Immune Disorders Notes

Disorders of the Immune System

  • Three categories:
    • Hypersensitivity reactions
    • Autoimmune disorders
    • Immune deficiencies

Hypersensitivity Reactions

  • Injury to the body due to an exaggerated immune response.
  • Classified by how tissue is injured:
    • Type 1
    • Type 2
    • Type 3
    • Type 4
Hypersensitivity Reactions Examples
  • Anaphylaxis
  • Hemolytic transfusion reactions
  • Measles
  • Transplant rejections

Type 1 Hypersensitivity Reaction

  • Anaphylactic reaction.
  • Occurs immediately after exposure to an antigen.
  • Can range from mild to severe, even life-threatening.
  • Mechanism:
    • First exposure: Body produces IgE antibodies that attach to mast cells.
    • Second exposure: Antigen binds to IgE on mast cells, causing degranulation and release of histamine and other mediators (prostaglandins).
Type 1 Hypersensitivity Disorders
  • Allergic Rhinitis:
    • Most common form of allergy.
    • Symptoms: Sneezing, nasal itching, runny nose, itchy and red eyes.
  • Atopic Dermatitis:
    • Often called eczema.
    • Inflammatory skin response.
    • Symptoms: Pruritus, edema, extremely dry skin, blisters, crusts, scales.
      • Nursing Action: Administer prescribed antipruritics and offer a lukewarm soak, followed by emollient topical cream. Rationale: Antipruritics reduce the itch-scratch cycle. Lukewarm soaks followed with application of emollients relieve dryness, which contributes to the itching.
Anaphylaxis
  • Severe systemic type 1 reaction.
  • Widespread histamine release.
  • Symptoms:
    • Bronchial narrowing: Stridor, wheezing, respiratory arrest.
    • Hypotension, tachycardia, cardiac arrest.
  • Immediate treatment:
    • Oxygen.
    • Epinephrine.
    • Antihistamines.
    • Corticosteroids.
    • Vasopressors.
    • Mechanical ventilation.
  • Nursing care:
    • Early recognition.
    • Maintain airway.
    • Emotional support.
    • Education.
Urticaria (Hives)
  • Release of histamine.
  • Raised, pruritic, nontender, erythematous wheals on the skin.
  • Therapeutic interventions:
    • Epinephrine.
    • Antihistamines.
    • Corticosteroids.
    • Histamine H2 blockers.
Angioedema
  • Swelling in submucosal/subcutaneous tissue due to increased vascular permeability.
  • Causes: Allergic reaction, angiotensin-converting enzyme inhibitors, idiopathic, hereditary, acquired forms.
  • Symptoms: Painless, nonpruritic swelling.
  • Emergency if airway is involved.
  • Treatment:
    • Avoid allergen.
    • Cinryze, Berinert.
    • Antihistamines, corticosteroids.
    • Haegarda.
    • Ecallantide.
    • Icatibant.
    • Fresh frozen plasma.
Type 1 Hypersensitivity Disorder Nursing Diagnoses
  • Impaired Gas Exchange
  • Anxiety
  • Risk for Impaired Skin Integrity
  • Ineffective Health Self-Maintenance
Type 1 Hypersensitivity Disorder Nursing Care
  • Monitor respiratory status.
  • Monitor level of consciousness.
  • Stay with the patient and keep them informed.
  • Note and document skin and lesions.
  • Explain the need to avoid scratching; apply pressure or rub itching skin.
  • Explain the need for medical alert identification.
  • Discuss methods of avoiding the allergen.

