Exam 1 - Immune and Oncology

immunity

the body’s specific protective response to invading foreign agent or organism

bone marrow

production of WBC

-stem cells = undifferentiated cells

-lymphocytes = b and t cells

lymphoid tissues

lymph nodes serve as center for immune cell proliferation

-contain immune cells

2 types of immunity

natural (innate) and acquired (adaptive)

natural (innate) immunity components

-broad spectrum

-WBC action

-inflammatory response

-physical and chemical barriers

-immune regulation (balance and counterbalance)

acquired (adaptive) immunity components

-active (lasts a very long time)

-passive (temporary immunity

what is natural immunity

nonspecific response to any foreign invader

WBC action in natural immunity

-key to effective initiation of immune response

-granulocytes fight invasion of foreign bodies/toxins by releasing cell mediators such as histamine and by engulfing foreign bodies

types of WBCs in natural immunity

-neutrophils = 1st to arrive to site of inflammation

-eosinophils and basophils = increase during allergic reactions and stress

-monocytes (phagocytic cells) = engulf and ingest and destroy foreign bodies

-lymphocytes = b and t cells play a role in humoral and cell mediated responses

the inflammatory response

occurs in response to tissue injury or invading organisms

-walls off invading organism

-activates phagocytosis

-minimizes blood loss

-promotes formation of fibrous tissue and regeneration of injured tissue

physical and chemical barriers in natural immunity

physical = intact skin, cough, sneeze

chemical = mucous, gastric secretions, salive, enzymes in tears

immune regulation in natural immunity

-requires balance

-dysfunction can occur if immune components are inactivated, remain active too long, or fail to develop

acquired immunty

specific against a foreign antigen

-result of prior exposure to an antigen by contacting the disease or by vaccination

-weeks to months after exposure, body produces immune response to defend against re-exposure

2 types of acquired immunity

active = defense is developed by own body

passive = temporary, transmitted from a source outside the body

• ex. breastfeeding, receiving injections of immune globulin

acquired immunity 3 means of defense

1st protective response = phagocytic immune response

2nd protective response = humoral or antibody response

3rd protective response = cellular immune response

antigen

structural part of the invading organism

-responsible for stimulating antibody production

stages of immune response

recognition stage, proliferation stage, response stage, effector stage

recognition stage

-lymphocytes released from the lymph nodes recognize the antigen as foreign

-this triggers the second stage of the immune response

proliferation stage

-lymphocytes containing the invasion message return to the nearest lymph node

-t and b lymphocytes of stimulated to enlarge, divide, and proliferate

-for example, swollen or enlarged lymph nodes in your neck

response stage

-begins with the production antibodies by the b cells in response to a specific antigen

-t and b cells perform humoral and cellular responses

• transplant rejections, viral/fungal/parasitic infections, bacterial infections, immune diseases, bacterial pneumonia, sepsis

effector stage

antibody (of the humoral response) or killer t cell (of the cellular response) reaches and connects with the antigen on the invader cells surface

role of antibodies

also called immunoglobulins

-essentially large proteins

• agglutination of antigens = the clumping effect

• opsonization = sticky substance facilitates phagocytosis

-promote release of vasoactive substances (histamine); activation of complement system and phagocytosis

• act in concert with other components of the immune system

cellular immune response

-b lymphocytes (humoral immunity) = produce antibodies or immunoglobulins

-t lymphocytes (cellular immunity) = attack invaders directly, secrete cytokines, and stimulate immune system responses

-b and t cells work together

null cells and natural killer cells

null = destroy antigen coated with antibody

natural killer = defend against microorganisms and some malignant cells

complement system

circulating plasma proteins, made by the liver, activated when antibody connects with antigen

-assists with removal of infectious agent

-assists with initiating the inflammatory process

autoimmunity

normal protective immune response paradoxically turn against or attacks the body, leading to tissue damage

body produces inappropriate or exaggerated responses to specific antigens

hypersensitivity

gammopathies

overproduction of immunoglobulins

primary immune deficiency

deficiency results from improper development of immune cells or tissues

-usually congenital or inherited

secondary immune deficiency

deficiency results from some interference with an already developed immune system

-usually acquired later in life

variables that affect the immune system

-central nervous system integrity

-age and gender (immunosenescence = age related changes in the immune system)

-diet and nutrition (depletion of protein increases the susceptibility to infection)

-presence of conditions or disorders = cancer/neoplasm, chronic illness, autoimmune disorders, surgery/trauma

