asthma - immune

8/13/2019 Asthma - Immune

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THE IMMUNE SYSTEMCare of Clients with

Altered Immunity


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Altered Immunity

Immune System OVERVIEWFunction major defense againstinfectious organisms & abnormal ordamaged cells

Defends against bacteria, viruses,fungi & parasites

Removes & destroys damaged/deadcells

Identifies & destroys malignant cells


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Types of immunity

Innate (natural) present at birth

Occurs without prior contactwith antigen. Involvesneutrophils & monocytes


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Review of Immunity

Please review anatomy and

physiology of the immunesystem and notes fromFundamentals.Watch VT 137 and VT 134


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Types of Immune Response

Humoral Immunity (antibody-mediated) B cells divide & differentiate into plasma cells after antigen invades

Plasma cells product & secreteantigen-specific immunoglobulins(Ig)


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Five types of Ig

IgA, IgG and IgM respond to viraland bacterial invasion.IgD may assist in B cell bindingwith antigenIgE is present during inflammatoryresponses and causes allergicresponse


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Complement

Consists of approx 25 enzymes

that work with antibodies tohelp with puncturing bacterialcell walls to destroy (duringhumoral response)


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Types of Immune ResponseCell-Mediated occurs when antigen lives withinthe body cell (bacteria, virus, fungus, cancer)Macrophages identify antigen & T cells (killerTs, cytoxic cells) & defend against it.Delayed response- graft rejection, hypersensitivityreactions, tumor immunity, immunity against

bacteria, virus & fungus

Antigen specific Antigen must be present on cellsurface


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ALTERED IMMUNE

RESPONSESImmunoincompetance

Severe infection,immunodeficiency diseases,malignancy

Overactive System hypersensitivities


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TYPES OF

HYPERSENSITIVIIESType 1 anaphylactic local IgE antibodies produced after 1 st

exposure 2nd exposure causes smooth muscle

contraction, increased vascular

permeability, vasodilation, hypotension,increased mucous & itching d/t IgEcausing release of chemical mediators


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ANAPHYLATIC REACTIONSLocal response is cutaneous (wheal-and-flare). Example of

cause food, pollen, Rx, dustSystemic response is anaphylaxis

shock, rapid, weak pulse, hypotension, dyspnea, bronchialedema, crackles, wheezing, laryngeal edema, angioedema,increased mucous, strider &death if not treated STAT.Examples of cause food (shellfish, nuts peanuts, eggs,strawberries), Rx (PCN, Sulfas) insect bites (bees wasps),

antitoxin, (tetanus, rabies) blood, iodine-contrast media forIVP


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Treatment cotinued

Oxygen is used to maintain O2sat above 90%.

HOB 45 degrees to assist withrespiratory status.

Maintain BP (fluids, vasopressors dopamine & norepinephrine)

Aminophylline IV 6 mg/kg forsevere bronchospasm.

Albuterol nebs Q2 - 4 hrs


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Treatment continued

Monitor VS,O2 sat, LOC,

cardiac & respiratory status.Anticipate CPR, intubation &tracheotomy


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ANAPHYLACTIC REACTIONS

Atopic reactions

Allergic rhinitis (hay fever) Asthma bronchial constriction,

excessive mucous, mucousmembrane edema, dyspnea,wheezing, coughing, tight chest


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ANAPHYLACTIC REACTIONS

Atopic reactions continued atopic dermatitis chronic, inherited

disorder involving reddened vesicles,crust & cracks

Urticaria (hives) Angioedema edema of face,, hands

& feet, larynx, GI tract & genitalia.


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Type II IgM & IgG produce a cytotoxic

reaction that destroys the targetcell.

Cause exogenous (foreign tissue,blood incompatibility, drug)

Or endogenous (autoimmune

disorders autoimmune hemolyticanemia,Goodpastures syndrome)


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Type III Immune complex - mediated

reactions. IgG & IgM Produces complexes which are then

deposited in small blood vessel

walls. Sites include kidneys, skin, joints, and other small bloodvessels. The deposited complexes

activate complement, & tissue orvessel damage results Rheumatoid arthritis and systemic

lupus erythematosus


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Assessing the ImmuneSystem Age-Related ChangesDecreased size & activity of thymusDecreased production of T and Bcells

Delayed hypersensitivity response.Decreased cell-mediated immunityGreater susceptibility to infection

Higher incidence of tumors .


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Assessing the Immune

SystemWeight changes, skin lesion,rashes, or impaired healing.

