Immunologic Disorders

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Immunologic Disorders

• By Diana Blum RN MSN
• Metropolitan Community College

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Anatomy

• Bone marrow spongy center of the bones where
  WBCs are made
• Lymphatic System network of open ended tubes
  separate from the blood circulation system that
  collects the plasma left behind and returns it to
  the venous system.
• WBC travel through the tissues looking infection

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Anatomy

• Lymph fluidmix of plasma and cells
• Propelled along the lymphatic system by normal
  muscle contraction
• One way valves prevent the fluid from pooling
• Lymph nodes small patches of tissue that filter
  microorganisms from the lymph fluid before it is
  returned to the bloodstream.
• Located throughout the body
• Swell with infection and cancer
• Spleen in LUQ of the abdomen. Filters
  microorganisms from the blood. Once trapped,
  WBCs destroy them
• Removed if Trauma (MVA), hodgkins dx
• Greater risk of infection

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Anatomy

• Thymus located below the thryoid
• Early in life WBCs called lymphocytes migrate
  from bone marrow to the thymus where they mature
  into T Cells
• As humans age the thymus shrinks
• Stem Cellscalled progenitor cells
• Develop into various WBCs, RBCs, or Platelets
• Most located in bone marrow
• Some circulate in blood

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Anatomy

• WBCS (Leukocytes)produced by bone marrow
• Identify and destroy antigens (proteins)
• Life span of WBC is 12 hours
• Macrophages clean up WBC debris
• If WBCs build faster than macrophages can clean
  pus is formed.
• Neutrophilsfight bacterial infections
• Most numerous of the WBCs about 60

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Anatomy

• Monocytes circulate for 1 day before entering
  tissue
• Macrophagesmonocytes when they enter tissue
• Destroyed during phagocytosis
• Ingest foreign material and can live months to
  years

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Anatomy

• Eosinophilscombat parasitic infections
• Also associated with allergic responses
• Basophils can initiate massive inflammatory
  response to bring other WBCs to infection site
• Work with Immunoglobin E (IgE) by releasing
  histamine from cell vesicles in the basophil
• Histamine is a potent vasodialator that increases
  blood circulation to the site

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Anatomy

• Mast cells store histaminein cell vesicles.
  Located in tissue
• B cells manufacture antigen binding proteins
  (immunoglobins) on the cell membrane
• when immunoglobin binds w/ antigen, the b cell is
  stimulated to produce plasma cells and memory B
  cells.
• Plasma cells are antibody factories that produce
  large amounts of immunoglobins.
• Memory B cells go into a resting state but can be
  quickly reactivated.
• Once immunoglobin released it is called an
  antibody.
• 4 types
• IgMfirst to be secreted during primary immune
  response
• IgG secreted during 2nd ary immune response
• IgApresent in secretions like mucus and mothers
  milk
• IgEattaches to the cell membrane of basophils
  and mast cells where it triggers the cell to
  release histamine.

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Anatomy

• T Cells 2 types T helper(CD4) and T cytotoxic
• CD4 cells are found on cell membrane
• When CD4 cells come in contact with foreign
  antigens they secrete cytokines that activate
  other components of immune system
• CD4 cells can be infected with HIV
• Tc cells CD8 cells because protein complex on
  cell membrane.
• Tc cells destroy invaders
• Cytokines hormones secreted by cells to signal
  others (interferon, interleukin, tumor necrosis
  factor, granulocytemacrophage colony stimulating
  factor, EPO)
• Eicosanoidsclass of fatty acids that regulate
  blood vessel vasodilation, temperature elevation,
  WBC activation
• NSAIDS disrupt production

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T cell
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Functions

• Innate immunity operational at all times
• Present at birth
• Include barriers, inflammatory response,
  phagocytosis
• Barriers?skin and mucous membranes first line of
  defense, sweat glands
• Inflammatory response?dilate capillaries to
  increase permeability of affected area
• s/s rubor (redness), tumor (swelling), Calor
  (heat), and dolor (pain)
• Phagocytosis? process of ingesting and digesting
  invading pathogens, dead cells, and cellular
  debris
• Neutrophils, monocytes, and macrophages are
  capable and sometimes refered to as phagocytes

