NUR 101 – Fall 2019

Sheryl McCloud, MSN/ED RN

Objectives

Immunity

Immunity &
Inflammation
Infection

Medications
Objectives: Immunity
Upon completion of this module, the student will be able to :
Describe the immunological mechanism for the four types of hypersensitivities.
Discuss the type of immunity that is obtained with a vaccine.
Describe the two mechanisms of immunity.
Describe the data to be collected when caring for a patient with a hypersensitivity
reaction.
Discuss the etiologies, signs, and symptoms of hypersensitivity reactions of the immune
system.
Discuss the pathophysiology of hypersensitivity reactions of the immune system.
The Immune System
Immune response: a target-specific system of defense, primarily
involves the lymphocytes and lymphoid tissue
Anatomy and Physiology
◦ Immune system is a collection of specialized white blood cells and
lymphoid tissue that maintain immunocompetence, the ability to
cooperatively protect a person from external invaders and the body’s
own altered cells.
◦ Function of these structures is assisted and supported by natural killer
cells, antibodies, and nonantibody proteins (cytokines).
The Immune System—(cont.)
White blood cells (leukocytes): produced in bone
marrow; stem cells
◦ Types
◦ lymphocytes, neutrophils, and monocytes

Lymphocytes: T-cell or B-cell lymphocytes

◦ Primary participants in the immune response
◦ Distinguish harmful substances and ignore the natural
The Immune System—(cont.)
Lymphoid tissues: play a role in immune response and
prevention of infection
◦ Types
◦ Thymus gland: programs T lymphocytes to become regulator or
effector T cells
◦ Tonsils and adenoids: filter bacteria from tissue fluid
◦ Spleen: emergency reservoir of blood and removes bacteria and old or
damaged red blood cells from circulation
◦ Lymph nodes: vessels that drain tissue fluid (lymph)
Immunity Lines of Defense
Primary defenses
◦ Structures designed to prevent invaders from entering the body
◦ Skin, respiratory tract, eye, mouth, GI tract, and GU tract

Secondary defenses
◦ Phagocytosis, complement cascade, inflammation, fever

Tertiary defenses
◦ Specific immunity
◦ Humoral
◦ Cell-mediated
 Primary Defenses - Innate
Structural barriers consisting of the normal
(resident) flora of the body
Any disruption in the balance between normal
flora & bacteria can cause risk of infection
Environmental factors, such as diet, sanitary
conditions, air pollution, and hygienic habits—
influence what species make up a person’s
resident flora.
 Secondary Defenses
The release of waste from pathogens causes
the implementation of the body’s secondary
defenses
Phagocytosis: specialized white blood cells:
neutrophils, eosinophils & monocytes
Complement cascade: release of chemicals to
attack cell membranes of pathogens &
basophils to release histamines
inflammation
Inflammation: localized warmth & erythema,
accumulation of fluid in surrounding tissue
causing edema & pain
Fever: in core temp metabolism, inhibits
multiplication of pathogens
Tertiary Defenses
The process of specific immunity that prevent recurrent illness
Humoral
◦ Body’s response to antigens, macrophages & T helper cells that produce
antibodies (aka: immunoglobins)
◦ Purpose to destroy antigens
◦ 5 classes of antibodies: IgG, IgM, IgA, IgE, IgD
Cell mediated
◦ Destroys primarily viruses
◦ 4 T- cells are responsible: cytotoxic
 Immunoglobulins
(Antibodies)
IgG: (gamma) transfers across placenta coating microbes-
IgM: (mu) 1st antibodies to appear after immunization,
effective @ killing bacteria, blood
IgA: (alpha) found in high concentrations in body fluid
secretions guarding entrances in body-
IgD: (delta) attached to B cells& plays key role in initiating
early B response
IgE: (epsilon) responsible for symptoms of allergy & protect
against parasitic infections-anaphylaxis
 The Immune System—(cont.)
Types of Immunity
◦ Naturally acquired active immunity: occurs
as a direct result of infection by a specific microorganism
◦ Example: measles
◦ Artificially acquired active immunity: results from
administration of a killed or weakened microorganism or
toxoid
◦ Example: influenza
◦ Passive immunity: ready-made antibodies are given to a
susceptible person
◦ Example: Newborns receive passive immunity to some
disease for which their mothers have manufactured
antibodies.
Antibody –mediated
Immunity
•Active acquired immunity is
permanent
•IgA in mother’s milk convey
passive immunity
•Gamma globulin for hepatitis
is passive
Immune System
Immunity to a disease after recovery is possible because the first
exposure to the pathogen has stimulated the formation of memory
cells
Immunoglobulins bind with antigens and promote the destruction of
invading cells by hindering antigens physically
The Immune System - Assessment
Assessment
◦ History of immunizations, recent and past infectious diseases,
recent exposure to infectious diseases, drug history, allergy
history
Physical Examination
◦ Appears healthy, acutely or mildly ill, malnourished, extremely
tired, listless
◦ Examine the skin for rashes or lesions.
◦ Assess the abdomen for an enlarged liver or spleen.
◦ Inspect pharynx for large, red tonsils and drainage.
 The Immune System - Assessment
Diagnostic Tests
◦ Laboratory tests: complete blood count with differential
◦ Protein electrophoresis screens: diseases associated with
deficiency or excess immunoglobulins
◦ T-cell and B-cell assays: enzyme-linked immuunosorbent
assay
◦ Skin tests: disease-specific antigens
◦ Anergy: inability to mount an immune response
◦ Common with AIDS or immunosuppression
 Immunizations

