ncm 104 - immunology

8/8/2019 NCM 104 - Immunology

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Nursing Care Management 104


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Definition

Function


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Immune Systemy Constellation of responses to attacks from outside the

body.

y Cell and proteins which protect body from antigen.(viruses, bacteria, fungi )

y Immunity the bodys ability to resist infection.

y Maintains homeostasis

y Monitors degradationy Removal of damaged cells

y Discovers and destroys abnormal cells


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Immune Systemy General hosts

y Differentiate self from non self

y

Inflammation followed by phagocytosisy Specific Immune response

y Specific microorganism activates response

y T cells and B cells produce responses

y

Prevent organism entryy Physical

y Chemical

y Mechanical barriers


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Immune Systemy Antigen

y Substance foreign to the body

y Antibody (Immunoglobulins)y Molecule made by lymph tissue

y Defends body against bacteria, viruses, or other foreignbodies (antigens)

y Each antibody reacts to a certain foreign bodyy Allergen substance that causes inappropriate immune

response (allergy)

y Major Histocompatibility ComplexMain Menu


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Formation, development, and specialization

of all functional blood cells

Back


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Cells of the Immune System

y Cells destined to become

immune cells, like allblood cells, arise in thebone marrow from so-called stem cells.


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T-Cellsy T helper

y Apertinent coordinator ofimmune regulation.

y

To augment or potentiateimmune responses byactivating other WBC.

y T killer/suppressory Directly killing certain tumor

cells, viral-infected cells and

sometimes parasites.y also important in down-

regulation of immuneresponses.


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Natural KillerCells

y Effector cells that directly

kill certain tumors such asmelanomas, lymphomasand viral-infected cells,most notably herpes andcytomegalovirus-infectedcells.


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BCells

y Production ofantibodies in response

to foreign proteins ofbacteria, viruses, andtumor cells.


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y Granulocytesy composed of neutrophils,

eosinophils and

basophils, based on theirstaining characteristicswith certain dyes.

y Important in the removalof bacteria and parasitesfrom the body.


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yMacrophagesy regulation of immune

responses.

y Scavengers - pick up and

ingest foreign materialsand present these antigensto other cells

y Initiation of an immune

response


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Monocytes (2-6%) circulate in the blood

Macrophages found in body tissues Scavengers Secrete a wide variety of powerful

chemicals Activates T cells.

Phagocytes and Granulocytes


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Neutrophils (40-75%) Circulate in blood but move into tissues PRN Contain granules filled with potent chemicals Destroys microbes + key role in acute

inflammatory reactions.

Eosinophils(2-5%) Allergy, suppresses inflammation & helminthes

(parasitic worm) infection, Decrease granulocyte migration

Basophils(0.2-0.5%)

inflammatory mediator release Mast cells

granule-containing cells in tissue.


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Activation of B cells to make Antibody

y AB Cell uses one of itsreceptors to bind to itsmatching antigen, which the Bcell engulfs and processes.

y

The B cell then displays a pieceof the antigen, bound to aClass II MHC (majorhistocompatibility complex)protein, on the cell surface.

y This whole complex then binds

to an activated helper T cell tostimulates the transformationof the B cell into an antibody secreting Plasma cell.


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Immunoglobuliny ImmunoglobulinG / IgG (75%)

y Found in serum and tissue (instertitial fluid)

y A

ssumes a major role in blood and tissue born pathogeny Activates complement system

y Crosses the placenta

y ImmunoglobulinA/ IgA(15%)y Appears in the body fluid e.g. saliva, sweat,pulmo,

gastro, repro

y Prevents absorption of antigen from food

y Passes to neonates in breast milk


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Immunoglobuliny Immunoglobulin M / IgM (10%)

y Appears in the intravascular serum

y First Ig produced in response to bacterial and viral

y Activates the compliment system

y ImmunoglobulinD / IgD (0.2%)y Appears in small amount serum

y Influences B lymphocyte to differentiate

y Immunoglobulin E / IgE (.004%)y Appears in serum

y Takes part in allergic and hypersensitivity reaction

y Parasitic infection


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T - Cellsy T cells attacks and destroys

diseased cells they recognize asforeign.

