Download Immunization

Topic #5
Care of Patient with An Immune
Disorder Chapter 15 – Adult Health Nursing Book
BUT FIRST !
A Review
HOMEOSTASIS
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IMMUNOLOGY
– The study of the immune system
– Evolving science dealing with body’s ability to
distinguish self from nonself
– Distinction is made through complex network of
highly specialized cells and tissues
• Collectively called “the immune system”
• Also known as the “host defense system”
• Critical to our survival
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THREE FUNCTIONS OF THE
IMMUNE SYSTEM
• Protect the body’s internal environment against
invading organisms
• Maintain homeostasis by removing damaged cells from the
circulation
• Serve as a surveillance network for recognizing and
guarding against the development and growth of abnormal
cells (Mutations constantly formed in body but recognized
and destroyed)
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IMMUNO COMPETENCE
• When immune system responds
appropriately to a foreign stimulus,
body’s integrity is maintained
• Immune system mobilizes and uses its
antibodies/other responses to stimulation
by an antigen
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IMMUNO INCOMPETENCE :
– weak or too vigorous immune system
response causes disruption of homeostasis and
malfunction in system
– When disruption of homeostatic balance in
immune system occurs, diseases develop
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INAPPROPRIATE RESPONSES OF THE IMMUNE SYSTEM
…4 CATEGORIES OF IMMUNO INCOMPETENCE
– Hyperactive response against environmental
antigens (allergy)
– Inability to protect the body, as in
immunodeficiency disorders (AIDS)
– Failure to recognize the body as self, as in
autoimmune disorders (systemic lupus erythematosus)
– Attacks on beneficial foreign tissue (organ transplant
rejection or transfusion reaction)
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IMMUNITY
–The quality of being insusceptible to or
unaffected by a particular disease or
condition
–2 major subclassifications
• Innate immunity
• Adaptive immunity
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INNATE IMMUNITY (NONSPECIFIC)
•
First line of defense
•
Provides physical and chemical barriers to
invading pathogens and protects against the
external environment
•
Composed of the skin, mucous membranes, cilia,
stomach acid, tears, saliva, sebaceous glands, and
secretions and flora of the intestines and vagina
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ADAPTIVE (ACQUIRED)
IMMUNITY
If first line fails:
– Second line of defense
– Provides a specific reaction to each invading antigen
• Unique ability to remember invading antigen
– Protects the internal environment
– Composed of thymus, spleen, bone marrow, blood, and lymph
– Includes both humoral and cell-mediated immunity
– Produces antibodies in the cells after an infection or vaccination
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WHEN AN INFECTIOUS
AGENT ENTERS THE BODY…..
• 1 – encounters innate immune system
• 2 – if innate immune system cannot kill off- disease results and the
• 3 – adaptive immune system is activated
• 4 – the adaptive immune system helps patient to recover AND
establishes a specific immunologic memory.
• 5 – If reinfected with same agent – no disease results…the patient has
acquired immunity to the infectious agent
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CELLS OF THE IMMUNE
SYSTEM
Macrophages and Lymphocytes
• Macrophages (phagocytes)
– When organisms pass epithelial barriers, macrophages activated
– Engulf and destroy microorganisms that pass the skin and mucous membrane
– Also carry antigens to the lymphocytes
• Antigen
– A substance recognized by the body as foreign that can trigger an immune
response
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ADAPTIVE IMMUNITY
• Lymphoctyes
–Include T and B cells
–Also includes NK cells (natural killer)
• Large, granular lymphocytes
–70%-80% of all lymphocytes are T-cell
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LYMPHOCTYES - 70 – 80% ARE T CELLS –
ACTIVATED BY AN ANTIGEN
• When activated by an antigen, T cells release substance
called lymphokine
• Lymphokine attracts macrophages to the site of infection
or inflammation and prepares them for attack
• T cells cooperate with B cells to produce antibodies but
do not produce antibodies themselves
• T cells responsible for cell-mediated immunity
• Protect against viruses, fungi, and parasites
• Also provide protection in allografts and malignant cells
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FIGURE 15-3
Origin and processing of B and T cells.
