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LEARNING OUTCOMES
1. Explain the components and functions of the immune
system and the immune response
2. Compare antibody-mediated and cell-mediated
immune responses
3. Describe the pathophysiology of wound healing,
inflammation, and infection
4. Identify factors responsible for nosocomial infections
5. Discuss the purposes, nursing implications, and
health education for medications and treatments
used to treat inflammations and infections
6. Explain the nursing care necessary to prevent and/or
monitor the status of infections
CLINICAL COMPETENCIES
1. Apply standard precautions, particularly hand
hygiene, to prevent the spread of infection within
the patient, to other patients in the facility, and to
members of the interdisciplinary team and visitors
2. Use the nursing process as a framework to provide
safe, effective individualized care for patients with
inflammation and infection
3. Collaborate with the interdisciplinary care team to
integrate care of patients with infection
4. promote therapeutic levels and complete dosage
of antiinflammatory and anti-infective medication
through prompt administration and patient and
family teaching
KEY TERMS
1.
2.
3.
4.
5.
Acquired immunity
Active immunity
Adaptive immune response
Anergy
Antibodies
6. Antibody-mediated (humoral)
immune response
7. Antigens
8. B lymphocytes (B cells)
9. Cell-mediated (cellular) immune
response
10.cytokines
11.Endotoxins
12.Exotoxins
13.Immunity
14.Immunocompetent
15.Immunoglobulin (Ig)
16.Infection
17.Innate adaptive immunity
18.Lymphocyte
19.Macrophages
20.Natural killer cells (NK cells, null
cells)
16.Nosocomial infections
17.Passive immunity
18.Pathogens
19.Phagocytosis
20.T lymphocytes (T cells)
21.Vaccines
IMMUNE SYSTEM
COMPONENTS
The immune system consists the
following that produce the immune
response
1. Molecules
2. Cells
3. Organs
.These components may be involved
in the innate inflammatory response,
the adaptive immune response, or
both
1. LEUKOCYTES
Leukocytes (white blood cells, WBCs) are the primary
cells involved in both innate and adaptive immune
system responses
It is derive from stem cells, the hemocytoblasts,
in the bone marrow
Red blood cells (RBCs) are confined to the circulation
But Leukocytes use the circulation to transport
themselves to the site of an inflammatory or immune
response
As the mobile units of the immune system,
LEUKOCYTES detect, attack, and destroy anything
that is recognized as FOREIGN
2. GRANULOCYTES
3. MONOCYTES, MACROPHAGES,
AND DENDRITIC CELLS
4. LYMPHOCYTES
ANTIGENS
LYMPHOID SYSTEM
IMMUNOGLOBULINS
ADAPTIVE IMMUNE
RESPONSE
INTERDISCIPLINARY CARE
IMMUNIZATIONS
NURSING CARE
NORMAL IMMUNE
RESPONSE
PATHOGENIC ORGANISMS
NOSOCOMIAL INFECTIONS
ANTIBIOTIC-RESISTANT
MICROORGANISMS
MEDICATIONS
STANDARD PRECAUTIONS
TRANSMISSION-BASED
PRECAUTIONS
COMMUNITY-BASED CARE
CLINICAL COMPETENCIES
1. Assess functions health status of patients
with altered immunity and monitor,
document, and report abnormal
manifestations
2. Assess for hypersensitivities and
anticipate interdisciplinary interventions if
manifestations develop
3. Provide patient teaching about
hypersensitivities, avoidance of sensitizing
agents, and prophylactic treatment
EXAMPLES OF HYPERRESPONSIVENESS
IMMUNE FUNCTION
A. ALLERGIES
B. AUTOIMMUNE DISORDERS
C. REACTIONS TO ORGAN OR TISSUE
TRANSPLANTS
D. AIDS
E. IMMUNODEFICIENCY DISORDERS
.Altered immune system response include those
characterized by an impaired immune response
.Immunodeficiency disorders result from
impairment of the immune system
MEMORY CUE
1. B lymphocytes produce antibodies
and cytokines to cause extracellular
immunity and acquired immunity
2. T lymphocytes produce cytokines to
cause intracellular immunity and
acquired immunity
HEALTH HISTORY
Before conducting the health history, review
