Care of Patient with An Immune Disorder Chapter 15 – Adult Health Nursing Book Care of the Patient with an Immune Disorder Mosby items and derived items

Care of Patient with An Immune Care of Patient with An Immune Disorder Chapter 15 – Disorder Chapter 15 – Adult Health Nursing BookAdult Health Nursing Book

Care of the Patient with an Immune Disorder

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 2Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Immunology

• The study of the immune system• Evolving science dealing with body’s

ability to distinguish self from nonself• Distinction is made through complex

network of highly specialized cells and tissues

• Collectively called “the immune system”

• Also known as the “host defense system”

• Critical to our survival


Three Functions of the Immune System

• Protect the body’s internal environment against invading organisms

• Maintain homeostasis by removing damaged cells from the circulation

• Serve as a surveillance network for recognizing and guarding against the development and growth of abnormal cells (Mutations constantly formed in body but recognized and destroyed)


Immunocompetence

• When immune system responds appropriately to a foreign stimulus, body’s integrity is maintained

• Immune system mobilizes and uses its antibodies/other responses to stimulation by an antigen


Immunoincompetence:

• weak or too vigorous immune system response causes disruption of homeostasis and malfunction in system

• When disruption of homeostatic balance in immune system occurs, diseases develop


Inappropriate responses of the immune system …4 categories of Immunoincompetence

• Hyperactive response against environmental antigens (allergy)

• Inability to protect the body, as in immunodeficiency disorders (AIDS)

• Failure to recognize the body as self, as in autoimmune disorders (systemic lupus erythematosus)

• Attacks on beneficial foreign tissue (organ transplant rejection or transfusion reaction)


Immunity

• The quality of being insusceptible to or unaffected by a particular disease or condition

• 2 major subclassifications• Innate immunity• Adaptive immunity


Innate Immunity (Non-specific)

• First line of defense

• Provides physical and chemical barriers to invading pathogens and protects against the external environment

• Composed of the skin, mucous membranes, cilia, stomach acid, tears, saliva, sebaceous glands, and secretions and flora of the intestines and vagina


Adaptive (Acquired) Immunity

If first line fails:• Second line of defense• Provides a specific reaction to each invading

antigen• Unique ability to remember invading antigen

• Protects the internal environment• Composed of thymus, spleen, bone marrow,

blood, and lymph• Includes both humoral and cell-mediated

immunity• Produces antibodies in the cells after an infection

or vaccination


When an Infectious Agent enters the Body…..

See 15-1 on page

720

• 1 – encounters innate immune system• 2 – if innate immune system cannot kill

off- disease results and the• 3 – adaptive immune system is activated• 4 – the adaptive immune system helps

patient to recover AND establishes a specific immunologic memory.

• 5 – If reinfected with same agent – no disease results…the patient has acquired immunity to the infectious agent


Organization of the Adaptive Immune System


Cells of the Immune System

Macrophages and Lymphocytes

• Macrophages (phagocytes)• When organisms pass epithelial barriers, macrophages

activated• Engulf and destroy microorganisms that pass the skin and

mucous membrane• Also carry antigens to the lymphocytes

• Antigen• A substance recognized by the body as foreign that can

trigger an immune response


Adaptive Immunity

• Lymphoctyes• Include T and B cells• Also includes NK cells (natural killer)

• Large, granular lymphocytes

• 70%-80% of all lymphocytes are T-cell


Lymphoctyes - 70 – 80% are T cells – activated by an antigen

• When activated by an antigen, T cells release substance called lymphokine

• Lymphokine attracts macrophages to the site of infection or inflammation and prepares them for attack

• T cells cooperate with B cells to produce antibodies but do not produce antibodies themselves

• T cells responsible for cell-mediated immunity• Protect against viruses, fungi, and parasites• Also provide protection in allografts and

malignant cells


Figure 15-3

Origin and processing of B and T cells.


