Nursing Management in Anaphylaxis

Immunotherapy

By the end of the session the student will be enabled to:

Describe the bodys immune responses

Differentiate between humoral and cellular responses

Discuss with understanding the effect of ageing on the immune system

Describe the effect of incompatible bloods transfusions on the immune system

Discuss with understanding how to treat anaphylactic shock

Describe nursing management, drug treatments and collaborative care of patients with altered immune responses.

Peripheral lymphoid organs - Skin-associated lymphoid tissues, Lymph nodes

Peripheral lymphoid organs-Tonsils, Gut-associated lymphoid tissues, Genital-associated lymphoid tissues, Bronchial-associated lymphoid tissues

Lymphoid tissue - Found in the submucosa of the respiratory, genitourinary, and GI tracts

Skin-associated lymph tissue

Spleen= Primary site for filtering foreign substances from blood

Major site of immune responses to blood-borne antigens

The immune system functions as the human bodys

defense mechanism against invasion

Allowing a rapid response to foreign substances

Affected by a variety of factors:-

o CNS integrity

o General physical condition

o Emotional status

o Medications

o Dietary factors

o Illness, trauma, or surgery

Described as responsiveness to the invasion of foreign substances

Three functions:-

o Defense protection against micro-organisms

o Homeostasis Damaged cellular substances digested and removed

o Surveillance mutations recognized and removed

Types

o Innate response within minutes without prior exposure

o Acquired Development of immunity active having the disease, or inoculation

o Passive

Innate Present at birth primary role first line defense

neutrophils and monocytes primary WBCs this type is a non

specific response neutrophils and monocytes are the

primary white cells. Innate not cell specific so can respond

within minutes without prior exposure to the organism

Acquired on the other hand is the development of immunity.

With each reinvasion the body responds more rapidly .

Active may result naturally from having the disease or

through inoculation of a less virulent antigen.

Passive immunity is short lived

Active Acquired Immunity - invasion of foreign substances and subsequent development of antibodies and sensitized lymphocytes With each re-invasion the body responds more rapidly and vigorously to fight off infection . It can be acquired naturally from having the disease or artificially via injection innoculation of a less virulent antigen eg: immunizations . Immunity will take longer to develop via immunization but is long lasting

Passive Acquired Immunity The host receives antibodies to an antigen rather than synthesizing them e.g. transfer of immunoglobulin's across placenta. As well as passive transfer across the placenta you can also receive injection gamma globulins This has an immediate affect but is short lived because the host did not synthesize the antigens so has no memory cells for the antigen.

Passive acquired immunity short lived - lack of memory for the antigen

Antigen a substance that elicits an immune response

Antigens all body cells have antigens on their surface that are unique to the person and enable the body to recognize itself and so non responsive to self antigens

The immune system in a perpetual state of

vigilance to eliminate foreign substances but

maintaining the ability to accept self antigens.

Initial Central Tolerance immature T and B

lymphocytes deleted, before they develop into fully

immuno-competent cells, preventing self

destruction.

Peripheral tolerance - developed after T and B cells

mature and enter the periphery.

Acquired or induced tolerance refers to the

immune system's adaptation to external antigens

An antigen is a substance that elicits an immune response , most composed of protein. Unique to the person enabling the body to recognize itself Tolerance is therefore enabled.

Self antigens recognizing those factors innate to your own body Central tolerance occurs during lymphocyte development and operates in the thymus

and bone marrow. Here, T and B lymphocytes that recognize self antigens are deleted before they develop into fully immunocompetent cells, preventing autoimmunity. This process is most active in fetal life, but continues throughout life as immature lymphocytes are generated. Positive selection occurs first when naive T-cells are exposed to antigens in the thymus

Peripheral tolerance -tolerance developed after T and B cells mature and enter the periphery. The T cells that leave the thymus are relatively but not completely safe. Some will have receptors(TCRs) that can respond to self antigens that:

1.are present in such high concentration that they can bind to "weak" receptors2.the T cell did not encounter in the thymus (such as, tissue-specific molecules like those in the islets of Langerhans, brain or spinal cord)

Those self reactive T cells that escape intrathymic negative selection in the thymus can inflict cell injury unless they are deleted or effectively muzzled in the peripheral tissue. Several back mechanism silence such potentially auto reactive T cells are known to exist.

Acquired or induced tolerance refers to the immune system's adaptation to external antigens characterized by a specific non-reactivity of the lymphoid tissues to a given antigen that in other circumstances would likely induce cell-mediated or humoral immunity. One of the most important natural kinds of acquired tolerance is immune tolerance in pregnancy, where the fetus and the placenta must be tolerated by the maternal immune system.

The Lymphatic System forms part of the

circulatory system and consists of vessels,

nodes and tissues.

