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Immune Slide cquired immunity
Slide 1 This section discusses care of clients with selected alterations of the immune system. Slide 2 Self versus Non self. This is what immunity is all about. It is the ability of the cells of the body to be able to recognize cells or things that are not part or the normal body. How does the immune system know what is self? Each of us has specific cell surface characteristics which don’t perfectly match anyone else. An exception is identical twins. This is called our Human Leukocytic Antigens or HLA’s. Auto-immune problems occur when the body doesn’t recognize self & attacks it. Organ transplants are rejected because the donated organ has a different HLA than the host. The host’s immune system doesn’t recognize the HLA & attacks & destroys the transplant. Functions of the immune system are: (1) defense against bacteria, viruses, fungi and parasites. (2) homeostasis by removing and destroying damaged cells, and (3) surveillance by identifying continuous malignant cells and destroying them. Slide 3 Immunity is classified as innate or acquired. Innate immunity (natural immunity) is present at birth and exists in a person without prior contact with an antigen. Slide 4 Acquired immunity is classified as (1) active or natural which occurs following exposure to a disease such as measles, chickenpox or mumps; (2) active or artificial which occurs as the result of an injection of an antigen such as immunizations. These types take time to develop but last a long time. Slide 5 Acquired passive immunity can occur naturally as the result of antibodies being passed from mother to fetus or may be acquired artificially through injection of gamma-globulin (GG) to produce short term protection from disease. These types are short lived because no memory cells are present. Slide 6 Please review anatomy and physiology of the immune system from your text and notes from Fundamentals. Video tapes 137 and 134 found in the Nursing Lab also offer a good review. Slide 7 There are two types of immune responses. They are humoral or plasma mediated and cell-mediated. In humoral immunity, an invading antigen causes the B cells to divide and differentiate into plasma cells which secrete antigen-specific immunoglobulins ( Ig) Slide 8 There are five types of Ig. IgA, IgG and IgM respond to viral and bacterial invasion. IgD may assist in B cell binding with the antigen. IgE is present during inflammatory responses and causes allergic reactions.. Slide 9 During the humoral response, complement which consists of approximately 25 enzymes, works with antibodies to puncture the bacterial cell walls to destroy them. Slide 10 In cell-mediated immunity,the antigen such as bacteria, virus, fungus or cancer, lives within the body cell and is present on the cell surface. Macrophages identify the antigen and T cells defend against it. This is a delayed response such as might occur in graft rejection, hypersensitivy reactions, tumor immunity and immunity against bacteria, virus and fungus. Slide 11 Immunocompetence exists when the immune system is able to identify and destroy foreign substances. When the immune system in not competent to recognize or destroy foreign substances, infeciton, immunodeficiency diseases and cancer occur. When the immune system is overactive, hypersensitivies such as allergies and autoimmune diseases occur. Slide 12 There are four types of hypersensitivities, Type 1 is known as an anaphylactic reaction. On the first exposure to the allergen, IgE antibodies are produced and bind to mast cells and basophils. On next exposure, the allergen attaches to the IgE bound to mast cells or basophils, and causes release of chemical mediators from the cells. These chemicals cause vasodialation, hypotension, increased secretion of mucus, and itching.. A cutanous response, a wheal-and-flare reaction occurs. An example is a mosquito bite. Examples of the cause for local anaphylaxis is food, pollen, medication, and dust. Slide 13 Anaphylaxis occurs when the chemical mediators are released systemically. Anaphylaxis may be caused by food, particularly, shellfish, nuts, eggs and strawberries, drugs like PCN and Sulfa, insect bites (bees and wasps) antitoxins like Rabies or tetanus, and iodine-contrast media for IVPs and MRIs. Anaphylaxis can occur rapidly and is a medical emergency. Symptoms of anaphylactic shock include rapid, weak pulse, hypotension, dyspnea, bronchial edema, crackles, wheezing, laryngeal edema, angioedema, increased mucous, strider and death, if not treated immediately. Slide 14 Treatment for shock must be initiated STAT. Respiratory and cardiovascular systems must be assessed and monitored. Epinephrine 1:1000, 0.2 to 0.5 ml should be given either SQ or IV if