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HEC immunity/inflammation exam
Terms in this set (136)
lines of defense with examples **
first: non-specific anatomic (skin, perspiration, tears, saliva, mucous membranes, etc)
second: non-specific inflammatory (begins immediately, isolates and destroys pathogen via phago)
third: specific immune response (slow, retains memory, provides long-term permanent protection, antibodies)
divisions of immunity
inflammation: phago and fever (leukocytes)
immunity: humoral/antibody mediated immunity (B-lymphocytes)
cell mediated immunity: T-lymphocytes
Human leukocyte antigens
unique universal code for each person
determine our tissue type
the key for recognition (self-tolerance)
40 primary HLAs
foreign antigens stimulate immunity
autoimmunity a risk
bone marrow and stem cells
immune cells circulate in blood
stem cells multipotent depending on what the body needs and growth factors
renal failure and anemia
renal failure leads to decrease in erythropoietin resulting in anemia
(can give growth factors to pts)
majority of WBCs are neutrophils
normal WBC differential (%)
prod daily: 100 billion (can accelerate with GM-CSF/BCSF)
training time: 12-14 days
length of service: 12-18 hours, dies after phago
abundant in circulation = LEFT shift
monos transform to macros
immediate phago response
fights, repairs, identifies and secretes
long life = important to long term antibody/cell mediated immunity
cause the manifestations of inflammation (warm, red, etc)
weapon: heparin, histamine (constricts), serotonin, kinin (dilates and causes swelling) and leukotrienes
weapon: vasoactive chemicals, ameboid mobility, weak phagocytosis
role: counteract vascular effects of other WBCs. Parasitic infections, cancer, & allergic rxns
engulfing and destroying, removes debris such as burn tissue
5 cardinal signs of inflammation
heat, redness, swelling, pain, loss of function
stages of inflammation
Stage I (vascular): macrophages secrete histamine, serotonin, kinin- causes vasodilation of arteries
Phase I: vein constriction
Phase II: hyperemia and edema
*increases blood flow to deliver nutrients to repair
Stage II (cell exudate): dead neutrophil pus (high when injured), untreated leads to immature neutrophils
Stage III: tissue repair and replacement
NSAIDS suppress immune system- suppress neutrophils and do not get proper defense
immediate but short term
triggers antibody mediated and cell mediated defense
made: bone marrow and thymus
"humoral immunity" - B-lymphocytes
long term resistance
neutralizes, eliminates and destroys
natural, artificial and passive
training: bone marrow
specialized: secondary lymphoid tissue (spleen, lymphs, tonsils, intestinal mucosa)
sequence of antibody mediated immunity
1. Antigen invasion
2. Macrophage and T helpers introduce to "virgin" B-cell.
3. B-cell becomes sensitized and creates antibodies that float in blood
4. Bind to antigen and form immune-complex
5. Binding attracts leukocytes that eliminate antigen
IgM: produced first (10-15% of AnB)
IgG: 75% of antibodies - long term immunity
IgA: mucous membrane protector
IgE: antibody mediated hypersensitivity reaction
acquiring AMI (adaptive)
active immunity: natural, lasts years or lifetime. ex: reaction to vaccine
passive: transmitted from external source that has developed immunity. Not long term. ex: immunoglobulin from a hepatitis immune person, breastfeeding
Cell-mediated immunity (CMI)
for total immunocompetence CMI must function optimally. (T-lymphocytes)
1. differentiate self from nonself
2. release cytokines
3. prevent cancer
4. prevent hypersensitivity
helper T-cells (T4): IDs self vs nonself
supressor T-cells (T8): prevents hypersensitivity (overreaction)
natural killer (CD 16): kills cancer and viruses
*should have 2x as many helpers than suppressors
must acquire immunity
immature, nonspecific inflammatory response (20-30y has best immunity)
IgM, IgE, IgD and IgA develop later
lymphocytes accumulate later
B-lymph less effective