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Functions

• Acquired immunityfights a particular pathogen
  and is only activated when needed
• 2 types
• Antibody mediated activated when IgM detects
  foreign antigen. See page 594
• Can be active or passive
• Activethe person manufactures antibodies in
  response to infection
• permanent
• Passiveantibody is produced by animal or person
  and then transferred to another (ex. through
  breast milk)
• lasts 1-2 months after antibodies
  received
• Cell mediated aimed at intracellular defects
  like virus and cancer
• Delays hypersensitivity reactions and transplant
  rejections
• Tc are primary component
• When Tc cells recognize foreign antigens they
  secrete cytotoxic substances to destroy the
  defective cell (transplant organ)

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Tolerance

• Immune system must be able to recognize its own
  proteins and not fight itself
• Occurs as part of neonatal growth
• Autoimmune diseases occur when
• Example acute rheumatic fever, lupus, rheumatoid
  arthritis, diabetes, thyroiditis, graves disease

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Age Related Changes

• Bone marrow is less productive
• Immunity not usually affected unless unusual
  stress, trauma, chronic infection, cancer tx
• Lymphatic tissue grows between age 6-20
• As we age lymph tissue shrinks
• Result is fewer and smaller lymph nodes

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Assessment

• Hx of present illness frequent infections,
  prolonged bleeding, easy bruising, chronic
  fatigue
• PMH cancer, HIV, Splenectomy, long term venous
  access device, infections, current meds,
  immunizations
• System review skin-rash ulcers, enlarged lymph
  nodes
• Neuro-
• Respiratory-
• GI-
• GU-
• Muscle-
• Endocrine-
• See page 630

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Functional assessment

• Hobbies
• Occupation
• Self concept
• Activity and exercise
• Sleep and rest
• Nutrition
• Interpersonal relations
• Coping and stress
• Health perception

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Diagnostic tests/procedures

• Urine Tests-urine protein electrophoresis-measures
  immunoglobin in the urine
• Blood tests
• CBC
• Serum protein electrophoresis(measures
  immunoglobin in the blood) (used to look for
  multiple myeloma)
• Antinuclear antibody test-looks for lupus
• ELIZA- looks for HIV/AIDS
• Cultures-detect infection of blood, sputum,
  urine, stool

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Diagnostic tests/procedures

• Bone marrow biospy- done if CBC abnormal
• Diagnoses leukemia, WBC cancer, and Multiple
  Myeloma
• See page 600
• Lymphangiography-evaluates anatomy of lymph
  vessels and lymph nodes
• Helps stage cancer
• Liver- Spleen Scan-evaluates size and function of
  liver and spleen
• Gallium Scan-uses radioactive tracer to detect
  presence of malignancy
• Skin tests-Ex. TB tine

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Therapeutic Measure/ neutropenic precautions

• The lower the WBC the greater chance of infection
• See page 635
• Pvt room
• Vistors wash hands
• Monitor vs q2-4 hours
• Aseptic technique
• Isolation
• C and DB
• Patient wears mask when outside room
• No fresh flowers or plants in room

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Colony stimulating factors

• Stimulates bone marrow to produce more blood
  cells
• Drugs may be given to stimulate ex. Neupogen

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Bone marrow transplant/Stem cell

• Done to restore immune system
• Complications infection, thrombocytopenia, renal
  insufficiency, graft vs host dx

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WBC disorders

• Neutropenia neutrophils level low
• Leukemia cancer of WBC- bone marrow produces too
  many immature cells
• Cause exposure to benzene, large dose of
  radiation
• 2 types
• myelogenous-most often in adults
• Lymphocytic-most often in kids 2-6 yrs old-
• At risk for severe infection and bleeding
• s/sinfection, fever, nite sweats, low RBC ct,
  fatigue, paleness, tachycardia, tachypnea,
  petechiae, purpura, epistaxsis, gingival bleed,
  melena (blood in stool), bone pain, weight loss,
  swollen lymph nodes
• Tx high dose chemo, therapy

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Leukemia
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Therapy

