MR. BERNIE PEDRIGAL MALABANAN, RN

LECTURE SERIES

IMMUNOLOGY AND

INFLAMMATORY

Six “ links” in the chain of infection

Etiologic agent -the microorganism causing the disease Reservoir- sources of microorganism Portal of exit from reservoir -the sites from which the

organism leaves the resevoir Method of transmission -means of transmission to reach

another hostDirect transmission -transfer from person to personVehicle-Borne transmission - A vehicle is any substance

that provides a means of transport and introduces a pathogen into a host

Vector-borne transmission - A vector is an animal or a flying or crawling insect that serves as a means of transport

Airborne transmission -may involve droplet or dust Portal of entry to a susceptible host Susceptible host

BODY DEFENSES AGAINST INFECTION

1. NONSPECIFIC DEFENSESAnatomic and Physiologic BarriersInflammatory Response

2. SPECIFIC DEFENSESAntibody-Mediated DefensesCell-Mediated Defenses

NON-SPECIFIC DEFENSES

ANATOMIC AND PHYSIOLOGIC BARRIERSskin and mucous membranesnasal passagesalveolar phagocytessaliva (lactoferrin, lysozyme, IgA)tearsstomach acidityresident flora of large intestinesacidic vaginal pH

NONSPECIFIC DEFENSES

INFLAMMATORY RESPONSE Local nonspecific defensive response of the tissues to an injurious or infectious agent

CARDINALS SIGNSCallorTumorRuborDolor Functio laesa

STAGES OF INFLAMMATIONSTAGE 1: Vascular and Cellular ResponsesSTAGE 2: Exudate ProductionSTAGE 3: Reparative Phase

STAGE 1: VASCULAR AND CELLULAR RESPONSE

bradykinin

vasoconstriction

vasodilation hyperemia

heat

redness

Increased vascular

permeability

margination

chemotaxis

diapedesis

leukocytosis emigration edema

pain

loss of function

histamine

Injurious agent

serotonin

prostaglandin

STAGE 2: EXUDATE FORMATION

chemotaxis

phagocytosis

exudate formation

STAGE 3: REPARATIVE PHASE

Exudate production

Tissue bursts out

Lymphatic system

collection

Granulation tissue forms

shrinks

Collagen formation scar

SPECIFIC DEFENSES

ANTIBODY-MEDIATED DEFENSES (HUMORAL IMMUNITY)

facilitated and mediated by B lymphocytes

TYPES OF IMMUNITY INDUCED1) ACTIVE – antibodies are produced by body

NATURAL – due to active infectionARTIFICIAL – due to administration of vaccines

2) PASSIVE – antibodies are transferred to the bodyNATURAL – transfer from mother and breastmilkARTIFICIAL – immunoglobulins is injected

FIVE CLASSES OF IMMUNOGLOBULIN1) IgM2) IgG3) IgA4) IgD5) IgE

IMMUNOGLOBULINS FEATURES

Immunoglobulin M • Comprises about 10% of Igs• First Ig produced during immune response• High concentration in blood stream• Present in the course of infection• Can react efficiently with bacteria and virus

Immunoglobulin G • Comprises 75% of antibodies in plasma• Accelerates phagocytosis• Neutralizes bacterial toxins• In prenatal life, it diffuses across placental barrier to provide fetus with passive immune protection till the infant can produce adequate defense

Immunoglobulin A • Secretory Ig in external body secretions: saliva, sweat, tears, mucus, bile, colostrums• Provides defense versus pathogens or exposed surfaces, the respiratory and GIT

Immunoglobulin D • Present in plasma• Levels are elevated by chronic infection

Immunoglobulin E • Low concentration in serum• Involved in immediate hypersensitivity reaction• high serum levels occur in allergy prone persons• Also high in persons infected with certain parasites like helminthes

CELL MEDIATED DEFENSE (CELLULAR IMMUNITY)facilitated by T-cells released into lymphatic system

upon exposure to antigen

MAIN GROUPS OF T CELLS1) helper T cells2) cytotoxic T cells3) suppressor T cells

T CELLS AND CELL-MEDIATED IMMUNITY

T Cells – life span ranges from a few months to the duration of a person’s life - they account for long-term immunity - circulate and enter regions called thymus-

dependent zones e.g. lymphoid tissues, blood circulation or extravascular spaces to encounter antigens.

- defend the body against infected host cells or non-self cells.

(example: rejection of transplant tissue organs.)

T CELLS FEATUREST killer Cells (Cytotoxic cells) • Bind to the surface of the invading

cells (disrupts membranes, kills it by altering cellular environment)• Essential in killing virally infected cells• Its chief toxic proteins called lymphokines to the area and stimulate production of interferons (functions to suppress the spread of virus from cell to cell

T Helper Cells (T4 cells) • Stimulate B lymphocytes to differentiate into antibody producers• Also interacts with mononuclear phagocytes with the result of enhancing destruction pathogens.

Features of Lymphocytes

T suppressor Cells (T8 cells)

• Reduce the humoral response• Mechanism of control of production of Ig either: by regulating proliferation of B cells or inhibiting activity of helper T cells.

