Medical-Surgical Nursing Ist

1. UNIT IV
ALTERED IMMUNE RESPONSE
Submitted To
Mrs. Jisha Surendrakurup
Principal,
St. Catherine Hospital
& School of Nursing
Submitted By
Mr. Earnest Lamuel
Nursing Tutor,
St. Catherine Hospital
& School of Nursing

2. IMMUNITY
Immunity is the state of having sufficient
biological defenses to avoid infection, disease,
or other biological invasion. It is the capability
of the body to resist harmful microorganisms
or viruses from entering it.

3. TYPES OF IMMUNITY

4. INNATE IMMUNITY
Innate immunity or non specific immunity is
the natural resistances with which a person is
born. It provides a resistance through several
physical, chemical, and cellular approaches.

5. ADAPTIVE IMMUNITY
The adaptive immune system, also known as
the acquired immune system or, more rarely,
as the specific immune system, is a subsystem
of the overall immune system that is
composed of highly specialized, systemic cells
and processes that eliminate pathogens or
prevent their growth.

6. ADAPTIVE IMMUNITY
Adaptive immunity is often sub divided into two
major types-
Natural- Natural acquired immunity occurs
through contact with a disease causing agent
when the contact was not deliberate.
Artificial- Artificial acquired immunity develops
only through deliberate action such as vaccination.

7. NATURAL IMMUNITY
Natural immunity is often sub divided into two major
types-
 Active Immunity- The immunity which results from
the production of antibodies by the immune system
in response to the presence of an antigen.
 Passive Immunity- The short term immunity which
results from the introduction of antibodies from
another person.

8. ALTERED IMMUNE RESPONSE
The immune response is how our body recognizes and defends
against bacteria, viruses, and substances that appear foreign and
harmful.
The Immune system protects the body from possibly harmful
substances by recognizing and responding to antigens. Antigens
are substances on the surface of the cells, viruses, fungi, or bacteria.
Nonliving substances such as toxins, chemicals, drugs, and foreign
particles can also be antigens. The immune system recognizes and
destroys substances that contain antigens.

9. COMPLICATIONS
Complications due to an altered immune response-
Allergy or hypersensitivity
Anaphylaxis
Autoimmune disorders
Graft versus host disease
Immunodeficiency disorder
Transplant rejection

10. HYPERSENSITIVITY
Hypersensitivity (also called hypersensitivity reaction or intolerance) refers
to undesirable reactions produced by the normal immune system, including
allergies and autoimmunity. They are usually referred to as an over-reaction
of the immune system and these reactions may be damaging,
uncomfortable, or occasionally fatal.
Hypersensitivity reactions require a pre-sensitized (immune) state of the
host. They are classified in four groups after the proposal of P. G. H.
Gell and Robin Coombs in 1963.
Hypersensitivity describes an abnormal or pathologic immune reaction that
is caused by an immune response to repeated exposure to an antigen.

11. TYPES OF HYPERSENSITIVITY
 (Type I) Immediate
 (Type II) Antibody-mediated type
 (Type III) Immune complex mediate
 (Type IV) Cell mediated

12. (TYPE 1) IMMEDIATE
Immediate hypersensitivity is a rapid IgE and mast
cell mediated vascular and smooth muscle occurs in
genetically susceptible individuals upon exposure to
certain environmental antigens to which they have
been previously exposed.
These reactions are also known as allergies, and the
antigens that instigate these reactions are commonly
called allergens.

13. (TYPE II) ANTIBODY-MEDIATED
Type II Hypersensitivity results when antibodies
are directed against antigens on the surface of
cells or other tissue components.
These reactive antigens may be intrinsic, naturally
occurring antigens or the reactive antigen may be
an exogenous substance such as drug metabolite
that has absorbed to a cell surface.

