Download - Ncm 101 - Immunology - Part2
MR. BERNIE PEDRIGAL MALABANAN, RN
LECTURE SERIES
IMMUNOLOGY AND
INFLAMMATORY
Six “ links” in the chain of infection
Etiologic agent -the microorganism causing the disease Reservoir- sources of microorganism Portal of exit from reservoir -the sites from which the
organism leaves the resevoir Method of transmission -means of transmission to reach
another hostDirect transmission -transfer from person to personVehicle-Borne transmission - A vehicle is any substance
that provides a means of transport and introduces a pathogen into a host
Vector-borne transmission - A vector is an animal or a flying or crawling insect that serves as a means of transport
Airborne transmission -may involve droplet or dust Portal of entry to a susceptible host Susceptible host
BODY DEFENSES AGAINST INFECTION
1. NONSPECIFIC DEFENSESAnatomic and Physiologic BarriersInflammatory Response
2. SPECIFIC DEFENSESAntibody-Mediated DefensesCell-Mediated Defenses
NON-SPECIFIC DEFENSES
ANATOMIC AND PHYSIOLOGIC BARRIERSskin and mucous membranesnasal passagesalveolar phagocytessaliva (lactoferrin, lysozyme, IgA)tearsstomach acidityresident flora of large intestinesacidic vaginal pH
NONSPECIFIC DEFENSES
INFLAMMATORY RESPONSE Local nonspecific defensive response of the tissues to an injurious or infectious agent
CARDINALS SIGNSCallorTumorRuborDolor Functio laesa
STAGES OF INFLAMMATIONSTAGE 1: Vascular and Cellular ResponsesSTAGE 2: Exudate ProductionSTAGE 3: Reparative Phase
STAGE 1: VASCULAR AND CELLULAR RESPONSE
bradykinin
vasoconstriction
vasodilation hyperemia
heat
redness
Increased vascular
permeability
margination
chemotaxis
diapedesis
leukocytosis emigration edema
pain
loss of function
histamine
Injurious agent
serotonin
prostaglandin
STAGE 2: EXUDATE FORMATION
chemotaxis
phagocytosis
exudate formation
STAGE 3: REPARATIVE PHASE
Exudate production
Tissue bursts out
Lymphatic system
collection
Granulation tissue forms
shrinks
Collagen formation scar
SPECIFIC DEFENSES
ANTIBODY-MEDIATED DEFENSES (HUMORAL IMMUNITY)
facilitated and mediated by B lymphocytes
TYPES OF IMMUNITY INDUCED1) ACTIVE – antibodies are produced by body
NATURAL – due to active infectionARTIFICIAL – due to administration of vaccines
2) PASSIVE – antibodies are transferred to the bodyNATURAL – transfer from mother and breastmilkARTIFICIAL – immunoglobulins is injected
FIVE CLASSES OF IMMUNOGLOBULIN1) IgM2) IgG3) IgA4) IgD5) IgE
IMMUNOGLOBULINS FEATURES
Immunoglobulin M • Comprises about 10% of Igs• First Ig produced during immune response• High concentration in blood stream• Present in the course of infection• Can react efficiently with bacteria and virus
Immunoglobulin G • Comprises 75% of antibodies in plasma• Accelerates phagocytosis• Neutralizes bacterial toxins• In prenatal life, it diffuses across placental barrier to provide fetus with passive immune protection till the infant can produce adequate defense
Immunoglobulin A • Secretory Ig in external body secretions: saliva, sweat, tears, mucus, bile, colostrums• Provides defense versus pathogens or exposed surfaces, the respiratory and GIT
Immunoglobulin D • Present in plasma• Levels are elevated by chronic infection
Immunoglobulin E • Low concentration in serum• Involved in immediate hypersensitivity reaction• high serum levels occur in allergy prone persons• Also high in persons infected with certain parasites like helminthes
CELL MEDIATED DEFENSE (CELLULAR IMMUNITY)facilitated by T-cells released into lymphatic system
upon exposure to antigen
MAIN GROUPS OF T CELLS1) helper T cells2) cytotoxic T cells3) suppressor T cells
T CELLS AND CELL-MEDIATED IMMUNITY
T Cells – life span ranges from a few months to the duration of a person’s life - they account for long-term immunity - circulate and enter regions called thymus-
dependent zones e.g. lymphoid tissues, blood circulation or extravascular spaces to encounter antigens.
- defend the body against infected host cells or non-self cells.
(example: rejection of transplant tissue organs.)
T CELLS FEATUREST killer Cells (Cytotoxic cells) • Bind to the surface of the invading
cells (disrupts membranes, kills it by altering cellular environment)• Essential in killing virally infected cells• Its chief toxic proteins called lymphokines to the area and stimulate production of interferons (functions to suppress the spread of virus from cell to cell
T Helper Cells (T4 cells) • Stimulate B lymphocytes to differentiate into antibody producers• Also interacts with mononuclear phagocytes with the result of enhancing destruction pathogens.
