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Questions and Answers
Which type of hypersensitivity involves antibody-mediated destruction of specific organs or tissues?
What is the primary immune response decreased in elderly individuals?
Which of the following examples is classified under Type III hypersensitivity?
What is a critical step in the emergency management of anaphylaxis?
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Which cells are primarily involved in the cell-mediated immune response?
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Which type of hypersensitivity is characterized by 'free' antibodies not bound to cells?
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What term describes a condition where the immune system cannot effectively respond to antigens?
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Which type of hypersensitivity reaction would likely occur in response to poison ivy exposure?
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What is the primary mechanism of action in Type IV hypersensitivity reactions?
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Which characteristic is NOT associated with early-stage rheumatoid arthritis?
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Which laboratory test is specifically used to detect rheumatoid factors in rheumatoid arthritis diagnosis?
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What is the typical demographic profile for systemic lupus erythematosus (SLE) incidence?
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Which complication is typically associated with late-stage rheumatoid arthritis?
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In assessing lupus, which combination of symptoms is NOT typically considered diagnostic?
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What are the pharmacological interventions for managing lupus NOT including?
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Which assessment finding is most indicative of delayed hypersensitivity reactions?
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NSAIDS and Steroids: BOTH relieve ________________
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Avoid in patients with: ______________________________
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Example of NSAID: ________________
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Steroids: Strong _______________________
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Example of a steroid: _______
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Goal is to use ____________________________________________
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What are the side effects of NSAIDs and steroids?
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Used with caution with those with________&___________
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RA causes a decrease in bone density, which can lead to ___________________
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The use of steroid medications, such as prednisone, further increases the risk of _____________________
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Recommend adequate: ___
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What are immunosuppressants used for?
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What is the bad news regarding immunosuppressants?
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How are DMARDs similar to NSAIDs?____
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DMARDs differ from NSAIDs in that they ______________________.
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What are the two types of DMARDs?
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Nonbiologic DMARD: __________________________________
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Example of non-biologic DMARD: ___________________________________________________
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Unlike conventional DMARDs which can take ________________, biologics tend to work ___________.
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Time to see benefits from Methotrexate:_____________________________
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If no response after 2 months _______________________.
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Common side effect for Cyclosporine: _________________
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Patient teaching for all drugs includes: _____________________
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What is the expected cost of biologic DMARDs?
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Must have _____________________ to start! And test____________
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Key Point: REPORT _________________
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Example for Lupus:_______________
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Example for RA: TNF inhibitors _____________________________________
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Why are TNF inhibitors not given to those with lupus?
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What is the definition of immunity?
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Which of the following are types of immunity? (Select all that apply)
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What role do B cells play in the immune system?
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What are antibodies?
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The first responders in the immune system are called __________.
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Match the following immune disorders with their descriptions:
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Vaccines stimulate an immune response without causing disease.
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What is herd immunity?
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What are cytokines?
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An __________ is any substance that can provoke an immune response.
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HIV/AIDS is classified as an autoimmune disease.
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Study Notes
Immunity
- Body Parts Involved: The immune system is a complex network of cells, tissues, and organs that work together to protect the body from foreign invaders.
- Function: The primary role of the immune system is to identify and eliminate harmful substances, such as bacteria, viruses, fungi, and parasites. It also helps in recognizing and destroying abnormal cells, such as cancerous cells.
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Types of Immunity: There are two main types:
- Innate Immunity: This is the body's first line of defense. It is non-specific and acts immediately upon encountering a foreign invader. Examples include the skin, mucous membranes, macrophages, and neutrophils.
- Adaptive Immunity: This is the body's specific defense mechanism. It develops over time and targets specific invaders. It involves lymphocytes (B cells and T cells) and is characterized by memory, making the body quicker to respond to the same threat in the future.
White Blood Cells (Leukocytes)
- Granulocytes: These cells have granules in their cytoplasm and include neutrophils, eosinophils, and basophils. They are involved in engulfing and destroying foreign invaders.