14. (TYPE III) IMMUNE COMPLEX MEDIATE
Type III hypersensitivity diseases are some of the most
common immune-mediated diseases. In these diseases,
complexes of antibodies and antigens in circulation deposit
in the vascular walls of blood vessels leading to
inflammation.
Alternatively, the complexes may form “in situ” at locations
where the antigen or antibody has been initially deposited.
The antigens in these complexes may be exogenous or
endogenous.

15. (TYPE IV) CELL MEDIATED
Type IV hypersensitivity reactions are inappropriate
or excessive immune reactions that are mediated by a
specific subsets of CD4+ helper T cells or by CD8+
cytotoxic T cells.
These reactions form the basis of many common
diseases ranging in severity from contact dermatitis to
diseases such as type I diabetes and viral hepatitis.

16. ALLERGY
Allergies occur when the immune system
reacts to a foreign bodies such as pollen, bee
venom, or pet dander.
The immune system produce substances
known as antibodies. Some antibodies protect
us from unwanted invaders that could make
us sick or cause infection.

19. SYMPTOMS
Hay Fever (Rhinitis)
•Sneezing
•Itching of the nose , eyes or roof of the
mouth
•Runny, stuffy nose

20. SYMPTOMS
A Food Allergy
•Tingling mouth
•Swelling of lips, tongue, face or throat
•Hives
•Anaphylaxis

21. SYMPTOMS
An Insect Sting Allergy
•Edema
•Itching or hives all over body
•Cough, shortness of breath

22. SYMPTOMS
A Drug Allergy-
•Hives
•Itchy skin
•Rash
•Facial swelling
•Wheezing

23. CAUSES
Airborne allergens, certain food like wheat,
fish, egg, milk, insect stings, medications,
latex, etc.

24. TREATMENT
1. Allergens avoidance
2. Medication to reduce symptoms
3. Immunotherapy
4. Emergency epinephrine

25. COMPLICATIONS
1. Anaphylaxis
2. Asthma
3. Dermatitis
4. Sinusitis
5. Fungal complications

26. ASSESSMENT OF IMMUNE SYSTEM
The Agency for Toxic Substances and Disease Registry (ATSDR) basic panel of
immune function tests consists of a group of assessments that are performed
with serum and several other substances that are performed on whole blood.
Assays of serum include the following:
C Reactive Protein (CRP) – A marker of acute-phase reactions and a sensitive
indicator of tissue damage from a variety of causes
Immunoglobulins (Ig) G and M - Indicators of humoral immune status
IgA - An indicator of mucosal humoral immunity
Antinuclear antibody - An indicator of autoantibodies
Total protein - Used to correct the concentration of immunoglobulins for
concentration of blood proteins.

27. ALLERGIC DISORDERS
 Anaphylaxis
 Allergic Rhinitis
 Contact Dermatitis
 Atopic Dermatitis
 Drug Reactions
 Food Allergy
 Serum Sickness
 Latex Allergy

28. ANAPHYLAXIS
Anaphylaxis is a serious allergic reaction that is rapid in onset and may
cause death. It typically causes more than one of the following: an itchy
rash, throat or tongue swelling, shortness of breath, vomiting, light
headedness, and low blood pressure. These symptoms typically come on
over minutes to hours.
Common causes include insect bites and stings, foods, and
medications. Other causes include latex exposure and exercise. Additionally,
cases may occur without an obvious reason. The mechanism involves the
release of mediators from certain types of white blood cells triggered by
either immunologic or non-immunologic mechanisms. Diagnosis is based
on the presenting symptoms and signs after exposure to a
potential allergen.

31. ALLERGIC RHINITIS
Allergic Rhinitis, also known as hay fever, is a type of inflammation in the
nose which occurs when the immune system overreacts to allergens in the
air. Signs and symptoms include a runny or stuffy nose, sneezing, red, itchy,
and watery eyes, and swelling around the eyes. The fluid from the nose is
usually clear. Symptom onset is often within minutes following exposure
and they can affect sleep, the ability to work, and the ability to concentrate
at school. Those whose symptoms are due to pollen typically develop
symptoms during specific times of the year. Many people with allergic
rhinitis also have asthma, allergic conjunctivitis, or atopic dermatitis.

