Immune system

Type IV

The client exposed to poison ivy comes to the clinic with a skin rash. What type of hypersensitivity reaction is he experiencing? Serum sickness Anaphylaxis Type IV Type III

Answer: B Rationale: A decreased humoral immune response reflects decreased antibodies. T cells are a part of cellular immunity. Leukocytes are part of both innate and cellular immunity but an increase indicates an effective response. Dendritic cells link innate and adaptive immune response.

The nurse assesses for which of the following laboratory results with a decreased humoral-mediated immune response? (Select all that apply.) A. Decreased peripheral T cells B. Decreased antibody response C. Increased antibodies D. Increased dendritic cells E. Increased leukocytes

Answer: A, B, D, and E Rationale: Immunosenescene refers to those changes that occur with aging and their consequences— increased infection risk, increased risk of malignancy, and increased autoimmune disorders. Cancer, pneumonia, and arthritis are more common in the elderly. Shingles is also more common in the elderly due an increased risk of viral infections because of atrophy of the thymus gland.

The nurse associates which of the following findings to immunosenescence in a 68-year-old woman? (Select all that apply.) A. Pneumonia B. Shingles C. Cervical dysplasia D. Cancer E. arthritis

Answer: C Rationale: Pain is the most common presenting symptom with shingles.

The nurse caring for a patient with herpes zoster incorporates which nursing diagnosis into the plan of care? A. Risk for bleeding B. Persistent fatigue C. Pain D. Inadequate nutrition

Answer: A, B, and C Rationale: Antibody, B-cell, and T-cell production are part of the adaptive immune response. Phagocyte and eosinophil production are associated with the innate immune response

The nurse correlates diminished adaptive immune responses with which of the following? (Select all that apply.) A. Decreased peripheral B cells B. Decreased antibody response C. Decreased peripheral T cells D. Decreased phagocytic capacity E. Decreased eosinophils

Answer: C Rationale: Long lasting post-herpetic neuralgia or persistent pain can develop with a shingles infection. Bedrest is not encouraged as active ambulation is important to prevent lung, skin, bowel, and DVT problems. There is no need to limit fluids. Antibiotics are not indicated for shingles as it is a virus.

The nurse includes which information in the teaching plan about the management of shingles? A. Limit fluid intake B. Encourage bedrest C. Post-herpetic neuralgia can develop D. Take antibiotics as directed

Answer: A, B, and E Rationale: Recurrent infections and chronic illness may reflect immune dysfunction. Certain medications such as chemotherapy or steroids may decrease immune function. Dietary history is always important but not specific to the immune system. Fracture history is also important but indicates issues with the musculoskeletal system.

The nurse includes which of the following in the past medical history evaluating the immune response? (Select all that apply.) A. Recurrent infections B. Chronic illness C. Dietary history D. History of fractures E. Medication history

Constipation Recurrent infections Cardiac abnormalities Hypocalcemia

The nurse is caring for a child with newly diagnosed DiGeorge's Syndrome. What symptoms will the nurse anticipate? Select all that apply. Constipation Recurrent infections Cardiac abnormalities Hypocalcemia Tachycardia

Severe shortness of breath Hypotension

The nurse is caring for a client with a type I hypersensitivity reaction and signs of anaphylaxis. Which symptoms support this diagnosis? Select all that apply. Severe shortness of breath Hypotension Bradycardia Increased urinary output Cardiac dysrhythmia

Answer: A and B Rationale: Worsening pain and fever should be reported to the physician as further evaluation and treatment may be required. Malaise, nausea and headache are common symptoms and should ease as the infection runs its course.

The nurse monitors for which advancing clinical manifestations in a patient diagnosed with shingles? (Select all that apply.) A. Worsening pain B. High fever C. Malaise D. Nausea E. Headache

Immunoglobulins

antibodies, that B cells produce include the following five classes: IgA, IgD, IgE, IgG, and IgM. IgA Dominant Ig found in secretory-gland secretions such as breast milk, sweat, saliva, mucus, and tears IgD Located primarily on the surface of developing B lymphocytes Plays a role in B-cell activation IgE The least concentrated Ig that acts as a mediator of many common allergic responses Also acts as a defender against parasitic infections IgG Most abundant of the immunoglobulins. Transported across the placenta and effective against bacteria, viruses, and other toxins. IgM Largest of the Igs First antibody produced during the primary response to an antigen Expressed by competent B cells

