Immunological disorders

Nursing care management of child with AN Immune disorder 1

central and peripheral lymphoid organs and tissuesimmune disordersAnimmune disorderis a dysfunction of theimmune system. These disorders can be characterized in several different ways:By the component(s) of the immune system affectedBy whether the immune system is overactive or underactiveBy whether the condition is congenital or acquired

Immunological DisorderDefinition: A state of altered reactivity in which the body reacts with an exaggerated immune response to what is perceived as a foreign substance. Immune response that results in tissue injury or other physiological changes are called hypersensitivity (allergic) reactions. Hypersensitivity (allergy)Hypersensitivity reactions are classified into four types:Type I: Anaphylactic hypersensitivity

Type II: Cytotoxic hypersensitivity

Type III: Immune complex hypersensitivity

Type IV: Cell mediated hypersensitivity Types of hypersensitivity reactionsIt is an immediate reaction beginning within minutes of exposure to an antigen.It is mediated by antibodies.It requires previous exposure to specific antigen.It usually affects on skin, lungs and gastrointestinal tract.Examples:AsthmaAllergic rhinitisSystemic anaphylaxis.Atopic dermatitis

Type I: Anaphylactic hypersensitivity:

Anaphylactic (type I) Hypersensitivity

It occurs when the system mistakenly identifies a normal constituent of the body as foreign.This reaction may be a result of cross-reacting antibody, possibly leading to cell and tissue damageIt involves activation of complement by IgG or IgM antibody binding to an antigenic cell.Examples:Myasthenia gravisThrombocytopenia

Type II: Cytotoxic hypersensitivity Cytotoxic (type Il) Hypersensitivity

It involves in the formation of immune complexes when antigen binds to antibodies.These type III complexes deposit in tissues or vascular endothelium and leads to injury with the help of vasoactive amines and the increase number of circulating complexes. The joints and kidneys are particularly susceptible.Examples:Systemic lupus erythematousRheumatoid arthritisSerum sickness

Type III: Immune complex hypersensitivityImmune complex (type III) hypersensitivity

Also known as cellular hypersensitivityIt occurs 24-72 hrs after exposure to an allergenThe reaction is mediated by sensitized T cells and macrophages.The reaction results In tissue damage by releasing lymphokines, macrophages and lysozymes.Examples:Contact dermatitisTuberculin test.

Type IV: Cell mediated hypersensitivityCell mediated (type IV) HYPERSENSITIVITY

It is also called as Hay FeverDefinition: It is an inflammation of the nasal mucosa by an allergen.

Allergic Rhinitis

Pathogenesis: Allergic RhinitisInhalation of an antigen (sensitization)

Re-exposure

Nasal mucosa reacts (histamine is mediator)

Slowing of ciliary action, edema formation and leukocyte infiltration

Tissue edema and increase capillary permeability (vasodilatation).Clinical manifestations:Nasal congestionClear to greenish rhinorrheaIntermittent sneezing and nasal itchingHeadache EpistaxisFatigue, loss of sleep and poor coordination.

Medical management:Oral anti histamines (blocks the action of histamine)Nasal decongestantMast cell stabilizers.Analgesics and antipyretics.

Types of allergic rhinitis: PerennialSeasonalYear-round with allergic triggersEarly spring, early fall, early summer Sneezing, itching, watery discharge from nose and eyesIntense symptoms triggered by air-borne pollens, house dust and animal feather.Diagnostic tests:Nasal smears (nasal eosinophilia)

Total serum IgE

Medical management:Oral anti histamines (blocks the action of histamine)

Adrenergic nasal decongestant

Mast cell stabilizers.

Analgesics and antipyretics. Allergic rhinitisNursing management:

AssessmentExamination (Assess symptoms) History of patient (Allergy assessment)

DiagnosisIneffective breathing pattern related to allergic reactionsKnowledge deficit related to allergy and the recommended modifications in life style and self-care practicesIneffective individual coping with condition and need for environmental modification. Allergic rhinitisNursing interventions:

Patient is instructed to modify the environment to reduce the severity.

Encourage for deep breathing and cough frequently for adequate gas exchange.

Encourage for steam inhalation

4. Promote rest.Allergic rhinitisAtopic dermatitis (eczema)Definition:Inflammation of the skin

Incidences/Causes:Familial tendency

It is highest in infants and children

1% population is suffering from this disease

Aggravated in low humidity and in winter.

