NORMAL IMMUNOLOGY

Overall Characteristics of the Specific Immune System Response (5 Cardinal Features)

Self/ Not Self Tolerance
A unique feature of the immune system. Discrimination of self from not- self is the recursive ability of the immune cells to engage in the process of exploring the cellular environment. Healthy cells are left alone, and the immune cells identify and mount responses against foreign cells as well as cancerous or infected self- cells. Example of error- free self- identification that leads to self tolerance: maturation process of T Cells.

Self- regulation
The ability of the immune system to initiate, maintain, and down regulate immune activity independent of the nervous system or other controls.

Overall Characteristics of the Specific Immune System Response (5 Cardinal Features)

Specificity
The ability of the immune system to design and implement as immune response that is targeted only to a single, specific antigen or foreign cell.

Diversity
The body has an ability to develop a specific response to an indefinite number of different antigens. The human genetic repertoire provides us with an ability to mount a specific response to about 10, 000 different antigens.

Memory Once the immune system identifies antigen and mounts an immune response, it can store a memory of antigen and keep memory cells available throughout the life span to provide a prompter response to secondary exposure

The Immune System

1. Central Lymphoid Organs Bone Marrow
It contains the parent or stem cells from which lymphoid cells are derived. Red marrow- provides all of the blood cells in the body. Yellow marrow- stores lipids, serving as an energy reserve. Immature T lymphocytes are formed in the bone marrow. The originating cells (prulipotent hematopoietic stem cells) produce:
All the circulating blood cells Lymphoid and myeloid cells (WBC)s Erythrocytes (RBCs) Thrombocytes (platelets)

Thymus Gland
A primary lymphoid gland located in the mediastinal area of the chest. It weighs about 20 gm. At birth, grows rapidly in children, and reaches a maximum size at puberty (about 35 gm.), after which it gradually begins the process of involution. The thymus processes and matures lymphocytes in large numbers from the early years of life until puberty at diminishing rates throughout adult life. Lymphocyte maturation is the process of transformation of lymphocyte precursor cells into antigen- specific lymphocytes regulated only to respond to specific antigens under proper conditions of antigen recognition. Bone marrow produces immature immune cells Immature cells travels via the blood Cells reaches the cortex of thymus Maturation and development Reaches the medullary area of the thymus Lymphocytes become differentiated and transforms into immunocompetent cells. Cells enters the circulation. Identifies and reacts to foreign tissues.

Bone marrow produces immature immune cells

Immature cells travels via the blood

Cells reaches the cortex of thymus

Maturation and development

Reaches the medullary area of the thymus

Lymphocytes become differentiated and transforms into immunocompetent cells.

Cells enters the circulation.

Identifies and reacts to foreign tissues.

. Peripheral Lymphoid Organs and Tissues

Lymph Nodes
Are encapsulated secondary lymphoid organs that systematically distributed throughout the body to receive and process the lymph circulation.

Mucosa- Associated Lymphoid Tissue (MALT)

Aggregates of lymphoid tissue that are found in many organs specially the GI and respiratory tracts.
Gut- associated lymphoid tissues (GALT)
Lymph node- like tissues in the GI tract that collect antigen from epithelial surfaces in the lumen of the bowel. The lymphocytes form a follicle that protrudes within the lumen to enhance potential contact with antigen entering the GI tract. Include: tonsils, adenoids, vermiform appendix, and Payer's patches.

Peripheral Lymphoid Organs and Tissues

Bronchial- associated lymphoid tissue (BALT)
It has specificity for airborne pathogens. It is facilitated by the flow of mucus out of the lungs through the ciliary action of the columnar epithelial cells and the cough reflex.

Peripheral Lymphoid Organs and Tissues

Spleen
The largest internal lymphatic organ, weighing about 180 to 240 gm. It can function as a reservoir for blood in its venous sinuses and pulp. It also processes RBCs that squeeze through its pores.

Phagocytic cells, especially macrophages, line the pulp and sinuses of the spleen. These cells function in the process of immunity to clear blood- borne pathogens

Peripheral Lymphoid Organs and Tissues

Structural and Physiologic Barriers in Bodily Defense Physical barriers Intact skin
Primary barrier to entry into the body. The tight junctions of the skin in the skin, the presence of antibacterial peptides, and the shedding property of surface cells in the skin makes it difficult for pathogens to colonize or enter.

The Mucous membranes

Serve as physical barriers to invasion because of cellular alignment, ciliated epithelial functions, longitudinal flow over their surfaces, the movement of mucus, the presence of microbeactive enzymes, various pH levels, and fatty acids.

Saliva Tears Urine flow

Peripheral Lymphoid Organs and Tissues

Physiologic Barriers Acidic pH
A barrier to pH- sensitive pathogens.

