Assessment of Immune Function NURS 304: ADULT NURSINGLECTURER: Ms. Mackey

The Immune SystemImmunity: the bodys specific protective response to invading foreign agent or organismImmunopathologyImmune disordersAutoimmunity - normal protected immune responseHypersensitivity exaggerated response to antigenGammopathies over production of immunoglobulinsImmune deficiencies: primary and secondary

Immune SystemAntibodyAn antibody is a protein substance developed by the body in response to and interacting with a specific antigen.AntigenA substance that induces the production of antibodyImmunoglobulinsAntibodies (protein molecules IgA, E, G, M, D)

Central and Peripheral Lymphoid Organs

Development of Cells of the Immune System

Immune FunctionNatural immunity: nonspecific response to any foreign invader White blood cell action: release cell mediators such as histamine, bradykinin, and prostaglandins, and engulf (phagocytize) foreign substancesInflammatory responsePhysical barriers, such as intact skin, chemical barriers, and acidic gastric secretions or enzymes in tars and salivaAcquired immunity: specific against a foreign antigenResult of prior exposure to an antigen Active or passive

Cellular Immune ResponseB lymphocytes: humoral immunityProduce antibodies or immunoglobulinsT lymphocytes: cellar immunityAttack invaders directly, secrete cytokines, and stimulate immune system responsesHelper T cellsCytotoxic T cellsMemory cellsSuppressor T cells (suppress immune response)

Variables That Effect Immune System Function

Age and genderNutritionPresence of conditions or disorders: cancer/neoplasm, chronic illness, autoimmune disorders, surgery/traumaAllergiesHistory of infection or immunizationGenetic factorsLifestyleMedications and transfusionsPyschoneuroimmunologic factors

Tests to Evaluate Immune Function

WBC count and differentialBone marrow biopsyHumoral and cellular immunity testsPhagocytic cell function testComplement component testsHypersensitivity testsSpecific antigen-antibody testsHIV infection tests

Allergic ReactionsAllergyAn inappropriate often harmful response of the immune system to normally harmless substances Hypersensitive reaction to an allergen initiated by immunological mechanisms which is usually mediated by IgE antibodiesAllergen: the substance that causes the allergic responseAtopy: refers to the allergic reactions characterized by IgE antibody action and a genetic predisposition

Immunoglobulins and Allergic ResponseAntibodies (IgE, IgD, IgG, IgM, and IgA) react with other cells and molecules, to protect the bodyIgE 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, and neutrophil chemical substances cause the reactions seen in allergic response

Hypersensitivity A reflection of excessive immune responseSensitization: initiates the buildup of antibodies Types of hypersensitivity reactions:Anaphylactic: Type I, e.g. asthma, allergic rhinitisCytotoxic: Type II, e.g. myasthenia gravis, Rh isoimmunization Immune complex: Type III, e.g. SLE, rheumatoid arthritisDelayed-type: Type IV, occurs 1-3/7 after exposure to antigen, e.g. contact dermatitis

Management of Patients with Allergic DisordersHistory and manifestations; comprehensive allergy history Diagnostic testsCBCeosinophil countTotal serum IgESkin tests

Medication Oxygen, if respiratory needEpinephrine used for anaphylactic reactions Antihistamines (benadryl, zrytec, claratine)Corticosteroids (prednasone)

Prevention and Treatment of Anaphylaxis Screen and prevent!Treat respiratory problems, oxygen, intubation, and cardiopulmonary resuscitation as needed Epinephrine 1:1,000 SQ Auto injection system: epiPenMay follow with IV epinephrine IV fluids

Other Allergic DisordersContact dermatitisAtopic dermatitisDrug reactions (dermatitis medicamentosa)Urticaria Food allergySerum sicknessLatex allergy

Management of Patients With Immunodeficiency

Immunodeficiency DisordersPrimary: genetic Inborn errors of immune functionMay effect phagocytic function, B cells and/or T cells, or the complement system E.g DiGeorge Syndrome, IgA deficiency, Wiscot Aldrich Syndrome (thrombocytopenia), phagocytic disordersSecondaryAcquiredRelated to underlying disorders, diseases, toxic substances, or medications HIV/AIDS, autoimmune disorders e.g SLE,

Primary Immunodeficiency

Usually seen in infants and young childrenManifestations: vary according to type, severe or recurrent infections, failure to thrive or poor growth, positive family historyPotential complications: recurrent, severe, potentially fatal infections; related blood dyscrasias or malignancies Treatment: varies by type, treatment of infection, immunoglobulin Rx, stem cell or bone marrow transplant