33. POLLEN GRAINS FROM A VARIETY OF PLANTS, ENLARGED
500 TIMES AND ABOUT 0.4 MM WIDE

34. CONTACT DERMATITIS
Contact Dermatitis is a red, itchy rash caused by
direct contact with a substance or an allergic reaction to it.
The rash isn't contagious or life-threatening, but it can be
very uncomfortable. Many substances can cause such
reactions, including soaps, cosmetics, fragrances, jewellery
and plants.

37. ATOPIC DERMATITIS
Atopic Dermatitis (eczema) is a condition that
makes your skin red and itchy. It's common in
children but can occur at any age. It is long lasting
(chronic) and tends to flare periodically. It may be
accompanied by asthma or hay fever. No cure has
been found.

40. DRUG REACTIONS
Adverse Drug Reaction (ADR, or adverse drug effect) is a
broad term referring to unwanted, uncomfortable, or
dangerous effects that a drug may have.
Adverse drug reactions can be considered a form of toxicity;
however, toxicity is most commonly applied to effects of over
ingestion(accidental or intentional) or to elevated blood levels
or enhanced drug effects that occur during appropriate use
(e.g., when drug metabolism is temporarily inhibited by a
disorder or another drug).

43. FOOD ALLERGY
Food Allergy is an immune system reaction that
occurs soon after eating a certain food. Even a tiny
amount of the allergy-causing food can trigger
signs and symptoms such as digestive problems,
hives or swollen airways.

46. SERUM SICKNESS
Serum Sickness is an allergic reaction to an injection of serum, typically
mild and characterized by skin rashes, joint stiffness, and fever.
Serum sickness in humans is a reaction to proteins in antiserum derived
from a non-human animal source, occurring 5–10 days after exposure. It
is a type of hypersensitivity, specifically immune complex
hypersensitivity (type III). The term serum sickness–like reaction (SSLR) is
occasionally used to refer to similar illnesses that arise from the
introduction of certain non-protein substances, such as penicillin. It was
first characterized by Clemens von Pirquet and Béla Schick in 1906.

49. LATEX ALLERGY
Latex Allergy symptoms may include hives, itching,
stuffy or runny nose. Symptoms begin within minutes
after exposure to latex containing products. The most
severe latex allergy can result in anaphylaxis, a
serious allergic reaction involving severe breathing
difficulty and/or fall in blood pressure (shock).

52. APPROACHES TO TREAT
ALLERGIC DISEASES
 Allergen Avoidance
 Allergen Immunotherapy
 Medications to reduce symptoms
 Emergency Epinephrine

53. ALLERGEN AVOIDANCE
Careful Allergen Avoidance of the specific allergens responsible for
allergic disease should always be the first consideration in managing
patients with allergies. This is the primary form of treatment for food
allergies and some stinging insect allergies, as avoidance can be a
very effective strategy if patients are well educated about
precautionary measures. For example, a person allergic to jumper-ant
venom can minimise the chances of being stung by wearing shoes
and long-sleeved shirts when outdoors and gloves when gardening.
Accurate diagnosis of food allergies can enable patients to minimise
the disruption to their lives caused by an unnecessarily restrictive diet.

54. ALLERGEN IMMUNOTHERAPY
Allergen-specific Immunotherapy involves administration of
increasing doses of allergen to a patient to achieve clinical and
immunological tolerance over time.
Allergen injection immunotherapy induces T cell tolerance by several
methods, including decreased allergen-induced proliferation,
alteration of secreted cytokines, stimulation of apoptosis, and the
production of T regulatory cells.
This results in a reduction in inflammatory cells and mediators in the
affected tissues, the production of blocking antibodies, and the
suppression of IgE.

