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Normal Presentation of the Immune System

Immunity - state of responsiveness to foreign substances such as microorganisms, and tumor proteins
Immune response
Defense - prevents the development of infection by attacking foreign antigens and pathogens
-Removes and destroys damaged or dead cells
-Identifies and destroys malignant cells, preventing tumor formation

Immune response functions

is the body's ability to resist disease. Immune responses serve the following three functions:
1.Defense: The body protects against invasions by microorganisms and prevents the development of infection by attacking foreign antigens and pathogens.
2.Homeostasis: Damaged cellular substances are digested and removed. Through this mechanism, the body's different cell types remain uniform and unchanged.
3.Surveillance: Mutations continually arise in the body but are normally recognized as foreign cells and destroyed.

Types of Immunity

Innate
exists without prior contact with an antigen; involves no specific response; neutrophils and monocytes
Ex: humans are naturally immune to some infectious agents that cause illness in other species
Active Acquired Immunity
-Natural - contact with antigen via infection
-Artificial - immunizations
Passive acquired immunity
-Natural - transfer from mother to child
-Artificial - injection of Human globulin serum

antigen

is a substance that elicits an immune response.
-All of the body's cells have antigens on their surface that are unique to that person and enable the body to recognize itself. -The immune system normally becomes "tolerant" to the body's own molecules.
-Therefore it is nonresponsive to "self" antigens.
-it is captured, processed, and presented to a lymphocyte by a macrophage

central lymphoid organs

are the thymus gland and bone marrow.

peripheral lymphoid organs

are the lymph nodes; tonsils; spleen; and gut, genital, bronchial, and skin associated lymphoid tissues
-The spleen is important as the primary site for filtering foreign antigens from the blood; major sit of immune responses to blood borne antigens

Lymphocytes

are produced in the bone marrow and eventually migrate to the peripheral organs.
-The thymus is involved in the differentiation and maturation of T lymphocytes and is therefore essential for a cell-mediated immune response.

functions of lymph nodes

(1) filtration of foreign material brought to the site
(2) circulation of lymphocytes.

Health Impact of Immunization

• Can help control the spread of infections within communities.
• Can prevent disability and death from infectious disease for individuals.
• Reduces and can possibly eliminate polio, measles, and other diseases with widespread use.
• Decreased incidence of infectious diseases (e.g., influenza, pneumonia) when more people are vaccinated against these diseases.

mononuclear phagocyte system

-monocytes in the blood and macrophages found throughout the body
-They are responsible for capturing, processing, and presenting the antigen to the lymphocytes. This stimulates a humoral or cell-mediated immune response.

B lymphocytes

produced in the bone marrow; differentiate into plasma calls that produce antibodies (immunoglobulins)

T lymphocytes

responsible for immunity to intracellular viruses; tumor cells and fungi
-Cells that migrate from the bone marrow to the thymus differentiate into T lymphocytes
-live from a few months to the life span of an individual and account for long-term immunity.
can be categorized into T cytotoxic and T helper cells

T cytotoxic (CD8) cells

are involved in the direct attack of antigens on the cell membrane of foreign pathogens and releasing cytolytic substances that destroy the pathogen.
- These cells have antigen specificity and are sensitized by exposure to the antigen.
- like B lymphocytes, some do not attack the antigen but remain as memory T cells.
- As in the humoral immune response, a second exposure to the antigen results in a more intense and rapid cell-mediated immune response.

T helper (CD4) cells

are involved in the regulation of cell-mediated immunity and the humoral antibody response

Cells and tissues of the Immune System

-Leukocytes ( WBC) are primary cells involved in immune response
-Leukocytes are produced in the bone marrow and travel via the circulation to the site of injury
Normal number of WBC 4500-10,000
-In the presence of inflammation or infection large numbers of WBC's are released ( leukocytosis).
-Patients with active bacterial infections often manifest elevated leukocytes with a shift to the left which means there is an elevated level of immature white blood cells present.
-A decrease in WBC ( leukopenia) may occur when bone marrow activity is suppressed or cell destruction is increased - person at great risk for developing infections

Major Types of Leukocytes

Neutrophils - 55-70% of leukocytes; carry on phagocytosis; segmented (segs) are mature; Bands are immature. Patients with active bacterial infections often manifest increased bands causing a shift to the left
Eosinophils -1-4% of leukocytes; phagocytosis, protection from parasites and increase with allergic response
Basophils - 0.5-1% of leukocytes; not phagocytic; contain heparin, histamine, serotonin; released into the bloodstream during an acute hypersensitivity or stress response.