severe to cause vasoconstriction and bronchodilation. Benadryl IM or IV and Histamine H2 blockers such as Tagamet are given to decrease angioedema and urticaria Slide 15 Oxygen is given to maintain O2 sat at above 90%. The head of the bed should be raised to 45 degrees to assist with respiration. Blood pressure should be maintained with fluids and vasopressors such as dopamine and norepinephrine. Aminophylline is given IV at 6 mg/kg for severe bronchospasns. Albuterol nebs may be given every 2 – 4 hours. Slide 16 Vital signs, O2 sat, level of conscientious, cardiac and respiratory status should continue to be monitored and the RN should anticipate CPR, intubation and tracheotomy if necessary. Slide 17 Other examples of anaphylactic reactions are called Atopic reactions. These include allergic rhinitis, commonly known as hay fever, bronchial asthma, atopic dermatitis, urticaria, and angioedema. Individuals who experience these disorders have inherited an increased tendency to be sensitive to the environmental allergens. Hay fever is the most common. Symptoms are runny nose and eyes, sneezing, mucosal swelling and puritus around the eyes, nose, throat and mouth. Symptoms of asthma are listed on this slide. Slide 18 Atopic dermatitis involves generalized skin lesions which are vesicular and edematous. Urticaria or hives develops rapidly after exposure to an allergen and lasts for minutes to hours. Hives represents a wheal-flare response to the allergen. Angioedema is a localized skin reaction similar to hives but involving deeper layers of skin and submucosa. Swelling is usually seen in the eyelids, lips, tongue, larynx, hands, feet, GI tract and genitalia. This can be a medical emergency if respiration is compromised. Slide 19 Type II hypersensivity reactions are cytotoxic and cytolytic and destroy cells by binding IgM and IgE to cell surfaces which activates complement and phagocytosis. Examples of Type II reactions are blood transfusion reactions because of blood incompatibility, and drug- related hemolytic anemias. Goodpasture sysdrome is a rare disease in which the lungs and kidneys are damaged due to endogenous antibodies interacting with tissue antigens. Pulmonary hemorrhage and glomerulonephritis result. Slide 20 IgG and IgM form immune complexes in the body that get deposited in vessel walls and extravascular tissues. Complement is activated and chemical mediators of inflammation like histamine are released. Neutrophils respond to the inflammation that is created by the immune complexes, increasing tissue damage. Streptococcal infections are also causes of Type III reactions. Serum sickness caused by foreign serums like horse serum for anti tetanus. Pencillins and sulfonamides can cause serum sickness. Serum sickness produces fever, arthritis, uticaria, enlarged spleen and lymph nodes, 7 to 14 days after exposure .It is treated with adrenal cortical hormones- glucocorticords and mineral corticoids- these medications decrease the inflammatory process. Slide 21 A Type IV reaction is a cell-mediated response, causing tissue damage. The response takes 24 to 48 hours to occur. It is characterized by an interaction between antigens and antigen-responsive T lymphocytes. Examples are contact dermatitis, poison ivy, PPD and transplant rejection. Slide 22 After the cause of the allergic response has been identified, the client should avoid the allergen. This may simply involve avoiding certain foods, but may require making life changes such as moving to a different climate, changing occupations or giving up a pet. If a drug is the cause, he should avoid it and wear a Medic Alert bracelet, identifying the allergy. Drug therapy includes antihistimines for allergic rhinitis and urticaria. They work by blocking the histamine receptor sites. Sympathomimetic/decongestant drugs include Epinephrine (Adrenalin) is the treatment of choice for anaphylactic reactions. Minor decongestants include NeoSynephrine and Sudafed to treat allergic rhinitis. Corticosteroid nose sprays are effective for allergic rhinitis and oral corticosteroids are given for more severe allergic reactions. Antipruritics include topicals - calamine lotion, coal tar solutions, menthol and camphor. Mast cell- stabilizing drugs are used to asthma and allergic rhinitis. Examples are Cromolyn (Nasalcrom) and nedocromil (Tilade). They block release of histamines, leukotrienes and other chemicals from the mast cell after antigen- IgE interaction. Slide 23 The elderly have a decline in the immune system such as decreased size and activity of the thymus, decreased production of T and B cells, delayed hypersensitivity responses, decreased cell-mediated immunity, greater susceptibility to infection and higher incidence of tumors. The older adult should be encouraged a to eat