Filtrates protein and blood impurities from

the general circulation

Cells of the immune system which fight

bacteria and viruses are produced by the

normal lymphatic system

Central bone marrow, thymus gland

Peripheral tonsils, gut, genital, bronchial, skin associate skin tissues , lymph nodes, spleen.

Cells Mononuclear Phagocytes capturing processing and bringing the antigen to the lymphocytes. On presentation it triggers an immune response.

WBC are produced in the bone marrow two types B and T B mature in the bone marrow T move to the thymus where they mature into During childhood the thymus gland is large. The thymus is important in the differentiation and maturation of T lymphocytes

B Lymphocytes produce antibodies immunoglobulin's

T lymphocytes - 70 -80% of circulating lymphocytes responsible

for immunity to intracellular viruses , tumor cells and fungi

Life span few months to a lifetime

2 types T helper(CD4) and T cytotoxic

Dendrites function to capture antigens at point of contact

T helper (CD4) cell mediated immunity

Natural Killer Cells (Cytotoxic T Lymphocyte) - large lymphocytes

o Do not require prior sensitization for generation

o Mechanism of recognition not fully understood

o Significant role in immune surveillance for malignant cell changes

B lymphocytes - Differentiate into plasma cells when

activated and the plasma cells produce antibodies

(immune globulins).

T-lymphocyte subsets T helper cells (CD4) Regulate cell-

mediated immunity and the humoral antibody response

Dendrties primarily found in mucous membrane skin etc.

A cytotoxic T cell (also known as TC, Cytotoxic T

Lymphocyte, CTL, T-Killer cell, cytolytic T cell, CD8+ T-cells

or killer T cell) is a T lymphocyte (a type of white blood cell)

that kills cancer cells, cells that are infected (particularly

with viruses), or cells that are damaged in other ways.

http://www.youtube.com/watch?v=RO6qmpApyDM

T cells - 70%80%

B cells - 10%20%

Natural killer (NK) cells

Interactions of lymphocytes depend on cytokines

They instruct cells to alter proliferation differentiation

secretion or activity

Detrimental effect seen in chronic inflammation

autoimmune disease

Cytokines such as interferon are used clinically to:

o Stimulate hemopoiesis

o stimulate bone marrow to make WBC

o Treat malignancies

o Used as anti-inflammatory agents

Interferon for example is not an antiviral but produces an antiviral effect in cells by reacting with them inducing formation of a second protein which in turn alters the cells protein synthesis and preventing new viruses from assembling.

Soluble factors secreted by WBCs and a variety of other cells in the body, Act as messengers between cell types

Cytokine categories

Interleukins

Interferons

Tumor necrosis factor

Colony-stimulating factors

Erythropoietin

Cytokines - Enhances inflammatory response, and induces fever, stimulates antibody secretion, promotes differentiation of B cells into plasma cells.

Humoral immunity antibodies are produced by

plasma cells (differentiated B cells )

Protection Bacteria, viruses, Respiratory and GI pathogens

Examples- anaphylactic shock, transfusion reaction bacterial

infections atopic diseases

Cell mediated T lymphocytes and macrophages

Sensitized T cells and cytokines

Protection Fungus, intracellular viruses, chronic infection .

Tumor cells.

Examples - Graft rejection, tuberculosis, destruction of cancer

cells

Include monocytes in the blood and

macrophages found throughout the body

Capture, process, and present antigens to

lymphocytes to initiate humoral or cytotoxic

response

Capture antigens by phagocytosis

Virus enters the body makes it way into a cell/s in order to

replicate itself A macrophage digests the virus and displays

pieces of the antigen on its surface A T cell recognizes the

antigen and binds to he macrophage which stimulates the

cytokines which are intercellular messengers that provide

communication amongst cells T helper cells and T cytotoxic

cells to multiply The T helper cells release cytokines cause

B cells to multiply and produce antibiotics T cytotoxic cells

and natural killer cells destroy infected body cells

Antibodies bind to the virus and mark for macrophage

destruction Memory B and T cells remain behind to respond

quickly if the same virus attacks again

Antigens

Substances the body recognizes as foreign that

elicit an immune response

Most are composed of protein.

Antibodies

Immune globulins produced by lymphocytes in

response to antigens

Activates macrophages and granulocytes

Promotes the immune and inflammatory

responses

Kills tumor cells

Responsible for extensive weight loss

Associated with chronic inflammation and

cancer

Comparison of

Humoral and Cell-Mediated Immunity

Humoral Cellular

Cells involved B lymphocytes T lymphocytes

Macrophages

Products Antibodies Sensitized T cells

Cytokines

Memory cells Present Present

Antibody-mediated immunity

Antibodies produced by plasma cells (differentiated B lymphocytes) Primary immune response is evident 4 to 8 days after initial exposure to antigen.