T helper cells

Mature in the thymus gland and are located in the circulation, lymph system and tissues; control viral infections, destroy cancer cells, involved in hypersensitivity reactions and graft tissue rejection

B Cells

Mature in the bone marrow; located in the circulation and spleen; involved in the production of antibodies to specific antigens

Natural Killer (NK) cells

found in the spleen, lymph nodes, bone marrow and in the circulation to kill tumor cells, viruses and fungi and foreign tissue
-involved in cell mediated immunity not considered T lymphocytes

Cytokines

-Factors secreted by WBC's that act as messengers between cell types
-Instruct various cells to alter their proliferation, differentiation, secretion or activity
-Play a beneficial role in hematopoiesis and immune function
-They can also have detrimental effects such as those seen in chronic inflammation, autoimmune diseases and sepsis
(helps the body maintain homeostasis)

Effects of Aging on the Immune System

-Decline in immune system (thymus decreases in size and activity)
-High incidence of tumors
-Increased susceptibility to infections
-autoantibodies increase = factor in autoimmune diseases
-B cell activity declines, bone marrow is rarely effected
-Diminished reaction to an antigen
-Decline in T cells and cell mediated immunity = decreased tumor surveillance
*more susceptible to infections (e.g., influenza, pneumonia) from pathogens that they were relatively immunocompetent against earlier in life.
-Bacterial pneumonia is the leading cause of death from infections.
-The antibody response to immunizations (e.g., flu vaccine) is considerably lower
-Immunoglobulin levels decrease with age and therefore lead to a suppressed humoral immune response

Hypersensitivity Reactions

- immune response is over-reactive against foreign antigens or reacts against its own tissue, resulting in tissue damage
-These diseases are called autoimmune diseases (occur when the body fails to recognize self-proteins and reacts against self-antigens.)
Examples: Rheumatoid Arthritis, Systemic Lupus Erythematosus (SLE), Hashimoto's Thyroiditis, Ulcerative colitis, Scleroderma
-Types I, II, and III are immediate and are examples of humoral immunity. Type IV is a delayed hypersensitivity reaction and is related to cell-mediated immunity.

Type I: IgE-Mediated Reactions.

-Anaphylactic reactions are reactions that occur only in susceptible people who are highly sensitized to specific allergens.
- IgE antibodies, produced in response to the allergen, have a characteristic property of attaching to mast cells and basophils
- EX: localized, a cutaneous response termed the wheal-and-flare reaction occurs.
- characterized by a pale wheal containing edematous fluid surrounded by a red flare from the hyperemia.

Anaphylaxis

- mediators released systemically (e.g., after injection of a drug, after an insect sting).
-Reaction occurs within minutes and can be life threatening because of bronchial constriction, airway constriction and vascular collapse. Initial symptoms include edema and itching at the site of exposure
-Shock can result rapidly - rapid, weak pulse, Hypotension, dilated pupils, dyspnea and cyanosis, feeling of impending doom
-compounded by bronchial edema and angioedema. Death will occur if emergency treatment is not initiated

Common Allergens Causing Anaphylactic Shock

Drugs - antibiotics, insulins, chemotherapeutic drugs. Aspirin. Nonsteroidal antiinflammatory drugs
Insect venoms
Foods - eggs, nuts, shellfish. Chocolate, milk, fish strawberries
Animal serums - tetanus, diphtheria, rabies, snake venom antitoxin
Treatment measures - blood products, iodine contrast media, allergenic extracts

