Nursing 280: Pathophysiology Examination

1
Nursing 280 PathophysiologyExamination
1Module I Alterations in Cellular Growth,
Function, and Body Defenses

• Presented by
• Ronda M. Overdiek, M.S.N., R.N.
• Westminster College

2
Module I Brief OutlineExamination 1

• Section A
• Altered Cellular and Tissue Biology
• (Chapter 3)
• Section B
• I. Body defenses (immunity) (Chapter 5)
• II. Inflammatory Process (Chapter 6)
• III. Alterations in immunity and inflammation
• (Chapter 7)

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Section AAltered Cellular and Tissue
BiologyChapter 3

• Review
• Normal Cellular Anatomy and Physiology
• Chapter 1

4
Section AAltered Cellular and Tissue
BiologyChapter 3

• Objective 1
• Describe cellular adaptations to injury
• Adaptation
• To adjust or become adjusted to new requirements
  or conditions.
• Random House Websters Dictionary

5
Objective 1Cellular Adaptations to
InjuryFigure 3-1, Page 66

• Five Cellular Adaptations to Injury
• Atrophy
• Hypertrophy
• Hyperplasia
• Metaplasia
• Dysplasia

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Objective 1Cellular Adaptations to
InjuryAtrophy

• Decrease or shrinkage in
• cellular size.
• Physiological/Pathological
• Pathologic
• Decrease in
• Workload
• Pressure
• Use
• Blood supply
• Nutrition
• Hormonal Stimulation
• Nervous Stimulation

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Objective 1Cellular Adaptations to
InjuryHypertrophy

• Increase in size of cells causing
• increase in size of affected organ
• Associated w/ increase in the
• accumulation of protein NOT fluid.
• Caused by
• Hormone stimulation
• Increased functional demand
• Physiologic or Pathologic

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Objective 1Cellular Adaptations to
InjuryHypertrophy Continued
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Objective 1Cellular Adaptations to
InjuryHyperplasia

• Increase in number of cells
• resulting from increased rate of
• cellular division.
• Physiologic
• Compensatory
• Hormonal
• Pathologic

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Objective 1Cellular Adaptations to
InjuryMetaplasia

• Reversible replacement of one
• mature cell type by another.
• New cells are created because of
• signals generated by cytokines
• (growth factors) in the cells
• environment.

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Objective 1Cellular Adaptations to
InjuryMetaplasia Continued
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Objective 1Cellular Adaptations to
InjuryDysplasia

• Refers to abnormal changes in
• the size, shape, and organization
• of mature cells.
• High and low grade

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WHY?

• Objective 1
• Describe cellular adaptations to injury

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Section AAltered Cellular and Tissue
BiologyChapter 3

• Cell Injury
• Disruption in homeostasis of cell
• Two choices in injury reversible/irreversible
• Extent of injury
• Cell
• Type
• State
• Adaptive processes
• Injurious Stimulus
• Type
• Severity
• Duration

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Section AAltered Cellular and Tissue
BiologyChapter 3

• Objective 2
• Describe processes responsible for cell injury.
• Hypoxia
• Ischemia
• Chemical Injury
• Mechanical Injury
• Infectious Injury

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Objective 2Processes responsible for cell
injuryHypoxia/Ischemia

• Hypoxia
• Lack of sufficient oxygen (single most common
  cause of cellular injury)
• Causes of hypoxia
• Ischemia
• Reduced blood supply
• Time is muscle
• Gradual vs. acute blockage

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Objective 2Processes responsible for cell
injuryHypoxia/Ischemia
Figure 3-5, Page 70
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Objective 2Processes responsible for cell
injuryFree Radicals and Reactive Oxygen Species
Injury

• Free Radicals
• Electrically uncharged atoms or group of atoms
  having an unpaired electron.
• Causes
• Absorption of extreme energy sources
• Endogenous reactions when O2 is reduced to H2O
  created by systems involved in electron and
  oxygen transport (redox reactions)
• Enzymatic metabolism of exogenous chemicals or
  drugs
• Box 3-1 on page 73

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Objective 2Processes responsible for cell
injuryFree Radicals and Reactive Oxygen Species
Injury