IgG Largest component of total immune globulins, found in plasma and interstitial fluid. Only Ig to cross placenta and provide newborn with passive acquired immunity.

IgA = Found in body secretions = Saliva. tears. breast milk -colostrum, lines mucous membranes

IgM - Largest of immune globulins is found in plasma Responsible for primary immune response Forms antibodies to ABO blood antigens

IgE - Found in plasma and interstitial fluids, Causes symptoms of allergic reaction

Comparison of

Humoral and Cell-Mediated Immunity

Humoral Cellular

Protection Bacteria

Viruses

(extracellular)

Respiratory

pathogens

Gastrointestinal

pathogens

Fungus

Viruses

(intracellular)

Chronic infectious

agents

Tumor cells

When an individual is exposed to an antigen for a

second time, the response is faster (1 to 3 days)

and lasts longer.

Main product of secondary response is IgG rather

than IgM.

Memory cells account for more rapid production of

IgG.

Immune responses initiated through specific

antigen recognition by T cells

Several cell types involved in cell-mediated

immunityo T lymphocytes

o Macrophages

o Natural Killer cells

Greater susceptibility to pathogens - influenza pneumonia

Higher incident of malignancies

Bone marrow relatively unaffected

Immunoglobulin levels decrease

Leading to a suppressed immune response

Decreased numbers of T cells

Thymic output decreases, differentiation of T cells increases leading to an accumulation of memory cells rather then new precursor cells which are responsive to previously un-encountered antigens

Delayed hypersensitivity reaction

Assessment includes - CNS integrity, emotional status, medications, stress and illness, trauma, surgery, allergies

Physical assessment skin, presence of enlarged lymph nodes, tonsils etc

Using a gentle circular motion with your finger pads palpate both sides at the same time, comparing the two sides symmetrically. Normal cervical nodes should be less than one centimeter, movable, discrete, soft, and nontender.

The nurse will examine the tonsils for color, presence of exudates or lesions

When immune system is incompetent, under responsive or overreacts what is the result?

Under reaction severe infection immunodeficiency diseases and malignancies

Overreaction or hypersensitivity seen in anaphylactic shock for example not the first exposure but the second causes a trigger response and mass release of chemical mediators

Seen for example when giving antibiotics or a severe reaction to a bee or wasp sting

Atopic reaction eczema

Atopic reactions to environmental conditions

Allergic rhinitis sensitivity to grasses, pollens dust, animal dander, molds etc

Target areas conjunctiva of eyes, mucosa of upper respiratory tract

Symptoms include sneezing, nasal discharge, itching of the throat , eyes watering.

Atopic dermatitis chronic inherited skin disorder cause by several environmental allergens (see next slide)

Urticaria (hives) transient wheals; develops rapidly after exposure to allergen. Histamine causes localized vasodilation erythema

Angioedema localized cutaneous lesion swelling usually begins in the face and then spreads to other areas dilation and engorgement of the capillaries secondary to release of histamine causes the diffuse swelling. Can also occur in the GI tract, hands, feet, and genitalia.

Immediate response to an allergen insect bites, food

allergies, reaction to antibiotic therapy etcprovoked by re-

exposure to a specific type of antigen referred to as an

allergen. The reaction may be either local or systemic.

Exposure by ingestion, inhalation, injection, or direct

contact.

Vasodilation and smooth-muscle contraction occurs

Cytotoxic and Cytolytic reactions direct binding of IgG or IgM antibodies

to an antigen on the cell surface

Cellular tissues is destroyed by either :

o Activation of the complement system

o Enhanced phagocytosis

Target cells frequently destroyed are erythrocytes, platelets and

leukocytes. Antigens involved are ABO blood group Rh factor and drugs

ABO incompatibility transfusions Rh incompatibility autoimmune and

drug related hemolytic anemia's Tissues damage occurs rapidly

A blood group for example has anti B antibodies

B blood group for example has A antibodies

AB has no antibodies

O has both A and B antibodies

Transfusion

Antigens coat foreign erythyrocytes Clumping occurs blockage of small blood

vessels

Depletion of clotting factors

Cytolysis

Phagocytosis of agglutinated cells Complement fixed to the cells

Release of hemoglobin into the urine and plasma

Renal failure

Cytotoxic reaction causes vasospasm in the the kidney

Blockage of kidney tubules

Associated with autoimmune disorders

Occurs secondary to antigen antibody complexes

Soluble antigens combine with immunoglobulin's of the IgG

and IgM classes forming complexes too small to be

removed by mononuclear phagocyte system

Fixation of complement release of chemotactic factors

Leading to inflammation and destruction of the involved

tissue

Deposits found in kidneys, skin, joints, blood vessels and

lungs

Hypersensitivity reactions - Cell mediated

Tissue damage occurs but not in the

presence of antibodies or complement

Sensitized T cells attack antigens or release

cytokines attracting macrophages into the

area.

