Title: Immune Function
1 2Inflammation
- Response of vascular tissues to harmful stimuli
- i.e. pathogens, damaged cells, or irritants
- Protective attempt by the organism to remove
injurious stimuli and initiate the healing
process - May be acute or chronic
- Inflammatory response includes
- Vascular response
- Cellular response
- Formation of exudate
- healing
3Acute Inflammation
- Short term process characterized by the classic
signs of inflammation - Swelling
- Redness
- Pain
- Heat
- Predominant celltype neutrophils
4Chronic Inflammation
- Lasts for weeks years
- Injurious agent persistent
- Predominant cell type lymphocytes and
macrophages - Examples
- Autoimmune reactions
- Rheumatoid arthritis
- Prolonged exposure to chemical agents
- silica
5Immune system structures
- The immune system protects the body from
potentially harmful substances. The inflammatory
response (inflammation) is part of innate
immunity. It occurs when tissues are injured by
bacteria, trauma, toxins, heat or any other
cause.
6Lymphoid Organs
- Central lymphoid organs
- Thymus
- Bone marrow
- Peripheral lymphoid organs
- Tonsils
- Gut-, genital-, bronchial-, skin-associated
lymphoid tissue - Lymph nodes
- spleen
7Normal Immune Response
- Immunity
- State of responsiveness to foreign substances
such as microorganisms and tumor proteins - Types of Immunity
- Active Acquired Immunity
- Passive Acquired Immunity
8- Antigen
- Large molecules (usually proteins) on the surface
of cells, viruses, fungi or bacteria - Antibody
- Protein produced by the immune system in response
to the presence of an antigen
9- Antigens that get past the external barriers are
targeted for destruction by the immune system
10Antibodies
- Attach to specific antigen
- Make it easier for phagocytes to destroy antigen
11Acquired Immunity
- Is when the body is exposed to various antigens
and builds a defense that is specific to that
antigen
12Passive Immunity
- Antibodies that are produced in someone else's
body - Infants have passive immunity because antibodies
are transferred through the placenta from the
mother - Last 6-12 months
- Gamma globulin
- Given IV, IM
- Temporary protection
13Aging and the Immune System
- Decline in the immune system with aging
- Characterized by higher incidence of tumors in
elderly - Also seen with greater susceptibility to
infections such as influenza and pneumonia
14Altered Immune Response
- Immunocompetence
- ? immunity
- Immunodeficiency diseases
- Severe infections
- Malignancies
- ? immunity
- Hypersensitivity disorders
- Allergies
- Autoimmune diseases
15Hypersensitivity Reactions
- Autoimmune Diseases
- Four Types
- Type 1, II, III are immediate and humoral
- Type IV is a delayed hypersensitivity and
cell-mediated
16Type I Hypersensitivity Immediate/Anaphylactic
Reactions
- Occur in in susceptible people who are highly
sensitized to specific allergens - Mediated by IgE antibodies
- Release histamine and others by mast cells and
basophils - Result in systemic inflammatory response (seconds
to minutes) - Reaction can be local or systemic
- Runny nose ?anaphylaxis
- Mild irritation ? sudden death
17Type I Hypersensitivity Reactions
- Anaphylaxis
- Immediate release of mediators
- Injection
- Bee sting
- Reaction is within minutes
- Can be life threatening
- Bronchial constriction ? airway obstruction
- Vascular collapse
- Initial symptoms
- Edema, itching at site of exposure
- Can rapidly escalate into shock
- Rapid weak pulse
- Hypotension
- Dyspnea
- cyanosis
- See Table 12-12
18Anaphylactic Shock
- Most severe type of anaphylaxis
- From quick release of mast cells
- Estimated 1.3-16.8 of population are at risk
for having anaphylactic reaction especially to
insect stings and penicillin (see table 13-11) - Results in 1,000 deaths per year
- Usually related to sudden cardiovascular collapse
19Anaphylaxis
- IgE acts to release histamine from mast cells
- Histamine causes vasodilation of arterioles and
constriction of bronchioles in lungs
(bronchospasm) - Symptoms
- Respiratory distress Unconsciousness
- Hypotension Urticaria (hives)
- Flushed appearance Angioedema (swelling of lips,
face, throat) - Anxiety Abdominal pain
20Anaphylaxis
- Life-threatening medical emergency d/t rapid
constriction of the airway - Treatment
- Epinephrine (adrenaline)
- ?-2 adrenergic receptors - powerful
bronchodilator - EpiPen
- May also cause tachycardia
21Type I Hypersensitivity Reactions
- Atopic reactions
- Inherited tendency to become sensitive to
environmental allergens - Allergic rhinitis (hay fever), asthma,
dermatitis, urticaria
22Type II Cytotoxic and Cytolytic Reactions/
Antibody-Dependent Reactions
- Antibodies produced by the immune system bind to
antigens on pts own cell surface - Involve binding of IgG or IgM antibodies to
antigens - Antigen-antibody complexes activate the
complement system ? reaction/acute inflammation - Mediators of inflammation produce chemicals that
lyse (destroy) cells (erythrocytes, platelets,
leukocytes) - Hours to days
- Examples
- Hemolytic transfusion reactions
- Goodpasture syndrome
- Hashimotos thyroiditis
23Hemolytic transfusion reactions
- Results from ABO incompatibility
- Antibodies coat the foreign erythrocytes ?
