Chapter 31  Acquired immunity: specific against a
Assessment of Immune foreign antigen
Function
The Immune System
 Immunity: the body’s specific
protective response to foreign agent or
organism; resistance to a disease,
specifically infectious disease
 Immunopathology: the study of
diseases that results from dysfunction
within the immune system
 Components of immune system
o Bone marrow: T cells and B cells
o Lymphoid tissue: spleen and lymph
nodes
Maturity of Lymphocytes
 B lymphocytes mature in the bone
marrow
 T lymphocytes mature in the thymus,
where they also differentiate into cells
with various functions
Function of the Immune System
 To remove foreign antigens such as
viruses and bacteria to maintain
homeostasis
 Phagocytosis: monocytes responsible
for engulfing and destroying foreign
bodies and toxins
 Inflammatory response:
o Response to injury or invading
organisms
o Chemical mediators minimize blood
loss, wall off invading organisms,
activate phagocytes, promote
formation of scar tissue and
regeneration of injured tissue
Immunity
 Natural immunity: nonspecific
response to any foreign invader
o White blood cell action: release cell
mediators such as histamine, bradykinin,
and prostaglandins and engulf
(phagocytize) foreign substances
o Inflammatory response
o Physical barriers, such as intact skin,
chemical barriers, and acidic gastric
secretions or enzymes in tars and saliva
o Result of prior exposure to an antigen
o Active or passive
Active and Passive Immunity
 Active
o Immunologic defenses developed by
person’s own body
o Lasts many years; may last a lifetime
 Passive
o Temporary
o Results from transfer of a source
outside of the body that has developed
immunity through
previous disease or immunization
o Ex.: transfer of antibodies from mother
to infant through breast feeding; receiving
immune globulin through injections
*Neutrophils (polymorphonuclear
leukocytes) are the first cells to arrive at
the site where inflammation occurs.
Four Stages in Immune Response
 Recognition
 Proliferation
 Response
 Effector
Recognition Stage
 Recognition of antigens as foreign
 Use of lymph nodes and lymphocytes
for surveillance
 Lymphocytes recirculate from the
blood to lymph nodes and from the
lymph nodes back into the
bloodstream in a continuous circuit
 Macrophages play an important role in
helping the circulating lymphocytes
process antigens
 Both macrophages and neutrophils
have receptors for antibodies and
complement; as a result, they coat
microorganisms with antibodies,
complement, or both, thereby
enhancing phagocytosis
Proliferation Stage
 Circulating lymphocytes containing the
antigenic message return to the
nearest lymph node
 Stimulate some of the resident T and B
lymphocytes to enlarge, divide, and
proliferate
 T lymphocytes differentiate into
cytotoxic (or killer) T cells
 B lymphocytes produce and release
antibodies
Response Stage
 Begins with the production of
antibodies by the B lymphocytes in
response to a specific antigen
 Cellular response stimulates the
resident lymphocytes to become cells
that attack microbes; (killer) T cells
 Viral rather than bacterial antigens
induce a cellular response
 Most immune responses to antigens
involve both humoral and cellular
responses, although one usually
predominates
Effector Stage
 Humoral immunity
o Interplay of antibodies
 Cellular immunity
o Action by cytotoxic T cells
Response to Invasion
 Phagocytic immune response
o WBCs ingest foreign particles and
destroy invading agents
o Apoptosis; programmed cell death
 Humoral or antibody response
o Antibody response; B lymphocytes
transform themselves into plasma cells that
manufacture antibodies
 Cellular immune response
o T lymphocytes; cytotoxic killer cells
that can attack pathogens
Humoral Immune Response
 Antigen recognition
o B lymphocytes respond to antigens by
triggering antibody formation
 Antibodies
o Immunoglobulins: IgA, IgD, IgE, IgG,
IgM
o Defend against foreign invaders
o Agglutination, opsonization
 Antigen–antibody binding
o Antigenic determinant
Cellular Immune Response
 T lymphocytes: cellular immunity
o Attack invaders directly, secrete
cytokines, and stimulate immune system
responses
o Helper T cells
o Cytotoxic T cells
o Memory cells
o Suppressor T cells (suppress immune
response)
Non-T and Non-B Lymphocytes Involved in
Immune Response
 Null cells
o Destroy antigen coated with antibody
 Natural killer cells
o Defend against microorganisms and
some malignant cells
Complement System
 Circulating plasma proteins made in
the liver and activated when antibody
connects to antigen playing an
important defense against microbes
 Activated by three pathways: classic,
lectin, and alternative
 Three functions:  Hypersensitivity tests
o Defend the body against bacterial  Specific antigen–antibody tests
infection  HIV infection tests
o Bridge natural and acquired immunity
o Dispose of immune complexes and the Nurse’s Role in Evaluation of the Immune
by products System
 Offer support
Variables that Effect Immune System  Reduce anxiety
Function  Provide patient education and
 Age and gender counseling
 Nutrition
 History of infection or immunization
 Allergies
 Presence of conditions or disorders:
autoimmune disorders, cancer or
neoplasm, chronic illness, surgery or
trauma
 Medications and transfusions
 Lifestyle
 Psychoneuroimmunologic factors

