Unit 3 Immunity Key Terms: Human Immunodeficiency Virus Acquired Immunodeficiency Syndrome Anti-retroviral Therapy Opportunistic Diseases Post-exposure Prophylaxis Viral Load CD4 Count Textbook: Readings: Concepts for Nursing Practice Review Concept 22: Immunity (Giddens, 3rd Ed.) Medical-Surgical Nursing Chapter 14: Infection (Lewis, 11th Ed.) • Human Immunodeficiency Virus Infection Maternal Child Nursing Care Chapter 4: Reproductive system (Perry, 6th Ed.) concerns ▪ Human Immunodeficiency Virus (HIV) Stop at Zika Virus Chapter 24: Newborn Nutrition & Feeding ▪ Contraindications to Breast Feeding Chapter 43: The Child with Hematologic or Immunologic Dysfunction ▪ HIV Infection & Acquired Immune Deficiency Syndrome (AIDS) Giddens Innate immunity: natural or native; present at birth; a nonspecific response not antigen specific. Acquired immunity: gained after birth either actively or passively. Active acquired: develops after the introduction of a foreign antigen resulting in the formation of antibodies of sensitized T lymphocytes; immunization or exposure to virus. Passive acquired: introduction of preformed antibodies: i.e., immunoglobin (Ig) transfusion or from mother to fetus. Organs of the immune system (lymphoid organs) are where lymphocytes are formed, frown, matured, and released into the body. They include: Bone marrow, thymus gland, spleen, tonsils, adenoids, and appendix. All cells in the immune system are derived from stem cells in the bone marrow (myeloid progenitor or lymphoid progenitor cells). Myeloid progenitors: neutrophils, monocytes (become macrophages in body tissue), eosinophils, basophils, and mast cells. Lymphoid progenitors: B lymphocytes (become plasma or memory B cells), mature T lymphocytes, and natural killer cells. Antibodies are secreted by B lymphocytes. Nine classes of antibodies or immunoglobulin: (4) IgG, IgD, IgE, (2) IgA, IgM. Phagocytes: macrophages and neutrophils (primarily): first line of defense during immune response. B Lymphocytes and T Lymphocytes: undergo differentiation on exposure to foreign antigen. Primary Immunodeficiency (PI): the entire immune defense system is inadequate and the individual is missing some, if not all, of what is needed for a complete immune response. 10 Warning Signs of PI (via NIH) 1. 4 or more new ear infections within 1 year 2. 2 or more serious sinus infections within 1 year 3. 2 or more months of taking antibiotics with little effect 4. 2 or more pneumonias within 1 year 5. Failure of an infant to gain weight or grow normally 6. Recurrent, deep skin, or organ abscesses 7. Persistent thrush in mouth or fungal infection on skin 8. Need for intravenous antibiotics to clear infections 9. 2 or more deep-seated infections, including septicemia (blood poisoning) 10. Family hx of PI Secondary immunodeficiency: loss of immune functioning (previous normal functioning immune system) as a result of illness or treatment. Ex. Transplant rejection or result of cancer treatment. Four types of Exaggerated Immune Response (Hypersensitivity) Disorders: Autoimmune disorders: the immune systems attack and destroys healthy cells following a breakdown of “self-tolerance”. Many individuals have multiple autoimmune disorders. Associating with three potential outcomes: 1. Destruction of one or more types of body tissues 2. Abnormal organ growth, or 3. Changes in organ function Some include: rheumatoid arthritis, SLE, muscular sclerosis, Graves disease, and DM. Patient Hx: exposure to microorganisms that may cause immunosuppression: Epstein-Barr virus, HIV, cytomegalovirus, herpes simplex virus type 6, hepatitis B virus, etc. Clinical Findings Optimal Appears well and is well nourished Vital signs WNP for age Lymph nodes soft, movable, and non-tender (often not palpable among older adults) Any wounds present healing within normal time frame Suppressed Vitals signs may or may not be within normal parameters May not appear well nourished May present with weight loss or wasting syndrome May complain of generalized fatigue or malaise Impaired wound healing With advanced suppression, opportunistic infections and diseases may be present Inflammation and infection within CNS may cause change in cognitive functioning or depression Presence of seizure activity or changes in motor behavior should be determined Exaggerated Immune Function May vary from mild symptoms (sneezing, watery eyes, and nasal congestion) to severe responses (rashes, swelling, and shock syndrome) Often vague and less obvious, while still affecting multiple organ systems Can escalate to pericarditis, congestive heart failure, pulmonary or peripheral edema, and anemia – Glomerulonephritis and acute to chronic renal failure/ end-stage renal disease – Joint pain or inability to control movements Butterfly rash across nose and cheeks common finding with SLE Diagnostic Testing Primary Testing: RBC/WBC, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Allergy Testing Advanced or Disease-Specific Testing including TORCH (toxoplasmosis, rubella, cytomegalovirus, and herpes simplex) Test of Organ Function Exemplars Hodgkin and Non-Hodgkin Lymphoma HIV Leads to primarily to destruction of CD4+ T cells, leaving the individuals with an immune deficiency and diminished ability to fight opportunistic diseases and infections. Anaphylaxis Allergic Rhinitis (hay fever or pollen allergy) Systemic Lupus Erythematosus (SLE) Type 1 Diabetes Mellitus (DM) Multiple Sclerosis (MS) Med-Surg Human