agglutination ? occlusion of blood vessels - Cellular lysis
- ? Acute renal failure
24Type III Immune-Complex Reactions
- Results from antigen-antibody complexes
- IgG, IgM complexes are deposited in tissue
(kidneys, joints, lungs, small blood vessels) ?
inflammation and cellular destruction - Local or systemic
- Hours-days
- Associated with systemic lupus erthymatosus
(SLE), rheumatoid arthritis (RA)
25Type IV Delayed Hypersensitivity Reactions
- Cell-mediated (not antibody-mediated) immune
response causing tissue damage - Sensitized T lymphocytes attack antigens and
release cytokines which attract macrophages - 2-3 days
- Examples
- Contact dermatitis (poison ivy rash)
- Transplant rejection
26Allergic Disorders
- Assessment
- Health History
- Physical Examination
- Diagnostic Studies
- Skin Tests
- Procedure
- Results
- Precautions
27Chronic Allergies
- Characterized by chronic remissions and
exacerbations - Allergen recognition and control
- Skin testing
- Elimination diet
- Identification of aggravating factors
- Medic Alert bracelet
- Collaborative Care
- Epi Pen
- Antihistamines
28Allergic Disorders (cont.)
- Collaborative Care (cont.)
- Drug Therapy
- Antihistamines
- Sympathomimetic/decongestant drugs
- Corticosteroids
- Antipruritic drugs
- Mast cell-stabilizing drugs (cont.)
- Immunotherapy
- Mechanism of action
- Method of administration
29Systemic Lupus Erythematosus (SLE)
- Chronic, mulitisystem inflammatory disease
- Typically affects skin, joints, renal,
hematologic, neurologic systems - Etiology unknown
- Autoimmune reactions are directed against host
cells - Clinical manifestations are variable
30SLE
- Clinical Manifestations
- Dermatological, M/S, Cardiopulmonary, Renal,
Nervous system, Hematologic, Infection
susceptibility
31Polymysitis Dermatomyositis
- Diffuse, idiopathic, inflammatory myopathies of
muscle ? weakness - Clinical manifestations
- Fatigue, weakness
- Classic cyanotic heliotrope rash
- Joint pain
- Diagnostic Studies
- CK
- ESR
- Nursing Management
- Assistive
32Sjogren Syndrome
- Autoimmune disorder that targets moisture
producing glands ? dry mouth, dry eyes - Usually affects women over the age of 40
- gritty sensation of eyes
- Symptomatic treatment
33Immunodeficiency Disorders
- Immune system does not adequately protect the
body - Impairment of 1 or more immune mechanisms
- Primary Immunodeficiency Disorders
- Immune cells are improperly developed/absent
- Secondary Immunodeficiency Disorders
- Deficiency based on illness or treatment
- Graft-versus-Host Disease
- Transfusion or transplantation with
immunocompetent cells
34Immunosuppressive Therapy
- Goal adequately suppress immune response to
prevent rejection while maintaining sufficient
immunity to prevent overwhelming infection - Calcineurin Inhibitors
- Sirolimus
- Mycophenolate Mofetil
- Polyclonal Antibodies (Antithymocyte Globulin and
Antilymphocyte Globulin) - Monoclonal Antibodies
- New Immunosuppressive Therapy
35Corticosteroidal Therapy
- AKA steroids
- Prednisone
- Solu-medrol
- Discovered in 1948
- Believed to be miracle cure for arthritis
- Used to relieve the signs, symptoms of many
diseases - Long-term use leads to serious complications and
side effects - Became known as scaroids
36Corticosteroids
- What Are They?