y T lymphocytes are responsible

for cell-mediated immunity (orcellular immunity).

y T cells also orchestrate,regulate and coordinate theoverall immune response.

y T cells depend on unique cell

surface molecules called theMajor HistocompatibilityComplex (MHC) to help themrecognize antigen fragments


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T - Cellsy Immature T cells (termed T Stem cells)

y Migrate to the thymus gland in the neck, where theymature and differentiate into various types of mature T

cells.y Killer T cell

y Helper T cell

y Suppressor T cell

y Memory T cell

y Produce substances called Cytokinesy Interleukins which further stimulate the immune response.


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T Cells - Typesy Cytotoxic or killer T cells (CD8+)- do their work by releasing lymphotoxins,

which cause cell lysis

y HelperT cells (CD4+) - serve as managers, directing the immune response,

y

secrete chemicals called lymphokines that stimulate cytotoxic T cells andB cells to grow and divide, attract neutrophils, and enhance the ability ofmacrophages to engulf and destroy microbes

y SuppressorT cells

y a component of the immune system that suppress immune responses of other cells.

y These cells are involved in closing down immune responses after they have

successfully tackled invading organisms and also in keeping in check immuneresponses that may potentially attack one's own tissues ("autoimmunity").

y MemoryT cells - programmed to recognize and respond to a pathogen once ithas invaded and been repelled.


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Lymphatic Systemy The lymphatic system is a complex network of

lymphoid organs, lymph nodes, lymph ducts,

lymphatic tissues, lymph capillaries and lymph vessels.y They produce and transport lymph fluid from tissues

to the circulatory system.

y The lymphatic system is a major component of the

immune system.


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Lymphatic System Functions:y To collect and return interstitial fluid, including

plasma protein to the blood, and thus help maintain

fluid balance.y To defend the body against disease by producing

lymphocytes

y To absorb lipids from the intestine and transport them

to the blood.


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Lymphoid Organsy ThymusGland

y Red Bone Marrow

y Spleeny Lymph nodes

y Peyers Patches

y Tonsils

y Adenoid

yVermiformAppendix


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Natural (innate)

Acquired (adaptive)

Response to infection


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Innate (natural Immunity)y Provides a non specific response to invader

y Basis is their ability to recognize self and non self

y

Natural mechanismy Includes Physical and chemical barriers (Normal Flora)

y Skin

y Genitourinary

y Respiratory

y Muco cilliary actiony Cell of the innate immune response

y Inflamatory response

y Complement response


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Inflammatory Responsey The complex biological response of vascular tissues to

harmful stimuli, such as pathogens, damaged cells, orirritants

y Acute Inflammationy initial response of the body to harmful stimuli

y achieved by the increased movement of plasma andleukocytes from the blood into the injured tissues.

y cascade of biochemical events propagates and maturesthe inflammatory response, involving the local vascularsystem, the immune system, and various cells within theinjured tissue.


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Inflammatory Responsey Chronic Inflammation

y Prolonged inflammation

y

leads to a progressive shift in the type of cells which arepresent at the site of inflammation and is characterizedby simultaneous destruction and healing of the tissuefrom the inflammatory process.


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Causes ofAcute Inflammationy Microbial infections

y Hypersensitivity reactions

y Physical agents Irritant and corrosive chemicalsy Tissue necrosis


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Five Cardinal Symptoms ofAcute

Inflammationy Redness (rubor)

y Heat (calor)

y Swelling (tumor)y Pain (dolor)

y Loss of Function


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Vas ilatati n

CellularInjury

Temp ra

ryVas c nstricti ns

IncreasePermeability

IncreaseBlfl w

Heat (Cal r)

Re ness (Rub r)

Plasma Leak inttheaffecte part

Swelling (Tum r)

