Nursing Care Management 104

•Definition
•Function
Immune System
Constellation of responses to attacks from outside the
body.
Cell and proteins which protect body from antigen.
(viruses, bacteria, fungi )
Immunity – the body’s ability to resist infection.
Maintains homeostasis
Monitors degradation
Removal of damaged cells
Discovers and destroys abnormal cells
Immune System
General hosts
Differentiate self from non self
Inflammation followed by phagocytosis
Specific Immune response
Specific microorganism activates response
T cells and B cells produce responses
Prevent organism entry
Physical
Chemical
Mechanical barriers
Immune System
Antigen
Substance foreign to the body
Antibody (Immunoglobulins)
Molecule made by lymph tissue
Defends body against bacteria, viruses, or other foreign
bodies (antigens)
Each antibody reacts to a certain foreign body
Allergen substance that causes inappropriate immune
response (allergy)
Major Histocompatibility Complex
Main Menu
Formation, development, and specialization
of all functional blood cells

Back
Cells of the Immune System

Cells destined to become

immune cells, like all
blood cells, arise in the
bone marrow from so-
called stem cells.
T-Cells
T helper
 A pertinent coordinator of
immune regulation.
 To augment or potentiate
immune responses by
activating other WBC.
T killer/suppressor
 Directly killing certain tumor
cells, viral-infected cells and
sometimes parasites.
 also important in down-
regulation of immune
responses.
Natural Killer Cells
Effector cells that directly
kill certain tumors such as
melanomas, lymphomas
and viral-infected cells,
most notably herpes and
cytomegalovirus-infected
cells.
B Cells
Production of
antibodies in response
to foreign proteins of
bacteria, viruses, and
tumor cells.
Granulocytes
composed of neutrophils,
eosinophils and
basophils, based on their
staining characteristics
with certain dyes.
Important in the removal
of bacteria and parasites
from the body.
Macrophages
regulation of immune
responses.
Scavengers - pick up and
ingest foreign materials
and present these antigens
to other cells
Initiation of an immune
response
 Phagocytes and Granulocytes

• Monocytes (2-6%)
• circulate in the blood
• Macrophages
• found in body tissues
• Scavengers
• Secrete a wide variety of powerful
chemicals
• Activates T cells.
• Neutrophils (40-75%)
• Circulate in blood but move into tissues PRN
• Contain granules filled with potent chemicals
• Destroys microbes + key role in acute
inflammatory reactions.
• Eosinophils(2-5%)
• Allergy, suppresses inflammation & helminthes
(parasitic worm) infection,
• Decrease granulocyte migration
• Basophils(0.2-0.5%)
• inflammatory mediator release
• Mast cells
• granule-containing cells in tissue.
Activation of B cells to make Antibody
 A B – Cell uses one of its
receptors to bind to its
matching antigen, which the B
cell engulfs and processes.
 The B cell then displays a piece
of the antigen, bound to a
Class II MHC (major
histocompatibility complex)
protein, on the cell surface.
 This whole complex then binds
to an activated helper T cell to
stimulates the transformation
of the B cell into an antibody –
secreting Plasma cell.

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Immunoglobulin
Immunoglobulin G / IgG (75%)
Found in serum and tissue (instertitial fluid)
Assumes a major role in blood and tissue born
pathogen
Activates complement system
Crosses the placenta
Immunoglobulin A / IgA (15%)
Appears in the body fluid e.g. saliva, sweat,pulmo,
gastro, repro
Prevents absorption of antigen from food
Passes to neonates in breast milk
Immunoglobulin
Immunoglobulin M / IgM (10%)
 Appears in the intravascular serum
 First Ig produced in response to bacterial and viral
 Activates the compliment system
Immunoglobulin D / IgD (0.2%)
 Appears in small amount serum
 Influences B lymphocyte to differentiate
Immunoglobulin E / IgE (.004%)
 Appears in serum
 Takes part in allergic and hypersensitivity reaction
 Parasitic infection
T - Cells
 T cells attacks and destroys
diseased cells they recognize as
foreign.
 T lymphocytes are responsible
for cell-mediated immunity (or
cellular immunity).
 T cells also orchestrate,
regulate and coordinate the
overall immune response.
 T cells depend on unique cell
surface molecules called the
Major Histocompatibility
Complex (MHC) to help them
recognize antigen fragments