24 48 hours for a response to occur

Comes under the grouping delayed hypersensitivity disorders type IV

Cell mediated response

Sensitized T lymphocytes attack antigens or release cytokines which attract macrophages into the area The macrophages and the enzymes released are responsible for most of the damage

Takes 24 48 hours after contact

Includes contact dermatitis e.g. latex allergy, poisoned ivy , cosmetics, some dyes, fruits such as bannanas, pineapples, kiwi

Microbial Hypersensitivity reactions - bodies defense against TB *

Family history

Physical exam, skin testing, diagnostic workup

Clinical manifestations , determining time of year, any over

the counter medications

Female question about pregnancies, menstruation or

menopuase

Questions about pets, trees and plants on the property

May need to keep a food diary

Lifestyle and stressors

CBC with white cell differentiation meaning an absolute

lymphocyte count and eosinophil count

T cell and B cell quantification cell immunodeficiency

diagnosed if cell count is below 1200/uL

Esinophil count associated with specific immunodeficiency

syndromes. It is elevated with type I sensitivity

RAST test sensitivity to certain food types, severe

anaphylactic reactions

Sputum. Nasal and bronchial secretions

Asthma VC, FEV

Skin tests

Collaborative care aimed at :

o Reducing exposure

o Desensitizing person immunotherapy

For chronic allergies lifestyle

adjustment

Allergen recognition and control

Anaphylaxis

Anaphylaxis

Patent airway

High flow oxygen

Remove

stinger

Iv access

Administer drugs

Ongoing

Monitoring

Cardinal principle is speed in:

o Recognition of the signs and symptoms

o Maintenance of patients airway

o Prevention of spread by using a

tourniquet

o Administration of the appropriate drugs

o Treatment of shock

Epinephrine 1:10000 0.01mL/kg (0.3 -0.5 mL) mid

anterior thigh repeat 5 15 minutes

NB Patients with beta blockers may be resistant to

treatment and can develop bradycardia and

hypotension Glucagon should be administered

instead

Nebulized albuterol

Benadryl IM or IV

Corticosteroids - methylprednisolone

Antihistamines allergic rhinitis urticaria

Sympathomimetic Decongestant drugs

adrenaline

Corticosteroids prednisolone

Antipuritics topically applied protect skin and

provide relief from itching - calamine lotion coal tar

preparations

Anti-mast cell stabilizing drugs Cromolyn Intal

Nedocromil

Immunotherapy when the allergen cannot be

avoided

Immunotherapy

Accurate record keeping to prevent an adverse reaction

After administration anticipate adverse reactions puritis

urticarial, sneezing laryngeal edema

Administer away from the joint so a tourniquet can be

applied in an emergency

Rotate the site

Ensure you dont inject into the bloodstream

Observe for any reaction

An immune response against yourself

Lack of differentiation self from non-self

Immune cells tolerant to self antigens are activated

Cause unknown

Gender and hormones have a role in autoimmune disease

Principle factors include:

Inheritance of susceptibility genes

Initiation of auto reactive triggers such as infections may activate self reactive lymphocytes

Autoimmune diseases tend to cluster so a given person may have more than one autoimmune disease rheumatoid arthritis Addisonsdisease Genetic predisposition

More women than men have an autoimmune disease

Apheresis separation of separate components of blood followed by removal of one or more of these components

Plasmapheresis removal of plasma containing components thought to cause disease and replacement with saline fresh frozen plasma or albumin (known as plasma exchange)

Used to treat SLE, rheumatoid arthritis Guillan Barre ,glomerular nephritis for example

Involves the removal of whole blood

Inside the machine the blood is divided into cells and plasma components

Common side effects are hypotension and as the result of a vasovagal reaction citrate toxicity

Citrate is used as an anticoagulant and may cause hypocalcaemia manifesting as a headache dizziness or paresthesias

The home care nurse is assigned to visit a client who has returned home from the emergency room following treatment for a sprained ankle. The nurse notes that the client as sent home with crutches that have rubber axillary pads and needs instructions regarding crutch walking. On admission assessment, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should:

1) contact the physician

2) cover the crutch pads with cloth

3) call the local medical supply store and ask for a cane to be delivered

4) tell the client that the crutches must be removed from the house immediately

The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 4 is inappropriate and may alarm the client. The nurse cannot order a cane for a client. Additionally, this type of assistive device may not be appropriate, considering this clients injury. No reason exists to contact the physician at this time.

The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food item?

1) eggs

2) milk

3) yogurt

4) bananas

4 - Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be to the result of a possible cross-reaction between the food and the latex allergen. Options A, B, and C are unrelated to latex allergy.

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