Advances in Immunology
 Genetic engineering: DNA technology
 Stem cells:
o Research shows that stem cells can
restore an immune system that has been
destroyed
o Clinical trials using stem cells are under
way in patients with a variety of disorders
having an autoimmune component,
including systemic lupus erythematosus,
rheumatoid arthritis, scleroderma, and
multiple sclerosis
o Along with these remarkable
opportunities, many ethical challenges arise

Assessment of the Immune System

 Health history, including nutrition,
infections, immunizations, allergies,
autoimmune disorders, cancer, and
chronic illness
 Physical exam, including lymph node
assessment and skin examination, in
addition to other body systems

Tests to Evaluate Immune Function

 WBC count and differential
 Bone marrow biopsy
 Humoral and cellular immunity tests
 Phagocytic cell function test
 Complement component tests
 Chapter 32
Management of Patients
with Immune Deficiency
Disorders
Primary Immune Deficiency Disorders
(PIDD): Pathophysiology
 Genetic
 Majority diagnosed in infancy; some
may be diagnosed during adolescence
 Male-to-female ratio of 5 to 1
 Occasionally, adults may present with
persistent, recurrent, or resistant
infections
o Prevent body from developing normal
immune responses
o May affect phagocytic function, B cells
or T cells, or the complement system
Clinical Manifestations of PIDD
 Multiple infection despite treatment
 Infection with unusual/opportunistic
organisms
 Failure to thrive, poor growth
 Positive family history
Nursing Management
 Nursing care is meticulous
 Strategies to reduce risk of infection
o Appropriate hand hygiene
o Infection prevention precautions per
institution policy
o Continual monitoring for early signs of
infection
o Teach patients and caregivers to
administer medications and therapy at
home
o Provide ongoing education and support
Human Immune Deficiency Virus (HIV)
 Immune deficiency is acquired:
o Due to medical treatment such as
chemotherapy
o Infection from agents such as HIV
 Despite advances in treating HIV,
acquired immune deficiency syndrome
(AIDS) remains a public health issue
 Prevention, early detection, and
ongoing treatment are important
aspects for care
 PLWHA—persons living with HIV/AIDS
HIV: Modes of Transmission
 HIV-1 transmitted in body fluids that
contain infected cells:
o Blood and blood products
o Seminal fluid
o Vaginal secretions
o Mother-to-child: Amniotic fluid, breast
milk
o Not through casual contact
HIV: Prevention
 Education on how to eliminate or
reduce risks associated with HIV
infections and AIDS
 Prevention education:
o Behavioral interventions
o HIV testing
o Linkage to treatment and care
Strategies to Protect Against HIV
Infection
 Consistent and correct use of condoms
 Medical male circumcision
 Female condom
 Harm reduction framework for people
who inject drugs
o Needle exchange
o May use bleach to clean used needles
and syringes
o Avoid sharing needles and syringes
 Reproduction education
o Artificial insemination in some cases
o Benefits of ART
o Refrain from breastfeeding
 LGTB
o LGTB youth at high risk for HIV
infection
o Remain nonjudgmental in educating
about prevention
Reducing the Risk of Transmission to
Health Care Providers
 Standard precautions
 Hand hygiene
 Postexposure prophylaxis
o Antiretroviral medications within 72
hours of exposure
o 2 to 3 drugs prescribed for 28 days
*Antiretroviral medications are started as
soon as possible, but no more than 72
hours (3 days) after possible HIV exposure.
HIV: Pathophysiology