Nursing ManagementMonitor for signs and symptoms of infectionsMonitor lab valuesPromote good nutrition Address anxiety, stress, and copingStrategies to reduce risk of infectionHandwashing and strict aseptic techniquePatient protection and hygiene measures: skin care, promote normal bowel and bladder function, pulmonary hygiene

Patient Teaching Signs and symptoms of infectionMedication Prevention of infectionHand washingAvoid crowds and persons with infectionsHygiene and cleaning Nutrition and dietLifestyle modifications to reduce riskFollow-up care

HIV/AIDS InfectionHuman immunodeficiency virus is a member of the retrovirus family that causes AIDS.Characterized by long incubation periodCarries genetic material in form of RNAHIV infection is pandemic

Transmission of HIVTransmitted by body fluids containing HIV or infected CD4 lymphocytesBlood, seminal fluid, vaginal secretions, amniotic fluid, and breast milkMost prenatal infections occur during deliveryCasual contact does not cause transmissionBreaks in skin or mucosa increase risk

High-Risk BehaviorsSharing infected injection equipmentHaving sexual relations with infected individuals

PreventionStandard precautionsSafer sex practices and safer behaviorsAbstinence Reduce the number of sexual partners to oneAlways use latex condoms; if allergic to latex, use non-latex condomsDo not share drug injection equipmentBlood screening and treatment of blood products

Standard PrecautionsStandard precautions infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin.Hand hygienePersonal Protective Equipment (PPE)Respiratory hygieneProper disposal of soiled materialEnvironmental controlDisposal of sharps

Stages of HIV DiseasePrimary infection

HIV asymptomatic

HIV symptomatic

AIDS

Primary InfectionAKA acute HIV infection/acute HIV syndromePeriod from infection to development of HIV antibodiesSymptoms: none to flu-like syndromePeriod of rapid viral replication and dissemination through the bodyCD4+ (500 1500 cells/mm3)Viral set point: amount of virus in body

HIV AsymptomaticMore than 500 CD4+ T lymphpocytes/mm3 Chronic asymptomatic state beginsBody has sufficient immune response to defend against pathogensIndividual is relatively well

HIV Symptomatic200499 CD4+ lymphpocytes/mm3 CD4 T cells gradually fallThe patient develops symptoms or conditions related to the HIV infectionConditions are classified as category B conditionsOral candidiasis Cervical dysplasiaHerpes zoster (shingles)Fever, diarrhea x 1/12

AIDSLess than 200 CD4+ lymphocytes/mm3As levels drop below 100 cell/mm3 the immune system is significantly impairedDevelopment of category C conditionsCandidiasis of esophagus, lungsCervcal cancerKaposis sarcomaPneumoncystis pneumoniaWasting syndrome

Diagnostic TestsEnzyme immunoassay (ELISA) test to identify HIV antibodiesWestern Blot detects HIV antibodies & confirms EIAViral Load Measures HIV RNA in plasmaCD4 / CD8 monitors the function of immune systems and tracts the progression of the diseaseMeasures the ratio between the CD4 on helper T cells and the CD8 on suppressor and cytotoxic T cellsOrasure (saliva)OraQuick

Clinical Manifestations of HIV/AIDSRespiratoryPneumocystic carini pneumonia (PCP): Most common infectionInitial symptoms may be nonspecific and may include nonproductive cough, fever chills, dyspnea, and chest painIf untreated, progresses to pulmonary impairment and respiratory failureTreatment: pentamidine, TMP-SMZ (bactrim)Mycobacterium avium complex (MAC)- respiratory infectionTuberculosis

Clinical ManifestationsGastrointestinalOral candidiasisMay progress to esophagus and stomachTreatment with nystatin, ketoconazole

Diarrhea related to HIV infection or enteric pathogensOctretide acetate for severe chronic diarrhea

Wasting syndrome10% weight loss and chronic diarrhea or chronic weakness and fever with absence of other causeAnorexia, diarrhea, GI malabsorption, and lack of nutrition may contribute

Clinical ManifestationsKaposi's sarcomaCutaneous lesions, but may involve multiple organ systemsLesions cause discomfort, disfigurement, ulceration, and potential for infectionB-cell lymphomas

Clinical ManifestationsNeurologic HIV encephalopathyProgressive cognitive, behavioral, and motor declineCryptococcus neoformans fungal infection that can cause meningitisDepression

TreatmentTreatment and protocols are continually evolvingAntiretroviral agentsNucleoside reverse transcriptase inhibitors (NRTIs)Non-nucleoside reverse transcriptase inhibitors (NNRTIs)Protease inhibitors (PIs)Fusion inhibitorsUse of combination therapyManagement also focuses upon the treatment of specific manifestations and conditions related to the disease

TerminologyART = AntiRetroviral TherapyARV = AntiRetroViralsHAART = Highly Active AntiRetroviral TherapyTriple Therapy = Three AntiretroviralsThe Cocktail

Basic Facts about ARVsAlways use 3 or more different ARV medications for therapy.Regimen should be selected by an experienced HCW. Other medications interact with ARVs.ARVs are divided into 3 classes, each of which attacks HIV in a different way.New classes becoming available through clinical trials.

