Nursing Care of Clients Experiencing Immune Dysfunction

Review of immunology from H&P in 6th ed chapt 19 are self study: Slides 1-17 Identify key material to review from Fundamentals and A&P

Chapter 19: Key Terms to review from A&P

          

Self-tolerance Immunocompetent Antigens HLA Stem cell/figure19-3 Chart 19-1 Leukocytes/table 19-1 Absolute neutrophil count Left shift Vascular leak syndrome Sequence of inflammatory responses

        

Complement Agglutination Immunoglobulin Innate native immunity Natural active immunity Artificial active immunity Artificial passive immunity Natural passive immunity Hypersensitivity

Overview of Immune Response

INFLAMMATION

IMMUNITY CELL MEDIATED ANTIBODY MEDIATED

THREE DIVISION OF IMMUNITY: FUNCTION INDEPENDENTLY AND INTERDEPENDENTLY TO PROVIDE COMPLETE IMMUNITY. 3

FUNCTION OF THE INFLAMMATORY RESPONSE IN IMMUNITY



 

I.E.: tissue macrophages and granulocytes (neutrophils, basophils and eosinophils) Non Specific Response Initiated By Injury Or Invasion
Self study Question:
Cite two examples of an agent that can injure or invade.

FUNCTION OF THE INFLAMMATORY RESPONSE IN IMMUNITY



Vasoconstriction followed by
increased capillary permeability to localize response phagocytosis assisted by complement activation to ingest debris release of chemical factors that enhance localization(vasoactive), attract factors that assist in inflammatory response (chemotaxis) and release of factors (cytokines) to stimulate production of granulocytes

Self study Question: How would you explain this event to a client in terms that they could understand?

Ignatavicius Figure 19-6 Steps of phagocytosis assisted by complement activation and fixation Complement coats the
antigen

Self study Questions:

How does complement assist in phagocytosis? How would complement levels be effected by active inflammation?

FUNCTION OF THE ANTIBODY MEDIATED RESPONSE IN IMMUNITY (figure 19-8)



  

Known as humoral immunity (B-lymphocytes action is predominant although assisted by Tlymphocytes) creates two types of cells : plasma cells and memory cells plasma cells secrete immunoglobulins in response to a specific antigen memory cells are dormant yet sensitized to the specific antigen in case of a repeated exposure
THE OLDER CLIENT HAS A REDUCED CAPACITY TO RESPOND, PRODUCE, AND SUSTAIN AN IMMUNE RESPONSE USING THIS MECHANISM
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Ignatavicius Figure 19-7 Immune complex

AN ANTIGEN ENTERS THE BODY SENSITIZED B LYMPHOCYTES PRODUCE LARGE AMOUNTS OF ANTIBODIES IF REEXPOSED TO THE ANTIGEN MACROPHAGE AND T HELPER CELLS INTRODUCE ANTIGEN TO THE B LYMPHOCYTE

B LYMPHOCYTE IS SENSITIZED THE IMMUNE COMPLEX TRIGGERS OTHER LEUKOCYTES TO DESTROY IT

B LYMPHOCYTES PRODUCE ANTIBODIES SPECIFIC TO THE ANTIGEN

ANTIBODIES BIND TO THE ANTIGEN CREATING AN IMMUNE COMPLEX

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Self study Questions:

What happens when antibodies and antigens combine? What arm of immune response is responsible for this action?

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Types of Immunity


Innate-native immunity
genetically predisposed; not an adaptive response

acquired immunity through humoral response

immunity mediated by an adaptive response
Active Passive
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Active Vs. Passive Acquired Immunity



Active
natural: body responds to an antigen that is introduced naturally artificial: acquired immunity achieved through vaccines that have been attenuated to initiate exposure but not develop disease

Passive
natural:antibodies transferred to a fetus from mother artificial: injection of antibodies into a client
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Self Study Questions: What questions would you prepare to answer before administering a vaccine to identify what type of immunity the client will receive, and why? What additional questions would you ask if you had immune dysfunction, and why?

Classify the types of immunity:

Tetanus Toxoid oral polio vaccine hepatitis B vaccine post exposure protection from chicken pox immunoglobulins passed in breast milk

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FUNCTION OF CELL MEDIATED RESPONSE IN IMMUNITY



T helper cells, Suppressor T cells

T helper cells recognize self from non self:
facilitate B cell response through introduction of antigen stimulate bone marrow to rapidly produce myeloid and lymphoid stem cells function described as a calling to arms

T suppressor cells are inhibitory.