Increase NervePressure

Pain (Dolor)LOSSOF

FUNCTION

Hi i C l dil i d h i di i h f


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Histamine Causes vascular dilatationand the immediate transient phase ofincreased vascular permeability

stored in mast cells, basophil and eosinophil leukocytes, andplatelets

Lysosomalcompounds

released from neutrophils

increase vascular permeability

Prostaglandins a group of long-chain fatty acids derived from arachidonic acid and

synthesized by many cell types

prostaglandins potentiate the increase in vascular permeability

Leukotrienes synthesized from arachidonic acid, especially in neutrophils, andappear to have vasoactive properties

a mixture of leu otrienes is involved in type I hypersensitivity5-hydroxytryptamine(serotonin)

a potent vasoconstrictor

present in high concentration in mast cells and platelets

Lymphokines family of chemical messengers released by Iymphocytes


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Plasma Factorsy Complement system

y cascade system of enzymatic proteins activated duringinflammatory response

y

Coagulation systemy responsible for the conversion of soluble fibrinogen into

fibriny activate the coagulation, kinin and fibrinolytic systems

y Kinin system (stimulates pain receptors)y

activated by coagulation factory Bradykinin is also a chemical mediator of pain

y Fibrinolytic systemy Plasmin is responsible for the Iysis of fibrin into fibrin

degradation products


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Complement Systemy Circulating Plasma proteins made in the liver

y Activated when Antigen-antibody connects

y It coats microbes with molecules that make them more

susceptible to engulfment by phagocytesy They also encourage polys to adhere to the walls of

capillaries (margination) from which they can squeezethrough in a matter of minutes to arrive at a damaged area

y Emigration by squeezing of the wandering macrophagesthrough the capillary walls to the tissue

y Extravasation also know as diapedesis

y Once phagocytes do their job, they die and their"corpses," pockets of damaged tissue, and fluid form pus.


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Immunity

Acquired

Passive Active

Natural Artificial Natural Artificial


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Types ofAcquired Immunityy Acquired Active Immunity (exposure)

y The immunologic defenses are developed by the

persons own body in response to the presence ofantigens.

y Immunity last many years or even lifetime.

y Acquired Passive Immunity (transferred)

y Atemporary immunity transmitted from another sourcethat has developed immunity.


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Acquired Activey NaturallyAcquired Active

y Exposure to different pathogens leads to infections,

which result in a protective immune response againstthese pathogens.

y ArtificiallyAcquired Active

y Vaccine used for active immunization consist of live(attenuated) organism, killed whole organism, microbialcomponents or secreted toxin.


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Acquired Passivey NaturallyAcquired Passive

y Immunity is transferred form mother to fetus through

placental transfer of IgG

or colostral transfer of IgA

.y ArtificiallyAcquired Passive

y Artificially transferred by injection of gamma globulinsfrom other individual or gamma globulins from animmune animal.


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Phagocytic

Humoral

Cellular

Stages of Immune Response

Recognition

Proliferation

Response

Effector


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Phagocytosisy Involves WBC and Macrophages

y Has the ability to ingest foreign matter

y

They also responsible for removing bodys dead celly Cell in the necrotic tissue release a substance that cause

inflamatory response

y Apoptisis programmed death cell

Main Menu


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Antigen Recognition

Antigen Antibody Binding


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Antigen Recognitiony The mechanism by which the B lymphocytes

recognize the invading antigen and respond byproducing antibodies.


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Role ofAntibodiesy Defend against foreign

invaders in several ways.

y Agglutination bind orclumping together of antigenand antibody that helps clearthe body of the invadingorganism by facilitatingphagocytosis.

y Opsonization coating stickysubstances that facilitates

phagocytosis.y Each antibody molecule

consist of two subunits, each ofwhich contains a light and aheavy peptide chain.


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Antigen Antibody Binding

y AntigenicDeterminanty The portion of the

antigen involve in

binding with theantibody.

y Lock-and-key situationy The binding of the Fab

fragment (antibody-binding site) to theantigenic determinant.