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T - Cells
Immature T cells (termed T – Stem cells)
Migrate to the thymus gland in the neck, where they
mature and differentiate into various types of mature T
cells.
 Killer T cell
 Helper T cell
 Suppressor T cell
 Memory T cell
 Produce substances called Cytokines
 Interleukins which further stimulate the immune response.
T – Cells - Types
 Cytotoxic or killer T cells (CD8+) - do their work by releasing
lymphotoxins, which cause cell lysis
 Helper T cells (CD4+) - serve as managers, directing the immune response,
 secrete chemicals called lymphokines that stimulate cytotoxic T cells and
B cells to grow and divide, attract neutrophils, and enhance the ability of
macrophages to engulf and destroy microbes
 Suppressor T cells –
 a component of the immune system that suppress immune responses of other cells.
 These cells are involved in closing down immune responses after they have
successfully tackled invading organisms and also in keeping in check immune
responses that may potentially attack one's own tissues ("autoimmunity").
 Memory T cells - programmed to recognize and respond to a pathogen once
it has invaded and been repelled.
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Lymphatic System
The lymphatic system is a complex network of
lymphoid organs, lymph nodes, lymph ducts,
lymphatic tissues, lymph capillaries and lymph
vessels.
They produce and transport lymph fluid from tissues
to the circulatory system.
The lymphatic system is a major component of the
immune system.
Lymphatic System – Functions:
To collect and return interstitial fluid, including
plasma protein to the blood, and thus help maintain
fluid balance.
To defend the body against disease by producing
lymphocytes
To absorb lipids from the intestine and transport
them to the blood.
Lymphoid Organs
Thymus Gland
Red Bone Marrow
Spleen
Lymph nodes
Peyer’s Patches
Tonsils
Adenoid
Vermiform Appendix
•Natural (innate)
•Acquired (adaptive)
•Response to infection
Innate (natural Immunity)
Provides a non specific response to invader
Basis is their ability to recognize “self” and “non self”
Natural mechanism
Includes Physical and chemical barriers (Normal Flora)
 Skin
 Genitourinary
 Respiratory
 Muco cilliary action

Cell of the innate immune response

Inflamatory response
Complement response
Inflammatory Response
The complex biological response of vascular tissues to
harmful stimuli, such as pathogens, damaged cells, or
irritants
Acute Inflammation
initial response of the body to harmful stimuli
achieved by the increased movement of plasma and
leukocytes from the blood into the injured tissues.
cascade of biochemical events propagates and matures
the inflammatory response, involving the local vascular
system, the immune system, and various cells within
the injured tissue.
Inflammatory Response
Chronic Inflammation
Prolonged inflammation
leads to a progressive shift in the type of cells which are
present at the site of inflammation and is characterized
by simultaneous destruction and healing of the tissue
from the inflammatory process.
Causes of Acute Inflammation
Microbial infections
Hypersensitivity reactions
Physical agents Irritant and corrosive chemicals
Tissue necrosis
Five Cardinal Symptoms of Acute
Inflammation
Redness (rubor)
Heat (calor)
Swelling (tumor)
Pain (dolor)
Loss of Function
 Cellular
Injury

Temporary
Vasoconstrictions

Heat (Calor)
Vasodilatation Increase Blood
flow
Redness (Rubor)