Aka: vaccines
Live, attenuated or killed microorganisms that promote active
immunity
Inactivated vaccines: influenza immunizations
Live, attenuated: MMR
Toxoids:
 inactivated toxin –
 DPT, Td & DT
 Nursing Considerations

Immunization side effects vary from mild local rxns to

anaphylaxis
◦ Local rxns: redness, swelling, tenderness & muscle ache
◦ Administering in dominant arm  local discomfort
◦ Warm compresses
◦ Sometimes non-dominant arm
◦ Tylenol
Nursing Considerations

 expiration date & manufacturer’s instructions for administration, dosage, routes,

precautions & contraindications
Document observations even if tolerated well
Do not administer any immunization to a client w/an URI or other infection
Do not administer oral polio vaccines (OPV) or MMR to immunosuppressed person
Observe for 15 minutes & keep epinephrine available
Pregnancy - hold
Hx of high fever
Steroid therapy
 Allergic Disorders
Allergic disorder: characterized by a hyperimmune response to
weak antigens that usually are harmless
◦ Characterized by the manner in which the allergen gains entry to the
body and the intensity of the response
◦ Allergens: antigens that cause an allergic response; allergies can occur at any age
◦ Types: ingestants (food, drugs), inhalants (house dust and mites), contactants (latex),
injectants (drugs, bee venom)
◦ Allergy examples: allergic rhinitis, contact dermatitis, food allergy,
urticaria, angioedema
 Allergic Reaction - Medication
When the immune system identifies a medication as a foreign substance that should
be neutralized/destroyed
The first dose acts as an antigen antibodies against the drug = an antigen-
antibody reaction with next dose
Range from mild to severe
Small amount of medication can lead to
◦ Urticaria (hives)
Mild reaction within minutes - 2 weeks after
◦ Pruritus (itching)
exposure
◦ Edema of soft tissue & mucosa
◦ Rhinitis (inflammation of nasal mucosa)

