NCM112 Prelims - GMJ

Lecture - Module 2 III Disorder (2)

BASIC CONCEPT & TERMINOLOGIES defending against infection and invasion by other organisms.
Immune system Supporting this system are molecules that are responsible for
- the body ’s defense mechanism against invasion the interactions, modulations, and regulation of the system.
(immunity) and allows a rapid response to foreign CHARACTERISTICS OF THE IMMUNE SYSTEM
substances in a specific manner  To guard the body against pathogens and to eliminate
- qualitative or quantitative change in the components of them if they manage to pass through external barriers.
the immune system can produce profound effects on the  The neutrophils and macrophages of the hematologic
integrity of the human organism system assist the immune system by phagocytosis when
- affected by a variety of factors, such as central nervous an antigen is encountered.
system integrity; general physical and emotional status;  Chemical mediators, plasma cells, and B and T
medications; dietary patterns; and the stress of illness, lymphocytes play active roles in the immune response
trauma, or surgery  Both humoral and cellular immunity is carried out by the
Immune tolerance lymphocytic cells, a specialized type of WBC that
- the mechanism by which the immune system is originates in the bone marrow.
programmed to eliminate foreign substances such as  T lymphocytes, which provide cell-mediated immunity,
microbes, toxins, and cellular mutations but maintains the pass through the thymus, and migrate to the lymph tissues
ability to accept self-antigens throughout the body.
Immunopathology  T lymphocytes, which provide cell-mediated immunity,
- the study of diseases that result from dysfunctions within passthrough the thymus and migrate to the lymph tissues
the immune system throughout the body.
- Disorders of the immune system may stem from excesses  B lymphocytes migrate to lymphoid tissue, where they
or deficiencies of immunocompetent cells, alterations in wait in readiness to form either sensitized lymphocytes or
the function of these cells, immunologic attack on self- antibodies (immunoglobulins that identify and neutralize
antigens, or inappropriate or exaggerated responses to foreign objects)
specific antigens
 The lymph system, in addition to facilitating the work of
ORGANS OF THE IMMUNE SYSTEM
lymphocytes, also drains tissue fluid and put it back into
1. Bone marrow
circulation.
 Produces a type of stem cell that can produce all
 Innate (natural) immunity is nonspecific immunity that is
types of blood cells (WBCs, RBCs, and platelets),
in humans when they are born and makes them not
which then differentiate (acquire individual
susceptible to diseases of other species.
characteristics) into the cells of the hematologic and
immune systems.  Immunity can be acquired actively or passively.
 B lymphocytes are produced and mature in the bone
marrow and play a significant role in the humoral PHYSIOLOGY/PATHOPHYSIOLOGY OF CELL
immune response. DEVELOPMENT OF THE IMMUNE SYSTEM
2. Thymus gland
 located behind the sternum (breastbone), is where T
lymphocytes mature and are released into the
bloodstream
3. Lymph nodes and vessels
 circulate fluid called lymph which contains nutrients
such as proteins, glucose, monocytes, and
lymphocytes. - where most lymphocytes are initially
exposed to foreign antigens such as bacteria, fungi,
and viruses.
 lymph vessels are located near the blood vessels and
capillaries. The lymph system removes what is left
over after the plasma has delivered nutrients to the
cells TYPES OF IMMUNITY
 The lymph fluid drains into large veins, blending
with the plasma circulating in the bloodstream.
4. Tonsils and adenoids
 are lymph tissues that guard the airway from inhaled
microbes
5. Spleen
 filters blood, which allows lymphocytes to encounter
any circulating organism, thus activating the
appropriate lymphocyte response
 filters out damaged or old RBCs, recycling the
1. Natural (Innate) Immunity
hemoglobin in the production of bilirubin
- Unique innate, or inborn, features of human cells make a
6. Peyer patches
person naturally immune to certain diseases.
 lymphoid tissue typically found in the ileum portion
- provides a broad spectrum of defense against and
of the small bowel. These patches help defend against
resistance to infection
ingested pathogens.
- considered the first line of host defense following antigen
exposure, because it protects the host without
remembering prior contact with an infectious agent
FUNCTIONS, CHARACTERISTICS, AND
- co-coordinates the initial response to pathogens through
PROPERTIES OF THE IMMUNE SYSTEM
the production of cytokines and other effector molecules,
The immune system is composed of an integrated collection of
which either activate cells for control of the pathogen (by
various cell types, each with a designated function in
 elimination) or promote the development of the acquired phagocytes, and promoting the formation of fibrous scar
immune response tissue and regeneration of injured tissue.
