Chapter 35 Assessment of Immune Function Nursing considerations PDF

Preview

Summary

Lectures notes from ATI book and Lippincott book, High yield material....

Description

Chapter 35: Assessment of Immune Function Nursing Considerations 1. Cell-mediated response occurs when the specifically antigen-sensitized T lymphocytes attack whole cells of the same type that sensitized the T-lymphocyte clone. 2. The humoral defense or immunity, or antibody-mediated immunity, is also specific for one type of foreign cell or virus, but in this case there is a release of antibodies that will help the immune system cell destroy the antigen. 3. B-lymphocytes, when the sensitizer antigen present, produce the clone of plasma cells, which release the antibodies or immunoglobulins. 4. The humoral response is the immediate response of the immune system when it recognizes an antigen and then makes antibody. 5. Both, the cell-mediated and the antibody-mediated types of immunity, are caused by the memory cells produced in both types of immunity by the exposure to an antigen. 6. The memory cells are clones of cells that are only stimulated by the antigen that caused their production. When this happens, the T-memory cells produce Cytotoxic T-cells and the B-memory cells produce plasma cells which produce the antibodies. 7. The aging process can impair defenses in the respiratory tract, such as the cilia activity, and therefore favor an increase in the respiratory tract infectious diseases. Reduced ciliary action in the respiratory tract results in a decrease in the removal of harmful organisms 8. The C-reactive protein is produced in the liver as a response to the stimulation by factors released during inflammatory conditions. These inflammatory diseases could be infectious or not, and rheumatic or not. 9. Innate immunity is based on the genetic makeup of a particular species that allows that species to be immune to specific diseases without having had the infection themselves. An example is humans don’t get distemper, but dogs do. Humans do not get hoof-and-mouth disease, but cows do. 10. Passive natural immunity is the immunity a baby gets from the mother, in utero or from breast milk, that last for the first several months of the baby’s life. 11. Passive artificial immunity consists of immunoglobulins and anti-venoms. Immunoglobulins are foreign (passive) antibodies which transiently protect against infectious diseases. They are not produced by the body (artificial), but are industrially produced, and are administered by injection. Passive immunity only prevents further damage. Passive immunity provides the protection of antibodies made by someone else. Benefits last only as long as the injected antibodies are alive. 12. Acquired immunity usually develops as a result of prior exposure to an antigen through immunization. When the body is attacked by bacteria, viruses, or other pathogens it has three means of defense . The first line of defense, the phagocytic immune response , involves the WBCs that have the ability to ingest foreign particles. A second protective response is the humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells that manufacture antibodies. The natural immune response system is rapid nonspecific immunity present at birth. 13. An immunization or vaccination gives the recipient a “tiny dose” of a disease, enough to stimulate the production of antibodies. It is active, because the body produces its own antibodies; it is artificial, because is the result of an industrial process (the manufacture of the vaccine ) and not a natural process; and it is acquired, because the immunity is obtained after the vaccine is administered. 14. Active acquired immunity usually develops as a result of vaccination or contracting a disease. Natural immunity is present at birth and provides a nonspecific response to any foreign invader. Passive acquired immunity is temporary immunity transmitted from another source that has developed immunity through previous disease or immunization. 15. Gamma globulin (antibody), obtained from the blood plasma of people with acquired immunity, is used in emergencies to provide immunity to diseases when the risk for contacting a specific disease is great and there is not enough time for a person to develop adequate active immunity. Antibiotics would only help if what the patient was exposed to was a bacterial infection. Albumin would not give the patient passive acquired immunity. Measles-mumps-rubella vaccine would have no effect on this patient. 16. Neutrophils are the first cells to arrive at the site where inflammation occurs.

