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Inflammation & the Immune Response
Keith Rischer, RN, MA, CEN, CCRN
Objectives for this content
Inflammatory response #1-3
Infection/sepsis/chain of infection #4-10
Physiologic immune response #11-16
Three Lines of Defense
Anatomical Barriers
Acute Inflammatory Response
Immune System
Lines of Defense
Anatomical Barriers: First Line of Defense
Skin Mucous
membranes Normal bacterial flora
Clostridium difficile Yeast infections
Normal Body Defenses
Skin multilayer barrier, shed outer layer,
contains fatty acids that kills some bacteria Lungs
contain cilia in upper respiratory tract, macrophages
Urinary Tract flush action of urine washes away bacteria
Perry and Potter pg. 647 Ch 34 Table 34-3
Inflammatory Response
Inflammatory Response
Occurs in response to injury
Localized Immediate Beneficial Appropriate level of
response Non Specific
Causes of Inflammation
Physical Trauma Lacerations Burns
Chemical- Bites Allergic response
Micro-organisms Bacteria
Inflammatory Response
REDNESS SWELLING PAIN HEAT LOSS OF
FUNCTION
Purpose of inflammation
Neutralizes and Dilutes Toxins
Removes necrotic materials
Provides an environment for healing
Add “itis” to affected body part
4 Phases of Inflammation Vascular
Think blood vessels Cellular
Think WBC’s Formation of Exudate
Fluid & neutrophils Healing
regeneration or repair of tissue
Injury occurs Mediators intervene Vasodilation occurs Capillaries become
more permeable Swelling and
movement of fluid occurs
Vascular Phase: Blood Vessels
Cellular Phase – Think WBC’s
Injury occurs Chemotaxis begins White blood cells
rush in to help Neutrophils Monocytes Macrophages
Chemical Mediators
Coordinators of the inflammatory response
Histamine Prostagladins Cytokines
Laboratory tests
Erythrocyte sedimentation rate (ESR or sed rate) <20 mm/hr
CRP – C reactive protein non specific test identifying the presence of
inflammation <1.0 mg/dl
Application of the Nursing Process
Data/Assessment: History Local signs and
symptoms including pain assessment WILDA
Applicable lab work
Nursing Diagnosis
Acute pain related to tissue trauma Impaired physical mobility related to
discomfort
Nursing Interventions
Care will vary with causative agent and physical condition of the patient
What are some nursing actions you might implement or anticipate
How will you as the nurse evaluate the outcome
Expected Outcomes…
Healing of the wound or injury Prevent minor infections from becoming
overwhelming to the body UTI vs. urosepsis
Goals and outcomes will vary with each patient
Remember that your outcomes will drive your interventions/cares
Systemic Manifestations of Acute Inflammation
Fever/chills Cytokines Benefits
Increased killing of microorganisms Increased phagocytosis by neutrophils Increased activity of interferon
Leukocytosis Neutrophils “left shift”…band cells
Medications: NSAIDS
Ibuprofen, Toradol Mechanism of action
Inhibits prostaglandin synthesis Nursing implications
Give w/food Elderly-high risk GI bleed Prolongs bleeding times 1 day Assess renal function-creatinine w/chronic use
Medications: NSAIDS
Salicylates – Aspirin Mechanism of action
Inhibits production of prostaglandins Decreases platelet aggregation
Nursing implications Give w/food Prolongs bleeding times 4-7 days
Medications: Anti-histamines
Benadryl, Ranitidine (Zantec), Famotidine (Pepcid)
Mechanism of action– Block histamine at the receptor site– Decreases gastric acid secretion
Nursing implications– With meals– Drowsiness/dizziness
Medications: Corticosteroids
Prednisone Mechanism of action
Decrease inflammation by stabilizing neutrophils and lysosomes
Inhibit prostaglandin synthesis Inhibits chemotactic cytokines Decreases mast cell stimulation
Nursing implications Meals Chronic use complications
– Risk of infection
– Hyperglycemia
– SE
Inflammation Case Study 26 yr female with no
medical history CC
Severe epigastric abd pain the last 2 days
Severe pain all night, rates 10/10-sharp-nothing relieves. Appears uncomfortable
T-101.2 P-110 R-24 BP 168/88 sats 98% RA
Tender epigastric area, BS active x4
Labs K+-3.4 Na+ 138 Creatinine 0.6 ALT-81 AST-81 WBC-28.7 Lipase-1633
Case Study continued
Outcomes
Nursing diagnosis priorities
Plan of care
Evaluation
What is an infection?
