1. NURS 1228
Nursing Management of
Patients Experiencing an
Altered Immune System
Kathy Sims, MS, RN

2. Inflammatory Response
• Microorganisms invade
Vas
damaged tissue
Basophils release histamine and kinin
production occurs
Vasodilation occurs along with
increased capillary permeability
Blood flow increases to the affected
tissue, and fluid collects within it
Neutrophils and monocytes flock to
the invasion site to engulf and destroy
microorganisms
Tissue repair occurs

3. Inflammatory Response
Microorganisms invade
damaged tissue
Basophils release histamine and kinin
production occurs
Vasodilation occurs along with increased
capillary permeability
Blood flow increases to the affected
tissue, and fluid collects within it
VASCULAR RESPONSE

4. Inflammatory Response
Neutrophils and monocytes flock to the
invasion site to engulf and destroy
microorganisms
Lymphocytes arrive later. Primary
role is related to humoral and cell-
mediated immunity
Tissue repair occurs
CELLULAR RESPONSE

5. Inflammatory Response
Cellular Response
• 5 types of white blood cells
– Neutrophils
– Eosinophils
– Basophils
– Lymphocytes
– Monocytes
• Elevated WBC = leukocytosis
• Decreased WBC = leukopenia
• Fig 13-2 Lewis, Malarky pg 680

6. Neutrophils
First to arrive on scene – 6-12 hrs
Phagocytize bacteria, foreign material and damaged cells
They live for about 24-48hrs and then begin to
accumulate as dead material/pus
To keep up with severe assault, bone marrow releases
immature neutrophils (bands)
This increase in bands is called shift to the left – s/s
acute bacterial infections
WBC Differential shows “bands”
Elevated with bacterial infections, inflammatory diseases
and tissue necrosis
Decreased when supply is exhausted, bone marrow
damage

8. Monocytes & Lymphocytes
2nd type phagocytic cells – 3-5 days after injury
When they get there, they change to
macrophages and continue phagocytosis
Live for weeks
Lymphocytes arrive following monocytes and
their primary role is related to humoral and
cell-mediated immunity (B&T cells)
Elevated with acute infections, leukemia
Decreased with advanced cancer, deficiency
related disorders (HIV)

9. Eosinophils and Basophils
Eosinophils & Basophils are released in large
quantities during an allergic reaction
◦ They work together to mediate the effects of histamine
and serotonin
◦ They are involved with phagocytosis of allergen-
antibody complexes, and destruction of parasite cell
surfaces so antibodies can attack
◦ Elevated during the healing phase of inflammation, food
hypersensitivity, following radiation therapy and
leukemia disorders
◦ Decreased values during acute infection,
hyperthyroidism and stress

10. Chemical Mediators
• Complement system
– Occur in sequential order C1-C9
– Major function
• Enhanced phagocytosis
• Increased vascular permeability
• Chemotaxis
• Cellular lysis

11. Chemical Mediators
Prostaglandins & Leukotrines
• Stimulated by chemical mediators and
phagocytosis
– In general are pro-inflammatory – increased blood
flow, decrease platelet clumping
– NSAID medication inhibit PG synthesis
• Useful in chronic inflammatory conditions to decrease pain
& inflammation
– Corticosteroids inhibit PG’s & leukotrines
• Useful in inflammatory airway diseases because they
prevent bronchoconstriction 2nd to inflammation

12. REVIEW S/S INFECTION
• Local or Systemic S/S Infection?
• Fever______
• Edema_______
• Pain or Tenderness______
• Malaise______
• Warmth of Area ________
• Increased Pulse and Resp Rate_______

13. Normal Immune Response
Immunity is a state of responsiveness to foreign
substances such as foreign bodies and tumor
proteins (antigen)
• Serves three functions
1. Defense
2. Homeostasis
3. Surveillance

14. Classifications of Immunity
 Innate ( Natural ) – exists in a person without
prior contact to the antigen (born with)
◦ Nonspecific defense response by neutrophils and
monocytes
 Active Acquired – results from invasion and
development of specific antibodies and
sensitized lymphocytes
◦ With each following attack, the body responds
more vigorously
◦ Ex. Following inoculation or disease
 Passive Acquired – host receives antibodies to
the antigen rather than synthesizing them
◦ Short lived, host cells do not retain memory

