Immune

Exam Questions from Assigned Reading/Lectures Care of Client & Family with Immune System Disorders Nursing 304 Fall 2007 Understanding the Immune System Immune System – body’s major defense mechanism against

infectious organisms and abnormal or damaged cells Complex and intricate network of specialized cells, tissues, and

organs Cells of immune system seek out and destroy damaged cells and

foreign tissue, yet recognize and preserve host cells Functions of Immune System Defense – defends and protects the body from infection by bacteria,

viruses, fungi, and parasites Homeostasis – removes and destroys damaged or dead cells Surveillance – identifies and destroys malignant cells – preventing

further development of tumors Organs and Tissues of Immune System Bone Marrow Thymus

Lymph nodes Spleen Tonsils, Adenoids

Immune System Components Leukocytes Granulocytes Monocytes Lymphocytes

Antigens Antibodies Cytokines

Cells – Immune Response 

T lymphocytes – migrate from bone marrow to thymus (T cells, thymus dependent) T cytotoxic cells – killer T cells attack antigens directly



Helper T cells (CD4 cells) – coordinate immune response by



communicating with other cells; some stimulate B cells to produce

antibody; call in phagocytes; HIV invades T helper cells – cause decrease in # and function Suppressor T cells (CD8 cells) – immunoregulatory;



autoimmune disease Natural

Killer Cells (NK) – involved in cell mediated immunity; large

lymphocytes with numerous granules in cytoplasm; recognize & kill virus-infected cells, tumor cells, and transplanted grafts

Antigen Substance Anything Types 



that causes an immune response

that can trigger an immune response

of antigens

Microbes 

Germs (bacteria)



Viruses

Organisms 

Parasites



Fungi



Tissues or cells from another person (except identical twin) – why

you have tissue transplant rejection 

Harmless substance like ragweed pollen which result in allergy –

this type of antigen is called an allergen

Immunoglobulins (Antibodies) Large

proteins developed by the body in response to & interacting

with a specific antigen Antibodies

or immunoglobulins produces by B cells

Chart 50-2 pg 1790 Brunner Immunoglobulin

G (IgG)

IgM IgA IgD IgE

Cytokines Components

of the immune system communicate with one another

by exchanging chemical messengers called cytokines

Protein

– instruct cells to alter their proliferation, differentiation,

secretion and activity Types

of cytokines

Interleukins Interferons Growth Tumor

(IL)

– attack viruses and tumors

factors

necrosis factors – go after cancer cells

Complement System Circulating plasma proteins made in liver activated when an

antibody couples with its antigen Complements the action of the antibody to destroy bacteria Cascade or “falling domino” effect Part of innate immune system – cascade of proteins necessary for

optimal health Lymphoid System Components 

Central lymphoid organs Bone marrow



Thymus





Peripheral lymphoid organs 

Tonsils



Abdomen (gut), genital, bronchial, skin



Lymph nodes



Spleen



Adenoids



Appendix



Peyer’s cells

Lymphatic System Humoral & Cell Mediated Immunity Two types of immune response Humoral

immunity – Consist of antibody mediated immunity;

comes from Greek word Humor meaning body fluid; antibodies produced by plasma cells, B lymphocytes ( B cells) found in plasma Example

Cell

– anaphylactic shock

– Mediated Immunity – immune response initiated through

specific antigen recognition by T-cells; immunity against pathogens that survive inside of cells (viruses, mycobacterium); fungus; rejection of transplanted tissue; contact hypersensitivity reactions; tumor immunity Types of Immunity



Innate (natural or inborn) – is an inherited immunity of species (eg

human do not contract certain animal diseases), races and individuals to certain diseases. 

Acquired – development of immunity after birth (active or passive);

not inherited Active acquired immunity – results from invasion of the body by



foreign substance i.e. microorganisms → development of antibodies & sensitized lymphocytes (Body makes its own antibodies) 

Natural – from disease – takes time to develop, but last for a

lifetime 

Artificially – immunization (less virulent antigen)

Passive acquired immunity – host receives antibodies to an



antigen rather than making them (temporary immunity transmitted from another source) 

Natural – antibody transfer from mother to infant in utero

(across placental barrier) & breastfeeding 

Artificial – injection of serum globulin – immediate response

but short lived r/t host not making and having no memory Artificially Acquired immunity

Immunizations Purpose

or vaccination

– establish adequate levels of antibody and /or memory

cells to provide effective immunity Vaccinations

introduce disease producing antigen into body in

manner that will stimulate immune system to form antibodies and memory cells but will not produce disease Made

of killed organisms – e.g. Typhoid

Made

of live organism – attenuated or modified to reduce their

disease-producing capability – e.g. measles-mumps-rubella (MMR)