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LYMPHOCYTE - 20-30% ARE B CELLS
– Trigger production of antibodies and proliferate in response to a
particular antigen
– B cells migrate to peripheral circulation/tissues and eventually filtered
from lymph and stored in lymphoid tissue of body
– Initial formation of B cells does not require antigen stimulation
– However, B cell proliferation does require antigen stimulation
– B cells produce antibodies and protect against bacteria, viruses, and
soluble antigens
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HUMORAL IMMUNITY – B
CELLS
– One of the 2 forms of immunity
– Responds to antigens such as bacteria and foreign
tissue; mediated by B cells (B cells produce
antibodies)
– First exposure to antigen; primary humoral response
initiated (response generally slow compared with
subsequent exposures)
– When subsequent exposure occurs, memory B cells
cause quick response, regardless of whether 1st
exposure was to antigen or immunization
• Immunization-process by which resistance to
infectious disease is induced or increased.
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NATURE OF IMMUNITY
– Antigen is presented to T-helper cells by macrophages
– T lymphocytes categorized as:
• T-helper
• T-suppressor-maintain humoral response at
appropriate level for stimulus
– Antigen is taken to B cells and with T-helper assistance,
B cells begin antibody production
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ACTIVE AND PASSIVE
IMMUNITY
– Active immunity
• Antibodies are produced by one’s own body
(vaccines)
– Passive immunity
• Antibodies are formed by another in response to a
specific antigen and administered to an individual
(newborn immunity)
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NATURE OF IMMUNITY
• Number and function of T-helper/suppressor cells determines
strength and persistence of immune system.
• Normal ratio of helper to suppressor cells 2:1
• When ratio is disrupted, autoimmune/autodeficient diseases occur.
• Factors affecting immunocompetence
– Aging
– Viruses
– Radiation
– Chemotherapeutic drugs
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IMMUNE RESPONSE
• Exposure to antigen and response with antibody will activate either
– Humoral complement system which results in breakdown of
bacteria and release of lysosomes to destroy bacteria
– The antigen-antibody reaction, resulting in release of histamine
thus producing symptoms of allergy
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CELLULAR IMMUNITY – T CELLS
– Also called cell-mediated immunity
– T cells activated by antigen
– T cells becomes sensitized; released into blood and body tissues and remain
indefinitely
– On contact with antigen, attach to organism and destroy it
– Primary importance in:
• Immunity against pathogens that survive inside cells
• Fungal infections
• Rejection of transplanted tissues
• Contact hypersensitivity
• Tumor immunity
• Certain autoimmune diseases
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COMPLEMENT SYSTEM
• Includes proteins that interact with one another and
with other components of natural and acquired immune
system.
• Normally inactive and blood and body fluids
• When antigen and antibody interact, system activated
• Step-by-step process similar to clotting
• The complement system can destroy the cell membrane
of many bacterial species, and this action attracts
phagocytes to the area
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GENETIC CONTROL OF
IMMUNITY
• There is a genetic link to both well-developed
immune systems and poorly developed or
compromised immune systems
• Develops at different rates and times in fetal and
early life
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EFFECTS OF AGING ON THE
IMMUNE
SYSTEM
• Aging causes a decline in the immune system
– Higher incidence of tumors
– Greater susceptibility to infections (flu and pneumonia)
• Aging does not affect the bone marrow
• Decrease in thymus function plays important role to
immunosenescence causing reduction in T cells
• Aging also demonstrates delayed hypersensitivity response which is
decline in cell-mediated immunity
• Reflected in increased mortality rates of cancers, etc.