Features of Lymphocytes
T suppressor Cells (T8 cells)
• Reduce the humoral response• Mechanism of control of production of Ig either: by regulating proliferation of B cells or inhibiting activity of helper T cells.
FACTORS INCREASING SUSCEPTIBILITY TO INFECTION
AgeHeredityNature, Number and Duration of StressorNutritional StatusMedicationsHealth status
ASSESSMENT
NURSING HEALTH HISTORY ImmunizationScreening tests Infections in the past and treatment receivedRecurrence of infectionsMedications e.g. antibiotics, NSAIDS, steroids,
chemotherapeutic drugs Invasive diagnostic testsPrevious surgeriesEating habits Intake of vitamins and supplementsStress Loss of energy, appetite, nausea, headache
PHYSICAL ASSESSMENTLocalized swellingLocalized rednessPain or tendernessPalpable heatLoss of functionFeverIncreased PR and RREnlargement and tenderness of lymph nodes
LABORATORY DATAElevated leukocytesIncreased differentialsElevated erythrocyte sedimentation rate (ESR)Cultures of urine, blood, sputum, drainages
NURSING DIAGNOSIS
Risk for InfectionPotential Complication of Infection: FeverAcute PainImpaired Social InteractionAnxiety
NURSING INTERVENTIONS
Practice handwashing for at least 20 secondsUse alcohol based antiseptic hand rubsBreak chain of infectionUse caps, gloves, masks, gowns, goggles as neededEncourage proper hygienic practicesEnsure optimum nutrition: high calorie, vitamin CEncourage increased fluid intakeEncourage enough sleepMinimize stressDisinfect and sterilizePractice isolation
METHODS OF STERILIZATION1) Moist Heat – autoclave 2) Gas – ethylene oxide gas3) Boiling Water – should be done on minimum of 15
minutes4) Radiation – ionizing (x-ray) and ultraviolet rays
TYPES OF ISOLATION
1) CATEGORY-SPECIFIC ISOLATIONstrict isolation contact isolationrespiratory isolation tuberculosis isolationenteric precautions drainage precautionsbody fluid precautions
2) DISEASE-SPECIFIC ISOLATION
3) TRANSMISSION-BASED PRECAUTION
Airborne precautions – measles, varicella, tuberculosis
Droplet precautions – DP, mumps, rubella, pneumonia
Contact precautions – shigella, hepatitis A, influenza
SENSORY PERCEPTION
Components of the sensory Experience
2 Components :1. Sensory Reception2. Sensory Perception
Types of stimuli External stimuli. Internal Stimuli
Types of stimuli1. External stimuli Visual Auditory Olfactory Tactile gustatory
2. Internal StimuliGustatoryKinestheticStereognosisVisceral
Four Aspect of sensory Process
Stimulus : An agent or act that stimulates a nerve receptor
Receptor : A specialized nerve cell that converts the stimulus to a nerve impulse
Impulse conduction : After the nerve impulse is created it travels to the spinal cord or directly to the brain
Perception (awareness) : Specialized brain cells in the cerebral cortex interpret the nature and the quality of the sensory stimuli
Sensory perception begins with the stimulation of the of the nerve cellsNerve cell act as receptor by converting a stimulus into a nerve impulse the nerve impulse travels to the spinal cord or to the brain it is interpreted as sensation awareness of the sensation( sensory perception ) in the brain
Arousal Mechanism
Reticular activating system ( RAS)Located in the brainstemMediate the arousal mechanism2 components of RASReticular excitory area- responsible for stimulus arousal and wakefulnessReticular inhibitory areaSensoristasis- when a person is in optimal arousalAwareness ability to perceive enviromental stimuli and body’s
reaction
STATE OF AWARENESS
STATE DESCRIPTIONFull consciousness
alert; oriented to time, place, person, understands verbal and written words
Disoriented Not oriented to time, place or personconfused Reduced awareness,easily bewildered, poor
memory, misinterprets stimuli, impaired judgement
Somnolent Extreme drowsiness but will respond to stimuli
semicomatose Can be arouse by extreme or repeated stimuli
Coma Will not respond to verbal stimuli
SENSORY ALTERATIONS
Sensory deprivationSensory OverloadSensory Deficits
Sensory deprivation
Clinical ManifestationsExcessive yawning,drowsiness Decreased attention span, difficulty
concentrating ,decreased problem solvingImpaired memoryPeriodic disorientation, general confusion or nocturnal
confusionPreoccupation with somatis complainHallucination or delusionsCrying annoyance over small matters, depressionApathy, emotional lability
Sensory Overload
Factors that contribute to sensory overloadIncreased quantity or quality of internal
stimuliIncreased quantity or quality of external
stimuliInability to disregard stimuli selectively
Sensory Overload
Clinical manifestations:Fatigue, sleeplessnessIrritablity , anxiety, restlessnessPeriodic of general disorientationReduced problem- solving ability and task
performanceIncreased muscle tensionScattered attention and racing thought
Sensory Deficits
Clinical manifestations:BlindessDeafnessNote: They are at risk for both sensory
deprivation and sensory overload
FACTORS AFFECTING SENSORY FUNCTION
Developmental stageCulture Stress Medications and IllnessLifestyle and Personality
ASSESSMENT
Nursing historyPresent sensory perceptionUsual functioningSensory deficits and potential problems
CHARACTERISTICS OF NORMAL SENSORY PERCEPTION