Activity intolerance, frequent sorethroats, URI, swollen glands, easy

brusing, joint pain, swelling,enlarged lymph nodes. Acute: erythema, local heat, pain,

T > 100.4, P >90, R > 20,


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Assessment chronic allergySkin rashes, itchingEENT conjunctivitis, dark circlesunder eyes, excessive rubbing/ blinking, recurrent ear infection,diminished hearing, nasal voicerhinitis, pale, swollen mucousmembranes, throat clearing, swollenlips/ tongue, enlarged lymph nodes


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Diagnostic Studies

Lymphocyte count below 12/ ml in cellularimmunodeficiency.

Eosinophil count elevated in type 1hypersensitivityRadioallergosorbent test (RAST) confirmsallergy to specific food or drugs

Skin testing determines hypersensitivity toallergens


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Histocompatibility

HLA Typing

Crossmatching


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GVHD TREATMENT

There is no adequate treatment.Drug therapy Calcineurin inhibitors Prograf,

Sandimmune Antimetabolites - CellCept Corticosteroids Solu-Medrol Antibiotics, antivirals, antifungals


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INTERVENTION RISK FOR

INFECTIONHANDWASHINGReverse isolation

Monitor vital signs, assess for signs ofinfection, I/O, urine output Have patient wear mask and gloves when

out of room Adequate hydration and nutritionOral hygiene


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Risk for Impaired Tissue Integrity Assess for graft rejection if organtransplant Erythemia. Swelling over site, fever,

increased WBCs, Monitor labs

Assess for graft versus host Administer immunosuppressivetherapy.


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AUTOIMMUNITY

Occurs when immune system can nolonger recognize self from nonself

B and T cells attack self-antigen andcause physiologic tissue damageAutoimmune disease depends onwhich self-antigen is involvedMost autoimmune diseases havegenetic basis


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Connective Tissue Disorders

Selected Systemic

Autoimmune Disorders


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OA

Diagnostic History, physical No lab tests ESR may be slightly elevated

secondary to synovitis. X-rays show structural joint changes. CT, MRI, Bone scan show joint

change


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Medications

Pain Tylenol,NSAIDS,ASA

Capsaicin creamMuscle Spasms Muscle

Relaxants (Flexeril)


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Medications

Pain Tylenol,NSAIDS,ASA

Capsaicin creamMuscle Spasms Muscle

Relaxants (Flexeril)


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OA

Rest Immobilization of joint

Positioning Placed in functional position. Large pillow under contracture (if

present). Elevate 8 to 12 inches.

Heat with

heating pads- max 20 min


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OA

Diet High protein, Vitamin C

Weight loss if indicated

Surgery


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OA

Treatment options Arthroscopy- visual inspection of joint

Ostotomy- incision into bone, can re-align bone. May help decrease pain.

Arthroplasty-

reconstruction/replacement of joint.Can use screws or plates to hold jointin or cement joint.

Total joint replacement-hip/knee


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Gout Genetic or secondary to conditions that

increase uric acid. Urate crystals depositedinto joints Stress, Alcohol,some diuretics, cyclosporin

and salicylates can induce

Acute Gouty Arthritis Abrupt, acute pain, red, hot, swollen,

tender joint

Chronic Tophaceous Gout Tophi on joints, joint stiffness, limitedROM, deformity.


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Diagnostic

Uric Acid level: above 7.5 WBC:

20,000, elevated Eosinophils

24 hours urine Elevated uric acid

Arthrocentesis: Synovial fluid aspirated, will see crystals

Treatment Diet:

Increase fluids, avoid alcohol, red meats, organ meats

Monitor for kidney stones


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Medications

Allopurinol (Zyloprim) Reduces uric acid.

Increase fluids, monitor kidneys. NSAIDS & Steroids To decrease inflammation- Indocin

Colchicine Decreases urate crystals & inflammation. Used to treat acute attacks and to prevent

attacks.

Benemide for those who cant excrete uric acid.


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RHEUMATOID ARTHRITIS

(RA)Chronic systemic disease characterized

by inflammation of synovial joints

Periods of remission and exacerbationHigher incidence between 40 and 60years of age

Affects women 2 to 3 times more oftenthan menSmoking linked to RA


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Rheumatoid ArthritisPannus is vascular granulationtissue, composed ofinflammatory cells, that erodecartilage, destroying bone.

Fibrous adhesions, bonyankylosis, & calcifications occur,bone loses density and

secondary osterporosis occurs. .


