1. Care of Patient with An Immune Disorder Chapter 15 – Adult Health Nursing Book Topic #5

2. BUT FIRST ! HOMEOSTASIS A Review

3. Slide 3 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

4. Slide 4 Mosby 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

5. Slide 5 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

6. Slide 6 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

7. Slide 7 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

8. Slide 8 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

9. Slide 9 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. IMMUNITY –The quality of being insusceptible to or unaffected by a particular disease or condition –2 major subclassifications Innate immunity Adaptive immunity

10. Slide 10 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

11. 11

12. Slide 12 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

13. 13

14. 14

15. Slide 15 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

16. Slide 16 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. WHEN AN INFECTIOUS AGENT ENTERS THE BODY….. 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

17. Slide 17 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

18. Slide 18 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

19. Slide 19 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

20. Slide 20 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. FIGURE 15-3 Origin and processing of B and T cells.

21. Slide 21 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

22. Slide 22 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

23. Slide 23 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 1 st exposure was to antigen or immunization Immunization-process by which resistance to infectious disease is induced or increased.

24. Slide 24 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

25. Slide 25 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

26. Slide 26 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

27. Slide 27 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

28. Slide 28 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

29. Slide 29 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

30. Slide 30 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

31. Slide 31 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

32. Slide 32 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

33. Slide 33 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

34. Slide 34 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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.

35. Slide 35 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

36. Slide 36 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. IMMUNE RESPONSE 2 ways of helping the body to develop immunity –Immunization –Immunotherapy

37. Slide 37 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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.

38. Slide 38 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

39. Slide 39 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. IMMUNOTHERAPY – ALLERGY 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

40. Slide 40 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. IMMUNOTHERAPY VIDEO 40

41. Slide 41 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 41

42. Slide 42 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

43. Slide 43 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Arise when harmless substances such as pollens, danders, foods, and chemicals are recognized as foreign

44. Slide 44 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM 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 immediately 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)

45. Slide 45 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM Hypersensitivity disorders Clinical manifestations/assessment Pruritus (itching) Nausea Sneezing Excessive nasal secretions and tearing Inflamed nasal membranes Skin rash Diarrhea Cough; wheezes; impaired breathing

46. Slide 46 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

47. Slide 47 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

48. Slide 48 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM ANAPHYLAXIS 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

49. Slide 49 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM ANAPHYLAXIS 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

50. Slide 50 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50

51. Slide 51 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM ANAPHYLAXIS Anaphylaxis (continued) –Nursing interventions Pharmacological management –Epinephrine –Benadryl –Aminophylline IV access Oxygen Teaching: avoid allergen; use medical alert ID; administration of epinephrine

52. Slide 52 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

53. Slide 53 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

54. Slide 54 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

55. Slide 55 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 55

56. Slide 56 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

57. Slide 57 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

58. Slide 58 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM Transfusion reactions (continued) –Nursing interventions Mild –Pharmacological management Corticosteroids Diuretics Antihistamines –Stop transfusion –Administer saline –Physician may order transfusion continued at a slower rate

59. Slide 59 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM Transfusion reactions (continued) –Nursing interventions (continued) Moderate –Stop transfusion –Administer saline –Pharmacological management Administer antihistamines and epinephrine

60. Slide 60 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM 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

61. Slide 61 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

62. Slide 62 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. TRANSFUSION BLOOD PRODUCTS Donor numbers and recipients must be thoroughly checked by two nurses that the number match according to policy

63. Slide 63 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 63

64. Slide 64 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM DELAYED HYPERSENSITIVITY Delayed hypersensitivity –Reaction occurs 24 to 72 hours after exposure –Examples include: Poison ivy Tissue transplant rejection

65. Slide 65 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

66. Slide 66 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

67. Slide 67 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

68. Slide 68 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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.

69. Slide 69 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

70. Slide 70 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM – 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

71. Slide 71 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. DISORDERS OF THE IMMUNE SYSTEM – SECONDARY IMMUNITY DISORDERS –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 2 nd infect 71

72. Slide 72 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

73. Slide 73 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

74. Slide 74 Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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

75. Chapter 22 Immunologic Medications Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 75

76. 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 76 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

77. 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 77 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

78. 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) 78 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

79. Immunologic Medications  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 79 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

80. Immunologic Medications  Produce immunity in the body Uses  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 80 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

81. Immunologic Medications 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. 81 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

82. Immunologic Medications Drug Interactions Nursing Implications and Patient Teaching  Assess health history, immunization status, allergies to eggs or feathers, presence of infection, use of immunosuppressants, pregnancy 82 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

83. Antihistamines  Action  Compete with histamine for H 1 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 83 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

84. Antihistamines  Uses  Seasonal allergic rhinitis (SAR)  Perennial allergic rhinitis (PAR)  Perennial nonallergic rhinitis (PNAR)  Relieve symptoms of allergic disorders  Adjunctive therapy for anaphylaxis  Sedation 84 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

85. 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 85 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

86. 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.

87. 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 87 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.