Inability to perform activities of daily living

3. Interventions

a. Encourage activity as tolerated.

b. Maintain a constant room temperature.

c. Provide small frequent meals, eliminating foods that stimulate gastric secretions, such as spicy foods, caffeine, and alcohol.

d. Monitor for esophageal involvement; if present, advise the client to sit up for 1 to 2 hours after meals.

e. Provide supportive therapy as the major organs become affected.

f. Administer corticosteroids as prescribed for inflammation.

g. Provide emotional support and encourage the use of resources as necessary.

1. Description

a. Polyarteritis nodosa is a collagen disease; it is a form of systemic vasculitis that causes inflammation of the arteries in visceral organs, brain, and skin.

b. Treatment is similar to the treatment for SLE.

c. Polyarteritis nodosa affects middle-aged men.

d. The cause is unknown and the prognosis is poor.

e. Renal disorders and cardiac involvement are the most frequent causes of death.

2. Assessment

a. Malaise and weakness

b. Low-grade fever

c. Severe abdominal pain

d. Bloody diarrhea

e. Weight loss

f. Elevated ESR

3. Interventions

a. Provide supportive care as required.

b. Provide a well-balanced diet.

c. Administer corticosteroids and analgesics to control pain and inflammation.

d. Provide emotional support and encourage the client to verbalize feelings.

e. Initiate support services for the client.

1. Description

a. Pemphigus is a rare autoimmune disease that occurs predominantly between middle and old age.

b. The cause is unknown, and the disorder is potentially fatal.

c. Treatment is aimed at suppressing the immune response and blister formation.

2. Assessment

a. Fragile, partial-thickness lesions bleed, weep, and form crusts when bullae are disrupted.

b. Debilitation, malaise, pain, and dysphagia

c. Nikolsky’s sign: Separation of the epidermis caused by rubbing the skin

d. Leukocytosis, eosinophilia, foul-smelling discharge from skin

3. Interventions

a. Provide supportive care.

b. Provide oral hygiene and increase fluid intake.

c. Soothe oral lesions.

d. Assist with soothing baths, as prescribed for relief of symptoms.

e. Administer topical or systemic antibiotics as prescribed for secondary infections.

f. Administer corticosteroids and cytotoxic agents as prescribed to bring about remission.

A. Description

1. Goodpasture’s syndrome is an autoimmune disorder; autoantibodies are made against the glomerular basement membrane and alveolar basement membrane.

2. Goodpasture’s syndrome is most common in males and young adults who smoke; the exact cause is unknown.

3. The lungs and the kidneys are affected primarily, and the disorder usually is not diagnosed until significant pulmonary or renal involvement occurs.

B. Assessment

1. Clinical manifestations indicating pulmonary and renal involvement

2. Shortness of breath

3. Hemoptysis

4. Decreased urine output

5. Edema and weight gain

6. Hypertension and tachycardia

C. Interventions

1. Focus on suppressing the autoimmune response with medications such as corticosteroids, and on plasmapheresis (filtration of the plasma to remove some proteins) to remove the autoantibodies.

2. Provide supportive therapy for pulmonary and renal involvement.

A. Description

1. Lyme disease is an infection caused by the spirochete Borrelia burgdorferi, acquired from a tick bite (ticks live in wooded areas and survive by attaching to a host).

2. Infection with the spirochete stimulates inflammatory cytokines and autoimmune mechanisms.

B. Assessment

1. The typical ring-shaped rash of Lyme disease does not occur in all clients. Many clients never develop a rash. In addition, if a rash does occur, it can occur anywhere on the body, not only at the site of the bite.

C. Interventions

1. Gently remove the tick with tweezers, wash the skin with antiseptic, and dispose of the tick by flushing it down the toilet; the tick may also be placed in a sealed jar so that the health care provider can inspect it and determine its type.

2. Perform a blood test 4 to 6 weeks after a bite to detect the presence of the disease (testing before this time is not reliable).

3. Instruct the client in the administration of antibiotics as prescribed; these are initiated immediately (even before the blood testing results are known).

4. Instruct the client to avoid areas that contain ticks, such as wooded grassy areas, especially in the summer months.

5. Instruct the client to wear long-sleeved tops, long pants, closed shoes, and hats while outside.

6. Instruct the client to spray the body with tick repellent before going outside.

7. Instruct the client to examine the body when returning inside for the presence of ticks.

First Stage

Symptoms can occur several days to months following the bite.

A small red pimple develops that may spread into a ring-shaped rash; it may occur anywhere on the body.

Rash may be large or small, or may not occur at all.

Flulike symptoms occur, such as headaches, stiff neck, muscle aches, and fatigue.

