Nursing 1 Exam 3: Immunity

9 warning signs -consider PI if 2 or more are present

1. 4 or more new ear infection w/in 1 year 2. 2 or more serious sinus infections w/in 1 year 3. 2 or more months taking antibiotics with little effect 4. 2 or more pneumonias w/in 1 year. 5. Failure of an infant to gain weight or grow normally 6. Recurrant deep skin or organ abscesses 7. Persistent thrush in mouth or fungal infection on skin 8. Need for IV antibiotics to clear infections 9. 2 or more deep-seated infections including septicemia. (NIH identified 70 types of immunodeficiencies)

Neutrophils

1. Acute BACTERIA and FUNGAL infections (closely related to IgM response) 2. Drop in # with Chemotherapy, Sepsis, or with viral.

Clinical management of individuals with immunosuppression or hyperimmune conditions varies widely depending on the type of condition, severity, and attributes variables such as:

1. Age 2. Health status 3. Underlying medical conditions

Eosinophils

1. Allergic reactions 2. Chronic inflammation (Hodgkin's Disease) 3. Parasites (worms, etc.) 4. Drop in # with Corticosteroid use, stress

Recognize when an individual HAS Altered Immunity

1. Assessment of immune disorders and dysfunction begins with a thorough health history and physical examination 2. basic Laboratory and diagnostic testing procedures (followed by more specific tests depending on the individual's history and current symptoms) 3. Genetic testing may also be important to (1. confirm a diagnosis, 2. determine appropriate counseling concerning a persons prognosis, and 3. make reproduction recommendations.)

Monocytes

1. Chronic inflammation 2. TB, Protozal (Amoebas) infections 3. Viral (Mono, Mumps, measles) 4. Drop in # with corticosteroid use

Dendritic cell function in an immune response

1. Discovered 35 years ago; recognized as potent cells in asserting control from initiation to termination of the immune response. 2. have "sentinel" function throughout the body as they look for foreign antigens and alert lymphocytes to the presence of injury or infection 3. They bind to antigens and then process and present them to both B and T lymphocytes in an immune response. 4. Found to directly activate helper and killer T cells 5. Present cancer cells to cytotoxic T cells.

Phagocytosis

1. Exposure/invasion 2. Attraction 3. Adherence 4. Recognition 5. Cellular ingestion 6. Phagosome formation 7. Degradation

Suppressed immunity HIGH Risk Factors:

1. HIV, Hepatitis, shared needles, high risk sexual behaviors. 2. Alcoholism (compromises BOTH innate and acquired).

T cells- 3 primary groups

1. Helper T cells- (CD4)- helps in functions of the immune system by regulating most of the system's functions via the protein mediators, lymphokines. They direct and encourage other T cells and also help to activate B lymphocytes. 2. Cytotoxic T cells- ("killer cells")- directly kill foreign antigens and may kill "self" cells. 3. suppressor T cells: suppress the function of both helper and cytotoxic T cells in order to prevent hyper-immune responses.

Generalized immune response

1. Identify invader (IgM, innate immunity, IgA) 2. Call in Troops (Helper T-cells) 3. Tag invader (B-cells, antibodies, plasma cells, IgG) 4. Destroy invader (NK cells, Cytotoxic T-cells, Macrophages, Neutrophils) 5. Remember invader (DD8 T-cells a.k.a. "Memory T-cells")

clinical management: Primary prevention

1. Immunizations 2. Avoid high-risk behaviors 3. Adequate nutrition 4. Exercise 5. Infection control measures

Collaborative Care: Exaggerated Immune Response 2

1. Immunosuppression Pharmacotherapy: Corticosteroids, chemotherapeutic agents, NSAIDs, Immunomodulators. 2. Pain Management Pharmacotherapy: NSAIDs and Corticosteroids Hypothermia or hyperthermia treatments as appropriate Maintenance of mobility and physical activity.

The two major types of problems that result from suppressed immune response are:

1. Infection 2. Cancer (a depressed immune system may be created with medications in order to avoid rejection of transplanted tissue or it may be induced as a result of treatment for various types of cancer).

