Immunologic Disorders - Week 8

Med Surg

Immune System Function

As the body’s defense mechanism against invasion and allows a rapid response to foreign substances in a specific manner

• involves inflammation and immunity to work with other defenses in providing protection from harmful microorganisms and cells (both inflammation and immunity are critical in maintaining health and preventing disease)

Immunocompetent

When all the different parts and functions of inflammation and immunity are working well, giving the individual maximum protection against infection

Natural (Innate) Immunity

Nonspecific immunity, present at birth

• the first line host defense following antigen exposure, because it protects the host without remembering prior contact with an infectious agent

Acquired (Adaptive) Immunity

Specific immunity that develops at birth

• usually develops as a result of prior exposure to an antigen through immunization (vaccines) or by contracting a disease

Natural Immunity Cont…

Can also be called inflammation, it provides immediate protection against the effects of tissue injury and invading foreign proteins

• innate-native immunity: any natural protective feature of a person

• it can be a barrier to prevent organisms from entering the body or can be an attacking force that eliminates organisms that have already entered the body

Includes:

• Skin

• Mucosa

• Cilia of the respiratory tract

• Acidic gastric secretions

• Antimicrobial chemicals on the skin

Acquired Immunity Cont…

Internal protection that results in long-term resistance to the effects of invading microorganisms

• responses are NOT automatic, the body has to learn to generate specific immune responses when it is infected by or exposed to specific organisms

Antibody-Mediated (Humoral) immunity

Begins with B lymphocytes and transform into plasma cells that manufacture specific antibodies to disable invaders

Cell-Mediated Immunity

Involves T lymphocytes, which turn into special cytotoxic (or killer) T cells that can attack the pathogens

IgA Antibody

Most responsible for preventing infection in the upper and lower respiratory tracts, the GI tract, and the GU tract

IgD Antibody

Present in low blood concentrations in the conjunction with IgM

IgE

Binds to mast cells and causes their degranulation when an allergen (antigen) binds to IgE antigen recognition sites

IgG Antibody

Activates classic complement pathway and enhances neutrophil and macrophage actions

IgM Antibody

Effective at the antibody actions of agglutination and precipitation because of having 10 potential binding sites per molecule, activates complement pathway

Autoimmunity

A process whereby a person develops an inappropriate immunity, in this response, antibodies or lymphocytes are directed against healthy normal cells and tissues

• known as autoantibodies

Management of autoimmunities depends on the organ or organs affected as there is no cure

• anti-inflammatory drugs and immunosuppressive drugs are commonly used alone with symptomatic treatment to suppress the excess immunity

Immunity Changes with Aging: Inflammation

Reduced neutrophil function

Leukocytosis does not occur during a acute infection

Older adults may not have fever during inflammatory or infectious episodes

Immunity Changes with Aging: Antibody-Mediated Immunity

• The total number of colony-forming-B-lymphocytes and the ability of these cells to mature into antibody-secreting cells are diminished

• There is a decline in natural antibodies, decreased response to antigens, and reduction in the amount of time the antibody response is maintained

Immunity Changes with Aging: Cell-Mediated Immunity

The number of circulating T-lymphocytes decreases

Physical Assessment Immune

Neurosensory: cognitive dysfunction, hearing loss, visual changes, headaches, ataxia, tetany

Respiratory: changes in RR, cough, abnormal lung sounds, rhinitis, bronchospasm

Cardiovascular: hypotension, tachycardia, dysrhythmia, vasculitis, anemia

Gastrointestinal: hepatosplenomegaly, colitis, vomiting, diarrhea

Genitourinary: frequency and burning, hematuria, discharge

Musculoskeletal: joints mobility, edema and pain

Integumentary: lesions, dermatitis, purpura, urticaria, inflammation, or any discharge

Lymph: lymph nodes are palpated for location, size, consistency, and tenderness

Vital signs: temperature is recorded, and the patient is observed for chills and sweating

Rheumatic Diseases

Encompasses autoimmune, degenerative, inflammatory, and systemic conditions that affect the joints, muscles, and soft tissues of the body. Problems include:

• limitations in mobility and ADLs

• Pain

• Joint swelling and stiffness

• Fatigue

• Sleep disturbances

• Systemic effects that can lead to organ failure and death

Osteoarthritis

Also called degenerative joint disease, is a noninflammatory, localized progressive deterioration and loss of cartilage and bone in one or more joints

• not systemic or autoimmune disease

• as cartilage and the bone beneath the cartilage begin to erode, the joint space narrows and osteophytes (bone spurs) form

• secondary joint inflammation can occur when joint involvement is severe

Signs of Osteoarthritis

• Joint stiffness/pain

• Pain that diminishes after rest and worsens with activity

• Functional impairment

• Possible tenderness

• Crepitus

• Heberden’s Nodes (first knuckle)

• Boucharad’s Nodes (second knuckle)

• Joint Effusion

Interventions for Osteoarthritis

Supportive care

Pain management

• Tylenol, NSAIDs, COX2 inhibitors, opioids

• Cortisone injections Q3 months

PT/OT

Surgery

Post-Op Care of the Older Adult with a Total Hip Arthroplasty

• Abduction pillow/splint

  • prevent adduction

• Heel elevation

  • prevent pressure ulcers

• Do not rely on fever as a sign of infection

  • decreased mental status is a better indicator in the elderly

• Move patient slowly

  • orthostatic hypotension

• Encourage the patient to cough and deep breath, use incentive spirometry

• Get the patient up and out of bed when permitted (preferably ASAP)

• Anticipate the patient’s need for pain relief

• Expect a temporary change in mental status immediately after surgery as a result of anesthesia and unfamiliar sensory stimuli

  • reorient them frequently

Post-Op care of the Older Adult with Total Knee Arthroplasty

Apply continuous passive motion machine as soon as it is ordered

Manage the patient’s pain to provide comfort, increase participation in activity and improve joint mobility

Maintain the knee in a neutral position and not rotated internally or externally

Teach the patients that they are able to partially bear weight unless their prosthesis is not cemented

Complications of Total Joint Arthroplasty

Dislocation

VTE

Infection

Anemia

Neurovascular comprise

Rheumatoid Arthritis

Chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints

• transformed autoantibodies (rheumatoid factors) are formed that attack healthy tissue, especially synovium, causing inflammation. The disease then begins to involve the articular cartilage, joint capsule, and surrounding ligaments and tendons.