well-balanced diet, drink adequate fluids, and to get flu & pneumonia shots. They should practice good handwashing. They should be taught to report fever or other signs of infection, and changes in mental status, behavior or levels of activity Slide 24 The symptoms listed above may indicated an problem with immunity. Slide 25 These sypmtoms are indicative of chronic allergies Slide 26 Diagnostic tests used to confirm immunodeficiency problems include a CBC with WBC differential including an absolute lymphocyte and eosinophil count. Cellular immunodeficiency is diagnosed if the lymphocyte count is below 1200/microliters. The eosinophil count is elevated with type I hypersensitivity reactions involving IgE RAST test measures the quantity of antigen-specific Ig E in the blood. It is less sensitive and more expensive than skin testing and has no risk of anaphalaxis. Skin tests involve pricking the skin with suspected allergens or injecting interdermally. A local wheal-and-flare response indicates an allergy to the allergen. A very sensitive person is at risk for having an anaphylactic reaction. Slide 27 HLA is done to determine if it matches the HLA of the donor prior to transplant. Histocompatibility is essential prior to matching donors and recipients of blood, bone marrow and organ transplants. The human leukocyte antigen system is a series of inherited genes that occur on the sixth chromosome in humans. If the HLA matches on 5 – 6 antigens, there is less likelihood of rejection of the tissue. Crossmatching mixes blood from the donor and potential recepient to determine any cytotoxic (anti-HLA) antibodies to the donor blood. A negative crossmatch indicates no cytotoxic antibodies are present and transplant should have a positive outcome. Slide 28 In GVHD, the graft rejects the host. The new donor cells recognize the host as foreign and within 7 to 30 days, the donor T cells attack and destroy vulnerable host cells. GVHD targets the skin, GI tract and liver. Symptoms include a painful, itching rash that begins on the soles and palms and covers the chest, back and legs, causing desquamation. Liver involvement includes mild jaundice and elevated liver enzymes. GI symptoms include diarrhea, abdominal pain, bleeding and malabsorption. The biggest problem is infection – bacterial, viral and fungal. GVHD is most often seen following bone marrow transplant. Slide 29 Calcineurin inhibitors inhibit production of T cytoxic lymphocytes. Amtimetabolites suppress proliferation of T and B cells. Corticosteroids suppress inflammatory response and inhibit cytokine production and T cell activation. Typically, these three categories are used together. Please review side effects in your Pharmacology and Nursing textbooks. Infections are treated with antibiotics, antivirals or antifungals. Slide 30 Risk for infection is the biggest problem with GVHD. Careful handwashing for both client and the healthcare team is essential. Reverse isolation, adequate hydration and nutrition, and good oral hygiene are a must and careful monitoring for signs of infection and complications are required. Slide 31 If the client has received an organ transplant, he should be continually assessed for graft rejection. Signs of rejection include erythemia and swelling over the site, and elevated temperature along with increased WBC’s. This client should be assessed for GVHD and is treated with immunosuppressive therapy and should be monitored for infection. Slide 32 Autoimmune diseases are grouped according to organ-specific and systemic diseases. Several systemic diseases will be covered in this course. Organ-specific diseases will be covered in Advanced Adult Nursing and Pediatric Nursing Slide 33 This section discusses selected systemic autoimmune disorders of the connective tissue. Slide 34 Osteoarthritis, also known as degenerative joint disease, involves a progressive deterioration and loss of cartilage in the joints. The cartilage becomes soft and yellow resulting in a narrowing of the space between joints. Bone spurs develop and there is uneven stress on the joints and decreased motion. Slide 35 A single cause for OA has not been identified, but it is related to advancing age. Approximately 60% of clients over the age of 65 years have symptoms of the disease. After the age of 50, it is twice as great in females, which suggests decreased estrogen as a cause. Obesity is related to OA of the knee. Strenuous exercise and sports injuries have been linked to OA. Signs and symptoms include first, joint pain which gets worse with joint use. As OA progresses, joints become more painful, and enlarged. Heberden’s and Bouchards’ nodes may be found on the fingers. If the spine is involved, the client may have difficulty sitting and rising from a chair. Knee involvements results in