- Corticosteroids are drugs closely related to
cortisol, a hormone which is naturally produced
in the adrenal cortex (the outer layer of the
adrenal gland). - How Do They Work?
- Corticosteroids act on the immune system by
blocking the production of substances that
trigger allergic and inflammatory actions, such
as prostaglandins. However, they also impede the
function of white blood cells which destroy
foreign bodies and help keep the immune system
functioning properly. The interference with white
blood cell function yields a side effect of
increased susceptibility to infection.
37Corticosteroids
- What Conditions Do They Treat?
- Corticosteroids are widely used for many
conditions. They are also used to control
inflammation of the joints and organs in diseases
such as - rheumatoid arthritis
- lupus (systemic lupus erythematosus)
- ankylosing spondylitis
- juvenile arthritis
- inflammatory bowel disease
- polymyositis
- mixed connective tissue disease
- polymyalgia rheumatica
- scleroderma (systemic sclerosis)
- vasculitis
38Effects of Corticosteroids
- Anti-inflammatory Action
- ? circulating lymphocytes, monocytes and
eosinophils - Inhibit accumulation of leukocytes at site of
inflammation - Inhibit release of substances involved in
inflammatory response - Therefore, suppress manifestations of
inflammation (redness, tenderness, heat,
swelling, local edema)
39Effects of Corticosteroids contd
- Immunosuppression
- Cause atrophy of lymphoid tissue
- Suppress cell-mediated immune responses
- Decrease production of antibodies
- Blood pressure
- Vasoconstriction
- Retention of Na (and water)
- Carbohydrate and Protein Metabolism
- Increase hepatic glycogenesis
- Increase insulin resistance
- Redistribute fat in cushingoid pattern
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41HIV and AIDS
42AIDS in the U.S.
- Centers for Disease Control (CDC) estimated that
in 2007 about 1 million people in US are living
with HIV or AIDS - 46 estimated to be men who have sex with men
- 31 estimated to be adults/adolescents infected
through heterosexual contact - Blacks who make up 13 of population accounted
for almost ½ of the number of HIV/AIDS cases
diagnosed - In US and countries where latest therapies are
available, many patients have been managing their
HIV infection with antiretroviral therapy (ART)
for more than 20 years.
43AIDS Worldwide
- The magnitude of the global HIV/AIDS epidemic
vastly exceeds that in the United States. - At the end of 2001, more than 40 million people
were estimated to be living with HIV/AIDS, and - More than 20 million had already died from AIDS.
- Nearly three quarters of those with the disease
are living in sub-Saharan Africa, where access to
antiretroviral therapy is limited.
44HIV and AIDS
- The primary causative agent of AIDS is HIV
- HIV infects lymphocytes and results in severe
immunodeficiency. - Immunodeficiency can lead to infections, cancers
and neurological manifestations.
45The HIV Retrovirus
- HIV retrovirus has a particular affinity for
helper T lymphocytes (cells that control the
functions of other immune cells) - Once inside T lymphocytes, HIV produces abnormal
DNA and fuses with the cells normal DNA and
takes over the cells machinery. - The invaded lymphocyte then produces HIV particles
46The HIV Retrovirus contd
- These viruses exit the dying cell and repeat the
process in other T lymphocytes - Without treatment, T lymphocytes become depleted
as HIV particles increase - The person develops an infection or malignancy
47Transmission of HIV
- Major routes of transmission
- Through human blood
- Including infected needles
- Sexual Transmission
- Through exchange of semen, vaginal and cervical
fluids - Perinatal Transmission
- During pregnancy, labor, delivery or
breast-feeding
48Disease Development
- Typical course of HIV/AIDS is defined by three
phases - Primary infection phase
- Flu-like symptoms
- Few days ? two weeks
- Chronic asymptomatic/latency phase
- Little or no symptoms of illness
- Lasts average of 10 years
- Overt AIDS phase
- Occurs when person has a CD4 count (normal 800-1000 mm3) or
- Development of an AIDS defining illness
49Typical Untreated HIV Course
50HIV and AIDS
- AIDS diagnosed when individual with HIV develops
at least one of the following Table 14-1) - CD4T count of less than 200 cells/µl
- Healthy adults have CD4T count 1,000
