Introduction
An assessment of the immune system function begins with a health history and physical examination. The history should include the patient’s age along with information about the past and present conditions and any incidents that may have implications for his or her immune system.
Definition
The immune system assessment focuses on the examination of the status of defense mechanisms of the human body, any current risk or active infections, and the causative organisms as an aid in planning effective and appropriate treatment.
Purpose
- To understand the defense mechanism, dysfunction, and hyperresponsive physiological changes.
Indications
- Hypersensitivity reaction.
- Autoimmune diseases.
- Immune dysfunction.
Laboratory & Diagnostic Considerations
| Test | Purpose |
|---|---|
| CBC with differential | Evaluates WBC count and types (e.g., neutrophils, lymphocytes) |
| Immunoglobulin levels (IgG, IgA, IgM) | Assesses humoral immunity |
| T- and B-cell counts | Evaluates cellular immunity |
| Complement levels (C3, C4) | Detects deficiencies in innate immunity |
| CRP/ESR | Indicates inflammation or infection |
| HIV, ANA, RF, and other autoantibodies | Screens for immunodeficiency or autoimmune disease |
Preparation of the Equipment
| Articles | Purpose |
| A clean tray containing; | |
| Gloves | To follow aseptic technique. |
| Thermometer | To obtain baseline temperature. |
| Sphygmomanometer | To check blood pressure. |
| Stethoscope | To auscultate the lung and heart sounds. |
| Wristwatch | To identify the respiratory rate. |
| Torchlight | To visualize the particular part. |
| Weighing scale | To check weight. |
| Stadiometer | To check height. |
| Notebook with pen | For documentation. |
1) Components of Patient’s History Collection (Subjective Data)
Collect information about the following:
- Chief complaints: Weakness, breathing difficulty, any skin changes, hyperpigmentation, rashes, lesions, dermatitis, urticaria, and cachexia.
- Past medical and family history: History of any sexually transmitted disease, family history of cancer, chronic disease, DM, renal failure, COPD, pulmonary problems, and respiratory problems.
- Personal history: Dietary intake and nutritional status, smoking, consumption of alcohol, OTC drug use, exposure to any environmental hazard and pollutant, previous exposure to antigen through transfusion, unprotected sex, coping and stress pattern, any exposures to HIV infection, and history of any allergy to dust, cosmetic, food, medication, and vaccines.
2)Physical Examination
This involves observing the general appearance of the patient and correlating with pertinent physiological observations.
| Nursing Action | Interpretation | |
| 1. | General appearance Observe for fatigue or weakness, body build, and correlated symptoms. | Fatigue or weakness may indicate acute or chronic illness or immunodeficiency. |
| 2. | Anthropometric measurement Assess height, weight, and gesture of weight loss according to the age and calculated BMI. | Weight loss, uncoordinated gesture indicate low immunity. |
| 3. | Assessment: Inspection, palpation, and auscultation Skin and mucous membrane Assess skin color, temperature, and moisture. Assess for rashes, lesions, inflammation scar, or any discharge (any signs of infection are noted). Inspect the skin for wound (note the location, distribution, infection, inflammation of the wound). Inspect the mucous membranes of the nose and oral cavity for color and condition. | Pale or jaundiced skin (hemolytic reaction). Pallor (bone marrow suppression). Presence of lesions-lesions formed by fluid within the skin layers, examples include the following: – Vesicles and pustules. – Solid masses including nodules and tumors. – Flat lesions including patches and macules. Redness and swelling. Dirty white curd-like raised patches on the tongue and oral mucosa with raw reddish base when removed (oral thrush infection). |
| 4. | Head and neck Inspect and palpate the neck and cervical and axillary lymph nodes. | Lymphadenopathy. Swelling. Tenderness. |
| 5. | Respiratory system Assess the rate and rhythm of respiration, presence of cough. Auscultate the lungs for respiratory sounds. | Tachypnea/bradypnea. Apnea. Productive/nonproductive cough. Wheezing. Crackles. Rhonchi. Rhinitis. Hyperventilation. |
| 6. | Cardiovascular system Auscultate the heart sounds. | Tachycardia.Bradycardia.Dysrhythmia. |
| 7. | Upper and lower extremities Assess the range of joint motion.Assess for edema and pain (PQRST, COLD SPA).Inspect and palpate the joint for redness. | Stiffness and immobility of joints. Swelling.Tenderness or deformity (autoimmune disorder-muscle weaknessss). Inflammation, warmth, and redness. |
| 8. | Genitalia Assess the groin region for redness, rashes. Assess the genital area for rashes and bleeding. | Ulcers, chancre, swelling, tenderness, sores, lymphadenopathy (gonorrhoea, HIV/AIDS). Human papillomavirus infection/vaginitis. Warts. Rash, sores, ulcers, bleeding, dirty white vaginal discharge, itching, bleeding per vagina. |
Special Consideration
- Infants and older adults have immature or declining immune responses.
- Elderly patients may show blunted responses to infection or vaccination.
- Autoimmune diseases, cancer, HIV/AIDS, chronic illnesses (e.g., diabetes, renal failure) can impair immunity.
- History of frequent infections delayed wound healing, or unusual illnesses may signal immune dysfunction.
- Immunosuppressants (e.g., corticosteroids, chemotherapy), biologics, or long-term antibiotics can alter immune responses.
- Splenectomy, lymph node removal, or organ transplants affect immune surveillance.
- Assess for up-to-date vaccines, especially in immunocompromised or elderly patients.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884.
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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