Anaphylaxis - Management

The cardinal Principles in therapeutic management:
-Recognition of signs and symptoms
-Recognize early symptoms: pruritis, urticaria
-Be prepared for bronchoconstriction, airway obstruction and hypovolemic shock.
1) Maintenance of patent airway
2) Adequate oxygenation - 100% oxygen via non rebreather oxygen mask
3) Place recumbent and elevate legs
4) Prevention of spread of antigen via tourniquet (obstruct venous return without obstructing arterial flow) or removal of insect stinger
5) Start IV for fluid and Administration of drugs
6) prepare to administer epinephrin
7) anticipate intubation with severe respiratory distress
8) have diphendramine (Benadryl) and nebulized albuterol available
-Treatment for shock

Pharmacological Management of Anaphylaxis

Epinephrine 1:1000, 0.2-0.5 ml SQ for mild symptoms (pruritis, urticaria) at 10-15 minute intervals
Epinephrine 1:10,000, 0.5 ml IV at 5-10 minute intervals for severe reactions
Diphenhydramine ( Benadryl) IM or IV
Histamine H2 blockers such as cimetidine (Tagamet)
-Maintain blood pressure with fluids (fluid bolus, fluid challenge), volume expanders, vasopressors ( dopamine, norepinephrine) - purpose is to increase circulating volume in vessels
biggest problem- decrease BP and decrease perfusion to major organs

Anaphylaxis - Nursing Care monitoring

vital signs, respiratory effort, oxygen saturation, level of consciousness and cardiac rhythm
-Anticipate intubation with severe respiratory distress
-Anticipate tracheostomy with severe laryngeal edema
Patients receiving β-blockers may be resistant to treatment with epinephrine and can develop refractory hypotension and bradycardia. Glucagon* should be administered in this setting because it has inotropic and chronotropic effects that are not mediated through β-receptors.

atopic reactions

type of type 1: IgE mediated reactions
-having an inherited tendency to become sensitive to environmental allergens.
-The diseases that can result are allergic rhinitis, asthma, atopic dermatitis, urticaria, and angioedema.

Type II: Cytotoxic and Cytolytic Reactions.

-reactions involving the direct binding of IgG or IgM antibodies to an antigen on the cell surface.
-Antigen-antibody complexes activate the complement system, which mediates the reaction.
-Cellular tissue is destroyed in one of two ways:
(1) activation of the complement system resulting in cytolysis
(2) enhanced phagocytosis.
-Target cells frequently destroyed are: erythrocytes, platelets, and leukocytes.
EX: ABO incompatibility transfusion reaction, Rh incompatibility transfusion reaction, autoimmune and drug-related hemolytic anemias, leukopenias, thrombocytopenias, erythroblastosis fetalis (hemolytic disease of the newborn), and Goodpasture syndrome.

Hemolytic Transfusion Reactions: Type II

-occurs when a recipient receives ABO-incompatible blood from a donor.
-Naturally acquired antibodies to antigens of the ABO blood group are in the recipient's serum but are not present on the erythrocyte membranes.
-If the recipient is transfused with incompatible blood, antibodies immediately coat the foreign erythrocytes, causing agglutination (clumping).
-The clumping of cells blocks small blood vessels in the body, uses existing clotting factors, and depletes them, leading to bleeding.
-Within hours, neutrophils and macrophages phagocytize the agglutinated cells.
-The complement system is activated, and cell lysis occurs, which causes the release of hemoglobin into the urine and plasma.
- a cytotoxic reaction causes vascular spasms in the kidney that further block the renal tubules. Acute kidney injury can result from the hemoglobinuria.

Goodpasture syndrome: Type II

- disorder involving the lungs and kidneys.
- An antibody-mediated autoimmune reaction occurs involving the glomerular and alveolar basement membranes.
-The circulating antibodies combine with tissue antigen to activate the complement system, which causes deposits of IgG to form along the basement membranes of the lungs or kidneys.
-This reaction may result in pulmonary hemorrhage and glomerulonephritis.

Type III: Immune-Complex Reactions.

