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CENTRAL PHILIPPINE UNIVERSITY NURSING REVIEW CENTER

In Collaboration with
A1 PASSERS TRAINING, RESEARCH, REVIEW AND DEVELOPMENT COMPANY


ATTY.SALEX E.ALIBOGHA, RN, MAN, LLB (BAR)


MAINTAINING THE FUNCTION OF TUBES AND DRAINS
A. TRACHEOSTOMY TUBE

1. Overview
a. Tracheotomy is a surgical procedure that creates an opening in trachea to establish a patent
airway.
b. A tracheostomy is an opening (stoma) that is surgically created
c. A variety of tubes can be inserted into a tracheostomy , depending on whether it is temporary or
permanent, on length of anticipated use, on whether mechanical ventilation will be used , and
on need to be able to speak while in place (see figure 28-1)
d. Variations in tubes include double lumen or single lumen (inner cannula or no inner cannula),
cuffed or cuffles, and fenestrated or nonfenestrated (see table 28-1)
e. Clients who have permanent tracheostomies often use metal trach tubes, which are cuffles and
have an inner cannula; can be used long term with regular cleaning (example : Jackson tube)

2. Therapeutic management

a. Maintain head of bed elevated at least 30 degrees
b. Ensure that a manual resuscitation (Ambu) bag is at bedside at all times

FIGURE 28-1

















c. Keep spare tracheostomy set of same size, Obturator , and clamps at bedside for use if trach is
accidentally removed

d. Ensure that air and oxygen flowing into airway is humidified: notify respiratory therapy if water
bottle attached to oxygen flowmeter runs low

e. Encourage coughing and deep breathing to reduce risk of atelectasis and pneumonia

f. Perform respiratory assessments , including breath sounds, at regular intervals minimally every
4 hours

g. Monitor and document trend of oxygen saturation and/or arterial blood gas results

h. Suction client as indicated by results of assessment (cough , noisy respirations or adventitious
breath sounds are indicators of need to suction): hyperoxygenate client before and after, suction
for no more than 10 seconds at one time; assess nature of secretions (purulent secretions
indicate infection)
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Table 28-1 COMPARISON OF FEATURES OF TRACHEOSTOMY TUBES



























i. Assess stoma for redness or signs of infection: assess for and report subcutaneous
emphysema(subcutaneous air, also called crepitus)
j. Perform tracheostomy care every 8 hours: use half strength peroxide for cleansing site and
inner cannula unless agency policy is different
k. Change tracheostomy ties daily or more often if soiled; have assistance to hold trach in place so
client cannot cough trach out; if assistance is unavailable, place new ties before cutting and
removing old ones to prevent client from coughing tube out.
l. Monitor cuff pressures (if inflated) at least every 8 hours as indicated by agency policy (should
not exceed 20 cm) ; see endotracheal tube section that follows for cuff inflation techniques
m. Provide for alternate means of communication (word or picture board, writing pad) if client
cannot talk because of cuff inflation
n. If client has order or oral intake while trach is in place, inflate cuff to induce risk of aspiration and
sit client upright during meals and for 1 hour after ward as ordered.
o. Before capping or plugging trach as final stage of weaning prior to trach removal, ensure that
fenestrated trach is in use and that cuff, if present , is deflated

3. Complications (see Table 28-2)
4. Accidental removal
a. If trach inserted was during previous 72 hours , use manual resuscitation bag to ventilate client
while second nurse calls resuscitation or rapid response team
b. After 72 hours post placement, extend neck and open stoma by grasping retention sutures or
using curved clamp to spread tracheal tissue; insert obturator into trach tube. Insert tube into
trachea , remove obturator , ventilate with manual resuscitation bag, and assess air exchange
and respiratory status; if unsuccessful or ineffective, call for resuscitation or rapid response
team

5. Purposeful removal
a. Suction trachea and oropharyngeal area to remove any secretions
b. Ensure that cuff is deflated
c. Physician cuts sutures that hold tracheostomy in place and withdraws tube during exhalation
d. Place dry sterile dressing over stoma and tape gently in place
e. Stoma closes over next few days and leaves small scar


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B. Endotracheal tube (see figure 28-2)
1. Overview
a. An artificial that maintains airway patency and allows for client to receive mechanical ventilation ;
intended for short term use, up to 10 to 14 days
b. Consists of a long tube with a universal adapter and proximal end for attachment to oxygen source
or ventilator , inflatable cuff at distal end, and pilot balloon at proximal end for cuff inflation
2. Routes of insertion
a. Orotracheal insertion route allows for use of larger tube, rapidly restores airway,, and reduces
respiratory effort; disadvantages include discomfort to client, possible displacement through tongue
movement and occlusion from biting on tube; oral airway may need to be used
b. Nasotracheal route allow for use of smaller tube, prevents dislodgement with bleeding disorders,
epitaxis, or nasal obstruction
3. Therapeutic management
a. To check placement after insertion, ventilate with manual resuscitation bag, assess that both left and
right sides of chest rise and fall, and auscultate for bilateral breath sounds; if only right sided chest
movement and breath sounds are present , tube needs to be pulled back slightly from placement in
right mainstem bronchus
b. Auscultate over epigastric area to ensure esophageal intubation did not occur, if it did, ventilation
sounds will be louder over stomach than chest and

TABLE 28-2 COMPLICATIONS OF TRACHEOSTOMY
COMPLICATION PREVENTION AND THERAPEUTIC MANAGEMENT
Short term
Tube Displacement
Secure tube properly
Keep spare tube of same size at bedside
Do not allow client to pull at tube
Prevent traction on tube during care and avoid excessive tube movement
Tube obstruction Humidify oxygen
Suction as needed and note if secretions are becoming thick and viscous
Encourage client to cough and deep breathe
Keep inner cannula clean by doing trach care regularly as scheduled
Assess client for respiratory difficulty and/ or newly increased peak
pressure on mechanical ventilator
Prepare for rapid tube replacement in the event of obstruction caused by
cuff prolapsed over distal end of tube
Long term
Tracheomalacia
(tracheal dilation and
erosion caused by high
cuff pressures)
Note whether trach tube has low pressure cuff for prevention
Monitor air volumes needed to keep cuff inflated and cuff pressures as per
policy, identify and report increases
Assess for air leaks around cuff or lost tidal volume if mechanical
ventilation is being used
Assess for aspiration of bits of food or fluids if client is allowed oral intake
Monitor for a report onset of bleeding caused by pressure
Progress client to use of uncuffed tube at earliest opportunity
Tracheoesophageal
fistula (abnormal
connection between
posterior wall of trachea
and esophagus from
high cuff pressure)
Similar to tracheomalacia above.
Assess for coughing or respiratory distress while taking food or fluids
Administer supplemental oxygen by mask to treat hypoxemia
Prepare client for possible insertion of gastric or jejunostomy tube for
feedings if pressure of nasogastric tube in esophagus was contributing
factor
Tracheal stenosis
(tracheal lumen
narrowing from scar
formation secondary to
cuff irritation)
Prevent by avoiding high cuff pressures and avoiding traction or pulling on
tube
Observe for respiratory difficulty, increased coughing, inability to manage
secretions, or difficulty in speaking after cuff deflation or trach tube removal
Prepare client for surgical dilation of trachea for definitive treatment as
needed
Tracheal- innominate
artery fistula (erosion of
lateral wall of trachea
into artery caused by
pressure from distal end
of tube)
Prevent by keeping tube in midline position and avoiding on tube from any
cause
Assess for pulsation of trach tube with each client heartbeat and notify
physician immediately if it occurs
Note fresh bleeding at or through stoma and report immediately
Physician may remove trach tube immediately and apply direct pressure to
blood vessel at stoma site
Prepare client for immediate life saving surgical repair

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Abdomen will rise and fall with ventilations; tube is removed immediately if it occurs
c. A carbon dioxide (CO
2
) analyzer is frequently use to check proper placement in the trachea
using advanced cardiac life support (ACLS) protocols
d. Confirm placement by portable chest x-ray; distal tip of tube should be 1 to 2 cm above carina
(point of bifurcation of right and left mainstem bronchi)


















e. Note position of tube by noting centimetre marking at lip line and then tape tube in place or use
other securing device; monitor placement at least every 8 hours
f. Ensure manual resuscitation bag is kept at bedside at all times
g. Perform respiratory assessments every 4 hours and as needed; suction client as indicated by
results of assessment as with tracheostomy
h. Inflate cuff using minimal occluding volume technique by injecting air into pilot ballom just until
no air leakage sounds can be heard during inspiration with stethoscope placed over trachea
i. Inflate cuff using minimal leak technique by injecting air into pilot balloon until sealed and then
deflating slightly so that no harsh sounds can be heard at peak of inspiration
j. Insert oral airway if orotracheal route is used to prevent client from biting tube or displacing
tube with tongue movement
k. Reposition orotracheal tube from one side of mouth to other daily with assistance of one other
person; assess oral cavity for ulceration or necrosis
l. Provide oral care every 2 hours to prevent drying and cracking of lips and mucous membranes
m. Provide the alternative means of communication (word or picture board, writing pad)
4. Removal
a. Suction endotracheal tube well , then suction oropharyngeal area
b. Elevate head of bed to semi Fowlers or high-Fowlers position as tolerated
c. Cuff is deflated and client is asked to inhale; at peak inspiration. Tube is removed
d. Encourage client to cough and deep breathe to clear any residual secretions in pharyngeal area
e. Apply oxygen as ordered
f. Monitor client closely for first 30 minutes after extubation and continue to monitor frequently
thereafter; notify physician if respiratory rate or effort show steady increase , oxygen saturation
decreases, or respiratory distress occurs
g. Teach client that sore throat and hoarse voice are common; monitor status and report
hoarseness that doesnt improve over time, which may indicate damage to vocal cords

II. CLOSED CHEST DRAINAGE SYSTEMS

A. Overview
1. A chest tube is use to drain air (pneumothorax), blood (hemathorax), or large amounts of fluid
(pleural effusion) from pleural cavity
2. Restores negative pressure to intrapleural space
B. Design
1. Most systems in use today have 3 chambers: collection, water seal, and suction (figure 28-3)
2. Collection chamber lies under point attachment between tube and system and consists of marked
columns (generally three) that indicate amount of drainage collected
3. Water seal chamber is filled to 2-cm marking during system setup; water allows air to escape
system but not to reenter; water moves up and down in tube in this chamber with inhalation and
exhalation to indicate patency
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4. Suction control chamber allows use of suction to provide negative pressure to chest; negative
pressure aids in reinflating lung more quickly by removing air, blood, pus, or effusion; some
systems use dry suction, controlled by adjusting suction knob appropriate level, both types are
connected to low wall suction with a connecting tube.

