Assessment of Immune Function and Immunodeficiencies
•
Health history:
– Age.
– Nutrition.
– Infection & immunization.
– Allergy.
– Disorders & diseases.
– Medications & blood transfusions.
– Lifestyle & other factors.
 Physical examination.
Health History: Age
Immunodeficiencies
• Frequency & severity of infections are increased in elderly people due to:
– ↓ ability to respond adequately to invading organisms.
– ↓ production & function of T & B lymphocytes.
– ↑ incidence of autoimmune “body attacking self” diseases. b/c surveillance system
becomes weaker- body cannot detect between self and non-self.
• ↑ incidence of cancer.
Age related changes…
Normal age vs abn aging that’ll cause Immunodeficiencies
– Declining function of various organs:
• ↓ gastric secretions & motility. So secretions that do seep out are gonna sit
there. Higher chance of ulcers and for bacteria to enter. Leads to Diarrhea.
• ↓ renal circulation, filtration, absorption, & excretion. Will see severe UTIs.
• Prostatic enlargement & neurogenic bladder. Urinary stasis. Will also cause UTIs
b/c of poor bacterial clearance.
• Exposure to tobacco & environmental toxins.
• Skin becomes thinner & less elastic.
• Peripheral neuropathy, decreased sensation & circulation. Pts may not realize
they are injured.
Health History: Nutrition
Health History: Infection & Immunization
Immunodeficiencies
• Childhood/recent immunizations & diseases.
• TB: Exposure
•
PPD (Tuberculin) test- purified protein derivative
• CXR
• Recent exposure to infections. Especially to STDs.
• Past & present infections. Make sense…
• Multiple persistent infections, fevers of unknown origin, lesions or sores, any type of drainage.
Health History: Allergy
Immunodeficiencies
• Allergies & types of allergens.
– Is the band on?
• Seasonal variations.
– Better in summer, worse in fall?
• Occurrence & severity of symptoms.
• Testing & treatments received.
• Effectiveness of treatments.
Health History: Disorders & Diseases
Immunodeficiencies
• Autoimmune disorders
– Rare – All disorders account for 5% of U.S. population (lupus, RA, psoriasis,… very strong
link to genetics and being female) Women more prone to autoimmune disorder.
– Strong genetic link
– More common in Females
• Neoplastic disease “abn tissue mass as a result of neoplasia”
– Type of CA & date of diagnosis
– Immunosuppression contributes to Cancer & Cancer contributes to
Immunosuppression
– Treatments
• Radiation- Radiation for Local. Hair no grow.
• Chemo- Chemo for large/widespread. Hair regrow.
– Ask: who, what, where, when, successful?
• Leukemia and lymphoma…
Chronic illness & surgery:
• Renal failure =↓ lymphocytes, uremia.
• DM = ↑ infections (Microorganisms love sugar), vascular insufficiency, & neuropathy
(higher chance for injuries).
• COPD = recurrent respiratory tract infections →
ineffective airway clearance.
• Surgery = Removal of spleen (results in life-long antibiotics, cause the spleen helps fight
infection), lymph nodes, thymus, organ transplantation.
Special problems:
• Burns, injury & infection
– Impaired skin integrity & compromised first line of defense.
– Loss of large amounts of serum in burns patients → depletes body of
immunoglobulins & antibodies.
– Physiological & psychological stress → cortisol release → suppression of normal
immune responses.
Health History: Medications & Blood Transfusions
Immunodeficiencies
• Immunosuppressive drugs:
– High dose antibiotics- killin good w/ bad
– Corticosteroids- over time decr immun response
– Salicylates, NSAIDS- prone to ulcers
– Anesthetics- slow everything down (biological/immune processes)
• Blood Transfusions- multiple transfxns
• Herbal remedies
Health History: Lifestyle & Other Factors
Immunodeficiencies
• Smoking
• Alcohol consumption- tear up liver and GI tract
• Dietary intake & nutritional status
• Amount of perceived stress
• IV drug use- link to Aids and Hepatitis
• Sexual practices
• Occupational or residential exposure to radiation or pollutants
Psychoneuroimmunologic Factors
Immunodeficiencies
• Immune response regulated by neurotransmitters and endocrine function.
And (at same time)
• Immune processes can conversely affect behavior. Bidirectional interaction. People w/
good self esteem will simply be “healthier”
Evidence suggest immune function can be influenced via behavioral strategies.
ex: Bio-feedback, …
Physical Examination
Immunodeficiencies
• Skin & mucous membranes
– lesions, dermatitis, purpura “reddish/purple discoloration of skin”, urticaria “rash/hives”
• Signs of infection
– High Temp, Chills, sweating
• Palpable lymph nodes
– Large, tender?
• Joints
– Swelling, warmth, tender
• Assess major body systems
(CV, Resp, GI, GU, Neuro, etc.)
Diagnostic Evaluation
Immunodeficiencies
• Blood tests. (WBC w/ differential, , H&H, anemia is indicated…)
• Cultures
• Skin tests. (Allergies, allergen exposure)
• Bone marrow biopsy.
WBC and Differential
Immunodeficiencies
– Normal- WBC values – 5000 – 10000/mm3
– Or 5-10 x 109/L
–
–
–
–
Elderly WBC values – 3000 – 9000/mm3
Or 309 x 109/L
Differential – the % of each different type of WBC
Neutrophil (and Bands)
• Lymphocytes
• Eosinophils- allergic reaction
• Basophils (Mast Cells)
Nursing Management
Immunodeficiencies
• Be aware of…
– Physical pain and discomfort of exams/testing
– Psychological stress
Neutrophils- “new on the scene”. Severe bacterial infection, will see lots of bands
Immunodeficiency Disorders
Immunodeficiencies
•
A defect or deficiency in phagocytic cells, B lymphocytes, T lymphocytes, or the complement
system.
• ***Reference bk, but Childhood/Pedi omitted
Immunodeficiencies….
Chart 51-1, pg 1804
• Primary immunodeficiencies
– Genetic disorders
– Cellular defects
– Primarily in infants and young children
Common Variable Immunodeficiency (CVID)
• aka Hypogammaglobulinemia
– Very low level of immunoglobulin or non-existent
– Usually seen in early adulthood (20-30)
• The MOST COMMON primary immunodeficiency in adults.
– A B-cell deficiency
– Recurrent infection with fever
– Increased incidence of autoimmune diseases (1 : 80000)
– Low serum immunoglobulin levels
– And… Tired, don’t heal well
• Clinical Manifestations
– Pernicious anemia “Low B12”
– Lymphoid tissue hyperplasia
– Other autoimmune disorders
• Diagnosis
– Serum immunoglobulin levels
• Management
– Intravenous immunoglobulin infusions
– Treat symptoms
– Teach infection control
–
Immunodeficiencies….
• Secondary Immunodeficiencies
– Occur as a result of underlying disease processes and their treatments.
• Example causes:
– Malnutrition
- Chronic Stress
– Viruses
- Alcohol
– Recreational drugs (injecting bacteria into body)
– DM
• Most common 2° Immunodeficiency is AIDS
Secondary Immunodeficiencies
• Management:
– Diagnose and treat underlying disease
– Frequent reassessment (Follow-up)
– Monitor efficacy and side-effects of treatment
– Teach infection control
– Manage stress
– Lifestyle changes (Ex: Unprotected sex)
– Keep medical appointments
– Chart 51-3, pg 1810