Second Stage

This stage occurs several weeks following the bite.

Joint pain occurs.

Neurological complications occur.

Cardiac complications occur.

Third Stage

Large joints become involved.

Arthritis progresses.

1. AIDS is a viral disease caused by human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy

2. The syndrome is manifested clinically by opportunistic infection and unusual neoplasms.

3. AIDS is considered a chronic illness.

4. The disease has a long incubation period, sometimes 10 years or longer.

5. Manifestations may not appear until late in the infection.

B. Diagnosis and monitoring the client with AIDS

Complete Blood Cell Count

■ White blood cell (WBC) count (normal to decreased)

■ Lymphopenia (< 30% of the normal number of WBCs)

■ Thrombocytopenia (decreased platelet count)

Lymphocyte Screen

■ Reduced CD4+/CD8+ T-cell ratio

■ CD4+ (helper) lymphocytes decreased

■ CD8+ lymphocytes increased

Quantitative Immunoglobulin

■ Immunoglobulin G (IgG) level increased

■ IgA level frequently increased

Chemistry Panel

■ Lactate dehydrogenase level increased (all fractions)

■ Serum albumin level decreased

■ Total protein increased

■ Cholesterol level decreased

■ AST and ALT levels elevated

Anergy Panel

■ Nonreactive (anergic) or poorly reactive to infectious agents or environmental materials (e.g.,

pokeweed, phytohemagglutinin mitogens and antigens, mumps, Candida)

Hepatitis B Surface Antigen Testing

■ To detect the presence of hepatitis B

Blood Cultures

■ To detect septicemia

Chest Radiography

■ To detect Pneumocystis jiroveci infection or tuberculosis

C. High-risk groups

1. Heterosexual or homosexual contact with high-risk individuals

2. Intravenous drug abusers

3. Persons receiving blood products

4. Health care workers

5. Babies born to infected mothers

D. Assessment

1. Malaise, fever, anorexia, weight loss, influenza-like symptoms

2. Lymphadenopathy for at least 3 months

3. Leukopenia

4. Diarrhea

5. Fatigue

6. Night sweats

7. Presence of opportunistic infections

8. Protozoan infections (Pneumocystis jiroveci pneumonia, a major source of mortality)

9. Neoplasms (Kaposi’s sarcoma, purplish-red lesions of internal organs and skin, B-cell non– Hodgkin’s lymphoma, cervical cancer)

10. Fungal infections (candidiasis, histoplasmosis)

11. Viral infections (cytomegalovirus, herpes simplex)

12. Bacterial infections

E. Interventions

1. Provide respiratory support.

2. Administer oxygen and respiratory treatments as prescribed.

3. Provide psychosocial support as needed.

4. Maintain fluid and electrolyte balance.

5. Monitor for signs of infection.

6. Prevent the spread of infection.

7. Initiate standard and other necessary precautions.

8. Provide comfort as necessary.

9. Provide meticulous skin care.

10. Provide adequate nutritional support as prescribed.

1. Description: Skin lesions that occur primarily in individuals with a compromised immune system

2. Assessment

a. Kaposi’s sarcoma is a slow-growing tumor that appears as raised, oblong, purplish, reddishbrown lesions; may be tender or nontender.

b. Organ involvement includes the lymph nodes, airways or lungs, or any part of the gastrointestinal tract from the mouth to anus.

3. Interventions

a. Maintain standard precautions.

b. Provide protective isolation if the immune system is depressed.

c. Prepare the client for radiation therapy or chemotherapy as prescribed.

d. Administer immunotherapy, as prescribed, to stabilize the immune system.

A. Description

1. Secondary immunodeficiency is immunosuppression caused by therapeutic agents.

2. The client must take immunosuppressive agents for the rest of his or her life posttransplantation to decrease rejection of the transplanted organ or tissue.

B. Diagnosis and monitoring of posttransplantation clients

1. Check renal and hepatic function.

2. Monitor the complete cell count with differential to determine signs of infection.

3. Assess all body secretions periodically for blood.

C. High-risk clients

1. Clients with a history of malignancy or premalignancy have an increased susceptibility to malignancy if immunosuppressed.

2. Clients with recent infection or exposure to tuberculosis, herpes zoster, or chickenpox have a high risk for severe generalized disease when on immunosuppressive agents.

D. Assessment

1. Assess for signs of opportunistic infections.

2. Assess nutritional status.

3. Assess for signs of rejection (signs will depend on the organ or tissue transplant).

E. Interventions

1. Strict aseptic technique is necessary.

2. Provide teaching regarding asepsis and the signs of infection and rejection.

3. Provide psychosocial support as needed.

4. Provide client teaching about immunosuppressants.