Lymphocyte - 20-30% are B cells

• Trigger production of antibodies and proliferate in response to a particular antigen

• B cells migrate to peripheral circulation/tissues and eventually filtered from lymph and stored in lymphoid tissue of body

• Initial formation of B cells does not require antigen stimulation

• However, B cell proliferation does require antigen stimulation

• B cells produce antibodies and protect against bacteria, viruses, and soluble antigens



Humoral immunity – B cells

• One of the 2 forms of immunity• Responds to antigens such as bacteria and

foreign tissue; mediated by B cells (B cells produce antibodies)

• First exposure to antigen; primary humoral response initiated (response generally slow compared with subsequent exposures)

• When subsequent exposure occurs, memory B cells cause quick response, regardless of whether 1st exposure was to antigen or immunization

• Immunization-process by which resistance to infectious disease is induced or increased.


Nature of Immunity

• Antigen is presented to T-helper cells by macrophages

• T lymphocytes categorized as:• T-helper• T-suppressor-maintain humoral

response at appropriate level for stimulus

• Antigen is taken to B cells and with T-helper assistance, B cells begin antibody production


20


Active and Passive Immunity

• Active immunity• Antibodies are produced by one’s

own body (vaccines)• Passive immunity

• Antibodies are formed by another in response to a specific antigen and administered to an individual (newborn immunity)


Nature of Immunity

• Number and function of T-helper/suppressor cells determines strength and persistence of immune system.

• Normal ratio of helper to suppressor cells 2:1• When ratio is disrupted,

autoimmune/autodeficient diseases occur.• Factors affecting immunocompetence

• Aging• Viruses• Radiation• Chemotherapeutic drugs


Immune Response

• Exposure to antigen and response with antibody will activate either

• Humoral complement system which results in breakdown of bacteria and release of lysosomes to destroy bacteria

• The antigen-antibody reaction, resulting in release of histamine thus producing symptoms of allergy

• Allergen-produces signs of allergy• Immunogen-when immunity results from

exposure to antigen


Cellular immunity – T cells

• Also called cell-mediated immunity• T cells activated by antigen• T cells becomes sensitized; released into blood and body

tissues and remain indefinitely • On contact with antigen, attach to organism and destroy

it• Primary importance in:

• Immunity against pathogens that survive inside cells• Fungal infections• Rejection of transplanted tissues• Contact hypersensitivity• Tumor immunity• Certain autoimmune diseases


Complement System

• Includes proteins that interact with one another and with other components of natural and acquired immune system.

• Normally inactive and blood and body fluids• When antigen and antibody interact, system

activated• Step-by-step process similar to clotting• The complement system can destroy the cell

membrane of many bacterial species, and this action attracts phagocytes to the area


Genetic Control of Immunity

• There is a genetic link to both well-developed immune systems and poorly developed or compromised immune systems

• Develops at different rates and times in fetal and early life


Effects of Aging on the Immune System

• Aging causes a decline in the immune system• Higher incidence of tumors• Greater susceptibility to infections (flu and

pneumonia)

• Aging does not affect the bone marrow

• Decrease in thymus function plays important role to immunosenescence causing reduction in T cells

• Aging also demonstrates delayed hypersensitivity response which is decline in cell-mediated immunity

• Reflected in increased mortality rates of cancers, etc.


Immune Response

•2 ways of helping the body to develop immunity

• Immunization• Immunotherapy


Immune Response

• Immunization• A controlled exposure to a disease-producing

pathogen that triggers antibody production and prevents disease

• Provides protection for months to years• First vaccine: Edward Jenner and smallpox• Administer a weakened or dead antigen of the

disease• Vaccine stimulates humoral immunity

providing immunity for months/years.



Immunotherapy - Desensitization

• Treatment of allergic responses that involves administering increasingly large doses of the offending allergens to gradually develop immunity

• Preseasonal, coseasonal, or perennial

• Severe side effect: anaphylaxis• Also called desensitization


Immunotherapy Video 32


Immune Response - Immunotherapy

• Nursing and Immunotherapy• Observe patient for at least 20

minutes after administration because a hypersensitivity or anaphylaxis may occur

• Anaphylaxis treatment protocol with immunotheraphy is 02. – 0.5 ml of 1:1000 epinephrine hydrochloride subcutaneously every 20 minutes for three doses

33


Disorders of the Immune System

• System failure can occur in several ways and express itself in mild to severe forms

• Believed that failures occur due to• Genetic factors• Developmental defects• Infection• Malignancy• Injury• Drugs• Altered metabolic states