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IMMUNE RESPONSE
• 2 ways of helping the body to
develop immunity
–Immunization
–Immunotherapy
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IMMUNE RESPONSE
• Immunization
– A controlled exposure to a disease-producing pathogen that triggers
antibody production and prevents disease
– Provides protection for months to years
– First vaccine: Edward Jenner and smallpox
– Administer a weakened or dead antigen of the disease
– Vaccine stimulates humoral immunity providing immunity for
months/years.
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IMMUNOTHERAPY –
ALLERGY DESENSITIZATION
– Treatment of allergic responses that involves
administering increasingly large doses of the
offending allergens to gradually develop
immunity
– Preseasonal, coseasonal, or perennial
– Severe side effect: anaphylaxis
– Also called desensitization
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IMMUNOTHERAPY VIDEO
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IMMUNE RESPONSE IMMUNOTHERAPY
• Nursing and Immunotherapy
– Observe patient for at least 20 minutes after
administration because a hypersensitivity or
anaphylaxis may occur
– Anaphylaxis treatment protocol with immunotheraphy
is 02. – 0.5 ml of 1:1000 epinephrine hydrochloride
subcutaneously every 20 minutes for three doses
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DISORDERS OF THE IMMUNE
SYSTEM
• System failure can occur in several ways and express itself in mild to severe
forms
• Believed that failures occur due to
– Genetic factors
– Developmental defects
– Infection
– Malignancy
– Injury
– Drugs
– Altered metabolic states
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DISORDERS OF THE IMMUNE
SYSTEM
• Altered immune response
– Hypersensitivity
• An abnormal condition characterized by an excessive
reaction to a particular stimulus
– Hypersensitivity reaction
• An inappropriate and excessive response of the immune
system to a sensitizing antigen
– Hypersensitivity disorders
• Arise when harmless substances such as pollens, danders,
foods, and chemicals are recognized as foreign
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DISORDERS OF THE IMMUNE
SYSTEM
• Hypersensitivity disorders
– Etiology/pathophysiology
• Genetic defect that allows increased production of immunoglobulin E
(IgE) (humoral antibody)
• Causes release of histamine and other mediators
• Humoral reactions occur immediately
• Exposures may occur by inhalation, ingestion, injection, or touch
• Signs and symptoms caused by histamine release
• Reaction may be local (GI, resp, skin) or systemic (anaphylaxis)
• Several disorders result from hypersensitivity (asthma, uricaria)
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DISORDERS OF THE IMMUNE
SYSTEM
• Hypersensitivity disorders
• Clinical manifestations/assessment
• Pruritus (itching)
• Nausea
• Sneezing
• Excessive nasal secretions and tearing
• Inflamed nasal membranes
• Skin rash
• Diarrhea
• Cough; wheezes; impaired breathing
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DISORDERS OF THE IMMUNE
SYSTEM
• Hypersensitivity disorders (continued)
– Diagnostic tests
• History
• Physical exam
• Laboratory studies: CBC, skin testing, total serum IgE levels
– Medical management/nursing interventions
• Symptom management: antihistamines
• Environmental control: avoidance of the allergen
• Immunotherapy
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DISORDERS OF THE IMMUNE
SYSTEM ANAPHYLAXIS
• Anaphylaxis
– Etiology/pathophysiology
• System reaction to allergens
– Venoms
– Drugs—penicillin
– Contrast media dyes
– Insect stings
– Foods (eggs, shellfish, peanuts)
– Latex
– Vaccines
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DISORDERS OF THE IMMUNE
SYSTEM ANAPHYLAXIS
• Anaphylaxis Assessment
• Feelings of uneasiness to impending death
• Urticaria (hives) and pruritus (itching)
• Cyanosis and pallor
• Congestion and sneezing
• Edema of the tongue and larynx with stridor
• Bronchospasm, wheezing, and dyspnea
• Nausea and vomiting
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DISORDERS OF THE IMMUNE
SYSTEM ANAPHYLAXIS
• Anaphylaxis (continued)
– Clinical manifestations/assessment (continued)
• Diarrhea and involuntary stools
• Tachycardia and hypotension
• Coronary insufficiency, vascular collapse,
dysrhythmias, shock, cardiac arrest, respiratory
failure, and death