Increase Plasma Leak into

Permeability Swelling (Tumor)
the affected part

LOSS OF Increase Nerve

Pain (Dolor)
FUNCTION Pressure
Histamine Causes vascular dilatation and the immediate transient phase
of increased vascular permeability

stored in mast cells, basophil and eosinophil leukocytes, and

platelets

Lysosomal released from neutrophils

compounds
increase vascular permeability
Prostaglandins a group of long-chain fatty acids derived from arachidonic acid and
synthesized by many cell types

prostaglandins potentiate the increase in vascular permeability

Leukotrienes synthesized from arachidonic acid, especially in neutrophils, and
appear to have vasoactive properties

a mixture of leukotrienes is involved in type I hypersensitivity

5-hydroxytryptamine a potent vasoconstrictor
(serotonin)
present in high concentration in mast cells and platelets

Lymphokines family of chemical messengers released by Iymphocytes

Plasma Factors
Complement system
 cascade system of enzymatic proteins activated during
inflammatory response
Coagulation system
 responsible for the conversion of soluble fibrinogen into
fibrin
 activate the coagulation, kinin and fibrinolytic systems
Kinin system (stimulates pain receptors)
 activated by coagulation factor
 Bradykinin is also a chemical mediator of pain
Fibrinolytic system
 Plasmin is responsible for the Iysis of fibrin into fibrin
degradation products
Complement System
Circulating Plasma proteins made in the liver
Activated when Antigen-antibody connects
It coats microbes with molecules that make them more
susceptible to engulfment by phagocytes
They also encourage polys to adhere to the walls of
capillaries (margination) from which they can squeeze
through in a matter of minutes to arrive at a damaged area
Emigration by squeezing of the wandering macrophages
through the capillary walls to the tissue
Extravasation also know as diapedesis
Once phagocytes do their job, they die and their
"corpses," pockets of damaged tissue, and fluid form pus.
 Immunity

Acquired

Passive Active

Natural Artificial Natural Artificial

Types of Acquired Immunity
Acquired Active Immunity (exposure)
The immunologic defenses are developed by the
person’s own body in response to the presence of
antigens.
Immunity last many years or even lifetime.
Acquired Passive Immunity (transferred)
A temporary immunity transmitted from another
source that has developed immunity.
Acquired Active
Naturally Acquired Active
Exposure to different pathogens leads to infections,
which result in a protective immune response against
these pathogens.
Artificially Acquired Active
Vaccine used for active immunization consist of live
(attenuated) organism, killed whole organism,
microbial components or secreted toxin.
Acquired Passive
Naturally Acquired Passive
Immunity is transferred form mother to fetus through
placental transfer of IgG or colostral transfer of IgA.
Artificially Acquired Passive
Artificially transferred by injection of gamma globulins
from other individual or gamma globulins from an
immune animal.
•Phagocytic
•Humoral
•Cellular
•Stages of Immune Response
•Recognition
•Proliferation
•Response
•Effector
Phagocytosis
Involves WBC and Macrophages
Has the ability to ingest foreign matter
They also responsible for removing body’s dead cell
 Cell in the necrotic tissue release a substance that cause
inflamatory response
Apoptisis – programmed “death cell”