Lymphocytes

are active in both humoral and cell-mediated immune responses. - They are formed in the bone marrow and are found in the lymph nodes, spleen, and thymus and enter the bloodstream through the lymphatic system. • Natural killer cells • B Lymphocytes • Immunoglobulins • T Lymphocytes • Dendritic and mast cells

leukocytes

are formed in the bone marrow and lymph tissue; mature in the thymus or bone marrow; and are found in the blood, lymphatic system, spleen, and other body tissues - mobile units traveling through the bloodstream to defend the body against infection 5 Types • Neutrophils • Monocytes • Eosinophils • Basophils • Lymphocytes

Tonsils

are located between the palatine arches on either side of the pharynx. They function as traps to protect against bacteria and viruses that are inhaled.

Macrophages

are phagocytes and initiators of the inflammatory response that digest and destroy, or phagocytize, microorganisms and other debris. - They also activate helper T cells by secreting signaling proteins, called cytokines, and presenting processed antigens for destruction by the T cell. - in the bloodstream they are monocytes

B Lymphocytes

cells involved in humoral immune responses. - a subset of lymphocytes that mature in the bone marrow and produce antibodies, or immunoglobulins. - Antibodies bind with specific antigens, marking them for destruction by other components of the immune system, or directly neutralize the antigen by inhibiting an essential function necessary for its survival. - Once B cells are exposed to a specific antigen for the first time, they proliferate and differentiate into plasma cells and memory cells. - can function independently but typically require the help of T lymphocytes.

Lymph node

collection of stationary solid lymphatic tissue along lymph vessels

Natural killer (NK) cells

form of T cell, targets virus-infected and tumor cells. - As individuals age, the number of NK cells increases. - increase helps to control infections in the elderly and is important for successful aging.

Helper T cells

important cells in both adaptive and innate immunity. - augment the effectiveness of the innate immune response by activating macrophages. - augment both humoral and cellular immunity through the activation of B cells to produce antibodies. - activate cytotoxic T cells and natural killer cells.

Humoral-Mediated Immunity

Type of response Antibody mediated Cell type B lymphocytes (B cells) Defense modality Circulating antibodies Mechanism of defense Defends against extracellular microorganisms: bacteria, viruses

Cellular-Mediated Immunity

Type of response Cellular mediated Cell type T lymphocytes (T cells) Defense modality Circulating antibodies Mechanism of defense Defends against intracellular microorganisms: viruses, fungi, bacteria, tumor and transplant antigens

T Lymphocytes

- in cellular-mediated immune responses - activation occurs when macrophages present the T cell with a phagocytized antigen. - main functions include the elimination of cells infected by pathogens, continued activation of the inflammatory response against persistent infections, and regulation of innate and adaptive immune responses. include cytotoxic T cells, suppressor T cells, and helper T cells.

Pruritus Rapid onset of dyspnea Diarrhea Tachycardia

A client is admitted with an extreme anaphylactic reaction. Which symptoms demonstrate this? Select all that apply. Pruritus Rapid onset of dyspnea Diarrhea Crackles in the lungs Tachycardia

Granulocytes

A group of leukocytes containing granules in their cytoplasm; neutrophils, eosinophils, basophils.

Agranulocytes

A group of leukocytes without granules in their nuclei; lymphocytes, monocytes.

Answer: C Rationale: Shingles is a reactivation of varicella-zoster virus.

A nurse providing care for a patient with shingles understands that the illness is caused by reactivation of which of the following viruses? A. Cytomegalovirus B. Epstein-Barr virus (EBV) C. Varicella-zoster virus (VZV) D. Human Immunodeficiency Virus (HIV)

Complement system

Activation of the complement cascade • Ability to destroy pathogens • Activate every component of the inflammatory response

Tonsils, Adenoids, and Peyer's Patches

Additional lymphoid tissue -are located in close proximity to mucosal surfaces within the body and provide another means of protection against invading microorganisms.