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Rheumatoid ArthritisSigns and symptoms include:

Fatigue, weakness, anorexia,weightloss, persistent low-grade fever. Joints

involved are reddened, warm, stiff,swollen, and tender or painful,especially upon palpation or withmotion .Later, joint deformities lead toatrophy of muscles & tendons anddisability. Subluxation slipping of

joint surface against another (expopping knees) Hand deformities &bunions in feet

Rh t id A th iti


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Rheumatoid ArthritisSystemic

Fever, fatigue, round, moveable,nontender subQ nodules at ulnar surface ofarm,vasculitis, ischemic brown skin lesions,peripheral neuropathy

respiratory Pleuralsy and pneumonitis

cardiac complications

pericarditis and myocarditis Associated Syndromes

Sjogrens,Feltys, and Caplans..


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Rheumatoid Arthritis

Diagnostic: ANA Antinuclear antibodies, used to diagnosis

autoimmune diseases. Antibodies directedagainst self

Positive in some cases

Rheumatoid Factor: RF- Positive in about 80% of cases Titers rise during active disease


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DRUG THERAPY

Disease-modifying antirheumaticdrugs (DMARDs

Plaquenil for mild cases - sideeffects rash, abdominal discomfort& nausea. Rare irreversible retinaldegeneration. Need eye exam beforetreatment & every 6 months.

Corticosteroids for symptom control

Treatment:


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Treatment:

NSAIDs COX-2 ASA

Cytotoxic - Methotrexate side effects - bone marrow

suppression & hepatotoxicity Gold salts if dont respond to

Methotrexate IM side effects rash, mouth sores, diarrhea

Analgesic Darvon, Darvocett


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Rheumatoid Arthritis

Treatment:

Rest, positioning, ice, and heat Ice to hot joints Heat for morning stiffness Low impact walking or swimming

Complementary Therapy TENS Music Therapy Imagery, Music


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SystemicLupus ErythmatosusChronic, multisystem inflammatory diseaseOccurs most in women in childbearing yearsCan be mild or severeCourse of disease unpredictable withremissions & exacerbationsCause unknown, but genetics, hormones,sun exposure, drugs & autoimmunereactions related.

Immune complexes effect organs directly


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Lupus ErythmatosusPathophysiology

Abnormal antibodies areproduced, complement isactivated & immune complexesform & deposit in capillaries inkidney, heart, skin, brain, &joints,causing inflammation & damage.

SLE


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SLE Characterized by periods of

spontaneous remissions andexacerbations Assessment:

Inflamed, red rash, and discoid lesions on skin nephritis and renal failure Pericarditis and raynauds phenomenon Pleural effusions

Abdominal pain Joint inflammation Fever, fatigue, anorexia, and vasculitis Psychosis and seizures


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Diagnostic:

ANA level Anti - DNA testing, RF, ESR, Anti-Smith

(Sm)

Skin BXMedications NSAIDS for mild arthritis Steroids for severe polyarthritis or severe

skin lesions Antimalarial if polyarthritis present May need immunosuppressants


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Impaired Skin Integrity Due to risk of infection and rashes

Avoid sun-can trigger episode Keep skin clean and dry Altered protection

Due to treatments and multiple organproblems

Strict aseptic technique Monitor vitals and for signs of infection

Monitor lab values May need reverse isolation Adequate nutrition, hydration, and mouth

care


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Systemic Sclerosis

(Scleroderma)Chronic connective tissue disease withinflammation, fibrosis, and sclerosis of

organ. Cause is abnormal production of collagenleading to fibrosis in skin, joints, andinternal organs.

Assessment: Renal, joint pain, taut and shiny skin,

no wrinkles, dysphasia, GERD


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Systemic SclerosisCrest Manifestations: Calcium Deposits

Raynauds Phenomenon Esophageal Dysmotility Scleroderma of digits Talagiectasis- spider like angiomas Drugs are used to treat the symptoms. No cure

Diagnostic: No exact exam Elevated ESR


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Systemic Sclerosis

Nursing Maintain function ROM Diet

Difficult swallowing Antacids

Avoid chilling
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HIV & Personswith AIDS


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ETIOLOGYCaused by Human Immunodeficiency VirusHIV is a parasite & cant survive & replicateunless inside a living cell

HIV Binds to CD4 receptor sites on cells surface Viral RNA enters cell & inserts into cells geneticmaterial.When HIV replicates within cell, newly formedviruses bud out, infect other cells & kill host cell.Immune dysfunction results from destruction of T-helper or CD4+T lymphocytes


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CD4+Tcell counts

T Cell count Normal between 500 and 1,000 Antiviral therapy is recommended for 500 to

600. Less than 200, AIDS full blown. Viral load determined by HIV RNA, PCR or

branched DNA tests

TESTS FOR MAINTENANCE OF THERAPY


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Treatment for HIV Infection

Antivirals

Reverse Transcriptase Inhibitors Protease Inhibitors Prophylactics

Medications


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MedicationsNucleoside reverse transcriptaseinhibitors

Improves survival rates and times, decreasesdisease progression.