the biographic data including:
1. Age
2. Gender
3. Race
4. Ethnic background
.Many autoimmune disorders are more
prevalent in women than in men
.Family history is also important because there
is a genetic component in the etiology of many
disorders affecting the immune system
PHYSICAL ASSESSMENT
The techniques of INSPECTION and PALPATION
are used to assess a patients immune sytem
1. Assess the general appearance; evident
fatigue or weakness may indicate acute or
chronic illness or immunodeficiency
.Note whether the stated and apparent age
coincide
.Assess height, weight, and body type for
apparent weight loss or wasting
.Observe ease of movement and note any
evident stiffness or difficulty moving
PATHOPHYSIOLOGY
In a hypersensitivity reaction, an antigenantibody or antigen-lymphocyte interaction
causes a response that is damaging to body
tissues
Antigen-antibody responses characterize
types I, II, and III, also known as
IMMEDIATE HYPERSENSITIVITY
RESPONSES
Type IV hypersensitivity is an ANTIGENLYMPHOCYTE REACTION, resulting in a
DELAYED HYPERSENSITIVITY RESPONSE
PATHOPHYSIOLOGY
The mechanism that causes the immune
system to recognize host tissue as a
foreign antigen is not clear
FOLLOWING FACTORS UNDER STUDY SERVE
AS THE POSSIBLE CONTRIBUTORS TO THE
DEVELOPMENT OF AUTOIMMUNE
DISORDER
1. The release of previously HIDDEN
antigens into the circulation, such as DNA
or other components of the cell nucleus,
which elicits an immune response
INTERDISCIPLINARY CARE
Diagnosis of an autoimmune disorder
is based on the patients
manifestations
Although the manifestations of this
disorders can often be managed, a
cure typically is not possible unless
the affected target tissue is removed.
(e.g., colectomy for the patient with
ulcerative colitis)
DIAGNOSIS
Serologic assays are used to identify and measure
antibodies directed toward host tissue antigens or
normal cellular components
1. ANTINUCLEAR ANTIBODY (ANA) =detects
antibodies produced to DNA and other nuclear
material
.These antibodies can cause tissue damage
characteristic of autoimmune disorders such as SLE
.The patients serum is combined with nuclear
material and tagged antihuman antibody to detect
ANA-antihuman antibody complexes
.A negative, or normal, result is a titer <1:20
.When complexes are detected at higher titer levels
(>1:20), the test is positive for ANA
MEDICATIONS
A. ANTI-INFLAMMATORY MEDICATIONS
1. Aspirin
2. Nonsteroidal anti-inflammatory drugs (NSAIDs)
3. Corticosteroids
.This is to reduce the inflammatory response
.Minimize tissue damage
.When these agents are not effective or well
tolerated by the patient, disease-modifying
antirheumatic drugs or slow-acting antiinflammatory medications may be prescribed
7. Slow-acting anti-inflammatory
drugs, including gold salts,
hydroxychloroquine (Plaquenil), and
Penicillamine, may be used when
other therapies are ineffective or not
tolerated by the patient
.These drugs, however, are relatively
toxic and less frequently used
NURSING CARE
Nursing Interventions for the patient
with an autoimmune disorder are
individualized and tailored to needs
dictated by manifestations of the
disorder
NURSING DIAGNOSIS
1. Activity Intolerance related to
inflammatory effects of autoimmune
disorder
2. Ineffective Coping related to chronic
disease process
3. Interrupted Family Processes related to
lack of understanding about autoimmune
disorder and its effects
4. Ineffective Protection related to disordered
immune function
COMMUNITY-BASED CARE
1. Teaching the patient and family
about the disorder and its
management is a key nursing
intervention
2. Effective teachings for patient
taking drugs with multiple side
effects or long-term effects
3. Provide psychologic support,
listening and teachinh
3. Organ: Lung
.Graft type: Allograft
.Indications: pulmonary hypertension , cystic/pulmonary