Normal Course of an Infection
Incubation period Prodromal stage Full stage of illness Convalescence
Infectious agents/pathogens
Bacteria Virus Fungi Protozoa
Bacteria
Single cell Human cells vs.
bacteria count in body Gram +/-
Virus
Most common affliction of humans
Has no metabolism of it’s own
Is incapable of replicating outside a living cell
Takes over the metabolic machinery of host cells to survive and replicate
What influences Pathogen survival?
Food/Glucose Water Oxygen –
aerobic/anaerobic Temperature pH light
Reservoir
A place where a pathogen can survive but may or may not multiply
What is the most common reservoir?
What is a carrier?
Portal of exit
For the pathogen to cause an infection it must exit the reservoir
How can this happen?
Mode of Transmission
Direct or indirect
What is the major mode of transmission in the health care setting?
List the 4 categories of transmission
Portal of entry
Susceptible Host
What factors increase our susceptibility to infection? Age Stress Nutritional status Current medical
therapies Chemo Steroids
Presence of disease
Breaking the Chain
Leukocytes=Braveheart
Leukocytes
Normal Blood Count of all WBC: 4,000-11,000/ul
Neutrophils Monocytes Lymphocytes B cells:
mediate the humoral immune response
T cells: Mediate cellular immunity
Elderly considerations
Laboratory Studies CBC
Hgb (12-16 g/dl) Hct (33-51%) Platelets (140-440 thou/cu mm) WBC (4.5-11.0 thou/cu mm)
Differential Never-neutrophils (42-72%) Let-lymphocytes (20-44%) Monkeys-monocytes (<11.1%) Eat-eosinophils (<7.1%) Bananas-basophils (<3.0%)
Cultures, gram stains and sensitivities
Wound and skin cultures, body fluids, blood cultures
Gram stains
Sensitivities
Anti-infective Drugs
Determine if hypersensitive to medication
Check for interactions with other drugs
Educational needs of client
Determining effectiveness
Antibiotic Therapy
Anti-fungal Fluconazole, Nystatin
Cephalosporins Cephalexin (Keflex)
Penicillins Amoxicillin, Ampicillin
Sulfonamides Bactrim
Tetracyclines Doxycycline
Antibiotic Resistance
Bacteria adapt in ways which make an antibiotic less effective or ineffective MRSA – Methicillin resistant staphylococcus
aureus VRE – Vancomycin resistant enteroccus
Vancomycin
Anti-infective class other Effective against gram+ pathogens Used in potentially life-threatening
infections when other drugs are not effective
Action: binds to bacterial cell wall and cell death results
Poorly absorbed in GI tract, may be given IV
NCLEX Concepts of Emphasis
1. Define inflammation2. Is inflammation always present with infection?3. What are some patient examples that would limit or impair
their inflammatory response?4. What are the five physical manifestations of the inflammatory
response?5. Name each distinct phase of the inflammatory response and
unique characteristics of each?6. What are other causes of inflammation besides micro-
organisms?7. What are some common diseases of chronic inflammation?8. What are the medications that treat the inflammatory
response?
Sepsis
Patho Infection (susceptible host) Inflammation-systemic
SIRS Capillary permeability Vasodilation
Progressive Sepsis/SIRS Septic shock Multiple Organ Dysfunction Syndrome (MODS)
Article Case Study
70 yr female from NH CC:
weakness, diarrhea x3 weeks Assessment:
PMH: IDDM, HTN, CVA, COPD, UTI’s VS: T-97…101.8 P-109 R20-24 BP-93/41 91-98% a/o x3
Labs: WBC-26.5 Gluc 258
Article Case Study-Day 2
T-96.6 P-125 R-24 BP 80/43 Oriented to self only u/o 180cc over 8 hours Became more lethargic later in day T-96.5 P-100 R-24 BP 70/30 Labs
WBC 41.9 Lactate 2.2
Article Case Study-Day 3
T-96.5 P-100 R 14-32 BP 70/50 Labs
WBC 41.9 Creatinine 4.3
Vasoactive gtts Intubated Died day 7
Sepsis Case Study 58 yr female from NH
Found unresponsive with dramatically altered LOC Intubated and transferred to ED PMH
IDDM MI CHF Mitral valve regurgitation
T-102.7 P-110 R-16 intubated BP- 155/86 sats 95% Head to Toe
Remains unresponsive-even to pain Breath sounds coarse bilat S1S2 soft murmur reg Skin hot-dry to touch 1+ edema lower extremities Foley placed…urine thick white, yellow
Sepsis Case Study Initial labs
WBC-13.8 Neutrophils-82% Hgb-14.9 Platelets-213 Glucose-331 K+-5.0 Creatinine-2.03 ALT-89 AST-193 INR-2.2 Lactate 7.0
UA Bacteria-many WBC>100 Leukocyte esterase +
l
6 hours later… T-103.8 HR130 BP 64/30 despite 4
vasopressors IV continuous WBC-28.6 Neutrophils-95% Hgb-5.2 Platelets-64 Glucose-351 K+ 3.5 Creatinine-2.9 ALT-382 AST-590 INR-7.1 Lactate-14.0
Key Nursing Assessments Fever/chills
Hypothermia Altered LOC/confusion Break in skin integrity
Foley catheter Wound or incision
Tachycardia HR >100
What if elderly or on beta blockers?