Opposite of helper cells prevent over response and production of auto-antibodies circulating volume 1/2 of T helper cells

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Neutrophil maturation: What would happen with T helper cell action?

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FUNCTION OF CELL MEDIATED RESPONSE IN IMMUNITY



Cytotoxic T cell, natural killer cell

Cytotoxic T cells recognize viruses and protozoa that alter self cell antigenic surface
binding results in cell destruction

natural killer cells destroy unhealthy or abnormal self cells

does not rely on antigenic sensitivity to initiate activation called seek and destroy cells

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Self study Questions:

What are the types of T cells involved in immunity? The T cell arm of immunity is mostly effected by HIV infection. What would you expect to occur?

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Selected Stressors Associated With Immune Dysfunction



Hypersensitivity reactions
allergy

Immunodeficiency
AIDS

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Key medications to review



Beta agonists
Epinephrine 1:1000 aqueous solution
Epi-pen for SQ or IM injection

Epinephrine infusion for continuous infusion



Histamine antagonists
Diphenhydramine (H1 antagonists) Ranitidine (H2 antagonists)

  

Alpha 1 agonists
Afrin (oxymetazoline)

IV corticosteroids
Solumedrol

Inotropic agent that promotes catecholamine release

Glucagon
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Nursing Care of Clients Experiencing Hyperfunction of the Immune Response: Allergy and Autoimmunity

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Types of hypersensitivity Table 22-1

    

Type 1: excess circulating IgE with mast ell release hay fever, atopic asthma and allergic rhinitis Type 2: IgG reacts with host cell as in Myasthenia gravis, autoimmune hemolytic anemia Type 3: immune complex formation causing damage as in SLE Type 4: delayed reaction from T lymphocytes as in poison ivy and PPD reaction Type 5: overreacting target cell caused by autoantibody stimulation (graves disease)
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TYPE IV: Delayed Hypersensitivity Reactions



A sensitized T lymphocyte responds to an antigen

does not involve antibodies or complement takes hours to days to take effect characterized by edema, ischemia and tissue destruction, pruritis a positive PPD is a TYPE IV reaction
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Collaborative management of Type IV Hypersensitivity

   

Avoid offending antigen Apply OTC topical steroids Monitor for secondary infection No concern about progression to anaphylaxis since it is not a Type I reaction

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Over View Type I Hypersensitivity Reactions

 

Most common type of reaction exposure to allergen initiates inflammatory response

allergic asthma, allergic rhinitis, hay fever

route can be inhaled, ingested, injected, contact (key point to remember every time a client has a new drug therapy initiated) life threatening form of Type I is called Anaphylaxis
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Irritants associated with Type I hypersensitivity

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Latex allergy is a TYPE I Reaction



Incidence is increasing especially for individuals with frequent exposure may be mixed type I and Type IV
type IV are limited to cutaneous reactions

implications for nursing practice

early identification for latex allergy use of latex free products that can be inhaled or in contact with vascular system
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Risk groups for latex allergy

   

Health care workers Rubber industry workers Persons with spina bifida or urogenital abnormalities Persons who have undergone repeated or prolonged surgeries or mucous membrane exposure to latex devices, especially early in life Persons with an atopic history or history of food allergy (cross-reacting proteins, especially in banana, avocado, passion fruit, chestnut, kiwi fruit, melon, tomato, celery) Family history of allergy Source: Latex Allergy @ http://www.aafp.org/afp/980101ap/reddy.html
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Pathophysiology of TYPE I

Characterized by vasodilation, increased capillary permeability, mucosal edema

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Pathophysiology of Type I continued



First event can be local urticaria, pruritis, watery eyes, rhinitis Continuing events can lead to anaphylaxis with certain types of irritants, such as:
Latex, medications, peanut butter etc
More serious adverse event is call anaphylaxis

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Clinical Manifestations/Lab Diagnostics for low level type I



Clinical Manifestations:
Sign and symptoms of allergic rhinitis, hay fever, allergic asthma, contact dermatitis, cutaneous rash (client-specific response)

Lab tests:
elevated eosinophils, IgE identification of specific allergens by RAST testing

Specialized tests:
skin testing food challenge
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Collaborative care of TYPE I

 