-allergies

-history of infection or immunization

-physical, emotional, and genetic factors

-lifestyle and physiological stressors

-medications and transfusions

diagnostic evaluation of immune system

-WBC count and differential

-bone marrow biopsy

-humoral and cellular immunity tests

-phagocytic cell function test

-complement component tests

-hypersensitivity tests

-specific antigen-antibody tests

-HIV infection tests

myelosuppresion

depression of healthy bone marrow

-most often occurs 7-14 days after chemotherapy

-can result in thrombocytopenia, anemia, leukopenia, or neutropenia

thrombocytopenia

decreased platelets

-risk of bleeding and infection

anemia

decreased RBC

-secondary to decreased production, increased destruction (hemolysis) or loss of cells through bleeding

leukopenia

decreased WBC

-cancer treatments (chemo, radiation, bone marrow transplant)

-bone marrow diseases

neutropenia

decreased neutrophils (type of WBC)

assessment of a pt with neutropenia

less than 2,000

-no definitive symptoms

-signs of infection

-nursing management = infection prevention, patient education, use of growth factors such as colony-stimulating factors, reduce dose of chemo or radiation

-history and physical exam, lab tests (CBC with differential, blood cultures, urinalysis) to evaluate for infection and underlying causes

helper t cells

activated on recognition of antigens and stimulate the rest of the immune system

-secrete cytokines

cytotoxic t cells

attack the antigen directly by altering the cell membrane and causing the cell to lysis

memory cells

responsible for recognizing antigens from previous exposure and mounting an immune response

supressor t cells

decreases B cell production

-response that is compatible with health

-keeps the immune system from attacking healthy tissue

abnormal cells have invasive characteristics, infiltrate other tissues

metastasis

demonstrate uncontrolled growth that does not follow physiologic demand

malignant cancer cells

a pattern of growth in which cells lack normal characteristics and differ in shape and organization

anaplasia

malignant (carcinogenesis) 3 step process

initiation, promotion, progression

initiation stage of carcinogenesis

carcinogens cause mutations in DNA

-normally, alterations are reversed by body’s DNA repair mechanisms such as apoptosis

-mutations are not significant to cells until 2nd stage

promotion stage of carcinogenesis

repeated exposure to promoting agents causes proliferation

-promotion is reversible if promoting substance if removed

progression stage of carcinogenesis

altered cells demonstrate increased malignant behavior

-angiogenesis

-metastasize

malignant cells

cancerous

- undifferentiated (look little/different)
- neoplasia: rapid growth
- causes weight loss and damage
- invade surrounding tissue, gains access to blood and lymphatic tissue
- can cause death

benign cells

noncancerous

- well differentiated (look like health tissue)
- grow slowly

-does not spread by metastasis
- does not cause many problems unless size is an issue

primary prevention of cancer

concerned with reducing cancer risk in healthy people

-avoid known carcinogens

-lifestyle, dietary changes to reduce risk

-recommended vaccinations (like HPV)

-public and patient education

secondary prevention of cancer

involves detection, screening to achieve early diagnosis, and intervention

-goal = to identify precancerous lesions and early-stage cancer in those who lack signs and symptoms

tertiary prevention of cancer

focuses on monitoring for and preventing recurrence of primary cancer

-screening for development of second malignancies in cancer survivors

assessment using CAUTION

C = change in bowel or bladder habits

A = a sore that does not heal

U = unusual bleeding or charge

T = thickening or lump in the breast or elsewhere

I = indigestion or difficulty swallowing

O = obvious change in mart or mole

N = nagging cough or hoarseness of voice

diagnosis of cancer

testing to determine:

-presence, extent of cancer

-possible spread (metastasis) of disease or invasion of other body tissues

-evaluate function of involved, uninvolved body systems, organs

-obtain tissue, cells for analysis, including evaluation or tumor stage, grade

tumor grading

shape, size, color, arrangement, and how those cells deviate from healthy cells

-look under microscope

-poorly differentiated = high grade, cells abnormal, quickly spread

-well differentiated = looks like normal cells, low grade, spreads slowly

tumor staging

determines location, size of tumor, if it spreads anywhere else

-lymph node involvement, existence of metastasis

-look at MRI, CT, XRAY, ultrasound, lab results

TNM staging system of tumor

T = extent of primary tumor; 1, 2, 3, 4 (tx cannot be assessed)

N = lymph node involvement; 0, 1, 2, 3 (nx cannot be assessed)

M = extent of metastasis; M0, M1 (mx cannot be assessed)