Soluble factors in tissue and tissue secretions

Many chemicals are bacterially active and function through enzymatic reactions.

High tissue or body temperature

A defensive mechanism against temperature- sensitive pathogens.

Commensal organisms in the GI tract

Serve to regulate pH, available pathogen food supply, and available binding sites and access points for microbial invasion.

Peripheral Lymphoid Organs and Tissues

. Cells of the Immune System Cells of Innate, Non- specific Immunity
It includes the interaction of phagocytes with antigen as well as chemical mediators from other WBCs.

Macrophages
The mature cells of the mononuclear phagocyte system (or monocyte- macrophage system). They function in phagocytosis of antigen and in processing and presenting antigen to specific lymphocytes. They serve an essential function in removing foreign and devitalized mineral from the body. They trap and process antigens to present them to specialized lyphocytes.

Neutrophils
The most numerous and the most important cellular component of the innate, non- specific immune response. They serve to complete the phagocytic family of cells and a first-line defender in the body against bacterial invasion, colonization and infection.

Eosinophils
They are believed to play a pivotal role in defense against parasitic infections. They are components of innate immunity but can be activated by lymphocytes, and serve an adapted immunity

Basophils
They play a role in protecting mucosal surfaces throughout the body, and, like mast cells, they release substances that assist other cells in the inflammatory response.

Mast Cells
Derived from bone marrow cells that are distinct from basophils. They serve to provide substances that are supportive and enhancing of immune responses.

Peripheral Lymphoid Organs and Tissues

Cells of Adaptive, Specific Immunity
They are essential for producing immunity to disease and protection from other foreign agents.

B Lymphocytes
Are responsible for humoral immunity or immunoglobulin- mediated immunity, which is specific immunity for antigens that are found outside of the host cells. They originate in the bone marrow and mature either there or in some other site. They are capable of proliferating and differentiating into plasma cells and memory cells when exposed into a specific antigen. Plasma cells- capable of secreting large quantities of specific immunoglobulin, the immune active portion of humoral immunity. Immunoglobulin secreted by plasma cells is called antibody. Memory cells- serve the purpose of stockpiling a specific clone of B cells, so that immediate production of large quantities of the specific immunoglobulins results when the cells are next exposed to a particular antigen.

Immunoglobulins
1IgG- makes up about 75% of the antibodies normally circulating in plasma. IgG has been shown to carry the major burden in neutralizing bacterial toxins. This function is essential in accelerating the process of phagocytosis. 2IgA- most of IgA is in the form of secretory IgA in the external body secretions such as saliva, sweat, tears, bile, and colustrum. It provides a defense against pathogens on exposed surfaces of the body, especially those entering the respiratory and GI tract. 3IgM- Often called the macroglobulin (because it is the largest). It is the first immunoglobulin produced in quantity during an immune response, and so rise early in the course of infection. It is efficient in agglutinating antigen, fixing complement, and lysing cell walls. 4IgD- is present in plasma in very low concentration and is readily broken down. Its exact function is not well understood, but its presence on lymphocyte surfaces together with IgM suggests that it may be a receptor that helps find antigens to the cell surfaces. Its levels are elevated in chronic infections. 5IgE- serves to activate mast cells. It is normally fixed on tissue surfaces.

Cells of Adaptive, Specific Immunity

T Lymphocytes
They account for about 75% of the serum lymphocytes. They originate from stem cells in the bone marrow but are matured in the thymus gland and are sometimes called thymocytes. They can be functionally divided into three subgroups: Helper T Cells- stimulates B Lymphocytes to differentiate into antibody producers and serve to activate cytotoxic T lymphocytes and other T cell responses; they are therefore responsible for activating the specific immune response. Killer T Lymphocytes- bind to the surface of the infected cells, disrupt its membranes, and kill it by altering intracellular environment. Suppressor T Cells- reduce the humoral response. The production of immunoglobulins against a particular antigen can be reduced or abolished in the presence of these cells.

Types of Immunity
Innate (Natural) Immunity
Refers to those factors a person is born with to prevent disease. These can either be:
physical barriers (skin, mucous membranes, cough etc.) Chemical barriers Internal factors (mononuclear phagocytes and leukocytes)

Acquired Immunity
Refers to passive and active immune process.
Passive active immunity- occurs in early neonatal life, when some of the mothers immunity, which was passed through the placenta prenatally, continues to protect the infant from the disease. It protects for the first few months of life. Acquired active immunity- involves the response mounted by the persons immune system. Scientists have discovered the process of inducing acquired immunity through vaccination.

Types of Immunity
Adaptive Immunity
It is responsible for the protection of the human body from the disease. It requires a cellular and/or humoral response to an antigen. This type of immunity is an active process of specifics recognition of antigen and the production of a bank of cells that remember the antigen and quickly respond to repeat antigen introduction.