 HIV is in the subfamily of lentiviruses
and is a retrovirus because it carries its
genetic material in the form of (RNA)
rather than (DNA)
 HIV targets cells with CD4+ receptors,
which are expressed on the surface of
T lymphocytes, monocytes, dendritic
cells, and brain microglia
Steps in the Life Cycle of HIV
 Attachment/Binding
 Uncoating/Fusion
 DNA synthesis
 Integration
 Transcription
 Translation
 Cleavage
 Budding
Stages of HIV Infection
 Classified in five stages:
 Stages 1, 2, 3 based on CD4+ T-
lymphocyte count
 Stage O
o Early HIV infection; inferred from
laboratory testing
 Stage 1: Primary/acute
o Period from infection with HIV to the
development of HIV-specific antibodies
o Dramatic drops in CD4+ T-cell counts
normally 500 to 1500 cells/mm3 of blood
 Stage 2
o Occurs when T-lymphocyte cells are
between 200 and 499 cells/mm3
 Stage 3
o CD4+count drops below 200 cells/mm3
of blood
o Considered to have AIDS for
surveillance purposes
 Unknown
o No information on CD4+ T-lymphocyte
count or percentage
Clinical Manifestations of HIV
 Asymptomatic during first stage or
may exhibit fatigue or skin rash
 Later stages have variety of symptoms
related to immunosuppressed state
 Respiratory manifestations
o dyspnea, cough, chest pain
o Pneumocystis pneumonia,
Mycobacterium avium complex, TB
 Gastrointestinal manifestations
o anorexia, N and V, oral candidiasis,
diarrhea
o Wasting syndrome
 Oncologic manifestations
o Kaposi sarcoma
o AIDS-related lymphomas
 Neurologic manifestations
o Effects on cognition, motor function
attention, visual memory, visuospatial
function
o Peripheral neuropathy
o HIV encephalopathy
o Fungal infection, Cryptococcus
neoformans
o Progressive multifocal
leukoencephalopathy
o Depression and apathy
 Integumentary manifestations
o Herpes zoster
o Seborrheic dermatitis
 Gynecologic manifestations
o Genital ulcers
o Persistent, recurrent vaginal candidiasis
o Pelvic inflammatory disease
o Menstrual abnormalities
Treatment of HIV and AIDS
 Antiretroviral therapy: (ART)
o Overarching goal to suppress HIV
replication
o Reduce HIV-associated morbidity and
prolong duration and quality of life
o Restore and preserve immunologic
function
 o Maximally and durably suppress
plasma HIV viral load
o Prevent HIV transmission
Assessment of the Patient with HIV/AIDS
 Identification of potential risk factors
 Physical status
 Psychological status
 Immune system functioning
 Nutritional status
 Respiratory status
 Neurologic status
 Fluid and electrolyte balance
 Knowledge level
Problems/Potential Complications of the
Patient with HIV/AIDS
 Development of HAND
 Body image changes
 Adverse effects of medications
Planning and Goals for the Patient with
HIV/AIDS
 Goals for the patient may include
o Improved nutritional status
o Increased socialization and expression
of grief
o Increased knowledge regarding disease
prevention and self-care
o Absence of complications
 Improving knowledge of HIV
o Instruct patient and family about
routes of transmission and prevention
o Avoid sexual contact with multiple
partners
o Use condoms
o Do not use IV/injection drugs
 Monitoring and managing potential
complications
o Monitor for side effects of medications
o Monitor for HAND
o Encourage verbalization of body image
changes
Resources in the Community
 Home health care nursing
o Monitor adherence to therapeutic
regimen
o Complex wound care
o Respiratory care
 Community programs that help with
transportation, shopping, legal and
financial assistance
 Hospice nursing during terminal stages
o Provides physical and emotional
support

