Title: Inflammation
1Inflammation the Immune Response
- Keith Rischer, RN, MA, CEN, CCRN
2Objectives for this content
- Inflammatory response
- 1-3
- Infection/sepsis/chain of infection
- 4-10
- Physiologic immune response
- 11-16
3Three Lines of Defense
- Anatomical Barriers
- Acute Inflammatory Response
- Immune System
4Anatomical Barriers First Line of Defense
- Skin
- Mucous membranes
- Normal bacterial flora
- Clostridium difficile
- Yeast infections
5Normal Body Defenses
- Skin
- multilayer barrier, shed outer layer, contains
fatty acids that kills some bacteria - Lungs
- contain cilia in upper respiratory tract,
macrophages - Urinary Tract
- flush action of urine washes away bacteria
- Perry and Potter pg. 647 Ch 34 Table 34-3
6Inflammatory Response
7Inflammatory Response
- Occurs in response to injury
- Localized
- Immediate
- Beneficial
- Appropriate level of
- response
- Non Specific
8Causes of Inflammation
- Physical
- Trauma
- Lacerations
- Burns
- Chemical- Bites
- Allergic response
- Micro-organisms
- Bacteria
9Inflammatory Response
- REDNESS
- SWELLING
- PAIN
- HEAT
- LOSS OF FUNCTION
-
10Purpose of inflammation
- Neutralizes and Dilutes Toxins
- Removes necrotic materials
- Provides an environment for healing
- Add itis to affected body part
114 Phases of Inflammation
- Vascular
- Think blood vessels
- Cellular
- Think WBCs
- Formation of Exudate
- Fluid neutrophils
- Healing
- regeneration or repair of tissue
12 Vascular Phase Blood Vessels
- Injury occurs
- Mediators intervene
- Vasodilation occurs
- Capillaries become more permeable
- Swelling and movement of fluid occurs
13Cellular Phase Think WBCs
- Injury occurs
- Chemotaxis begins
- White blood cells rush in to help
- Neutrophils
- Monocytes
- Macrophages
14Chemical Mediators
- Coordinators of the inflammatory response
- Histamine
- Prostagladins
- Cytokines
15Laboratory tests
- Erythrocyte sedimentation rate
- (ESR or sed rate)
- lt20 mm/hr
- CRP C reactive protein
- non specific test identifying the presence of
inflammation - lt1.0 mg/dl
16Nursing Diagnosis
- Acute pain related to tissue trauma
- Impaired physical mobility related to discomfort
17Nursing Interventions
- Care will vary with causative agent and physical
condition of the patient - What are some nursing actions you might implement
or anticipate - How will you as the nurse evaluate the outcome
18Expected Outcomes
- Healing of the wound or injury
- Prevent minor infections from becoming
overwhelming to the body - UTI vs. urosepsis
- Goals and outcomes will vary with each patient
- Remember that your outcomes will drive your
interventions/cares
19Systemic Manifestations of Acute Inflammation
- Fever/chills
- Cytokines
- Benefits
- Increased killing of microorganisms
- Increased phagocytosis by neutrophils
- Increased activity of interferon
- Leukocytosis
- Neutrophils
- left shiftband cells
20Medications NSAIDS
- Ibuprofen, Toradol
- Mechanism of action
- Inhibits prostaglandin synthesis
- Nursing implications
- Give w/food
- Elderly-high risk GI bleed
- Prolongs bleeding times 1 day
- Assess renal function-creatinine w/chronic use
21Medications NSAIDS
- Salicylates Aspirin
- Mechanism of action
- Inhibits production of prostaglandins
- Decreases platelet aggregation
- Nursing implications
- Give w/food
- Prolongs bleeding times 4-7 days
22Medications Anti-histamines
- Benadryl, Ranitidine (Zantec), Famotidine
(Pepcid) - Mechanism of action
- Block histamine at the receptor site
- Decreases gastric acid secretion
- Nursing implications
- With meals
- Drowsiness/dizziness
23Medications Corticosteroids
- Prednisone
- Mechanism of action
- Decrease inflammation by stabilizing neutrophils
and lysosomes - Inhibit prostaglandin synthesis
- Inhibits chemotactic cytokines
- Decreases mast cell stimulation
- Nursing implications
- Meals
- Chronic use complications
- Risk of infection
- Hyperglycemia
- SE
24Normal Course of an Infection
- Incubation period
- Prodromal stage
- Full stage of illness
- Convalescence
25Infectious agents/pathogens
- Bacteria
- Virus
- Fungi
- Protozoa
26Bacteria
- Single cell
- Human cells vs. bacteria count in body
- Gram /-
27Virus
- Most common affliction of humans
- Has no metabolism of its own
- Is incapable of replicating outside a living cell
- Takes over the metabolic machinery of host cells
to survive and replicate
28What influences Pathogen survival?
