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Inflammation & the Immune Response

Inflammation & the Immune Response. Keith Rischer, RN, MA, CEN, CCRN. Objectives for this content. Inflammatory response #1-3 Infection/sepsis/chain of infection #4-10 Physiologic immune response #11-16. Three Lines of Defense. Anatomical Barriers Acute Inflammatory Response

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Inflammation & the Immune Response

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  1. Inflammation & the Immune Response Keith Rischer, RN, MA, CEN, CCRN

  2. Objectives for this content • Inflammatory response • #1-3 • Infection/sepsis/chain of infection • #4-10 • Physiologic immune response • #11-16

  3. Three Lines of Defense • Anatomical Barriers • Acute Inflammatory Response • Immune System

  4. Skin Mucous membranes Normal bacterial flora Clostridium difficile Yeast infections Anatomical Barriers: First Line of Defense

  5. Normal Body Defenses Skin multilayer barrier, shed outer layer, contains fatty acids that kills some bacteria Lungs contain cilia in upper respiratory tract, macrophages Urinary Tract flush action of urine washes away bacteria Perry and Potter pg. 647 Ch 34 Table 34-3

  6. Inflammatory Response

  7. Inflammatory Response • Occurs in response to injury • Localized • Immediate • Beneficial • Appropriate level of response • Non Specific

  8. Causes of Inflammation • Physical • Trauma • Lacerations • Burns • Chemical- Bites • Allergic response • Micro-organisms • Bacteria

  9. Inflammatory Response • REDNESS • SWELLING • PAIN • HEAT • LOSS OF FUNCTION

  10. Purpose of inflammation • Neutralizes and Dilutes Toxins • Removes necrotic materials • Provides an environment for healing • Add “itis” to affected body part

  11. 4 Phases of Inflammation • Vascular • Think blood vessels • Cellular • Think WBC’s • Formation of Exudate • Fluid & neutrophils • Healing • regeneration or repair of tissue

  12. Injury occurs Mediators intervene Vasodilation occurs Capillaries become more permeable Swelling and movement of fluid occurs Vascular Phase: Blood Vessels

  13. Injury occurs Chemotaxis begins White blood cells rush in to help Neutrophils Monocytes Macrophages Cellular Phase – Think WBC’s

  14. Chemical Mediators Coordinators of the inflammatory response • Histamine • Prostagladins • Cytokines

  15. Laboratory tests Erythrocyte sedimentation rate (ESR or sed rate) <20 mm/hr CRP – C reactive protein non specific test identifying the presence of inflammation <1.0 mg/dl

  16. Nursing Diagnosis Acute pain related to tissue trauma Impaired physical mobility related to discomfort

  17. Nursing Interventions Care will vary with causative agent and physical condition of the patient What are some nursing actions you might implement or anticipate How will you as the nurse evaluate the outcome

  18. Expected Outcomes… • Healing of the wound or injury • Prevent minor infections from becoming overwhelming to the body • UTI vs. urosepsis • Goals and outcomes will vary with each patient • Remember that your outcomes will drive your interventions/cares

  19. Systemic Manifestations of Acute Inflammation • Fever/chills • Cytokines • Benefits • Increased killing of microorganisms • Increased phagocytosis by neutrophils • Increased activity of interferon • Leukocytosis • Neutrophils • “left shift”…band cells

  20. Medications: NSAIDS Ibuprofen, Toradol Mechanism of action Inhibits prostaglandin synthesis Nursing implications Give w/food Elderly-high risk GI bleed Prolongs bleeding times 1 day Assess renal function-creatinine w/chronic use

  21. Medications: NSAIDS • Salicylates – Aspirin • Mechanism of action • Inhibits production of prostaglandins • Decreases platelet aggregation • Nursing implications • Give w/food • Prolongs bleeding times 4-7 days

  22. Medications: Anti-histamines Benadryl, Ranitidine (Zantec), Famotidine (Pepcid) Mechanism of action Block histamine at the receptor site Decreases gastric acid secretion Nursing implications With meals Drowsiness/dizziness

  23. Medications: Corticosteroids • Prednisone • Mechanism of action • Decrease inflammation by stabilizing neutrophils and lysosomes • Inhibit prostaglandin synthesis • Inhibits chemotactic cytokines • Decreases mast cell stimulation • Nursing implications • Meals • Chronic use complications • Risk of infection • Hyperglycemia • SE