Penetrates the nervous system and is useful inHIV dementia, thrombocytopenia, and it iseffective in preventing transmission of infectionto infants.

Inhibits viral enzyme reverse transcriptase.Slowing HIV replication, reducing theprogression of HIV infection.

Nucleoside Reverse


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Nucleoside ReverseTanscriptase Inhibitors

Retrovir Must be taken around the clock for

maximum effect. Monitor for

dizziness, headaches, anemia,leukopnea, insomnia,nausea.

Zalcitabine Aminoglycocides increase toxicity.

Monitor for abdominal pain, diarrhea.

uc eos e everse


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Tanscriptase InhibitorsDidanosive videx Take on an empty stomach, chew or

crush tablet. Monitor for dizziness,neuropathy, anemia, seizures, and

pancreatitis.

Stavudine Monitor for peripheral neuropathy.

Non-Nucleocide Reverse


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Trancriptase Inhibitors

Crosses placenta, and found in CSF. Inhibitscatalytic reaction of reverse transcriptaseindependent of nucleotide binding Nevirapine

Monitor for headache, hepatoxicity,rash,peripheral neuropathy.

Delavirdine Monitor for above. Increases blood

levels of sedatives, antiarrhythmic

agents, calcium channel blocker.

Protease Inhibitors


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Protease Inhibitors

Blocks protease. This slows down replicationand progression.

Crixivan Monitor for dizziness, abdominal pain,

hyperglycemia, ketoacidosis and back pain.High fat and protein and grapefruitdecreased absorption. Monitor glucose andliver enzymes.

Nelfinavir Monitor for seizures, emotional liability,

diarrhea, dehydration, parestesia, liverenzymes, and CBC.


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Rifampin Used for TB, and MAC. Assess breath

sounds, hepatic functions, CBC, andU/A. May turn secretions orange .

Diflucan Used for candidas and cryptococcal

meningitis. Monitor hepatic function,abdominal pain, fever, diarrhea.


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New Medications.. Pentafuside (T-20) A fusion inhibitor. It binds to a protein on

HIVs surface called gp41. This blocksHIVs ability to successfully bind withsurface of T-cells, thus preventing the cellsability to infect healthy cells.

Proleukin Interleukin-2. Boosts the production and

activity of the immune system.

Treatment


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Treatment

Medications HAART- highly active antiretroviral therapy.

A cocktail of medications Combining medications

Immune Enhancement- bone marrowtransplants, interleukin-2.

Health Promotion Health diet Handwashing Avoid sick people Take medications


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Education

Prevention of transmitting HIV to others No contact with infected body fluids semen, blood,

vaginal secretions, and breast milk Not spread in tears, saliva, urine, emesis, sputum,

feces, or sweat Practice safe sex

Do not share needles & stop use of street drugs Modify alcohol intake In case of spills of body fluids, use 10% bleach


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Opportunistic Infections

Fungal

BacterialViral


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ryp ococca men ng s


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Debilitating meningitis and occasionallydisseminated disease. Signs include fever,

headache, blurred vision, nausea, vomiting,nucal rigidity, mild confusion, and othermental status changes. Some patientsexperience seizures and other focalneurologic abnormalities. Others complainof malaise and fever without headache.


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Cytomegalovirus retinitis

CMV retinitis appears late in progression of diseaseSymptoms are decreased vision,floaters, and one-sided visual

field lossUntreated, causes blindness


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Mycobacterium avium complex

MAC is a bacterial disease thateffects the GI tractCan cause infection in blood,spleen, lymph nodes, bonemarrow & liver


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Opportunistic Malignancies

Kaposis Sarcoma

Non-Hodgkins LymphomaCervical Invasive Neoplasia

Aids Related Problems


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Aids Related Problems AIDS dementia complex

Effects 70 % of people Characterized with cognitive,

motor, and behavioralimpairments, peripheralneuropathy, paresthesia, andburning sensation, pain, and gaitchanges.

Malnutrition, wasting syndrome,

asthma - immune

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