Effects of Aging on the Immune System Secretory

immunoglobulin (IgA) declines – potential increase for

infections on mucosal surfaces Thymus

gland involuted – impaired cell-mediated immune response

Lymphoid Antibody

tissue decreased – Malignancies increase

production impaired – response to acute infection reduced

Decreased

growth response of T and B cells – potential recurrence

of latent herpes zoster and tuberculosis Autoantibodies

decreased – autoimmune disease increases

Assessment of Altered Immune System Function Health

History

Review

Family

biographic data – age, sex, race, and ethnic background

history – genetic component may cause disorder

Family

Interview

allergies atopic reactions – identify risk questions are very sensitive

Provide

for privacy

Request

family members to leave prior to asking sensitive

questions (illicit drugs or sexual activity) Cultural

sensitivity needed for effective communication

Health History Past and Present allergies Social & environmental factors Identify allergies & type of reaction (ABX, Penicillin, IV contrast,

Iodine) Previous transfusion – reaction? Previous anesthesia – reaction? Immunization – pneumonia, Influenza, Tetanus

Physical Assessment Assess

general appearance

Note

if client’s stated and apparent age coincide

Fatigue

Assess

or weakness

height, weight, and body type for apparent weight loss or

wasting Observe Check

mobility – note stiffness or difficulty moving

vital signs – elevated temp indicate infection or inflammation

Assess

skin color, temperature and moisture

Inspect

and palpate lymph ( cervical, axillae & groin) nodes for

evidence of lymphadenopathy (swelling) or tenderness Physical Assessment Inspect mucous membranes of nose and mouth for color &

condition Pale,

boggy (edematous) nasal mucosa associated with chronic

allergies Petechiae,

white patches, or lacy white plaques in oral mucosa

may indicate hemolysis or immunodeficiency Assess musculoskeletal system by inspecting and palpating joints

for redness, swelling, tenderness or deformity autoimmune disorder Diagnostic Studies

CBC with WBC Differential with absolute (complete) lymphocyte

count & eosinophil count Radioallergosorbent test (RAST) – in vitro Dx test for IgE antibodies

to specific allergens; expensive; safe but less sensitive & takes longer than skin test Sputum, nasal, & bronchial secretions tested for presence of

eosinophils Bone marrow biopsy

Bone Marrow

Technique

– removal of bone marrow through locally anesthetized

site to evaluate blood-forming tissue Nursing

Responsibilities

Explain

procedure

Signed

consent

Pre-med Apply

sterile pressure dressing after procedure

Assess May

– narcotic analgesic

biopsy site for bleeding

need to give pain med after procedure – tenderness at site

Bone Marrow

Diagnostic Studies Nurse aware – pain and discomfort experienced with certain types

of Dx procedures Psychological reactions – fear of test Anxious about results & impact on employment, insurance, personal

relations Nurses role – counsel, educate, support through Dx process

Skin Testing Used

to assess cell-mediated immunity

Known

antigen (tuberculin purified protein derivative (PPD) or

candida injected intradermally Site

then observed for induration and erythema – typically peaks at

24 to 48 hours Induration

of at least 10 mm in diameter is a positive reaction

indicating previous exposure and sensitization to the antigen No

reaction or anergy indicated depressed cell-mediated immunity

Skin Testing (cont.) 2

methods Cutaneous

scratch or prick

Intracutaneous

(intradermal) injection

Arm

or back

Results

– hypersensitive to allergen - + reaction will occur;

manifested by wheal-and-flare response Precautions

– Risk for anaphylactic reactions; never be left alone

during testing period Reactions

– apply tourniquet, immediately remove extract; anti-

inflammatory topical cream applied; intracutaneous arm, apply tourniquet; SC injection of epinephrine

Hypersensitivity Altered

immune response to an antigen that results in harm to the

client Antigen

is environmental or exogenous – allergy

Antigen

Tissue

is called an allergen

response to the hypersensitivity reaction may be irritating or

bothersome (runny nose or itching eyes) or it can life threatening leading to hemolysis or laryngospasm Classified

by type of immune response that occurs on contact with

allergen; and classified as immediate or delayed hypersensitivity responses

Hypersensitivity (Pathophysiology) Immune

system overreactive against foreign antigen; fails to

maintain self-tolerance; abnormal, heightened reaction to any type of stimuli – response is damaging to body tissues (4 types of reactions) Exaggerated

or inappropriate response that occurs on second

exposure to the antigen

Type

I, II, III – Immediate hypersensitivity response Humor immunity

(B cells) Type

IV - delayed response; cell mediated immunity (T cells)

