Immunologic Disorders

1. By: Diana Blum RN MSN Metropolitan Community College Immunologic Disorders

3. 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

4. Anatomy • Lymph fluid=mix 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), hodgkin’sdx • Greater risk of infection

5. 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 Cells=called progenitor cells • Develop into various WBCs, RBCs, or Platelets • Most located in bone marrow • Some circulate in blood

6. 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. • Neutrophils=fight bacterial infections • Most numerous of the WBCs about 60%

7. Anatomy • Monocytes= circulate for 1 day before entering tissue • Macrophages=monocytes when they enter tissue • Destroyed during phagocytosis • Ingest foreign material and can live months to years

8. Anatomy • Eosinophils=combat 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

9. 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 • IgM=first to be secreted during primary immune response • IgG= secreted during 2ndary immune response • IgA=present in secretions like mucus and mother’s milk • IgE=attaches to the cell membrane of basophils and mast cells where it triggers the cell to release histamine.

10. 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, granulocyte=macrophage colony stimulating factor, EPO) • Eicosanoids=class of fatty acids that regulate blood vessel vasodilation, temperature elevation, WBC activation • NSAIDS disrupt production

11. T cell

12. 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

14. Functions • Acquired immunity=fights 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 • Active:the person manufactures antibodies in response to infection ***permanent • Passive:antibody 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)

16. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

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

24. Bone marrow transplant/Stem cell • Done to restore immune system • Complications: infection, thrombocytopenia, renal insufficiency, graft vs host dx

25. 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/s:infection, 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

26. Leukemia

27. 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)

28. 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 nutrition<less than body requirements • Anxiety • Ineffective therapeutic regimen management

29. 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

30. 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

31. HIV

32. transmission

33. 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 stage=opportunistic infections • 2-3 years • Once CD4 Level below 200 it is considered AIDS

34. Complications • Opportunistic infections • Pneumonia • Herpes • CMV retinitis • Meningitis • toxoplasmosis • Wasting • Weight loss • malnutrition • Cancer • Kaposi’s sarcoma • Non hodgkins • Anal cancer • Cervical cancer • Dementia • From encephalitis

35. s/s • Flu like symptoms • Fever • Night sweats • Swollen lymph nodes • Headache • Skin lesions that don’t heal • Sore throat • Dyspnea • Burning with urination • diarrhea • Fatigue • Weight loss

36. diagnosis • Positive ELIZA test • Positive Western Blot test

37. 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

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

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

41. 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

43. 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%

44. 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%

45. 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

47. Any Questions