C. Therapeutic management
1. Maintain occlusive dressing at chest tube insertion site; dressing is secured with large strips of
wide tape or Elastoplast; dressing may be reinforced as needed but not changed.
2. Secure all chest tube and suction tubing connections with tape
3. Keep collection apparatus below chest level to allow gravity to promote chest drainage; keep
tubing straight to prevent dependent loops of obstructions
4. Milk chest tube to maintain patency only if ordered ; milking chest tube can cause tissue drainage
5. Chest tube is not to be clamped when client is mobile and is never clamped without a physician
order; keep a clamp at bedside for use or surgeon if needed and as noted by agency policy and
procedure
6. Monitor chest tube drainage at 1 to 4 hour intervals; report and document bright red blood,
sudden increase in drainage, or consistent drainage greater than 100mL/hour (physician may
also specify volume to report)
7. Maintain 2-cm water level in water seal chamber; low water volume creates higher suction than
may be desired, contributing to pleural tissue damage





















8. Assess for fluctuation in water seal chamber , which indicates tube is patent; lack of fluctuation
may indicate tube obstruction, loop or kink (requires correction) or may indicate full lung
reexpansion (indicating tube is ready for removal);
9. Assess for bubbling in water seal chamber
a. Continuous bubbling indicates an air leak in systems and needs to be corrected; if leak
is not found, notify surgeon of problem
b. Intermittent bubbling with inspiration indicates drainage of air (pneumothorax) from
pleural space and proper function of chest tube; continue with usual monitoring
10. Assess suction control chamber for correct amount of suction by either dial (dry suction system) or
water level (fluid system) ; add sterile water if level is low (excessive will suction can cause
more rapid evaporation); remove excessive water by aspiring from rubber seal in chamber
11. Suction control chamber in system that uses water should have gentle. Continuous bubbling as
sign of proper function ; vigorous bubbling will evaporate water but not increase suction, and
lack of continuous bubbling will not harm client but will not provide suction that assist in clearing
pneumothorax or hemathorax
12. Assess respiratory status breath sounds oxygen saturation, and comfort level of 4 hours or as
indicated; assess that dressing in intact and check for an report subcutaneous emphysema
13. Change client position every 4 hours and encourage coughing and deep breathing
14. Anticipate that client may have frequent (up to daily) portable chest x-rays to monitor lung
reexpansion
15. Keep occlusive dressing materials and sterile water at bedside for emergency use (petrolatum
gauze, dry sterile gauze, wide adhesive tape).
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16. If drainage system becomes damaged or broken, insert chest tube into sterile water to re-establish
underwater seal and replace with new system
17. If chest tube is accidentally pulled out of chest, pinch skin together, apply occlusive dressing using
materials noted above, and notify surgeon immediately
18. Chest tube removal
a. Indicated when fluctuation stops in water seal chamber, chest x-ray shows full lung
expansion, and client has returned to normal or baseline respiratory status
b. Obtain suture removal set, petrolatum gauze, dry sterile gauze or Telfa gauze, and wide
adhesive tape, premedicate client with oral medication 30 minutes prior to removal if
impossible
c. Instruct client to take deep breath, hold breath (valsalva) or exhale according to surgeon
preference just prior to tube removal
d. Open and prepare dressing materials just prior to removal of tube by physician; assist
with application of dressing, and obtained follow up chest, x-ray if ordered
e. Assess respiratory status post removal

D. Heimlich valve
1. Used instead of chest tube for selected ambulatory clients who have pneumothorax or to treat
tension pneumothorax
2. Valve allows air to escape from chest cavity during exhalation but closes during inhalation to
prevent air from reentering pleural cavity

III. RENAL AND URINARY TUBES
A. Nephrostomy or ureteral tube
1. Position tube carefully (no kinks or compression) to maintain patency ; do not clamp tube
2. Monitor and record urine output carefully; report output of less than 30 mL/hr or no drainage for 15
minutes or more
3. Never irrigate tube unless there is a specific order allowing it
4. Irrigate with a maximum of 5ml volume and use strict surgical aseptic technique
5. Report and document immediately if irrigation fails to restore patency of tube
B. Indwelling urinary catheter
1. Insert using sterile technique; measure and record initial outflow amount and characteristics of
urine
2. Properly position drainage bag below level of bladder and secure catheter to thigh to prevent
traction of tube balloon against urethra and bladder neck
3. Measure and record outputs accurately
4. Provide routine catheter care using soap and warm water; follow standards precaution
5. Wash front to back for females ; in males retract forekin if present, and return to original position
after cleansing
6. Explain procedure to client just prior to removal; empty and record drainage, deflate balloon, and
withdraw catheter while client exhales to reduce discomfort

IV. NASOGASTRIC TUBED

A. OVERVIEW
1. Inserted via naris to stomach for decompression of stomach and occasionally for enteral feeding
2. Commonly used tube in Salem sump, double lumen tube with air vent that allows for continuous
(rather than intermittent) suction for gastric decompression
3. Much less commonly used tube is Levin tube, single lumen tube that requires use of intermittent
suction (lack air vent causes tube collapse if continuous suction is used)
B. Insertion procedure
1. Sit client upright (High Fowlers position)
2. Place distal end of tube at tip of nose and measure to earlobe and then to xiploid process to
determine distance for tube insertion; apply tape to tube to indicate point at which to top insertion
3. Lubricate distal 2 to 3 inches tubewith lidocaine gel or water- soluble gel according to policy (not
pretrolatum / oil-based lubricant, which could cause pneumonia if tube enters trachea)
4. Ask client to tilt head downward to close epiglottis and allow tube to enter esophagus
5. Insert tube into naris and advance upward and backward until resistance is met at back of nose;
rotate catheter gently and advance into nasopharynx
6. Ask client to take sips of water if able while tube advance into nasopharynx
7. Stop tube insertion and pull back on tube if client coughs or chokes during procedure; when client
respiratory status returns to normal, continue insertion
8. Stop advancing tube one tape reaches naris; check placement as outlined below
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9. Tape tube in place
10. Place tube to low continuous (Salem sump)or intermittent (Levin) suction for gastric
decompression
11. Do not begin enteral feedings by nasogastric tube unless placement confirmed by chest x-ray

C. Therapeutic management
1. Assess placement
a. Chest x-ray is most reliable method of assessing tube placement
b. Aspirate gastric contents using piston syringe and apply to strip of ph test paper (color
indicating ph of 4 or less is consistent with gastric placement and ph of 6 or greater
indicates intestinal placement); note that enteral feedings could alter ph and make this
method less reliable
c. Insert 5 to 10 ml air into tube while listening over epigastric area with stethoscope for
whooshing or popping sound as air enters stomach; this method is less reliable than x-
ray or gastric ph measurement
2. Assess residual prior to and regularly during enteral feedings
3. Irrigate tube with 30 to 50 ml water or saline as ordered to check tube patency instill fluid using
piston syringe and aspirate contents back ; repeat if tube is difficult to irrigate or sluggish;
document fluid instilled and aspirated back on intake and output record
4. Assess naris for ulceration from pressure when changing tape daily ; provide nose care by
removing any crusted areas with moist swabs
5. Provide mouth care every 2 hours ; presence of tube in nose leads to mouth breathing and
dryness
6. Tube removal
a. Check order and apply gloves
b. Remove tape securing tube to nose
c. Ask client to hold breath
d. Withdraw tube smoothly over 3-6 seconds while coiling tube around hand for control
e. Provide comfort care and document procedure

VI. COMBINED ESOPHAGEAL AND GASTRIC TUBES
A. OVERVIEW
1. Exert pressure against or provide tamponade to bleeding esophageal varices
2. Contraindicated if client has history of esophageal surgery or has ulceration or necrosis of
esophageal area
3. Airway management is an ongoing priority concern
4. Sengstaken-Blakemore tube- has three lumens; one gastric lumen provides low intermittent gastric
suction while round gastric balloon apply pressure against bleeding blood vessels
a. Gastric balloon, if inflated first, and then esophageal balloon is inflated (25 to 45mmHg
pressure) if gastric balloon is insufficient to stop bleeding
b. Traction is needed to maintain position of inflated balloons
c. Check placement of tube by x-ray of chest and upper abdomen
d. Prepare to insert nasogastric tube in apposite naris to suction secretions that
accumulate above esophageal balloon in esophagopharyngeal area to prevent
aspiration
5. Minnesota tube is similar to Sengstaken Blakemore tube but has additional (fourth) lumen to drain
secretions from esophagopharyngeal area, eliminating need for separate tube placement in this
area
B. Therapeutic management
1. Position client upright for insertion
2. Check all balloons clamp lumens to avoid air leaks
3. Double clamp lumens to avoid air leaks
4. Keep head or bed raised after insertions
5. Obtain x-ray to verify placement
6. Release esophageal balloon pressure intermittently per agency policy to prevent isophageal injury
from ulceration or necrosis
7. Keep scissors at bedside to cut tube to rapidly deflate balloons if respiratory distress occurs
8. Monitor for complications
a. Continued bleeding: steady or increased body drainage from gastric suction port
b. Esophageal rupture: upper abdominal and back pain , hypotension, tachycardia; report
immediately : this is medical emergency