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DISORDERS OF THE IMMUNE
SYSTEM ANAPHYLAXIS
• Anaphylaxis (continued)
– Nursing interventions
• Pharmacological management
– Epinephrine
– Benadryl
– Aminophylline
• IV access
• Oxygen
• Teaching: avoid allergen; use medical alert ID; administration of
epinephrine
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DISORDERS OF THE IMMUNE
SYSTEM LATEX ALLERGIES
• Latex allergies
– Allergic reaction when exposed to latex products
– Type IV allergic contact dermatitis
• Caused by the chemicals used in the manufacturing
process of latex gloves
– Type I allergic reactions
• Response to the natural rubber latex proteins
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DISORDERS OF THE IMMUNE
SYSTEM LATEX ALLERGIES
• Latex allergies (continued)
– Clinical manifestations/assessment
• Type IV contact dermatitis
– Dryness; pruritus; fissuring and cracking of the
skin followed by erythema, edema, and crusting
• Type I allergic reaction
– Skin erythema, urticaria, rhinitis, conjunctivitis,
or asthma to anaphylactic shock
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DISORDERS OF THE IMMUNE
SYSTEM LATEX ALLERGIES
• Latex allergies (continued)
– Medical management/nursing interventions
• Identification of patients and health care workers sensitive to
latex is crucial in the prevention of adverse reactions
• Use nonlatex gloves when possible
• Use powder-free gloves
• Do not use oil-based hand creams
• Know the signs and symptoms of latex allergy
• Wear a medical alert bracelet and carry an epinephrine pen
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DISORDERS OF THE IMMUNE
SYSTEM TRANSFUSION
REACTIONS
• Transfusion reactions
– Etiology/pathophysiology
• Reactions that occur with mismatched blood
– Clinical manifestations/assessment
• Mild
– Diarrhea
– Fever and chills
– Urticaria
– Cough
– Orthopnea
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DISORDERS OF THE IMMUNE
SYSTEM TRANSFUSION
REACTIONS
• Transfusion reactions (continued)
– Clinical manifestations/assessment (continued)
• Moderate
– Fever and chills
– Urticaria
– Wheezing
• Severe
– Fever and extreme chills
– Severe urticaria
– Anaphylaxis
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DISORDERS OF THE IMMUNE
SYSTEM
• Transfusion reactions (continued)
– Nursing interventions
• Mild
– Pharmacological management
• Corticosteroids
• Diuretics
• Antihistamines
– Stop transfusion
– Administer saline
– Physician may order transfusion continued at a slower rate
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DISORDERS OF THE IMMUNE
SYSTEM
• Transfusion reactions (continued)
– Nursing interventions (continued)
• Moderate
– Stop transfusion
– Administer saline
– Pharmacological management
• Administer antihistamines and epinephrine
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DISORDERS OF THE IMMUNE
SYSTEM
• Transfusion reactions (continued)
– Nursing interventions (continued)
• Severe
– Stop transfusion
– Administer saline
– Pharmacological management
• Administer antihistamines and epinephrine
– Return blood or blood product to lab for testing
– Obtain urine specimen
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TRANSFUSION BLOOD
PRODUCTS
• Blood should be properly typed and cross-matched
• Should be properly refrigerated until 30 minutes prior to
adminstration
• Administer blood within 4 hours of removal from refrigerator
• Blood products within 6 hours
• Best prevention is use of autologous blood-can be frozen and store
for up to 3 years
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TRANSFUSION BLOOD
PRODUCTS
• Donor numbers and recipients
must be thoroughly checked by
two nurses that the number match
according to policy
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DISORDERS OF THE IMMUNE
SYSTEM DELAYED
HYPERSENSITIVITY
• Delayed hypersensitivity
–Reaction occurs 24 to 72 hours after
exposure
–Examples include:
• Poison ivy
• Tissue transplant rejection
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DISORDERS OF THE IMMUNE
SYSTEM TRANSPLANT
REJECTION
• Transplant rejection
– Types of grafts
• Autograft
• Isograft (identical twins)
• Allograft (homograft; members of same species; most common)
• Heterograft
– Antigenic determinants on the cells lead to graft rejection via the immune
process
– To avoid, antigenic determinants matched as close as possible.