Tissue damage occurs secondary to antigen-antibody complexes.
-Soluble antigens combine with immunoglobulins of the IgG and IgM classes to form complexes that are too small to be effectively removed by the mononuclear phagocyte system.
-Therefore the complexes deposit in tissue or small blood vessels.
-They cause activation of the complement system and release of chemotactic factors that lead to inflammation and destruction of the involved tissue.
-may be local or systemic and immediate or delayed.
-clinical manifestations depend on the number of complexes and the location in the body.
-Common sites for deposit are the kidneys, skin, joints, blood vessels, and lungs.
-Severe reactions are associated with autoimmune disorders such as systemic lupus erythematosus, acute glomerulonephritis, and rheumatoid arthritis

Type IV: Delayed Hypersensitivity Reactions.

- a cell-mediated immune response, usually protective mechanisms, tissue damage occurs
-sensitized T lymphocytes attack antigens or release cytokines. Some of these cytokines attract macrophages into the area. -The macrophages and enzymes released by them are responsible for most of the tissue destruction.
-takes 24 to 48 hours for a response to occur.
*Clinical examples: contact dermatitis; hypersensitivity reactions to bacterial, fungal, and viral infections; and transplant rejections. Some drug sensitivity reactions also fit this category.

Diagnostic Studies: testing for allergies

-A complete blood count (CBC) with WBC differential is done, with an absolute lymphocyte count and eosinophil count.
-Immunodeficiency is diagnosed if the lymphocyte count is below 1200/µL (1.2 × 109/L).
-T cell and B cell quantification is used to diagnose specific immunodeficiency syndromes.
-The eosinophil count is elevated in type I hypersensitivity reactions involving IgE.
-The serum IgE level is also generally elevated in type I hypersensitivity reactions and serves as a diagnostic indicator of atopic diseases.

Skin testing

three different methods:
(1) a scratch or prick test
(2) an intradermal test
(3) a patch test.
-The areas of the body usually used in testing are the arms and the back.
-Allergen extracts are applied to the skin in rows with a corresponding control site opposite the test site.
-Saline or another diluent is applied to the control site.
- In the scratch test a drop of allergen is placed on the skin, and then a pricking device is used so the allergen can enter the skin.
-In the intradermal test the allergen extract is injected under the skin, similar to a PPD test for TB.
-In the patch test an allergen is applied to a patch that is placed on the skin
*If a severe reaction occurs, the extract is immediately removed and antiinflammatory topical cream is applied to the site.
For intradermal testing, a tourniquet can be applied during a severe reaction. A subcutaneous injection of epinephrine may also be necessary.

Allergy blood testing

recommended if a person
(1) is using a drug that interferes with skin test results (e.g., antihistamines, corticosteroids) and cannot stop taking it for a few days
(2) cannot tolerate the many needle scratches required for skin testing
(3) has a skin disorder (e.g., severe eczema, dermatitis, psoriasis).

Chronic Allergies

- characterized by exacerbations and remissions
Treatment focuses on ID and control of allergens - Mostly done via skin tests
Many are aggravated by fatigue and emotional stress.

Chronic Allergies - Interventions

-Relaxation techniques
-Change in occupation
-Moving to a different climate
-Pets
-Sleep in air conditioned room
-Damp dust daily
-Cover mattresses and pillows with hypoallergic covers
-Wear mask outdoors
-Wear medic alert bracelet for drug allergies
-For insects, carry a commercial bee-sting kit with preinjectable epinephrine

Chronic Allergies - Pharmacology

given to control symptoms, but must eliminate aggravating factors
-Antihistamines (Rhinitis and urticaria) block the effect of histamines (best drugs to use)
-Sympathomimetic/decongestants (epinephrine) - causes vasoconstriction and relaxes bronchial smooth muscles
-Corticosteroids - Decrease inflammatory process
-Antipruritic Drugs - applied when skin is not broken, protect skin and relief of itching
-Mast cell stabilizing drug - inhibits the release of histamines, leukotrines, and other agents from mast cells after the antigen-IgE interaction
-Leukotriene receptor antagonist - block leukotriene, one of the major mediators of the allergic inflammatory process

Immunotherapy.

injecting allergen extracts that will stimulate increased IgG that combines more readily with allergens without releasing histamine
-recommended treatment for control of allergic symptoms when the allergen cannot be avoided and drug therapy is not effective.
-In individuals with anaphylactic reactions to insect venom ... is definitely indicated.
-involves administration of small titers of an allergen extract in increasing strengths until hyposensitivity to the specific allergen is achieved.
-teach the patient to avoid the offending allergen whenever possible because complete desensitization is impossible.
-Food allergies cannot be safely treated with this therapy, and eczema may worsen with immunotherapy.