*elderly and cancer: may not have fever with infection due to low WBC activity
hyperacute: immediate attack, cannot reverse
acute: 1-3mo and pt must take immunosuppressant meds forever
chronic: organ becomes damaged over time and pt may need another transplant later in life
nurses role in immunocompromised pts
monitor/treat infection: vitals and antibiotics within 30m of fever
Type I: Rapid Hypersensitivity Reactions
"atopic allergy" - most common
allergens: inhaled (pollens, dander, dust, grass, ragweed), ingested, injected (bee sting, drugs) or contact
IgE produced by mast cells and attache to cells, cells release amines like histamine
Type I reaction manifestations
local: watering, itching, sneezing
systemic: widespread vasodilation, decreased CO, bronchoconstriction - anaphylaxis
collaborative nursing care for local reactions
history and family, allergy testing, oral food challenges (not done for anaphylactic foods)
labs: increased eosinophils (should be 1-2%), IgE, RAST
interventions for allergies
environmental change: AC with windows closed, drapes, upholstery, carpeting, pets
drug therapy for allergies
mast cell stabilizers
uneasiness, weakness, "doom"
swollen lips, tongue and palate
hives and pruritis
respiratory: bronchospasm, wheezing, dyspnea, hypoxia
hypotension: rapid, weak, irregular pulse, systolic <90
GI: nausea, cramping, diarrhea
rapid and systemic
*should have 2 unexpired epipens
common anaphylactic triggers
drugs: antibiotics, ACE inhibitors, chemo, opiates, lidocaine, IVP dye
foods: peanuts, shellfish, eggs
creatures: stings, fire ants, venom
other: pollen, mold, latex
interventions for anaphylaxis
intubation and tracheostomy tray at bedside, apply O2 (consider corticosteroids)
start IV - epinephrine 1:1000 q5min until ok (0.3-0.5 mL IV/IM)
position, raise feet
stay with patient
Type II cytotoxic reactions
autoantibody attaches to self cell ad both are destroyed by phago
clinical examples: hemolytic anemia, thrombocytopenic purpura, hemolytic transfusion, Goodpasture syndrome
Txt: stop cause, plasmapheresis (removes cause from blood stream)
Type III: immune complex reactions
excess antigens cause complexes to form in blood and lodge in vessels, trigger inflammation and damage
sites: kidneys, skin, joints, vessels
examples: rheumatoid arthritis, lupus, serum sickness
Type IV: delayed hypersensitivity
T-lymphocytes, not histamine.
no antibodies or complements
local collection of lymphos and macros cause edema, induration, ischemia, and damage
examples: mantoux, dermatitis, poison ivy, stings, transplant rejection, sarcoidosis
Txt: removal, corticosteroids
Type V: stimulatory
excess stimulation of a cell by an autoantibody resulting in a continuous "turned-on" state of the cell.
txt: remove stimulated tissue or immunosuppressive drugs
ex: graves disease (continuous stimulation of thyroid)
causes of autoimmunity
hyperimmune response, cannot differentiate
maybe triggered by microorganisms or drugs
results of autoimmunity
abnormal organ growth
change in organ function
exams and tests for autoimmunity
CRP: protein appears on blood in acute inflammatory DOs (<6 mg/L normal)
ESR, males <50: 0-15mm/hr, >50: 0-20 mm/hr
females <50: 0-20mm/hr, >50: 0-30mm/hr
*more proteins bound to RBCs with autoimmunity, so they fall faster
goal of autoimmune treatment
maintain body's ability to fight disease
liver is the largest internal organ
lobule: functional unit
blood supply: hepatic artery and portal vein
gets 30% of CO/min @ 1500mL
Compensated v uncompensated cirrhosis
ascites - spontaneous bacterial peritonitis
portal systemic encephalopathy
increased portal pressure
venous congestion in spleen
portal hypertension treatment
fluid and sodium restriction
most dangerous complication of cirrhosis: 50% die
result of high portal pressure
medical emergency: hypovolemic shock
blood and clotting factor transfusion
drugs: octreotide (statin), propranolol - RESTRICTS VESSELS
injection sclerotherapy - clots
ligation with elastic band
multilumen tube places pressure of bleeding varices.