55. NURSING MANAGEMENT
OF THE CLIENT WITH THE
ALTERED IMMUNE RESPONSE
 Avoidance of stress
 Environmental control - air conditioned room, damp dusting
daily, hypoallergenic covers, mask outdoors
 Monitor for side effects
 Evaluate the progress of the client
 Encourage self care
 Maintain close supervision
 Educate the attender about the follow up care

56. AUTO IMMUNE DISEASES
An Autoimmune Disease is a condition arising from an abnormal immune
response to a normal body part. There are at least 80 types of autoimmune
diseases. Nearly any body part can be involved. Common symptoms include
low grade fever and feeling tired. Often symptoms come and go.
The cause is generally unknown. Some autoimmune diseases such as lupus run
in families, and certain cases may be triggered by infections or other
environmental factors. Some common diseases that are generally considered
autoimmune include celiac disease, diabetes mellitus type 1, Graves'
disease, inflammatory bowel disease, multiple sclerosis, psoriasis, rheumatoid
arthritis, and systemic lupus erythematosus. The diagnosis can be difficult to
determine.

57. TYPES
 Rheumatoid Arthritis
 Systemic Lupus Erythematosus
 Ankylosing Spondylitis
 Graft Versus Host Disease

58. RHEUMATOID ARTHRITIS
Rheumatoid Arthritis is a systemic disorder in which
immune cells attack and inflame the membrane around
joints. It can affect the heart, lungs and the eyes as well.
It is an inflammatory disorder of unknown origin that
primarily involves the synovial membrane of the joints.

59. CLINICAL FEATURES
• Joint Pain
• Swelling
• Warmth
• Erythema
• Lack of basic functions of the extremities.

60. ASSESSMENT &
DIAGNOSTIC METHODS
 Several factors contribute to an RA diagnosis
• Rheumatoid Nodules
• Joint Inflammation
• Laboratory Findings
• Extra articular Changes
 RBC Count & C4 Compliment are decreased
 Erythrocyte Sedimentation Rate is elevated
 C Reactive Protein and Anti Nuclear Antibody Test results may be positive
 Arthrocentesis and X Rays

61. DIAGNOSTIC EVALUATIONS
 ANA - Antinuclear Antibody
Titer
 RF - Rheumatoid Factor
 Latex Fixation
 Agglutination Reactions
 Serum Complementation
 ESR - Erythrocyte Sedimentation
Rate
 CBC – Complete Blood Count
 Ig (IgM & IgG) –
Immunoglobulins
 X Rays
 Radionuclide Scans
 Direct Arthroscopy
 Synovial Fluid Aspiration
 Synovial Membrane Biopsy

62. MEDICAL MANAGEMENT
 NSAIDS
 Immunosuppressants
 Reconstructive Surgery
 Corticosteroids
 Antidepressants

63. NURSING MANAGEMENT
 Relieving Pain & Discomfort
 Reducing Fatigue
 Increasing Mobility
 Facilitating Mobility
 Improving Body Image
 Progressive Coping Skills
 Monitoring Potential Complications

64. SYSTEMIC LUPUS ERYTHEMATOUS
Systemic Lupus Erythematous is an inflammation of the
connective tissues, which can afflict every organ system. It is up
to nine times more common in women than men and strikes
black women three times as often as white women. The
condition is aggravated by sunlight.
It is a chronic inflammatory autoimmune disease of unknown
aetiology that commonly affects women of child bearing age.
Lethargy and fatigue are described as the most disabling of
lupus symptoms.

65. CLASSIFICATION
 Systemic Lupus Erythematosus
 Discoid Lupus Erythematosus
 Drug Associated Lupus Syndrome
 Antiphospholipid Syndrome

66. EPIDEMIOLOGY
Lupus is 10 to 20 times more common in women
that in men and is most likely to develop between
the ages of 15 to 40.