Most likely antibiotics, biological agents, & diagnostic agents

Allergic Disorders—(cont.)
Pathophysiology and Etiology
◦ First exposure to an allergen does not produce
symptoms.
◦ Sensitization: process by which cellular and chemical
events occur after a second or subsequent exposure
to an allergen
◦ Once sensitization occurs, one of four types of
hypersensitivity responses can occur; may be immediate or
delayed
◦ Types: types I, II,III, and IV
 Allergic Disorders—(cont.)
Immediate hypersensitivity response: due to antibodies
interacting with allergens and occurs rapidly
◦ Type I, atopic or anaphylactic: mediated by immunoglobulinE (IgE)
antibodies (most severe)
◦ Type II, cytotoxic: mediated by immunoglobulin M or G (IgM or
IgG) antibodies
◦ Type III, immune complex: mediated by IgG antibodies
Type I and II occur within minutes; type III responses reach
a peak within 6 hours after exposure to an allergen.
 Allergic Disorders—(cont.)
Anaphylaxis: rapid and profound type I hypersensitivity
response
◦ A massive release of histamine causes vasodilation; increased
capillary permeability
◦ Signs: angioneurotic edema is the acute swelling of the face, neck,
lips, larynx, hands, feet, genitals, internal organs; hypotension;
bronchoconstriction
Delayed Hypersensitivity Response: Type IV
◦ Antigens are initially phagocytized by macrophages; sensitized T cells
then produce cytokines that cause an inflammatory reaction.
◦ May develop over several hours or days
 Anaphylactic Reaction
Life-threatening allergic reaction that occurs immediately after administration
Produces sudden constriction of bronchioles, edema of the larynx & pharynx, severe
shortness of breath, wheezing, and severe hypotension
Immediate treatment
◦ Stop medication
◦ Administration of epinephrine, IV fluids, steroids, and antihistamines
◦ Respiratory support may also be required
 Medications that Affect the Immune System
Either support or inhibit the immune response

Classifications Anti-infectives/antimicrobials/antibiotics
Antihistamines ◦ Penicillin
◦ Cephalosporin
Glucocorticoids
◦ Tetracycline
Nasal decongestants ◦ Macrolides
◦ Aminoglycosides
NSAIDs
◦ Quinolones
Immunosuppressant ◦ Sulfonamides
◦ Antitoxins
◦ Antituberculosis agents
◦ Antifungals
◦ Antivirals
◦ Antiretroviral
 Epinephrine (adrenaline chloride, Epi-pen)
Classification
◦ Antiasthmatics, bronchodilator, vasopressor
Category C
Form: SQ, IV,IM, inhalant, intratracheal, intraosseous
Action: inhibits the release of mediators of immediate
hypersensitivity rxns from mast cells: Therapeutic effect:
bronchodilation, maintenance of heart rate & BP.
Localization/prolongation of local/spinal anesthetic
Adverse rxn: nervousness, restlessness, tremor, headache,
paradoxical bronchospasms (wheezing), nausea, vomiting,
palpitations, sweat
 Antimicrobials
•Chemicals that eliminate living (kill or damage) microorganisms, that
are pathogenic
•May come from chemical or living organisms of origin
• Developed from living microorganisms-antibiotics
•Often classified by the type of pathogen it destroyed (bacteria, fungus,
virus). Maybe subdivided by chemical families (penicillins, tetracycline's
& aminoglycosides
•Drugs that have been more refined, purified & sensitive due to long-
term testing = generation

27
 Introduction to Penicillins

Group of antibiotics for treatment of susceptible pathogens

Actions: Cell wall synthesis; DNA or RNA synthesis; protein synthesis
There are four groups of penicillins: (1) natural penicillins, (2)
penicillinase-resistant penicillins, (3) aminopenicillins, and (4) extended-
spectrum penicillins
 Penicillins
•The 1st true antibiotics to be grown & used
against pathogenic bacteria in humans
•Remain one of the most common & widely
used
•Microorganisms can develop a protective
mechanism making them resistant to
penicillin
•Mixing with other medications has added in
preventing resistance.
•Development of penicillinase-resistant
penicillins

29
Penicillin •Side Effects
• Diarrhea
• Abnormal liver &
renal function
• Thrombophlebitis
• Electrolyte imbalance
•Interactions
• Oral contraceptives
• Antacids

30
Penicillins
•amoxicillin (Amoxil) Combination Products
•ampicillin •amoxicillin & potassium clavuanate
(Augmentin)
•dicloxacillin
•ticarcillin & potassium clavulante
•penicillin G (Timentin)
•penicillin V potassium

31
 Cephalosporin
•Chemically related to penicillin with similar
mechanism of activity
•Divided into 2 groups (generations)
• 1st generation: gram-positive micro
• 2nd generation: somewhat  against Gram(-)
• 3rd generation: active against penicillinase-
producing bacteria
• 4th generation: broad spectrum w/both gram (-)
& gram (+) coverage

32
 Cephalosporin
•Used for : •cefaclor (Ceclor)
• Some UTI’s & URI’s
• Abdominal infections •cefotaxime (Claforan)
• Bacteremia •cefotetan (Cefotan)
• Meningitis
• osteomyelitis
•cefoxitin (Mefoxin)
•ceftriaxone (Rocephin)
•cephalexin (Keflex)