airway hazard - HAVE SCISSORS AT BEDSIDE
Transjugular intrahepatic portosystemic shunt (TIPS)
shunts blood from portal vein around liver to bypass it - lowers pressure, but then the liver cannot detoxify
*compounded by decreased albumin and leads to a decrease in hydrostatic pull into vessels
give albumin if they are nutrient deficient or to raise BP
treatment of ascites
antibiotics to prevent peritonitis
low sodium and high vitamin diet
*bacteria will migrate from bowels to abdomen
Portal Systemic Encephalopathy (PSE)
likely due to increased ammonia
altered LOC, can lead to coma
neuromuscular disturbances (asterixis)
becomes obstructed if liver inflamed and everything backs up.
hepatic artery brings 25% of flow to liver as well as oxygen
function of the liver
stores vitamins A, D, E, K and blood (can bleed out quickly if liver lacerated)
kupffer cells remove bacteria and bilirubin
detoxifies: ammonia, steroids, drugs, alcohol, proteins
synthesizes: albumin, prothrombin, fibrinogen
lab diagnostics for liver
PTT: 11-12.5s (increases if liver not producing enough clotting factors like vitamin K)
Bilirubin: <1.5mg, <2.5 indicates disease
serum ammonia: <110mg
AST: found in heart, liver, skeletal muscle, and pancreas
ALT: found primarily in liver
biopsy - uf of large needle, LAY PT ON RIGHT SIDE AFTER
chronic and progressive, diffuse inflammation, fibrosis, structure and function change
4th cause of death for middle aged
causes: tylenol, alcohol, viruses, autoimmunity, and fatty liver disease (especially in children)
largest cause of cirrhosis
worldwide: Hep B and D
cirrhosis pathophysiologic changes
fatty infiltration (no symptoms, can be prevented if caught in this stage)
*3/4 of the liver can be destroyed before there is a change in function
lactulose (cephulac): oral syrup, acidifies colon pH, pulls ammonia into bowels
neomycin (mycifradin): via NG tube, decreases colon bacteria that convert urea and amino acids to ammonia
diet: moderate protein and fats, simple carbs
when liver can't remove bilirubin
deposits in skin, sclera, urine (brown), but not stool (clay)
Pruritis biosalts in bilirubin makes skin itchy - fatty topical lotion, oatmeal bath, soft fabric, mitts
cirrhosis of liver ans escites causes altered perfusion to kidneys
kidneys are still normal
cirrhosis increases risk of cancer
*40x higher if cirrhosis induced by alcohol
5 year survival <5% without treatment
cirrhosis is most common reason for transplant
physical assessments for cirrhosis
change in bowels
change in output
most common immune def. disease in the world - epidemic
african american gay/bi men susceptible
HIV infection process
CD4+helper inducer Tcells become a factory that produces viral stuff daily
CD4+Tcells decrease and virus rises
everyone with aids has HIV but not vice versa
stage 1: HIV confirmed, CD4 >500, no AIDS
stage 2: CD4 200-499, no AIDS
stage 3: CD4 <200 OR anyone with confirmed AIDS regardless (transition from HIV to AIDS)
stage 4: confirmed HIV, but no count info
life factors can affect progression:
re-exposure, other STDs, nutrition, stress
exposure to HIV
flu-like symptoms after 4 wks initial exposure - tests negative because too early to detect
health promotion of HIV
transmitted: sex, parental, perinatally
not transmitted: casually, sharing household items, bugs
highest concentration of HIV: semen and blood (and all other bodily fluids)
CDC sexual transmission protection
B: be faithful
clean needles and paraphernalia
needle exchange programs
infant exposure to blood and fluids
positive breast milk
transmission in health care
needle sticks - most common
exposure to wounds/mucous or fluids
use standard precautions
collaborative management assessments
kaposi's sarcoma, malignant lymphomas, cancers (cervical), HPV
monitor every 2-6 mo
What is the first immunoglobulin introduced when someone is being newly sensitized to an antigen?
Suppressor T-cells prevent?