- Agranulocytes: These cells lack granules in their cytoplasm and include lymphocytes (B cells and T cells) and monocytes. Lymphocytes are responsible for specific immune responses. Monocytes differentiate into macrophages which phagocytize invaders.
Immunity Terms
- Immunocompetent: This refers to an individual with a properly functioning immune system capable of defending against infection and disease.
- Immunodeficiency: This occurs when the immune system is weakened or compromised, making the individual more susceptible to infections and diseases.
- Hypersensitivity: This involves an exaggerated or inappropriate immune response to a harmless substance or antigen. This leads to allergic reactions and other inflammatory conditions.
- Autoimmune Disorders: These are conditions in which the body's immune system mistakenly attacks its own tissues and organs.
Age Related Changes in the Elderly
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Inflammation: The elderly may have a delayed or blunted inflammatory response.
- Neutrophils: May have reduced function and their number may decrease.
- Leukocytes: May have a decreased response to infection.
- Fever: The elderly may experience lower fever temperatures, even with severe infections.
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Antibody-Mediated Immunity:
- B lymphocytes: Production and function may decline, leading to weakened antibody responses.
- Antibody responses: May be slower and less robust.
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Cell-Mediated Immunity:
- T lymphocytes: Number and function may decline.
Hypersensitivity Reactions
- Type 1: Immediate/Rapid/Atopic: This is the most common type of hypersensitivity. It involves an immediate response to an allergen, mediated by IgE antibodies. Examples include anaphylaxis, allergic asthma, angioedema, and allergic rhinitis.
- Type 2: Cytotoxic: This type involves antibody-mediated destruction of specific cells or tissues. IgG or IgM antibodies target antigens on cell surfaces. It can lead to autoimmune hemolytic anemia, pernicious anemia, Graves disease, and Myasthenia Gravis.
- Type 3: Immune Complex-Mediated: This type involves the formation of antigen-antibody complexes that deposit in tissues and cause inflammation. Examples include lupus and rheumatoid arthritis.
- Type 4: Delayed: This type is mediated by T cells and does not involve antibodies or complement. It typically takes more than 12 hours to develop after exposure to the antigen. Examples include contact dermatitis, local responses to insect stings, and positive TB tests.
Type I: Immediate / Rapid / Atopic
- Allergic Rhinitis: This is a common allergic condition characterized by inflammation of the nasal passages, leading to symptoms like sneezing, runny nose, and congestion.
- Drug Therapy: For treating allergic rhinitis, antihistamines, nasal corticosteroids, and decongestants are commonly used.
Type I: Immediate / Rapid / Atopic : Anaphylaxis
- Life-Threatening: Anaphylaxis is a severe, potentially fatal allergic reaction that can cause a rapid, life-threatening drop in blood pressure and airway closure.
- Rapid Onset: Symptoms develop within minutes of exposure to the allergen.
- Assessment: Assessing the severity of symptoms is crucial. Look for signs like hives, itching, swelling, difficulty breathing, wheezing, and a decrease in blood pressure.
- Interventions: Immediate action is necessary for life-threatening anaphylaxis. Remove the allergen if safe, administer epinephrine, and be prepared to assist with airway management and oxygen therapy.
- Emergency Management: Immediate emergency medical care is essential for patients experiencing anaphylactic shock to ensure airway patency and proper oxygenation.
Type II: Cytotoxic
- Mechanism: This type involves the destruction of specific cells or tissues by antibodies.
- Consequences: Antibodies can bind to cell surface receptors, altering cell function. They can also activate the complement pathway, leading to cell lysis (destruction).
- Antibody-Dependent Cellular Cytotoxicity: This involves Natural Killer (NK) cells recognizing and destroying antibody-coated cells.
- Examples: Cell dies in autoimmune hemolytic anemia and pernicious anemia. Grave's disease and Myasthenia Gravis involve severe disruption of cell function.
Type III: Immune Complex-Mediated
- Mechanism: This type involves the formation of immune complexes (antigen-antibody) in the circulation. These complexes can then deposit in tissues, causing inflammation and tissue damage.
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Key Features:
- Excess antigens: There is an abundance of antigens.