- Food/Glucose
- Water
- Oxygen aerobic/anaerobic
- Temperature
- pH
- light
29Reservoir
- A place where a pathogen can survive but may or
may not multiply - What is the most common reservoir?
- What is a carrier?
30Portal of exit
- For the pathogen to cause an infection it must
exit the reservoir - How can this happen?
31Mode of Transmission
- Direct or indirect
- What is the major mode of transmission in the
health care setting? - List the 4 categories of transmission
32Portal of entry
33Susceptible Host
- What factors increase our susceptibility to
infection? - Age
- Stress
- Nutritional status
- Current medical therapies
- Chemo
- Steroids
- Presence of disease
34Leukocytes
- Normal Blood Count of all WBC 4,000-11,000/ul
- Neutrophils
- Monocytes
- Lymphocytes B cells mediate the humoral immune
response - T cells Mediate cellular immunity
- Elderly considerations
35Laboratory Studies
- CBC
- Hgb (12-16 g/dl)
- Hct (33-51)
- Platelets (140-440 thou/cu mm)
- WBC (4.5-11.0 thou/cu mm)
- Differential
- Never-neutrophils (42-72)
- Let-lymphocytes (20-44)
- Monkeys-monocytes (lt11.1)
- Eat-eosinophils (lt7.1)
- Bananas-basophils (lt3.0)
36Cultures, gram stains and sensitivities
- Wound and skin cultures, body fluids, blood
cultures - Gram stains
- Sensitivities
37Anti-infective Drugs
- Determine if hypersensitive to medication
- Check for interactions with other drugs
- Educational needs of client
- Determining effectiveness
38Antibiotic Therapy
- Anti-fungal
- Fluconazole, Nystatin
- Cephalosporins
- Cephalexin (Keflex)
- Penicillins
- Amoxicillin, Ampicillin
- Sulfonamides
- Bactrim
- Tetracyclines
- Doxycycline
39Antibiotic Resistance
- Bacteria adapt in ways which make an antibiotic
less effective or ineffective - MRSA Methicillin resistant staphylococcus
aureus - VRE Vancomycin resistant enteroccus
40Vancomycin
- Anti-infective class other
- Effective against gram pathogens
- Used in potentially life-threatening infections
when other drugs are not effective - Action binds to bacterial cell wall and cell
death results - Poorly absorbed in GI tract, may be given IV
41NCLEX Concepts of Emphasis
- Define inflammation
- Is inflammation always present with infection?
- What are some patient examples that would limit
or impair their inflammatory response? - What are the five physical manifestations of the
inflammatory response? - Name each distinct phase of the inflammatory
response and unique characteristics of each? - What are other causes of inflammation besides
micro-organisms? - What are some common diseases of chronic
inflammation? - What are the medications that treat the
inflammatory response?
42Sepsis
- Patho
- Infection (susceptible host)
- Inflammation-systemic
- SIRS
- Capillary permeability
- Vasodilation
- Progressive
- Sepsis/SIRS
- Septic shock
- Multiple Organ Dysfunction Syndrome (MODS)
43Article Case Study
- 70 yr female from NH
- CC
- weakness, diarrhea x3 weeks
- Assessment
- PMH IDDM, HTN, CVA, COPD, UTIs
- VS T-97101.8 P-109 R20-24 BP-93/41 91-98
- a/o x3
- Labs
- WBC-26.5
- Gluc 258
44Article Case Study-Day 2
- T-96.6 P-125 R-24 BP 80/43
- Oriented to self only
- u/o 180cc over 8 hours
- Became more lethargic later in day
- T-96.5 P-100 R-24 BP 70/30
- Labs
- WBC 41.9
- Lactate 2.2
45Article Case Study-Day 3
- T-96.5 P-100 R 14-32 BP 70/50
- Labs
- WBC 41.9
- Creatinine 4.3
- Vasoactive gtts
- Intubated
- Died day 7
46Key Nursing Assessments
- Fever/chills
- Hypothermia
- Altered LOC/confusion
- Break in skin integrity
- Foley catheter
- Wound or incision
- Tachycardia
- HR gt100
- What if elderly or on beta blockers?
