I.

Introduction

According to MedlinePlus, the National Institutes of Health’s Web site, immune

response is how your body recognizes and defends itself against bacteria, viruses, and
substances that appear foreign and harmful. Inflammatory response (inflammation) also
occurs when tissues are injured by bacteria, trauma, toxins, heat, or any other cause.
The damaged cells as a result of substances mentioned above would then release
chemicals including histamine, bradykinin, and prostaglandins thus these chemicals
cause blood vessels to leak fluid into the tissues, causing swelling. Consequently, this
then helps isolate the foreign substance from further contact with body tissues.

Humans live in a world that is heavily populated by both pathogenic and non-
pathogenic microbes, and that contains a vast array of toxic or allergenic substances that
threaten normal homeostasis. The community of microbes includes both obligate
pathogens, and beneficial, commensal organisms, which the host must tolerate and hold
in check in order to support normal tissue and organ function. Pathogenic microbes
possess a diverse collection of mechanisms by which they replicate, spread and threaten
normal host functions. Our environment contains a huge range of pathogenic microbes
and toxic substances that challenge the host by a very broad selection of pathogenic
mechanisms. It is not surprising, therefore, that the immune system uses a complex array
of protective mechanisms to control and usually eliminate these organisms and toxins;
according to National Center for Biotechnology Information, U.S. National Library of
Medicine.

With relations to reaction of immune system, sometimes this network breaks down
because of such infectious agents resulting it to reacts inappropriately. According to
Clinical aspects of Immunology, inappropriate immune responses may be (1)
exaggerated against environmental antigens (allergy); (2) misdirected against the host’s
own cells (autoimmunity); (3) directed against beneficial foreign tissues, such as
transfusions or transplants (alloimmunity); or (4) insufficient to protect the host (immune
deficiency).

Immunodeficiency, anaphylaxis and autoimmune are some of the example of

complications from altered immune responses occur when the immune system response

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is directed against body tissue, is excessive, or is lacking. All of these can be serious or
life threatening. Exaggerated immune responses (allergy) are the most common, but
usually the least life threatening.

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II. Body

When injuries or other infectious agents are present, inflammation is the body’s
normal response. Inflammation is a complex process involving various types of immune
cells, clotting proteins and signaling molecules.

The cells of our immune system immediately travel to the site of injury or irritation
and cause inflammation. This includes a widening of local blood vessels that result in an
outflow of fluid and immune cells into surrounding tissues. This process often causes
temporary discomfort, resulting to have four cardinal signs of inflammation (1) warmth,
(2) redness, (3) swelling) and (4) pain.

A. Risk factors that could contribute to the development of problems in

inflammatory and immunologic reaction

Exogenous Causes:

 Physical Agents
Mechanical Agents: fractures, foreign corps, sand, etc.
Thermal agents: burns, freezing
 Chemical Agents: toxic gases. acids, bases
 Biological Agents: bacteria, viruses, parasites

Endogenous Causes:

 Circulation disorders: thrombosis, infarction, hemorrhage

 Enzymes activation – e.g. acute pancreatitis
 Metabolic products deposals: uric acid, urea
 Immune reactions – e.g. allergic rhinitis, acute glomerulonephritis

Nursing Responsibilities for clients with inflammation

Immediate treatment may prevent the extension and complications of

inflammation. Rest, drug therapy, or specific treatment of the injured site. Rest, ice,
compression, and elevation (RICE) is a key concept in treating soft tissue injuries and
related inflammation.

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  Drug Therapy

Cold at time of initial trauma and Heat 24-48 hrs. later to increase circulation
and promote healing

 Compression and Immobilization

Compression counters vasodilation effects and development of edema.

Compression by direct pressure over a laceration occludes blood vessels
and stops bleeding. Compression bandages provide support to injured
joints that have tendons and muscles unable to provide support on their
own. (Assess distal pulses and capillary refill before and after application of
compression to evaluate if compression would be safe and to evaluate that
compression has not compromised circulation.)