- Immune complexes: These complexes form due to the interaction of free antibodies with their corresponding antigens.
- Lodging in Small Vessels: These complexes can get trapped within small blood vessels, leading to inflammation and tissue injury.
Type IV: Delayed
- Mechanism: T cells are the primary players in this type of hypersensitivity. Antibodies and complement are not involved.
- Process: Macrophages often destroy the antigen.
- Timing: It takes more than 12 hours to develop after exposure to the antigen.
- Examples: Examples include contact dermatitis, local responses to insect stings, and positive PPD for TB.
Rheumatoid Arthritis (RA)
- Incidence/Prevalence: RA is a chronic autoimmune disorder affecting joints, primarily the hands, wrists, and knees. It can also impact other organs.
- Pathophysiology: The exact cause is unknown, but the immune system mistakenly mounts an attack on joint tissue and surrounding structures, leading to inflammation and damage.
- Rheumatoid Factors: These are antibodies produced by the immune system, specifically targeting the body's own tissues, contributing to inflammation in RA.
RA - Assessment
- Physical Assessment: Careful observation of joint deformities and swelling, range of motion, and signs of inflammation are important.
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Stages: Disease progression is categorized in stages:
- Early (Fatigue, anorexia, morning joint stiffness, fever, weakness, paresthesia): These are common initial symptoms, often presenting before classic joint involvement.
- Late Joint: Deformities (swan neck or boutonniere) develop, alongside moderate to severe pain, and prolonged morning stiffness.
- Late Systemic (Osteoporosis, severe fatigue, vasculitis, pericarditis, kidney problems): As RA progresses, it can impact other organs and systems leading to substantial complications.
- Complications: RA can lead to joint damage, deformity, disability, and systemic issues affecting other organ systems.
- Psychosocial: RA can significantly impact quality of life, affecting mental health, physical function, and relationships.
RA - Diagnosis
- Rheumatologist: A specialist in rheumatic diseases, specializing in diagnosing and managing conditions like RA.
- Medical History: Detailed information regarding symptoms, family history, and prior treatments is vital for diagnosis.
- Physical Assessment: Examining the musculoskeletal system, checking for tenderness, swelling, and decreased range of motion.
- Arthrocentesis: A procedure involves extracting fluid from the joint for analysis.
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Laboratory Tests:
- ESR and CRP: These blood tests measure inflammation levels.
- ANA and RF: These blood tests detect certain antibodies associated with RA.
- CCP Antibodies: A more specific test for RA compared to RF.
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Diagnostic Imaging:
- X-ray: Provides a detailed picture of bone structures and joint changes.
- CT/MRI: Offer more detailed imaging for evaluating joint damage and surrounding tissues.
RA - Pharmacology
- NSAIDs: Non-steroidal anti-inflammatory drugs are used to reduce pain and inflammation.
- Steroids: Corticosteroids are powerful anti-inflammatory medications, often used for symptom management and short-term flare-ups.
- Immunosuppressants: These medications suppress the immune system to reduce inflammation and protect joints.
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DMARDs: Disease-modifying antirheumatic drugs, slow joint damage and improve symptoms.
- Non-Biologics: Examples include methotrexate, sulfasalazine, and hydroxychloroquine.
- Biologics: These are newer medications that target specific components of the immune system, such as TNF-alpha.
- Plasmapheresis: A procedure to filter and remove harmful antibodies and inflammatory components from the blood.
- Surgical: Surgical interventions may be needed to repair joint damage.
- CAM: Complementary and alternative medicine therapies such as acupuncture, massage, and yoga can be used to manage pain and improve well-being.
RA - Treatment and Education
- Positioning: Proper positioning and support are essential to maintain joint alignment, minimizing pain and discomfort.
- Applying Heat/Cold: Both therapies can be helpful: Heat can relax muscles and increase blood flow, while cold can reduce inflammation and numb pain.
- Low-Impact Exercise: Regular physical activity is crucial for maintaining muscle strength, flexibility, and overall joint health.
