Inflammation & the Immune Response

Keith Rischer, RN, MA, CEN, CCRN

Objectives for this content

Inflammatory response #1-3

Infection/sepsis/chain of infection #4-10

Physiologic immune response #11-16

Three Lines of Defense

Anatomical Barriers

Acute Inflammatory Response

Immune System

Lines of Defense

Anatomical Barriers: First Line of Defense

Skin Mucous

membranes Normal bacterial flora

Clostridium difficile Yeast infections

Normal Body Defenses

Skin multilayer barrier, shed outer layer,

contains fatty acids that kills some bacteria Lungs

contain cilia in upper respiratory tract, macrophages

Urinary Tract flush action of urine washes away bacteria

Perry and Potter pg. 647 Ch 34 Table 34-3

Inflammatory Response

Inflammatory Response

Occurs in response to injury

Localized Immediate Beneficial Appropriate level of

response Non Specific

Causes of Inflammation

Physical Trauma Lacerations Burns

Chemical- Bites Allergic response

Micro-organisms Bacteria

Inflammatory Response

REDNESS SWELLING PAIN HEAT LOSS OF

FUNCTION

Purpose of inflammation

Neutralizes and Dilutes Toxins

Removes necrotic materials

Provides an environment for healing

Add “itis” to affected body part

4 Phases of Inflammation Vascular

Think blood vessels Cellular

Think WBC’s Formation of Exudate

Fluid & neutrophils Healing

regeneration or repair of tissue

Injury occurs Mediators intervene Vasodilation occurs Capillaries become

more permeable Swelling and

movement of fluid occurs

Vascular Phase: Blood Vessels

Cellular Phase – Think WBC’s

Injury occurs Chemotaxis begins White blood cells

rush in to help Neutrophils Monocytes Macrophages

Chemical Mediators

Coordinators of the inflammatory response

Histamine Prostagladins Cytokines

Laboratory tests

Erythrocyte sedimentation rate (ESR or sed rate) <20 mm/hr

CRP – C reactive protein non specific test identifying the presence of

inflammation <1.0 mg/dl

Application of the Nursing Process

Data/Assessment: History Local signs and

symptoms including pain assessment WILDA

Applicable lab work

Nursing Diagnosis

Acute pain related to tissue trauma Impaired physical mobility related to

discomfort

Nursing Interventions

Care will vary with causative agent and physical condition of the patient

What are some nursing actions you might implement or anticipate

How will you as the nurse evaluate the outcome

Expected Outcomes…

Healing of the wound or injury Prevent minor infections from becoming

overwhelming to the body UTI vs. urosepsis

Goals and outcomes will vary with each patient

Remember that your outcomes will drive your interventions/cares

Systemic Manifestations of Acute Inflammation

Fever/chills Cytokines Benefits

Increased killing of microorganisms Increased phagocytosis by neutrophils Increased activity of interferon

Leukocytosis Neutrophils “left shift”…band cells

Medications: NSAIDS

Ibuprofen, Toradol Mechanism of action

Inhibits prostaglandin synthesis Nursing implications

Give w/food Elderly-high risk GI bleed Prolongs bleeding times 1 day Assess renal function-creatinine w/chronic use

Medications: NSAIDS

Salicylates – Aspirin Mechanism of action

Inhibits production of prostaglandins Decreases platelet aggregation

Nursing implications Give w/food Prolongs bleeding times 4-7 days

Medications: Anti-histamines

Benadryl, Ranitidine (Zantec), Famotidine (Pepcid)

Mechanism of action– Block histamine at the receptor site– Decreases gastric acid secretion

Nursing implications– With meals– Drowsiness/dizziness

Medications: Corticosteroids

Prednisone Mechanism of action

Decrease inflammation by stabilizing neutrophils and lysosomes

Inhibit prostaglandin synthesis Inhibits chemotactic cytokines Decreases mast cell stimulation

Nursing implications Meals Chronic use complications

– Risk of infection

– Hyperglycemia

– SE

Inflammation Case Study 26 yr female with no

medical history CC

Severe epigastric abd pain the last 2 days

Severe pain all night, rates 10/10-sharp-nothing relieves. Appears uncomfortable

T-101.2 P-110 R-24 BP 168/88 sats 98% RA

Tender epigastric area, BS active x4

Labs K+-3.4 Na+ 138 Creatinine 0.6 ALT-81 AST-81 WBC-28.7 Lipase-1633

Case Study continued

Outcomes

Nursing diagnosis priorities

Plan of care

Evaluation

What is an infection?