Nursing Interventions for the Patient with

HIV/AIDS

 Improving nutritional status

o Monitor weight, dietary intake, serum
albumin
o Dietary consult as needed
o Instruct ways to supplement nutrition
 Decreasing the sense of isolation
o Assess pattern of social interaction
o Observe for behaviors indicative of
social isolation
o Assist with identifying resources
 Coping with grief
o Identify resources for support and
mechanisms for coping
o Consult mental health counselors as
needed
 Chapter 33
Assessment and Management of Patients
with Allergic Disorders
Allergic Reactions
 Allergy
- An inappropriate, often harmful response
of the immune system to normally harmless
substances
- Hypersensitive reaction to an allergen
initiated by immunologic mechanisms that
is usually
mediated by IgE antibodies
 Allergen: the substance that causes
the allergic response
 Atopy: refers to IgE-mediated diseases,
such as allergic rhinitis, that have a
genetic component
 Manifestation of tissue injury resulting
from interaction between an antigen
and an antibody
 Body encounters allergens that are
types of antigens
 Body’s defenses recognize antigens as
foreign
 Series of events occurs in an attempt
to render the invaders harmless,
destroy them, and remove them from
the body
Immunoglobulins and Allergic Response
 Antibodies (IgE, IgD, IgG, IgM, and IgA)
formed by lymphocytes and plasma
cells
 IgE antibodies are involved in allergic
disorders
 IgE molecules bind to an allergen and
trigger mast cells or basophils
 These cells then release chemical
mediators such as histamine,
serotonin, kinins, SRS-A, and
neutrophil factor
 These chemical substances cause the
reactions seen in allergic response
Role of B Cells and T Cells in Allergic
Response
 B cells; also known as B lymphocyte
- Programmed to produce one specific
antibody
- Stimulates production of plasma cells;
antibody production
- Results in outpouring of antibodies
 T cells; also known as T lymphocyte
- Assist B cells
- Secrete substances that destroy target
cells and stimulate macrophages
- Digest antigens and remove debris
Function of Chemical Mediators
 Allergen triggers the B cell to make IgE
antibody, which attaches to the mast
cell. When that allergen reappears, it
binds to the IgE and triggers the mast
cell to release its chemicals.
Chemical Mediators
 Primary
 Histamine
 Eosinophil chemotactic factor of
anaphylaxis
 Platelet-activating factor
 Prostaglandins
 Secondary
 Leukotrienes
 Bradykinin
 Serotonin
Hypersensitivity
 Abnormal heightened reaction to a
stimulus of any kind
 Types of hypersensitivity reactions:
- Anaphylactic: type I; most severe
- Cytotoxic: type II
- Immune complex: type III
- Delayed: type IV
Type I: Anaphylactic Reaction
- An anaphylactic reaction is characterized
by vasodilation, increased capillary
permeability, smooth muscle contraction,
and eosinophilia.
- Ex. extrinsic asthma, allergic rhinitis,
systemic anaphylaxis, and reactions to
insect stings.

Type II: Cytotoxic Reaction

- A cytotoxic reaction, which involves
binding either the IgG or IgM antibody to a
cell-bound antigen, may lead to eventual
cell and tissue damage.
- Ex. myasthenia gravisGoodpasture
syndrome, pernicious anemia, hemolytic
disease of the newborn, transfusion
Management of Allergic Disorders
reaction, and thrombocytopenia
 Two types of reactions: atopic and
nonatopic
Type III: Immune Complex Reaction
 Atopic
- An immune complex reaction is marked by
- Asthma, allergic rhinitis, atopic
acute inflammation resulting from
dermatitis
formation and deposition of immune
- Familial
complexes.
 Nonatopic
- S&S: urticaria, joint pain, fever, rash, and
- Lack genetic component
adenopathy (swollen glands)
- Latex
Type IV: Delayed or Cellular Reaction
Medications to Treat Allergic Reactions
- A delayed, or cellular, reaction occurs 1 to
 Oxygen, if respiratory assistance is
3 days after exposure to an antigen.
needed
 Epinephrine used for anaphylactic
Assessment of Patients with Allergic
reactions Histamines
Disorders
 Corticosteroids
 History and manifestations;

comprehensive allergy history
Anaphylaxis
 Diagnostic tests
 Mild, moderate, and severe systemic
- CBC: eosinophil count
reactions
- Total serum IgE
 Symptoms are sudden in onset and
- Skin tests: prick, scratch, and intradermal
progress in severity over minutes to
hours
- Flushing
- Urticaria
- Angioedema
- Hypotension
- Bronchoconstriction
- Antibiotics most common; penicillin