Type 2 Hypersensitivity Reaction

  • Destruction of a substance having an antigen.
  • Beneficial for pathogens (bacteria).
  • Examples: Blood types (A, B, O, AB; Rh−, Rh+), where O is the universal donor and AB is the universal recipient.
  • Not beneficial when incompatible red blood cells (RBC) are sensed as foreign.
  • Mechanism:
    • Antibodies attach to normal self-marking cell membrane antigens.
    • Foreign antibodies attach to the normal self-marking cell membrane antigens causing RBC membrane degradation.
Hemolytic Transfusion Reaction
  • RBCs with foreign antigens are rapidly lysed.
  • Occlude blood vessels, leading to ischemia and necrosis.
  • Life-threatening; prevention is key.
    • Give RhoGAM to exposed Rho(D) negative patients.
    • Careful blood transfusion administration.
  • Therapeutic interventions:
    • Antihistamines
    • Corticosteroids
    • Sympathomimetics
  • Nursing care:
    • Monitor transfusion; if reaction symptoms occur, immediately stop the blood.
    • Monitor patient.
    • Infuse normal saline with new tubing.
    • Follow agency transfusion reaction policy.
    • Return unused blood and tubing to blood bank.
    • Educate patient.

Type 3 Hypersensitivity Reaction

  • Initial sensitization to an antigen, followed by a reaction to a later exposure.
  • Causes red edematous lesion, bleeding, necrosis.
  • Immune complexes formed by antigens and antibodies.
  • Antigen–antibody complexes form within blood vessels.
  • Enzymes lead to blood vessel damage.
  • Mechanism:
    • First Exposure to antigen.
    • Second Exposure: Antigen-antibody complexes form, deposit in tissues and blood vessels leading to occlusion.
Serum Sickness
  • Antigen–antibody complexes form from exposure to nonhuman proteins.
  • From exposure to antivenoms, rabies vaccines, immune modulating agents.
  • Causes inflammation, tissue damage, and necrosis.
  • Symptoms appear in 7 to 21 days.
  • Brief and self-limiting condition when antigen exposure is removed.
  • Treatment based on symptoms:
    • Antipyretics
    • Analgesics
    • Anti-inflammatories
    • Antihistamines
    • Corticosteroids
  • Nursing care:
    • Monitoring of symptoms
    • Evaluation of medication effects
    • Education

Type 4 Hypersensitivity Reaction

  • Delayed reaction.
  • Sensitized T lymphocyte contacts antigen.
  • Cell-mediated immune response.
  • Causes necrosis.
  • Mechanism:
    • Antigens are encountered.
    • Sensitized T cells are activated and release cytokines.
    • Leading to destruction of target cells.
Contact Dermatitis
  • Chemical comes in contact with the skin.
  • On second exposure, T cells secrete chemicals.
  • Examples: Poison ivy, poison oak, latex.
  • Reddened, pruritic, fragile vesicles.
  • Therapeutic interventions:
    • Antihistamines, topical drying agents, corticosteroids, topical immunomodulators.
    • Relieve itching.
    • Tepid baking soda baths or Aveeno baths.
    • Wash with brown soap (Fels-Naptha).
    • Latex allergy protocols.
  • Nursing diagnoses:
    • Impaired Skin Integrity
    • Ineffective Health Self-Maintenance
Transplant Rejection
  • Transplanted living tissue sensed as foreign.
  • Lymphocytes are sensitized immediately.
  • Invade transplanted tissue and destroy it, leading to failure of the tissue or organ.
  • Prevention:
    • Immunosuppression therapy.
      • Infection can result in death.
  • Education: Medications, rejection signs.