Cell- mediated Immunity

Is mediated through contact between T cells and antigen and by cystokines. The interaction sets off a complex series of steps leading to subsequent destruction of the antigen.

Stages of the Immune Response (Please see attachment)

I. Recognition Stage II. Prilifiration Stage Response Stage Effector Stage

INTEGRATION OF THE NURSING PROCESS

I. ASSESSMENT: Identifying modifiable risks based on: Health History
Age
People at the extremes of the lifespan are more likely to develop problems related to immune system functioning than are those in middle years.

Nutrition
Adequate nutrition is essential for optimal functioning of the immune system. Vitamins:
Essential for DNA and protein synthesis, if inadequate, may lead to proteincalorie deficiency and subsequently to impaired immune function. Also help in the regulation of cell proliferation and maturation of immune cells.

Fatty acids: the building blocks that that make up the structural component s of cell membrane. Depletion of protein reserves results in atrophy of lymphoid tissue, depression of antibody response, reduction in the number of circulating T cells, and impaired phagocytic function.

INTEGRATION OF THE NURSING PROCESS

Infection and Immunity
Immunizations received recently and those in childhood and the usual childhood disease. Known past or present exposure to tuberculosis. A history of past and present infections and the dates and types of treatments that were used, along with a history of any multiple persistent infections, FUO, lesions or pores, or any type of drainage, are obtained.

Allergy
History of any allergy and types of allergens:
Pollens Dust Plants Cosmetics Food Medications Vaccines etc.

Symptoms experienced History of testing and treatment

Disorders and Diseases

Autoimmune disorders:

More common in females

Believed to be the result of the activity of the sex hormones. Lupus erythematosus Rheumatoid arthritis Psoriasis

Neoplastic Disease
Any history of cancer, its type and date of diagnosis. Dates and results of any cancer screening tests. All treatments that the patient has received or is currently receiving, such as radiation or chemotherapy. Family History of cancer

Disorders and Diseases

Chronic Illness and Surgery
History of Chronic Illness:
DM Renal diseases COPD

Medications and Blood Transfusions

Large doses of:
Antibiotics Corticosteroids Cytotoxic agents Salicylates NSAID Anesthetics

History of surgical removal of:

Spleen Lymph nodes Thymus

History of organ transplantation

Special problems
Burns and other forms of injury and infection Physiologic and Psychological stressors

Single or multiple blood transfusions

Disorders and Diseases

Lifestyle and other factors
Smoking Alcohol consumption Dietary intake Nutritional status Amount of perceived stress Occupational or residential exposure to radiation and pollutants

Physical Examination (Indications of Immune Dysfunction)

Skin
Lesions Dermatitis Purpura Urticaria Inflammation Any Discharge

Temperature is recorded
Note chills and sweating

Posterior cervical, axillary, and inguinal lymph nodes are palpated

Location Size Consistency Tenderness

Physical Examination (Indications of Immune Dysfunction

Joints
Tenderness Swelling Limited ROM

Cardiovascular System
Hypotension Tachycardia Dysrhythmia Vasculitis Anemia

Respiratory System
Changes in RR Cough Abnormal lung sounds Rhinitis Hyperventilation Bronchospasm

Gastrointestinal System
Hepatosplenomegaly Colitis Vomiting Diarrhea

Physical Examination (Indications of Immune Dysfunction

Genitourinary system
Frequency and burning on urination Hematuria Discharge

Neurosensory
Cognitive dysfunction Hearing loss Visual changes Headaches and migraines Ataxia Tetany

Selected Tests for Evaluating Immunologic Status

Leukocytes and Lymphocyte Tests
WBC Count and differential Bone marrow high

Humoral (Antibody- mediated) Immunity Tests

B- cell quantification with monoclonar antibody In vivo immunoglobulin synthesis with T- cells subsets Specific antibody response Total serum globulins and individual immunoglobulins

Phagocytic Cell Function Tests

Nitroblue tetrazolium reductase assay

Selected Tests for Evaluating Immunologic Status

Complement Component Tests

Total serum hemolytic complement Individual complement component titrations Radial immunodiffusion Electroimmunoassay Radioimmunoassay Immunophlelometric assay Immunoelectrophoresis
Scratch test Patch test Intradermal test Radioallergosorbent test (RAST)

Hypersensetivity Tests

PLANNING AND IMPLEMENTATION

Maintenance and Promotion of Normal Immune System Response
Dietary/ nutritional instruction Vaccination/ Immunization

PLANNING AND IMPLEMENTATION

Prevention Against Microbial Invasion
Aseptic Techniques

Universal Precaution