Prevention and Management of

Interpretation of Reactions
Anaphylaxis
 Screen and prevent
 Treat respiratory problems, oxygen,
intubation,
 and cardiopulmonary resuscitation as
needed
 Epinephrine 1:1000 subcutaneously
 Autoinjection system: EpiPen
 May follow with IV epinephrine
 IV fluids
Allergic Rhinitis
 Hay fever, seasonal allergic rhinitis
 A common respiratory allergy
presumed to be mediated by a type I
hypersensitivity
 Affects 12% of adults
 Major symptoms: copious amounts of
serous nasal discharge, nasal
congestion, sneezing, nose and throat
itching
 May affect the quality of life, sleep
disturbance, impairment of daily
activities, and missed school and work
Assessment of the Patient with Allergic
Rhinitis
 Health history includes personal and
family history
 Allergy assessment
 Subjective data include symptoms and
how the patient feels before
symptoms become obvious
 Note relationship between symptoms
and seasonal changes, emotional
problems, or stress
 Identify nature of antigens, seasonal
changes in symptoms, and medication
history
Collaborative Problems/Potential
Complications of the Patient with Allergic
Rhinitis
 Anaphylaxis
 Impaired breathing
 Nonadherence to therapeutic regimen
Planning and Goals for the Patient with
Allergic Rhinitis
 Goals may include:
- Restoration of normal breathing pattern
- Increased knowledge about the causes
and control of allergic symptoms
- Improved coping with alterations and
modifications
- Absence of complications
Nursing Interventions for the Patient with
Allergic Rhinitis
 Improving breathing
- Modify the environment to reduce
allergens
- Reduce exposure to people with URI
- Take deep breaths and cough
frequently
 Patient teaching
- Instruction to minimize allergens
- Use of medications
- Importance of keeping appointments
- Desensitization procedures
Other Allergic Disorders
 Contact dermatitis
 Atopic dermatitis
 Drug reactions (dermatitis
medicamentosa)
 Urticaria and angioneurotic edema
 Hereditary angioedema and cold
urticaria
 Food allergy: peanut most common
 Latex allergy
Latex Allergy
 Allergic reaction to natural rubber
proteins
 Implicated in rhinitis, conjunctivitis,
contact dermatitis, urticarial, asthma,
anaphylaxis
 Prevalence has been decreasing due to
the use of nonlatex gloves
 Different types of reactions to latex;
refer to Table 33-6
Chapter 34
Assessment and Management of Patients
with Inflammatory Rheumatic Disorders
 ● Limited movement
DISEASES ● Stiffness
● Connective tissue disorders ● Weakness
o Rheumatoid arthritis ● Fatigue
o Systemic lupus erythematosus
● Gout *The most common symptom in the
● Fibromyalgia rheumatic diseases is pain. Other common
symptoms include joint swelling, limited
RHEUMATIC DISEASE movement, stiffness, weakness, and
● Encompass autoimmune, degenerative, fatigue.
inflammatory, and systemic conditions
● Affect the joints, muscles, and soft tissues Assessment
of the body ● Health history
● More than 100 types of rheumatic o Include onset of and evolution of
diseases symptoms
● Problems caused by rheumatic diseases o Family history
include: o Past health history
o Limitations in mobility and activities of o Contributing factors
daily living o Previous treatments and their
o Pain and fatigue effectiveness
o Altered self-image o Patient’s support systems
o Sleep disturbances ● Physical Assessment
o Systemic effects that can lead to organ ● Physical examination
failure and death ● Functional assessment
● Most commonly manifest the clinical o Combination of history and observation
features ofarthritis (inflammation of a joint) o Gait, posture, general musculoskeletal
and pain size andstructure
● Marked by periods of remission and o Gross deformities and abnormalities in
exacerbation movement
● Classification o Symmetry, size, and contour of other
o Monoarticular or polyarticular connective tissues, such as the skin and
o Inflammatory or noninflammatory adipose tissue