SMELLDiscrimination of primary odors:CamphoraceousMuskyFloralPeppermintyEtherealPungentputrid
Characteristics of normal sensory perception
SOMATIC SENSESTouchPressureVibrationPositionTicklingTemperaturePain
Mental statusLOCOrientationMemoryAttention span
Physical Examination Visual acuityHearing acuity ( weber & Rinne tuning fork
tests)Olfactory senseGustatory sense Tactile sense
Characterictics of normal sensory perception
VISION
Visual acuity of 20/20Full field visionTri-color vision ( red, green, blue )
Characterictics of normal sensory perception
HEARINGAuditory acuity of sounds at an intensity of 0 –
25 decibelsFrequency- 8000 cycles / sec. TASTEDiscriminations of sweet, sour, salty, bitter
Client at risk
Sensory Deprivation:Confined in a non stimulating or monotonous
environmentHave impaired vision or hearingHave mobility restrictionsClients who are unable to process stimuliHave emotional disordersHave limited contact with family and friends
Sensory OverloadHave pain or discomfortILL and and have been admitted to acute care
facilityAre being closely monitored in an ICUHave decreased cognitive ability
Client Environment
Assess for :Quality, quantity.and type of stimuliStimuli that decrease the incidence of sensory
deprivation- Radio- Clock or calendar- Reading material or toys for children- Number and compatibility of roommates- Number of visitors
Social support Network
Assess Whether the client lives aloneWho visits and whenAny signs of social deprivation
NURSING DIAGNOSIS
Disturbed Sensory PerceptionAcute ConfusionChronic ConfusionImpaired memory
PLANNING
Prevent injuryMaintain the function of existing sensesDevelop an effective communication
mechanismPrevent sensory overload or deprivationReduce social isolationPerform ADL independently and safely
Nursing Intervention
ENSURING CLIENT SAFETYPlace bed in lowest positionRaise the siderailsPlacing the call light within reachAssisting the patient with ambulation and careUsing handrailsFrequent observationRestraints as prescribed
NURSING INTERVENTIONPREVENTING SENSORY OVERLOAD Minimize unnecassary light, noise, and distraction. Control pain as indicated. Introduce yourself by name, and address the client by name. Provide orienting cues. Provide private room Limit visitors. Plan care to allow for uninterrupted periods for rest or sleep Schedule a routine of care so that client knows when and what to expect Speak in a low tone of voice and in an unhurried manner Provide new information gradually Describe any test and procedures to the client beforehand. Reduce noxious odors. Take time to discuss the client’s problems and to correct
misinterpratations. Assist the client with stress reducing technique.
PREVENTING SENSORY DERPRIVATION Encourage the client to use eyeglasses and hearing aids Address the client by name & touch the client while speaking if this is
not culturally offensive Communicate frequently with the client and maintain meaningful
interactions. Provide a telephone ,radioand /or TV,clock and calendar. Provide murals, pictures, sculptures, and wall hangings Have family and friends bring freshly cutflowers and plants. Consider having a resident pet Include different textured object to feel. Increase tactile stimulation Encourage social interaction Encourage the use of crossword puzzle, or games to stimulate mental
function. Encourage environment changes Encourage the use of self-stimulation techniques
HEALTH TEACHING TO PREVENT SENSORY DISTURBANCES
Have regular health examinations Have regular eye examinations Seek early medical attention Obtain regular immunizations against diseases capable of
causing hearing loss Avoid giving infants and toddlers toys with log pointed handles Teach school age children and adolescents the proper use of
sports equiptment Wear protective eye googles when using power tools,riding
motorcycles, spraying chemicals etc. Wear ear protector when working in an environment with high
noise levels Wear dark glasses with UV protection
SENSORY AIDS
VISUAL Eyeglasses of the correct prescription clean and in good repair Adequate room lighting, including night-lights Sunglasses or window shades Bright contrasting colors in the environment Magnifying glass Phone dialer with large numbers Color code or texture code or texture code on stoves, washer,
medicine containers etc. Clock and wristwatch with large numbers. Colored or raised rims on dishes Reading materials with large print Braile or recorded book Seeing-eye dog
SENSORY AIDS
HEARINGHearing aid in good orderLip readingSign languageAmplified telephonesTelecommunication device for the deafAmplified telephone ringers and doorbellsFlashing alarm clocksFlashing smoke detectors
SENSORY AIDS
SMELLflower arrangements in roomfresh foodsperfumes
TASTEfresh foodright temperaturesips of water in between foodsno mixing of foodsTOUCHtherapeutic touch* lotion for pt.with sensory deprivationmassagesturning and repositioninghairbrushing and groomingNOTE: For pt. with sensory overload provide a private
room whenever feasible
Communicating Effectively
Convey respectEnhance the persons self-esteemEnsure the exchange of correct informationPls read BOX 38-5