Advantages of ARV TherapyImproved patient healthReduced illness Reduced hospitalisationsFewer deaths from AIDS

How do ARVs control HIV?ARVs reduce the ability of the HIV virus to replicate

This increases the functioning of the immune system

How NRTIs WorkHIVNucleoside reverse transcriptase inhibitors (NRTIs) latch onto the new strand of DNA that reverse transcriptase is trying to build.

How NNRTIs WorkHIVNon-nucleoside reverse transcriptase inhibitors (NNRTIs) hook onto reverse transcriptase and stop it from working

HIVProtease inhibitors (PIs) prevent final assembly and completion of new HIV viruses within the cellHow PIs Work

Use of ARVsThe Stage of HIV depends upon:

Immunological markers (CD4 count)

Clinical symptoms (Opportunistic infections)

It also depends on whether the patient is READY to start

Bahamas - Adult ARV TherapyHIV infected adults and adolescents should start ARV therapy when they have:CD4 count less than 250/mm3Normal or not extreme lab valuesCr > 2mg/dl/lHgb < 6.5 g/dlALT > 175 IU/l (alanine aminotransferase)

Goals of AVR TherapyDecline in viral load from pre-treatment levels by 6-8 weeks after initiating ARVs

Undetectable viral load = ultimate goal

ARVs Require near perfect adherenceHIV resistanceSide effectsToxicity

Basic Facts about Adherence and ARV therapyARV blood concentrations must remain constant; low concentrations allow HIV to mutate. HIV mutations cause drug resistance.ARV medications must be taken every day otherwise they will not work.Things that can lower drug concentrations:Missing 1 or 2 ARV medication doses regularlyTaking ARV medication late Taking ARVs with certain foods or other medications

Determinants to Effective ARV Therapy

Patient is not ready? he/she may be non-adherent

Patient doesnt understand the drugs? he/she may take them incorrectly

Patient doesnt expect side effects? he/she may be shocked and get put off ARVs or not report any problems

Patient feels alone and unsupported? he/she may be frightened, reluctant to take drugs or to report any problems

Nurses Role in MonitoringVerbal Reporting:Nurses are often the first point of contactPatients often feel more comfortable raising issues with nursesNursing activities (e.g. vital signs) provides opportunity for informal conversation re: problems/issuesAssessment: Is patient experiencing any side effects? How are they feeling? Any problems?Follow up: Referral of concerns to Doctor; Recognising urgent referrals; Good communication

Blood SamplesCorrect clinical decisions depend on meaningful clinical laboratory information

Nurses have a direct responsibility to ensure that accurate results are obtained which may inform appropriate clinical decisions

This depends on proper specimen collection

Common blood tests:CD4 CountViral LoadMonitoring Labs (FBC, LFTs)Resistance Testing

Side Effects of NRTIsAZT (Retrovir): anaemia, headache, neutropenia, fatigue3TC (Epivir): nausea, diarrhoea, headache, fatigue, skin rash, abdominal pain, increase LFTs d4T (Zerit): headache, nausea, vomiting, diarrhoea, rash, increase LFTs, peripheral neuropathy, pancreatitisddI (Videx): nausea, vomiting, diarrhoea, abdominal pain, peripheral neuropathy, increase LFTs, pancreatitis

Side Effects of NNRTIsEfavirenz (Efavirenz): rash, sedative effects, headache, nausea, diarrhoea, vivid dreams, insomnia, increase LFTs, hepatitis, Nevirapine (Viramune): headache, nausea, rash, diarrhoea, increase LFTs, hepatitis, liver failure

Severe Side Effects or Adverse EventsSome side effects may be severe e.g. rash, hepatitis, lactic acidosis, pancreatitis, hyperlipidaemia, peripheral neuropathyARVs may need to be stopped/or changedEarly identification and prompt, appropriate management is essential

Other toxicities..