- cells involved in this response are monocytes, GENERAL IMMUNE RESPONSE
macrophages, dendritic cells, natural killer (NK) cells, When the body is invaded or attacked by bacteria, viruses, or
basophils, eosinophils, and granulocytes. other pathogens, it has three means of defense:
- also comes in a protein chemical form, called innate 1. Phagocytic immune response
humoral immunity. E.g., complement system and - first line of defense which primarily involves the WBCs
substances called interferon and interleukin-1 (which (granulocytes and macrophages), which can ingest foreign
causes fever) particles and destroy the invading agent.
Dendritic cells (DCs) are antigen-presenting cells that link - Phagocytes also remove the body ’s own dying or dead
innate and adaptive immunity and are critical for the cells. Cells in necrotic tissue that are dying release
induction of protective immune responses against pathogens substances that trigger an inflammatory response.
Interferon is a viricidal protein that is naturally produced by 2. Humoral or antibody immune response
the body and can activate other components of the immune - A second protective response, the humoral immune
system. response (sometimes called the antibody response)
- Natural immune mechanisms can be divided into two - B lymphocytes, which can transform themselves into
stages: plasma cells that manufacture antibodies
a) Immediate (generally occurring within minutes e.g. - antibodies are highly specific proteins that are transported
physical and chemical barriers) in the bloodstream and attempt to disable invaders (IgA,
b) Delayed (occurring within several days after IgD, IgE, IgG, and IgM)
exposure e.g. 12–24 hours at a minimum for signs of - major function is to provide protection against acute,
inflammation to occur locally when in contact with rapidly developing bacterial and viral diseases and is also
antigen) involved in allergic and transfusion reactions
2. Acquired (Adaptive) Immunity
- Acquired or specific immunity develops after birth.
- Occurs through active production of antibodies when the
body is invaded by pathogens or through an immunization
that causes antibodies to a specific pathogen to form
- Weeks or months after exposure to the disease or vaccine,
the body produces an immune response that is sufficient
to defend against the disease on re-exposure.
- this form of immunity relies on the recognition of specific
foreign antigens
- Two Types of Acquired (Adaptive) Immunity:
a) Active acquired immunity (immunologic defenses
developed by the person’s own body; lasts many
years or even a lifetime)
b) Passive acquired immunity (temporary immunity 3. Cellular immune response
transmitted from a source outside the body that has - A third protective response, the T lymphocytes, which can
developed immunity through previous disease or turn into special cytotoxic (or killer) T cells that can
immunization; immunity resulting from the transfer attack the pathogens. This direct contact is called "killer
of antibodies from the mother to an infant in utero or activity"
through breastfeeding or receiving injections of - often termed delayed hypersensitivity as it usually
immune globulin) requires 12–24 hours at a minimum for signs of
- The acquired immune response is broadly divided into inflammation to occur locally
two mechanisms: - The structural part of the invading or attacking organism
a) Cell-mediated response - involving T- cell that is responsible for stimulating antibody production is
activation called an antigen (or an immunogen)
b) Effector mechanisms - involving B-cell maturation CELL-MEDIATED IMMUNITY
and production of antibodies Types of T Lymphocytes T cell:
NATURAL MECHANISMS IN THE BODY a) Effector T cells (Helper T cells and Cytotoxic T
1. Physical and Chemical Barriers cells)
Physical barriers - Intact skin, mucous membranes, and b) Suppressor T cells
cilia of the respiratory tract (with coughing and sneezing), c) Memory T cells
which prevent pathogens from gaining access to the body. Killer T Directly attack the antigen directly by
Chemical barriers - Mucus, acidic gastric secretions, cell destroys altering the cell membrane,
enzymes in tears and saliva, and substances in sebaceous (CD8+ antigens causing cell lysis
and sweat secretions destroy invading bacteria and fungi. cells) (disintegration), and
Viruses are countered by other means, such as interferon* releasing cytolytic enzymes
2. Cellular Response (White Blood Cell Action) and cytokines
- key to the effective initiation of the immune response. Helper T Stimulates T activated on recognition of
WBCs, or leukocytes, participate in both the natural and cell & B cells antigens and stimulate the
the acquired immune responses. (CD4+ rest of the immune system;
- Granular leukocytes or granulocytes fight invasion by cells) secrete cytokines, which
releasing cell mediators, such as histamine, bradykinin, attract and activate B cells,
and prostaglandins, and by engulfing the foreign bodies or cytotoxic T cells, NK cells,
toxins. macrophages, and other cells
- Granulocytes include neutrophils, eosinophils, and of the immune system
basophils. Suppresso Inhibits T& B ability to decrease B-cell
3. Inflammatory Response r T cell cells production, thereby keeping
- major function of the natural immune system that is the immune response at a
elicited in response to tissue injury or invading organisms level that is compatible with
- Chemical mediators assist this response by minimizing health
blood loss, walling off the invading organism, activating Memory T Remembers are responsible for
 cell antigen for recognizing antigens from
future previous exposure and
encounters mounting an immune
response
T cells interact closely with B cells, indicating that humoral
and cellular immune responses are not separate, unrelated
processes but rather are branches of the immune response that
interact
Complement System
 circulating plasma proteins, known as complement, are
made in the liver, and activated when an antibody
connects with its antigen.