Nursing Management: Immunotherapy

- Always anticipate adverse reactions, (esp when using a new-strength dose, after a previous reaction, or after a missed dose)
- Early manifestations of a systemic reaction include pruritus, urticaria, sneezing, laryngeal edema, and hypotension. -Emergency measures for anaphylactic shock should be initiated immediately.
-Describe a local reaction according to the degree of redness and swelling at the injection site. If the area is greater than the size of a quarter in an adult, report the reaction to the health care provider so that the allergen dosage may be decreased.
*always carries the risk of a severe anaphylactic reaction. health care provider, emergency equipment, and essential drugs should be available whenever injections are given.

Nursing Management: Immunotherapy cont

-administer in an extremity away from a joint so that a tourniquet can be applied for a severe reaction.
-Rotate the site for each injection.
*Aspirate for blood before giving an injection to ensure that the allergen extract is not injected into a blood vessel.
-carefully observe the patient for 20 minutes
-warn the patient that a delayed reaction can occur as long as 24 hours later.

Humoral immunity

-consists of antibody-mediated immunity.
-antibodies are produced by plasma cells (differentiated B cells) and found in plasma
-Production of antibodies is an essential component in a humoral immune response.
-Each of the five classes of immunoglobulins (Igs)—that is, IgG, IgA, IgM, IgD, and IgE—has specific characteristics
-Memory cells account for the memory of the first exposure to the antigen and the more rapid production of antibodies.

IgG

76%
found in: Plasma, interstitial fluid
characteristics: Is only immunoglobulin that crosses placenta, Is responsible for secondary immune response

IgA

15%
found in:Body secretions, including tears, saliva, breast milk, colostrum
characteristics: Lines mucous membranes and protects body surfaces

IgM

8%
found in: Plasma
characteristics: Is responsible for primary immune response, Forms antibodies to ABO blood antigens

IgD

1%
found in: Plasma
characteristics: Is present on lymphocyte surface, Assists in the differentiation of B lymphocytes

IgE

0.002%
found in: Plasma, interstitial fluids
characteristics: Causes symptoms of allergic reactions, Fixes to mast cells and basophils, Assists in defense against parasitic infections

cell-mediated immunity.

-Immune responses that are initiated through specific antigen recognition by T cells
-The cell types involved include: T lymphocytes, macrophages, and NK cells.
-primary importance:
(1) immunity against pathogens that survive inside of cells, including viruses and some bacteria (e.g., mycobacteria)
(2) fungal infections
(3) rejection of transplanted tissues
(4) contact hypersensitivity reactions
(5) tumor immunity.

Allergic contact dermatitis

- delayed hypersensitivity reaction involving the skin.
-The reaction occurs when the skin is exposed to substances that easily penetrate the skin to combine with epidermal proteins.
-Over a period of 7 to 14 days, memory cells form to the antigen.
-On subsequent exposure to the substance, a sensitized person develops eczematous skin lesions within 48 hours.
* potentially antigenic substances encountered are metal compounds (e.g., those containing nickel or mercury); rubber compounds; catechols present in poison ivy, poison oak, and poison sumac; cosmetics; and some dyes.