- Self-Management and Promotion: Encouraging patients to actively participate in their care by understanding their condition, medications, and taking proactive steps to manage symptoms.
- Enhancing Body Image: Addressing the emotional and psychological impact of RA on body image and self-esteem is important.
- Immobilizers: Splints or braces can be used to stabilize joints, reduce pain, and prevent further damage.
Systemic Lupus Erythematosus (SLE)
- Incidence and Prevalence: SLE is an autoimmune disorder characterized by chronic inflammation, affecting various tissues including the skin, joints, kidneys, heart, and brain.
- Incidence: Approximately 18,000 new cases are diagnosed each year in the United States.
- Prevalence: It is primarily found in women, particularly those of childbearing age.
Lupus - Pathophysiology
- Immune System Imbalance: The immune system mistakenly attacks the body's own healthy tissues.
- Autoantibodies: These antibodies created by the immune system erroneously target the body's own cells and tissues, leading to inflammation and damage.
- Immune Complexes: These complexes form when autoantibodies bind to antigens in the body. They can deposit in tissues and activate the complement pathway leading to inflammation.
Lupus - Types
- Discoid Lupus: This type predominantly affects the skin, causing lesions that may leave scars.
- Systemic Lupus: This type involves multiple organ systems, causing a wider range of symptoms.
Lupus - Assessment
- Multi-Systemic Involvement: Systemic lupus can impact various organs and tissues.
- Unexplained Fevers: Fever often suggests lupus activity, making it important to rule out other causes.
- Musculoskeletal: Joint pain, stiffness, and swelling are common symptoms.
- Dermatologic: Butterfly rash across the face, discoid lesions, and photosensitivity are characteristic skin manifestations.
- Pulmonary: Pleuritis (inflammation of the lining of the lungs) and pneumonitis are possible.
- Renal: Lupus nephritis, a serious condition that can cause kidney damage.
- Neurologic: Seizures, headaches, and cognitive dysfunction are possible.
- Hematologic: Anemia and low platelet counts are possible.
- Cardiac: Pericarditis (inflammation of the lining surrounding the heart) and myocarditis (inflammation of the heart muscle) can occur.
Lupus - Diagnosis
- Physical Changes: Assessing the presence of characteristic symptoms and physical findings.
- Criteria: Diagnosing SLE requires at least 4 of 11 specific clinical features or lab findings.
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Laboratory Analyses:
- Autoantibody Tests (ANA): Testing for antinuclear antibodies, often positive in patients with lupus.
- Inflammatory Markers: Elevated ESR, C-reactive protein (CRP), and other markers can indicate inflammation.
- Creatinine: To assess kidney function.
- WBC (White Blood Cell Count): May be abnormal, indicating inflammation or infection.
Lupus - Treatment
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Avoid the 4 S’s:
- Sun: Avoiding excessive sun exposure, as it can trigger lupus flares.
- Smoking: Smoking worsens lupus symptoms.
- Stress: Managing stress levels is important as it can aggravate symptoms.
- Supplements: Use of supplements, especially herbal remedies, should be discussed with a doctor, as they can potentially interact with medications.
- Symptom Management: Treating specific symptoms like pain, inflammation, and fatigue.
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Pharmacological Interventions:
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Immunosuppressants: These medications suppress the immune system to reduce inflammation and protect tissues.
- Hydroxychloroquine: Often used to treat mild to moderate lupus symptoms.
- DMARDS (Disease-Modifying Antirheumatic Drugs): These are used to slow disease progression and prevent further damage.
- Biologics: These targeted therapies are used to block specific immune system components involved in the inflammation of lupus.
- Other Immunosuppressants: Depending on the severity, other medications may be used to further control the immune system.
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Immunosuppressants: These medications suppress the immune system to reduce inflammation and protect tissues.