15. Components of the Immune Response
• Antigens
– Elicits an immune
response
– Composed of proteins
– Unique to that person
– “Tolerant” to it’s own
molecules (except in
autoimmune disease)

16. Lymphoid System
• Central (primary) lymph organs – bone
marrow and thymus gland
– Lymphocytes are produced in bone marrow
– Thymus gland differentiates them into B & T
• Peripheral lymph organs are in the
submucosa of the respiratory, gentiourinary
and gastrointestinal tracts and the skin (ex.
skin reactions)
– Protects from external organisms (ex. Tonsils)

17. Lymphoid System
Peripheral (con’t)
Lymph Nodes
1) filtration of foreign material brought to the site
from the bloodstream into the lymph system
2) circulation of lymphocytes throughout the
body
Spleen is primary site for filtering foreign
substances and is the major site of immune
responses to blood-borne antigens

18. Lymphoid
Organs

19. Cell Involved in Immune Response
• Mononuclear Phagocytes
– Responsible for capturing, processing, and
presenting the antigen to the lymphocyte
– Present within 3-7 days of exposure
– Stimulation of humoral or cell- mediated
response
– Capturing accomplished through
phagocytosis

20. Cells Involved in Immune Response
• Lymphocytes
– B lymphocytes
– T lymphocytes
• T cytotoxic cells
• T helper and T suppressor cells
– Natural killer cells
– Dendritic Cells

21. Cytokines
• Soluble factors secreted by WBC’s and a
variety of other cells in the body
• Acts as messengers between the cell types
• Instructs cells to alter their function
• 100 different cytokines
– Interleukins
– Interferons
– Tumor Necrosis Factor
– Colony-Stimulating Factors
– Erythropoietin

22. Comparison of Humoral and Cell
Mediated Immunity
• Humans need BOTH humoral and cell-mediated
immunity to remain healthy.
• Humoral immunity – based on the development
of antibodies to antigens (produced by
differentiated B Cells)
• Cell mediated – initiated through specific
antigen recognition by T cells

23. Comparison
• Humoral • Cell Mediated
– Antibody (B lymphocytes)
– T cell recognition
mediated immunity
immunity
– Produced in the Plasma
– Primary importance in
cells
• Pathogens inside
– Primary Response noted
the cells
in 4-8 days after the
exposure • Fungal infections
– Subsequent exposure • Rejection of
results in faster transplanted tissues
responses, due to • Contact
memory cells hypersensitivity
reactions
• Tumor immunity

24. Effects Across
the lifespan
• Hypo function in the young and old
• Older populations more susceptible to infections
– Bone marrow is not affected (so no big change in
RBC, etc. )
– Decreased WBC response, even with infection
– Thymus decreases in size and activity
• T cells
• B cells

25. Effects Across
the lifespan
Infants receive passive immunity from mother in
form of IgG near end of gestation
Eventually produce antibodies (active acquired
immunity) beginning at about 3 months of age
Breastfed infants receive antibodies from breast
milk, protected from many infectious diseases
including influenza, measles, mumps, and
chickenpox

26. Patients with Altered Immune
Systems
Primarily an issue of lymphocyte response to conditions
triggering the inflammatory response
◦ Acute infections & inflammatory conditions
 Anaphylatic reactions
 Exposure to new antigens & development of immunity
◦ Chronic inflammatory conditions
 Long-term immunity
 Chronic diseases such as asthma, COPD, chronic allergies
(including latex, seasonal), autoimmune diseases such as
lupus or secondary immunodeficiency disorders

27. Altered Immune Response
• Hypersensitivity Reactions
– Immune response is over-
reactive against foreign
antigens or fails to maintain
self-tolerance resulting in
tissue damage
– There are four categories

28. Types of Hypersensitivity Reactions
Type I Anaphylactic
Type II Cytotoxic
Type III Immune-complex
Type IV Delayed Hypersensitivity

29. Mediators of Allergic Response
• Histamine
• Leukotrienes
• Prostaglandins
• Platelet-Activating
Factor
• Kinins
• Serotonin
• Anaphylatoxins

30. Anaphylactic Shock – Type 1

32. Nursing Assessment
• Past medical history
• Current medications
• Family history
• External manifestations
• Other objective data