Type I IgE- Mediated Hypersensitivity Common

Hypersensitivity reactions

Allergic asthma



Allergic rhinitis (hay fever)



Allergic conjunctivitis



Hives



Anaphylactic shock



Response

is triggered when an allergen interacts with IgE bound to

mask cells and basophils

Antigen-antibody

complex prompts release of histamine and other

chemical mediators, complement, acetylcholine, kinins, and chemotatic factors Systemic

response anaphylaxis, urticaria, or angioedema results

Anaphylaxis Immediate life threatening systemic reaction, occurs after exposure

to particular substance (antigen) Causes – immunotherapy (desensitization to a known allergen),

stinging insects, skin testing, medication, contrast media, foods, latex

Type I Hypersensitivity Patho Release

of chemical mediators resulting in

Massive

vasodilation

Increased Smooth

capillary permeability

muscle contraction (spasms)

Bronchospasms Activation

(Bronchoconstriction)

of platelets, eosinophils ,neutrophils & coagulation

cascade Mucosal

edema & inflammation

Increase

vascular permeability

Mucus

secretion

Cellular

infiltration by eosinophils & neutrophils

Clinical Manifestations (SSx) 

Neurologic – HA, dizziness, paresthesia (numbness, tingling),

feeling of impending doom or fright (sense of uneasiness, foreboding) 

Respiratory – laryngeal edema, bronchospasms, barking cough,

wheezing, lump in throat, nasal congestion, SOB ( air hunger), stridor, sneezing, rhinitis, asthma 

CV – urticaria (hives), erythema (flushing), prurtitis, periorbital

edema, tearing of eyes, hypotension, cardiac arrest 

GI – N/V, diarrhea, abdominal cramping



Skin – pruritus, hives, angioedema, erythema, urticaria, sweating,

itching palms & scalp

Management 

Prevention - strict avoidance of potential allergens



Assess allergies



Depends on severity



Promptly ID S/Sx and immediate intervention



Apply tourniquet above test-site (allergy injection)



Drug of choice : epinephrine (adrenalin) SQ or IM, IV 



vasoconstriction, decrease cap. Permeabl., relax smooth muscle

Other: 

bronchodilators: albuterol



antihistamines: benadryl



IV fluids (Normal Saline 0.9%)



Corticosteroids (decrease vascular perm) – systemic and topical

forms- anti-inflammatory effect 

Oxygen – increase tissue perfusion



Tracheotomy – ET – mech vent maintain patent airway

Anaphylaxis Cardinal

principle of treatment – SPEED

Recognize Maintain Prevent

SSx

patent airway (airway management takes highest priority)

spread of allergen using tourniquet

Administration Treatment

of drugs

of shock

Nursing Care

ABCs,

vital signs, history of onset

Establish Prompt Oxygen

and maintain airway

notification of MD and preparation for emergency measures therapy – high flow via non-rebreather mask

Place

in recumbent and legs elevated (trendelenburg position)

Keep

warm

IV

fluids & insert foley (monitor kidney function)

Reduce

anxiety (inform family plan of care and progress)

Documentation Verify

allergies!!!! Don’t rely on chart!!!

Patient Education Recognize Admin.

early SSx; explain disorder in “lay terms”

Of Epi-pen (0.3 mg) – autoinjection adm premeasured dose

of epinephrine; Medic-Alert tag or bracelet Importance Read Be If

of F/U

all drug labels; KNOW NAMES OF MEDS

aware of foods that cause reactions

allergic to bees, avoid perfumes, hairsprays, wear shoes at all

times Type I Allergic Rhinitis

Inflammation

of the nasal mucosa caused by allergens, vasodilation

and increase capillary permeab. Etiology:

airborne allergens (pollen, mold), dust mites, animal

dander, seasonal or year-round Clinical

manifestations: nasal congestion, itching, watery rhinorrhea,

itching/burning/tearing eyes, fullness in ears, throat itching, nonproductive cough, sneezing Management Avoidance

Wear mask



Acute



Antihistamines (benadryl sedation, less expensive, short acting)



Claritin and Zyrtec (more expensive, long acting)



Decongestants (shrink nasal mucosa - rebound)



Anticholinergics (drying agents)