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VII. TUBE FOR GASTRIC LAVAGE

A. Overview
1. Used to remove toxins from the stomach that occur as a result of drug or chemical poisoning or
overdose
2. An Ewald tube is a large, reusable tube with a single lumen used for one time rapid irrigation
followed by aspiration of stomach content
3. A Lavacuator tube has a lavage/vent lumen for irrigation and another lumen to provide continuous
suction so that irrigation and suction can occur simultaneously
B. Therapeutic management
1. Determine that the poison is appropriate for removal by lavage prior to procedure
2. Substances that have probably already been absorbed or substances that must be dialyzed out
would contraindicate the need for irrigation
3. Airway management is a priority because of risk of aspiration, especially with possible decreased
level of consciousness depending on poison or substance overdosed

VIII. WOUND DRAINS
A. Closed wound drainage system
1. Consists of wound drain connected to electric suction apparatus or portable drainage suction (such
as Jackson Pratt drain or Hemovac drain)
2. Tube is sutured into place in surgery and attached to drainage reservoir
3. Measure and record drainage every shift; notify physician if drainage increases suddenly or
becomes brighter red in color; drainage should decrease over time
4. Wear gloves when emptying reservoir; avoid touching drainage port to prevent infection
5. Re-establish suction after emptying by compressing device with one hand while cleansing
drainage port with alcohol swab and then closing cap or plug before releasing pressure
6. Often removed between 3 and 5 days postop, so prepare to teach some clients how to empty and
maintain system at home.
B. Penrose drain
1. A surgical drain less commonly used but may be optimal when excessive serosanguineous or
purulent drainage is expected
2. Usually inserted via a stab wound a few inches away from original incision to keep incision dry:
drain is often 0.5 to 1.5 inches in diameter and up to 10 to 14 inches long
3. Advantage is preventing formation of abscesses because of excessive drainage
4. Drain may be pulled out or shortened by 1 to 2 inches each day as drainage lessens
5. Thick dressings, need for frequent dressing changes, and careful assessment of underlying skin
are all priorities based on nature of drainage
6. Use of sterile technique is essential to prevent infection

ALTERNATIVE AND COMPLEMENTARY THERAPIES

I. NONPHARMACEUTICAL COMPLEMENTARY THERAPIES
A. Massage
1. Relaxes muscles and leads to release of lactic acid that accumulates during exercise
2. Stretches joints and relieve pain
3. Improves blood and lymph flow
4. Reduces anxiety and provides for relaxation and sense of well being, enhances readiness for
meditative state
5. When providing back massage , cover areas other than back to avoid chilling
6. Warm lotion before applying to back
7. Use combination of circular and long strokes on back, and continue massage for approximately 3-5
minutes using an unhurried manner
8. Assess skin during back massage and document findings and client response to massage
9. Use caution in massaging clients at risk for skin breakdown to prevent damage to skin and
underlying tissue

Massage is a basic touch therapy that many clients respond well to. Consider this therapy as an early choice
for client who are tense and cannot sleep

B. Progressive relaxation
1. Reduces chronic pain and relieves stress by controlling bodily responses to anxiety and tension
2. Consists of tensing and then relaxing 7 major muscle groups
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3. Leads to decreased oxygen consumption, muscle tension, metabolism , and vital signs (heart rate,
respiratory rate, and blood pressure)
4. Should be done for minimum of 10 minutes
5. Assists client to assume correct posture, such as sitting with feet flat on floor (body parts
supported, joints slightly flexed, and arms and legs uncrossed)

Position clients properly before engaging in progressive relaxation. The body must be fully supported to
prevent risk of fall or other injury.
6. Tense and release muscles is specific sequence (more than one sequence available)
a. Right first, left first, then both firsts
b. Both firsts and both arms
c. Toes, then ankles, then knees
d. Buttocks and groin
e. Stomach and lower back
f. Chest and upper back, then shoulders
g. Forehead , then jaw

C. IMAGERY
1. Uses power of imagination to assist with physical, psychological and spiritual healing
2. Often involves visualization but can also utilize other senses to create desired image
3. When imagery is assisted, it is called guided imagery
4. Consists of creating one or more of several types of images
a. Healing a specific body part or increasing energy in bodily area (body mind)
b. Destroying microorganisms or increasing local circulation (correct biologic)
c. Being is a healed state (end state)
d. Experiencing sense of unity, light , power, or spirituality (generalized healing)
e. Connecting with higher levels consciousness (transpersonal)

D. MEDITATION
1. Produces combined state of deep peace and rest along with mental alertness
2. May or may not be associated with religious practice or prayer
3. Includes relaxation and focused attention; may focus on object (concentrative meditation) or remain open
to all stimuli (mindfulness meditation)
4. General guidelines
a. Choose specific time (early morning or evening, at least 2 hours after meal and comfortable,
distraction-free environment)
b. Keep spine straight and body relaxed: may sit cross-legged on floor or be upright in straight
backed chair
c. Close eyes and place palms on thighs
d. Use deep breathing or relaxation exercises; focus on either breathing or selected mental image;
let distracting thoughts drift out of mind without focusing on them
e. Perform daily for 10 to 20 minutes at a time

E. MUSIC THERAPY
1. Often used in preoperative holding and cardiac units , birthing and counselling rooms, rehabilitation units,
and for sleep induction
2. Use to alter ordinary level of consciousness , change mental focus, or change perception of time
3. Type of music chosen (classical, romantic , impressionistic, New Age, and others) depends on client
preferences ad goals of therapy
4. Choose music without words to enhance relaxation
5. Encourage clients to record preferred musical selections
6. Typical use is for approximately 20 minutes
7. Encourage client to let body respond to music spontaneously (such as relax muscles, lie down, hum or
clap)
F. HUMOR AND LAUGHER
1. Helps client to establish relationships by decreasing social distances and placing people at ease
2. Helps to relieve anxiety or tension
3. Assists in relieving aggression or anger
4. Helps to facilitate learning if carefully planned
5. Laugher raises heart and respiratory rates and increases oxygen exchange and muscular tension
6. A relaxation phase follows laugher. which reverses these changes
7. Humor can stimulate endorphin production, which reduces pain
8. Has healing properties because it fosters positive emotion
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G. CLINICAL AROMATHERAPY
1. Consists of controlled use of essential oils to achieve measureable outcomes
2. Use to improve mood and reduce stress, edema, acne, bruising and allergies
3. Uses essential oil from plants that are inhaled, added to bath water, massaged into body, or applied as
cold or warm compresses; over 300 oils currently in use
4. Oils vary in quality and are unregulated; caution client to use carefully
5. Teach a client to use only as directed ; some oils; such as wintergreen and camphor, are toxic if inhaled
a. Before using topical application of oil, test skin for allergies with a small amount of diluted oil
b. Dilute essentials oils properly before applying to skin
c. Do not use near eyes or internally
d. Store in dark covered bottles and keep away from light and heat
e. Consult health care provider before using essential oils if pregnant; some are reported to bring
on menstruation while others are reportedly useful in pregnancy and delivery

Essential oils are chemicals. As such, they can be toxic. Use them cautiously after consulting with primary
health care provider.

H. NURSES ROLE
1. Asses client use alternative therapies , such as those discussed in this section and other alternative
therapies , such as acupuncture , massage therapy, or hyposis provided by other practitioners
2. Communicate openly with client to build trust
3. Educate client about how to evaluate data sources , such as internet or infomercials
4. Do not provide advice regarding use of alternative therapy regimens; instead, communicate data to
primary care provider, who will collaborate with client

II. PRINCIPLES OF USING HERBS AS DIETARY SUPPLEMENTS
A. General use
1. Not intended for acute illness episodes or long term therapy
2. Appropriate as adjunct to conventional Western therapies
3. Therapeutic effectiveness is slower than prescription medications; may take as long as several
weeks, depending on the herb
4. Many herbs are available in multiple forms, including teas, extracts, tinctures, and capsules or
tablets containing powdered or freeze dried forms of the herb
5. Most herbs are multipurpose, used, for example, as skin wash, gargle, compress, lotion and eye
bath
6. They are not intended to replace healthy lifestyle
7. Safe use in pregnancy and lactation is either contraindicated or unknown and may dry up breast
milk during lactation ; ginger may be an exception
8. Although they may be effective in children, herbs should be avoided in acute, sudden-onset illness
9. Many herbs interact with other herbs, food and prescription medications
B. Government regulation
1. The Dietary Supplemental Health and Education Act (DSHEA) of 1994 defines herbs as dietary
supplements
2. Because they are not defined as medicines , herbs cannot be promoted with therapeutic claims but
only with information about how they affect structure and function of human body
3. The Food and Drug Administration (FDA) does not regulate use of the herbs in the United States
but approves certain herbs for their action on the body (how they affect structure and function);
does not monitor herbs for quality, composition or preparation
4. Formulations vary in their potency and recommended dosage, with frequent lack of consensus on
dosing
C. Safety, labelling, and purity
1. Container levels must carry a disclaimer stating the FDA does not evaluate the product for treating
, curing or preventing disease
2. Labels should contain specific direction for dosing and use
3. Only the standardized extract, when available, should be use
4. Not all herbs have empirical support for their safety and efficacy
5. Much of the research and standardization originates in Europe, where use of herbs popular,
particularly in Germany
6. Many herbs contain toxic substances (e.g. , arnica, belladonna, hemlock, lily of the valley, and
sassafras)
7. Health care providers should report all adverse effects of herbs to the FDA