33. Clinical Manifestations
Depend on local vs systemic access
Local – wheal and flare at application or bite
site, edema and itching at site of exposure
Systemic – local reaction + s/s shock
◦ Rapid weak pulse
◦ Hypotension
◦ Dilated pupils
◦ Bronchial edema = bronchoconstriction = dyspnea
and cyanosis

34. Anaphylactic Shock
• Find out the causative factor
• Insure patent airway
• Epinephrine SQ/IV
• Administer high flow O2
• Recumbent position with legs elevated
• Keep warm
• Administer H1 blocker (Benadryl)
• Administer H2 blocker (Tagamet)
• Maintain blood pressure
– Fluids
– Vasopressors (Dopamine)
– Norepinephrine bitartrate (Levophed)

35. Atopic Reactions
• 20% pop – inherited sensitivity to
environmental allergens
– Allergic rhinitis, asthma, atopic dermatitis, uticaria
and angioedmea
• Review s/s of each

36. Type II Cytotoxic/Cycolytic Reactions
• Cellular tissue is destroyed by activation of the
complement system – causes mass
phagocytosis and cytolysis
• Target cells are usually erythrocytes, platelets
and leukocytes
• EX: Blood incompatibilities, Rh factor and drug
reactions

37. Type III: Immune-Complex Reactions
• Tissue damage secondary to antigen-antibody
complexes that are too small to be effectively
removed by phagocytosis and deposit
themselves in the tissue and small vessels
• Associated with diseases such as SLE (lupus),
acute glomerulonephritis and rheumatoid
arthritis

38. Type IV: Delayed Hypersensitivity
Reactions
• Cell mediated response where sensitized T
lymphocytes attack antigens and release large
amounts of cytokines which attract
macrophages to the area
• Takes 24-48 hours for a response to occur
• Ex. Contact dermatitis, transplant reactions
and some drug reactions (topical usually)

39. Latex Allergy – 2 types anaphylactic
and type 4 delayed hypersensitivity
Identification is crucial
Risk factors
◦ Long-term multiple
exposures
◦ History of: Hay fever,
Asthma, and certain food
allergies (avocados, guava,
kiwi, bananas, water
chestnuts, hazelnuts,
tomatoes, potatoes,
peaches, grapes, apricots)

40. Teaching to prevent latex allergy
• Use non latex gloves whenever possible
• Use powder free gloves
• DO NOT use oil based creams or lotions in
association with glove use
• Know symptoms
• Wear medi-alert bracelet & carry epi pen
• Avoid latex equipment with pts with chronic
illnesses – especially children

42. General Assessment for Allergic
Disorders
• Comprehensive health history
– Individual and family
– Environmental factors
– THINK PQRST
– Weekly food/med diary
– Level of stress & lifestyle
• Comprehensive physical exam
• Review table 14-2

43. Diagnostic Exams

44. Diagnostic Tests
• CBC with WBC differential – why?
• What about B & T cell counts?
• What does an elevated eosinophil level tell you?
• RAST test – what is the purpose?
• Sputum, bronchial secretions and nasal swabs
may be done to look for eosinophils – looking for
allergies
• If asthma – PFT testing

45. Skin testing
• Used to confirm specific sensitivity in patients
with atopic disease (a type 1 reaction)
• Cannot be performed on patients who are
medications to suppress the immune system
• Done by scratch method or intracutanous
injection with control site
• + reaction will occur in min and last 8-12hrs
• + reaction is wheal and flare response – size does
not correlate with severity
• Always an anaphylactic risk – pt should never be
left alone, anti-inflammatory cream may be used
– prepared with tourniquet and epinephrine

46. Nursing Teaching for Chronic
Allergens
• Allergen recognition and control
• Lifestyle adjustments
• Elimination diet
• Avoidance of stress
• Environmental allergens – air conditioned
room, damp dusting daily, hypoallergenic
covers, mask outdoors
• Communicate drug allergies
• Insect – carry kits with epi & bracelet

47. Drug Therapy
• Antihistamines
– Take when s/s appear – usually short term
• Sympathomimetic/Decongestants
– Review differences – relaxation of bronchial muscles, short term
• Corticosteroids
– Nasal sprays – no more than 3 days or 3 times a day
• Anitprurtics
– Non-broken skin, short-term use
• Mast cell stabilizing drug
– Inhibit immune response, used long-term, low side effects
• Leukotriene
– Used long-term, take same dose daily for effect
– Ex: Singulair