FACTORS INCREASING SUSCEPTIBILITY TO INFECTION

AgeHeredityNature, Number and Duration of StressorNutritional StatusMedicationsHealth status

ASSESSMENT

NURSING HEALTH HISTORY ImmunizationScreening tests Infections in the past and treatment receivedRecurrence of infectionsMedications e.g. antibiotics, NSAIDS, steroids,

chemotherapeutic drugs Invasive diagnostic testsPrevious surgeriesEating habits Intake of vitamins and supplementsStress Loss of energy, appetite, nausea, headache

PHYSICAL ASSESSMENTLocalized swellingLocalized rednessPain or tendernessPalpable heatLoss of functionFeverIncreased PR and RREnlargement and tenderness of lymph nodes

LABORATORY DATAElevated leukocytesIncreased differentialsElevated erythrocyte sedimentation rate (ESR)Cultures of urine, blood, sputum, drainages

NURSING DIAGNOSIS

Risk for InfectionPotential Complication of Infection: FeverAcute PainImpaired Social InteractionAnxiety

NURSING INTERVENTIONS

Practice handwashing for at least 20 secondsUse alcohol based antiseptic hand rubsBreak chain of infectionUse caps, gloves, masks, gowns, goggles as neededEncourage proper hygienic practicesEnsure optimum nutrition: high calorie, vitamin CEncourage increased fluid intakeEncourage enough sleepMinimize stressDisinfect and sterilizePractice isolation

METHODS OF STERILIZATION1) Moist Heat – autoclave 2) Gas – ethylene oxide gas3) Boiling Water – should be done on minimum of 15

minutes4) Radiation – ionizing (x-ray) and ultraviolet rays

TYPES OF ISOLATION

1) CATEGORY-SPECIFIC ISOLATIONstrict isolation contact isolationrespiratory isolation tuberculosis isolationenteric precautions drainage precautionsbody fluid precautions

2) DISEASE-SPECIFIC ISOLATION

3) TRANSMISSION-BASED PRECAUTION

Airborne precautions – measles, varicella, tuberculosis

Droplet precautions – DP, mumps, rubella, pneumonia

Contact precautions – shigella, hepatitis A, influenza

SENSORY PERCEPTION

Components of the sensory Experience

2 Components :1. Sensory Reception2. Sensory Perception

Types of stimuli External stimuli. Internal Stimuli

Types of stimuli1. External stimuli Visual Auditory Olfactory Tactile gustatory

2. Internal StimuliGustatoryKinestheticStereognosisVisceral

Four Aspect of sensory Process

Stimulus : An agent or act that stimulates a nerve receptor

Receptor : A specialized nerve cell that converts the stimulus to a nerve impulse

Impulse conduction : After the nerve impulse is created it travels to the spinal cord or directly to the brain

Perception (awareness) : Specialized brain cells in the cerebral cortex interpret the nature and the quality of the sensory stimuli

Sensory perception begins with the stimulation of the of the nerve cellsNerve cell act as receptor by converting a stimulus into a nerve impulse the nerve impulse travels to the spinal cord or to the brain it is interpreted as sensation awareness of the sensation( sensory perception ) in the brain

Arousal Mechanism

Reticular activating system ( RAS)Located in the brainstemMediate the arousal mechanism2 components of RASReticular excitory area- responsible for stimulus arousal and wakefulnessReticular inhibitory areaSensoristasis- when a person is in optimal arousalAwareness ability to perceive enviromental stimuli and body’s

reaction

STATE OF AWARENESS

STATE DESCRIPTIONFull consciousness

alert; oriented to time, place, person, understands verbal and written words

Disoriented Not oriented to time, place or personconfused Reduced awareness,easily bewildered, poor

memory, misinterprets stimuli, impaired judgement

Somnolent Extreme drowsiness but will respond to stimuli

semicomatose Can be arouse by extreme or repeated stimuli

Coma Will not respond to verbal stimuli

SENSORY ALTERATIONS

Sensory deprivationSensory OverloadSensory Deficits

Sensory deprivation

Clinical ManifestationsExcessive yawning,drowsiness Decreased attention span, difficulty

concentrating ,decreased problem solvingImpaired memoryPeriodic disorientation, general confusion or nocturnal

confusionPreoccupation with somatis complainHallucination or delusionsCrying annoyance over small matters, depressionApathy, emotional lability

Sensory Overload

Factors that contribute to sensory overloadIncreased quantity or quality of internal

stimuliIncreased quantity or quality of external

stimuliInability to disregard stimuli selectively

Sensory Overload

Clinical manifestations:Fatigue, sleeplessnessIrritablity , anxiety, restlessnessPeriodic of general disorientationReduced problem- solving ability and task

performanceIncreased muscle tensionScattered attention and racing thought

Sensory Deficits

Clinical manifestations:BlindessDeafnessNote: They are at risk for both sensory

deprivation and sensory overload

FACTORS AFFECTING SENSORY FUNCTION

Developmental stageCulture Stress Medications and IllnessLifestyle and Personality