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D. Nurses role and client education
1. Obtain a complete history and physical before starting any therapy with herbs
2. Herbs are not effective for or to be used for acute illness or episodes
3. Herbs take longer to work than do prescription medications, usually weeks
4. Report use of all herbs to health care provider
5. Explain that client should start with one herb at a time, at lower than recommended doses, and
closely monitor response
6. Teach client to know particular use, dosing and safe administration of each herb and take only as
directed
7. Herbs may cause allergic reactions and adverse effects; if one occurs , discontinue herb and
report symptoms to health care provider
8. Become familiar with all herb-herb, herb-drug, and herb-food interactions
9. Client should purchase herbs from a reputable source and be aware of where and how the herb
was processed, and should purchase standardized form herbs if possible
10. Terms such as natural or all natural do not equate with safety or efficacy of herb
11. Become familiar with various names by which particular herbs are identified
12. Client should avoid use of herbs in pregnancy, lactation, and in children
13. Client should accurately assess advertising claims ; few definitive clinical trials have demonstrated
safety and efficacy of these agents
14. Nurses should continue to read new evidence that emerges from research in this field, such as
studies founded by National Center for Complementary and Alternative Medicine
15. Nurses should refrain from recommending or endorsing any particular product or agent

III. SPECIFIC HERBAL SUPPLEMENTS
A. Bilberry ( Vaccinium myrtillus, European blueberry, huckleberry, whortleberry)
1. Description
a. Relative of blueberry and cranberry; shrub with small, sweet, black berries
b. Active ingredients : anthocyanoside (antioxidant bioflavonoid), pectin (soluble fiber)
c. Stabilizes collagen activity
d. Prevents production and release of compounds that promote inflammation such as histamine
and prostaglandins
e. Relaxes smooth muscle in vasculature
f. Inhibits platelet aggregation
g. Reduces permeability and strengthens capillary wall membrane
2. Uses
a. Most commonly used for treatment of simple diarrhea
b. Prevention and treatment of eye disorders: diabetic retinopathy, night blindness, macular
degeneration, glaucoma, cataracts
c. Diabetes mellitus
d. Antioxidant
e. Possible treatment of varicose veins, haemorrhoids
3. Precautions
a. May increase coagulation time
b. May interfere with iron absorption when taken internally
c. Use cautiously with acetylsalicylic acid (aspirin), anticoagulants , vitamin E, fish oils,
feverfew, garlic, ginger, ginkgo
d. Contraindicated in pregnancy and lactation
e. Avoid long term large doses: doses over 1.5 grams/kg/day may be fatal, and doses over 480
mg/day may be dangerous
B. Black cohosh (Cimicifuga racemosa, black snakeroot, rattleweed, rattleroot, squawroot, cimifuga)
1. Description
a. Active ingredients : triperpenoid glycosides, isoflavenones, aglycones
b. Binds to estrogen receptors
c. Inhibits luteinizing hormone
d. Apparent estrogen-like activity
2. Uses
a. Primarily used for treatment of premenstrual syndrome (PMS), and post menopausal symptoms
b. Promotes labor of pregnancy
c. Decreases blood pressure
d. Use to treat snake bites
e. Recommended uses by herbalists: dysmenorrhea, rheumatism,antispasmodic, astringent,
diuretic, expectorant, sedative

12

3. Precautions
a. Contraindicated use with antihypertensives or hormone replacement therapy
b. May cause bradycardia , hypotension, joint pain
c. Contraindicated in lactation
d. Use in pregnancy only when birth is imminent to promote labor
e. Adverse side effects include nausea. dizziness , decreased pulse rate, and increased
perspiration
C. Echinacea (Echinacea purpurea , snake root, purple or American cone flower, Sampson root, black
Sampson, hedgehog, survey root)
1. Description
a. Member of daisy family , with 9 species
b. Active ingredients: polysaccharides, alkylamides, flavonoids, caffeic acid derivatives
(echinocosides), essential oils and other
c. Available in capsule, tablet, candle, glycerite, hydroalcoholic extract, fresh-pressed juice,
lollipop, lozenge, tea and tincture forms
d. Activates T lymphocytes and intensifies phagocytosis of macrophages
e. Stimulates tumor necrosis factor, interferon, and interleukin
f. Nonspecific stimulation of immune system
g. Stabilizes hyaluronic acid (a component of connective tissue) to protect cells and connective
tissue from microorganism invasion and attack from free radicals
h. Inhibits lipoxygenase to reduce inflammation
2. Uses
a. Most common : prevention or reduction of symptoms of cold or influenza
Recall that enchinacea is an ingredient in some sore throat drops. This will aid in remembering that it is
most effective if used early for colds and sore throats
b. Boosts immune system and increases body resistance to infection, particularly upper respiratory
and urinary infection
c. Use to treat herpes simplex and Candida infection
d. Topically : improves wound healing , provide antioxidant protection from ultraviolet A and B light
rays
3. Precautions
a. Not to be used in presence of autoimmune disease (e.g., HIV/AIDS), collagen disease, multiple
sclerosis , tuberculosis) severe illness , or allergy to sunflower or daisy family
b. Not to be used with immunosuppressant (e.g., corticosteroids or cyclosporine)
c. Prolonged use (longer than 8 weeks) may cause hepatotoxicity and suppression of immune
systems
d. Not to be used with other hepatotoxicants (e.g. , anabolic steroids , amiodarone, methotrexate,
ketoconazole)
e. May influence fertility by spermatozoa enzyme interference
f. Many tinctures contain large amounts of alcohol
g. Contraindicated in alcoholism, children, pregnancy, and lactation
h. Adverse effects: allergic reaction and anaphylaxis
D. Feverfew (Tanacetum parthenium, bachelors button, febrifuge plant, feather few feather foil)
1. Description
a. Short, bushy perennial; member of daisy family; has yellow flowers and yellow-green leaves
resembling chamomile
b. Active ingredients; sesquiterpene lactones , especially parthenolide, essential oils
c. Suppresses secretion of granules in platelets and neuthrophils to inhibit platelet aggregation
d. May suppress production of prostaglandins (thromboxane, leukotriene)
e. Inhibits release of serotonin
2. Uses
a. Principle use: prevention of recurrent migraine headaches , treatment of arthritis
b. Relief of menstrual pain
c. Astma
d. Dermatitis , psoriasis
e. Antipyretic (promotes diaphoresis)
3. Precautions
a. Long term studies not done
b. Contraindicated in pregnancy, lactation, and under age 2
c. Cross allergy to ragweed
d. Adverse effects; allergic reaction , lip and tongue swelling, mouth ulcers and loss of taste from
chewing leaves, abdominal colic, palpitations increased menstrual flow
13

e. Sudden withdrawal may cause post feverfew syndrome (muscle aches, pain and stiffness):
taper off to discontinue
f. Other proven (conventional ) remedies for relief of migraine should be use first; do not use fever
few while taking prescription drugs for headache
g. May interfere with blood clotting mechanism ; not to be used with anticoagulants such as
aspirin, warfarin (Coumadin ), bilberry, garlic, ginger, ginkgo
h. Feverfew is known to cause rebound headaches
E. Garlic (allium sativum, stinking root or rose, nectar of the goals, camphor of the poor , poor mans
treacle, rustic treacle)
1. Description
a. Empirical support for effectiveness and use; most widely researched herb
b. Active ingredients (23 constituents ): allicin (odourless, sulphur containing amino acid), ajoene
c. Should be crushed or bruised to effectively convert various enzymes, protein, lipids, amino
acids, and other ingredients to allicin
d. Allicin and ajoene not found in dried garlic but may be present if dried at low temperatures or
taken in enteric coated tablets
e. Inhibits platelet aggregation
f. Well documented research shows that it reduces and inhibits metabolism of cholesterol
g. Increases bile acid secretion
2. Uses
a. Principle uses: reduces cholesterol (decreases triglycerides and low density lipoproteins;
increases high-density lipoproteins; increases high density lipoproteins) and lowers mild
hypertension
b. Reduces risk o stroke
c. Antibacterial, antiviral, antifungal
d. Anticancer properties
e. Lay use: antihelmintic, antispasmodic, diuretic, carminative (relieves flatulence ), digestant ,
expectorant, topical antibiotic