ANATOMY AND PHYSIOLOGY OVERVIEW

Anatomy of the immune system • Thymus • Bone marrow • Spleen • Lymph nodes and lymphatic system • Tonsils, adenoids, and Peyer's patches • Cells

Spleen

Approximately the size of a fist, located in the left upper quadrant of the abdominal cavity. As a part of the lymphatic system, it serves as a blood filter. It is divided into compartments that contain red and white splenic pulp. The red pulp serves as the filtering site for old or damaged red blood cells. It can also store blood. The white pulp of lymphoid tissue houses lymphocytes and macrophages, filtering unwanted debris like a lymph node. Although it is a redundant organ in the immune system, if it is removed due to accident or disease, the patient may become immunocompromised, with high-risk patients requiring lifetime antibiotics.

Cleft palate, Gastroesophageal reflux, Recurrent infections, Cardiac abnormalities CORRECT. Assessment data the nurse should anticipate when providing care to a client diagnosed with DiGeorge's syndrome include recurrent infections, cardiac abnormalities, cleft palate, and gastroesophageal reflux. Hypocalcemia, not hypercalcemia, is also expected. Constipation, not diarrhea, is another assessment finding the nurse should anticipate.

Can you differentiate assessment data for immunodeficiency disorders? For each disorder, drag and drop the clinical manifestations associated with the specific disorder to the box. DiGeorge's Syndrome Recurrent infections Cardiac abnormalities Hypercalcemia Gastroesophageal reflux Diarrhea Cleft palate

Dyspnea, Vomiting, Bronchospasm, Urticaria, Stridor CORRECT. An extreme anaphylactic reaction is characterized by severe and rapid onset of symptoms. The client may experience bronchospasm with extreme dyspnea, shortness of breath, wheezing, urticaria, pruritus, nausea, vomiting, and diarrhea. Hoarseness and stridor, a high-pitched crowing sound that indicates narrowing of the airways, may also occur. Severe or untreated reactions result in anaphylactic shock with hypotension and tachycardia due to vasodilation and capillary leakage from the circulatory system to the interstitial space.

Can you differentiate assessment data for immunodeficiency disorders? For each disorder, drag and drop the clinical manifestations associated with the specific disorder to the box. Extreme Anaphylactic Reaction Dyspnea Vomiting Bronchospasm Insidious onset Hypertension Urticaria Stridor

Lymphadenopathy, Nephritis, Urticaria, Arthralgia, Angioedema CORRECT. Clinical manifestations associated with serum sickness include fever, joint pain, lymphadenopathy (swollen lymph nodes), malaise, possible polyarthritis (arthritis in multiple joints), nephritis (inflammation of the nephrons in the kidney), urticaria (hives), a patchy or generalized rash, or extensive edema involving the face, neck, and joints.

Can you differentiate assessment data for immunodeficiency disorders? For each disorder, drag and drop the clinical manifestations associated with the specific disorder to the box. Serum Sickness Lymphadenopathy Nephritis Urticaria Hypothermia Dependent edema Arthralgia Angioedema

Allergic rhinitis, Anaphylaxis, Bronchial constriction CORRECT. A type I hypersensitivity reaction is an immediate and rapid allergic reaction. The reaction of IgE antibody with antigen-releasing mediators like histamine causes allergic rhinitis, bronchial constriction, and anaphylaxis. Myasthenia gravis, rheumatoid arthritis, serum sickness, and latex allergies are types II, III, and IV.

Can you differentiate assessment data for immunodeficiency disorders? For each disorder, drag and drop the clinical manifestations associated with the specific disorder to the box. Type I Hypersensitivity Reaction Allergic rhinitis Anaphylaxis Latex allergy Bronchial constriction Serum sickness Myasthenia gravis Rheumatoid arthritis

Autoimmune thrombocytopenia purpura, Transfusion reaction, Goodpasture's syndrome CORRECT. Type II cytotoxic reaction occurs when IgG interacts with host cell membranes or antigens absorbed by the host cell membrane. These reactions include Goodpasture's syndrome, autoimmune thrombocytopenia purpura, and blood transfusion reactions. Histamine mediated, systemic lupus erythematosus, contact dermatitis and Graves' disease are types I, III, IV, and V reactions.

Can you differentiate assessment data for immunodeficiency disorders? For each disorder, drag and drop the clinical manifestations associated with the specific disorder to the box. Type II Hypersensitivity Reaction Histamine mediated Goodpasture's syndrome Systemic lupus erythematosus Contact dermatitis to poison ivy Autoimmune thrombocytopenia purpura Transfusion reaction Graves' disease

Rheumatoid arthritis, Serum sickness, Systemic lupus erythematosus CORRECT. Type III immune complex reactions are a formation of immune complex of antigen and antibodies deposited in the walls of blood vessels, resulting in complement release and inflammation. Systemic lupus erythematosus, serum sickness, and rheumatoid arthritis are examples of this type. A positive TB skin test and asthma are types I and IV. Parkinson's disease is not associated with autoimmune disorders.

