Chapter 55 Care of the Patient with an Immune Disorder Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.

Nature of Immunity 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 Immune is a word meaning “free from burden” in Latin. How does the definition correspond to our understanding of the functions of the immune system? A healthy functioning immune system is necessary for survival. It is this system that enables the body to protect itself. What body parts make up the immune system?

Nature of Immunity Immunocompetence Immunity Immunology The immune system responds appropriately to a foreign stimulus Immunity The quality of being insusceptible to or unaffected by a particular disease or condition Immunology The study of the immune system An appropriately functioning immune system reacts by a process known as immunocompetence. What are examples of exposures that will cause immunocompetence?

Nature of Immunity Inappropriate responses of the immune system 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) When the immune system does not work against potential pathogens, homeostasis is affected.

Nature of Immunity Innate (natural) immunity 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 Nonspecific immunity There are two subclassifications of immunity: innate and adaptive. Innate acts as a barrier between the body and the outside world. Its components act as soldiers against potentially invasive microorganisms. Does innate immunity always work? What will occur if it does not?

Nature of Immunity Adaptive (acquired) immunity Second line of defense Provides a specific reaction to each invading antigen Protects the internal environment Composed of thymus, spleen, bone marrow, blood, and lymph Produces antibodies in the cells after an infection or vaccination In the event the body’s innate immunity does not effectively handle pathogens, adaptive immunity is the next line of defense. This type of immunity has the characteristic of specificity and memory. How do each of these concepts relate to the immune process?

Figure 55-2 Organization of the immune system. The body organs identified assist in maintaining the lines of defense. Outline what role each of the listed parts does to aid in this function. (From Grimes, D. [1991]. Infectious diseases. St. Louis: Mosby.) Organization of the immune system.

Origin and processing of B and T cells. Figure 55-3 The process of adaptive immunity utilizes cells in defending the body. A specific type of white blood cell, known as a lymphocyte, is involved. Discuss the differences between T cells and B cells. (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) Origin and processing of B and T cells.

Nature of Immunity Macrophages (phagocytes) Lymphokine Antigen Engulf and destroy microorganisms that pass the skin and mucous membrane Carry antigen to the lymphocytes Lymphokine One of the chemical factors produced and released by T cells that attracts macrophages to the site of infection or inflammation Antigen A substance recognized by the body as foreign that can trigger an immune response Adaptive immunity is assisted by helper cells. These cells include macrophages and lymphocytes. How are these cells similar? How do they differ? Discuss where these cells are produced. What determines their number?

Nature of Immunity Humoral immunity Responds to antigens such as bacteria and foreign tissue Result of the development and continuing presence of circulating antibodies in the plasma 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 (HBIG) In humoral immunity, the body produces B cells in response to a challenge by an antigen. The concept of memory is important to the success of humoral immunity.

Nature of Immunity Cellular immunity Also called cell-mediated immunity Primary importance in: Immunity against pathogens that survive inside cells Fungal infections Rejection of transplanted tissues Contact hypersensitivity Tumor immunity Certain autoimmune diseases When potential pathogens are introduced into the body, T cells are activated. This process results in a full cellular response. What action is taken by the T cells once activated? Is there a specific type of pathogen targeted by the T cells?

Complement System The complement system can destroy the cell membrane of many bacterial species, and this action attracts phagocytes to the area The complement system is an organized series of enzymatic proteins. These enzymes are “awakened” when the body comes into contact with an antigen. What would you liken this process to? It is similar to a video game, such as Pac-Man.

Genetic Control of Immunity There is a genetic link to both well-developed immune systems and poorly developed or compromised immune systems Theories of immunity support the impact of heredity. What influences can be attributed to immunity? Provide examples of genetics interacting with illness and disease

Effects of Normal Aging on the Immune System Aging causes a decline in the immune system Higher incidence of tumors Greater susceptibility to infections Aging does not affect the bone marrow As the human body ages, there is a natural increase in disease process. What disorders increase with aging? What factors associated with growing older can encourage the onset of illness?

Immune Response Immunization A controlled exposure to a disease-producing pathogen that triggers antibody production and prevents disease Provides protection for months to years There are two ways to assist the body to develop immunity. They are immunization and immunotherapy. The concept of immunization dates back to the late 1790s. Vaccines and toxoids are weakened forms of disease-causing organisms, administered to provide protection from disease. Compare and contrast live and dead vaccines. For which diseases are vaccines routinely provided?

Immune Response Immunotherapy 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 Immunotherapy is a long-term management option to treat allergies. In most cases this therapy is initiated in the physician’s office. When is home maintenance appropriate? If home maintenance is initiated, what are the responsibilities of the nurse? What supplies will be needed in the home if home therapy is ordered?

Disorders of the Immune System 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 Harmless substances such as pollens, danders, foods, and chemicals are recognized as foreign Immune responses result as the body tries to protect itself. What factors can be attributed to a failure in immune response?

Disorders of the Immune System Hypersensitivity disorders Etiology/pathophysiology Genetic defect that allows increased production of immunoglobulin E (IgE) Exposures may occur by inhalation, ingestion, injection, or touch When hypersensitivity reactions result, what will determine the degree of reaction?

Disorders of the Immune System Hypersensitivity disorders (continued) Clinical manifestations/assessment Pruritus Nausea Sneezing Excessive nasal secretions and tearing Inflamed nasal membranes Skin rash Diarrhea Cough; wheezes; impaired breathing The types of clinical manifestations seen in a hypersensitivity reaction might vary between individuals.