Types of Latex Allergies.

type IV allergic contact dermatitis
-caused by the chemicals used in the manufacturing process of latex gloves.
-delayed reaction that occurs within 6 to 48 hours.
- first dryness, pruritus, fissuring, and cracking of the skin, followed by redness, swelling, and crusting at 24 to 48 hours. -Chronic exposure can lead to lichenification, scaling, and hyperpigmentation. The dermatitis may extend beyond the area of physical contact with the allergen.
type I allergic reaction
-response to the natural rubber latex proteins and occurs within minutes of contact with the proteins.
-manifestations of these allergic reactions can vary from skin redness, urticaria, rhinitis, conjunctivitis, or asthma to full-blown anaphylactic shock.
-Systemic reactions to latex may result from exposure to latex protein via various routes, including the skin, mucous membranes, inhalation, and blood
latex-food syndrome
banana, avocado, chestnut, kiwi, tomato, water chestnut, guava, hazelnut, potato, peach, grape, and apricot. In people with latex allergy

Nursing and Collaborative Management Latex Allergies

-Identifying patients and health care workers sensitive to latex .
-Obtain a thorough health history and history of any allergies, -greatest risk factor is long-term multiple exposures to latex products (e.g., health care personnel, individuals who have had multiple surgeries, rubber industry workers).
- factors include a patient history of hay fever, asthma, and allergies to certain foods

Immunodeficiency disorders

involve an impairment of one or more immune mechanisms, which include
(1) phagocytosis
(2) humoral response
(3) cell-mediated response
(4) complement
(5) a combined humoral and cell-mediated deficiency.
- primary if the immune cells are improperly developed or absent, rare and often serious
-secondary if the deficiency is caused by illnesses or drug induced immunosuppression, are more common and less severe

Human Leukocyte Antigen System

-The antigens responsible for rejection of genetically unlike tissues are called the major histocompatibility antigens.
-These antigens are products of histocompatibility genes.
- In humans they are called the ....
- this is used in matching organs and tissues for transplantation.

Hemolytic Transfusion Reactions

Incompatible transfusion results in immediate coating for foreign erythrocytes causing agglutination, depletes clotting factors and results in bleeding
*blood must be checked 3 times before it is administered
-must get baseline vitals, 15 min after infusion get vitals again
-reactions typically occur within 15 min
-#1 reaction- itching, more serious; headache, backache, fluid overload
-stop infusion STAT, start NS infusion, call Dr, send blood back to the lab and pt sample of blood
-dr will order benadryl and start over
-if temp increases more than .1 or could be a early sign

Organ Transplantation

-Patients are matched to available donors based on:
1) ABO blood
2) human leukocyte antigen (HLA) typing
3) Rh antigens
-The degree of HLA matching is dependent on the type of organ and the transplant center
-Corneas fairly universally transplantable
-HLA mismatches have shown little impact on on liver transplants.
-For heart and lung transplants, minimizing HLA mismatches significantly improves survival
-For kidneys and bone marrow, HLS matching is important

crossmatch

-uses serum from the recipient mixed with donor lymphocytes to test for any preformed anti-HLA antibodies to the potential donor organ.
positive crossmatch - indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation. If transplanted, the organ would undergo hyperacute rejection.
negative crossmatch - indicates that no preformed antibodies are present and it is safe to proceed with transplantation. -especially important for kidney transplants, may not be done for lung, liver, and heart transplants.

Transplant rejection

-occurs as a normal immune response to foreign tissue.
-can be prevented by using immunosuppression therapy, performing ABO and HLA matching, and ensuring that the crossmatch is negative.
-Prevention, early diagnosis, and treatment of rejection are essential for long-term graft function.

Types of Organ Rejection

Hyperacute rejection - occurs minutes to hours after transplantation (blood vessels are destroyed), patient had previous antibodies against the transplanted tissue/ organ. No treatment and organ is removed STAT
Acute Rejection - Occurs days to the first 6 months after the transplant; T lymphocytes attack the foreign organ; usually reversible via immunosuppression therapy but this increases risk for infection
Chronic Rejection - Occurs over months or years and is irreversible; organ is infiltrated with T and B cells causing a low grade immune mediated injury, No definitive treatment but changing immunosuppresion therapy