67. CAUSES
 Hormonal Changes
 Environmental Changes
 Drugs
 Genetic Factors

68. TREATMENT
Physical Exercises
Aerobic Exercises
Strengthening Exercises
Proper Positioning
Ultrasonography
Aqua Therapy
Occupational Therapy

69. NURSING MANAGEMENT
 Relieving Pain & Discomfort
 Reducing Fatigue
 Increasing Mobility
 Facilitating Mobility
 Improving Body Image
 Progressive Coping Skills
 Monitoring Potential Complications

70. ANKYLOSING SPONDYLITIS
Ankylosing Spondylitis (AS) is a type of arthritis that affects
your spine. It can cause pain, stiffness, and inflammation from your
neck to your lower back. When you have this condition, the vertebrae
in your spine can fuse together. This makes your spine less flexible
and might lead to a hunched-over posture and trouble breathing.
Early diagnosis and treatment can control the condition and prevent
these and other problems.

71. SYMPTOMS
• Pain and stiffness
• Bony fusion
• Pain in ligaments and
tendons
• Bent posture
• Breathing problems
• Heart trouble
• Eye problems
• Inflammatory bowel
disease
• Psoriasis
• Fatigue
• Dactylitis
• Fever

72. RISK FACTORS
Age - It tends to start between in teens and 30s.
Gender - Men are two to three times more likely to get
the disease than women.
Genetics - One can inherit it from parents. One gene,
called HLA-B27, is common in people with AS.
Ethnicity - AS appears more often among native tribes in
the U.S. and Canada, especially Alaskan Eskimos.

73. TYPES
 Axial Ankylosing Spondylitis
 Peripheral Ankylosing Spondylitis

74. DIAGNOSTIC EVALUATIONS
 X-ray
 MRI - Magnetic Resonance Imaging
 CT Scan
 Blood Tests

75. TREATMENT
Nonsteroidal anti-inflammatory drugs
(NSAIDs)
• Ibuprofen
• Indomethacin
• Meloxicam
• Naproxen
Corticosteroid shots in your joints
Disease-modifying anti-rheumatic
drugs (DMARDs)
• Methotrexate
• Sulfasalazine
Biologic DMARDs
• Adalimumab (Humira)
• Certolizumab Pegol (Cimzia)
• Etanercept (Enbrel)
• Golimumab (Simponi)
• Infliximab (Remicade)
• Secukinumab (Cosentyx)

76. NURSING CONSIDERATIONS
 Exercise daily - Moving helps in staying flexible. It can help ease back
pain and stiffness. A physical therapist can teach how to exercise safely.
Work out in a warm pool to make movement easier.
 Practice posture - Sitting and standing up straight may help with pain
and stiffness.
 Heat and cold therapy - Using moist heat pads or taking hot showers can
ease the stiffness, sore back. Cold packs can lower swelling in inflamed
joints.
 Healthy lifestyle and food choices - Keep a healthy body weight or ask
the doctor how you can lose weight if you need to. Extra pounds stress
the back and other joints. Smoking makes AS worse.

77. NURSING CONSIDERATIONS
 Follow the treatment plan - Take medications as prescribed,
don’t smoke, and exercise daily to help ease inflammation and
prevent spine fusion or organ damage.
 Watch for signs of inflammation in other areas - Talk to the
doctor if pain or redness in eyes, pain in your stomach, or a
patchy rash on your skin persists.
 Get support - It’s helpful to talk to others who have AS. The
Spondylitis Association of America has support groups in many
areas as well as online communities.

78. GRAFT VERSUS HOST DISEASE
Graft Versus Host Disease is a process in which donor T-cells
attack by the host cell, manifesting primarily in skin, liver and
gastrointestinal complication. Graft-versus-host disease (GvHD) is
a medical complication following the receipt of transplanted tissue
from a genetically different person. GvHD is commonly associated
with stem cell transplants such as those that occur with bone
marrow transplants. GvHD also applies to other forms of
transplanted tissues such as solid organ transplants.

79. GRAFT VERSUS HOST DISEASE

80. PATHOPHYSIOLOGY
 Acute GVHD occurs in several steps
 High dose conditioning regimen causes cell
injury and inflammation in the host cells,
leading to a release of cytokines.
 Host Antigen Presenting Cells (APCs) cause
activation of the donor T cells.
 Cell Injury and death is induced by cytokines
and donor T cells.