- Development of opportunistic infection (OI)
- Development of opportunistic cancer
- Wasting syndrome
- Loss of 10 of total body mass
- Development of dementia
51AIDS Defining Illnesses
- Opportunistic Infections (OIs)
- Develop in people with weakened immune systems,
including people with HIV disease - Most common opportunistic infections are
- Pneumocystis carinii pneumonia (PCP)
- Oropharyngeal or esophageal candidiasis (thrush)
- Cytomegalovirus (CMV)
- Infections causing diarrhea
52AIDS Defining Illnesses contd
- Neurological disorders
- Affect between 40 -60 of all people with AIDS
- Most common AIDS-related dementia
- Mechanism by which HIV infects the central
nervous system is not known - Characterized by progressive cognitive
dysfunction with motor and behavioral alterations - Onset is insidious and follows and unpredictable
course
53AIDS Defining Illnesses contd
- Malignancies
- Most frequently seen AIDS-related malignancy is
Kaposis Sarcoma (KS) - Tuberculosis
- Leading cause of death from AIDS worldwide
- Can affect any body siteusually lungs
- Needs to be treated aggressively with drugs and
isolation to prevent its spread to others
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55Pnuemocystis Pneumonia (PCP)
- Most common opportunistic infection requiring
hospitalization - Caused by pneumocystis jiroveci, formerly known
as pneumocystis carinii - PCP is the indicator condition in 38 of AIDS pts
- Classic triad of symptoms
- Fever, exertional dyspnea, nonproductive cough
56Pneumocystis Pneumonia
57Kaposis Sarcoma
- Once considered rare
- Usually seen in elderly men or organ transplant
patients - In the past 20 years cases have been associated
with HIV infection - With prophylaxis and treatment, the number of
cases d/t to HIV infection has ?d by 85
58Kaposis Sarcoma
- Typically causes tumors to develop in the tissues
below the skin surface, or mucous membranes
?lesions - Lesions typically
- Raised blotches or nodules
- Purple, brown or red
- Sometimes associated with painful swelling
- Skin lesions are disfiguring but not life
threatening - Can be life threatening when it involves lungs,
liver or GI tract - Bleeding
- Difficulty breathing
59Kaposis Sarcoma
60Collaborative Care
- Monitoring HIV disease progression and immune
function - Initiating and monitoring highly active
antiretroviral therapy (HAART) - Preventing and detecting opportunistic infections
61Collaborative Care
- Preventing and treating complications of
therapies - Ongoing health assessment
- Baseline data including HP, immunization
history, psychosocial and dietary evaluation
62Collaborative Care
- Education about spectrum of HIV, treatment,
preventing transmission, improving health, and
family planning - Repeating and clarification of information is
necessary due to shock and denial
63Antiretroviral Therapy (ART)
- Rapid development of new drugs, combinations
- Since the introduction of ART survival with AIDS
has improved dramatically - From an average of 3.1 years to 13 years
- New recommendations are to start antiretroviral
therapy later than previously thought - Drug resistance
- Medication side effects
- Uncertain benefit
64Antiretroviral Therapy
- In the US alone, ART has saved an estimated total
of at least 3 millions years of life. - ART associated with clinically important adverse
reactions
65Antiretroviral Therapy
- Side effects are considerable
- Most common and serious s/e include
- Diabetes
- Cardiovascular disease
- Cytopenias
- Pancreatitis
- Peripheral neuropathy
- Hypersensitivity (rash, fever, risk of death)
- Hepatitis
- GI toxicity (diarrhea and nausea)
66Antiretroviral Therapy
- Different drug groups used to treat HIV
- Work at different points along the replication
cycle - Nucleoside reverse transcriptase inhibitors
(NRTIs) - Non-nucleoside reverse transcriptase inhibitors
(NNRTIs) - Protease Inhibitors
- Fusion Inhibitors
- Most critical, modifiable factor affecting
success patient adherence to drug regimen
67Nucleoside reverse transcriptase inhibitors
(NRTIs)
- Block reverse transcriptase, a protein HIV needs
in order to replicate - As NRTIs were introduced and used in combination
- survival increased
- Increase in drug related complications
- Nausea
- Vomiting
- Painful neuropathies
- Life-threatening pancreatitis
68NRTIs
- Combivir
- Emtriva
- Epivir
- Epixicom