• Altered immune response• Hypersensitivity

• An abnormal condition characterized by an excessive reaction to a particular stimulus

• Hypersensitivity reaction• An inappropriate and excessive response of the

immune system to a sensitizing antigen• Hypersensitivity disorders

• Arise when harmless substances such as pollens, danders, foods, and chemicals are recognized as foreign



• Hypersensitivity disorders• Etiology/pathophysiology

• Genetic defect that allows increased production of immunoglobulin E (IgE) (humoral antibody)

• Causes release of histamine and other mediators• Humoral reactions occur immediatly • Exposures may occur by inhalation, ingestion, injection, or

touch• Signs and symptoms caused by histamine release• Reaction may be local (GI, resp, skin) or systemic

(anaphylaxis)• Several disorders result from hypersensitivity (asthma,

uricaria)



• Hypersensitivity disorders

• Clinical manifestations/assessment• Pruritus (itching)• Nausea• Sneezing• Excessive nasal secretions and tearing• Inflamed nasal membranes• Skin rash• Diarrhea• Cough; wheezes; impaired breathing



• Hypersensitivity disorders (continued)• Diagnostic tests

• History• Physical exam• Laboratory studies: CBC, skin testing, total

serum IgE levels• Medical management/nursing interventions

• Symptom management: antihistamines• Environmental control: avoidance of the

allergen• Immunotherapy


Disorders of the Immune System Anaphylaxis

• Anaphylaxis• Etiology/pathophysiology

• System reaction to allergens• Venoms• Drugs—penicillin • Contrast media dyes• Insect stings• Foods (eggs, shellfish, peanuts)• Latex• Vaccines



• Anaphylaxis Assessment

• Feelings of uneasiness to impending death• Urticaria (hives) and pruritus (itching)• Cyanosis and pallor• Congestion and sneezing• Edema of the tongue and larynx with stridor• Bronchospasm, wheezing, and dyspnea• Nausea and vomiting



• Anaphylaxis (continued)• Clinical manifestations/assessment

(continued)• Diarrhea and involuntary stools• Tachycardia and hypotension• Coronary insufficiency, vascular

collapse, dysrhythmias, shock, cardiac arrest, respiratory failure, and death



• Anaphylaxis (continued)• Nursing interventions

• Pharmacological management• Epinephrine • Benadryl• Aminophylline

• IV access• Oxygen• Teaching: avoid allergen; use medical alert ID;

administration of epinephrine


Disorders of the Immune System Latex allergies

• Latex allergies• Allergic reaction when exposed to latex

products• Type IV allergic contact dermatitis

• Caused by the chemicals used in the manufacturing process of latex gloves

• Type I allergic reactions• Response to the natural rubber latex proteins


Disorders of the Immune System Latex Allergies

• Latex allergies (continued)• Clinical manifestations/assessment

• Type IV contact dermatitis• Dryness; pruritus; fissuring and cracking of the

skin followed by erythema, edema, and crusting

• Type I allergic reaction• Skin erythema, urticaria, rhinitis, conjunctivitis, or

asthma to anaphylactic shock


Disorders of the Immune System Latex Allergies

• Latex allergies (continued)• Medical management/nursing interventions

• Identification of patients and health care workers sensitive to latex is crucial in the prevention of adverse reactions

• Use nonlatex gloves when possible• Use powder-free gloves• Do not use oil-based hand creams• Know the signs and symptoms of latex allergy• Wear a medical alert bracelet and carry an

epinephrine pen


Disorders of the Immune System Transfusion Reactions• Transfusion reactions

• Etiology/pathophysiology• Reactions that occur with mismatched

blood• Clinical manifestations/assessment

• Mild• Diarrhea• Fever and chills• Urticaria• Cough• Orthopnea


Disorders of the Immune System Transfusion Reactions• Transfusion reactions (continued)

• Clinical manifestations/assessment (continued)

• Moderate• Fever and chills• Urticaria• Wheezing

• Severe• Fever and extreme chills• Severe urticaria• Anaphylaxis



• Transfusion reactions (continued)• Nursing interventions

• Mild• Pharmacological management

• Corticosteroids• Diuretics• Antihistamines

• Stop transfusion• Administer saline• Physician may order transfusion

continued at a slower rate



• Transfusion reactions (continued)• Nursing interventions (continued)