17. A history of surgical removal of the spleen, lymph nodes, or thymus may place the patient at risk for impaired immune function. 18. The structural part of the invading or attacking organism that is responsible for stimulating antibody production is called an antigen. For example, an antigen can be a small patch of proteins on the outer surface of the microorganism. The antigen triggers the production of antibodies which will fight the antigen. 19. Vaccines and toxoids consist of antigens which cause acquired active immunity stimulating the production of memory cells and antibodies. Not all antigens are naturally immunogenic and must be coupled to other molecules to stimulate the immune response. 20. A single bacterium or large molecule, such as corynebacterium diphtheriae or tetanus toxin, may have several antigens, or markers, on its surface, thus inducing the body to produce a number of different antibodies. 21. Bacteria are cellular microorganisms. 22. A virus is a non-cellular organism that can cause disease. 23. When there is an infection, the lymph nodes near to the actual infection site enlarge; this is evidence that the T lymphocytes are activated; the B lymphocytes are making antibodies, and the activity in the lymph node has caused it to enlarge. 24. Antibodies help destroy an antigen by mechanically harming it , activating the complement system, and releasing chemicals that alter the environment of the antigen. 25. The nurse should take precautions to prevent infection in the patient who has a reduction in immune function. The most important infection control technique is hand-washing. It does not matter whether the reduction in immune function is temporary or permanent. Teaching the family what to do after the patient is discharged from the hospital would not be the primary action. Taking vital signs would be an important action but would not prevent infection, which is the priority. 26. A left shift or increase in circulating band neutrophils indicates that the patient cannot produce a sufficient number of mature neutrophils. One condition that can cause this to happen is sepsis, which triggers an accelerated production of neutrophils. Assessing vital signs, including temperature, can assist the nurse in planning the next action. There would be no reason to keep the patient on bed-rest, to prepare the patient for surgery, or to increase the patient’s oxygen at this point. The most appropriate action is assessing for a problem. 27. Inflammation can occur without infection. A joint sprain or injury can cause inflammation of the joint. The nurse should not assume that there is an infection just because inflammation is evident. 28. Injured tissues secrete histamine, serotonin, and kinins, which dilate the arterioles in the area of injury, increasing blood flow and delivery of nutrients and causing warmth. 29. Blood flow to the area of injury is increased, causing edema. Edema at the site of injury protects the area from further injury by creating a cushion. A heating pad would enhance circulation to the area. Injecting pain medication and starting an IV infusion of a vasoconstricting drug would not be warranted. The best action is to elevate the extremity after ensuring adequate circulation. 30. Because a solid organ transplanted into a host is seldom a perfectly identical match of human leukocyte antigens (unless the organ is obtained from an identical sibling) between the donated organ and the recipient host, the patient’s immune system cells recognize a newly transplanted organ as non-self. Without intervention, the host’s immune system starts inflammatory and immunologic actions to destroy or eliminate these non-self cells. The immune response is suppressed with immunesupressant drugs so that the body will not attack the new organ. 31. The spleen is involved in B-lymphocyte maturation. People who undergo splenectomies for any reason may have a decreased antibody-mediated immune response and thus would be more susceptible to infection. They are specially vulnerable to streptococcal infections and can develop a fulminant streptococcal pneumonia (pneumococcus), so these patients should receive the vaccine against pneumococcus regardless their age. Patients will still develop fever after splenectomy and are not at increased risk for allergies or fever. 32. A left shift in the WBC count indicates that the patient is experiencing a continuing infection and that the patient’s bone marrow cannot produce the required neutrophils, so it is now releasing immature neutrophils into the blood. Immature white blood cells are released when the more mature circulating cells have not been able to combat an ongoing bacterial infection. These immature white blood cells are described in the Complete Blood Count (CBC) as “bands”. 33. Vaccination with hepatitis A vaccine is an artificial way of stimulating the immune system to make antibodies against hepatitis A (artificially acquired active immunity). If a patient has had hepatitis A, this patient’s immune system has responded to an actual infection with hepatitis A by making many antibodies to hepatitis A (naturally acquired active immunity); therefore he does not need a vaccination (artificial acquired active immunity) for this virus.

34. During allergic episodes, the eosinophil count is elevated both to respond to the presence of allergens and to limit the tissue level responses of inflammatory cells by releasing enzymes capable of degrading the vasoactive amines secreted by other leukocytes. 35. As per the Centers for the Disease Control and Prevention (CDC) tetanus toxoid boosters should be administered routinely every 10 years. In some cases, emergency departments use 5 years as the cutoff for re-vaccination. If the patient’s medical records substantiate that he did indeed receive a tetanus toxoid booster really recently (less than 5 years ago), or if the patient states so and he/she seems to be a reliable historian, he does not need another one now. It also recommended that older adults and people with splenectomy receive the pneumonia (streptococcal) vaccine. An additional recommendation for older adults, people with respiratory impairment, and health care workers to acquire an annual influenza immunization. 36. Older adult patients often do not demonstrate typical signs and symptoms of infection because of the diminished immune function seen with aging. Often, the first sign of infection is mental status changes. Any change in mental status in the older postoperative patient should lead the nurse to assess for a wound infection. Locally, a purulent discharge from the wound would indicate infection. Wound infections are bacterial and cause an elevation of white blood cells above 10,000/mm3 and left shift (increase in band neutrophils). 37. If a nurse does not have detectable levels of antibodies to the varicella zoster virus, the most likely explanation for this is that she or he has never been infected with the virus, although it is possible the infection occurred at such a young age that the nurse was unable to generate sufficient antibodies. The nurse should not be assigned to take care of patients with this virus until after he/she receives the vaccine. 38. Passive immunity occurs when the individual is given antibodies (immune globulins) that were created in the laboratory (artificial) or by another person (natural). Active immunity occurs after exposure of the host to an antigen (natural) or vaccination (artificial). Cell-mediated immunity is carried out by T-cells in response to specific antigens. 39. The baby receives passive immunity from antibodies that are passed through the placenta in utero. Maternal passive immunity is temporary and will last for only a short time after birth....