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Role of T - Lymphocytes

Role of Null Lymphocytes and Natural Killer (NK) Cells


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Cell Mediated Immunityy CD - stands for Cluster ofDifferentiation(CD8+ is read

"CD8 positive)

y The large number of molecules on the surfaces oflymphocytes allows huge variability in the forms of thereceptors

y They are produced with random configurations on theirsurfaces


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I. Recognition StageII. Proliferation StageIII. Response Stage

IV. Effector Stage


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I. Recognition Stage

y Recognize invaders asforeign

y Presentation to the

macrophagesy Macrophages plays an

important role inprocessing the antigen


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II. Proliferation Stagey The dormant lymphocytes proliferate and differentiate

into cytotoxic (killer) T Cells or B Cells responsiblefor formation and release of antibodies


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III. Response Stagey The cytotoxic T cell and the B Cell perform cellular

and humoral function respectively.


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IV. Effector Stagey Antigens are destroyed or neutralized through the

action of antibodies, complement, macrophages andcytotoxic T Cells.


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History

Physical Assessment


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HISTORYy Age

y Life style

y

Nutritiony Recent exposure to pathogen

y Drug intake

y immunization

y History of immune disorder


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Respiratoryy Changes in respiratory rate

y Cough (dry or productive)

y Abnormal lung soundsy Rhinitis

y Hyperventilation

y

Bronchospasm


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CardiovascularyHypotension

yTachycardia

yDysrhytmia

yVasculitis

yAnemia


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GenitourinaryyFrequency and burning on urination

yHematuria

yDischarge


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GastrointestinalyHepatosplenomegally

yColitis

yVomiting

yDiarrhea


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Skiny Rashes

y Lesion

yDermatitis

y Hematoma or purpura

y Edema or urticaria

y Inflammation

y Discharge


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Neurosensoryy Cognitive dysfunction

y Hearing loss

y

Visual designy Headaches and migraine

y Ataxia

y Tetany

Main Menu


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Leukocyte and Lymphocyte Tests

Humoral (Antibody Mediated) Immunity Test

Cellular (Cell Mediated) Immunity Test

Phagocytic Cell Function TestComplement Component Test

Hypersensitivity Test

HIV Infection Test


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Overviewy Caused by an oversensitive immune system

y An allergic reaction is when the immune system reacts

to substances (allergens) that are generally harmlessand in most people do not cause an immune response.


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y In a person with allergies, the first exposure to theallergen triggers the immune system to recognize thesubstance.

y Succeeding exposurewill usuallyresult in symptoms.


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yWhen an allergen enters the body of a person with asensitized immune system, histamine and otherchemicals are released by certain cells.

y This causes itching, swelling, mucus production,

muscle spasms, hives, rashes, and othersymptoms.

y Symptoms vary in severity from person to person.


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ySome disorders may be associated with allergies.These include eczemaand asthma, amongothers.

y Commonallergens include those that contactthe skin, breathing passages, or the surface of the

eye (such as pollen; see also allergy to mold,dander, dust).

y Food allergies and drugallergies are common.y Allergic reactions can be caused by insect bites,

jewelry, cosmetics, and almost any substance thatcontacts the body.


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Signs & Symptomsy runny nose

y tearing eyes, burning oritching eyes

y red eyes, conjunctivitisy swollen eyes

y itching nose, mouth,throat, skin, or any other

area

ywheezing

y coughing

y difficulty breathing

y hives (skin wheals)

y skin rashes

y stomach cramps

y

vomitingy diarrhea

y headache


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Preventiony Children who have been breastfed are less likely

to have allergies.

y There is also evidence that infants exposed tocertain airborne allergens (such as dust mitesand cat dander) may be less likely to developrelated allergies.

yOnce allergies have developed, treating theallergies and carefullyavoiding those things thatcause reactions can prevent allergies in thefuture.