Intranasal

cromolyn (Nasalcrom) - spray that acts to stabilize mast

cell membrane; reduce release of histamine and other mediators Helps to prevent



Takes up to four weeks to work; taken regularly during allergy



season

Management cont. Corticosteriods

intranasal; more severe cases - beclomethasone

(Beconase, Vancenase), budesonide (Rhinocort), dexamethasone (Decadron), fluticsone (Flonase), triamcinolone (Nasacort); metered spray device Immunotherapy 

Allergen desensitization used to treat IgE-mediated disease by

injection of allergen extracts Skin

testing &serial injections done in doctors office (remain 30 mins

after; Epi is available) Inject For

an extract of the allergen(s) in gradual increasing doses

allergic rhinitis or asthma related to inhaled allergens, and insect

venom With

weekly or biweekly SC injections of allergen client develops

IgG antibodies to the allergen Drug Therapy Antihistamines

– act by competing with histamine of H1-receptor

sites, thus blocking effect of histamine Benadryl Chlor-Trimeton

Phenergan Cause

sedation (diminished alertness, slow reaction time,

somnolence) and stimulation (restless, nervous, insomnia) Warn

patient operating machinery & driving may be dangerous

(sedative effect); Not to take with alcohol

Drug Therapy (cont.) Sympathomimetic/decongestant

drugs



Epinephrine (Adrenalin) – drug of choice for anaphylactic reaction



Action last only a few minutes; given SC

Minor

Sympathomimetic



Phenylephrine (NeoSynephrine)



Pseudoephedrine (Sudafed)



Given orally or nasally; last several hours; allergic rhinitis

Corticosteroids Mast

cell-stabilizing drugs – cromolyn (Nasalcrom) – inhibit release

of histamines, leukotrines, and other agents from mask cells Nursing Care Obtain

history of SSx and assessment of ROS

Intranasal

saline OTC

Teach Side

self-admin. of meds

effects of meds (I.e. antihistamines - sedation)

Rebound

effects: nasal decongestants, 2-3 day use,causes mucosa

edema Long

term use of nasal corticosteriods may cause nasal septum

rupture, spray away from septum Immunotherapy

teach to avoid rubbing or scratching injection site

and continuing series for period of time required; monitor closely for signs of anaphylaxis each time injection is given

Type II Cytotoxic/Cytolytic Hypersensitivity Antibody

antigen reaction causing agglutination (cells clump

together) i.e. ABO

incompatibility (hemolytic transfusion reaction)

hemolysis of cells Occurs

when a recipient receives ABO – incompatible blood from

a donor Prevent

by following transfusion protocols

Type III Immune Complex Reaction

 Associated

with systemic lupus erythematosus (SLE), rheumatoid

arthritis (RA), certain types of nephritis and some types of bacterial endocarditis (Seniors) Type IV Delayed Hypersensitivity Cell

mediated rather than antibody mediated involve T cells

Occurs

24-72 hrs after exposure to an allergen

Classic

- effect of an intradermal injection of TB antigen or

positive purified protein derivative (PPD) Contact

dermatitis resulting form exposure to allergens

(cosmetics, adhesive tape, topical meds, med additives and plant toxins [poison ivy]) Latex

allergy

Symptoms Organ

include itching, erythema and raised lesions

transplant rejection

Latex Allergy 

Allergic reaction to natural rubber proteins



Natural rubber in manufactured items (gloves or residue powder,

toys, household items, balloons, condoms, rubber bands) 

Types 

Irritant dermatitis (powder or chemical residue on gloves)



Type IV (cell mediated, delayed) localized contact; Contact

dermatitis caused by chemicals used in manufacturing process of latex gloves; reaction within 6-48 hrs 

Type I (IgE mediated, immediate) a systemic reaction; allergy to

the natural latex proteins; occurs within minutes of exposure Clinical Manifestations Irritant Type

dermatitis: erythema and pruritis at area of contact-

IV: vesicular skin lesions, papules, erythema, pruritis, edema,

crusting and thickening of skin, flushing, rhinitis, coughing occur 1-48 hrs after contact Type

I: urticaria, dyspnea, conjunctivitis, lead to anaphylaxis

Management 

Avoidance! (Prevention)



Latex free gloves and products



Latex allergy alert & use of latex free cart (hospital)



Topical corticosteriods



Oral antihistamines



Teach SSx & products containing latex



Teach use of Epi-pen



Medic- alert tags or bracelets



National Institute for Occupational Safety and Health (NIOSH)

recommendations for prevention of allergic reactions to latex in the workplace – pg. 253 (Lewis)