Name four growth factors and their actions
1. Granulocyte Colony-stimulating Factor (G-CSF) = increases #'s and maturity of neutrophils
2. Granulocyte Macrophage colony-stimulating factor (GM-CSF) = increases growth and maturation of myeloid stem cells
3. Erythropoietin = increases growth and differentiation of erythrocytes
4. Thrombopoietin = increases growth and differentiation of platelets
What two cells are responsible for transplant rejection?
Natural killer cells and cytotoxic/cytolytic t-cells— which kill cells from other people or animals.
Define maintenance therapy r/t organ transplant
Continuous immunosuppression user after a solid organ transplant
usually a combination of calcineurin inhibitor, a corticosteroid and an antiproliferative agent
Define rescue therapy
Is used to treat acute rejection episodes.
Which immunity can be transferred from one person or animal to another?
Antibody-mediated immunity (also known as humoral immunity)— can be transferred
Patients who take an immunosuppressive drug are at higher risk for what?
Infection and cancer development
Cell-mediated immunity control and coordinate what?
The entire inflammatory and immune response.
Which test is specific for testing type one reactions
Skin testing can show which specific allergens are the cause of a type 1 reaction.
What two meds are discontinued two weeks before a skin test?
Systemic glucocorticoids and antihistamines to avoid suppressing the test response.
nasal sprays may be permitted, except for sprays with antihistamine
What is intradermal testing reserved for?
Reserved for substances that are strongly suspected of causing allergy but did not test positive with scratch test.
What is an oral food challenge used for?
Are sued for patients who have allergic rhinitis when the allergen is eat rather than inhaled.
not performed using food that have previously caused a serious or anaphylactic reaction in the patient being tested
What are some drugs used for symptom relief
Steroidal and non steroidal agents, vasoconstrictors, antihistamines, mast cell stabilizers and drugs that inhibit the release or action of leukotrienes.
decongestants are available as systemic oral drugs or nasal sprays
What is important to teach a patient who may start taking any decongestant
Teach patients with high BP, glaucoma or urinary retention to consult with a health care professional before taking any decongestant
because effects are systemic
What is desensitization therapy?
Commonly called "allergy shots", may be needed when allergens are identified and cannot be avoided easily.
Common foods that cause anaphylaxis
Common insects that cause anaphylaxis
-bees, wasps, hornets (Hymenoptera)
What three things should you teach a patient who has a history of allergic reactions?
1. Avoid allergens whenever possible
2. Wear a medical alert bracelet
3. Alert health care personnel about specific allergies
When checking an epi pen what three things will you note
1. Expiration date
2. Drug clarity (if the drug is discolored, obtain replacement)
3. Security of cap (if the cap is loose or comes off accidentally obtain replacement device)
When injecting an epi pen through ones pants what two areas should you avoid?
1. Avoid seems
2. Pockets where the fabric is thicker
Protect your epi pen from what two things?
1. Protect from light
2. Avoid temperature extremes
People who have an allergy to bananas, avocados and some nuts are more likely to have what kind of allergy?
An allergy to latex, although this is not universal
What is the right dose of epinephrine for anaphylaxis
Epinephrine 1:1000 concentration, 0.3 to 0.5mL IV push or IM
repeat drug administration as needed every 5 to 15 minutes until patient responds
Who is more likely to have autoimmunities?
Occur much more commonly among women than men.
women 5:1 to men 20:1
Portal hypertension can cause what?
Blood can flow back into the spleen, causing spenomegaly. (Spleen enlargement)
Portal hypertension can result in what 4 things (not including splenomegaly)
2. Esophageal varices
3. Prominent abdominal veins
Bleeding esophageal varices can look like what two things?
2. Melena (black, tarry stools)
What is hepatic encephalopathy
Complex cognitive syndrome that results from liver failure and cirrhosis.
What might the pt with hepatic encephalopathy report?
1. Sleep disturbance
2. Mood disturbance
3. Mental status changes
4. Mental status changes
5. Speech problems (early)
Stage 4 Hepatic Encephalopathy pt may progress to what?