-once a cancer is staged at diagnosis, the stage will not change

grading a tumor in detail

assess cell under microscope to how much those cells deviate from healthy cells

-grade 1 = low differentiation, looks like normal healthy cells

-grade 2 = moderate grade, look a little different

-grade 3 = high grade, poorly differentiated, different shapes and sizes

-grade 4 = high grade, extremely abnormal

cancer management

cure, control, and palliation

surgical treatment of cancer

used as a primary treatment and a diagnostic procedure

-biopsy, endoscopic surgery, laparoscopic robotic surgery, surgical approach as tx, wide excision, local excision, prophylactic surgery, reconstructive surgery, palliative surgery

biopsy

- analysis OR tx
- margins are clear/clean, if they go back in

types = excisional (removes an entire lump), needle (take tiny tissue sample), incisional (removes part of a lump)

endoscopic surgery

minimally invasive

-thoracic and abdominal

minimally invasive surgical treatment

endoscopic surgery and laparoscopic robotic surgery

laparoscopic robotic surgery

more precision and dexterity

-prostate

surgical approach as treatment

local excision and wide excision

local excision

often used when mass is small

-removal of mass and small margin of normal tissue

wide excision

removal of primary tumor, lymph nodes, involved structures, and surrounding tissue

alternative surgical treatment

prophylactic surgery (can be before cancer diagnosis, test positive for a gene), reconstructive surgery (following prior surgery, for appearance), palliative (pain control, quality of life)

2 types of radiation therapy

external radiation (external beam radiation therapy) = precise beam of highly charged electrons penetrate body and target tumor

internal radiation = implanted by needle, seed, or catheter inside of body cavity

radiation toxicity

acute/early toxicity = stomatitis, xerostomia, radiodermatitis, changes in taste, anorexia, N/V/D, alopecia (depends on where radiation is), thrombocytopenia, systemic effects (fatigue, malise, anorexia)

late effects = tissue changes; changes to lungs, heart, CNS, and bladder

nursing management of pt undergoing radiation therapy

goal = promote healing, comfort, and quality of life

-patient, family education (need strong support system)

-restrictions, precautions

-skin care, oral care

-nutritional status

-protections of care providers (time, distance, shielding (diometer badges), private room, visitors)

chemotherapy goal

curative, control, or palliative

chemotherapy

antineoplastic drugs used to destroy tumor cells by interfering with cellular function, including replication and DNA repair

-may be used in conjunction with radiation or surgery

-each time a tumor is exposed to chemotherapy, a percentage of the tumor cell is destroyed

-repeated doses are needed to achieve regression of the cancer

-actively proliferating cells are most sensitive

cell kill and the cell cycle

-each time the tumor is exposed to chemo, a percentage of the tumor cells are destroyed

-repeated doses are necessary to achieve tumor regression

-actively proliferating cells are most sensitive

administration of chemotherapy agents

-dosage = based on pt total body surface area, weight, previous exposure and response, function of major organs

-extravasation

-hypersensitivity reactions

chemotherapy toxicity

can be acute or chronic, cells with rapid growth rates are most susceptible

-GI, hematopoietic (leukopenia, neutropenia, anemia, thrombocytopenia), renal, cardiac, repro, neuro, fatigue

nursing management in chemotherapy

-assessing fluid and electrolyte status

-assessing cognitive status

-modifying risks for infection, bleeding

-preventing nausea and vomiting

-administering chemotherapy

-protecting caregivers

hematopoietic stem cell transplantation

-Used for hematological cancers that affect marrow; treated with chemotherapy dosage that ablates bone marrow

-peripheral blood cell collection by apheresis (from an eligible donor)

-types = allogeneic, autologous, syngeneic, myeloablative, nonmyeloablative

nursing management in stem cell transplant: graft vs. host disease

-major cause of morbidity (greatest risk occurs within first 100 days)

-donor cells recognize the recipient cells as foreign and mount an immune response = rash to blistering, mucosal irritation, inflammation of GI tract, severe diarrhea, elevated liver enzymes

-prevention = immunosuppressant drugs

nursing management in stem cell transplant

-Implementing pre-transplantation care (nutritional assessment, organ function tests, psychological and physical exam)

-Providing care during treatment (monitor vital signs & oxygen sats)

-Adverse rxn = fever, chills, sob, cp, n/v/ hypotension, tachycardia, anxiety

-Providing post-transplantation care

-Caring for recipients (skin, liver, intestine, esophagus, eyes, lungs, joints, GVHD)

-Caring for donors (mood alterations, decrease self-esteem, guilt if fails)

immunotherapy

involves the use of medications or biochemical mediators to stimulate or suppress components of the immune system to kill cancer

-types = non specific immunotherapy, monoclonal antibodies, checkpoint inhibitors, cancer vaccines, CAR t-cell therapy

nonspecific immunotherapy

-Does not target cancer cells directly

-Boosts the immune system to enhance cancer cell destruction

-Can be used in conjunction with chemo or radiation

monoclonal antibodies

-Growing and producing targeted antibodies for specific malignant cells

-The MoAb attaches to the cell surface antigen and blocks communication between malignant cells