altered gait. Joint pain is increased with falling barometric pressure before rain. It is true that the client can predict rain “in his bones”. Slide 36 OA is diagnosed by history and physical. There are no lab tests, although the Sed rate may be elevated if synovitis is present. Bone scan, CT and MRI may show early joint changes and x-rays will show joint space narrowing Slide 37 The client with mild to moderate pain can use Tylenol and Capsaicin cream for relief. The cream should not be used with a heating pad. Other clients benefit from the NSAIDs or ASA. If the client experiences muscle spasms, muscle relaxants such as Flexeril may be necessary. Review your Pharmacology notes for more information on these drugs. Slide 38 The OA client needs to balance rest with activity. During acute pain, the joint should be rested and placed in a functional position, using pillows, splints, or braces. The joints should not be immobilized more than one week to prevent joint stiffness. Heat or cold applications may be helpful. Glucosamine and chrondroitin sulfate may help with synthesis of new cartilage. Slide 39 Weight loss is very beneficial for OA of the knee in the obese client. A healthy diet should be followed for all OA clients. Surgery may be indicated for some clients. Slide 40 This slide lists some of the surgical treatment options. Slide 41 Hyperuricemia is caused by increased uric acid production, underexcretion of uric acid by the kidneys of increase of foods containing purines (sardines, herring, muscles, liver, goose, sweetbreads). Stress, alcohol, thiazide diuretics, immunosuppressive drugs, and prolonged fasting can induce gout. Gouty arthritis usually affects no more than four joints, the most common being the great toe. The onset is rapid and it usually subsides in 2 to 10 days. Attacks can reoccur if not treated. Chronic gout involves multiple joints and tophi develop, causing deformity Slide 42 Diagnosis can usually be made on clinical symptoms alone. Serum and urine uric acid levels will be elevated as will as WBC’s. Synovial fluid aspiration is usually not necessary. Treatment includes life style changes such as watching diet, losing weight if necessary and decreasing or avoiding alcohol. The client should be monitored for kidney stones. Rest of the joint, heat and cold applications may be helpful Slide 43 Medications useful for treating gout are (1)Zyloprim which is useful during the acute stage and as a maintanence drug to prevent further attacks, (2) Colchicine used with NSAIDs and (3) Benemide which can’t be used for clients who have reduced creatinine clearance. ASA must be avoided because it inactivates Banemid. Cozaar may be useful in promoting urate diuresis . Cozaar and Zyloprim may be given together Slide 44 . RA is a chronic, systemic disease characterized by inflammation of connective tissue in the synovial joints. The cause is unknown but it is known to affect women between the age of 40 and 60, 2-3 times more often than men. Smoking has also been linked to RA. Slide 45 The autoimmune and genetic theories explains that a genetically susceptible individual develops an abnormal IgG in response to a antigen, and then develops autoantibodies known as rheumatoid factor (RF) against the abnormal IgG. These combine to form immune complexes and are deposited in the joints, causing inflammation and joint changes followed later by cartilage and destruction by a pannus. Slide 46 The pannus usually effects fingers, knees, and is worse in toes, ankles, and feet. Slide 47 This slide shows a pannus. Slide 48 This slide list signs and symptoms of RA. Morning stiffness usually occurs for one hour in the morning. Please refer to your text for pictures of deformities on p 1726. Also note complications of RA on p 1727 Slide 49 This slide lists several associated problems of RA. Caplan’s syndrome causes fibrosis in the lungs and is seen a lot with coal miners. Felty’s causes splenomegaly. Slide 50 Diagnostic tests used to determine RA include (1) the ANA which indicates the presence of an autoimmune disease and is positive in some cases of RA, (2) the RF which is positive in about 80% of cases, Slide 51 (3) and the sed rate and C-reactive protein tests which detect acute and chronic inflammation. Elevated WBCs are present in synovial fluid analysis. Bone scans, MRI and CT show early joint changes and can confirm RA. As RA progresses, narrowing between joints and deformity can be seen on x-ray. Slide 52 DMARDs should be started early in the disease to prevent disability. Plaquenil is indicated for mild cases. It is important that the client have an eye exam every 6 months to monitor for irreversible retinal degeneration. Slide 53 NSAIDs , especially the Cox 2 inhibitors are frequently prescribed. Aspirin relieves pain, but