3. Precautions
a. Avoid large amounts of garlic with ASA (aspirin) , anticoagulants such as warfarin (Coumadin) ,
and other herbs that affect coagulation( bilberry, fever-few , ginger , ginkgo
b. May potentiate diabetes drugs
c. Adverse effect: contact dermatitis, vertigo, garlic breath or scent, hypothyroidism, GI irritation,
nausea and vomiting with large doses
d. Enteric coated tablets containing powdered form may reduce bad breath but are not as potent
as raw garlic
e. Contraindicated in pregnancy. GI (peptic ulcer and GERD) and bleeding disorders
f. Chronic use may lower haemoglobin levels
g. When used to decreased cholesterol levels, plan should be monitored by the health care
provider
F. Ginger (Zingiber officinal , Jamaica ginger, Cochin ginger, black ginger, race ginger)
1. Description
a. Green purple flower resembling the orchid
b. Active ingredient : sesquiterpenes, aromatic ketones (gingerols), and volatile oils
c. Inhibits thromboxane production to enhance effects of anticopagulation
d. Inhibits leukotriences and prostaglandins to produce anti inflammatory and analgesic effect
2. Usage
a. Principle use:antiemetric; improves appetite
b. Diuretic , digestion aid ; alleviates dyspepsia
c. Anti inflammatory in treatment of rheumatoid arthritis and osteoarthritis
d. Relieves muscle pain
e. May reduce motion sickness and relieve vertigo
3. Precautions
a. Adverse effect: headache, anxiety insomnia, elevated blood pressure, tachycardia, asthma
attack, postmenopausal bleeding
b. Contraindicated and postoperative nausea in clients with increased risk of bleeding
c. Not to be used concomitantly with bilberry, feverfew, garlic, ginkgo, or other anticoagulants
such as ASA (aspirin) or warfarin (coumadin)
d. Severe overdose: possible CNS depression and cardiac arrhythmias
e. Excess of 6 grams/day results in gastric irritation and ulcer formation
f. Conflicting data related to safe use during pregnancy (relatively safe according to FDA);
contraindicated in treatment of hyperemesis gravidarum
14

G. Ginkgo (Ginkgo biloba, GBE 761, GBE, GBX, Tebonin, Tebofortan, Ginkogink)
1. Description
a. Active ingredients: flavones glycosides , flavonoids, terpene lactones (such as ginkgolides and
bilobalide)
b. Ginkgo biloba extract referred to as GBE
c. Flavonoids act as antioxidants by destroying lipid layer of cell membrane
d. Flavone glycosides produce mild platelet aggregation
e. Ginkgolides antagonize platelet activating factor to decrease coagulation
f. Bilobalide increases cerebral circulation to improve tissue perfusion and increase memory
g. Protects brain from effects of hypoxia
2. Uses
a. Cerebrovascular insufficiency and symptomatic relief of organic brain dysfunction to improve
short term memory loss
b. Peripheral vascular disease (e.g. , Raunauds disease, intermittent claudication), varicosities
c. Senile macular degeneration
d. Treatment of age related mental decline such as short term memory loss and poor
concentration
e. Treatment of depression related cognitive disorders
f. Treatment of depression in older adults , particularly depression related to chronic
cerebrovascular deficiency that does not respond to standard drug therapy
g. Tinnitus
3. Precautions
a. Effects may not be apparent for 4-8 weeks
b. Not to be used concomitantly with bilberry, feverfew, garlic, ginger, or other anticoagulants ,
such as ASA (aspirin) or warfarin (coumadin)
c. Avoid use of unprocessed ginkgo leaves that contain allergens related to urushiol, the chemical
responsible for the itch in poison ivy
d. Crude, dried leaf or tea may not contain sufficient active ingredient to be effective
e. Large doses may cause restlessness, headaches, nausea, vomiting, diarrhea, dizziness , or
palpitations
f. Edible solid form sold in Orientals shops should be kept out of reach of children because seeds
may cause seizures
g. Avoid use in pregnancy, lactation, and children

H. Ginseng , Korean (Panax ginseng, American ginseng, Panaschinseng)
1. Description
a. Active ingredients : titerpenoid saponin glycosides (ginsenosides panaxosides)
b. Possible effect on pituitary gland with action similar to corticosteroids
c. Improves serum glucose , glycosylated haemoglobin (HbA
1c
) and aminoterminalpropeptide
concentrations
d. Hypertensive effect with low doses, hypotensive effect with higher doses
2. Uses
a. Most common: counteracts effects of physical and mental fatigue and improves stamina and
concentration in healthy individuals
b. Used to treat chronic hepatotoxicity related to alcohol and drug ingestion
c. Improves body ability to resists stress and disease; increases vitality
d. Regulates blood pressure
e. Improves psychomotor performance (attention, auditory reaction time); may reduce mood
swings
f. Regulates blood glucose levels in type 2 diabetes
g. Aphrodisiac
3. Precautions
a. Most side effects reported are related to excessive or inappropriate use
b. Avoid concomitant use with stimulants, such as coffee, tea, cola
c. May potentiate MAOI actions
d. Adverse effects : insomnia, palpitations , pruritus , nervousness , euphoria

I. Ginseng , Siberian (Eleutherococcus senticosus, five fingers, tartar root, Western Ginseng , seng
and sang, Asian ginseng. Jintsam)
1. Description
a. Active ingredients : eutherosides
b. Pharmacologic actions not well understood
c. Elevates lymphocyte count (T cells), boosts immune system
15

2. Uses
a. Enhances physical and mental performance under stress
b. Improves athletic performance
c. Increases oxygen metabolism , work capacity, and exhaustion time in a variety of illness (e.g. ,
atherosclerosis, diabetes, chronic bronchitis )
d. Stimulates WBC production in clients undergoing antineoplastic therapy
3. Precautions
a. Adverse reactions: hypertension, tachycardia, insomnia and irritability
b. Contraindicated in pregnancy , lactation, premenopausal women, hypertension, CNS stimulants
, or with antipsychotic medications
J. Hawthorn (Crataegus oxyacantha , Mayblossom, Maybush, whitehorn, Ll 132)
1. Description
a. Small to medium tree of several species ; leaves , flowers , berries (fruit) are used in
standardized extracts
b. Active ingredients : flavonoids , primarily procyanidins and proanthocyanidins
c. Acts as antioxidant that decreases damage by free radicals to cardiovascular system by
increasing levels of vitamin C intracellularly
d. Increase coronary and myocardial circulation
e. Decreases peripheral vascular resistance to decrease blood pressure
f. Increases strength of myocardial contraction (positive inotropic effect) and decreases heart rate
(negative chronotropic effect)
g. Angiotensin 1 to angiotensin II, a potent vasoconstrictor
2. Uses
a. Treatment of mild hypertension
b. Treatment of athero and arteriosclerosis
c. Treatment (prevention) of chronic angina: not intended for acute angina
d. Treatment of early congestive heart failure
3. Precautions
a. Contraindicated with concomitant use of prescription antihypertensives or nitrates
b. Supervision of health care provider necessary for those with existing cardiac disease
c. May interfere with digoxin pharmacodynamics and monitoring
d. Adverse effects: nausea, fatigue, perspiration and cutaneous eruption of the hands, increased
CNS depression and sedation
e. Contraindicated in pregnancy and lactation

K. Milk thistle (Silbyum marianum, Mary thistle, Marian thistle, Ladys thistle, Holy thistle silymarin ,
the liver herb)

1. Description
a. Tall plant, prickly leaves, milky sap, member of daisy family
b. Active ingredients ; silymarin and its component silybinin to act as hepatoprolectant
c. Promotes glutathione production, a powerful endogenous antioxidant
d. Binds to hepatocyte membrane and blocks uptake of toxins into liver cells
e. Stimulates nucleolar polymerase. A activity to promote new liver cell growth
f. Stimulates regeneration of liver by stimulating protein synthesis
g. Inhibits action of leukotriene by Kupffer cells
h. Binds to site on liver cell membrane, blocking availability for attack from phalloidine, the toxin in
death cap mushroom
i. Stabilizes liver cell membrane by decreasing turnover rate of phospholipids

Note that the words milk and thistle both contain the letters/ and i, which may help you to associate this herb
with the liver
2. Uses
a. Reduces hepatotoxicity related to psychoactive drugs such as phenothiazines
b. Adjunct therapy in liver inflammation related to cirrhosis, hepatitis, and fatty infiltrate related to
alcohol or other toxins
c. Treatment of overdose of death cap mushroom
3. Precautions
a. Insoluble in water, not to be taken in a tea form
b. Avoid alcohol based extract in decompensated cirrhosis
c. Cross allergy to ragweed
d. Adverse effects: loose stools, diarrhea in high doses
e. Contraindicated in pregnancy and lactation
16

f. Close monitoring by health care provider in presence of active liver disease
L. Saw palmetto (Serenoa repens, sabal, American dwarf palm free, LSESR)
1. Description
a. Shrublike palm tree with reddish brown to black berries
b. Active ingredients: saturated and unsaturated fatty acids and sterols from berries (liposterolic
acid)
c. Reduces action 5-alpha reductase enzyme that converts testosterone to dehydrotestosterone
(DHT) in aging (effects similar to finasteride [Proscar]with fever side effects)
d. No effect on prostatic specific antigen
e. May reverse testicular and mammary gland atrophy
f. May increase sperm production and increase sexual vigor
2. Uses
a. Demonstrated effects through research: symptomatic treatment of benign prostatic hyperplasia
(BPH)
b. Helps initiate urine stream; decreases urinary frequency, residual volumes nocturia, and dysuria;
unclear whether actual prostatic size is reduce
c. Lay uses: treatment of asthma, bronchitis, and gynecomastia
3. Precautions
a. Long term use with approximately 6 weeks for initial effects
b. Insoluble in water; not to be taken in tea form
c. Adverse effects: nausea ; abdominal pain, hypertension, headache , diarrhea with large doses
d. May interfere with iron absorption
e. Supervision by health care provider necessary for diagnosed BPH
f. Should not be used by pregnant or lactating women
M. St. Johns wort (Hypericum perforatum, amber, goat weed, touch-and heal, Johnswort witchs
herb, Klamath weed, chassediable, devils scourge)
1. Description
a. Yellow perennial flower with red pigmented leaves containing small black dots
b. Active ingredient: hypericin from red pigmented leaves, pseudohypericin and flavonoids,
tannin and others
c. Inhibits reuptake of serotonin; actions not well determined or understood
d. Low monoamine oxidase inhibitor (MAOI)
e. Effects comparable to imipramine (Tofranil)
f. Produces fewer side effects than prescription antidepressants
2. Uses
a. Treatment of mild to moderate depression
b. Not intended for treatment of suicidal ideation, psychotic behavior, or severe depression
c. Possible antibacterial , antiviral, wound healing properties
3. Precautions
a. Not to be used concurrently with prescription antidepressants , especially selective
serotonin reuptake inhibitors (SSRI) or MAOLS or food containing tyramine (such as aged
cheese, smoked meats, liver, figs, dried or cured fish, yeast, beer, Chianti wine).
b. Not to be use concurrently with opioids, amphetamines, or OTC cola and flu preparations
c. May inhibit absorption of iron
d. Adverse effects (may continue for 4 to 4 weeks): GI distress, emotional vulnerability,
fatigue, pruritus, weight gain, headaches, dizziness, restlessness
e. May cause photosensitivity: avoid sun exposure , especially if fair skinned
f. May decrease digoxin levels
g. Contraindicated in pregnancy, lactation, and children