81. RISK FACTORS
Donor/Recipient Factors
• Increased Age
• Female Donor & Male Recipient
• Unrelated Donor

82. TYPES
• Acute GVHD
• Chronic GVHD

83. ACUTE GVHD
The onset of Acute GVHD develops with
conventional allogenic transplant between 14-35
days after infusion, but typically can occur up to
100 days or longer.
Reduced intensity transplant recipients can
develop acute GVHD weeks to months after the
transplant.

84. CHARACTERISTICS
Acute GVHD graded using one of two
scales. The Glucksberg scale was
developed over 30 years ago and is still
used in many institutions.

85. SKIN
 Skin GVHD is graded according to the percentage
of body surface area involved.
 Must differentiate from drug reaction and skin
infection.
 Biopsy can help in differentiation.

86. LIVER
 Liver GVHD graded according to the bilirubin level.
 Liver biopsy can clarify.

87. GUT
 Gut GVHD is graded according to the volume of stool
daily.
 Typically presents nausea, anorexia, abdominal pain and
watery diarrhea which can be liters per day.
Severe cases may experience bloody diarrhea.

88. OTHER ORGANS
Some feel that GVHD can also affect the lung,
causing problems such as alveolar hemorrhage,
interstitial pneumonitis, bronchiolitis and other lung
conditions.

89. CHRONIC GVHD
Chronic GVHD typically occurs 60-400
days after transplant and can last from
months to years after. The median time to
develop chronic GVHD with an unrelated
donor is 133 days and 201 days.

90. CHARACTERISTICS
Chronic GVHD resembles autoimmune
disorders, such as lupus, Sjogren’s
syndrome and scleroderma. The skin, oral
mucosa, liver and lacrimal glands are the
most frequently involved areas.

91. SKIN
 Skin changes can vary greatly ranging from
erythematous or purple maculopapular rash and
scaling to pigmentation changes and fibrosis.
 Skin can become fibrotic, immobile and fixed to tissue
below it.
 Hair may be brittle, thin, fall out.
 Sweat gland can be damaged.

92. EYES
 Chronic GVHD causes fibrosis of the
lacrimal glands.
 Patient reports dry or burning eyes,
photophobia or sensation of something
under eyelid.

93. ORAL
 Damaged to salivary gland results in
decreased saliva production, dry mouth,
irritation and dental decay.
 Ulceration and white plaques can
develop in the oral mucosa.

94. LIVER
 Damages bile duct epithelium and can
cause cholestasis.
 Elevation in bilirubin, alkaline and
phosphate is common.

95. OTHER SITES
GI Tract – Esophageal Fibrosis
Lungs – Cough, Wheezing & Dyspnea
Immune Suppression – Bone Marrow
Suppression
Musculoskeletal, Vulvar and Vaginal, Cardiac
and Kidney Changes can occur.

96. TREATMENT
 Corticosteroids - Destroy T cells and suppress
cytokine production via anti-inflammatory
effects.
 Cyclosporine - Immunosuppressant.
 Tacrolimus - Immunosuppressant.
 Methotrexate - Chemotherapy agent
 Anti-thymocyte Globulin

97. NURSING CONSIDERATIONS
Skin
• Topical steroid creams may be used.
• Maintain skin integrity with lotions, creams and or moisture barriers.
• Wound care blistering or open areas.
• Burn care for severe cutaneous involvement.
Liver
• Education about liver biopsy.
• Cautious use of hepatotoxic medication.

98. NURSING CONSIDERATIONS
Gut
• Maintain input and output chart.
• Rectal care consisting of cleansing after each bowel movement
and moisture barrier cream.
• Monitor for GI bleeding, test emesis and stool for occult blood.
• Monitor hemoglobin, hematocrit and platelet counts.
• Management of fecal incontinence.
• NPO Diet.

99. THANK
YOU