Pathophysiology of Rheumatologic Diagnostic Tests

Disorders ● Laboratory studies: Refer to Table 34-1
● Imaging studies
● Three distinct characteristics: o X-rays
● Inflammation o CT scan
o Complex process resulting in pannus o MRI
● Autoimmunity o Arthrography
o Hallmark of rheumatologic disease
o Body recognizes own tissue as foreign Planning and Goals for the Patient with a
antigen Rheumatic Disorder
● Degeneration ● Major goals may include:
o Secondary process to inflammation o Relief of pain and discomfort
o Relief of fatigue
o Maintain optimal functional mobility
o Performs self-care activities
Common Symptoms of Rheumatic Disease independently
● Pain o Adapts to physical and psychological
● Joint swelling changes
 o Effective coping behaviors
o Absence of complications Education Plan for Newly Diagnosed
Rheumatic Disease
Interventions for the Patient with a
Rheumatic Disorder ● Explain the disease and principles of
disease
● Pain management
o Provide comfort measures ● Medication teaching and safe self-
o Administer anti-inflammatory, administration
analgesic medications ● Pain management techniques
● Cope with stress
● Fatigue ● Dietary plan including vitamin
o Explain energy-conserving techniques supplementation
o Facilitate development of activity/rest ● Identify need for health promotion,
schedule prevention, and
screening
● Functional mobility ● Community resources and sources of
o Assess for need of PT/OT support
o Encourage independence in mobility
Interventions to Maintain Functional
● Self-care Ability
o Assist in identifying self-care deficits ● Range of motion
and factors that interfere with ability to ● Isometric exercise
perform self-care activities ● Dynamic exercise
o Provide assistive devices ● Aerobic exercise
o Consult with community agencies ● Pool exercise

● Physical and psychological changes

o Assist to identify elements of control SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
over
disease ● Inflammatory, autoimmune disorder that
o Encourage verbalization of affects nearly every organ in the body
feelings/fears ● Affects women > men

● Effective coping behaviors ● Pathophysiology: exact cause unknown;

o Identify areas of life affected by disease
o Develop plan for managing symptoms
and enlisting support of family and friends
to promote daily function
● Absence of complications secondary to
medications
o Perform periodic clinical assessment
and laboratory evaluation
o Provide education about correct self
administration, potential side effects, and
importance of monitoring
o Counsel regarding methods to reduce
side effects and manage symptoms
o Administer medications in modified
doses asprescribed if complications occur
SLE causes the body to inaccurately
recognize one or more of the cell’s nucleus
as foreign
o Antigen antibody complexes
o Antibodies destroy host cells
● Clinical Manifestations
o Fever, fatigue, skin rashes, joint pain &
swelling
o Cutaneous system manifestation
o Cardiac manifestations
o Nephritis (lupus nephritis)
o CNS involvement
● Assessment and Diagnostic Findings
o H&P, blood tests
 o Assess for manifestations as described o Diet
above

● Medical management FIBROMYALGIA

o Control exacerbations, manage chronic
condition ● Chronic pain syndrome
o Pharmacologic therapy o Chronic fatigue, generalized muscle
● Pain management, nonspecific aching, stiffness, sleep disturbances,
immunosuppression functional impairment
o Affects women > men
● Nursing management
o Fatigue, impaired skin integrity, body ● Pathophysiology
image disturbance, lack of knowledge for o Neurogenic pain; CNS pathways
self management decisions function abnormally = amplification of pain
o Education signals
o Long term complications o Predisposing factors

GOUT ● Assessment and Diagnostic Findings

● Inflammatory arthritis
o Affects men > women
o Incidence of gout increases 1) age, 2)
BMI, 3)
ETOH, 4) HTN, 5) Diuretic use
o Increased risks of CVD; comorbid
conditions
● Pathophysiology
o Hyperuricemia
● Macrophages phagocytize urate
crystals; increasing inflammation;
accumulation of sodium urate crystals,
renal uratelithiasis, possible chronic kidney
disease
o Rule out other conditions
o Achilles pain assessment + “I have a
persistent deep aching all over my body”
affirmation
● Medical Management
o Related to symptoms reported by
patient
o NSAIDs, TCAs, Muscle relaxants,
cognitive behavioral therapy, SNRIs,
anticonvulsants
● Nursing Management
o Psychosocial support, support groups

● Clinical manifestations
o Acute gouty arthritis, tophi, uric acid
urinary calculi
o Four stages of gout
● Medical management
o Definitive diagnosis
o Management of gout + comorbid
conditions
o Treatment for acute attacks
o Management between gout attacks

● Nursing management
o Education