Pathophysiology: Atopic dermatitisAllergen /Sensitizing antigen

Affect the skin (changes in lipid content, sebaceous gland activity and sweating)

Reduced water-binding capacity of the skin

Higher trans epidermal water loss and decreased water content

Dry skin

Itching, rubbing leads to infection Clinical manifestations: Atopic dermatitisRed oozing crusting rash (in childhood)Dry thick brownish grey and scaly skin (later stage)PruritusLesion are mostly found on hand, foot, back of the knees, neck, face, eyelids and elbow bands.

Medical Management: Atopic dermatitis MoisturizersAntibioticsAntihistamines

Medical Management: Atopic dermatitis MoisturizersTopical and systemic steroidsAntibioticsAntihistaminesPerform allergen test

Nursing management: Atopic dermatitisAssess and maintain hygiene (daily bath)

Determine dietary and other allergen (cow milk, egg, Soya, wheat, nut, fish)

Teach to avoid allergen

Keep wound area moist

Teach proper use of medicines

Avoid scratching (wear cotton fabrics, washing with mild detergent)

Prevent from secondary infection AnaphylaxisDefinition:It is an immediate life threatening systemic reaction that can occur on exposure to particular substances

It is an immediate (type I hypersensitivity) immunologic reaction, results from IgE antibody

This reaction affects many tissues and organs. Death may occur due to respiratory tract spasm and constriction or collapse.

Causes

Food ( peanuts, fish, milk, eggs, wheat and chocolate).

Medications (penicillin, NSAIDs)

Insects stings (bees, ants)

Causes of anaphylaxisDirect activation of mast cells- opiates, tubocurare, dextran,radiocontrast dyesMediators of arachidonic acid metabolism- Aspirin (ASA)- Nonsteroidal anti-inflammatory drugs(NSAIDs)Mechanism unknown- SulphitesCauses of anaphylaxisImmunologic mechanismsIgE-mediated- drugs- foods- hymenoptera (stinging insects)- latexNon-IgE mediated- anaphylotoxins-mediated e.g. mismatched bloodPathophysiology: Anaphylaxis

Interaction of foreign antigen with IgE antibodies

Release of histamine

Activation of platelets, eosinophils and neutrophils

smooth muscle spasm, bronchospasm, mucosal edema and inflammation.

MildModerateSevereOccurs within first 2hrs of exposureSameSamePeripheral tinglingFlushingBronchospasmSensation of warmthItchingLaryngeal edemaFullness in mouth and throatBronchospasmSevere Dyspnea, cyanosisNasal congestionEdema of larynxHypotensionPeriorbital swellingDyspneaCardiac arrest and coma may follow.Pruiritus CoughSneezingwheezingClinical manifestations: Anaphylaxis

Risk of anaphylaxisYocum etal. (Rochester Epidemiology Project) 1983-1987:incidence: 21/100,000 patient-yearsfood allergy 36%, medications 17%, insect sting 15%31Frequency of symptoms inAnaphylaxis

AnaphylaxisOnset of symptoms of anaphylaxis: usually in 5 to 30 minutes; can be hours laterA more prolonged latent period has been thought to be associated with a more benign course.Mortality: due to respiratory events (70%), cardiovascular events (24%)Prevention of anaphylaxisAvoid the responsible allergen (e.g. food, drug, latex, etc.).Keep an adrenaline kit (e.g. Epipen) and Benadryl on hand at all times.Medic Alert bracelets should be worn.Venom immunotherapy is highly effective in protecting insect-allergic individuals.Treatment of anaphylaxisEPINEPHRINE (1:1000) SC or IM- 0.01 mg/kg (maximal dose 0.3-0.5 ml)- administer in a proximal extremity- may repeat every 10-15 min, p.r.n.EPINEPHRINE intravenously (IV)- used for anaphylactic shock not responding to therapy- monitor for cardiac arrhythmiasEPINEPHRINE via endotracheal tubeTreatment of anaphylaxisPlace patient in Trendelenburg position.Establish and maintain airway.Give oxygen via nasal cannula as needed.Place a tourniquet above the reaction site (insect sting or injection site).Epinephrine (1:1000) 0.1-0.3 ml at the site of antigen injectionStart IV with normal saline. Treatment of anaphylaxisBenadryl (diphenhydramine)- H1 antagonist

