C1
Define tissue integrity
ability of body tissues to regenerate and/or repair to maintain normal physiological processes.
List some risk factors associated with impaired immunity
age, injury, illness, comorbidities, tissue trauma, surgical wounds
Define immunity
The normal physiologic response to microorganisms and proteins as well conditions associated with an inadequate or excessive immune response.
Name the 3 types of immunity
innate, active/adaptive/acquired, passive
What populations are at greatest risk for altered immunity and why?
Infants: thinner and weaker skin than adults and more prone to infection.
Elderly: thin skin due to mature epidermal cells, circulation and collagen are also impaired so increased risk for skin tears and pressure sores.
Define blanching and its 2 stages.
pressuring the skin to test if it goes back to normal skin color.
stage 1: not open
stage 2: open
What are symptoms that you would see in localized and systemic effects during an acute hypersensitive reaction?
localized: cardinal signs
systemic: fever, chills, sweats
Name some nursing interventions for immunity. at least 3
avoid allergens, do skin testing for allergies, blood testing/biopsies for autoimmune, immunotherapy, pharmacotherapy, environmental control, CBC, skin and serum, globulins, negative pressure room
The 3 organs involved in immunity
Spleen, Thymus, and Lymph Nodes
What are some priority nursing interventions for tissue integrity? name at least 3
-good hand hygiene
-braden scale-risk assessment
-repositioning every 2 hours
-early ambulation
-nutritional support
-proper PPE
-cleaning wounds and bandages
What are the primary, secondary and tertiary prevention measures for tissue integrity?
primary: good hygiene, good nutrition, reduce sun exposure, increase exercise
secondary: mostly cancer screenings, treatment of chronic illness
tertiary: wound care, surgical care, education
what do macrophages do?
help with phagocytosis. essential for clearing out bacteria in organs by engulfing them
what is the largest white blood cell that is released from bone marrow into the bloodstream? what do they mature into?
monocytes and mature into macrophages
What do you do if a patient has dehiscence and/or evisceration?
-place patient in low folwer's position
-covered exposed contents with wet sterile dressing
- notify provider
-NERDS/STONES: means worsening infection
Define innate, passive and adaptive/acquired immunity
innate: immediate response, the first line of defense. ex. epithelium, inflammation, fever
passive: immunity transferred from another source (mother to baby)
adaptive/acquired: delated response unless the host has been previously exposed to a specific antigen. (humoral or cell-mediated)
what is the BEST way to reduce friction or tearing of skin breakdown?
repositioning the client ever 2 hours.
What are the 4 types of exaggerated immunity and define them
I - (Immediate or anaphylaxis): A rapid onset characterized by edema typically in larynx, hypotension, bronchospasm, and cardiovascular collapse.
II - (cytotoxic): occurs when antibodies are erected against antigens on cells or basement membranes of tissues. Reaction can lead to cell lysis and tissue damage. Ex: giving someone the wrong blood type
III - (Immune Complex): damaging inflammatory reaction caused by the insoluble immune complexes formed by antigens that bind to antibodies. Ex: rheumatoid arthritis, autoimmune
IV - (delayed): is a T-cell-mediated immune response after exposure to antigen. Typically occurs 24-48 hrs after exposure.
Differentiate Suppressed and Exaggerated
suppressed: neutropenia, rare, chronic. the immune response is weakened to the point that it cannot mount a proper immune response to protect the body from pathogens
exaggerated: hypersensitive reactions or inappropriate immunologic responses occurring in response to an antigen or allergen
who's skin integrity are you more concerned about between infants and children and why?
between middle-aged adults and the elderly?
Infants bc their skin is thin and prone to damage vs children are more prone to injuries than their tissue integrity.
elderly have decreased sensation and increased neuropathy and comorbidities so more prone to weak skin. prone to jarring and skin tears.
where is the origin of cells in an immune response?
bone marrow