immunodeficiency virus (HIV): chronic disease caused by a retrovirus (RNA: replicate backwards, RNA to DNA) that causes immunosuppression. Transmitted through contact with infected blood, semen, vaginal secretions, or breast milk; it is NOT spread casually. Antiretroviral therapy (ART): a combination of medications used to control and suppress HIV replication. HIV reaches a point where so many CD4 cells are destroyed that there are not enough left to regulate immune responses: opportunistic diseases are then able to develop. Acute HIV infection: about 2-4 weeks after infection individual may have mononucleosis-like syndrome of fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, and/or a diffuse rash. Some may exhibit neurologic complications including aseptic meningitis, peripheral neuropathy, facial palsy, or Guillain-Barre syndrome. During this, there is a high viral load (amount of HIV circulating in the blood). The CD4 count falls temporarily, but quickly returns to baseline or near-baseline levels. Most people mistake this acute infection for the flu. During the first several (around 10) years of initial HIV infection, most people are asymptomatic. There is usually a 10-year time lapse between an initial untreated HIV infection and the development of AIDS. Symptoms begin to develop including persistent fever, frequent night sweats, chronic diarrhea, recurrent headaches, and sever fatigue. Oropharyngeal candidiasis (thrush) is one of the MOST COMMON infections associated with HIV advancements into its more active stage. Other infections include: shingles, persistent vaginal candida infections, outbreaks of oral or genital herpes, bacterial infections, and Kaposi sarcoma (KS) caused by human herpesvirus 8; oral hairy leukoplakia – an Epstein-Barr virus infection that causes painless, white, raised, lesions on the lateral aspect of the tongue. Window period: it can take several weeks after infection before a screening test can detect HIV. Generally, this period is about 3 weeks. Lab tests include CD4 count and viral load. CD4: marker of immune function; as the disease progressed the CD4 count lowers. Normal range for CD4 is 800 to 1200 cells/uL. Viral levels assess disease progression: lower the viral load, the less active the disease. “Undetectable” means the viral load is at the lowest level possible and prevents sexual transmission to others. ART Preexposure prophylaxis (PrEP) Antivirals Help prevent HIV infection in uninfected people Ex. Tenofovir disoproxil fumarate (Tenofovir DF) in combination with emtricitabine. Persons with HIV require a specific and ongoing assessment. Nursing Dx include: Risk for infection Lack of knowledge Difficulty Coping Impaired nutritional status Planning and Interventions Adhere to drug regimens Adopt a healthy lifestyle (avoid other blood/sexually transmitted diseases) Protect others from HIV Maintain or develop healthy and supportive relationships Maintain activities and productivity Explore spiritual issues Come to terms with disease/death/disability related issues Cope with symptoms caused by HIV and treatments HIV-infected patients on ART for a long time may develop metabolic disorders, these include: lipodystrophy (changes in body shape caused by redistribution of fat in the abdomen, upper back, and breast along with fat loss in the arms, legs, and face), hyperlipidemia (high triglycerides, high low-density lipoproteins, and decreased high-density lipoproteins), insulin resistance, hyperglycemia, bone disease) osteoporosis, osteopenia, avascular necrosis), lactic acidosis, renal disease, and cardiovascular disease. Maternal Child Nursing Care (Perry, 6th Ed.) Chapter 4: Reproductive system concerns ▪ Human Immunodeficiency Virus (HIV) Stop at Zika Virus Chapter 24: Newborn Nutrition & Feeding ▪ Contraindications to Breast Feeding Chapter 43: The Child with Hematologic or Immunologic Dysfunction ▪ HIV Infection & Acquired Immune Deficiency Syndrome (AIDS) All women should be screened for HIV/AIDS. The most commonly reported opportunistic disease are Pneumocystis (jirovecii) pneumonia (PCP), Candida esophagitis, and wasting syndrome. HSV and cytomegalovirus are also common in women over men. Once HIV enters the body, seroconversion to HIV positivity occurs within 6-12 weeks. Can be symptomatic, but usually associated with flu-like symptoms. HIV is usually diagnosed by using HIV-1 and HIV-2 antibody tests. Must be confirmed by an additional test such as the Western blot or an immunofluorescence assay. Triple-drug antiviral or highly active antiretroviral therapy (HAART) during pregnancy decreases perinatal transmission (usually 25%) to less than 1%. HIV infection to fetus may occur at any time during circulation as early as first trimester. There is also a risk during birth and from fluid (like breastmilk) during feeding. HIV antibodies crosses the placenta. Recommended that C-section be performed at 38 weeks of gestation when viral load is more than 1000 copies/mL. Viral birth may be an option when the viral load is less than 1000 copies/mL at 36 weeks, if there are ruptured membranes and labor is progressing rapidly, or if she declines a C-section. Blood transfusions in the ‘80s. HIV-2 is dominant in Africa, while HIV-1 is common in the USA. Enzyme-linked immunosorbent assay (ELISA) and Western blot immunoassay are used to determine infection in children 18 months or older. After 18 months, the positive results from the mother’s antibodies dissipate.