Can you differentiate assessment data for immunodeficiency disorders? For each disorder, drag and drop the clinical manifestations associated with the specific disorder to the box. Type III Hypersensitivity Reaction Rheumatoid arthritis Parkinson's disease Systemic lupus erythematosus Asthma Serum sickness Positive TB skin test

Positive reaction to a TB skin test, Skin rash from poison ivy, Latex allergy CORRECT. Type IV hypersensitivity reactions are delayed reactions that are T-cell mediated. They include dermatitis from poison ivy, TB skins tests, and latex allergy. B-cell gammopathies are type V reactions, osteoarthritis is non-autoimmune, and scleroderma in autoimmune but not a hypersensitive reaction.

Can you differentiate assessment data for immunodeficiency disorders? For each disorder, drag and drop the clinical manifestations associated with the specific disorder to the box. Type IV Hypersensitivity Reaction Positive reaction to a TB skin test Skin rash from poison ivy Osteoarthritis Latex allergy Scleroderma B-cell gammopathies

Answer: D Rationale: Thymus and bone marrow are central lymphoid organs. Secondary lymphoid, or peripheral, organs include the spleen, lymph nodes, tonsils, adenoids, and Peyer's patches.

Central lymphoid organs include which of the following? A. Spleen and tonsils B. Bone marrow and lymph nodes C. Thymus and Peyer's patches D. Thymus and bone marrow

lymphatic system

Composed of a network of vessels, ducts, nodes, and organs. Provides defense against infection.

Box 18.1 Comprehensive Patient History

Current Problem • Constitutional: fevers, chills, night sweats, weight loss, fatigue, malaise, rashes • Dizziness; changes in mental status, memory, gait • Shortness of breath, cough, wheezing • Chest pain, palpitations, presyncope, syncope • Loss of appetite, nausea, vomiting, diarrhea, abdominal pain • Bleeding: site, characteristic, associated symptoms • Enlarged nodes: site, characteristic, associated symptoms, predisposing factors • Joint pain, stiffness, swelling, muscle weakness, myalgias, arthralgias • Extremity swelling: unilateral/bilateral, characteristic, predisposing factors, associated symptoms, treatment • Medications: chemotherapy, immunosuppression, antibiotics/antivirals, interferon, leukotriene antagonists • Allergies and severity of reactions • Physical activity and tolerance Past Medical and Surgical History • Childhood illnesses • Medications: chemotherapy, antibiotics, immunosuppression, steroids • Malignancy • Recurrent infections • Surgery or trauma (splenectomy) • Chronic illnesses with or without risk factors • Blood transfusions • Tuberculosis (TB) or other infectious history Immunization History • Immunizations based on current Centers for Disease Control and Prevention (CDC) immunization guidelines Family History • Malignancy • Anemia • Recent infections • TB history • Immune disorders • Hemophilia Social History • Lifestyle factors • Smoking status • Alcohol intake • Illicit drug use • Recent foreign travel • Employment history • Environmental exposure history

Function Evaluated: Humoral immunity

Diagnostic Test: Antibody production: • Total immunoglobulin (Ig) levels: IgA, IgG, and IgM • Levels of antibodies against vaccines B-cell numbers: • Lymphocytes with surface Ig • Flow cytometry Test Interpretation: Presence of antibody-producing B cells Ability to produce IgM, IgG antibodies Presence of circulating B cells

Function Evaluated: Leukocyte and lymphocyte evaluation

Diagnostic Test: Bone marrow evaluation: • Bone marrow aspiration • Bone marrow biopsy Test Interpretation: Status of blood-forming tissue Presence of hematological malignancies or primary bone marrow disorders Nursing Considerations: Prepare the patient for procedural specifics, including positioning and technique, pain or discomfort, and risk of bleeding or infection.