fibrosis, COPD
.RATE: 52.6% at 5 years
4. Organ: Liver
.Graft type: Allograft
.Indications: severe liver dysfunction due to chronic active
hepatitis, primary biliary cirrhosis. Sclerosing cholangitis
.RATE: 73.6% 5-year survival
5. Organ: Bone marrow
.Graft type: Autograft or allograft
.Indications: leukemia, aplastic anemia, congenital
immunologic deffects
.Rate: 30-70% cure
6. Organ: Skin
.Graft type: Autograft, allograft, or
xenograft
.Indications: severe burns, plastic
surgery
.Rate: > 95% at 5 years
7. Organ: Cornea
.Graft type: Allograft
.Indication: corneal ulceration and
opacification
.Rate: >95% at 5 years
8. Organ: Pancreas
.Graft type: Allograft
.Indication: Pancreatic Insufficiency,
diabetes
.Rate: 88.1% at 5 years
9. Organ: Islet cells
.Graft type: Allograft (multiple donor)
.Indication: Type 1 Diabetes Mellitus
.Rate: 100% > 2 years
PATHOPHYSIOLOGY
AUTOGRAFT = a transplant of the patients own
tissue, is the most successful type of tissue
transplant
Skin grafts are the most common example
Autologous bone marrow transplants and blood
transfusions are being used to reduce immunologic
responses
ISOGRAFT = when the donor and the recipient are
identical twins
Because of the high likelihood of an HLA match, the
success of these grafts is good and rejection of
episodes are mild
Identical twins belongs to the few people that can provide tissue
for donation, and when the need is for an organ such as heart,
liver, or lungs, a living donor transplantation is not possible
ALLOGRAFTS = grafts between members of the same species that
have different genotypes and HLA
Most often organ and tissue transplants
Allografts may come from living donors
Examples
1. Bone marrow
2. Blood
3. Kidney
.Most often, organs for transplantation are obtained from a
CADAVER
.Donors are people who meet the criteria for
1. Brain death
2. Less than 65 years old
3. Free of systemic disease
4. Free from malignancy
5. Free from infection, including HIV, Hepatitis B or Hepatitis C
HYPERACUTE TISSUE
REJECTION
Occurs immediately to 2-3 days after the transplant of
new tissue
Rejection is due to performed antibodies and sensitized T
cells to antigens in the donor organ
It is more likely to occur in patients who have had a
previous organ or tissue transplant
Example:
1. Blood transfusion = may be evident even before the
transplant procedure is completed
.The grafted organ appears initially pink and healthy, but
soon becomes soft and cyanotic as blood flow is impaired
.Organ function deteriorates rapidly, and manifestations
of organ failure develop
INTERDISCIPLINARY CARE
Pretransplant care and post-transplant care are directed
toward reducing the risk that transplanted tissue will be
rejected or result in GVHD
Diagnostic studies are directed first at identifying the
potential recipients blood type and histocompatibility
Potential donors are identified through diagnostic studies,
and the recipients immune response to the transplant is
monitored
Immunosuppressive therapy with medications is a vital part
of post-transplant care
The development of effective immunosuppressive drugs as
well as improved methods of tissue typing are responsible
for the success of organ transplants using allografts
DIAGNOSTIC TEST
1. Blood type of both the donor and recipient are
determined and they must match
2. DNA Sequencing = is made on blood cells to
determine histocompatibility
.Sequencing can be completed quickly
.Quick response is important to minimize cold
ischemia in cadaverous organs
3. Crossmatchinhg of the patients serum against the
donors lymphocytes is performed to identify any
performed antibodies against antigens on donor
tissues
4. If present, these antibodies would likely result in an
immediate or hyperacute graft rejection with
probable loss of the transplant
IMPAIRED IMMUNE
RESPONSE
ANTIRETROVIRAL DRUGS