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HYPERSENSITIVITY REACTIONSy Are immune responses to allergens that result in tissue

destruction

y Type I (ANAPHYLACTIC) reactions. Anaphylaxis is an

acute, life-threatening allergic reaction marked by rapidlyprogressive urticaria & respiratory distress which mayresult in anaphylactic shock.

y ETIOLOGY. Results from ingesting or systemic exposure to

allergenic substances (drugs, foods, insect-venom)

PATHOPHYSIOLOGY


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PATHOPHYSIOLOGY

Exposure to allergen

Production of IgE binds to mast cells & basophils

Reexposure IgE reacts immediately to the allergen

Release of potent chemicals mediators (histamine, ECF-A)

Ig G or IgM releases 2 other chemical mediators (bradykinin

& leukotrienes)Profound vascular changes

Vascular collapse ANAPHYLACTIC SHOCK

SS SS NT F ND N S


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ASSESSMENT FINDINGSy LOCAL EFFECTS wheals with surrounding red

flares & urticaria

y SYSTEMIC MANIFESTATIONS.

Intense urticaria and edema at the site of injection

rapidly spreading in the face, hands and otherbody areas

Respiratory distress from bonchospasm, coughing,sneezing or wheezing

Arrhythmias, tachycardia, or bradycardia,hypotension & signs of circulatory collapse

NURSING MANAGEMENT


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NURSING MANAGEMENTy

Establish patent airwayy Administer epinephrine, IM or SQ to constrict

blood vessels, raise RR, improve myocardialcontractility

y

Establish patent IV line for f luid administrationyOxygen therapy

y Administer prescribed medications (anti-histamine, bronchodilators, vasopressors,

corticosteroids)y Teach preventive measures

y Maintain safety precautions


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y Type II (CYTOTOXIC) reactions are mediated by

Ig G and IgM, which attach to cells (usuallycirculating blood elements) and cause cell lysis.Ex. Hemolytic anemia

y Type III (IMMUNE COMPLEX) reaction are

mediated by antigen-antibody complexes thatdeposit in the lining of blood vessels or on tissuesurfaces ex. Rheumatoid arthritis, serum sickness

y Type IV (DELAYED HYPERSENSITIVITY)

reactions are mediated by lymphokines releasedfrom sensitized lymphocytes


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AIDSy Acquired immunodeficiency syndromey Collection of symptoms and infections resulting

from the specific damage to the immune system

caused by infection with the humanimmunodeficiency virus (HIV) which allowsnormally benign organisms to f lourish and causedisease.

y

The virus causes cell death and a decline inimmune function resulting in opportunisticinfections, malignancies & neurologic problems


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Anatomy of the HIVVirus

Gp120 Envelope ProteinGp41 Envelope ProteinP17 matrix protein

P24 Capsule Protein

Reverse Transcriptase

The Lipid Membrane


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Anatomy of the HIVVirus HIV Human Immuno Virus

AIDS CD4 count is


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Etiologyy Risk factor

y Unprotected vaginal, anal. Or oral intercourse

y

IV drug used with contaminated needlesy HIV infected mother to child in utero (Vertical

Transmission)

y Contaminated needle stick

y

Blood and blood product recipienty Semen used for AI (artificial insemination)


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PATHOPHYSIOLOGYHIV (Retrovirus)

Carries genetic information as RNA

Attach to surface antigen (CD4)

Transmits genetic information into the human cell

Primary cells affected are the Helper T cells

Direct infiltration into the CNS

HIV RNA enters the cell, reverse transcriptase converts RNA

to DNA (deoxyribonucleic acid) material

As DNA, the virus is able to replicate as the cell replicate

Rapid cell destruction & proliferation can occur

Virus can lie dormant for approx. 10 years


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Stages of HIV diseasey Primary Infection (Acute HIV)

y Period from infections with HIV to the development ofantibodies to HIV

y Viremia stage

y Severe-flu like symptoms

y Window period

y Test negative with HIV antibody test

y Viral set pointy Balance between HIV and immune response


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y HIV asymptomatic

y CD4 is > 500

y Feeling well

y HIV symptomatic

y CD4 is 200-499

y Gradual falling of CD4

y AID

S


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Symptomsy Flu-like symptoms

y

No symptoms (asymptomatic)

y Fever, Fatigue, Diarrhea, Skin Rashes, NightSweats, Loss of appetite, lymphadenopathy