 functions are bridging natural and acquired immunity and
disposing of immune complexes and the by-products
associated with inflammation
FOUR STAGES OF AN IMMUNE RESPONSE
STAGE 1: Recognition Stage
- Recognition of antigens as foreign, or non-self, by the
immune system, is the initiating event in any immune
response
- involves the use of lymph nodes and lymphocytes for
surveillance which discharge small lymphocytes into the
bloodstream and patrol the tissues and vessels that drain
the areas served by that node and recirculate from the
blood to lymph nodes in a continuous circuit
- Lymphocytes and other cells have “microbial sensors”
that identify molecules on microbes and other
microorganisms (pathogen-associated molecular patterns
or PAMP)
- Both macrophages and neutrophils have receptors for
antibodies and complement; as a result, they coat
microorganisms with antibodies, complement, or both,
thereby enhancing phagocytosis
STAGE 2: Proliferation Stage
- The circulating lymphocytes containing the antigenic
message return to the nearest lymph node. Once in the
node, these sensitized lymphocytes stimulate some of the
resident T and B lymphocytes to enlarge, divide and
proliferate
- T lymphocytes differentiate into cytotoxic (or killer) T
cells, whereas B lymphocytes produce and release
antibodies
STAGE 3: Response Stage
- differentiated lymphocytes function in either a humoral or
a cellular capacity
- This stage begins with the production of antibodies by the
B lymphocytes in response to a specific antigen. The
cellular response stimulates the resident lymphocytes to
become cells that attack microbes (killer cells) directly
rather than through the action of antibodies
STAGE 4: Effector Stage
- In the effector stage, either the antibody of the humoral
response or the cytotoxic (killer) T cell of the cellular
response reaches and connects with the antigen on the
surface of the foreign invader.
- This involves interplay of antibodies (humoral immunity),
complement, and action by the cytotoxic T cells (cellular
immunity)
ANTIBODIES AND ITS DIFFERENT TYPES
 are large proteins, called immunoglobulins, that consist of
two subunits, each containing a light and a heavy peptide
chain held together by a chemical link composed of
disulfide bonds
 Each subunit has one portion that serves as a binding site
for a specific antigen and another portion that allows the
antibody molecule to take part in the complement system.
 Types of Antibodies:
FACTORS AFFECTING THE IMMUNE RESPONSE
a) Gender – females have a higher incidence of autoimmune
disease because offset hormones
b) Age – postmenopausal females are at a greater risk for
UTI due to residual urine, urinary incontinence, and
estrogen deficiency, breakdown of natural mechanical
barriers
c) Nutrition – deficiencies in micronutrients have been
connected to impairment in various body functions,
including immunity; Depletion of protein reserves results
in atrophy of lymphoid tissues, depression of antibody
response, reduction in the number of circulating T cells,
and impaired phagocytic function
d) Immunization – vaccinations to provide protection
against influenza, pneumococcal disease, pertussis, herpes
simplex, and the usual childhood diseases
e) Infection – a history of past and present infections and
the dates and types of treatments, along with a history of
any multiple persistent infections, fevers of unknown
origin, lesions or sores, or any type of drainage, as well as
the response to treatment, are obtained
f) Allergy – all medication and food allergies, symptoms
exp, seasonal occurrence, and severity, prescribed OTC,
and effectiveness are listed on medical records to alert
others
g) Disorders and Diseases
 Autoimmune disease within a family strongly suggests a
genetic predisposition to more than one autoimmune
disease
 Neoplastic Disease: large tumors can release antigens into
the blood, and these antigens combine with circulating
antibodies and prevent them from attacking the tumor
cells
 Hematologic cancers are associated with altered
production and function of WBCs and lymphocytes
 Chemotherapy and other CA treatments affect bone
marrow function, destroying cells that contribute to an
effective immune response and resulting in
immunosuppression
h) Chronic Illness and Surgery