Function Evaluated: Complement

Diagnostic Test: Complement component: • Complement CH50 • Complement C3 level • Complement C4 level • Complement fixation ratio Test Interpretation: Decreased if secondary deficiencies or autoimmune disorders Decrease can increase risk for pulmonary infections Decrease present with immune complex disease Immunofluorescence to detect antigen-antibody reactions

Leukocytes

Diagnostic Test: Complete blood count with differential Leukocyte (white blood cell) total Differential: • Neutrophils • Lymphocytes • Monocytes • Eosinophils • Basophils • Absolute neutrophil count (ANC) • Absolute lymphocyte count (ALC) Test Interpretation: Measures total leukocytes, with a breakdown of leukocyte types and percentage present Increases in leukocytes with an increase in immature neutrophils, also know as band neutrophils, indicates infection or inflammation; referred to as a left shift Normal values: 4.5-11.1 103/mm3 Normal values: Number (%) 6,300 (40-70) 4,100 (20-40) 1,800 (2-8) 250 (1-3) 60 (less than 1) ANC calculates number of neutrophils available for fighting bacterial infections ALC calculates number of lymphocytes available to fight viral and opportunistic infections Nursing Considerations: For all testing, provide patient teaching on what to expect, what the test is, and why it is being done.

Function Evaluated: Cellular immunity

Diagnostic Test: Delayed hypersensitivity skin test: • Skin test to measure reaction to exposed antigens T-cell numbers: • Numbers of T cells reacting to sheep erythrocytes or CD3 or CD11 antigen T-cell proliferation: • Proliferation response to mitogens (substances that stimulate mitosis) • Proliferation response to antigens Test Interpretation: Presence of antigen-responsive T cells Presence of circulating T cells Ability of T cells to divide with nonspecific stimulation Ability of antigen-reactive T cells to respond to antigens

Function Evaluated: Inflammation

Diagnostic Test: Erythrocyte sedimentation rate C-reactive protein Test Interpretation: Screening for presence of inflammatory process Detected if inflammatory process or tissue destruction is present

Function Evaluated: Specific antigen-antibody panels

Diagnostic Test: Hepatitis A or B, cytomegalovirus, or respiratory syncytial virus Test Interpretation: Immunofluorescence to detect antibodies or core antigens to specific viral antigens

Function Evaluated: Phagocytic cell function

Diagnostic Test: Nitroblue tetrazolium test Test Interpretation: Status of phagocytic cell function to evaluate for chronic granulomatous disease

Function Evaluated: Organs and structures

Diagnostic Test: Radiologic imaging: computed tomography scan, magnetic resonance imaging, ultrasound, positron emission tomography (PET) scan Test Interpretation: Imaging to detect presence of lymphadenopathy, tumor formation, or metastatic disease Nursing Considerations: If contrast necessary, confirm absence of iodine allergy or previous contrast intolerance. Patient may be NPO for a period of time prior to the scheduled test. If patient claustrophobic, sedation may be necessary. For PET scan, blood sugar must be under 200 mg/dL.

Function Evaluated: Hypersensitivity

Diagnostic Test: Tissue allergy panel Test Interpretation: Ability to mount an antibody response to an injected antigen Nursing Considerations: Prepare the patient for possible discomfort at injection site and positive wheal reaction.

Mast cells

Differentiated from bone marrow cells Found in tissue Innate immune response/inflammation Release histamine, heparin when stimulated Associated with allergic reactions Similar to basophils

Adenoids

Located at the nasopharyngeal border - defend against inhaled bacteria and viruses

Lymph nodes and lymphatic system

Monitor the composition of lymph; engulf pathogens; stimulate immune response

Answer: D Rationale: The immunity acquired by the infant from mom is passive immunity. Humoral- and cell-mediated immunity are active adaptive processes.

The nurse understands that immunity acquired by an infant through his or her mother is an example of which type of immunity? A. Cell-mediated immunity B. Humoral-mediated immunity C. Adaptive immunity D. Passive immunity

Answer: A Rationale: Skin is a mechanical barrier to protect against infection. Teeth are not a barrier to infection. B and T cells are a part of the adaptive immune response.

The nurse understands which of the following is an important component of the innate immune response? A. Skin B. T cells C. B cells D. Teeth

Epinephrine

Which medication is used to treat type I hypersensitivity reactions? ACE inhibitor Bronchodilator Epinephrine Electrolyte replacement

Answer: A, C, and D Rationale: Neutrophils, basophils, and eosinophils are all phagocytic granulocytes. Agranulocytes include monocytes and lymphocytes.