33
 Cephalosporins: Interactions
Drug Common use Effect of
interaction
Aminoglycosides Anti-infective Increased risk for
nephrotoxicity

Oral anticoagulants Blood thinner Increased risk for

bleeding
Hypertension, Increased
Loop diuretics reduce edema cephalosporin blood
level
 •amikacin (Amikin)
Aminoglycosides •gentamycin (Garamycin)
•Used primarily against •kanamycin (Kantrex)
gram–negative
•neomycin (Neo-fradin)
microorganisms
• UTI, meningitis, wound •streptomycin
infections life-threatening (Streptomycin)
septicemias •tobramycin (Tobramycin)
• Prior to surgery to reduce
GI flora

35
 Aminoglycosides: Contraindications
and Precautions
Contraindicated in patients:
◦ With hypersensitivity to aminoglycosides, pre-existing
hearing loss, myasthenia gravis, parkinsonism; during
lactation and pregnancy (category C and D). Long-
term therapy risk: ototoxicity and nephrotoxicity.
Used cautiously in:
◦ Elderly patients; patients with renal failure and
neuromuscular disorders
 Important lab studies
Peak drug levels: specimen 15-30
minutes after dose administered
Trough drug levels: specimen
draw immediately prior to
administration
Serum creatinine & BUN

37
Vancomycin
•Only drug in its class: tricyclic glycopetide
•Because of serious toxicity only used in serious
infections when other antibiotics have failed
•Vancomycin-resistant Enterococcus (VRE) is becoming
a common problem
•Administer over 60 minutes

38
 Vancomycin Reaction
•Anaphylactoid reaction “red-neck” or “red
man”
•Pruritus, erythematous rash that involves
the face, neck, and upper torso.
•Appear about 4–10 min after an infusion
started or may begin soon after its
completion

39
 Anti-Fungal (-zole)
•Topical meds, usually
•Jock itch, ringworm, thrush (oral candiasis), diaper rash
(cutaneous candidiasis), vaginal candidiasis
•Clients should avoid tight clothing, avoid contact with eye
•Systemic antifungal agents: amphoterin B*, fluconazole
(Difflucan)
• Interactions with anticoagulants and oral hypoglycemic

40
 Other Antimicrobials
Sulfonamides
◦ Trimethoprim-sulfamethoxazole(Bactrim)
◦ Earliest classification of antibiotics- many are allergic to
Tetracycline
◦ Doxycycline (vibramycin)
◦ Not used in children or pregnant women = permanent staining of teeth
Antituberculin
◦ Rifampin (rifadin)
Antivirals
◦ Acyclovir (zovirax)

41
Transmission Based Precautions – 2nd Teir
Name/type When to Use Placement & PPE Equipment Other
Transport
Contact* When direct Consult with Gloves, non- Keep outside Precautions
contact with Infection Control sterile room related to
patient or Private roomǂ Gown, if contact Use disposable organism
environment Area is covered Cleaned room D/C after signs
can lead to Separate from daily & symptoms
spread public have resolved
Droplet Spread via Pvt room or 3ft Supplies out of Precautions
moist, large separating other room related to
droplets. Direct infectious pts, Mask w/in 3ft. organism
or indirect w/privacy drape Masks D/C after signs
contact pulled. Limit out Cough etiquette & symptoms
of room-mask have resolved
2nd Tier Precautions
Name/type When to Use Placement & PPE Equipment Other
Transport
Airborne Transmitted Negative Fit-tested mask Maintain Precautions
Precautions person-to- pressure for TB & outside of room related to
person on air isolation room smallpox organism
currents. Small w/HEPA Respirator mask D/C after signs
enough to be filtration. For rubeola, & symptoms
transmitted Room door chicken pox, have resolved
through closed. disseminated
ventilation Cover lesion, zoster only
systems, masks on immune
fanning sheets, patient to caregivers
shaking towels, transport
etc… Limit out of
room
 Protective Environment
Immunosuppressed clients or neutropenic
Protective or reverse isolation
Likely to become infected by pathogens existing in
their own body than those transmitted by others
Private room, restricted visitors, wearing a mask,
gown or gloves for patient care
Special cleaning of patient equipment & supplies