• Counteracting Free Radicals
• Antioxidants
• Vitamin E, Vitamin C, Cysteine, Glutathione,
  Albumin, Ceruloplasmin, Transferrin
• Enzymes

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Objective 2Processes responsible for cell
injuryChemical

• Plasma membrane damage leading to increased
  permeability
• Examples
• Lead
• Carbon monoxide
• Attaches to hemoglobin on red blood cells
• 300 times the affinity for hemoglobin than O2
• Ethanol/other drugs

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Objective 2Processes responsible for cell
injuryMechanical Injury

• Cell injury
• Definitions
• Contusion
• Hematoma
• Abrasion
• Laceration

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Objective 2Processes responsible for cell
injuryInfectious Injury

• Extent of cell injury depends on microorganisms
  ability to
• Invade/destroy cells
• Produce toxins
• Produce hypersensitivity reactions

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Objective 3Manifestations of Cell
InjuryCellular Infiltration

• Infiltrationaccumulation
• Physiologic/Pathologic
• Fluids/electrolytes
• Triglycerides (lipids)
• Glycogen
• Uric acid
• Protein
• Melanin
• Bilirubin

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Objective 3Manifestations of Cell InjuryCell
Swelling

• Extracellular water shifted into the cells.

Figure 3-19 Page 86
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Objective 3Manifestations of Cell Injury

• Signs/Symptoms
• Fever
• Increased heart rate
• Increased in leukocytes
• Pain
• Laboratory
• Electrolyte abnormalities
• Lactate
• Creatine Kinase
• AST/ALT/ALP
• Amylase
• Aldolase

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Objective 3Manifestations of Cell
InjuryNecrosis

• Cellular dissolution

Figure 3-24 Page 91
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Section AAltered Cellular and Tissue Biology

• Why is it important to know it?

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Section B Alterations in Body DefenseChapter 5

• Part I Immunity
• Part II Inflammatory Process
• Part III Alterations in immunity and
• inflammation.

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Section B Alterations in Body DefenseChapter 5

• Why talk about immunity and inflammation together?

Table 5-1 Page 128
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Section B Part IImmunity

• Objective 1 Describe characteristics of
  immunity.

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Section B Part IImmunityObjective 1
Describe characteristics of immunity.
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Section B Part I ImmunityObjective 2
Describe how the immune response is induced.

• Antigen
• Molecule or complex of molecules that reacts with
  components of the immune system
  (lymphocytes/antibodies).
• Almost any biochemical can be an antigen
• Diverse ability to produce an immune response

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Section B Part I ImmunityObjective 2
Describe how the immune response is induced.

• Immunogen
• An antigen that can also induce the formation of
  components of the immune system (T and B lymphs,
  antibody production).
• In order for an antigen to be immunogenic it
  must
• Be sufficiently foreign to the host
• Sufficiently large and complex
• Present in sufficient amounts

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Section B Part I ImmunityObjective 2
Describe how the immune response is induced.

• Hapten
• Antigens that are too small to be immunogens by
  themselves but become immunogenic in combination
  with other large molecules.
• Allergic reactions to medications

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Section B Part I ImmunityObjective 2
Describe how the immune response is induced.

• HLA Antigens (Human Leukocyte Antigen)
• Major histocompatibility complex (MHC) is group
  of genes that produce HLA antigens known as the
  HLA complex.
• They recognize if something is foreign or self
• Found on the surface of almost every cell in the
  body
• Important for transplant patients

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Section B Part I ImmunityObjective 2
Describe how the immune response is induced.

• Rh System

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Section B Part I ImmunityObjective 3
Differentiate the humoral from the cell mediated
response
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Section B Part I ImmunityObjective 4
Describe the function of the lymphoid tissue in
the immune response

• Lymphoid Organs
• Primary
• Thymus and the bone marrow
• Secondary
• Spleen
• Lymph nodes
• Tonsils
• Peyer patches of the small intestine

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Section B Part I ImmunityObjective 4
Describe the function of the lymphoid tissue in
the immune response

• Lymphoid Organs/Tissues
• Link the hematologic and immune systems together
• Residence
• Proliferation
• Differentiation

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Section B Part I ImmunityObjective 4
Describe the function of the lymphoid tissue in
the immune response