Which of the following cells are classified as granulocytes? (Select all that apply.) A. Basophils B. Monocytes C. Neutrophils D. Eosinophils E. Lymphocytes

Answer: C and D Rationale: Total lymphocyte count is helpful in evaluating both humoral and cellular immunity. The production of helper T cells is a part of the cellular mediated response. Total Ig levels, specific antibody response evaluate humoral immunity. A CBC evaluates the body's response to inflammation/infection as part of innate and humoral immunity

Which of the following diagnostic tests is drawn to assess cellular immunity? (Select all that apply.) A. Total Ig levels B. Specific antibody response C. Total lymphocyte count D. Helper T-cell functions E. Complete blood count

Answer: B Rationale: Staying away from people with a compromised immune function such as a renal transplant patient on immunosuppressive drugs is key for a patient with an active shingles infection as those patients are especially susceptible to infection. Maintaining a normal schedule is possible as long as the patient is comfortable. Blisters are a common presenting symptom and do not need to be reported after initial assessment. Fluid restriction is not necessary

Which statement by Ms. Hill indicates that teaching has been effective? A. "I'm so glad I can continue my exercise schedule." B. "I need to stay away from my aunt who had a kidney transplant." C. "So I should contact you if I have more blisters appear?" D. "I don't drink a lot of fluids so it shouldn't be hard for me to limit my fluid intake."

Answer: C Rationale: Bone marrow biopsy may reveal leukemia. Lymph nodes do enlarge with immune system disorder. The need for a bone marrow biopsy may cause anxiety necessitating the need for antianxiety medication, but the procedure itself does not carry a risk of death.

Which statement by a patient undergoing a bone marrow biopsy indicates a need for additional teaching? A. "My lymph nodes are enlarged because of my immune system disorder." B. "I might need something to calm my nerves before having this biopsy." C. "Odds are that I will die from this procedure." D. "My biopsy results may show that I have a problem with my immune system."

Bone marrow

Within the cavities of bone - myeloid tissue, consisting of red (active) marrow and yellow (inactive) marrow. This is where B- and T-lymphocyte formation and differentiation of B cells and T cells occur. B cells stay within the bone marrow to mature. T cells migrate to the thymus to mature and become active as regulatory T cells (suppressor T cells) or effector T cells (helper T cells and cytotoxic T cells

Thymus

a soft organ located within the chest cavity near the heart. It is large in children and decreases in size into adulthood. It is the central lymphoid organ that produces thymosin (a hormone that stimulates T-cell production) and is where T-cell development takes place

Suppressor T cells

activated by helper T cells when the immune response is no longer needed.

Peyer's Patches

lymphoid follicles located on the mucosa of the small intestine. They are known as intestinal immune sensors and defend against pathogens that gain entry to the intestinal tract.

Monocytes

monocytes are a part of the adaptive immune response, presenting pathogens to T cells for destruction. - In the tissue, they develop into macrophages and are a part of the tissue macrophage system.

Neutrophils

phagocytes of early inflammation that destroy bacteria

Eosinophils

phagocytes that destroy allergens and combat parasitic infections

Basophils

release heparin as an anticoagulant and histamine during the early inflammatory response

Cytotoxic T cells

respond to foreign cells, including tumors, non-self cells, and virus-laden cells.

Memory cells

restimulated by the same antigen, mount a specific antigen-antibody response, sometimes long after the initial exposure.

Plasma cells

secrete antibodies after the first exposure to the antigen.

Dendritic and mast cells

type of macrophage that reside in lymphoid tissue and are the most potent of the antigen-presenting cells (APCs). APCs capture and engulf antigens, producing a molecule, the major histocompatibility complex (MHC), that identifies the antigen to aid in T-cell and B-cell recognition and response.