  • characterized by natural remissions and exacerbations

Rheumatoid Arthritis Early Symptoms

Joint: symmetric joint pain, inflammation and stiffness especially in the morning

Systemic: low-grade fever, fatigue, weakness, anorexia, parasthesias

Late Manifestations of Rheumatoid Arthritis

Joint: deformities like swan neck or ulnar deviation, moderate to severe pain, morning stiffness, swelling, warmth, erythema, lack of function

Systemic: fever, weight loss, fatigue, anemia, lymph node enlargement, subcutaneous nodules, peripheral neuropathy, pericarditis, and cardiovascular disease

Interventions for Rheumatoid Arthritis

Nonpharamcological:

• ice, heat, proper positioning, adequate rest, proper diet, hot shower in the morning

Pharmacological:

• anti-inflammatory and analgesics

  • NSAIDs, COX2 inhibitors

  • Glucocorticoids

• Immunosuppressives/DMARDs

  • methotrexate and hydroxychloroquine

• Surgery

  • synovectomy

  • total joint replacement

Systemic Lupus Erythematosus

An inflammatory, autoimmune disorder that affects nearly every organ in the body

• involves chronic states where symptoms are minimal or absent and acute flare ups

Lupus Nephritis

Subtype of lupus due to the autoimmune complexes in SLE tend to be most attracted to the glomeruli of the kidneys

Discoid Lupus Erythematosus

Subtype of lupus that primarily affects the skin on the face

SLE Signs: Skin

Inflamed, red butterfly rash, discoid lesions, oral ulcers

SLE Signs: Renal

Nephritis, kidney failure

SLE Signs: Cardiovascular

Pericarditis, myocarditis, HTN, dysrhythmias, atherosclerosis, raynauds

SLE Signs: Pulmonary

Pleural effusions

SLE Signs: Neuro

Psychosis, cognitive impairment, seizures, neuropathies, stroke

SLE Signs: GI

Abdominal pain

SLE Signs: Musculoskeletal

Joint inflammation, arthralgia, polyarthritis

SLE Signs: Other

Fever, fatigue, anorexia, weight loss

SLE Interventions

Supportive care

Pharmacological:

• topical cortisone preparations

• analgesics

• anti-malarial agent

  • hydroxychloroquine

• Steroids

• Immunosuppressive agents

  • methotrexate or azathioprine

• Biologic/monoclonal antibody

  • belimumab

Sjorgren's Syndrome

Systemic autoimmune disease that progressively affects the lacrimal and salivary glands of the body

• Problems:

  • keratoconjuctivitis sicca

  • xerostomia

  • dry vagina

• Cause by autoimmune destruction (excess immunity) of the lacrimal, salivary, and vaginal mucus-producing glands

Signs of Sjorgren’s Syndrome

Dry eyes, blurred vision and burning/itching of the eyes

Thick mattering of the conjunctiva

Dry mouth, difficulty swallowing

Changes in taste

Epistaxis

Frequent URIs

Vasculitis, arthralgia, neuropathy

Interventions for Sjorgren’s Syndrome

Nonpharmacological

• artificial tears, artificial saliva, humidifiers, lubricants, moisturizers

• eat small frequent meals and omit spicy, salty or irritating foods

• avoid smoking, excessive alcohol use, and drugs with anticholinergic side effects

Pharmacological:

• DMARDs

  • methotrexate, cyclophosphamide, cyclosporine, hydroxychloroquine

Gout

An inflammatory arthritis and a systemic disease in which urate crystals deposit in the joints and other body tissues causing inflammation

• incidence of gout increases with age, BMI, alcohol consumption, HTN and diuretic use

• secondary gout causes include:

  • renal insufficiency, diuretic therapy, crash diets, and certain chemotherapeutic agents decrease the normal excretion of uric acid and other waste products

Signs of Gout

Joint inflammation, painful even to touch

Swelling, redness, warmth

Tophi

Renal calculi

Gout Labs

No tests for gout but

• serum uric acid

• ESR

• arthrocentesis

Gout Interventions

Low-purine diet

For acute: colchicine, NSAIDs, corticosteroid

Chronic: allopurinol, probenecid

Fibromyalgia

Chronic pain syndrome (not inflammatory) where pain, stiffness, and tenderness are located at specific sites in the back of the neck, upper chest, trunk, low back and extremities

• tender points are also called trigger points and can typically be palpated to elicit pain in a predictable, reproducible pattern

• 25-65% of these patients also have other rheumatologic conditions

Fibromyalgia Signs

Chronic fatigue

Generalized muscle aching

Stiffness

Sleep disturbances

Functional impairment

Forgetfulness

Concentration problems

Fibromyalgia Interventions

Supportive care

• limit caffeine, alcohol, exercise regularly, and a establish a sleep pattern

• PT and CBT

Pharmacological:

• Antidepressants: TCAs, SNRIs, SSRIs

• Analgesics: NSAIDs, muscle relaxants, tramadol

• Anticonvulsants: gabapentin, pregabalin