RA and Lupus Immunosuppressants
- NSAIDs and Steroids relieve pain and inflammation
- NSAIDs are non-steroidal anti-inflammatory drugs and they prevent the production of chemicals that cause inflammation and pain
- Avoid NSAIDs in patients with: gastrointestinal problems, heart failure, high blood pressure, or kidney disease
- Examples of NSAIDs include ibuprofen, naproxen, and celecoxib
- Steroids are a strong anti-inflammatory medication
- Examples of steroids include prednisone and methylprednisolone
- Steroids work by suppressing inflammatory responses in the body
- The goal of using steroids is to reduce inflammation and improve symptoms while minimizing side effects
- Side effects of steroids include: weight gain, high blood sugar, osteoporosis, cataracts, and glaucoma
- Steroids are not usually used for long-term therapy due to potential side effects
- Use steroids with caution in patients with diabetes and osteoporosis
- RA causes a decrease in bone density, which can lead to fractures
- The use of steroid medications, such as prednisone, further increases the risk of osteoporosis
- Recommend adequate calcium and vitamin D intake
- Immunosuppressants help the body stop attacking itself, but they also increase the risk for infection and cancer
- Immunosuppressants also increase the risk for opportunistic infections
- DMARDs are disease-modifying antirheumatic drugs
- DMARDs are similar to NSAIDs in how they reduce inflammation, but they differ in their long-term effects on disease progression
- DMARDs can slow down the progression of joint damage and improve symptoms
- Two types of DMARDs: non-biologic DMARDs and biologic DMARDs
- Non-biologic DMARDs are traditional medications that have been used to treat RA for many years
- Examples of non-biologic DMARDs include methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide
- Biologic DMARDs are newer medications that target specific parts of the immune system
- Examples of biologic DMARDs include etanercept, infliximab, adalimumab, certolizumab pegol, golimumab, and tocilizumab
- Unlike conventional DMARDs which can take weeks or months to work, biologics tend to work faster
Non-biologic DMARDs
- Hydroxychloroquine (Plaquenil) decreases inflammation
- Hydroxychloroquine can increase energy levels, but it takes several weeks to reach therapeutic levels
- Major adverse effects of hydroxychloroquine include: damage to the retina, gastrointestinal problems, and skin rashes
- Benefits of hydroxychloroquine include: reducing joint pain and swelling, slowing down the progression of RA, and improving quality of life
- Osteoporosis medications may be needed while taking hydroxychloroquine
- Hydroxychloroquine is safe during pregnancy
- Methotrexate works by slowing down the growth of cells that cause inflammation in the body
- Methotrexate is the mainstay of therapy for RA because it is effective and well-tolerated
- Methotrexate needs to be taken for several weeks before positive effects are seen
- Methotrexate has no cure, no prevention, and no pain relief
- Methotrexate does not relieve pain
- Bone marrow suppression is a decrease in the production of blood cells
- Thrombocytopenia is platelets under 150,000/mm3
- Report symptoms of bleeding with thrombocytopenia, including: nosebleeds, easy bruising, bleeding gums, heavy menstrual periods, and blood in the urine or stool
- Neutropenia is a decrease in the number of white blood cells
- Neutropenia can lead to increased risk for infections
- Neutropenia can cause no fevers, no pain, and no swelling
- Report any signs of infection with neutropenia, such as fever, chills, cough, sore throat, or any other unusual symptoms
- A fetus has quickly replicating cells which could equal birth defects
- Do NOT conceive or become pregnant while taking methotrexate
- Must be on reliable contraception while taking methotrexate
- Need to be off methotrexate for more than 3 months before trying to conceive
Memory trick with Methotrexate is Meth-NO-trexate!
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No cure
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No prevention
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No pain relief
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No conception
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No pregnancy
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Time to see benefits with Methotrexate is several weeks
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If no response after 2 months of taking methotrexate, the doctor may switch to a different medication
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Azathioprine (Imuran) and Cyclosporine are also used to treat RA
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A common side effect of Cyclosporine is kidney problems
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Tell the doctor if you notice any changes in your urine or if you experience any other symptoms of kidney problems
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Patient teaching: Be sure to tell the doctor about any medications, including over-the-counter medications and herbal supplements, that you’re taking before starting treatment
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Biologic DMARDs can take weeks or months to work effectively
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Biologic DMARDs are expensive
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Biologic DMARDs have a high risk of developing serious infections
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Must have a TB test done before starting biologic DMARDs
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Must have a blood test done before starting biologic DMARDs
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Must monitor blood counts regularly once starting biologic DMARDs
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Must avoid live vaccines while taking biologic DMARDs
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Stay away from sick people if you’re taking biologic DMARDs
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Report any signs of infection, such as fever, chills, cough, sore throat, or any other unusual symptoms.
