1. Chapter 55 Care of the Patient with an Immune Disorder
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2. 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?

3. 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?

4. 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.

5. 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?

6. 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?

7. 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.

8. 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.

9. 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?

10. 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.

11. 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?

12. 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.

13. 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

14. 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?

15. 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?

16. 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?

17. 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?

18. 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?

19. 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.

20. 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?

21. 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.

22. 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.

23. 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

24. 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.

25. 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?

26. 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?

27. 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.

28. 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?

29. 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?

30. 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

31. 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?

32. 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?

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

34. 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.

35. 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?

36. 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?

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

38. 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?

39. 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