– 7 to 10 days after vascularization occurs, sensitized lymphocytes appear in
sufficient numbers for sloughing to occur
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DISORDERS OF THE IMMUNE
SYSTEM TRANSPLANT
REJECTION
• Transplant rejection (continued)
– Immunosuppressive therapy
• Agents that significantly interfere with the ability of the
immune system to respond to antigenic stimulation by
inhibiting cellular and humoral immunity
– agents include
• Corticosteroids
• Cyclosporine (Neoral, Sandimmune)
• Azathioprine (Imuran)
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IMMUNOSUPPRESSIVE
THERAPY
• Nursing tip : When a transplant patient is receiving
immunosuppressive therapy (Imuran, cyclosporine),
remember that the purpose of these drugs is to suppress
the immune reponse, so the critical nursing goal is to
minimize the risk for infection for these patients
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DISORDERS OF THE IMMUNE
SYSTEM IMMUNODEFICIENCY
• Immunodeficiency
– An abnormal condition of the immune system in which cellular or
humoral immunity is inadequate and resistance to infection is decreased
– May cause recurrent infections, chronic infections, severe infections,
and/or incomplete clearing of infections
– Defects in genes leading to immunodeficiency provide hereditary link to
disease
– Can be induced (chemotherapy)
– Associated with many diseases including AIDS, multiple myeloma, etc.
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DISORDERS OF THE IMMUNE
SYSTEM IMMUNODEFICIENCY
DISORDERS
• Disorders involve an impairment of one or more immune mechanisms
• Primary immunodeficiency disorders
• Immune cells are improperly developed or absent
– Phagocytic defects
– B-cell deficiency
– T-cell deficiency
– Combined B-cell and T-cell deficiency
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DISORDERS OF THE IMMUNE
SYSTEM – SECONDARY IMMUNODEFICIENCY
DISORDERS
– Drug-induced immunosuppression
• Cytotoxic drugs in chemo, transplant rejection
prevention, etc.
– Stress-Effects interrelationships between nervous,
endocrine, and immune systems
– Malnutrition-Extended protein deficiency results in
thymus gland atrophy & lymphoid tissue decreases;
infection raised
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DISORDERS OF THE IMMUNE
SYSTEM – SECONDARY IMMUNITY DISORDERS
– Radiation-destroys lymphocytes, BM atrophies, and
pancytopenia occurs
– Surgical removal of lymph nodes, thymus, or spleen
– Hodgkin’s lymphoma-impairs immune response and
places demand on immune system resulting in
impaired response to 2nd infect
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AUTOIMMUNE DISORDERS
• Autoimmune
– The development of an immune response to one’s own tissues
– Body is unable to distinguish “self” protein from “foreign” protein
– Tend to cluster so patient may have more than one or same/related
disease found in other members of family
– Possible genetic predisposition to autoimmune disease
– Examples of disorder: rheumatoid arthritis, pernicious anemia; GuillainBarré syndrome; scleroderma; systemic lupus erythematosus, Crohn’s
disease
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AUTOIMMUNE DISORDERS
TREATMENT
• Plasmapheresis
– Removal of plasma that contains components causing/though to cause
disease
– Replaced with fluid such as saline, albumin, fresh frozen plasma
– Also called “plasma exchange”
– Used to treat autoimmune disease
– Rationale to remove pathogenic substances in plasma
– May also remove inflammatory mediators that cause tissue damage
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AUTOIMMUNE DISORDERS
• Plasmapheresis
– Whole blood removed through needle inserted in one arm and circulation
of the blood through cell separator
– Separator divides the blood into plasma and its cellular components
through centrifugation
– Plasma, platelets, WBC, RBCs separated selectively
– Undesirable component removed and remainder of blood returned to
patient via needle in opposite arm
– Plasma typically replaced with saline, LR, FFP, albumin
– May only remove 500mL a time
– Observe for s/s hypotension and citrate toxicity (anticoagulant); HA,
paresthesias, dizziness
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Chapter 22
Immunologic Medications
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Immunity
Types of Immunity
 Naturally acquired active
immunity: person has had the
disease and made antibodies;
antibodies remain for life
 Artificially acquired active
immunity: person is given a live or
weakened (attenuated) antigen in
a vaccine to stimulate antibody
production to prevent specific
diseases for an extended time;
“boosters” may be necessary
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Immunity
Types of Immunity (cont.)