Key Nursing Assessments Tachypnea
RR >20 Hypotension
SBP <90 SBP drop of >20-30mm/Hg
Decreasing urine output…<30cc/hr
Labs WBC Neutrophils Creatinine
Nursing Diagnosis statements w/infection/sepsis?
Ineffective breathing pattern Decreased cardiac output Ineffective tissue perfusion…manifested
by: Altered mental status Behaviorial changes (restlessness) Renal…creatinine
Acute confusion
NCLEX Concepts of Emphasis
1. Why is the older adult at risk for infection and cancer development?
2. Inflammation and immunity are provided primarily through what body cells?
3. Differentiate the 5 types of leukocytes and what each type does to protect the body from micro-organisms
4. Which leukocyte is elevated in bacterial infection? 1. Why…
5. What body cell is able to recognize and destroy non-self cells?
6. What vital sign changes are seen in sepsis?7. What assessment findings are seen in sepsis?
The Immune Response
Immune Response
Passive Acquired Immunity
Present at birth Short lived Body needs to develop
own
Active Acquired Immunity
After birth Active
Long-term Exposure to micro-
organisms immunizations
What comprises the immune system?
Bone Marrow
WBC
Lymph system
Thymus Gland
Misc: Tonsils, Spleen, Mucosa, Appendix
Lymphatic System
Lymphocytes
WBC that allow the body to remember and recognize previous invaders.
Two types B lymphocytes T lymphocytes.
NK or natural killer cells
Specific Defenses
Humoral (circulating) immunity Reside in B lymphocytes Mediated by antibodies
(immunoglobulin) produced in B cell
Produce antibodies when activated
Cell-mediated defenses T –cells released when
exposure to an antigen occurs 70-80% total lymphocytes
Antigens An antigen is a substance
that elicits an immune response
Mostly comprised of protein
A foreign substance that invades the body is called an antigen
All cells have antigen unique to that individual allowing the body to recognize itself
Humoral (antibody) Immunity Antibody mediated
immunity
Antibodies are produced by B cells
Antibodies can bind to antigens
Immunoglobulins (IgG, IgA, IgM, IgD, IgE)
Cell Mediated
T-cells able to recognize
infected cells Cytotoxic
Natural killer cell
Cytokines
Soluble, hormone-like protein produced by white blood cells act as a messengers between cells
Stimulate or inhibit the growth and activity of various immune cells
Can be beneficial or harmful
Antipyretics
Acetaminophen
Ibuprofen
Aspirin
Immunopathology
Alterations in Immunity and Inflammation Hypersensitivity Autoimmunity
Hypersensitivity
Immediate Allergy Anaphylaxis
Delayed Poison Ivy Mantoux Test
Hypersensitivity
Nursing Assessment Think ABC’s How fast is the allergic
response? How serious? What to ask the
patient? Is this an allergic
response or drug side effect?
Name that response…
Baby is crying continually and pulling at her ear. Mom is frantic.
Young man- ate shellfish and then went to play tennis. Now is having difficulty breathing.
Young woman went hiking in the woods last week & now has hives present and is scratching.
12 year old girl crying and shaking, holding her very swollen arm/elbow - injured playing baseball
Autoimmunity
Recognizes self antigens as foreign
Produces antibodies against own tissue
Examples Lupus Rheumatoid
Arthritis
How do immunizations work?
The exposure (usually injection) to a small amt of virus triggers an immune response Help body prepare
antibodies
Type of immunity Active artificial
NCLEX Concepts of Emphasis
1. What are the similarities and differences between cellular and humoral immunity?
2. How do vaccinations work?3. To be fully immune requires which three
essential components of the inflammation/immune response?
4. What is the mechanism of Prednisone and the nursing considerations when giving?
5. What is the difference between an allergic reaction and side effect of a medication?
6. What is the similarities & differences between hypersensitivity and anaphylactic reaction?
Bronchospasm associated with hypersensitivity reaction is the result of:
A. histamine release B. pulmonary ventilation C. dilation of the alveoli D. inadequate antibody production
Which symptom indicates a possible allergic reaction?
A. fever B. diaphoresis C. rash D. chills