• Lymph Nodes
• Site of development or activity of lymphocytes,
  monocytes, and macrophages
• Clustered around lymphatic veins that collect
  interstitial fluid from the tissues and transport
  it back into the circulatory system.
• Transported fluid is lymph
• Lymph filters through nodes
• Cleansed by monocytes and macrophages
• Microorganismsstimulate lymphocytes to develop
  into antibody-producing plasma cells

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Section B Part I ImmunityObjective 4
Describe the function of the lymphoid tissue in
the immune response

• Spleen
• Filter and cleanse the blood
• Lymphocytes mount an immune response to
  blood-borne microorganisms
• Serves as a blood reservoir
• Immune function decreases in the absence of the
  spleen

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Section B Part I ImmunityObjective 4
Describe the function of the lymphoid tissue in
the immune response

• Thymus
• Organ where stem cells migrate to produce T-cells
  and cell mediated immunity

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Section B Part I ImmunityObjective 4
Describe the function of the lymphoid tissue in
the immune response

• Bone Marrow
• Where stem cells migrate to produce B-cells and
  the humoral immune response.

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Section B Part I ImmunityObjective 5
Differentiate the various classes of antibodies
and their primary functionsAntibody Production

• Humoral Immune Response
• B-cell production in the bone marrow
• B-cells form plasma-membrane antibodies that bind
  with antigens
• Functions of Antibodies are
• 1. Neutralize bacterial toxins
• 2. Neutralize viruses
• 3. Opsonizing bacteria
• 4. Activating components of the inflammatory
• response

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Section B Part I ImmunityObjective 5
Differentiate the various classes of antibodies
and their primary functionsAntibody Production
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Section B Part I ImmunityObjective 5
Differentiate the various classes of antibodies
and their primary functionsClasses of Antibodies

• Terms
• Immunoglobulin Serum glycoproteins produced by
  plasma cells in response to a challenge by an
  antigen.
• Antibody Are immunoglobulins known to have
  specificity for a particular antigen.
• Classes of Immunoglobulins
• IgG, IgM, IgA, IgD, and IgE

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Objective 5 Differentiate the various classes
of antibodies and their primary
functionsAntibodies

• Antibodies are found
• Circulating in blood
• Suspended in body secretions
• Come in contact with Antigen
• Direct Effect
• Agglutination, precipitation, neutralization
• Indirect Effect
• Inflammatory response

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Objective 5 Differentiate the various classes
of antibodies and their primary
functionsNeutralization/Agglutination/Precipitat
ion/Opsonization

• Bacteria
• Produce toxins that hurt cell
• Antibodies act as antitoxins that neutralize the
  bacterial toxins
• After neutralization
• Agglutination (clumping together)
• Precipitation (falling out of solution)

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Objective 5 Differentiate the various classes
of antibodies and their primary
functionsNeutralization/Agglutination/Precipitat
ion/Opsonization
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Primary Vs. Secondary Immune Responses

• Primary Response
• Response to initial exposure to antigen is slow
• Antibodies produced are broken down
• Immune system is primed
• Secondary Response
• Re-exposed to antigen
• Rapid production of larger amount of antibody
  than the primary response
• Immunizations dead or attenuated

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Section B Part I ImmunityObjective 6
Differentiate the mature T-Cells and their major
functions

• Memory Cell
• Induce the secondary immune response
• Lymphokine Producing Cell
• Interleukins proteins secreted to aid in immune
  response
• Delayed hypersensitivity inflammatory response

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Section B Part I ImmunityObjective 6
Differentiate the mature T-Cells and their major
functions

• Cytotoxic
• Mediate the direct, cellular killing of target
  cells including
• Virally infected cells
• Tumors
• Foreign grafts

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Section B Part I ImmunityObjective 6
Differentiate the mature T-Cells and their major
functions

• Suppressor Cells
• Inhibit both humoral and cell-mediated immunity
• Helper Cells
• Facilitate both humoral and cell-mediated immune
  responses

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Section B Part I ImmunityObjective 6
Differentiate the mature T-Cells and their major
functions
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Section B Part I Immunity

• What are the clinical applications of
• Understanding
• Immunity?

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Section B Part IIInflammation

• Why talk about inflammation?