Autoimmune Disorders

  • Immune system recognizes the body’s own cells as foreign.
  • Immune response destroys these cells.
Autoimmune Disorders Examples
  • Rheumatoid arthritis
  • Ulcerative colitis
  • Multiple sclerosis
Pernicious Anemia
  • Antibodies against gastric parietal cells interfere with intrinsic factor.
  • Vitamin B12 deficiency results, decreasing RBC production and causing anemia.
  • Can be acquired through gastric or small bowel resections.
  • Symptoms: Weakness, anorexia, glossitis, pallor, peripheral neuropathy.
  • Therapeutic interventions:
    • Corticosteroids
    • Lifelong vitamin B12 supplementation.
  • Nursing care:
    • Vitamin B12 education
    • Care and safety due to fatigue
Idiopathic Autoimmune Hemolytic Anemia
  • Autoantibodies attach to RBCs, causing them to lyse or agglutinate.
  • Signs and symptoms:
    • Mild fatigue
    • Pallor
    • Hypotension
    • Dyspnea
    • Jaundice
  • Therapeutic interventions:
    • Immunosuppressive medications
    • Oxygen
    • Corticosteroids
    • Folic acid
    • Transfusion
    • Erythrocytapheresis
    • Splenectomy
  • Nursing care:
    • Monitor symptoms.
    • Plan rest periods.
    • Educate patient.
Hashimoto’s Thyroiditis
  • Autoantibodies for thyroid-stimulating hormone form.
  • The thyroid gland is overstimulated, leading to enlargement (hyperthyroidism).
  • Then, different autoantibodies destroy thyroid cells, leading to hypothyroidism.
  • Requires lifelong thyroxine.
  • Nursing care:
    • Rest periods
    • Compression stockings
    • Daily weights, intake and output
    • Medication education
Lupus Erythematosus
  • Three types:
    • Discoid lupus erythematosus (DLE): Skin lesions.
    • Drug-induced systemic lupus erythematosus (DILE): After certain medication use.
    • Systemic lupus erythematosus (SLE): Chronic, inflammatory, multisystem disorder.
Lupus Erythematosus: Signs and Symptoms
  • DLE:
    • Patchy, crusty, sharply defined skin plaques.
    • Occur on face and sun-exposed areas.
  • DILE:
    • Pleuropericardial inflammation.
    • Fever
    • Rash
    • Arthritis
  • Systemic Lupus Erythematosus (SLE)
    • Etiology
      • Young women of childbearing years
      • First-degree relatives of lupus patients
      • Black, Asian, Hispanic, American Indian population more likely to develop.
    • Signs and Symptoms
      • Early symptoms vague: Fatigue, fever
      • Dermatological: Butterfly rash, bruising photosensitivity, alopecia, pain, pruritis
      • Musculoskeletal: Arthralgia, arthritis
      • Hematological: Anemia, leukocytopenia, thrombocytopenia
      • Cardiopulmonary: Pericarditis, myocarditis, myocardial infarction, vasculitis, pleurisy, valvular disease
      • Renal: Kidney disease, urinary tract infections, fluid and electrolyte imbalances
      • Central nervous system: Cranial neuropathies, seizures, cognitive impairment
      • Gastrointestinal: Anorexia, ascites, pancreatitis, intestinal vasculitis
      • Ophthalmological: Conjunctivitis, dry eyes, glaucoma, cataracts, retinal pigmentation
    • Therapeutic interventions
      • Symptomatic management
      • NSAIDs
      • Immunosuppressants
      • Corticosteroids
      • Antimalarials
      • Immunoglobulin
    • Complications
      • Osteonecrosis
      • Kidney disease
      • Thrombocytopenia
      • Emboli
      • Myocarditis
      • Vasculitis
      • Mesenteric or intestinal vasculitis
      • Sepsis
    • Nursing Diagnoses
      • Acute Pain
      • Disturbed Body Image
      • Fatigue
      • Ineffective Health Self-Maintenance
Ankylosing Spondylitis
  • Chronic progressive inflammatory disease of sacroiliac, costovertebral, and large peripheral joints.
  • Signs and symptoms:
    • Lower back stiffness
    • Pain
    • Lordosis, kyphosis
    • Spasms
    • Fatigue
    • Anorexia, weight loss
  • No cure, supportive care, surgery.
  • Nursing care:
    • Education on posture, range-of-motion, firm mattress, thin pillow

Immune Deficiencies

  • One or more components of the immune system is completely absent or deficient.
Hypogammaglobulinemia
  • Absence/deficiency of one or more of five immunoglobulins from defective B cell function.
  • Prone to infections.
  • Therapeutic interventions:
    • Minimizing infections
    • IgG injections
    • Fresh frozen plasma
    • Genetic counseling