 Kidney injury is associated with a deficiency in
circulating lymphocytes
 Immune defenses may be altered by acidosis and uremic
toxins
 In DM, an increased incidence of infection has been
associated with vascular insufficiency, neuropathy, and
poor control of serum glucose levels -Recurrent
respiratory tract infections are associated with COPD
because of altered inspiratory and expiratory function and
ineffective airway clearance
 Organ transplantation or surgical removal of the spleen,
lymph nodes, or thymus may place the patient at risk for
impaired immune function
i) Special Problems
 Burns and other forms of injury and infection may
contribute to altered immune system function, impaired
skin integrity, and compromise the body’s first line of
defense
 Loss of large amounts of serum occurs with burn injuries
and depletes the body of essential proteins, including
immunoglobulins
 Physiologic and psychological stressors associated with
surgery or injury stimulate cortisol release from the
adrenal cortex contributes to immunosuppression
j) Medications and Blood Transfusions
 previous exposure to foreign antigens through transfusion
may be associated with abnormal immune function
 Risk of HIV infection through BT
 Herbal agents and OTC medications with their effects not
been fully identified
k) Lifestyle Factors
 functions of the immune system are interrelated with
other body systems
 Although factors that are not consistent with a healthy
lifestyle are predominately responsible for ineffective
immune function, positive lifestyle factors can also
negatively affect immune function
 Negative: Poor nutritional status, smoking, excessive
consumption of alcohol, illicit drug use, STIs, and
occupational or residential exposure to environmental
radiation and pollutants have been associated with
impaired immune function
 Positive: rigorous exercise or competitive exercise can be
a physiologic stressor and cause negative effects on
immune response
l) Psychoneuroimmunologic Factors
 The immune response is regulated and modulated in part
by neuroendocrine influences
 the immune system is integrated with other
psychophysiological processes and is regulated and
modulated by the brain
 Growing evidence indicates that a measurable immune
system response can be positively influenced by
biobehavioral strategies such as relaxation and imagery
techniques, biofeedback, humor, hypnosis, and
conditioning
NURSING IMPLICATIONS
Physical Assessment
- the skin and mucous membranes are assessed for lesions
and any signs of infection; Temp is recorded
- The anterior and posterior cervical, supraclavicular,
axillary, and inguinal lymph nodes are palpated for
enlargement
- The patient’ s respiratory, cardiovascular, genitourinary,
gastrointestinal, and neurosensory systems are evaluated
for signs and symptoms indicative of immune
dysfunction. Any functional limitations or disabilities the
patient may have are also assessed
Diagnostic Evaluation
- A series of blood tests and skin tests, as well as bone
marrow biopsy, may be performed to evaluate the
patient’s immune competence.
Nursing Management
- Counsel, educate, and support patients throughout the
diagnostic process
INFLAMMATION: BASIC CONCEPT &
TERMINOLOGIES
Inflammatory process
- the naturally occurring protective response of the body to
a threat in terms of tissue damage
- this process defends the body against harm, it aims to rid
the body of damaged tissue and promotes the restoration
of normal tissue.
Five Cardinal Signs of Inflammation:
1. Pain (Dolor) - occurs with the release of chemicals
secondary to the damage of cells and tissues
2. Heat and warmth (Calor) - occur as the result of the
vasodilation and the increased blood flow to the
affected area.
3. Redness (Rubor) -results from the vasodilation of
blood vessels that occurs in response to the injury.
4. Swelling (Tumour)- occurs as the body 's fluids enter
the area of the injury and tissue damage.
5. Dysfunction of the area - occurs as the result of the
swelling and pain associated with the inflammatory
process.
Inflammatory Response
- major function of the natural immune system that is
elicited in response to tissue injury or invading organisms
- facilitated by physical and chemical barriers that are part
of the human organism.