Table 5-1 Page 128
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Section B Part IIInflammation

• Purpose Increase the movement of plasma and
  blood cells from the circulation into the tissues
  surrounding the injury.
• Defends the host against infection
• Facilitates tissue repairing
• Inflammation/repair phases
• 1. Capture/remove injurious agents
• 2. Wall off/confine agents to limit effects on
  host
• 3. Stimulate/enhance immune effects
• 4. Promote healing

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Section B Part IIInflammation

• Inflammation vs. Immune Systems
• Inflammatory Response
• Nonspecific
• Reoccurs in the same manner regardless of number
  of exposures
• Self-limiting
• Immune Response
• Antigen specific
• Has memory
• Inducible due to specific stimulus

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Section B Part II InflammationObjective 1
Identify characteristics of the phases of
inflammation

• Acute inflammatory response
• Starts after cellular/tissue damage
• Triggered by dead cells (host, microorganisms,
  parasites)
• Starts immediately
• Figure 6-2 Page 155

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Section B Part II InflammationObjective 1
Identify characteristics of the phases of
inflammation

• Chronic Inflammation
• Last weeks or longer, regardless of cause
• Characterized by dense infiltration of
  lymphocytes/macrophages
• Granuloma
• If macrophages are unable to protect the host
• Infected site is walled off

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Section B Part II InflammationObjective 1
Identify characteristics of the phases of
inflammation

• Resolution
• Restoration of original structure and physiologic
  function
• Repair
• Replacement of destroyed tissue with scar tissue
• Primary Intension
• Wounds that heal under conditions of minimal
  tissue loss
• Secondary Intension
• Longer process, cell injury is more extensive

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Section B Part II InflammationObjective 2
Identify the biochemical mediators and their
primary function for each phase of inflammation

• Mast Cell
• Most important activator of inflammatory response
• Cellular bags of granules that are released
• Located in loose connective tissue close to blood
  vessels
• Activate the inflammatory response in two ways
• 1. Degranulation 2. Synthesis of mediators
• Basophils
• Found in the blood/function same as tissue mast
  cells

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Section B Part II InflammationObjective 2
Identify the biochemical mediators and their
primary function for each phase of inflammation

• Neutrophils
• First phagocytic leukocytes to arrive
• Ingest bacteria, dead cells, and cellular debris
• They die and then are removed as pus

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Section B Part II InflammationObjective 2
Identify the biochemical mediators and their
primary function for each phase of inflammation

• Eosinophils
• Granulocytes that have lysosomes containing
• Caustic protein that is capable of dissolving the
  surface membranes of parasites
• Help control the vascular effects of inflammation
• Serotonin (released by platelets)
• Histamine (by degranulation from mast cell)

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Section B Part II InflammationObjective 2
Identify the biochemical mediators and their
primary function for each phase of inflammation

• Leukotrienes/Prostaglandins
• Inflammatory mediators synthesized by mast cells
• Leukotrienes
• Smooth muscle contraction, increased vascular
  permeability, neutrophil/eosinophil chemotaxis
• Prostaglandins
• Increased vascular permeability
• Neutrophil chemotaxis
• Pain

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Section B Part II InflammationObjective 2
Identify the biochemical mediators and their
primary function for each phase of inflammation
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Section B Part II InflammationObjective 3
Identify how components of inflammation are
activated

• Inflammation is activated by plasma protein
  systems
• 1. Complement System
• 2. Clotting System
• 3. Kinin System

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Section B Part II InflammationObjective 3
Identify how components of inflammation are
activated

• Complement System
• Components participate in every aspect of the
  inflammatory response
• Activated by
• Antigen-antibody complexes
• By-products released from invading bacteria
• Different components can
• Enhance inflammation
• Opsonizing bacteria, attracting leukocytes by
  chemotaxis, inducing degranulation of mast cells
• Create pores in cell/bacterial membranes
• Cause the cell to burst or prevent reproduction

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Section B Part II InflammationObjective 3
Identify how components of inflammation are
activated

• Clotting System
• Plasma protein system
• Traps microorganisms, exudates, and foreign
  bodies
• 1. Prevents spread of infection/inflammation
• 2. Facilitates phagocytic activity
• 3. Forms a clot

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Section B Part II InflammationObjective 3
Identify how components of inflammation are
activated