Tagamet (cimetidine)- H2 antagonist

Corticosteroid therapy: hydrocortisone IV or prednisone poTreatment of anaphylaxisBiphasic courses in some cases of anaphylaxis:- Recurrence of symptoms: 1-8 hrs later- In those with severe anaphylaxis, observe for 6 hours or longer.- In milder cases, treat with prednisone; Benadryl every 4 to 6 hours; advise to return immediately for recurrent symptomsTreatment of Anaphylaxis in Beta Blocked PatientsGive epinephrine initially.If patient does not respond to epinephrine and other usual therapy:- Isoproterenol (a pure beta-agonist) 1 mg in 500 ml D5W starting at 0.1 mcg/kg/min- Glucagon 1 mg IV over 2 minutesFatal Food-induced Anaphylaxis

Use of epinephrine inFood AllergyEpinephrine should be used immediately after accidental ingestion of foods that have caused anaphylactic reactions in the past.An individual who is allergic to peanut, nuts**, shellfish, and fish should immediately take epinephrine if they consume one of these foods.A mild allergic reaction to other foods (e.g. minor hives,vomiting) may be treated with an antihistamineExercise-induced anaphylaxis Exercise induces warmth, pruritus, urticaria.Hypotension and upper airway obstruction may follow.Some types: associated with food allergies (e.g. celery, nuts, shellfish, wheat)In other patients, anaphylaxis may occur after eating any meal (mechanism has not been identified)Cold-induced anaphylaxisCold exposure leads to urticaria.Drastic lowering of the whole body temperature (e.g. swimming in a cold lake): hypotensive event in addition to urticariamechanism: unknownDRUG ALLERGYDRUG ALLERGYAdverse drug reactions- majority of iatrogenic illnesses- 1% to 15% of drug coursesNon-immunologic (90-95%): side effects, toxic reactions, drug interactions, secondary or indirect effects (eg. bacterial overgrowth) pseudoallergic drug rx (e.g. opiate reactions, ASA/NSAID reactions)Immunologic (5-10%)Drugs as immunogensComplete antigens- insulin, ACTH, PTH- enzymes: chymopapain, streptokinase- foreign antisera e.g. tetanus antitoxinIncomplete antigens- drugs with MW < 1000- drugs acting as haptens bind to macromolecules (e.g. proteins, polysaccharides, cell membranes)Factors that influence the development of drug allergyRoute of administration:- parenteral route more likely than oral route to cause sensitization and anaphylaxis- inhalational route: respiratory or conjunctival manifestations only- topical: high incidence of sensitizationScheduling of administration:-intermittent courses: predispose to sensitization Factors that influence the development of drug allergyNature of the drug:- 80% of allergic drug reactions due to:- penicillin- cephalosporins- sulphonamides (sulpha drugs) - ASA/NSAIDsGell and Coombs reactionsType 1: Immediate Hypersensitivity- IgE-mediated- occurs within minutes to 4-6 hours of drug exposureType 2: Cytotoxic reactions- antibody-drug interaction on the cell surface results in destruction of the celleg. hemolytic anemia due to penicillin, quinidine, quinine,cephalosporinsGell and Coombs reactionsType 3: Serum sickness- fever, rash (urticaria, angioedema, palpable purpura), lymphadenopathy, splenomegaly, arthralgias- onset: 2 days up to 4 weeks- penicillin commonest causeType 4: Delayed type hypersensitivity- sensitized to drug, the vehicle, or preservative (e.g. PABA, parabens, thimerosal)Penicillin Allergybeta lactam antibioticType 1 reactions: 2% of penicillin coursesPenicillin metabolites:- 95%: benzylpenicilloyl moiety (the major determinant)- 5%: benzyl penicillin G, penilloates, penicilloates (the minor determinants)Penicillin AllergySkin tests: Penicillin G, Prepen (benzyl-penicilloyl-polylysine): false negative rate of up to 7%