Main Menu
•Antigen Recognition
•Antigen – Antibody Binding
Antigen Recognition
The mechanism by which the B –lymphocytes
recognize the invading antigen and respond by
producing antibodies.
Role of Antibodies
 Defend against foreign invaders
in several ways.
 Agglutination – bind or
clumping together of antigen
and antibody that helps clear
the body of the invading
organism by facilitating
phagocytosis.
 Opsonization – coating sticky
substances that facilitates
phagocytosis.
 Each antibody molecule consist
of two subunits, each of which
contains a light and a heavy
peptide chain.
Antigen – Antibody Binding
Antigenic Determinant
The portion of the
antigen involve in
binding with the
antibody.
Lock-and-key situation
The binding of the Fab
fragment (antibody-
binding site) to the
antigenic determinant.
•Role of T - Lymphocytes
•Role of Null Lymphocytes and Natural Killer (NK) Cells
Cell – Mediated Immunity
CD - stands for Cluster of Differentiation (CD8+ is read
"CD8 positive)
The large number of molecules on the surfaces of
lymphocytes allows huge variability in the forms of the
receptors
They are produced with random configurations on their
surfaces
I. Recognition Stage
II. Proliferation Stage
III. Response Stage
IV. Effector Stage
I. Recognition Stage
Recognize invaders as
foreign
Presentation to the
macrophages
Macrophages plays an
important role in
processing the antigen
II. Proliferation Stage
The dormant lymphocytes proliferate and
differentiate into cytotoxic (killer) T – Cells or B –
Cells responsible for formation and release of
antibodies
III. Response Stage
The cytotoxic T – cell and the B – Cell perform
cellular and humoral function respectively.
IV. Effector Stage
Antigens are destroyed or neutralized through the
action of antibodies, complement, macrophages and
cytotoxic T – Cells.
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•History
•Physical Assessment
HISTORY
Age
Life style
Nutrition
Recent exposure to pathogen
Drug intake
immunization
History of immune disorder
Respiratory
Changes in respiratory rate
Cough (dry or productive)
Abnormal lung sounds
Rhinitis
Hyperventilation
Bronchospasm
Cardiovascular
Hypotension
Tachycardia
Dysrhytmia
Vasculitis
Anemia
Genitourinary
Frequency and burning on urination
Hematuria
Discharge
Gastrointestinal
Hepatosplenomegally
Colitis
Vomiting
Diarrhea
Skin
Rashes
Lesion
Dermatitis
Hematoma or purpura
Edema or urticaria
Inflammation
Discharge
Neurosensory
Cognitive dysfunction
Hearing loss
Visual design
Headaches and migraine
Ataxia
Tetany

Main Menu
•Leukocyte and Lymphocyte Tests
•Humoral (Antibody – Mediated) Immunity Test
•Cellular (Cell – Mediated) Immunity Test
•Phagocytic Cell Function Test
•Complement Component Test
•Hypersensitivity Test
•HIV Infection Test
Overview
Caused by an oversensitive immune system
An allergic reaction is when the immune system
reacts to substances (allergens) that are generally
harmless and in most people do not cause an immune
response.
In a person with allergies, the first exposure to the
allergen triggers the immune system to recognize the
substance.
Succeeding exposure will usually result in symptoms.
When an allergen enters the body of a person with a
sensitized immune system, histamine and other
chemicals are released by certain cells.
This causes itching, swelling, mucus production,
muscle spasms, hives, rashes, and other
symptoms.
Symptoms vary in severity from person to person.
Some disorders may be associated with allergies.
These include eczema and asthma, among
others.
Common allergens include those that contact
the skin, breathing passages, or the surface of the
eye (such as pollen; see also allergy to mold,
dander, dust).
Food allergies and drug allergies are common.
Allergic reactions can be caused by insect bites,
jewelry, cosmetics, and almost any substance that
contacts the body.
Signs & Symptoms
runny nose wheezing
tearing eyes, burning or coughing
itching eyes difficulty breathing
red eyes, conjunctivitis hives (skin wheals)
swollen eyes skin rashes
itching nose, mouth, stomach cramps
throat, skin, or any other vomiting
area
diarrhea
headache
Prevention
Children who have been breastfed are less likely
to have allergies.
There is also evidence that infants exposed to
certain airborne allergens (such as dust mites
and cat dander) may be less likely to develop
related allergies.
Once allergies have developed, treating the
allergies and carefully avoiding those things
that cause reactions can prevent allergies in the
future.
HYPERSENSITIVITY REACTIONS
Are immune responses to allergens that result in tissue
destruction
Type I (ANAPHYLACTIC) reactions. Anaphylaxis is an
acute, life-threatening allergic reaction marked by rapidly
progressive urticaria & respiratory distress which may
result in anaphylactic shock.
ETIOLOGY. Results from ingesting or systemic exposure
to allergenic substances (drugs, foods, insect-venom)
PATHOPHYSIOLOGY
Exposure to allergen