Normal Course of an Infection

Incubation period Prodromal stage Full stage of illness Convalescence

Infectious agents/pathogens

Bacteria Virus Fungi Protozoa

Bacteria

Single cell Human cells vs.

bacteria count in body Gram +/-

Virus

Most common affliction of humans

Has no metabolism of it’s own

Is incapable of replicating outside a living cell

Takes over the metabolic machinery of host cells to survive and replicate

What influences Pathogen survival?

Food/Glucose Water Oxygen –

aerobic/anaerobic Temperature pH light

Reservoir

A place where a pathogen can survive but may or may not multiply

What is the most common reservoir?

What is a carrier?

Portal of exit

For the pathogen to cause an infection it must exit the reservoir

How can this happen?

Mode of Transmission

Direct or indirect

What is the major mode of transmission in the health care setting?

List the 4 categories of transmission

Portal of entry

Susceptible Host

What factors increase our susceptibility to infection? Age Stress Nutritional status Current medical

therapies Chemo Steroids

Presence of disease

Breaking the Chain

Leukocytes=Braveheart

Leukocytes

Normal Blood Count of all WBC: 4,000-11,000/ul

Neutrophils Monocytes Lymphocytes B cells:

mediate the humoral immune response

T cells: Mediate cellular immunity

Elderly considerations

Laboratory Studies CBC

Hgb (12-16 g/dl) Hct (33-51%) Platelets (140-440 thou/cu mm) WBC (4.5-11.0 thou/cu mm)

Differential Never-neutrophils (42-72%) Let-lymphocytes (20-44%) Monkeys-monocytes (<11.1%) Eat-eosinophils (<7.1%) Bananas-basophils (<3.0%)

Cultures, gram stains and sensitivities

Wound and skin cultures, body fluids, blood cultures

Gram stains

Sensitivities

Anti-infective Drugs

Determine if hypersensitive to medication

Check for interactions with other drugs

Educational needs of client

Determining effectiveness

Antibiotic Therapy

Anti-fungal Fluconazole, Nystatin

Cephalosporins Cephalexin (Keflex)

Penicillins Amoxicillin, Ampicillin

Sulfonamides Bactrim

Tetracyclines Doxycycline

Antibiotic Resistance

Bacteria adapt in ways which make an antibiotic less effective or ineffective MRSA – Methicillin resistant staphylococcus

aureus VRE – Vancomycin resistant enteroccus

Vancomycin

Anti-infective class other Effective against gram+ pathogens Used in potentially life-threatening

infections when other drugs are not effective

Action: binds to bacterial cell wall and cell death results

Poorly absorbed in GI tract, may be given IV

NCLEX Concepts of Emphasis

1. Define inflammation2. Is inflammation always present with infection?3. What are some patient examples that would limit or impair

their inflammatory response?4. What are the five physical manifestations of the inflammatory

response?5. Name each distinct phase of the inflammatory response and

unique characteristics of each?6. What are other causes of inflammation besides micro-

organisms?7. What are some common diseases of chronic inflammation?8. What are the medications that treat the inflammatory

response?

Sepsis

Patho Infection (susceptible host) Inflammation-systemic

SIRS Capillary permeability Vasodilation

Progressive Sepsis/SIRS Septic shock Multiple Organ Dysfunction Syndrome (MODS)

Article Case Study

70 yr female from NH CC:

weakness, diarrhea x3 weeks Assessment:

PMH: IDDM, HTN, CVA, COPD, UTI’s VS: T-97…101.8 P-109 R20-24 BP-93/41 91-98% a/o x3

Labs: WBC-26.5 Gluc 258

Article Case Study-Day 2

T-96.6 P-125 R-24 BP 80/43 Oriented to self only u/o 180cc over 8 hours Became more lethargic later in day T-96.5 P-100 R-24 BP 70/30 Labs

WBC 41.9 Lactate 2.2

Article Case Study-Day 3

T-96.5 P-100 R 14-32 BP 70/50 Labs

WBC 41.9 Creatinine 4.3

Vasoactive gtts Intubated Died day 7

Sepsis Case Study 58 yr female from NH

Found unresponsive with dramatically altered LOC Intubated and transferred to ED PMH

IDDM MI CHF Mitral valve regurgitation

T-102.7 P-110 R-16 intubated BP- 155/86 sats 95% Head to Toe

Remains unresponsive-even to pain Breath sounds coarse bilat S1S2 soft murmur reg Skin hot-dry to touch 1+ edema lower extremities Foley placed…urine thick white, yellow

Sepsis Case Study Initial labs

WBC-13.8 Neutrophils-82% Hgb-14.9 Platelets-213 Glucose-331 K+-5.0 Creatinine-2.03 ALT-89 AST-193 INR-2.2 Lactate 7.0

UA Bacteria-many WBC>100 Leukocyte esterase +

l

6 hours later… T-103.8 HR130 BP 64/30 despite 4

vasopressors IV continuous WBC-28.6 Neutrophils-95% Hgb-5.2 Platelets-64 Glucose-351 K+ 3.5 Creatinine-2.9 ALT-382 AST-590 INR-7.1 Lactate-14.0

Key Nursing Assessments Fever/chills

Hypothermia Altered LOC/confusion Break in skin integrity

Foley catheter Wound or incision

Tachycardia HR >100

What if elderly or on beta blockers?