does not stop disease. Gold Salts- decrease disease activity. Given PO or IM, but IM is more effective. Cytotoxic medications may slow down the disease. Methotrexate is the drug of choice in moderate to severe cases. It has a rapid antiinflammatory effect & relives symptoms in days to weeks. Analgesics are used for pain control. Review these drugs in your Pharmacology text. Slide 54 Clients can benefit from hot and cold compresses and mild exercise after the acute phase. Complementary therapies may be helpful. Clients should be taught to eat a balanced diet, take NSAIDs with food, and to get frequent mild exercise. Assistive devices may useful to protect the joints. Slide 55 Systemic Lupus Erthmatosus is a chronic, multisystem disease that occurs mostly in women in their 30sand 40s. The cause is unknown but it is considered to be an autoimmune Slide 56 Auto antibodies are produced by b cell hyperactivity, complement is activated and immune complexes are deposited in body organs. SLE may be drug induced by drugs such as procainamide and hydralazine. Symptoms disappear when the Rx is discontinued. Slide 57 Signs and symptoms depend on the organs involved. Vascular lesions usually develop in sun-exposed areas with the classic butterfly rash across the nose occurring in alopecia over lesions is common. Arthritis occurs in more than 90% of cases. Arrhythmias can be fatal. Renal damage can result in glomerulonephritis. Seizures and Organic Brain Syndrome result from deposits of immune Slide 58 No specific tests are diagnostic for SLE. ANA is present along with other antibodies. Tests that are most specific are anti-double stranded DNA and anti-Smith which are rarely found in other diseases. RF may be positive because of the relation of RA to SLE ESR may be used to monitor disease activity. Steroids are the drug of choice. Slide 59 The client should be taught to monitor the skin for infection, to avoid sun and to keep skin clean and dry. Because many clients are immunosuppessed, they need to monitor for systemic infection and may need reverse isolation. Depending on which organs are involved, symptoms such as decreased urine output , neurological changes, and chest pain should be assessed. Slide 60 Systemic sclerosis is a chronic disease of the connective tissue in which there is excessive formation of fibrous connective tissue and fibrosis of the skin. The cause is an abnormal production of collagen. Clients present with joint pain, tight shiny skin, no wrinkles, renal symptoms, dysphasia, and GERD. Slide 61 This slide lists CREST manifestations of Systemic Sclerosis. Raynaud’s which is described as paroxysmal vasospasm in digits which limits arterial blood flow when exposed to cold. Client experiences blanching, followed by cyanosis and then erythema during rewarming phase. May procede onset of SS by months or decades.) Skin changes are seen in fingers & hands & the trunk. The face becomes expressionless. Joints in the jaw and hands lose ROM. Internal organ involvement includes fibrosis of the esophagus, causing GERD & difficulty swallowing . Lung involvement causes pulmonary abnormalities. Congestive Heart Failure occurs from fibrosis. Renal disease is progressive and is the major cause of death due to renal failure. Drugs are used to treat the symptoms, but there is no cure. There is no diagnostic test; the Sed rate may be elevated. Slide 62 Nursing care is aimed at maintaining ROM and preventing complications such as aspiration. The respiratory, cardiac and renal systems need to be monitored closely for complications. Slide 63 This section discusses HIV and Persons with AIDS. Slide 64 Please review the etiology of HIV and AIDS from your Fundamentals course. Slide 65 The incidence of AIDS is increasing worldwide, especially in the under 25 y/o population. Slide 66 The Elisa test is used to diagnose HIV antibodies which can be detected after 12 weeks. The Western blot test is used to confirm the diagnosis. There are other tests on the market now, including ones that can be done at home. Slide 67 Normal CD 4 count is above 1000. When the count is 500 or below, symptoms of HIV are seen. When the count is below200, opportunistic infections begin and the client is sero converting to AIDS. The amount of CD4 cell presence reflects the severity of the infection, as does the viral load, referring to the amount of HIV in the bloodstream. The higher the viral load, the more advanced the disease. As the virus continues to kill cells bearing CD4 receptors, the CD4 cell count drops, signaling progressive immunosuppression. Ultimately, after the development of an AIDS defining illness, AIDS is diagnosed. Criteria for Diagnosis is CD4 +T cell count below 200cells/microliter, or development of an opportunistic infection or indicator condition