ASSESSMENT

Nursing historyPresent sensory perceptionUsual functioningSensory deficits and potential problems

CHARACTERISTICS OF NORMAL SENSORY PERCEPTION

SMELLDiscrimination of primary odors:CamphoraceousMuskyFloralPeppermintyEtherealPungentputrid

Characteristics of normal sensory perception

SOMATIC SENSESTouchPressureVibrationPositionTicklingTemperaturePain

Mental statusLOCOrientationMemoryAttention span

Physical Examination Visual acuityHearing acuity ( weber & Rinne tuning fork

tests)Olfactory senseGustatory sense Tactile sense

Characterictics of normal sensory perception

VISION

Visual acuity of 20/20Full field visionTri-color vision ( red, green, blue )

Characterictics of normal sensory perception

HEARINGAuditory acuity of sounds at an intensity of 0 –

25 decibelsFrequency- 8000 cycles / sec. TASTEDiscriminations of sweet, sour, salty, bitter

Client at risk

Sensory Deprivation:Confined in a non stimulating or monotonous

environmentHave impaired vision or hearingHave mobility restrictionsClients who are unable to process stimuliHave emotional disordersHave limited contact with family and friends

Sensory OverloadHave pain or discomfortILL and and have been admitted to acute care

facilityAre being closely monitored in an ICUHave decreased cognitive ability

Client Environment

Assess for :Quality, quantity.and type of stimuliStimuli that decrease the incidence of sensory

deprivation- Radio- Clock or calendar- Reading material or toys for children- Number and compatibility of roommates- Number of visitors

Social support Network

Assess Whether the client lives aloneWho visits and whenAny signs of social deprivation

NURSING DIAGNOSIS

Disturbed Sensory PerceptionAcute ConfusionChronic ConfusionImpaired memory

PLANNING

Prevent injuryMaintain the function of existing sensesDevelop an effective communication

mechanismPrevent sensory overload or deprivationReduce social isolationPerform ADL independently and safely

Nursing Intervention

ENSURING CLIENT SAFETYPlace bed in lowest positionRaise the siderailsPlacing the call light within reachAssisting the patient with ambulation and careUsing handrailsFrequent observationRestraints as prescribed

NURSING INTERVENTIONPREVENTING SENSORY OVERLOAD Minimize unnecassary light, noise, and distraction. Control pain as indicated. Introduce yourself by name, and address the client by name. Provide orienting cues. Provide private room Limit visitors. Plan care to allow for uninterrupted periods for rest or sleep Schedule a routine of care so that client knows when and what to expect Speak in a low tone of voice and in an unhurried manner Provide new information gradually Describe any test and procedures to the client beforehand. Reduce noxious odors. Take time to discuss the client’s problems and to correct

misinterpratations. Assist the client with stress reducing technique.

PREVENTING SENSORY DERPRIVATION Encourage the client to use eyeglasses and hearing aids Address the client by name & touch the client while speaking if this is

not culturally offensive Communicate frequently with the client and maintain meaningful

interactions. Provide a telephone ,radioand /or TV,clock and calendar. Provide murals, pictures, sculptures, and wall hangings Have family and friends bring freshly cutflowers and plants. Consider having a resident pet Include different textured object to feel. Increase tactile stimulation Encourage social interaction Encourage the use of crossword puzzle, or games to stimulate mental

function. Encourage environment changes Encourage the use of self-stimulation techniques

HEALTH TEACHING TO PREVENT SENSORY DISTURBANCES

Have regular health examinations Have regular eye examinations Seek early medical attention Obtain regular immunizations against diseases capable of

causing hearing loss Avoid giving infants and toddlers toys with log pointed handles Teach school age children and adolescents the proper use of

sports equiptment Wear protective eye googles when using power tools,riding

motorcycles, spraying chemicals etc. Wear ear protector when working in an environment with high

noise levels Wear dark glasses with UV protection

SENSORY AIDS

VISUAL Eyeglasses of the correct prescription clean and in good repair Adequate room lighting, including night-lights Sunglasses or window shades Bright contrasting colors in the environment Magnifying glass Phone dialer with large numbers Color code or texture code or texture code on stoves, washer,

medicine containers etc. Clock and wristwatch with large numbers. Colored or raised rims on dishes Reading materials with large print Braile or recorded book Seeing-eye dog

SENSORY AIDS

HEARINGHearing aid in good orderLip readingSign languageAmplified telephonesTelecommunication device for the deafAmplified telephone ringers and doorbellsFlashing alarm clocksFlashing smoke detectors

SENSORY AIDS

SMELLflower arrangements in roomfresh foodsperfumes

TASTEfresh foodright temperaturesips of water in between foodsno mixing of foodsTOUCHtherapeutic touch* lotion for pt.with sensory deprivationmassagesturning and repositioninghairbrushing and groomingNOTE: For pt. with sensory overload provide a private

room whenever feasible

Communicating Effectively

Convey respectEnhance the persons self-esteemEnsure the exchange of correct informationPls read BOX 38-5