Key Nursing Assessments Tachypnea

RR >20 Hypotension

SBP <90 SBP drop of >20-30mm/Hg

Decreasing urine output…<30cc/hr

Labs WBC Neutrophils Creatinine

Nursing Diagnosis statements w/infection/sepsis?

Ineffective breathing pattern Decreased cardiac output Ineffective tissue perfusion…manifested

by: Altered mental status Behaviorial changes (restlessness) Renal…creatinine

Acute confusion

NCLEX Concepts of Emphasis

1. Why is the older adult at risk for infection and cancer development?

2. Inflammation and immunity are provided primarily through what body cells?

3. Differentiate the 5 types of leukocytes and what each type does to protect the body from micro-organisms

4. Which leukocyte is elevated in bacterial infection? 1. Why…

5. What body cell is able to recognize and destroy non-self cells?

6. What vital sign changes are seen in sepsis?7. What assessment findings are seen in sepsis?

The Immune Response

Immune Response

Passive Acquired Immunity

Present at birth Short lived Body needs to develop

own

Active Acquired Immunity

After birth Active

Long-term Exposure to micro-

organisms immunizations

What comprises the immune system?

Bone Marrow

WBC

Lymph system

Thymus Gland

Misc: Tonsils, Spleen, Mucosa, Appendix

Lymphatic System

Lymphocytes

WBC that allow the body to remember and recognize previous invaders.

Two types B lymphocytes T lymphocytes.

NK or natural killer cells

Specific Defenses

Humoral (circulating) immunity Reside in B lymphocytes Mediated by antibodies

(immunoglobulin) produced in B cell

Produce antibodies when activated

Cell-mediated defenses T –cells released when

exposure to an antigen occurs 70-80% total lymphocytes

Antigens An antigen is a substance

that elicits an immune response

Mostly comprised of protein

A foreign substance that invades the body is called an antigen

All cells have antigen unique to that individual allowing the body to recognize itself

Humoral (antibody) Immunity Antibody mediated

immunity

Antibodies are produced by B cells

Antibodies can bind to antigens

Immunoglobulins (IgG, IgA, IgM, IgD, IgE)

Cell Mediated

T-cells able to recognize

infected cells Cytotoxic

Natural killer cell

Cytokines

Soluble, hormone-like protein produced by white blood cells act as a messengers between cells

Stimulate or inhibit the growth and activity of various immune cells

Can be beneficial or harmful

Antipyretics

Acetaminophen

Ibuprofen

Aspirin

Immunopathology

Alterations in Immunity and Inflammation Hypersensitivity Autoimmunity

Hypersensitivity

Immediate Allergy Anaphylaxis

Delayed Poison Ivy Mantoux Test

Hypersensitivity

Nursing Assessment Think ABC’s How fast is the allergic

response? How serious? What to ask the

patient? Is this an allergic

response or drug side effect?

Name that response…

Baby is crying continually and pulling at her ear. Mom is frantic.

Young man- ate shellfish and then went to play tennis. Now is having difficulty breathing.

Young woman went hiking in the woods last week & now has hives present and is scratching.

12 year old girl crying and shaking, holding her very swollen arm/elbow - injured playing baseball

Autoimmunity

Recognizes self antigens as foreign

Produces antibodies against own tissue

Examples Lupus Rheumatoid

Arthritis

How do immunizations work?

The exposure (usually injection) to a small amt of virus triggers an immune response Help body prepare

antibodies

Type of immunity Active artificial

NCLEX Concepts of Emphasis

1. What are the similarities and differences between cellular and humoral immunity?

2. How do vaccinations work?3. To be fully immune requires which three

essential components of the inflammation/immune response?

4. What is the mechanism of Prednisone and the nursing considerations when giving?

5. What is the difference between an allergic reaction and side effect of a medication?

6. What is the similarities & differences between hypersensitivity and anaphylactic reaction?

Bronchospasm associated with hypersensitivity reaction is the result of:

A. histamine release B. pulmonary ventilation C. dilation of the alveoli D. inadequate antibody production

Which symptom indicates a possible allergic reaction?

A. fever B. diaphoresis C. rash D. chills