Production of IgE binds to mast cells & basophils

Reexposure IgE reacts immediately to the allergen

Release of potent chemicals mediators (histamine, ECF-A)

Ig G or IgM releases 2 other chemical mediators (bradykinin

& leukotrienes)
Profound vascular changes
Vascular collapse ANAPHYLACTIC SHOCK
ASSESSMENT FINDINGS
LOCAL EFFECTS – wheals with surrounding red
flares & urticaria
SYSTEMIC MANIFESTATIONS.
Intense urticaria and edema at the site of injection
rapidly spreading in the face, hands and other
body areas
Respiratory distress from bonchospasm, coughing,
sneezing or wheezing
Arrhythmias, tachycardia, or bradycardia,
hypotension & signs of circulatory collapse
NURSING MANAGEMENT
Establish patent airway
Administer epinephrine, IM or SQ to constrict
blood vessels, raise RR, improve myocardial
contractility
Establish patent IV line for fluid administration
Oxygen therapy
Administer prescribed medications (anti-
histamine, bronchodilators, vasopressors,
corticosteroids)
Teach preventive measures
Maintain safety precautions
Type II (CYTOTOXIC) reactions – are mediated
by Ig G and IgM, which attach to cells (usually
circulating blood elements) and cause cell lysis.
Ex. Hemolytic anemia
Type III (IMMUNE COMPLEX) reaction – are
mediated by antigen-antibody complexes that
deposit in the lining of blood vessels or on tissue
surfaces ex. Rheumatoid arthritis, serum sickness
Type IV (DELAYED HYPERSENSITIVITY)
reactions – are mediated by lymphokines released
from sensitized lymphocytes
AIDS
Acquired immunodeficiency syndrome
Collection of symptoms and infections resulting
from the specific damage to the immune system
caused by infection with the human
immunodeficiency virus (HIV) which allows
normally benign organisms to flourish and cause
disease.
The virus causes cell death and a decline in
immune function resulting in opportunistic
infections, malignancies & neurologic problems
Anatomy of the HIV Virus
 Gp120 Envelope Protein
Gp41 Envelope Protein
P17 matrix protein

 P24 Capsule Protein

 Reverse Transcriptase

 The Lipid Membrane

Anatomy of the HIV Virus
 HIV – Human Immuno Virus
 AIDS
 CD4 count is <200
 Acquired Immunodeficiency Syndrome
 Most severe form of continuum of illness associated with
HIV
 Targets the CD4 helper T cells
 Leaves the client at risk for the development of numerous
opportunistic infections
 Infectious agent is the retrovirus
 RNA (ribonucleic acid) virus which have the reverse transcriptase
 THERE IS NO CURE
Etiology
Risk factor
Unprotected vaginal, anal. Or oral intercourse
IV drug used with contaminated needles
HIV infected mother to child in utero (Vertical
Transmission)
Contaminated needle stick
Blood and blood product recipient
Semen used for AI (artificial insemination)
 HIV (Retrovirus)
Carries genetic information as RNA

Attach to surface antigen (CD4)

Transmits genetic information into the human cell

Primary cells affected are the Helper T – cells

Direct infiltration into the CNS

HIV RNA enters the cell, reverse transcriptase converts RNA

to DNA (deoxyribonucleic acid) material

As DNA, the virus is able to replicate as the cell replicate

Rapid cell destruction & proliferation can occur

Virus can lie dormant for approx. 10 years
Stages of HIV disease
Primary Infection (Acute HIV)
Period from infections with HIV to the development of
antibodies to HIV
Viremia stage
 Severe-flu like symptoms
 Window period
 Test negative with HIV antibody test