(enlarge lymph nodes)


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Opportunistic Infectionsy Pneumocystis Carinii Pneumonia

y Cryptococcal Meningitis

y Toxoplasmosis

y Candidiasis

y Histoplasmosis

y Cytomegaloviris infection

y Tuberculosis

y Kaposis sarcoma, an AIDS related lymphomay Neurologic deficit (AIDS dementia) characterized by behavioral,

cognitive and motor deterioration

y Problems with other organs; lungs, liver, kidneys, intestines, andheart.


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LABORATORY ANDDIAGNOSTIC

STUDYy ELIZA(enzyme linked immunosorbent assay) Diagnostics.

y Identifies antibodies directed specifically against HIV.

y Western Blot Assay

y To confirm HIV antibodies

y Viral Load

y Measures HIV RNA in the plasma

y Better predictor of the risk of HIV progression than CD4

y CD4 count, CD4/CD8 ratioy Significantly lowering of CD4 over CD8

y Ora Quick Rapid HIV 1 Antibody Test

y Detects antibodies to HIV 1


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Complications:y HIV Encephalopathy

y AIDS dementia complex

y Progressive decline in cognitive, behavioral, and motor

functionsy Wasting syndrome

y Profound involuntary wt loss exceeding 10% of baseline bodyweight.

y Either theres a presence of chronic diarrhea for more than 30days or chronic weakness with documented fever


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Cachexia


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Kaposis Sarcomay tumor caused byHuman herpesvirus 8 (HHV8)y KS lesions are nodules or blotches that may be red,

purple, brown, or black, and are usuallypapular

(ie palpable or raised).y Can lead to venous stasis, lymphedema (fluid

retention)y Skin lesion increase discomfort and infectiony

Death may result from tumor progression


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NURSING MANAGEMENT


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NURSING MANAGEMENTAdminister prescribed medications

- Includes antibiotics for HIV-related infections,antiretroviral therapy, antidiarrheals and antiemetics

Promote preventive measures related to thetransmission of HIVPromote public education regarding HIV & AIDS (teach

clients & families to practice safe sex, avoid sharingneedles, avoid touching anothers body fluid withoutprotection)

Maintain skin integrityInstruct the client to avoid scratching, strong perfumedsoaps and adhesive tapes

NURSING MANAGEMENT


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NURSING MANAGEMENTHelp maintain nutritional status

- By controlling nausea & vomiting

- Encourage foods that are easy to swallow

- Encouraging oral hygiene before and after meals

- Promoting a high-protein, high-calorie diet

- Monitoring weight, intake & output

- Monitoring fluid & electrolyte balance

- Administering appetite stimulants

Teach ways to cope with chronic illness to theclient & significant others.

NURSING MANAGEMENT


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NURSING MANAGEMENTPromote infection prevention

- Discuss importance of personal hygiene, keepingbathrooms and kitchens clean

- Avoid exposure to individuals who are sick, avoidingsmoking and alcohol

-A

dequate rest, activity and a well-balanced dietDiscuss ways the client and family can assist with

mental status problems.These includes putting notes on note boards, using

calendar and clocks to orient the client to time & place.


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Terminologiesy Infection

y The invasion and multiplication of microorganism inthe body tissue that result in cellular injury.


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Terminologies contdy Microorganism

y Infectious agent

y Pathogeny

Microorganism that causes a diseasey Pathogenicity

y The ability of the microorganism to produce a disease

y Virulencey The degree of pathogenicity

y Sepsisy The state of infection

y Asepsisy The freedom from disease causing microorganism


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InfectiousAgentReservoirPortal of Exit from ReservoirMode of Transmission

Portal of Entry to the Susceptible HostSusceptible Host


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ncm 104 - immunology

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