Immunosupression Therapy

triple therapy usually includes:
Corticosteroids (prednisone) - Suppress inflammatory response; observe for peptic ulcers, hypertension, osteoporosis, Na and H2o retention, muscles weakness, easy bruising, delayed healing, hyperglycemia, infection
Calcineurin Inhibitors (cyclosporine, tacrolimus) - Inhibits production of T and B cells; nephrotoxic, infection, neurototoxic, hepatoxic, tremors, seizures, leukopenia, gingival hyperplasia
Cytotoxic Drug (mycophenolate mofetil) -Inhibit T and B cells; diarrhea, nausea, vomiting, neutropenia, thrombocytopenia, infection, malignancies
drugs are reduced over time

corticosteroids

-if given for a long time have an increased risk for infection
- increased glucose even if the pt is not diabetic, level will fluctuate = increased pt risk for delayed healing and infection
-steroid use is prone to peptic ulcers, adrenal glands may crisis bc they have stopped working for so long.
-hypertension, decreased Ca in bones
suppresses immune response

Immunization Schedule for Adults.

Human Papillomavirus (HPV) - IM injection; women and men through age 26; consists of three doses. Dose 1 and 2 four weeks apart; 12 weeks between 2 and 3; Delay vaccine if pregnant
Zoster (shingles) - age 60 and older; one injections regardless of previous history of herpes zoster (shingles) or chicken pox;
Seasonal Influenza - Given annually at beginning of influenza season; safe for infants (6mo or older), children and adults. Avoid if allergic to eggs; Recommended for people over 65 years of age or age 19-64 with chronic illness, immunosuppresed or receiving immunosuppresion therapy as a result of organ or bone marrow transplant, chemotherapy

Immunization Schedule for Adults. cont

Pneumococcal polysaccharide - for people over 65 years of age or age 19-64 with chronic illness, immunosuppresed or receiving immunosuppresion therapy as a result of organ or bone marrow transplant, chemotherapy
Tetanus - Given every ten years; can be given regardless of interval since previous injection in the case of penetrating or traumatic injury
Pertussis - recommended for adults of any age who are in contact with infants younger than 12 months
Hepatitis A - All ages to prevent Hepatitis A; Adults age 40 years or younger with recent exposure to HAV; Immunoglobulin is preferred for people older than age 40 with recent exposure
Hepatitis B -All adults for protection

Graft-versus-host disease (GVHD)

- occurs when an immunoincompetent (immunodeficient) patient receives immunocompetent cells.
- response may result from the infusion of any blood product containing viable lymphocytes, therapeutic blood transfusions, transplantation of fetal thymus, fetal liver, or bone marrow.
- most situations the biggest concern is the patient's (host's) rejection of the organ or transplant.
- in GVHD disease, the graft (donated tissue) rejects the host (recipient) tissue.
- may begin 7 to 30 days after transplantation, little can be done to modify its course.
- involves donor T cells attacking and destroying vulnerable host cells.

The target organs for the GVHD phenomenon

are the skin, liver, and GI tract.
skin disease may be a maculopapular rash, which may be pruritic or painful.
-initially involves the palms and soles of the feet but can progress to a generalized erythema with bullous formation and desquamation (shedding of the outer layer of skin).
liver disease may range from mild jaundice with elevated liver enzymes to hepatic coma.
intestinal disease may be manifested by mild to severe diarrhea, severe abdominal pain, GI bleeding, and malabsorption.

problem with GVHD

is infection,
-different types of infections seen in different periods.
-Bacterial and fungal infections predominate immediately after transplantation when granulocytopenia exists.
-The development of interstitial pneumonitis is the primary concern later in the course of the disease.
* no adequate treatment of GVHD once it is established.
-corticosteroids are often used, they enhance the susceptibility to infection.
-The use of immunosuppressive agents (e.g., methotrexate, cyclosporine) has been most effective as a preventive rather than a treatment measure.
-Radiation of blood products before they are administered is another measure to prevent T cell replication.

reverse isolation

protect patients from ppl who might have infections
-for pt with low immune systems, put in private room, full PPE, not given raw foods, no plants in room; anything that could cause infection
-WBC less than 4500 (more than 10,000=inflammation)

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