such as TB, pneumonias, and invasive cervical cancer. End-stage AIDS is defined as CD4 counts below 50. Slide 68 There is no cure for AIDS, but medications are increasingly able to control the disease and clients are living longer, healthier lives. New drugs are being developed every day. The drugs of choice at present are the antivirals in the reverse transcriptase inhibitors and the protease inhibitors groups. The next 5 slides offer a brief review. Also, please review your notes from your Medication Administration course. Slides 69 – 73 Review Slide 74 and 75 Because opportunistic diseases are frequently seen in the AIDS client, medications are given to prevent or treat these diseases. Slides 75 and 76 are examples of prophylactic drugs which are used. Slide 77 Two newer medications are Pentafuside, a fusion inhibitor which prevents HIV’s binding to healthy T-cells, and Proleukin which boosts the immune system. Slide 78 Typically, a combination of several medications (HAART) is used. Also, efforts to boost the immune system, such as a bone marrow transplant and use of interleukins is used in some cases. Although drug therapy is the major treatment, emphasis should also be placed on promoting health in the immunosuppressed client. Diet, careful handwashing, avoiding infection and taking medications properly are necessary components of treatment. Slide 79 Education of the client with HIV is highly important in preventing the spread of AIDS. Clients and their families need correct information to prevent isolation of the client. The client and family also need to know the signs and symptoms of opportunistic diseases, so that immediate treatment is provided. Slide 80 There are numerous nursing diagnoses that apply to the AIDS client. Nutrition is a common problem due to nausea from medication and the presence of thrush. Soft foods and high calorie, high protein foods should be offered. Diarrhea is a common problem. Good skin care is necessary to prevent further infections. The client will be fearful and may lack support because of discrimination from others. He may have low self esteem related to his diagnosis. This is a physically and emotionally draining disease that always ends in death. The client may react with anger or denial and may be noncompliant. He must be encouraged to make any necessary lifestyle changes to modify the disease process. Individual and group therapy is usually helpful. Slide 81 Opportunistic infections may be caused by fungus, bacteria or virus. The more common ones are pneymocystis carinii pneumonia, cryptococcal meningitis, cytomegalovirus retinitis, mycobacterium avium complex, Kaposi’s sarcoma, and AIDS – dementia complex Slide 82 PCP is sometimes the first indication that the client has AIDS. In HIV positive clients, it can be prevented by use of maintenance antibiotics. Nursing intervention includes monitoring the respiratory status, fever symptoms, administering oxygen, IV fluids and antifungals and nutrition. Slide 83 This disease is caused by a fungus and is treated with antifungal drugs. It is important that the client remain on maintenance drugs after the acute stage is over because 50-75% will have a recurrence within a year without them. Slide 84 CMV can also effect the respiratory, GI and CNS. Ocular disease does not appear until there is severe immunosuppression. Clients with AIDS should have frequent eye exams so that CMV is detected and early treatment with antivirals can begin.The goal is to prevent loss of vision, but even with treatment, blindness may occur. Slide 85 MAC frequently causes GI symptoms, especially chronic diarrhea in HIV clients. Positive cultures can be isolated from the lymph nodes, bone marrow or blood. Symptoms of MAC include diarrhea, abdominal pain, fever, weight loss, malaise, anemia, neutropenia, malabsorption syndrome and obstructive jaundice. Treatment is with the same antiinfectives that are used for TB, which is also frequently seen in the immunosuppressed client. Slide 86 KS is the most common neoplasm seen in AIDS clients. It occurs in 21% of clients. It is thought to be caused by Human herpes virus. Small lesions which are not painful are typically found on the skin and mouth. Lesions may also be found in the lungs & GI tract and can cause bleeding & respiratory distress. Diagnosis is made with biopsy. Successful treatment with ARTs can resolve the disease. Other malignancies are treated with chemotherapy as indicated. Slide 87 ADC occurs in the terminal stages of AIDS and is caused by HIV infection of the brain or other systemic opportunistic problems. If the cause is reversible, such as dehydration, appropriate treatment is started. If not, the client and family is supported to a comfortable death.
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