- Chemical mediators assist this response by:
Minimizing blood loss, walling off the invading
organism; activating phagocytes; promoting the formation
of fibrous scar tissue and regeneration of injured tissue
- It can be acute (lasting for a few days) or chronic (in
response to an ongoing and unresolved insult).
a. Histamine is secreted by basophils and mast cells
causes capillaries to become more permeable to white
blood cells and other proteins, which proceed to
target and attack foreign bodies in the affected tissue
b. Kinins are proteins in the blood that cause
inflammation
c. Prostaglandins are hormones created during a
chemical reaction at the site where an injury or other
issue occurs. Prostaglandins play a key role in
inflammation by contributing to the development of
redness, swelling, heat, and pain
PHASES OF ACUTE INFLAMMATION
Vascular Phase
- small blood vessels adjacent to the injury dilate
(vasodilatation) and blood flow to the area increases
- Endothelial cells initially swell, then contract to increase
the space between them, thereby increasing the
permeability of the vascular barrier
- Exudation of fluid leads to a net loss of fluid from the
vascular space into the interstitial space, resulting in
edema (tumor)
- Increased tissue fluid acts as a medium through which
inflammatory proteins (such as complement and
immunoglobulins) can migrate. It may also help to
remove pathogens and cell debris in the area through
lymphatic drainage
Cellular Phase
- predominant cell of acute inflammation is the neutrophil
which is attracted to the site of injury by the presence of
*chemotaxis, the mediators released into the blood
immediately after the insult
- The migration of neutrophils occurs in four stages:
a) Margination – cells line up against the endothelium
b) Rolling – close contact with and roll along the
endothelium
c) Adhesion – connecting to the endothelial wall
d) Emigration – cells move through the vessel wall to
the affected area
Chemotaxin - A substance released by bacteria, injured tissue,
and white blood cells that stimulates the movement of
neutrophils and other white blood cells to the injured area
HEALING PROCESS
When the skin is injured, our body sets into motion an
automatic series of events, often referred to as the “cascade of
healing,” to repair the injured tissues.
  Avoid massaging over bony prominences to prevent
further tissue damage.
 Turn every 1 to 2 hours to avoid prolonged pressure in
one area.
 Turn with care (e.g., avoid shearing) to prevent injury to
fragile skin.
 Position with pillows to elevate pressure points off the
bed.
 Use specialty beds and mattresses as needed to provide
pressure relief and increase circulation to the site.
 Use devices on the bed (e.g. Sheepskin) that protect the
1. The homeostasis/bleeding phase individual from pressure.
- is accompanied by vasoconstriction, thrombin formation,  Apply elbow and heel protectors as appropriate to avoid
platelet formation, and the formation of a fibrin mesh for pressure.
healing that begins the healing process  Assist individual in maintaining a healthy weight as the
- the body activates its emergency repair system, the blood risk for pressure ulcers is increased in people who are
clotting system, and forms a dam to block the drainage obese or very thin.
2. The inflammation phase
- also referred to as the lag or exudate phase is
accompanied by pain, swelling, edema, and the beginning
of wound debris removal with phagocytosis to prevent
infection.
3. The proliferative and granulation phase
- is accompanied with the fibroblastic production of
granulation tissue and collagen
4. The maturation/remodeling phase
- is characterized by the continued development and
maturation of the fragile skin over the wound.
- This phase can last up to two years during which time the
wound remains at risk and vulnerable for injury until full
healing and good tensile strength is complete

NURSING MANAGEMENT
Thermoregulation
 Monitor temperature as frequently as is appropriate to
evaluate patient status.
 Monitor blood pressure, pulse, and respiration to
determine responses to increased temperature.
 Administer antipyretic medication to lower temperature.
 Cover the patient with only a sheet to aid in lowering
body temperature.
 Monitor temperature closely to prevent treatment-induced
hypothermia, which will cause a rebound rise in
temperature.
Fluid Balance
 Monitor fluid status including intake and output and
insensible fluid loss (e.g., diaphoresis) to determine risk
for or presence of fluid volume deficit.
 Encourage oral fluid intake to promote fluid balance
 Monitor weight because fluid loss is reflected in
decreasing body weight.
 Maintain a steady IV infusion flow rate to replace fluid
lost because of fever and diaphoresis.
 Monitor vital signs because increasing pulse and
respirations and decreasing blood pressure can indicate
hypovolemia.
 Observe for indications of dehydration (e.g., poor skin
turgor, delayed capillary refill, weak or thready pulse,
severe thirst, dry mucous membranes, decreased urine
output, hypotension) to ensure early treatment of fluid
deficit.
 Assist the patient with ambulation in case of postural
hypotension, which results from hypovolemia.
Tissue Integrity: Skin and Mucous Membrane
 Use an established risk assessment tool to monitor an
individual’s risk factors (e.g., Braden scale) to reduce or
eliminate factors that contribute to the development or
progression of the pressure ulcer. Document any previous
incidences of pressure ulcer formation to identify specific
risks to the patient.
 Remove excessive moisture on the skin resulting from
perspiration, wound drainage, and fecal or urinary
incontinence to prevent maceration.