Inflammatory response (2nd line defense)

• Acute cellular injury

Adaptive immune response (3rd line defense)

• Cellular-mediated response (T cell) • Activated to defend against intracellular microorganisms • Humoral-mediated response (B cell) • Occurs in reaction to an antigenic challenge

Past Medical and Surgical History (questions)

• Childhood illnesses • Medications: chemotherapy, antibiotics, immunosuppression, steroids • Malignancy • Recurrent infections • Surgery or trauma (splenectomy) • Chronic illnesses with or without risk factors • Blood transfusions • Tuberculosis (TB) or other infectious history

Current Problem (questions)

• Constitutional: fevers, chills, night sweats, weight loss, fatigue, malaise, rashes • Dizziness; changes in mental status, memory, gait • Shortness of breath, cough, wheezing • Chest pain, palpitations, presyncope, syncope • Loss of appetite, nausea, vomiting, diarrhea, abdominal pain • Bleeding: site, characteristic, associated symptoms • Enlarged nodes: site, characteristic, associated symptoms, predisposing factors • Joint pain, stiffness, swelling, muscle weakness, myalgias, arthralgias • Extremity swelling: unilateral/bilateral, characteristic, predisposing factors, associated symptoms, treatment • Medications: chemotherapy, immunosuppression, antibiotics/antivirals, interferon, leukotriene antagonists • Allergies and severity of reactions • Physical activity and tolerance

DIAGNOSTIC STUDIES

• Diagnostic studies to evaluate state of an individual's immune competence • Blood tests • Skin tests • Bone marrow aspiration and biopsy • Radiological imaging • Immune deficiencies • Primary • Secondary

Leukocytes classes

• Granulocytes • Agranulocytes

AGE-RELATED CHANGES

• Immune competence may decrease as immune system changes and weakens with age • Aging has been noted to negatively affect: • Innate immune response • Adaptive immune response • Immunosenescence • Innate and adaptive immune responses actively provide defenses against tumor cells (These responses decline with aging, creating an increased incidence of cancers. Older adults are also noted to have a decline in T-cell production and function and in antibody production when exposed to specific antigen challenges. They also tend to have an increase in the production of autoantibodies, leading to autoimmune disorders. A decrease in B-cell production and function and antigen-specific Ig activity may also be seen, creating a diminished immune memory and delayed hypersensitivity reactions. Malnutrition, which is associated with immune system defects, is sometimes seen in the older individual as a result of chewing and swallowing problems, blunted taste sensations, and chronic conditions that interfere with the absorption of food and nutrients.) (Atrophy of the thymus gland enhances with age, increasing the risk of viral infections)

INTRODUCTION to immunity

• Immune system and immunity • Innate and adaptive immune responses provide 3 lines of defense against unwanted antigens • • Innate (natural) immunity • • Inflammatory response • • • Interferon (IFN) • • • Complement • • • Phagocytosis • • Acquired (adaptive) immunity

Immunization History (questions)

• Immunizations based on current Centers for Disease Control and Prevention (CDC) immunization guidelines

IMMUNE FUNCTION PHYSIOLOGY

• Innate immune response (1st line defense) • Physical and mechanical barriers • Biochemical barriers • Inflammatory response (2nd line defense) • Acute cellular injury • Initiation of the inflammatory response • Vasodilation with increased capillary permeability • Increases blood flow and leukocyte movement •Adaptive immune response (3rd line defense) • Cellular-mediated response (T cell) • Activated to defend against intracellular microorganisms • Humoral-mediated response (B cell) • Occurs in reaction to an antigenic challenge

Cytokines

• Interleukins • Tumor necrosis factor alpha are small proteins that act to regulate immune responses. -They are produced in response to specific antigens by cells of the acquired immune system. -They have systemic and local signaling effects that enable them to signal cells of the immune system.

Social History (questions)

• Lifestyle factors • Smoking status • Alcohol intake • Illicit drug use • Recent foreign travel • Employment history • Environmental exposure history

Family History (questions)

• Malignancy • Anemia • Recent infections • TB history • Immune disorders • Hemophilia

Innate immune response (1st line defense)

• Physical and mechanical barriers • Biochemical barriers

Initiation of the inflammatory response

• Vasodilation with increased capillary permeability • Increases blood flow and leukocyte movement

ASSESSMENT OF THE IMMUNE SYSTEM

•History • Physical examination •Inspection (inspect are changes in skin color and skin integrity, rashes, dermatitis-type lesions, hematomas, petechiae, or purpura) •Auscultation (Listen to the lungs for adventitious (abnormal) breath sounds such as crackles, wheezing, rubs, or rhonchi. Also note if there is any decrease in or absence of breath sounds. Listen to heart sounds; note if tachycardia, rubs, or irregularity of heart rhythm is present. Check for bowel sounds and note if they are hyperactive, hypoactive, or absent.) •Palpation and percussion (lymph nodes for evidence of enlargement or tenderness; enlargement of the liver or spleen)