 Passive immunity
 Naturally acquired passive immunity
 Antibodies pass from mother to infant
through breast milk
 Artificially acquired passive immunity
 Immunoglobulins are injected into a
person who does not have immunity to
the antigen
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Immunization Schedule
The following vaccines are recommended:









Hepatitis B
Diphtheria, tetanus, pertussis
Haemophilus influenzae type b
Inactivated poliovirus
Measles, mumps, rubella
Varicella
Pneumococcal
Influenza
Hepatitis A (for selected populations)
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Immunologic Medications
 Vaccines = attenuated or killed antigens in a
formula that produces an antigen-antibody
response in the body
 Hepatitis B
 Toxoids = attenuated or weakened toxins that
produce an antitoxin response, causing
immunity in the body
 Tetanus
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Immunologic Medications
 Produce immunity in the body
Uses
 Routine schedule of active immunizations for
adults and children
 Specific biologic agents for endemic disease
areas
 Specific biologic agents to people at high risk
 Screening for disease exposure
 Modify disease process in previously
unimmunized persons
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Immunologic Medications
Adverse Reactions
Mild reactions common: mild
local pain and swelling at site
Occasional effects include
altered levels of consciousness,
headache, lethargy, rash,
urticaria, vesiculation, diarrhea,
increased respiratory rate,
arthralgia, dyspnea, fever,
lymphadenopathy, and malaise.
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Immunologic
Medications
Drug Interactions
Nursing Implications and Patient Teaching
Assess health history, immunization status,
allergies to eggs or feathers, presence of
infection, use of immunosuppressants,
pregnancy
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Antihistamines
Action
 Compete with histamine for H1 receptor sites to limit its
effectiveness
 Limits capillary permeability, and swelling
 Limits acetylcholine release, which dries secretions in the
bronchioles and gastrointestinal system
 Sedative effect on the CNS
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Antihistamines
 Uses
Seasonal allergic rhinitis (SAR)
Perennial allergic rhinitis (PAR)
Perennial nonallergic rhinitis (PNAR)
 Relieve symptoms of allergic
disorders
Adjunctive therapy for anaphylaxis
Sedation
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Antihistamines
 Adverse Reactions
Most due to anticholinergic activity of
drug
Changes in blood pressure, blurred vision
Tachycardia, insomnia, dry mouth,
nausea
Restlessness, excitability, sedation, tinnitus
Constipation, urinary retention
Overdose is potentially fatal, especially in
children
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Antihistamines
 Drug Interactions
 Sedative effect increased with other CNS
depressants (sedatives, hypnotics, ETOH)
 Can strengthen anticholinergic effects
 When used with ototoxic drugs (ASA,
streptomycin), can mask ototoxic effects
 May decrease effects of corticosteroids and
other hormones
loratadine, diphenhydramine, fexofenadine
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Antihistamines
Life span considerations
Pediatrics:
Infants and young children often have
anticholinergic side/adverse effects
Paradoxical reactions may occur: increased
nervousness, confusion, or hyperexcitability
 Elderly
More likely to develop side effects such as dizziness,
syncope (fainting), confusion, and extrapyramidal
reactions
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