Immobilization of the inflamed or injured area promotes healing by

decreasing metabolic needs of the tissues. Immobilization with a cast or
splint supports fractured bones and prevents the possibility of further tissue
injury by sharp bone fragments severing nerves or blood vessels and the
possibility of hemorrhage. As with compression, you should evaluate the
patient's circulation after application and at intervals in the event swelling
occurs within the closed space of a cast that could compromise circulation.

 Elevation

Above the level of the heart will reduce the edema, also helps reduce pain
associated with blood engorgement (contraindicated for pts with
significantly reduced arterial circulation)

B. What are the assessment and screening procedures for patients having
immunologic disorder?

Assessment

Begin the assessment with a thorough history. Because the immune system affects all
body functions, be sure to investigate the patient’s overall health.

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1. Current Health Status

Among patients with immunologic disorders, common complaints include fatigue or lack
of energy, light-headedness, frequent bruising, and slow wound healing.
Ask these questions to elicit details about your patient’s current illness:

• Have you noticed enlarged lymph nodes?

• Have you experienced weakness or joint pain? If so, when did you first notice the
problem? Does it affect one side of your body or both sides?

• Have you recently had a rash, abnormal bleeding, or a slow healing sore?

• Have you experienced vision disturbances, fever, or changes in elimination patterns?

• Have you felt more tired recently? If so, when did it start?

2. Previous Health Status

Explore the patient’s previous major illnesses, recurrent minor illnesses, accidents or
injuries, surgical procedures, and allergies. Ask if he has had a procedure that could affect
the immune system, such as a blood transfusion or an organ transplant.

3. Family and Social History

Find out if the patient has a family history of cancer or hematologic or immune disorders.
Ask about his home and work environments to help determine if he’s being exposed to
hazardous chemicals or other agents.

Physical Examination

The effects of immune disorders are far-reaching and may materialize in several body
systems. Pay special attention to the skin, hair, nails, and mucous membranes.

Begin with IPPA Method (Inspection, Palpation, Percussion, Auscultation)

Inspection

• Observe for pallor, cyanosis (blue-tinged skin), and jaundice. Also check for erythema
(redness), indicating a local inflammation, and plethora (a red, florid complexion).

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• Evaluate skin integrity. Note signs and symptoms of inflammation or infection, such as
redness, swelling, heat, tenderness, poor wound healing, wound drainage, induration
(tissue hardening), and lesions.

• Check for rash, and note its distribution.

• Observe hair texture and distribution, noting alopecia (hair loss) on the arms, legs, or
head.

Palpation

After inspection, palpate the peripheral pulses, which should be symmetrical and regular.
Next, palpate the abdomen, noting enlarged organs and tenderness, and then the joints,
checking for swelling, tenderness, and pain.

Noting the nodes

Palpate the superficial lymph nodes in the head and neck and in the axillary, epitrochlear,
inguinal, and popliteal areas. If palpation reveals an enlarged node or other abnormalities,
note the node’s location, size, shape, surface, consistency, symmetry, mobility, color,
tenderness, temperature, pulsations, and vascularity.

Percussion

Next, percuss the anterior, lateral, and posterior thorax, comparing one side with the
other. A dull sound indicates consolidation, which may occur with pneumonia. Hyper
resonance (increased percussion sounds) may result from trapped air, as from bronchial
asthma.

Auscultation

Finally, auscultate over the lungs to check for adventitious (abnormal) sounds. Wheezing
suggests asthma or an allergic response. Crackles may signal a respiratory tract infection
such as pneumonia.

Diagnostic Tests

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Two commonly ordered studies to evaluate the immune response are general cellular
tests (which help diagnose immunodeficiency disorders) and delayed hypersensitivity
skin tests (which evaluate the cell-mediated immune response).

1. General Cellular Test

Such as T- and B-lymphocyte assays, help diagnose primary and secondary

immunodeficiency disorders.