Collaborative Care: Suppressed Immune Response

1. Infection clinical management of infection and opportunistic diseases are important part of clinical care (antibiotics) 2. Gastrointestinal Dysfunction Pharmacologic treatment of diarrhea, candidiasis, and fluid and electrolyte loss. 3. Skin Disorders Pharmacologic treatment of skin rash 4. Nutrition Multiple vitamin and mineral supplements Dietary supplements such as Ensure or equivalent Evaluation of weight and BMI

Basiophils

1. Leukemia 2. Anaphylaxis or hypersensitivity reactions 3. Fungal infections 4. Drop in # with Hyperthyroidism

Collaborative Care: Immunodeficiency

1. Monitor immune function 2. Nutrition 3. Prevent opportunistic infections 4. Monitor and treat opportunistic infections 5. Drug therapy

Clinical Management: Screening

1. No routine screenings for general population 2. Human immunodeficiency virus (HIV) screening for those with specific risk factors

Innate Immunity

1. Present at birth 2. NON-specific response not considered antigen specific 3. ANY natural protective feature of a person 4. provides IMMEDIATE protection against effects of tissue injury and foreign proteins- critical to health and well-being. 5. Causes VISIBLE symptoms and can rid body of harmful organisms; tissue damage may result from excessive response.

Common Diagnostic Tests: Primary Testing

1. Red blood cell count and white blood cell count with differential. 2. Fluorescent antinuclear antibody 3. C-reactive protein (CRP) 4. Erythrocyte sedimentation rate (ESR)

Primary Immunodeficiency (PI)

1. Situation wherein the entire immune defense system is inadequate and the individual is missing some or all of the components necessary for a complete immune response.

Review of Immune Response

1. Works to enhance the immune response and help rid the body of antibody antigen complexes 2. Comprised of 25 proteins- circulate in an inactive form in the blood. 3. Engage in a cascade of interactions when the first protein molecule (C1) encounters an antigen-antibody complex. (Cascade is responsible for the dilation and ultimate leaking of fluid from the vascular system, leading to the redness and swelling during the inflammatory process.

Symptoms of Exaggerated Immune Functioning

1. allergic symptoms 2. pain 3. fatigue 4. fever

Other Diagnostic Tests and Disease-Specific Testing

1. allergy testing 2. Genetic testing 3. Rheumatoid factors (RFs) 4. Western blot test 5. TORCH antibody panel 6. Organ function tests

Cancer vs. immunity

1. assess client for cancer 2. in treatment of some leukemia: destruction of the bone marrow before healthy stem cells may be reintroduced and a health immune system regrows; During process immune system is partially destroyed leaving individual immunocompromised. 3. In multiple myeloma, Hodgkin's disease and non-Hodgkins lymphomas: directly lead to immune system dysfunction and immunocompromise.

Exaggerated Immune Response- Chronic body-wide system disease

1. autoimmune disorder occurs when immune system attacks and destroys healthy cells of the "self" following a breakdown of what has been termed "self tolerance" 2. 80 autoimmune disorders identified- may have more than 1 simultaneously 3. Three potential outcomes for autoimmune disorder (destruction of body tissue, abnormal organ growth and change in organ function.)

Elements of Immune History

1. past medical history 2. family history 3. genetic history 4. current medications 5. allergies to medications or other substances 6. lifestyle behaviors 7. occupation 8. social environment

A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? 1) Fever 2) Intact skin 3) Inflammation 4) Lethargy

2) Intact skin Intact skin is considered a primary defense against infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.

A patient comes to the physician's office complaining of generalized malaise and states, "I just don't feel well." The nurse knows that the patient is in what stage of infection? A. Decline B. Illness C. Prodromal D. Convalescence

C. Prodromal The prodromal stage is characterized by complaints of vague, nonspecific symptoms.

Assess client for cancer

C.A.U.T.I.O.N.

Exaggerated Immunity response can occur from Environmental or medication exposure.

Foods, drugs, pollens, dust, molds, bee venom, vaccines, or serum may evoke a reaction. (NOTE: The EXAGGERATED response usually doesn't kick in to high gear until SECOND exposure. Example: kid eats peanut...gets sick. Next week same kid eats peanut...gets sick but also throat starts to close up.)

IgD

Found in Plasma Helps mature B Lymphocytes for specific responses

IgA

Found in the mucous membranes 1. Saliva, Tears, Colostrum, Bronchial, GI, prostate and vagina 2. Protects surfaces from invasion.

Suppressed immunity Risk Factors

Greater risk if you are: 1. Very young 2. Very old 3. Not immunized 4. Chronic illness (esp. HIV, but also diabetes, COPD, malnutrition, cancer).

Exaggerated Immune Response Type 1

IgE- mediated or atopic "allergic" 1. seasonal allergic rhinitis, bee sting 2. systemic anaphylactic reactions (bee sting)

Mr. Jefferson has an acute infection. If lab work reveals that IgM, but not IgG, is present in his blood, what can you conclude about this infection?

IgM is present the first time an individual is exposed to a particular pathogen. If IgG is not present, you can conclude that the exposure occurred less than 10 days ago.