Resolution of penicillin allergy- 50% lose penicillin allergy in 5 yr- 80-90% lose penicillin allergy in 10 yrCephalosporin allergybeta-lactam ring and amide side chain similar to penicillindegree of cross-reactivity in those with penicillin allergy: 5% to 16%skin testing with penicillin determinants detects most but not all patients with cephalsporin allergyAmpicillin rashnon-immunologic rashmaculopapular, non-pruritic rashonsets 3 to 8 days into the antibiotic courseincidence: 5% to 9% of ampicillin or amoxicillin courses; 69% to 100% in those with infectious mononucleosis or acute lymphocytic leukemiamust be distinguished from hives secondary to ampicillin or amoxicillinSulphonamide hypersensitivitysulpha drugs more antigenic than beta lactam antibioticscommon reactions: drug eruptions (e.g. maculopapular or morbilliform rashes, erythema multiforme, etc.)Type 1 reactions: urticaria, anaphylaxis, etc.no reliable skin tests for sulpha drugsre-exposure: may cause exfoliative dermatitis, Stevens-Johnson syndromeASA and NSAID sensitivityPseudoallergic reactions- urticaria/angioedema- asthma- anaphylactoid reactionprevalence:0.2% general population8-19% asthmatics30-40% polyps & sinusitisASA quatrad: Asthma, Sinuitis, ASA sensitivity, nasal Polyps (ASAP syndrome)ASA & NSAID sensitivityASA sensitivity: cross-reactive with all NSAIDs that inhibit cyclo-oxygenaseASA & NSAID sensitivityno skin test or in vitro test to detect ASA or NSAID sensitivityto prove or disprove ASA sensitivity: oral challenge to ASA (in hospital setting)ASA desensitization: highly successful with ASA-induced asthma; less successful with ASA-induced urticariaAllergy skin testingSkin tests to detect IgE-mediated drug reactions is limited to:Complete antigens- insulin, ACTH, PTH- chymopapain, streptokinase- foreign antisera Incomplete antigens (drugs acting as haptens)- penicillins- local anesthetics - general anestheticsManagement of drug allergyIdentify most likely drugs (based on history).Perform allergy skin tests (if available).Avoidance of identified drug or suspected drug(s) is essential.Avoid potential cross-reacting drugs (e.g. avoid cephalosporins in penicillin-allergic individuals).

Management of drug allergyA Medic-Alert bracelet is recommended.Use alternative medications, if at all possible.Desensitize to implicated drug, if this drug is deemed essential.Desensitization to medicationsBasic approach: administer gradually increasing doses of the drug over a period of hours to days, typically beginning with one ten-thousandth of a conventional doseIt is a type III hypersensitivity reaction.

The reaction result from administration of therapeutic Anti-Sera taken from animal source for the treatment and prevention of infectious diseases like tetanus, rabies, diphtheria

Serum sickness

12/3/2014immune disorders Localized:Inflammatory reaction at the site of injection.

Generalized:Skin rashes Tenderness and swelling of joints vasculitis mostly in kidneys results in proteinuriaGlomerulonephritisPeripheral neuritis leads to temporary paralysisFever Clinical manifestations Serum sickness12/3/2014Medical management:AntihistaminesCorticosteroids

Nursing management:Encourage for ROM exercises, provide DVT stockings (a deep vein thrombosis and pulmonary embolism are treats to these patients.Serum sickness12/3/2014Transplant rejectionoccurs whentransplantedtissue is rejected by the recipient'simmune system, which destroys the transplanted tissue.Transplantation can be:autologous (own)homologous (alogenic) - human tissueheterologous - animal tissue (pig skin, ovine pericardium)

Transplantation Rejectionhyperacute (Ab mediated) - widespread arteriolitis, arteritis, ischemic necrosis (minutes-hours)acute (cell mediated) - vasculitis, tubulitis, edema (days-months)chronic - vascular changes - sclerosis, intimal fibrosis (months-years)

Rejection Reactions

12/3/2014immune disorders Thank you Urticaria/angioedema 88%

Upper airway edema 56%

Dyspnea or wheeze 47%

Flush 46%

Dizziness, hypotension, syncope 33%

Gastrointestinal sx 30%

Rhinitis 16%

SERIESYUNGINGER

(n=7)SAMPSON

(n=6)

Ages16-43 years2-16 years

Atopy

All asthmatics

Locale1/7 at home1/6 at home

AllergenPeanut- 4

Tree nut- 1

Seafood- 2Peanut- 3

Tree nut- 2

Egg- 1