47Key Nursing Assessments
- Tachypnea
- RR gt20
- Hypotension
- SBP lt90
- SBP drop of gt20-30mm/Hg
- Decreasing urine outputlt30cc/hr
- Labs
- WBC
- Neutrophils
- Creatinine
48Nursing Diagnosis statements w/infection/sepsis?
- Ineffective breathing pattern
- Decreased cardiac output
- Ineffective tissue perfusionmanifested by
- Altered mental status
- Behaviorial changes (restlessness)
- Renalcreatinine
- Acute confusion
49NCLEX Concepts of Emphasis
- Why is the older adult at risk for infection and
cancer development? - Inflammation and immunity are provided primarily
through what body cells? - Differentiate the 5 types of leukocytes and what
each type does to protect the body from
micro-organisms - Which leukocyte is elevated in bacterial
infection? - Why
- What body cell is able to recognize and destroy
non-self cells? - What vital sign changes are seen in sepsis?
- What assessment findings are seen in sepsis?
50Immune Response
- Passive Acquired Immunity
- Present at birth
- Short lived
- Body needs to develop own
- Active Acquired Immunity
- After birth
- Active
- Long-term
- Exposure to micro-organisms
- immunizations
51What comprises the immune system?
- Bone Marrow
- WBC
- Lymph system
- Thymus Gland
- Misc Tonsils, Spleen, Mucosa, Appendix
52Lymphocytes
- WBC that allow the body to remember and recognize
previous invaders. - Two types
- B lymphocytes
- T lymphocytes.
- NK or natural killer cells
53Specific Defenses
- Humoral (circulating) immunity
- Reside in B lymphocytes
- Mediated by antibodies (immunoglobulin) produced
in B cell - Produce antibodies when activated
- Cell-mediated defenses
- T cells released when exposure to an antigen
occurs - 70-80 total lymphocytes
54Antigens
- An antigen is a substance that elicits an immune
response - Mostly comprised of protein
- A foreign substance that invades the body is
called an antigen - All cells have antigen unique to that individual
allowing the body to recognize itself
55Humoral (antibody) Immunity
- Antibody mediated immunity
- Antibodies are produced by B cells
- Antibodies can bind to antigens
- Immunoglobulins (IgG, IgA, IgM, IgD, IgE)
56Cell Mediated
- T-cells
- able to recognize infected cells
- Cytotoxic
- Natural killer cell
57Cytokines
- Soluble, hormone-like protein produced by white
blood cells - act as a messengers between cells
- Stimulate or inhibit the growth and activity of
various immune cells - Can be beneficial or harmful
58Antipyretics
- Acetaminophen
- Ibuprofen
- Aspirin
59Immunopathology
- Alterations in Immunity and Inflammation
- Hypersensitivity
- Autoimmunity
60Hypersensitivity
- Immediate
- Allergy
- Anaphylaxis
- Delayed
- Poison Ivy
- Mantoux Test
61Hypersensitivity
- Nursing Assessment
- Think ABCs
- How fast is the allergic response?
- How serious?
- What to ask the patient?
- Is this an allergic response or drug side effect?
62Name that response
- Baby is crying continually and pulling at her
ear. Mom is frantic. - Young man- ate shellfish and then went to play
tennis. Now is having difficulty breathing. - Young woman went hiking in the woods last week
now has hives present and is scratching. - 12 year old girl crying and shaking, holding her
very swollen arm/elbow - injured playing baseball
63Autoimmunity
- Recognizes self antigens as foreign
- Produces antibodies against own tissue
- Examples
- Lupus
- Rheumatoid Arthritis
64How do immunizations work?
- The exposure (usually injection) to a small amt
of virus triggers an immune response - Help body prepare antibodies
- Type of immunity
- Active artificial
65NCLEX Concepts of Emphasis
- What are the similarities and differences between
cellular and humoral immunity? - How do vaccinations work?
- To be fully immune requires which three essential
components of the inflammation/immune response? - What is the mechanism of Prednisone and the
nursing considerations when giving? - What is the difference between an allergic
reaction and side effect of a medication? - What is the similarities differences between
hypersensitivity and anaphylactic reaction?
66Bronchospasm associated with hypersensitivity
reaction is the result of
- A. histamine release
- B. pulmonary ventilation
- C. dilation of the alveoli
- D. inadequate antibody production
67Which symptom indicates a possible allergic
reaction?
- A. fever
- B. diaphoresis
- C. rash
- D. chills