• Moderate• Stop transfusion• Administer saline• Pharmacological management

• Administer antihistamines and epinephrine



• Transfusion reactions (continued)• Nursing interventions (continued)

• Severe• Stop transfusion• Administer saline• Pharmacological management

• Administer antihistamines and epinephrine

• Return blood or blood product to lab for testing

• Obtain urine specimen


Transfusion Blood products

• Blood should be properly typed and cross-matched

• Should be properly refrigerated until 30 minutes prior to adminstration

• Administer blood within 4 hours of removal from refrigerator

• Blood products within 6 hours

• Best prevention is use of autologous blood-can be frozen and store for up to 3 years


Transfusion Blood Products

•Donor numbers and recipients must be thoroughly checked by two nurses that the number match according to policy


Disorders of the Immune System Delayed Hypersensitivity

• Delayed hypersensitivity• Reaction occurs 24 to 72 hours after exposure

• Examples include:• Poison ivy• Tissue transplant rejection


Disorders of the Immune System Transplant Rejection

• Transplant rejection• Types of grafts

• Autograft• Isograft (identical twins)• Allograft (homograft; members of same species; most

common)• Heterograft

• Antigenic determinants on the cells lead to graft rejection via the immune process

• To avoid, antigenic determinants matched as close as possible.

• 7 to 10 days after vascularization occurs, sensitized lymphocytes appear in sufficient numbers for sloughing to occur


Disorders of the Immune System Transplant Rejection

• Transplant rejection (continued)• Immunosuppressive therapy

• Agents that significantly interfere with the ability of the immune system to respond to antigenic stimulation by inhibiting cellular and humoral immunity

• agents include• Corticosteroids• Cyclosporine (Neoral, Sandimmune)• Azathioprine (Imuran)


Immunosuppressive Therapy

•Nursing tip : When a transplant patient is receiving immunosuppressive therapy (Imuran, cyclosporine), remember that the purpose of these drugs is to suppress the immune reponse, so the critical nursing goal is to minimize the risk for infection for these patients


Disorders of the Immune System Immunodeficiency

• Immunodeficiency• An abnormal condition of the immune system

in which cellular or humoral immunity is inadequate and resistance to infection is decreased

• May cause recurrent infections, chronic infections, severe infections, and/or incomplete clearing of infections

• Defects in genes leading to immunodeficiency provide hereditary link to disease

• Can be induced (chemotherapy)• Associated with many diseases including AIDS,

multiple myeloma, etc.


Disorders of the Immune System Immunodeficiency Disorders

• Disorders involve an impairment of one or more immune mechanisms

• Primary immunodeficiency disorders

• Immune cells are improperly developed or absent

• Phagocytic defects• B-cell deficiency • T-cell deficiency • Combined B-cell and T-cell deficiency


Disorders of the Immune System – Secondary Immunodeficiency DO

• Secondary immunodeficiency disorders• Drug-induced immunosuppression

• Cytotoxic drugs in chemo, transplant rejection prevention, etc.

• Stress-Effects interrelationships between nervous, endocrine, and immune systems

• Malnutrition-Extended protein deficiency results in thymus gland atrophy & lymphoid tissue decreases; infection raised

• Radiation-destroys lymphocytes, BM atrophies, and pancytopenia occurs

• Surgical removal of lymph nodes, thymus, or spleen• Hodgkin’s lymphoma-impairs immune response and places

demand on immune system resulting in impaired response to 2nd infect


Autoimmune Disorders

• Autoimmune• The development of an immune response to

one’s own tissues• Body is unable to distinguish “self” protein

from “foreign” protein• Tend to cluster so patient may have more than

one or same/related disease found in other members of family

• Possible genetic predisposition to autoimmune disease

• Examples of disorder: rheumatoid arthritis, pernicious anemia; Guillain-Barré syndrome; scleroderma; systemic lupus erythematosus, Crohn’s disease


