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 that causes an immune response

Anything that can trigger an immune response

Types 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 (IL)

Interferons – attack viruses and tumors

Growth factors

Tumor 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 – anaphylactic shock

Cell – 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 or vaccination

Purpose – 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 tissue decreased – Malignancies increase

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

Family history – genetic component may cause disorder

Family allergies atopic reactions – identify risk

Interview 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 or weakness

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

wasting

Observe mobility – note stiffness or difficulty moving

Check 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 – narcotic analgesic

Apply sterile pressure dressing after procedure

Assess biopsy site for bleeding

May 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 is called an allergen

Tissue 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 capillary permeability

Smooth muscle contraction (spasms)

Bronchospasms (Bronchoconstriction)

Activation 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 SSx

Maintain patent airway (airway management takes highest priority)

Prevent spread of allergen using tourniquet

Administration of drugs

Treatment of shock

Nursing Care
ABCs, vital signs, history of onset

Establish and maintain airway

Prompt notification of MD and preparation for emergency measures

Oxygen 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 early SSx; explain disorder in “lay terms”

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

of epinephrine; Medic-Alert tag or bracelet

Importance of F/U

Read all drug labels; KNOW NAMES OF MEDS

Be aware of foods that cause reactions

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

For 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 self-admin. of meds

Side 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 include itching, erythema and raised lesions

Organ 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 dermatitis: erythema and pruritis at area of contact-

Type 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)