N. Valerian root ( valerian officinalis, wild valerian, garden heliotrope, setwall, capons tail, all-heal,
Amantilla, Baldrian wurzel, benedictal)
1. Description
a. Tall perennial with hallow stem, leaves , and white or red flowers
b. Active ingredients : valepotriates and susquiterpine derivatives, valeric acid, valeranone,
and other
c. Binds weakly to gammaaminobutyric acid (GABA) receptor sites to decrease CNS activity,
causing sedation with decreased side effects
d. Action similar to benzodiazepines but non-addicting and produces no morning hangover
2. Uses
a. Sedative , reduction of anxiety
b. Treatment of insomia

17

Remember that valerian is an ingredient often found in teas that are recommended for sleep.
c. Adjunct therapy for benzodiazepine withdrawal
d. Possible antispasmodic
3. Precautions
a. Valepotriate (which may be carcinogenic) should be removed from final product
b. Not to be used concurrently with other sedative or hypnotics, anxiolytics , or
antidepressants
c. May be used safety while operating machinery or car, although CNS effects should be
monitored
d. Sedation is not increased with alcohol use, although caution should be exercised
e. Adverse effects: headaches ; mild, temporary upset stomach
f. Adverse effects with overdose or long term use (overdose with 2.5 grams): excitability ,
insomnia, cardiac dysfunction , blurred vision, hepatotoxicity , severe headache, morning
headache and nausea
g. May cause hepatotoxicity ; monitor liver function and avoid use in hepatic dysfunction
h. Extract contains 40% to 60% alcohol ; avoid use in hepatic dysfunction
i. Contraindicated in pregnancy and lactation

IMMUNOLOGICAL AND ANTI-INFECTIVE MEDICATIONS

I. IMMUNOMODULATORS
A. Description
1. Immunodulators can either suppress or enhance immune response
2. Depending on intended immune response, client is administered either an immune
stimulant or an immunosuppressant , which suppress bodys response to an antigen
(a substance that stimulates production of antibodies)
3. Can be used to stimulate platelet production to prevent severe thrombocytopenia
(abnormally low platelet count) caused by platelet destruction
4. Increase development of bone marrow, which is adversely affected by administration of
chemotherapy agents used after bone marrow transplantation or to treat cancer
B. Colony- stimulating factors
1. Action and use
a. Glycoproteins that increase production of white blood cells that enhance cellular
immunity (immunity of host affecting body cells)
b. Are described as granulocyte colony stimulating factors (G-CSF) or macrophage
and granulocyte colony stimulating factors (G-CSF)
c. Reduce neutropenia ( abnormally low neutrophil count) and decrease incidence
of infection; they assist in the mobilization of stem cells, allowing for stem cell
collection
2. Common medication are listed and described in Table 46-1

Associate the E epoetin alfa with the E in erythrocyte to recall that it stimulates red blood cell growth.
Use the same strategy to associate Neupogen with neutrophil count (WBC)

3. Administrations considerations
a. Sargramostim (Leukine; reconstitute with sterile water; avoid shaking vial
reconstitution; use for 21 days after bone marrow transplantation and clients with
acute myelogenous leukemia, around either day 11 following chemotherapy dose
or 4 days after chemotherapy induction)
b. Epoetin alfa (Erythropoetin): goal of administration in clients with acquired
immunodeficiency syndrome (AIDS) receiving ziduvudine therapy should be to
maintain hematocrit (Hct) at 30% to 33% (maximum 36%); usually given 3 times
per week
c. Filgrastim (Neupogen): do not give during or 24hrs after dose of cytotoxic
chemotherapy; dosage may be titrated depending on neutrophil count , stop drug
if absolute neutrophil count (ANC) exceeds 10,000/mm
3

4. Contraindications
a. Sargramostim: pregnancy, hypersensitivity to yeast products or E. Coli; leukemic
myeloblasts in the bone marrow; use cautiously with hepatic or renal insufficiency
and lactation
b. Epoetin alfa: uncontrolled hypertension , pregnancy, and hypersensitivity to
albumin
c. Filgrastim : pregnancy, hypersensitivity to E. Coli products
18

5. Side/ adverse effects
a. Nausea, vomiting,anorexia, constipation, diarrhea
b. Headache, stomatitis, edema, rash, mucositis, generalized pain, bone pain
c. Supraventicular dysrhythmias, tachycardia
d. Renal or hepatic dysfunction, dyspnea, seizures, porphyria
e. Report neutrophil count of 20,000/mm
3
to physician
f. Adult respiratory distress syndrome (ARDS), pleural effusion
g. Myocardial infarction (MI), gastrointestinal (GI) hemorrhage, thrombus formation
6. Nursing considerations for sargramostim (Leukine)
a. Assess CBC and platelet count before administration and 2 times per week
during medication administration
b. Assess renal and hepatic function
c. Assess for excessive myeloid blasts in bone marrow
d. Do not administer during pregnancy; use cautiously during lactation
e. Dilute with normal saline and store in the refrigerator; administer only one dose
per vial

Table 46-1 COMMON IMMUNOSTIMULANT MEDICATIONS
Generic / Trade Names Actions
Sargramostim (Leukine) Increases the production of granulocytes and macrophages before
and after bone marrow transplantation, so labelled as a GM-CSF
Epoetin alfa (Epogen) Increases the RBC count in clients with chronic renal failure, cancer
or human immunodeficiency virus; is actually a haematological, not
an immunological, colony stimulating factor, but is used in client who
have immunodeficiency
Filgrastim (Neupogen)
Pegfilgrastim (Neulasta)
Increase neutrophil (granulocyte ) production in cancer clients to
prevent infection, so labelled as a G-CSF

7. Nursing considerations for epoetin alfa (Epogen)
a. Assess blood pressure (BP) prior to administration and regularly during therapy;
hypertension may occur if hematocrit level rises rapidly
b. Epoethin alfa should be used cautiously during lactation
c. The client should eat food rich in iron and possibly take an iron supplement to
increase effectiveness of therapy on RBC formation
d. Assess Homans sign periodically to detect thrombus development with
increased RBC counts
e. Administer cautiously with lactation
f. Do not shake solution after it has been reconstituted
g. Assess Hct to determine if it has been risen 4 points in 2 weeks; a rapid elevation
of 4 points may lead to hypertension and seizures
8. Nursing considerations for filgrastim (Neupogen)
a. Assess results of CBC, differential , and platelet count before administration and
2 times per week during therapy
b. Do not administer 24 hours before or after chemotherapy
c. Assess for hypersensitivity to E. Coli products
d. Filgrastim is pregnancy category C; use cautiously with lactation
e. Administer only one dose per vial, and discard after 24 hours; store medication in
the refrigerator
f. Reconstitute in dextrose 5% , and avoid shaking the bottle to prevent damage to
the protein
g. Avoid exposure to infection because clients lowered white cell count indicates
increased risk of infection
9. Client education for sargromostim (Leukine)
a. Avoid exposure to infection and be aware of signs and symptoms of infection
b. Report difficulty breathing and fever
c. CBC and platelet count must be done periodically
d. Address body image with client because of alopecia
10. Client education for epoetin alfa (Epogen)
a. Administration of medication at home with home dialysis; action, side effects, and
nursing implications associated with epoetin alfa administration
b. Signs and symptoms of clot formation
c. Self monitor BP
d. Eat and diet high in iron and take iron supplement it ordered
19

11. Client education for filgrastim (Neupogen)
a. Report pain in the joints and bones
b. Maintain good hygiene and avoid exposure to crowds because of susceptibility of
infection

C. Cell stimulating medications
1. Action and use
a. Interleukins are biologic response modifies that prevent thrombocytopenia and
stimulate platelet production
b. In the helper T cells, cellular immunity is increase along with number of
lymphocytes
c. Interleukins are a group of proteins, produced by lymphocytes, that have
antitumor activity , causing cells to change to a nonproliferative type
d. Aldesleukin (Proleukin) is use to treat renal carcinoma and prevents severe
thrombocytopenia
e. Levamisole (Ergamisol) increases immune response by increasing activity of B
cells. T cells, and macrophages; it is used in combination with fluorouracil to treat
Dukes stage C colon cancer
f. Oprelvekin (Neumega) is used following chemotherapy that causes
myelosuppression chemotherapy (suppressed bone marrow function in
manufacture of blood cells); it increases thrombocyte and megakaryocyte
production to prevent and treat thrombocytopenia in clients receiving
chemotherapy
2. Common medications are listed in table 46-2

Table 46-2 Common Cell-Stimulating Medications
Aldes =leukin (Proleukin) Increases lymphocytes , platelets, and tumor necrosis factor
Levamisole (Ergamisol) Increases B cell activity and antibody formation by increasing monocyte and
macrophage action
Oprelvekin (Neumega) Increases thrombocyte and megakaryocyte production, thus preventing
thrombocytopenia