Exaggerated Immune Response Type 3

Immune complex-mediated 1. systemic lupus erythematosus

Lymphocytes

In infants B-lymphocytes develop in the LIVER and T-lymphocytes in the THALAMUS 1. chronic BACTERIAL infections (Hepatitis) 2. VIRAL (Mono, mumps, measles) 3. Leukemia 4. Drop in # with SEPSIS

Immunodeficiency (Suppressed): Primary

Occurs as a result of improperly developed cells or an absence of cells required to execute immune responses.

Acquired Immunity: Passive: (NATURAL)

Occurs by the introduction of preformed antibodies either from an artificial or natural routes. EXAMPLE: From mother to fetus thru placental blood transference or colostrum transfer during breastfeeding.

Acquired Immunity: Passive: (ARTIFICIAL)

Occurs by the introduction of preformed antibodies either from an artificial or natural routes. EXAMPLE: Transfusion of immunoglobulin (IgG)

Systemic Lupus Erythematosus (SLE)

Occurs more often in women then men by a 10:1 ratio and African Americans are 8 times more likely to contract the disease than Caucasians and non-Hispanics.

Exaggerated Immunity

leads to autoimmune diseases and disorders such as: Rheumatoid arthritis, Systemic Lupus Erythematosus (SLE), etc.

Myeloid cells

neutrophils, monocytes, eosinophils, basophils, and mast cells.

Organs involved with immune response

termed "lymphoid" organs Include: bone marrow, thymus gland, spleen, tonsils, adenoids, and appendix. (Lymphocytes are formed, grow, mature and are released into the body from these organs.)

Altered Immunity: Suppressed

aka "Immunocompromised" or "Immunodeficiency" Individuals are unable to provide adequate immune defense against invasion. 1. significant risk for infection 2. risk for cancer if immunosupression occurs over time due to loss or removal of mutating cells.

Acquired immunity

immunity gained AFTER birth either actively or passively

Review of Immune Response (Complement System response).

1. 25 primary proteins 2. Amplifying and increasing the efficiency and efficacy of the other components of the immune system. 3. Contributes to the inflammatory response.

Suppressed immunity Pregnancy

Basically the baby is the "star of the show" in the belly, so the mother is immunocompromised until she gives birth. (NOTE: if mother is allergic to something and is exposed to it during pregnancy, the baby will have a good chance of having a EXAGGERATED immune response to the same thing later in life.)

Which of the following is not included in the body's secondary defense against a pathogen? A. Lysozymes in the saliva in the mouth B. Differentiation of monocytes into macrophages C. Release of histamine and other chemical mediators D. An oral temperature of 101.8°F (38.8°C)

A. Lysozymes in the saliva in the mouth Lysozymes are an example of the body's primary defense.

Collaborative Care: Exaggerated Immune Response

ANAPHYLAXIS 1. Support of airway, breathing, and circulation Subcutaneous epinephrine if type 1 reaction Other broncodialators Intubation and ventilator support circulatory volume expanders Vasopressors to maintain blood pressure and circulating volume. 2. Pharmacotherapy Subcutaneous epinephrine if Type 1 reaction Other broncodialators 3. Education: Avoiding contact with pathogen initiating anaphylactic response, proper use of an EpiPen for self-administration of epinephrine.

Cells associated with immune response

All cells are derived from stem cells in the bone marrow and begin as either myeloid or lymphoid cells.

Review of Immune Response (B Lymphocyte function)

B lymphocyte response 1. plasma cells 2. memory cells 3. Ig cells (immunoglobulins are primarily responsible for the body's response to invading bacteria and viruses and provide the humeral immunity component of an immune response)

Lymphoid cells

B lymphocytes, mature T lymphocytes, and natural killer cells.

A 64-year-old patient has peripheral vascular disease. In assisting the patient to decrease her risk for infection, the clinic nurse would teach her to do which of the following? A. Change her bath habits and only bathe twice a week B. Begin an exercise program of yoga to decrease her stress C. Eat a high-fiber, low-protein, low-calorie diet D. Refuse the flu vaccine because it can be dangerous for her

B. Begin an exercise program of yoga to decrease her stress Research has shown a positive correlation between stress and a decrease in immune functioning. Bathing only twice a week would not be enough to remove potentially harmful surface bacteria. Nutrients are needed to produce the cells of the immune system. Because this patient has a chronic illness, she should be encouraged to ask her healthcare provider for a flu shot; and flu vaccines are not considered dangerous.

Which of the following actions violates a principle that is key to proper handwashing at the bedside? A. Washing your hands for 1 minute B. Shaking your hands dry over the sink C. Using warm, not very hot, water D. Using the soap provided by the agency

B. Shaking your hands dry over the sink Shaking your hands will not completely remove the excess moisture, allowing for the reacquisition of bacteria on the area. In addition, it splashes water into the environment, which could be contaminated with organisms from the hands.