T- and B-lymphocyte surface marker assays

Surface marker assays identify specific cells involved in the immune response and
examine the balance between the regulatory activities of several interacting cell types—
notably, T-helper and T-suppressor cells. These tests use highly specific monoclonal
antibodies to define levels of lymphocyte differentiation and to analyze both normal and
malignant cells.

The results of T- and B-lymphocyte surface marker assays help to:

• assess immunocompetence in chronic infections

• evaluate immunodeficiencies

• classify lymphocytic leukemia, lymphoma, and immunodeficiency diseases such

as acquired immunodeficiency syndrome (AIDS)

• identify immunoregulation associated with autoimmune disorders

• diagnose disorders marked by abnormal numbers and percentages of T-helper

cells, T-suppressor cells, and B lymphocytes.

Nursing considerations

• Inform the patient that the test requires a blood sample.

• As ordered, perform a venipuncture. Send the blood sample to the laboratory

immediately to ensure viable lymphocytes. The sample must not be refrigerated or
frozen. Apply pressure to the venipuncture site until bleeding stops.

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 • Many patients with T- and B-cell changes have a compromised immune system,
so be sure to keep the venipuncture site clean and dry.

2. Delayed hypersensitivity skin tests

Delayed hypersensitivity skin tests evaluate the cell-mediated immune response. They
include intradermal skin tests and scratch and puncture allergy tests.

Intradermal skin tests

For intradermal skin tests, recall antigens (antigens to which the patient may have
been previously sensitized) are injected into the superficial skin layer with a needle
and syringe or a sterile four-pronged lancet.

TB or not TB?

Tuberculin skin tests (such as the tine or Mantoux) produce a delayed

hypersensitivity reaction in patients with active or dormant tuberculosis (TB).

Recalling past antigens

Recall antigen tests for Candida, tetanus, and mumps induce depressed or
negative delayed hypersensitivity reactions in patients with infections and
immunodeficiencies. Recall antigen tests induce positive delayed hypersensitivity
reactions in patients who can maintain a nonspecific inflammatory response to the
antigen.

Nursing considerations

• Tell the patient when he can expect a reaction to appear (usually after 2 days).
Check his history for hypersensitivity to the test antigens and for previous reactions
to a skin test.

• Using alcohol, clean the volar surface (palm side) of the arm, about 2 or 3
fingerbreadths distal to the antecubital space (triangle of the elbow) to protect the
wheal from potential infection. You may also clean the area with acetone to remove
skin oils that may interfere with test results.

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 • Make sure the test site you’ve chosen has adequate subcutaneous tissue and is
free from hair and blemishes. Let the skin dry completely before administering the
injection to avoid inactivating the antigen.

• Instruct an outpatient to return at the prescribed time to have test results read.

Treatments

Treatments for immune disorders include drug therapy and bone marrow transplantation.
Both may cause additional immunosuppression, so you’ll need to take special precautions
to maintain strict asepsis and prevent infection and injury.

1. Drug Therapy

 Antihistamines, which prevent or relieve allergic reactions

 Immunosuppressant’s, used to combat tissue rejection and help control
autoimmune disorders
 Corticosteroids, which prevent or suppress the cell-mediated immune response
and reduce inflammation
 Cytotoxic drugs, which kill immunocompetent cells
 Adrenergic, which stimulate the sympathetic nervous system.

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III. References

Larkin EA, Carman RJ, Krakauer T, Stiles BG. Staphylococcus aureus: The Toxic
Presence of a Pathogen Extraordinaire. Curr Med Chem. 2009; 16:4003–4019

U.S. Department of Health and Human Services, National Institutes of Health,

MedlinePlus

Gell P G H , Coombs RR A , Lachman P T : Clinical aspects of immunology Oxford,

England , 1975 , Blackwell Scientific .

Hiemstra PS. The role of epithelial beta-defensins and cathelicidins in host defense of the
lung. Exp Lung Res. 2007;33:537–542.

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