Assessment of Immune Response or Infection
The portion of the serum laboratory results looking at the percentage of each type of white blood cell is known as the?
What is differential?
The differential is ordered as part of an overall complete blood count (CBC) that breaks down the percentage of each individual type of WBC within the total WBC count
often referred to as a "CBC with Diff"
What are the primary participants in cellular mediated immune response?
What are Lymphocytes
Which are either T-cell or B-cell lymphocytes, comprise 20% to 30% of all leukocytes. These are most often active with viral infections
A patient with a diagnosis of a urinary tract infection requires what type of precautions?
What are standard precautions?
Assumption that all patients may carry infectious agents and using appropriate barrier precautions for all patient encounters ie wearing gloves when emptying a urinal
A localized reaction of tissue to injury, irritation, or infection that is manifested by five cardinal signs is known as?
what is inflammation?
The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?
A. Percussion of patient's abdomen
B. Palpation of patient's liver
C. Auscultation of patient's apical HR
D. Palpation of the patient's lymph nodes
What is D, palpation of the lymph nodes
During the assessment of immune function, the anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement. If palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Because of the central role of lymph nodes in the immune system, they are prioritized over the heart, liver, and abdomen, even though these would be assessed.
These are connected by channels and capillaries distributed throughout the body with the purpose of removing foreign material before it enters the bloodstream
What are lymph nodes?
What is the proper order for donning personal protective equipment?
What is: Gown, Mask, Goggles, GLoves
Rationale: Per the Centers of Disease Control and Prevention (CDC), the nurse applies the gown, mask, goggles, then gloves. Think of this as going up the body with the gloves last.
What is the primary purpose of inflammation?
What is protection? What is Repair? What is Healing?
All 3 are the primary functions of inflammation; remember the inflammatory response is part of our innate immunity
An antibody that is produced and targets the body's own cells/tissues is known as?
What is an autoantibody?
These are responsible for many of the autoimmune disorders we will be discussing this semester
The nurse should recognize a patient's risk for impaired immune function if the patient has undergone surgical removal of which of the following:
A. Thyroid Gland
B. Spleen
C. Kidney
D. Pancreas
What is B, spleen.
A history of surgical removal of the spleen, lymph nodes, or thymus may place the patient at risk for impaired immune function. Removal of the thyroid, kidney, or pancreas would not directly lead to impairment of the immune system.
Spleen plays an important role in immunity, a predominant site of macrophage activity responsible for important phagocytic roles
Tuberculosis, measles, and disseminated herpes zoster are indications for a patient to be on what type of precautions.
What is airborne precautions?
Influenza, & Covid 19 would require droplet precautions. MRSA, VRE, and ESBL all require contact precautions.
Is the process of inflammation specific or nonspecific?
What is nonspecific?
The body's inflammatory response is going to respond in the same fashion whether it is due to a bee sting, scrapped knee or a severe burn injury.
The nurse is caring for an older patient admitted to the health-care facility with a new onset of confusion and a low-grade fever. Which age-related changes might contribute to decreased functioning of the immune system?
A. Decreased Kidney Function
B. Thickening of Skin
C. Increased Gastric Secretions
D. Increased ciliary action
What is A decreased kidney function
Decreased kidney function, changes in lower urinary tract function (enlargement of the prostate), and altered genitourinary tract flora all contribute to increased urinary tract infections. With age, the skin thins, gastric secretions decrease, and ciliary action decreases.
These allow our immune system to continuously survey our bodies and recognize our own tissues as our own.
What are Human Leukocyte Antigens (HLAs)? Will also accept concept of Self-Tolerance.
This is what prevents our bodies from being in a constant state of inflammation and prevents inappropriate responses.
A patient on droplet precautions needs to leave their room for an urgent CT scan. How should the nurse address the droplet precautions?
What is have the patient wear a mask while outside of their room?
Patients on droplet precautions are able to leave their rooms but with the appropriate precautions taken ie the patient must wear a mask
What are the 5 Cardinal Signs of Inflammation?
What are: Warmth, Redness, Swelling, Pain & Decreased (or loss) of function
Don't confuse these with the 5 P's of circulatory compromise - Pain, Pallor, Pulselessness, Paresthesia and Paralysis
When obtaining a set of blood cultures to assess for the presence of and the specificity of a particular pathogen, they should be completed:
A: After the start of the first dose of IV antibiotics
B: After the first dose of oral antibiotics
C: Prior to the start of any antibiotics
D: Only after the patient has become febrile
What is C
Blood cultures need to be collected before the initiation of antibiotics to have the best chance of identifying the specific pathogen responsible for the infection.A Sensitivity is done following the results of a culture to identify what antibiotic(s) a particular pathogen is susceptible to. Why is this important if antibiotics have already been started?
When there is an excess of immature neutrophil precursor cells released into the bloodstream generally indicative of severe infection
What is a bandemia, AKA "Left Shift"
An umbrella term for a number of safety and infection prevention precautions taken when an individual has an abnormally low absolute neutrophil count are known as?
What are neutropenic precautions?
Some of these measures in an acute care setting include: Strict hand hygiene before and after entering the room, no fresh fruits or flowers in the patient's room, masking of all visitors
Does the inflammatory process ever involve transient vasoconstriction?
What is yes?
At the initial onset of the inflammatory process there is transient vasoconstriction. This is designed to be protective against hemorrhage.