Exaggerated Immune Response Type 4

Cell-mediated or delayed hypersensitivity 1. Contact sensitivity to poison ivy and metals (Jewelry)

Optimal Immune Functioning

Clinical indicators of optimal immune functioning reveal an individual who: 1. Generally appears well- and well nourished 2. Vital signs WNP for age 3. Lymph nodes are soft, movable, not-tender (older adults may not have palpable ones) 4. Wounds are healing within a time frame of "normal" for type of wound.

Collaborative care: Exaggerated Immune Response 3

Clinical outcomes: 1. Adequate ventilation 2. Restoration of blood pressure and pulse to pre-reaction normal levels. 3. Adequate urine output indicating adequate circulatory volume. 4. Modulation of hypersensitivity response. 5. Management of pain experience 6. Maintenance of joint and muscle mobility; self-care for ADLs where possible; restoration or maintenance of adequate levels of physical activity.

Collaborative Care: Suppressed Immune Response 2

Clinical outcomes: 1. Normal GI transit time 2. Resolution of infection 3. Adequate hydration 4. Adequate nutrition 5. Resolution of skin rash 6. Restoration of adequate nutrition, body weight, and BMI

A patient who is HIV positive and immunocompromised develops an eye infection caused by the cytomegalovirus. The retinitis would be considered which of the following types of infection? A. Endogenous infection B. Primary infection C. Vector infection D. Secondary infection

D. Secondary infection The HIV infection is the primary infection. There is no vector involved in cytomegalovirus transmission, and it does not arise from the patient's own floras.

Acquired Immunity: Active (NATURAL)

Develops after the introduction of a foreign antigen resulting in the formation of antibodies or sensitized T lymphocytes. EXAMPLE: Exposure to infectious pathogens like chicken pox.

Acquired Immunity: Active (ARTIFICIAL)

Develops after the introduction of a foreign antigen resulting in the formation of antibodies or sensitized T lymphocytes. EXAMPLE: Immune response to an immunization

IgE

Exocrine secretions, plasma, and interstitial fluid 1. Think E-eosinophils, thus ENERGY 2. Trigger release of Histamine in mast and Basophil cells 3. involved in Anaphylaxis

Review of Immune Response (T lymphocyte function)

T lymphocyte response 1. Undergo differentiation on exposure to a foreign antigen, developing into subtypes of cells that may directly attack the antigen or stimulate the activation of other leukocytes 2. cytotoxic T lymphocytes attack and kill antigens directly with preference for viruses or mutated cells that have become cancerous (This process is termed "Cellular or cell-mediated immunity") 3. Several types of T lymphocytes (T-cells)

Immunodeficiency (Suppressed): Secondary

Loss of immune functioning as a result of an illness or treatment.

Secondary immunodeficiency

Other health problems develop for immunocompromised patients 1. increase in incidence of infection by bacteria and viruses 2. Development of super-infections (MRSA, C-diff) 3. Development of treatment-resistant fungal infections secondary to antibiotic treatment for primary bacterial infections.

IgG

PRIMARY and MOST ABUNDANT immunoglobulin. 1. Protects Newborns (crosses placenta) 2. Activates complement cascade 3. Binds to Macrophages; increase phagocytosis 4. 2nd responder

Antibody production

Secreted by B lymphocytes

Exaggerated Immune Response

Sounds good right? NOT!!! The body doesn't recognize it's own cells, so it starts attacking it. So your body is killing itself. These reactions are called: 1. Allergic reactions 2. Cytotoxic reactions 3. Autoimmune reactions.

Identify and describe the purpose of the body's three major lines of defense against infection.

The primary defense mechanisms prevent entry of pathogens into the body. Primary defense mechanisms include intact skin, mucous membranes at body openings, normal floras, and a rich vascular supply at potential sites of entry for infection, including the mouth and vagina. They also include processes such as crying, salivating, vomiting, peristalsis, and diarrhea. The secondary defense mechanisms are activated if a pathogen gains entry into the body. Secondary defense mechanisms include phagocytosis, the complement cascade, inflammation, and fever. Specific immunity, a third line of defense, protects against specific pathogens and builds immune "memory" in the process. The humoral response produces antibodies that inactivate invading antigens. The cell-mediated response results in the production of T cells that destroy body cells infected with invaders.

Exaggerated Immune Response Type 2

Tissue-specific or cytotoxic 1. autoimmune thrombocytopenic purpura, Graves' disease, autoimmune hemolytic anemia.

IgM

found in plasma; 1st responder! 1. 1st made by newborn 2. used in diagnostic testing (indicate infection) 3. Activates Complement 4. Natural antibodies (Kills Bacteria) 5. Involved heavily with ABO blood typing (Type 2) 6. Think M for MOM, you call your mom 1st