- Hivid
- Retrovir
- Trizivir
- Truvada
- Videx EC
- Viread
- Zerit
- Ziagen
69Protease inhibitors (PIs)
- Block protease
- Protein needed for HIV replication
- Introduced December, 1995
- Approved for use in combination with NRTIs
70PIs
- Agenerase
- Aptivus
- Crixivan
- Fortovase
- Invirase
- Keletra
- Lexiva
- Norvir
- Prezista
- Reyataz
- viracept
71Antiretroviral drugs
72Highly Active Antiretroviral Therapy (HAART)
- HAART is a treatment regimen that combines 3
antiretroviral drugs - 2 from NRTI class
- 1 from PI class
- Widespread use of PIs in 1996, successful
treatment of HIV infection extended life by
decades - HAART also associated with problems
- Poor oral bioavailability
- High pill burden
- Intolerable adverse reactions
- Long-term toxicities
- Most of these problems have been minimized
73Chronic challenges
- Because HAART has significantly reduced
mortality, HIV is now considered a chronic,
manageable illness - Patients and their families must face
difficulties of any chronic illness - Medication toxicities
- Exacerbation of mental health issues
- Complex medication regimens
- Lifestyle adjustments
- Lipid and Glucose abnormalities
74Dyslipidemia
- Most patients with HIV infected patients who
arent on HAART have lipid abnormalities - PIs are most often associated with dyslipidemia
- Can lead to accelerated atherosclerosis
75Insulin Resistance
- 25 of population has insulin resistance
- In patients receiving PI therapy, insulin
resistance 60-85 - Insulin resistance usually appears 10 20 years
before type 2 diabetes
76Patient Teaching
- Encourage your patient to
- Exercise
- Control his/her weight
- Reduce cardiovascular risk
- Quit smoking
- Use low-dose aspirin therapy
- Manage lipids
- Maintain BP within normal limits
- Monitoring for diabetes
77Independent Nursing Interventions
- Most important interventions for reducing
cardiovascular risk - Teaching patients about smoking cessation
- Encouraging exercise
- Optimal weight control
78Smoking HIV
- Prevalence of adult smokers in US 21
- In HIV population 72
- In HIV-infected I.V. drug users 96
- Besides contributing to C-V disease, smoking is
major contributor to - Bacterial pneumonia
- Abdominal aortic aneurysms
- Cataracts
- Periodontal disease
- Cancers of lung, stomach, uterus, pancreas, kidney
79Smoking and HIV
- When nurses advise and encourage hospital
patients who smoke to quit, 15 - 20 of them
quit, compared with 3 who dont receive
counseling at all. - 4 As of smoking cessation counseling
- Ask about his smoking
- Advise him to quit smoking
- Assist him with quitting by providing educational
materials, or referral for pharmacologic aids - Arrange follow-up to discuss progress toward
smoking cessation
80Other HIV/AIDS drugs
81Nsg Diagnosis Alteration in comfort nausea
- Alteration in comfort nausea related to
medications, opportunistic infections - Goal stable/ideal weight
- Appropriate nutritional intake
- Interventions
- Avoid hot, spicy or greasy food
- BRAT diet (bananas, rice, applesauce, toast)
- Eat dry food (crackers, toast, dry cereal)
- Sip cold, carbonated beverages (ginger ale) or
try peppermint, chamomile or ginger tea - Antiemetics as ordered
82Nsg Diagnosis Alteration in Skin Integrity
Rash
- Alteration in Skin Integrity Rash r/t
medications (especially NNRTIs) - Goal skin intact
- Interventions
- Natural skin moisturizer (aloe)
- Antihistamines (benadryl) for mild rash
- Antihistamine Corticosteroid (prednisone) as
ordered for severe rash - Avoid harsh soaps and perfumes
83Nsg Diagnosis Potential for Impaired Gas
Exchange
- Alteration in tissue perfusion r/t anemia, d/t
disease process, medications (especially AZT) - Goal
- Hgb/Hct within acceptable range
- Acceptable pO2 without supplemental O2
- Interventions
- Administration of erythopoietin (Epogen) as
ordered - O2 as ordered
- Blood products as ordered
- Teach to rest between periods of activity
- ? HOB during episodes of dyspnea
84Nsg Diagnosis Potential for Injury/ Infection
- Potential for Infection r/t disease or treatment
- Goal
- No signs/symptoms of active infection
- WBC maintained within acceptable range
- Interventions
- Compromised Host Precautions private room,
etc. - Good handwashing by all visitors and personnel
- VS q 2 hours
- Minimize invasive procedures
- Avoid raw fruits, vegetables and milk products
85Thats all folks.