Disorders of the Immune System 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 What information should be collected from the patient concerning the events surrounding a hypersensitivity reaction?

Disorders of the Immune System Anaphylaxis Etiology/pathophysiology System reaction to allergens Venoms Drugs—penicillin Contrast media dyes Insect stings Foods Anaphylaxis is the most severe type of allergic reaction. It involves the systemic reaction to the allergen. Discuss the events that result in the anaphylactic response demonstrated.

Disorders of the Immune System Anaphylaxis (continued) Clinical manifestations/assessment Feelings of uneasiness to impending death Urticaria (hives) and pruritus Cyanosis and pallor Congestion and sneezing Edema of the tongue and larynx with stridor Bronchospasm, wheezing, and dyspnea Nausea and vomiting The onset of symptoms from the time of exposure is rapid. Early intervention can often stop the onset of more severe reactions in the patient.

Disorders of the Immune System 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

Disorders of the Immune System Anaphylaxis (continued) Medical management/nursing interventions Pharmacological management Epinephrine Benadryl Aminophylline IV access Oxygen Teaching: avoid allergen; use medical alert ID; administration of epinephrine Upon recognition of anaphylaxis, treatment must begin quickly to reduce complications and potential death. What are the actions of the recommended medications? How are the medications administered? Identify two nursing diagnoses for the patient diagnosed with anaphylaxis.

Disorders of the Immune System 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 Latex allergies are growing. What factors can be related to this increase in latex allergies?

Disorders of the Immune System 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 The identification of people at risk for the development of latex allergies is key in the prevention of allergic reactions. What risk factors are associated with the development of a latex allergy?

Disorders of the Immune System 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 The development of a latex allergy in a health care worker is serious. What are the responsibilities of the workplace regarding the environment and work supplies? Ask if any of the students have latex sensitivities. Further, if there are affirmative responses, ask what the impact has been on their clinical experiences.

Disorders of the Immune System Transfusion reactions Etiology/pathophysiology Reactions that occur with mismatched blood Clinical manifestations/assessment Mild Diarrhea Fever and chills Urticaria Cough Orthopnea An allergic reaction due to a blood transfusion is serious. What steps can the nurse take to reduce the likelihood of this happening?

Disorders of the Immune System Transfusion reactions (continued) Clinical manifestations/assessment (continued) Moderate Fever and chills Urticaria Wheezing Severe Fever and extreme chills Severe urticaria Anaphylaxis When a transfusion reaction results, what data must be collected by the nurse?

Disorders of the Immune System Transfusion reactions (continued) Medical management/nursing interventions Mild Pharmacological management Corticosteroids Diuretics Antihistamines Stop transfusion Administer saline Physician may order transfusion continued at a slower rate

Disorders of the Immune System Transfusion reactions (continued) Medical management/nursing interventions (continued) Moderate Stop transfusion Administer saline Pharmacological management Administer antihistamines and epinephrine When a transfusion reaction results, the patient could have an antihistamine and epinephrine administered. How do these medications work? What nursing implications accompany their administration?

Disorders of the Immune System Transfusion reactions (continued) Medical management/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 Care of the patient who has experienced a blood transfusion reaction has several steps. The physician must be notified, the transfusion stopped or slowed, and medications given. What nursing diagnoses are appropriate for this patient? What information should be documented in the patient’s medical record?

Disorders of the Immune System Delayed hypersensitivity Reaction occurs 24 to 72 hours after exposure Examples include: Poison ivy Tissue transplant rejection

Disorders of the Immune System Transplant rejection Types of grafts Autograft Isograft Allograft (homograft) Heterograft Antigenic determinants on the cells lead to graft rejection via the immune process 7 to 10 days after vascularization, lymphocytes appear in sufficient numbers for sloughing to occur The introduction of tissue into the body might be done for a variety of reasons. What treatment plans utilize tissue transplantation? Define each of the tissue types used in transplantation.

Disorders of the Immune System Transplant rejection (continued) Immunosuppressive Agents that significantly interfere with the ability of the immune system to respond to antigenic stimulation by inhibiting cellular and humoral immunity Pharmacological agents are administered to reduce the risk of tissue rejection. What classification of agents can be used?

Disorders of the Immune System 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 Can be induced (chemotherapy) A healthy, functioning immune system provides the body with protection against pathogens. When the immune system fails to adequately provide protection, illness and disease will result. What are examples of immunodeficiency diseases?

Disorders of the Immune System Primary immunodeficiency disorders Phagocytic defects B-cell deficiency T-cell deficiency Combined B-cell and T-cell deficiency

Disorders of the Immune System Secondary immunodeficiency disorders Drug-induced immunosuppression Stress Malnutrition Radiation Surgical removal of lymph nodes, thymus, or spleen Hodgkin’s disease How do each of the factors listed contribute to immunodeficiency disorders?

Autoimmune Disorders Autoimmune Plasmapheresis The development of an immune response to one’s own tissues Body is unable to distinguish “self” protein from “foreign” protein Examples of disorder: pernicious anemia; Guillain-Barré syndrome; scleroderma; systemic lupus erythematosus Plasmapheresis Removal of plasma that contains components causing disease Used to treat autoimmune disease