Download REIMBURSEMENT ISSUES

Care of Patient with An Immune
Disorder Chapter 15 – Adult Health Nursing Book
Care of the Patient with an
Immune Disorder
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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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Slide 2
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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Slide 3
Immunocompetence
• 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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Slide 4
Immunoincompetence:
• 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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Slide 5
Inappropriate responses of the immune system
…4 categories of Immunoincompetence
• 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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Slide 6
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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Slide 7
Innate Immunity (Non-specific)
•
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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Slide 8
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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Slide 9
When an Infectious Agent enters
the Body…..
• 1 – encounters innate immune system
• 2 – if innate immune system cannot kill offdisease 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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See 15-1 on page
720
Slide 10
Organization of the Adaptive
Immune System
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Slide 11
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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Slide 12
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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Slide 13
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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Slide 14
Figure 15-3
Origin and processing of B and T cells.
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Slide 15
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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Slide 16
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Slide 17
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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Slide 18
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 Thelper assistance, B cells begin antibody
production
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Slide 19
20
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Slide 20
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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Slide 21
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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Slide 22
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
• Allergen-produces signs of allergy
• Immunogen-when immunity results from exposure to
antigen
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Slide 23
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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Slide 24
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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Slide 25
Genetic Control of Immunity
• There is a genetic link to both welldeveloped immune systems and poorly
developed or compromised immune
systems
• Develops at different rates and times in
fetal and early life
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Slide 26
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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Slide 27
Immune Response
• 2 ways of helping the body
to develop immunity
• Immunization
• Immunotherapy
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Slide 28
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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Slide 29
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Slide 30
Immunotherapy 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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Slide 31
Immunotherapy Video
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32
Slide 32
Immune Response Immunotherapy
33
• 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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Slide 33
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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Slide 34
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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Slide 35
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 immediatly
• 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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Slide 36
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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Slide 37
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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Slide 38
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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Slide 39
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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Slide 40
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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Slide 41
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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Slide 42
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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Slide 43
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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Slide 44
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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Slide 45
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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Slide 46
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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Slide 47
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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Slide 48
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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Slide 49
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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Slide 50
Transfusion Blood products
• Blood should be properly typed and crossmatched
• 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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Slide 51
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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Slide 52
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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Slide 53
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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Slide 54
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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Slide 55
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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Slide 56
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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Slide 57
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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Slide 58
Disorders of the Immune System
– Secondary Immunodeficiency DO
• 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
• 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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Slide 59
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; Guillain-Barré syndrome;
scleroderma; systemic lupus erythematosus, Crohn’s
disease
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Slide 60
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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Slide 61
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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Slide 62
Chapter 22
Immunologic Medications
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63
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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65
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
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
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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
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
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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