 Viral set point

 Balance between HIV and immune response
HIV asymptomatic
CD4 is > 500
Feeling well
HIV symptomatic
CD4 is 200-499
 Gradual falling of CD4
AIDS
Symptoms
Flu-like symptoms

No symptoms (asymptomatic)

Fever, Fatigue, Diarrhea, Skin Rashes, Night

Sweats, Loss of appetite, lymphadenopathy
(enlarge lymph nodes)
Opportunistic Infections
 Pneumocystis Carinii Pneumonia
 Cryptococcal Meningitis
 Toxoplasmosis
 Candidiasis
 Histoplasmosis
 Cytomegaloviris infection
 Tuberculosis
 Kaposis sarcoma, an AIDS related lymphoma
 Neurologic deficit (AIDS dementia) characterized by behavioral,
cognitive and motor deterioration
 Problems with other organs; lungs, liver, kidneys, intestines, and
heart.
LABORATORY AND DIAGNOSTIC
STUDY
ELIZA (enzyme linked immunosorbent assay) Diagnostics.
 Identifies antibodies directed specifically against HIV.
Western Blot Assay
 To confirm HIV antibodies
Viral Load
 Measures HIV RNA in the plasma
 Better predictor of the risk of HIV progression than CD4
CD4 count, CD4/CD8 ratio
 Significantly lowering of CD4 over CD8
Ora Quick Rapid HIV – 1 Antibody Test
 Detects antibodies to HIV – 1
Complications:
HIV Encephalopathy
 AIDS dementia complex
 Progressive decline in cognitive, behavioral, and motor

functions
Wasting syndrome
 Profound involuntary wt loss exceeding 10% of baseline body
weight.
 Either there’s a presence of chronic diarrhea for more than 30

days or chronic weakness with documented fever

Cachexia
Kaposi’s Sarcoma
tumor caused by Human herpesvirus 8 (HHV8)
KS lesions are nodules or blotches that may be
red, purple, brown, or black, and are usually
papular (ie palpable or raised).
Can lead to venous stasis, lymphedema (fluid
retention)
Skin lesion increase discomfort and infection
Death may result from tumor progression
NURSING MANAGEMENT
Administer prescribed medications
- Includes antibiotics for HIV-related infections,
antiretroviral therapy, antidiarrheals and antiemetics
Promote preventive measures related to the
transmission of HIV
 Promote public education regarding HIV & AIDS
(teach clients & families to practice safe sex, avoid
sharing needles, avoid touching another’s body fluid
without protection)
Maintain skin integrity
 Instruct the client to avoid scratching, strong
perfumed soaps and adhesive tapes
NURSING MANAGEMENT
Help maintain nutritional status
- By controlling nausea & vomiting
- Encourage foods that are easy to swallow
- Encouraging oral hygiene before and after meals
- Promoting a high-protein, high-calorie diet
- Monitoring weight, intake & output
- Monitoring fluid & electrolyte balance
- Administering appetite stimulants

Teach ways to cope with chronic illness to the

client & significant others.
NURSING MANAGEMENT
Promote infection prevention
- Discuss importance of personal hygiene, keeping
bathrooms and kitchens clean
- Avoid exposure to individuals who are sick, avoiding
smoking and alcohol
- Adequate rest, activity and a well-balanced diet
Discuss ways the client and family can assist with
mental status problems.
 These includes putting notes on note boards, using
calendar and clocks to orient the client to time & place.
Terminologies
Infection
The invasion and multiplication of microorganism in
the body tissue that result in cellular injury.

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Terminologies cont’d
Microorganism
 Infectious agent
Pathogen
 Microorganism that causes a disease
Pathogenicity
 The ability of the microorganism to produce a disease
Virulence
 The degree of pathogenicity
Sepsis
 The state of infection
Asepsis
 The freedom from disease – causing microorganism

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Infectious Agent
Reservoir
Portal of Exit from Reservoir
Mode of Transmission
Portal of Entry to the Susceptible Host
Susceptible Host

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