Regular monitoring of blood levels is essential to identify ARV toxicities

Appropriate intervention can then be made

CBC/FBC

Liver function

Kidney function

Cholesterol

Glucose

Our Role As nurses, we have a vital role to play in ensuring side effects are identified, managed and treatedappropriately and effectively

How do we do this?........Educating patients

Prompt recognition and reporting

Understanding lab tests and results

Explaining lab tests to patients

Therapeutic intervention

Providing support and counselling for patient and family

Ensuring follow up of patients

Educating the general public

Collaborative Problems/Potential ComplicationsOpportunistic infectionsImpaired breathing or respiratory failureWasting syndrome Fluid and electrolyte imbalanceAdverse reaction to medication

Opportunistic InfectionsAn opportunistic infection is an infection caused by pathogens, particularly opportunistic pathogens (bacterial, viral, fungal or protozoan) that usually do not cause disease in a healthy host.ParasiticPneumocystis carinii

FungalCandidaCryptococcus

Opportunistic InfectionsBacterialTuberculosis (TB)Strep pneumoniaViralKaposi SarcomaHerpesInfluenza (flu)Toxoplasma gondii encephalitisCryptosporidium spp. infection

Aims & Collaborative GoalsMonitoring of disease progressionPrevent opportunistic infectionMonitoring antiretrovital treatmentManagement of signs and symptomsPrevent complications of treatments

Nursing Management: Assessment Assess physical and psychosocial statusIdentify potential risk factors: IV drug abuse, risky sexual practicesImmune system functionNutritional statusSkin integrityRespiratory & neurologic statusFluid and electrolyte balanceKnowledge level

Skin IntegrityFrequent routine assessment of skin and mucosaReposition at least every 2 hours and as neededPressure reduction devicesInstruct patient to avoid scratchingUse gentle, nondrying soaps or cleansers Avoid adhesive tapePerianal skin care

Promoting Usual Bowel PatternAssess bowel pattern and factors that may exacerbate diarrheaAvoid foods that act as bowel irritants, such as raw fruits and vegetables, carbonated beverages, spicy foods, and foods of extreme temperaturesSmall, frequent mealsAdminister medications as prescribedAssess and promote self-care strategies to control diarrhea

Activity IntoleranceMaintain balance between activity and restInstruction regarding energy conservation techniquesRelaxation measuresStrengthening muscles

Maintaining Thought ProcessesAssess mental and neurologic statusUse clear, simple language if mental status is altered Establish and maintain a daily routineOrientation techniquesEnsure patient safety and protect from injuryInstruct and involve family in communication and care

NutritionMonitor weight, I&O, dietary intake, and factors that interfere with nutritionDietary consult Control of nausea with antiemeticsOral hygiene Treatment of oral discomfort Dietary supplements May require enteral feedings or parenteral nutrition

Decreasing IsolationPromote an atmosphere of acceptance and understanding Assess social interactions and monitor behaviorsAllow patient to express feelings Address psychosocial issuesProvide information related to the spread of infectionEducate ancillary personnel, family, and partners

Other InterventionsImproving airway clearancePosition in semi-Fowler's or high Fowlers Pulmonary therapy; coughing and deep breathing, postural drainage, percussion, and vibration Ensure adequate restPain Medications as prescribedSkin and perianal care

Prevention of InfectionHand HygieneProper washing of handsReverse barrier nursing for patients whos decrease WBC (neutropenia)Proper use of protective barriersMonitor blood investigations (WBC) for early intervention, report abnormal readingsMonitoring of V/S

Prevention of InfectionMinimize visitors with infections because of pts. Immune responseUse strict asepsis for all invasive procedures

Prevention of InfectionEnsure pts. environment is kept clean to prevent transfer of organismsEducate pt. on importance of hand washing, clean environment to prevent transmission of organismsEnsuring pt. receives a nutritionally balanced diet for maintenance of immune systemAdministration of anti infectives if prescribed

ObjectivesBy the end of this session you should be able to:Define the term SLEIdentify the etiology of SLEExplain the pathiphysiology of SLE;Discuss the signs and symptoms of SLE; andDiscuss the medical and nusring management of SLE.