• Kinin System
• Bradykinin
• Dilation of vessels
• Induces pain
• Extravascular smooth muscle contraction
• Increases vascular permeability
• Increase leukocyte chemotaxis

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Section B Part II InflammationObjective 3
Identify how components of inflammation are
activated

• The Complement System
• Activates/assists inflammatory and immune
  processes
• Plays role in the direct destruction of cells
  (bacteria)
• The Clotting System
• Traps bacteria in injured tissue/interacts
  w/platelets to prevent hemorrhage
• The Kinin System
• Helps to control vascular permeability

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Section B Part II InflammationObjective 4
List the hallmarks of inflammation and the
biologic processes responsible

• All local manifestations of inflammation are
  caused by
• Vascular changes
• Exudate
• Functions
• Dilute toxins, carry plasma proteins
  leukocytes, to carry away debris/products of
  inflammation
• Redness/Heat increased perfusion to area
• Pain/Swelling/Loss of function accumulation of
  exudate, accumulation of prostaglandins and
  bradykinin

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Section B Part II InflammationObjective 5
Identify the cellular components of inflammation
and their function.
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Section B Part II InflammationObjective 5
Identify the cellular components of inflammation
and their function.

• Platelets
• Interact with components of the coagulation
  cascade to stop bleeding
• Degranulate, releasing biochemical mediators
  (serotonin) which have vascular effects similar
  to histamine.
• Activated by
• Products of inflammation (collagen),
  antigen-antibody complexes, and mast cell release
  of platelet activating factor.

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Section B Part II InflammationObjective 5
Identify the cellular components of inflammation
and their function.

• Fibroblasts
• Most important cells during reconstructive phase
  of wound healing because they synthesize and
  secrete collagen.
• Collagen is the material of tissue repair.

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Section B Part II InflammationObjective 6
Differentiate the process of inflammation

• Know the following definitions
• Chemotaxis
• Phagocytosis
• Degranulation
• Opsinization
• Margination
• Exudation

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Section B Part II InflammationObjective 7
Identify the systemic responses associated with
inflammation.

• Fever
• Induced by mediators (PGE, IL).
• Leukocytosis
• Ratio of immature to mature neutrophils
• Circulating Plasma Proteins
• Measured in laboratory
• C-reactive protein, fibrinogen, sedimentation
  rates.

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Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses

• Hypersensitivity
• Altered immunologic reaction to an antigen that
  results in a pathologic immune response after
  reexposure.
• Disease caused by hypersensitivity
• Characterized by immune mechanisms that initiate
  inflammation and result in the destruction of
  healthy tissue

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Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses

• Allergy
• Deleterious effects of hypersensitivity to
  environmental antigens
• Immunity
• Refers to the protective responses to antigens
  expressed by disease-causing agents.
• Autoimmunity Disturbance in the immunologic
  tolerance to self antigens.
• Alloimmune Immune system of one person produces
  an immunologic reaction against tissues of
  another.

80
Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses

• Hypersensitivity
• Type I IgE mediated reactions
• Type II Tissue-specific reactions
• Type III Immune-Complex-Mediated reactions
• Type IV Cell-Mediated tissue reactions

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Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses
Type I IgE-mediated reactions.
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Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses

• Type II
• Tissue-Specific Reactions
• Characterized by the destruction or altered
  function of a target cell through the action of
  antibody against an antigen on the cells plasma
  membrane.
• Cell has tissue specific antigens
• Destroy or alter cells by
• Complement mediated lysis
• Phagocytosis
• Antibody-dependent cell-mediated cytotoxicity
• Receptor blockage

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Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses

• Type II (Tissue Specific)

84
Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses

• Type III
• Immune-Complex Mediated Reactions
• Caused by antigen-antibody complexes formed in
  the circulation and deposited later in vessel
  walls or extravascular tissues.
• Not organ specific

85
Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses

• Type III Immune-Complex

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Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses

• Type IV
• Cell-Mediated Tissue Reactions
• Tissue destruction caused by direct killing by
  toxins from cytotoxic T cells or release of
  soluble factors (macrophages).

87
Section B Part III Alterations in
Immunity/InflammationObjective 1 Identify
inappropriate immune responses

• Type IV Cell Mediated