Autoimmune Disorders treatment

• Plasmapheresis• Removal of plasma that contains components

causing/though to cause disease• Replaced with fluid such as saline, albumin,

fresh frozen plasma• Also called “plasma exchange”• Used to treat autoimmune disease• Rationale to remove pathogenic substances in

plasma• May also remove inflammatory mediators that

cause tissue damage


Autoimmune Disorders

• Plasmapheresis• Whole blood removed through needle inserted in one arm and

circulation of the blood through cell separator• Separator divides the blood into plasma and its cellular

components through centrifugation • Plasma, platelets, WBC, RBCs separated selectively• Undesirable component removed and remainder of blood

returned to patient via needle in opposite arm• Plasma typically replaced with saline, LR, FFP, albumin• May only remove 500mL a time• Observe for s/s hypotension and citrate toxicity

(anticoagulant); HA, paresthesias, dizziness

Chapter 22

Immunologic Medications

Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

63

Immunity Types of Immunity Naturally acquired active

immunity: person has had the disease and made antibodies; antibodies remain for life

Artificially acquired active immunity: person is given a live or weakened (attenuated) antigen in a vaccine to stimulate antibody production to prevent specific diseases for an extended time; “boosters” may be necessary

64Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Immunity

Types of Immunity (cont.)

Passive immunity

Naturally acquired passive immunity

Antibodies pass from mother to infant through breast milk

Artificially acquired passive immunity

Immunoglobulins are injected into a person who does not have immunity to the antigen


Immunization Schedule

The following vaccines are recommended:

Hepatitis B Diphtheria, tetanus, pertussis Haemophilus influenzae type b Inactivated poliovirus Measles, mumps, rubella Varicella Pneumococcal Influenza Hepatitis A (for selected populations)



Vaccines = attenuated or killed antigens in a formula that produces an antigen-antibody response in the body

Hepatitis B

Toxoids = attenuated or weakened toxins that produce an antitoxin response, causing immunity in the body

Tetanus



Produce immunity in the bodyUses

Routine schedule of active immunizations for adults and children

Specific biologic agents for endemic disease areas

Specific biologic agents to people at high risk Screening for disease exposure Modify disease process in previously

unimmunized persons



Adverse Reactions

Mild reactions common: mild local pain and swelling at site

Occasional effects include altered levels of consciousness, headache, lethargy, rash, urticaria, vesiculation, diarrhea, increased respiratory rate, arthralgia, dyspnea, fever, lymphadenopathy, and malaise.



Drug Interactions

Nursing Implications and Patient Teaching Assess health history, immunization

status, allergies to eggs or feathers, presence of infection, use of immunosuppressants, pregnancy


Antihistamines

Action Compete with histamine for H1 receptor sites to limit its

effectiveness

Limits capillary permeability, and swelling

Limits acetylcholine release, which dries secretions in the bronchioles and gastrointestinal system

Sedative effect on the CNS


Antihistamines

Uses Seasonal allergic rhinitis (SAR) Perennial allergic rhinitis (PAR) Perennial nonallergic rhinitis

(PNAR)

Relieve symptoms of allergic disorders Adjunctive therapy for anaphylaxis Sedation


Antihistamines Adverse Reactions

Most due to anticholinergic activity of drug

Changes in blood pressure, blurred vision

Tachycardia, insomnia, dry mouth, nausea

Restlessness, excitability, sedation, tinnitus

Constipation, urinary retention Overdose is potentially fatal, especially

in children


Antihistamines Drug Interactions

Sedative effect increased with other CNS depressants (sedatives, hypnotics, ETOH)

Can strengthen anticholinergic effects

When used with ototoxic drugs (ASA, streptomycin), can mask ototoxic effects

May decrease effects of corticosteroids and other hormones

loratadine, diphenhydramine, fexofenadine

Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antihistamines

Life span considerations Pediatrics:

Infants and young children often have anticholinergic side/adverse effects

Paradoxical reactions may occur: increased nervousness, confusion, or hyperexcitability

Elderly More likely to develop side effects such as

dizziness, syncope (fainting), confusion, and extrapyramidal reactions


Documents

Care of Patient with An Immune Disorder Chapter 15 – Adult Health Nursing Book Care of the Patient with an Immune Disorder Mosby items and derived items