NIC: Allergy Management chart 22-1 Treating Symptoms (chart 22-3)

decongestants (alpha adrenergics)
stimulate vasoconstriction (Neosynephrine)

antihistamines
inhibit vasodilation (Diphenhydramine)

leukotriene antagonists
block leukotriene receptor (Singulair)

desensitization therapy
allergy shots

Pt teaching regarding s/s of anaphylaxis

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Nursing Care of Clients At risk for Experiencing Type I Reactions



Risk for Ineffective Respiratory Function r/to Allergic Response

Health teaching
Food avoidance allergy to molds allergy to pollen stinging insects use of medication; desired and untoward effects s/s of anaphylaxis

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Nursing Care of Clients At risk for Experiencing Type I Latex allergy response


Risk for latex allergy response

Assess for history of reactions from:
dental work, tape, condom, elastic, balloons, rubber cement

Assess for hx of:

asthma, rhinitis, conjunctivitis, eczema, etc

Assess for presence of food allergies to:

Peach banana, tomato, mango papaya etc
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Nursing Care of Clients At risk for Experiencing Type I Latex allergy response (continued)


Assess for frequent instrumentation/surgical procedures

Spina bifida clients, surgery early in life

 

Assess for occupational exposure to latex Eliminate exposure to latex products Initiate health teaching
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Anaphylaxis


 

Life-threatening Type I hypersensitivity reaction Occurs rapidly, systemically Affects multiple organs

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Clinical Manifestation of Anaphylaxis (Early)

    

Feelings of uneasiness, apprehension Weakness, impending doom Anxious and frightened Generalized pruritus/urticaria (hives) Angioedema
 diffuse swelling of eyes, lips and tongue

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Clinical Manifestation of Anaphylaxis (Late)

       

Bronchoconstriction Mucosal edema, excess mucus production Crackles, wheezing, diminished breath sounds Laryngeal edema, stridor, hypoxia, hypercapnia Hypotension, weak, rapid, irregular pulse Faintness, diaphoresis Loss of consciousness Dysrhythmias, shock
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Guidelines for care



Evidence- based practice

The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immuno 2005 Mar;115(3 Suppl):S483-523. [232 references] Pubmed

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Shock management according to latest guideline see chart 22-2



Assess airway, breathing, circulation, and level of consciousness Administer Aqueous epinephrine 1:1000 dilution (1 mg/mL), 0.2 to 0.5 mL intramuscularly or subcutaneously every 5 minutes, as necessary,
should be used to control symptoms and increase blood pressure.
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Shock management according to latest guideline



How should you administer Epi?

Intramuscular epinephrine injections into the thigh have been reported to provide more rapid absorption and higher plasma epinephrine levels

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Place in trendelenburg Establish airway with Endotracheal tube Administer oxygen Monitor HR and BP continually Start (2) IV NS 5-10ml/kg in first 5 minutes (may require 7 liters) and watch for fluid overload with heart disease

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Client is not responsive to SQ or IM injection and volume replacement



Administer epinephrine IV
can be administered intravenously over several minutes and repeated as necessary in cases of anaphylaxis not responding to epinephrine injections and volume resuscitation.

Initiate epinephrine drip

1mg epinephrine in 250 ml D5W at 4 10 mcg/min
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Client is not responsive to SQ or IM injection and volume replacement



Administer antihistamine, H2 antagonist, beta agonist nebulizers and corticosteroids

Benadryl 50 mg IVP Ranitidine 50 mg IV Inhaled beta-agonist for bronchospasm Solumedrol IVP 1-2 mg/kg/day Glucagon (dose unspecified) to increase release of Catecholamines Vasopressors such as dopamine may be required

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Collaborative Management of Anaphylaxis

Transfer to ICU Allergist/immunology consult after recovery client/family are instructed in use of epi-pen to self-administer when early s/s of anaphylaxis are present

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Summary
 

 

There are five types of hypersensitivity for which we are emphasizing understanding in Type 1 and Type 4. These types of hypersensivities both respond to irritant but follow a different course due to their individual pathophysiologies. Type I has the potential to be more life threatening, even if it is innocuous in its earliest presentation. Reduction of risk potential for anaphylaxis requires careful screening and analysis of high risk groups to minimize exposure. The life threatening reaction of anaphylaxis is managed using NIC: shock management and vasoactive agents that stop the capillary leaking that causes the shock condition. A review of the emergency medications emphasizing the mechanism of action, adverse effects, management side effects and contraindications are required when providing care.
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