• Induction therapy-initial dose of chemo
• Maintenance therapy- lower dose of chemo over 1-3
  years
• Intensification and consolidation therapy- bone
  marrow transplant(monitor for infection, bleeding)

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NSG DX

• Risk for injury r/t infection aeb
  thrombocytopenia and anemia.
• Goal absence of injury from infection, bleeding,
  and inadequate oxygenation aeb normal body
  temperature, no bruising, or frank bleeding,
  pulse and respiratory, rates WNL
• Fatigue
• Impaired oral mucous membranes
• Imbalanced nutritionltless than body requirements
• Anxiety
• Ineffective therapeutic regimen management

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interventions

• Thorough hand washing
• Encourage patient to shower everyday
• Discourage patients from eating fresh fruit and
  veggies and dairy
• Possible transfusions
• Monitor for stomatitis
• Encourage patients and family to express their
  feelings and ask questions

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SLE page 641

• LUPUS
• S/S Butterfly rash characteristic sign,
  malaise, anorexia, muscle pain, swollen joints,
  photosensitivity etc
• DX no one test definitely diagnoses SLE
• Tx No cure. Minimize symptoms, steroids,
  cytotoxic agents

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HIV
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transmission
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HIV Stages

• Initial lasts 4-8 weeks
• High levels in blood
• Flulike symptoms
• Latent inactive until a virus presents than
  replication begins
• Lasts 2-12 years
• Asymptomatic
• Third stageopportunistic infections
• 2-3 years
• Once CD4 Level below 200 it is considered AIDS

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Complications

• Opportunistic infections
• Pneumonia
• Herpes
• CMV retinitis
• Meningitis
• toxoplasmosis
• Wasting
• Weight loss
• malnutrition

• Cancer
• Kaposis sarcoma
• Non hodgkins
• Anal cancer
• Cervical cancer
• Dementia
• From encephalitis

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s/s

• Flu like symptoms
• Fever
• Night sweats
• Swollen lymph nodes
• Headache
• Skin lesions that dont heal
• Sore throat
• Dyspnea
• Burning with urination
• diarrhea

• Fatigue
• Weight loss

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diagnosis

• Positive ELIZA test
• Positive Western Blot test

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Treatment

• No cure
• Treat symptoms
• Prevent infections
• Encourage to eat balanced diet
• Exercise regularly
• Maintain good dental hygiene
• Smoking/illegal drug cessation
• Limit alcohol
• Minimize stress
• Practice safe sex

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Nursing care

• Early stages- usually treated outpatient
• Late stages- more intensive in nature
• Infection is the leading cause of death in those
  with HIV

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Nursing diagnosis

• Ineffective therapeutic regimen
• Anxiety
• Infection
• Impaired oral mucosa
• Imbalanced nutrition less than body requirements
• Disturbed thought process
• pain

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Interventions

• Provide education
• Offer support group
• Encourage questions
• Encourage them to express self
• Anti infectives
• Medication education
• Encourage regular dental hygiene
• Have dietician see
• Appetite stimulants
• Saftey precautions
• Monitor pain

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Non Hodgkins Lymphoma

• Estimated 53900 new cases diagnosed in 2002
• Stages
• Low grade
• Intermediate grade
• High grade
• The higher the grade the more aggressive
• Tx chemo, bone marrow transplant, stem cell
  transplant
• 5 year survival rate is 52

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Hodgkins Disease

• Characterized by reed- sternberg cells in the
  lymph nodes
• Highest occurance is in 20s and50s
• Men are more likely than women to have
• Tx radiation, chemo, bone marrow transplant,
  stem cell transplant
• Survival rates vary
• 5 yr survival rate is 82

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Multiple Myeloma

• Cancer of the plasma cells
• Most common over the age of 60
• No known cause
• Genetics and radiation exposure play a part
• s/s bone pain, hyperuricemia (kidneys), anemia,
  hypercalcemia, fractures, spinal cord compression
• Diagnosis radiographs, serum and urine protein
  electrophoresis, bone marrow biopsy
• No known cure
• Tx chemo and radiation to treat symptoms

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Any Questions