3. administration considerations
a. Aldesleukin (Proleukin): because of seriousness of side effects, this medication is
given in a hospital that has an intensive care unit of medical specialists available;
after 14 doses, a waiting period ensues , followed by another 14 doses
b. Levamisole (Ergamisol): drug therapy should begin 7 to 30 days after bowel
resection surgery; maintenance dose is 50 mg every 8 hours for 3 days with
fluorouracil
c. Oprelvekin (Neumega); administration can be continued for 21 days or until
platelet count is greater than 100,000 cells/mm
3
; reconstitute in an isotonic
solution; do not agitate; administer within 3 hours of reconstitution
4. Side / adverse effects
a. Aldesleuken: cardiac dyshythmias, fluid retention, lethargy, myalgia
b. Levamisole; flulike symptoms, bone marrow depression, GI upset
c. Oprelvekin: cardiac dysrhythmias,fluid retention
5. Nursing considerations
a. Assess CBC, differential, and platelet count
b. Assess heart rate, BP, respirations, and lung sounds
c. Maintain fluid and electrolyte balance, particularly during flulike symptoms
d. Provide good hygiene practices
6. Client and family education
a. Home medication administration
b. Assessment of fluid retention and irregular heart rate
c. Measures to assist in preventing infection
d. Care and management of flulike symptoms

D. Immunosuppressants
1. Action and use
a. Immunosuppressants inhibit inflammatory response and block immune response
to an antigen
b. Inhibit t cells and block production of antibodies by b cells
c. Prevent rejection of organs that have been transplanted
20

2. Common medications are listed in table 46-3
3. Administrations consideration
a. Azathioprine (Imuran) : reaches the peak blood concentration in 1 to 2 hours and
duration of action in 10 hours
b. Cyclosporine (Sandimmune): reaches its peak level in 4-5 hours after
administration and duration or reaction is 20 to 54 hours
c. Basiliximab (Simulect): administered IV 24 hours after transplant, the 4 days after
transplant
d. Daclizumab (Zenapax): administered IV 24 hours after transplant for total of 5
doses
e. Muromonab CD3 (Orthoclone OKT 3): therapy should begin as soon as rejection
is identified
f. Mycophenolate (CellCept): renal transplant clients receive 1 gram 2 times per
day; therapy should begin 72 hours after transplant
g. Tacrolimus (Prograf) : administered 6 hours after transplant
4. Side/ adverse effects
a. Increased risk for infection: hypertension; acne
b. Hepatotoxicity and/or renal toxicity


Table 46-3 COMMON IMMUNOSUPPRESSANT MEDICATIONS
Generic/ Trade Names Actions
Azathioprine (Imuran) Prevents rejection in renal transplants; administered for life after the transplant

Basiliximab (Simulect) Prevents acute renal transplant rejection; must be given in combination with
cyclosporine and a glucocorticoid
Daclizumab (Sandimmune) Prevents transplant rejection
Cyclosporine
(Sandimmune)
Prevents rejection solid organ transplant
Muromonab CD3
(Orthoclone OKT3)
Suppresses T cells to prevent renal transplant rejection
Mycophenolate (CellCept) Prevents rejection in kidney transplant
Tacrolimus (Protopic,
Prograf)
Prevents rejection in solid organ transplant , primarily liver transplant

c. Flulike symptoms and/or headache, diarrhea, nausea and/or vomiting
d. Contraindicated with allergy to drug, or during pregnancy, or lactation
5. Nursing considerations
a. Assess for signs and symptoms of infection
b. Provide supportive care for flulike symptoms
c. Complete serum laboratory tests as ordered, such as CBC, platelet count BUN,
creatinine, and hepatic function tests
d. Assess nutritional status; encourage well-balanced meals with small frequent
feedings
6. Client education: need for lab studies , prevention of infection, and all aspects of
medication administration, including action, side effects , and nursing implications

I. OVERVIEW OF ANATOMY AND PHYSIOLOGY OF IMMUNE SYSTEM

A. Basic structures of the immunologic system
1. Lymphoid system
a. Lymphoid system consists of lymphoid organs (lymph nodes, spleen, thymus and
tonsils), lymphoid tissues (lymphocytes and plasma cells in mucosa and connective
tissues) and bone marrow, a myeloid tissue involved in blood cell formation.
b. Lymphatic system consist of a communication network of vessels, lymph nodes, lymph
node clusters, and circulating and resident lymphocytes that function as a primary
component in immune system response
2. Central lymphoid organs
a. Thymus gland, which assists in T lymphocyte formation, is located in superior
mediastinum behind sternum
b. Bone marrow sources can be found in iliac crest, sternum , and in bone cavities
throughout body
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3. Peripheral organs
a. Tonsils are a group of lymphoid tissue found in palatine area of oropharyx
b. A lymph is a small rounded mass of tissue from which lymph fluid drains; lymph nodes
are found throughout body
c. Mucosa associated lymph tissue (MALT) consist of a group of lymph tissue found in
many organs of body that work together to promote an immune response; specific
locators identify source of tissue; for example: bronchial-associated lymph tissue
(BALT), gut-associated lymph tissue (GALT), skin-associated lymph tissue (SALT)
d. Spleen, located in left upper quadrant of abdomen, is composed of white and red pulp;
white pulp is composed of B and T lymphocytes; red pulp is composed of erythrocytes
4. Mononuclear phagocyte system (MPS)
a. Monocytes are largest component of white blood cells (WBCs) and have one nucleus
and very little cytoplasm; they are considered to be agranulocytes
b. Macrophages are mature cells of the MPS; they migrate to different areas of body,
becoming specialized cells to perform function of defense
c. MPS protect body by participating in immune response; it secretes chemical
components and factors (enzymes, complement proteins, and interleukins)

B. Basic functions of immunologic system
1. Thymus gland produces T lymphocytes , which are involved in cell mediated immunity ; secretes
thymic hormones such as thymosin (stable from birth to age 25 and then gradually decreases
because gland atrophies with age)
2. Bone marrow
a. Serves as a diagnostic predictor for immunologic, hematologic , and oncologic
disorders
b. Provides for analysis of chemical markers that identify specific disease processes
c. Is a primary lymphoid action that helps to initiate and maintain immune response;
marrow give rise to cellular components of blood and stores stem cells
d. Give rise to B lymphocytes and humorally mediated responses (humoral immunity)
that involve production of antibodies , specific substance produced in response to
specific antigens
3. Spleen
a. Site of destruction of RBCs , a storage site for blood, and a reservoir for B
lymphocytes to develop into mature plasma cells
b. Filters and removes foreign material and worn out cells and forms of cellular debris

II. NORMAL IMMUNE RESPONSE
A. DEFENSE
1. Communication network of protection that involves both non specific and specific forms of
defense
2. Nonspecific defense relates o external reactions that include anatomic and chemical barriers
such as skin and mucous membranes ; nonspecific defences are activated against any
foreign substance that body encounters
3. Specific defense related to internal physiological reactions that include both cell mediated
and humorally mediated antibodies ; antibodies are unique substances that require
activation
4. Immune response is activated in presence of an antigen , a protein substance that triggers
antibody production
B. Homeostasis : body seeks to maintain a balanced response of circulating and resident
lymphocytes to maintain adequate protection
C. Surveillance
1. Bodys ability to use memory and recognition to maintain an immune response
2. Body remembers activation response even if person doesnt remember a specific insult

III. TYPES OF IMMUNITY
A. Acquired immunity
1. Long term response that leads to development of antibodies that offer protection
a. Individual develops antibodies in response to having a disease process or by a
response to artificial antigens such as a vaccine or toxoid
b. Response can be boosted and maintained via repeated injections
c. Titer serum levels can be monitored to indicate whether or not immunity is present
22

2. Passive acquired immunity requires an antibody be introduced to individual, either by maternal
transfer (placenta and/ or colostrum) or immune serum antibody injection, to promote a specific
antigen response

B. Natural immunity
1. Related to a species , race or genetic trait
2. An individual is born with natural immunity

C. Humoral immunity
1. Involves recognition of antigens by B lymphocytes
2. B lymphocytes differentiate into plasma cells and memory cells
3. Memory cells lead to a more rapid response by remembering an original insult
4. Plasma cells secrete immunoglobulins, a group of glycoproteins , each of which has four
polypeptide chains (two heavy and two light chains); the FAB fragment, which is different in
each immunoglobulin , denotes specific antigen binding sites
5. Immunoglobulins are identified as IgA, IgD, IgE, IgG, and IgM: see table 67-1 for listing and
characteristics of immunoglobulins

D. Cell mediated immunity
1. T lymphocytes recognize a specific major histocompatibility complex (MHC), a group of
proteins that participate in autoimmune recognition and tissue rejection, and bind to them to
elicit an immune response
2. Protein markers on surface of T-cell help define specific function receptor sites: these are called
CD antigens or clusters of differentiation; CD markers serve as an important prognostic indicator
of immune function and are used to diagnose and manage human immunodeficiency virus (HIV)
and acquired immunodeficiency syndrome (AIDS).
3. Humoral immunity is considered a long term process whereby T lymphocytes help protect body
against bacterial, viral, and fungal infections
4. Cell mediated immunity is also responsible for mediation of transplant rejection

E. Other immune system participants
1. Natural killer cell (null cell, NK cell) activity is present at birth, increases as individual reaches
adulthood and decreases gradually in old age; null cells do not require prior sensitization and
are not considered T or B lymphocytes.