Factors that may lead to hepatic encephalopathy in patients with cirrhosis include
1. High protein diet
3. Hypovolemia (decrease fluid volume)
6. GI bleeding
7. Drugs (hypnotics, opioids, sedatives, analgesics, diuretics, illicit drugs)
Since cirrhosis has a slow onset, many of the early manifestations are vague and nonspecific. Assess for?
-significant changes in weight
-GI symptoms such as anorexia and vomiting
-abdominal pain and liver tenderness
What is asterixis?
Rapid, nonrhythmic extensions and flexiones in the wrists and fingers (hand-flapping)
associated with ascites
Cause of ascites
Caused by increased hydrostatic pressure from portal hypertension.
is collection of free fluid within the peritoneal cavity
What is the causative agent of hepatitis A and how can you destroy it?
-ribonucleic acid virus fo the enterovirus family (its a virus that lives and survives on human hands). can be chronic. has a vaccine.
-most often spread by the fecal-oral route by person-to-person (food, water, sexual contact, *
common in shellfish
virus resistant to detergents and acids but is destroyed by chlorine (BLEACH) and extremely high temps
Hepatitis B transmitted how?
-unprotected sexual intercourse
-blood transfusions (vaccine available)
Symptoms of hepatitis B
• Anorexia, nausea, and vomiting
• Right upper quadrant pain
• Dark urine with light stool
• Joint pain
• Jaundice (Ignatavicius 1203)
How is hepatitis C transmitted
Blood to blood— IV drug needle sharing is the highest incidence
How is hepatitis D transmitted?
Primarily by parenteral rounds, having sex with a person who is contaminated is also a high risk factor.
How is hepatitis E transmitted?
Caused by fecal contamination of food and water.
People in us with this are people who are international travelers.
When should the pt consult the dr before taking decongestants?
Can you inject epi through pants? When should pts use epi?
When ANY anyphylactic symptom is present- carry 2 on you at all times and keep away from light
How long should the pt be monitored at a hospital following an epi injection?
What are signs of reduced perfusion with anaphylaxis?
Absent deep tendon reflex
What is the clinical criteria 3 for anaphylaxis?
Systolic less than 90 mmHg or 30% lower than baseline
What should you do with the IV running if pt experiences anaphylaxis?
Change tubing and hang/start normal saline
If a pt has anaphylaxis and hypotension, what should HOB be? What should it be if pt has no hypotension?
With which client is it most important for the nurse to use latex free gloves?
A. 38 year old woman taking oral contraceptives
B. 68 year old man with total hip replacement
C. 38 year old man allergic to shellfish and nuts
D. 28 year old woman with spina bifida
D. 28 year old woman with spina bifida
What should pts do before a paracentesis? What to do after?
What are interventions for pts with hepatopulmonary syndrome?
HOB 30 degrees
The nurse is providing teaching for a client scheduled for a paracentesis. Which statement by the client indicates the teaching has been successful?
A. "I must not use the bathroom prior to the procedure."
B. "I will lie on my stomach while the procedure is performed."
C. "I will not be allowed to eat or drink anything the night before surgery."
D. "The physician will likely remove 2 to 3 liters of fluid from my abdomen
Which intervention will the nurse include in the plan of care for a client with severe liver disease?
A. Encourage the client to eat a low-protein, high-carbohydrate diet.
B. Administer Kayexalate enemas.
C. Instruct the client to eat a high-protein, low-carbohydrate diet.
D. Teach the client to participate in frequent vigorous activity.
which couple has the highest risk for sexual transmission of HIV without the use of a condom or dental dam?
A. uninfected male performing vaginal intercourse with an infected female
B. Infected male performing vaginal intercourse with an uninfected female
C. uninfected male performing anal intercourse with an infected male
D. infected male performing oral sex on an uninfected male
B. Infected male performing vaginal intercourse with an uninfected female
What are some manifestations of AIDS?
what is the most important question the nurse asks the client prescribed to begin highly active antiretroviral therapy?
A. Do you have any symptoms now of active infection?
B. Is there any possibility that you are pregnant?
C. Are you currently sexually active?
D. What other medications do you take?
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