48. Immunotherapy
• Recommended for control of
allergic symptoms, when the
allergen can not be avoided or
tx ineffective
• Small titers given to develop
immunity
• Useful if allergic to insects, not
for food or ezcema allergies
• Must be observed for a
minimum of 20 minutes for
anaphylactic response – done
in an area with ER equipment

49. Autoimmunity Conditions
• Inappropriate reaction to self proteins
• Causative factors
– Age?
– Genetic Susceptibility
– Initiation of Auto-reactivity
• Virus
• Medication
• Hormonal

50. Treatment
• Apheresis
– Use of a procedure to
separate the
components of the
blood followed by the
removal of one or more
of the components
– Complications can
include hypotension and
citrate toxicity- causes
hypocalcemia

51. Examples of Autoimmune Diseases
• Lupus • Addison’s disease
• Rheumatoid Arthritis • Type I Diabetes Mellitus
• Autoimmune Hemolytic • Ulcerative Colitis
Anemia
• Goodpasture syndrome
• Multiple Sclerosis
• Guillain-Barre syndrome • Autoimmune Hepatitis
• Myasthenia Gravis
• Table 14-16

52. Immunodeficiency disorders
• Definition- the immune system does not
adequately protect the body
• Involves impairment of one or more immune
mechanisms
• Can be primary or secondary disorders
• Patients are at HIGH RISK for infection
– NDX-Ineffective Protection

53. Primary Immunodeficiency
• Primary- immune cells are improperly
developed or absent. Involves phagocytic
defects, B cell, T cell deficiencies, or combined
B and T cell deficiencies. Primary disorders
are rare and often serious

54. Secondary Immunodeficiency
• Most common is Drug • Surgery
induced immunodeficiency • Anesthesia
– Chemotherapy • Burns
– Corticosteroids
• Disease Processes
• Stress – AIDS
• Age – Alcoholic Cirrhosis
– Infants – Chronic Renal Disease
– Older Adults – Diabetes Mellitus
• Malnutrition – Cancer
• Radiation – Systemic Lupus
Erythematous

55. Graft-versus-Host Disease
Occurs when an immunoincompetent patient is
transfused or transplanted with
immunoincompetent cells
Response may result from the infusion of blood
products containing viable lymphocytes
In most transplant cases, there is a concern for
the Host to reject the Graft, in Graft versus Host
it is reversed

56. GVH Disease
• Response in 7-30 days • Target organs
• Once the reaction starts – Skin
there is little that can be – GI tract
done – Liver
• Mechanism not completely • There is no adequate
understood, it is thought treatment
that the donor T cells are – Corticosteroids
attacking the and – Immunosuppressive agents
destroying the host cells – Radiation of blood
products

57. Immunosuppressive Therapy
• Goal is to adequately
suppress the immune
response to prevent
rejection of the
transplanted organ
while maintaining
sufficient immunity to
prevent an
overwhelming infection
• Aseptic technique and
infection prevention is a
priority

58. Nursing Diagnosis
• Risk for Infection
• Ineffective Protection
• Pain
• Hyperthermia
• Fatigue
• When do you use which one?
• What are the r/t?
• What are the AMB?

59. Nursing Interventions
• Aseptic technique is a priority
• Handle and collect specimens appropriately
• Patient will be on reverse isolation
• Limit visitors
• Teach about decreasing stress
• Avoid public areas, if possible
• Teach about proper diet
• Teach about proper hygienic practices
• Refer to community resources
• Do you remember the different types of
precautions? (Airborne, Contact etc.)?

60. Associated diagnostic tests – Lewis
page 677-683
• RBC, HGB & HCT
• ESR
• Lymph Node Assessment
• Lymph Node Biopsy
• Bone Marrow
• CT, PET & MRI scans

61. REVIEW
• Which type of WBC are the first cells to
respond to a bacterial infection? _____
• Which type of WBC responds primarily to
viral infections (may be elevated with mono
or TB which are bacterial)?_____
• Which type of WBC are elevated with
allergic reactions?________________
• What happens to a patient’s ESR level when
there is an active inflammatory process or
infection? ____________

62. Questions?
• Do questions at end of chapter
• Review main bullets of reading
• Focus on nursing care/teaching
• ATI Med Surg BookUnit 13 Chapter 98
• Review notes from 1117 class on Infection