TABLE 67-1 TYPES OF IMMUNOGLOBULINS
IgA Body secretions
Tears saliva
Colostrums and breast milk
Lines mucous membranes
Protects body surface
IgD Plasma Present on lymphocytes
IgE Plasma
Interstitial fluids
Exocrine secretions
Allergic/anaphylaxis
Bound to mast cells
IgG Plasma
Interstitial
Crosses placenta
Complement fixation
Secondary immune response
IgM Plasma Complement fixation
Primary immune response
Involved in ABO antigens

2. Cytokinase (also referred to as lymphokines and monokines) are soluble protein mediators of
immune response; interleukins, tumor necrosis factor, and interferon are examples of these
chemical messengers, which are treatment options in boosting immune response
F. Complement system
1. Group of glycoproteins activated in sequential order; provide a link to humoral response
2. IgG and IgM are responsible for activating complement cascade; once activated, complement has
been fixed or complement fixation has taken place
3. Complement assays are used to diagnose immunodeficiencies and autoimmune diseases
4. There is a classic pathway and an alternate pathway whereby complement system can be
activated



23

G. Biological response modifies (BRMs)

1. Group of substances that can elicit, modify , and restore biological response between an individual
and a tumor cell
2. Examples
a. Monoclonal antibodies, (produced by a specific group of identical cells) may be used to
treat tumors because of their specific targeting effect
b. Colony stimulating factors, (a group of proteins that stimulate growth of either RBCs or
WBCs) prevent or help reduce a clients adverse response to disease; these types of
BRMs are used in a variety of hemotologic and immunologic diseases

IV. COMMON TESTS AND PROCEDURES OF THE IMMUNE SYSTEM

A. Skin Testing
1. A small quantity of allergen is introduced into skin by scratching or intradermal (ID) injection
2. A scratch test is used to test many antigens at a single time; it is of lower sensitivity than injection,
but many allergens can be tested at once and result can be obtained in 30 minutes
3. ID injection is more accurate but leads to higher incidence of systemic reactions
4. Patch test evaluates contact allergens by applying allergen directly to skin and covering with a
dressing
5. Antihistamines that could impair immune response should be discontinued 72 hours prior to skin
testing
6. Immediate positive reaction usually occurs within 10 to 30 minutes and consists of wheal formation
and erythema formation greater than 3 millimeters of a positive control (histamine)
7. Minor itching at site can be relieved by cool compresses, topical steroids , and topical oral
antihistamines

B. Radioallergosorbent test (RAST)
1. Reveals elevated levels of IgE associated with atopy (allergic reactions stemming from hereditary
disposition)
2. Allergen is usually planted on a surface such as paper disk
3. Client blood is then applied to surface and incubated
4. Antibodies specific to an allergen bind to allergen, but others wash away, and level of IgE can be
measured
5. More sensitive than skin testing but also more time consuming and expensive

C. Pulmonary functions tests to diagnose asthma

D. Blood assays reveal increased circulating IgE in presence of allergic disease

E. Eosinophilia may be present with allergic disease

V. HYPERSENSITIVITY REACTIONS

A. Hypersensitivity is an abnormal exaggerated immune response to a specific response to a specific
response

B. The Gell and Coombs Classification of Hypersensitivity Reactions categorizes a reaction
according to type, class, and immunity

Table 67-2 GELL AND COOMBS CLASSIFICATION

Type Class Immunity
I Immediate hypersensitivity Humoral
II Cytotoxic Humoral
II Immune complex related Humoral
IV Cell -mediated

C. Type I: anaphylactoid reactions
1. Involves an immediate response; however, potential response can be cumulative; for example,
initial and sensitizing dose may not elicit a strong response, but subsequent contacts, even is
not long term in nature, may cause a stronger response

24

2. Involves characteristics activation of IgE bound to mast cells, with release of histamine
3. Clinical manifestations range from bronchospasm , wheezing, rhinorrhea, and urticaria to
angioedema and finally anaphylaxis; there may be progression from local to systematic
reactions; characteristic allergic gape and allergic shiner can be seen in individuals with
atopy
4. Diagnostic and laboratory test findings; immunoglobulin titers are predictive of potential allergen
response; skin and patch testing are performed to determine potential allergens
5. Therapeutic management
a. Antihistamine medications such as diphenhydramine (Benadryl) are used to block
chemical release of mediators (histamines)
b. Mast cell degradation inhibitors such as cromolyn sodium (Intal) also are used to block
chemical response
c. Decongestants and corticosteroids help minimize immune response; however, in
potential anaphylactic reactions, use of epinephrine is warranted; an Epipen may be
prescribed as appropriate therapy for individuals at profound risk for hypersensitivity
reactions, they are available in both adult and pediatric dosages
d. Immediately withdraw offending allergen in presence of documented or suspected
reaction
e. Manage client according to ABC (airway, breathing, and circulation) protocol

D. Type II: cytotoxic and cytolytic reactions
1. Involves activation of complement and is considered a form of humoral immunity
a. Involves production of autoantibodies that result in destruction of own cells or tissues
b. IgA and IgM are involved with this type of response, and complement system is activated
2. Clinical manifestations: range from hemolytic reactions (such as transfusion, erythroblastosis
fetalis, hemolytic anemia , and drug induced hemolysis) to target cell destruction as in Good
pastures syndrome (autoimmune disease affecting pulmonary and renal systems) and other
autoimmune disease processes such as myasthenia gravis and Graves disease
3. Diagnostic and laboratory test findings: Coombs blood test can define presence of hemolytic
anemia and identify potential ABO incompatibility
4. Therapeutic management
a. Use proper identification during blood product administration to prevent exposure and
sensitization
b. Recognize that certain blood types and potential drug interactions can cause antigen
complex activation to detect reactions early
c. Remain in the room during first 15 minutes and any blood product administration because
clients are more likely to experience a reaction during this time frame
d. Make sure to follow agency policy and procedure for the administration of any and all
blood products

E. TYPE III:immune complex reactions
1. Involves formation of antigen-antibody complexes (a binding together of an antibody and an
antigen)
a. Leads to activation of serum factors, causing inflammation and leading to activation of
complement cascade
b. Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are examples of Type
III reactions
c. Deposits of antigen-antibody complexes in body tissues are not localized and can result in
extensive tissue or organ destruction
2. Complement activation impacts vulnerable organs and leads to intravascular changes
3. Clinical manifestations
a. Arthrus reaction involves a localized inflammatory response with excess IgG causing
edema and necrotic lesions
b. Serum sickness involves a systemic response leading to deposit and activation of
complement throughout body manifested as joint pain, pyrexia, and / or lymphadenopathy
c. Reactions can be acute or chronic in nature
4. Diagnostic and laboratory test findings : complement assays indicate acute and/or chronic process
; erythrocyte sedimentation rate (ESR) is elevated ; proteinuria may be found on urinalysis
5. Therapeutic management
a. Analgesics, antihistamines and topical steroids may provide symptom relief; disease
process is usually self-limiting because of use of human antitetanus serum and availability
of antibiotics
25

b. Assess localized inflammatory reactions that may develop at site of serum injections after
1 week; this can be followed by more systemic response involving both regional as well as
generalized lymphadenopathies
c. If symptoms arise, monitor client for potential complications; this is especially important
because organ damage can occur and the kidneys can be compromised

F. Type IV: delayed hypersensitivity reactions
1. A form of cell mediated immunity involving T lymphocytes : considered a delayed response
2. Involve recognition and response of T lymphocytes to foreign substances
3. Clinical manifestations
a. Wide range of presentations from tuberculin response, poison ivy, and contract dermatitis
to transplant or graft rejection; edema, ischemia, and eventual tissue destruction may
ensue
b. Pyrexia , pain, edema, and failure of transplanted organ characterized transplant rejection
4. Diagnostic and laboratory test findings: purified protein derivative (PPD) test result of induration
more than 5mm identifies type IV hypersensitivity to tubercle bacillus; abnormal test results
indicating declining function of transplanted organ are used to diagnose transplant rejection
5. Therapeutic management
a. Monitor client for evidence of potential transplant rejection
b. Medicate client with immunosuppressive protocol drugs to prevent tissue rejection
c. Identify potential irritants that can cause contact dermatitis and avoid exposure
d. Teach client to avoid offending irritant is a past exposure has been documented
e. Use topical and oral medications as indicated to alleviate many symptoms and increase
client comfort

VI. ANAPHYLAXIS

A. Overview
1. Sudden and severe allergic reaction mediated by massive histamine release from cells
2. Common cause are drugs , foods (especially nuts and shellfish), latex exposure insect bites, and
stings
3. Can lead to shock state and death if not treated immediately
4. Onset of symptoms can be within minutes to an hour, with more rapid onset associated with
severe episode

B. Nursing assessment
1. Hives and urticaria (itching)
2. Angioedema (swelling of face, lips, neck, and/or tongue)
3. Dyspnea and wheezing
4. Syncope and hypotension
5. Difficulty swallowing
6. Skin flushing
7. Respiratory obstruction
8. Shock
9. Circulatory collapse and possible death

C. Therapeutic management
1. Maintain patent airway
2. Subsutaneous epinephrine injection
3. Remove or discontinue causative agent
4. Administer oxygen
5. Place in modified Trendelenburg position for shock
6. Give IV fluids such as normal saline or lactated Ringers to support circulation
7. Provide antihistamines or corticosteroids as ordered
8. Provide supportive care to stabilize client emotional support

D. Client teaching
1. Avoid future contact with allergen
2. Wear Medic-Alert identification listing allergy
3. Tell all future caregivers about allergy and symptoms
4. Learn how to use epinephrine auto-injector pen


26

VII. AUTOIMMUNE DISORDERS
A. Overview
1. concept of autoimmunity
a. An abnormal response of the bodys immune system whereby it perceives self
as that threat
b.