-The results may include inability to reproduce or invade surrounding tissues

-Destroy cancer cells and spare normal cells

checkpoint inhibitors

-Block proteins that diminish recognition by the immune system

-When the proteins are blocked, the immune system can identify and mount a response on the cancer cells

cancer vaccines

– Autologous vaccines: made from patient’s own cancer cells that are killed

– Prophylactic vaccines: HPV

CAR t-cell immunotherapy

– Chimeric antigen receptor T-cell therapy uses spec

– Uses genetically modified T-cells to kill cancer

neutropenia

neutrophil count less than 2,000

-pts with this do not always exhibit classic signs of infection

nursing management of neutropenia

■ Infection prevention

■ Patient education

■ Use of growth factors such as colony-stimulating factors

■ Reduce dose of chemo or radiation

■ Hand hygiene; oral hygiene

■ Avoid crowds

■ Do not share food, drinks, personal items like chapstick or toothbrushes

■ Shower and bathe daily

■ Cook meat, eggs all the way

■ Avoid or carefully wash fresh fruits and veggies

■ Avoid handing pet excreta (litter boxes/bird cages)

■ Use gloves for gardening/Avoid fresh flowers, soil and stagnant water

■ Appropriate vaccinations

points to remember with neutropenia

■ Be cautious with food preparation:

– Avoid undercooked or raw meat or eggs.

– Raw or unpasteurized products (check the label on the dairy products such as milk and cheese and

fruit juices, to ensure they are pasteurized).

– Unwashed fruits or vegetable

■ Protect from injury and infection

– Wear gloves when gardening

– Avoid manicures, pedicures and biting your nails

– Switch to an electric razor

– Good oral care

stomatitis

– Inflammatory process of the mouth

– Develops 3 to 14 days after certain chemotherapeutic agents, immunotherapies or targeted therapies and radiation

alopecia

– Permanent or temporary, begins 1-3 weeks after initial chemo/radiation; regrowth begins within 8 weeks of last treatment

– Prevent or minimize hair loss; scalp cooling if appropriate

– Prevent trauma to scalp

– Suggest ways to assist in coping with hair loss:

– Encourage patient to wear own clothes, retain social contacts

– Explain that hair growth usually begins again once therapy is completed

radiaition-associated impairment of skin

– Radiodermatitis

■ Wet desquamation: with drainage

■ Dry desquamation: without drainage

– Avoid sun exposure

– Avoid tight bandages or other sources of irritation or trauma

pt teaching: impaired skin integrity

■ Avoid use of soaps, cosmetics, perfumes, powders, lotions and ointments, deodorants, lukewarm water to bathe

■ Avoid rubbing or scratching area

■ Avoid shaving area with straight-edged razor

■ Avoid applying hot-water bottles, heating pads, ice, adhesive tape to area

■ Avoid exposing area to sunlight or cold weather

■ Avoid tight clothing in area; use cotton clothing

■ Topical agents such as Aquaphor and aloe vera ointment may be used

pt teaching: impaired nutrition

■ Assess GI status including nausea and vomiting

– previous experiences, expectations of nausea and vomiting, including causes, interventions used

– Anorexia

■ Alterations of taste, early satiety, sense of fullness, nausea and vomiting

■ Psychological distress

– Malabsorption

■ Damage to mucosal cells of bowel, altered GI tissue or peristalsis, decreased absorption

– Anorexia-Cachexia syndrome

■ Changes in tases; ”mouth blindness”, early satiety

■ Results from a combination of increased energy expenditure and decreased intake

■ Continued weight loss and malnutrition

-Adjust diet before, after drug administration according to patient preference, tolerance

-Prevent unpleasant sights, odors, sounds in environment

-Use distraction, music therapy, biofeedback, self-hypnosis, relaxation techniques, guided imagery before, during, after chemotherapy

pt teaching: nausea and vomiting

■ Administer prescribed antiemetic, sedatives, corticosteroids before chemotherapy, afterward as needed

■ Ensure adequate fluid hydration before, during, after drug

administration; assess intake, output

■ Encourage frequent oral hygiene

■ Provide pain relief measures if necessary

■ Consult with dietician as needed

■ Assess, address other contributing factors to nausea, vomiting

pt teaching: disturbed body image

■ Assess patient’s feelings about body image, level of self- esteem

■ Identify potential threats to patient’s self-esteem, encourage patient to verbalize concerns, individualize care

■ Encourage continued participation in activities, decision making

■ Assist patient in self care when fatigue, lethargy, nausea,

■ Assist patient to select/use cosmetics, scarves, hair pieces

■ Refer to specialists as needed

pt teaching: pain

■ Caused by underlying cancer process, associated with treatments, trauma from surgery, or neuropathies

■ Pharmacological and nonpharmacological approaches