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Report any signs of new or worsening symptoms, such as joint pain, swelling, or fatigue
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Patients must have a TB test if they are going to start taking biologic DMARDs, because there is an increased risk of reactivation of latent TB
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Contraindications include: recent or current active infection, heart failure, and certain types of cancer
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Patients taking biologic DMARDs are expected to have an elevated C-reactive protein (CRP) level
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Examples of TNF inhibitors include: etanercept, infliximab, adalimumab, certolizumab pegol, golimumab, and tocilizumab
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TNF inhibitors are not given to those with Lupus because they can worsen the disease
Immunity Overview
- The body's ability to resist infection and disease.
- Two main types: innate and adaptive.
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Innate immunity:
- Non-specific defenses, immediate response, no memory.
- Includes physical barriers like skin and mucous membranes, and immune cells such as macrophages, neutrophils, and natural killer cells.
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Adaptive immunity:
- Specific response to pathogens, involves memory cells.
- Develops over time after exposure to antigens.
- Involves B cells that produce antibodies and T cells that directly attack infected cells.
Immune System Components
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White blood cells (WBCs or leukocytes):
- Neutrophils: First responders that engulf and destroy pathogens.
- Lymphocytes: Include B cells and T cells, responsible for specific immune responses.
- Antibodies: Proteins produced by B cells that bind to specific antigens, neutralizing pathogens.
- Cytokines: Signaling molecules that regulate immune responses and inflammation.
- Complement system: Group of proteins that enhance antibody and phagocyte function in clearing microbes.
Immune Response Phases
- Recognition: Immune cells detect pathogens.
- Activation: Immune cells become activated and proliferate in response to the pathogen.
- Response: The activated immune cells eliminate the pathogen through various mechanisms.
- Memory: Memory cells are formed and provide a faster response to the same pathogen in the future.
Immunization
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Vaccines: Stimulate the immune system to create immunity without causing disease.
- Types include live attenuated, inactivated, subunit, and mRNA vaccines.
- Herd immunity: When a large percentage of the population is immunized, indirectly protecting those who cannot be vaccinated.
Immune Disorders
- Autoimmune diseases: Immune system attacks healthy cells, e.g., rheumatoid arthritis, lupus.
- Immunodeficiency: Reduced immune response, leaving the body vulnerable to infections, e.g., HIV/AIDS
- Hypersensitivity reactions: Exaggerated immune response to harmless substances, e.g., allergies.
Nursing Considerations
- Assess patient's immunization history, including previous vaccinations and current status.
- Educate patients about the importance of vaccinations for preventing diseases.
- Monitor for signs of immune dysfunction, such as frequent infections, unusual allergies, or changes in blood cell counts.
- Implement infection control practices to protect immunocompromised patients.
NCLEX Tips
- Be familiar with common medications used to manage immune disorders, such as corticosteroids and immunoglobulins.
- Understand lab values related to immunity, like white blood cell count (WBC), absolute neutrophil count (ANC), and CD4 cell count in HIV.
- Practice prioritizing care for patients with immune disorders, understanding their unique needs and potential complications.
Key Terminology
- Antigen: Any substance that can trigger an immune response.
- Pathogen: A microorganism capable of causing disease.
- Vaccine: A biological preparation that induces acquired immunity to a specific disease.
- Herd immunity: Protection of individuals who are not immune due to the high vaccination rate in the overall population.
Studying That Suits You
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Description
Test your knowledge on the immune system and its components, including the roles of innate and adaptive immunity. This quiz covers the various cells involved, particularly focusing on white blood cells and their functions in protecting the body from invaders.