Systemic Lupus Erythematosus (SLE)Chronic multisystem inflammatory diseaseOccurs more frequently in womenMore common in black women Associated with abnormalities of immune systemResults from interactions among genetic, hormonal, environmental, and immunologic factors

IncidenceSLE affects 2 to 8 persons per 100,000 in United StatesMost cases occur in women of childbearing yearsPeak incidence occurs between 15 40yrs.Female to male ratio of 9:1African, Asian, Hispanic, and Native Americans three times more likely to develop than whites

EtiologyEtiology is unknownMost probable causesGenetic influenceHormonesEnvironmental factors (ultra violet light)Certain medicationsHydralazine, procainanmideQuinidine, methyldopa, isoniazid, phenytoin

SLE: PathophysiologyThere is a disturbed immune regulation that causes an over production of autoantibodiesThis disturbance is caused by a combination of factors:GeneticHormonalEnvironmentalMedication

Pathophysiology contd.Abnormal suppressor T cell function causes the increase in autoantibody productionThe autoantibodies combine with antigens to form immune complexesThe immune complexes are deposited in vascular and tissue surfaces which triggers an inflammatory responseThe inflammatory process leads to tissue damage

Clinical ManifestationsOnset may be acute (sudden) or insidious (gradual)Ranges from a relatively mild disorder to rapidly progressingCan affect any body systemMost commonly affects the skin/muscles, lining of lungs, heart, nervous tissue, and kidneysCharacterized by exacerbations and remission

Fig 65-9Clinical Manifestations

Clinical ManifestationsDermatologic Cutaneous vascular lesionsDiscoid LE (chronic rash)Butterfly rashOral/nasopharyngeal ulcersAlopecia

Clinical ManifestationsMusculoskeletalPolyarthralgia with morning stiffnessArthritisSwan neck fingersUlnar deviationSubluxation with hyperlaxity of joints

Clinical ManifestationsRenalLupus nephritisRanging from mild proteinuria to glomerulonephritisPrimary goal in treatment is slowing the progressionSerum creatinine and urinanalysis is done to screen for renal involvement

Clinical ManifestationsNervous systemGeneralized/focal seizuresPeripheral neuropathyCognitive dysfunctionDisorientationMemory deficitsPsychiatric symptoms

Diagnostic StudiesNo specific testSLE is diagnosed primarily on criteria relating to patient history, physical examination, and laboratory findings

Diagnostic TestsCBC for hematologic problemsUA for lupus nephritisX-rays of affected jointsChest x-ray for pulmonary problemsECG for cardiac problemsAntinuclear antibody test (ANA)

Collaborative CareGoals:Early diagnosisPreventing loss of organ fucntionsMinimize disease related disabilitiesPreventing complicaitons from therapy

SLE: Drug therapy

NSAIDsReduce inflammationAntimalarial drugsControls disease by decreasing bodies production of antigens

SLE: Drug therapy cont.

Corticosteroids (prednisone)Used to stabilize cells reducing the inflammatory processBlock chemical pathways & decrease # of circulating lymphocytesImmunosuppressive and Steroid-sparing drugs

Nursing ManagementNursing DiagnosesFatigueAcute painImpaired skin integrityIneffective therapeutic regimen managementBody image disturbance

Nursing ManagementPlanningOverall goalsHave satisfactory pain reliefComply with therapeutic regimen to achieve maximum symptom managementDemonstrate awareness of, and avoid activities that cause disease exacerbation (triggers)Maintain optimal role function and a positive self-image

Nursing ManagementNursing ImplementationAcute interventionDuring exacerbation, patient will become abruptly, dramatically illRecord severity of symptoms and response to therapy

Nursing ManagementNursing ImplementationAcute intervention (contd)Observe forFever patternJoint inflammationLimitation of motionLocation and degree of discomfortFatigability

Nursing ManagementNursing ImplementationAcute intervention (contd)Monitor weight and I&OCollect 24-hour urine sampleAssess neurological statusExplain nature of diseaseProvide support

Nursing ManagementNursing ImplementationAmbulatory and home care (Discharge)Reiterate that adherence to treatment does not necessarily halt progressionMinimize exposure to precipitating factors fatigue, sun, stress, infection, drugsTeach energy conservation and relaxation exercisesFor joint problems, all the teaching for RA related to joint protection, ROM, and positioning to prevent contractures

Nursing Management

Nursing Management

Lupus and pregnancyInfertility can result from SLE treatment regimenSLE is associated with complications of pregnancyPregnancy & post partum can cause exacerbations of SLEWomen with serious SLE should be counseled against pregnancy

Nursing Management

Psychosocial issuesCounsel patient and family that SLE has good prognosisPhysical effects can lead to isolation, self-esteem, and body image disturbancesAssist patient in developing goals

Nursing ManagementEvaluationExpected outcomes Performance of activities of daily living without painLimitation of direct exposure to sun and use of sunscreen No open skin lesions

Nursing ManagementEvaluationExpected outcomes (contd)Expression of satisfaction with activity levelPacing of activities to match level of toleranceExpression of confidence in ability to manage SLE over time and in home environment

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