  24. Normal Course of an Infection Incubation period Prodromal stage Full stage of illness Convalescence

  25. Bacteria Virus Fungi Protozoa Infectious agents/pathogens

  26. Bacteria • Single cell • Human cells vs. bacteria count in body • Gram +/-

  27. Virus • Most common affliction of humans • Has no metabolism of it’s own • Is incapable of replicating outside a living cell • Takes over the metabolic machinery of host cells to survive and replicate

  28. What influences Pathogen survival? Food/Glucose Water Oxygen – aerobic/anaerobic Temperature pH light

  29. Reservoir • A place where a pathogen can survive but may or may not multiply • What is the most common reservoir? • What is a carrier?

  30. Portal of exit • For the pathogen to cause an infection it must exit the reservoir • How can this happen?

  31. Mode of Transmission • Direct or indirect • What is the major mode of transmission in the health care setting? • List the 4 categories of transmission

  32. Portal of entry

  33. Susceptible Host • What factors increase our susceptibility to infection? • Age • Stress • Nutritional status • Current medical therapies • Chemo • Steroids • Presence of disease

  34. Normal Blood Count of all WBC: 4,000-11,000/ul Neutrophils Monocytes Lymphocytes B cells: mediate the humoral immune response T cells: Mediate cellular immunity Elderly considerations Leukocytes

  35. Laboratory Studies CBC Hgb (12-16 g/dl) Hct (33-51%) Platelets (140-440 thou/cu mm) WBC (4.5-11.0 thou/cu mm) Differential Never-neutrophils (42-72%) Let-lymphocytes (20-44%) Monkeys-monocytes (<11.1%) Eat-eosinophils (<7.1%) Bananas-basophils (<3.0%)

  36. Cultures, gram stains and sensitivities • Wound and skin cultures, body fluids, blood cultures • Gram stains • Sensitivities

  37. Anti-infective Drugs Determine if hypersensitive to medication Check for interactions with other drugs Educational needs of client Determining effectiveness

  38. Antibiotic Therapy Anti-fungal Fluconazole, Nystatin Cephalosporins Cephalexin (Keflex) Penicillins Amoxicillin, Ampicillin Sulfonamides Bactrim Tetracyclines Doxycycline

  39. Antibiotic Resistance Bacteria adapt in ways which make an antibiotic less effective or ineffective MRSA – Methicillin resistant staphylococcus aureus VRE – Vancomycin resistant enteroccus

  40. Vancomycin Anti-infective class other Effective against gram+ pathogens Used in potentially life-threatening infections when other drugs are not effective Action: binds to bacterial cell wall and cell death results Poorly absorbed in GI tract, may be given IV

  41. NCLEX Concepts of Emphasis • Define inflammation • Is inflammation always present with infection? • What are some patient examples that would limit or impair their inflammatory response? • What are the five physical manifestations of the inflammatory response? • Name each distinct phase of the inflammatory response and unique characteristics of each? • What are other causes of inflammation besides micro-organisms? • What are some common diseases of chronic inflammation? • What are the medications that treat the inflammatory response?

  42. Sepsis • Patho • Infection (susceptible host) • Inflammation-systemic • SIRS • Capillary permeability • Vasodilation • Progressive • Sepsis/SIRS • Septic shock • Multiple Organ Dysfunction Syndrome (MODS)

  43. Article Case Study • 70 yr female from NH • CC: • weakness, diarrhea x3 weeks • Assessment: • PMH: IDDM, HTN, CVA, COPD, UTI’s • VS: T-97…101.8 P-109 R20-24 BP-93/41 91-98% • a/o x3 • Labs: • WBC-26.5 • Gluc 258

  44. Article Case Study-Day 2 • T-96.6 P-125 R-24 BP 80/43 • Oriented to self only • u/o 180cc over 8 hours • Became more lethargic later in day • T-96.5 P-100 R-24 BP 70/30 • Labs • WBC 41.9 • Lactate 2.2

  45. Article Case Study-Day 3 • T-96.5 P-100 R 14-32 BP 70/50 • Labs • WBC 41.9 • Creatinine 4.3 • Vasoactive gtts • Intubated • Died day 7

  46. Key Nursing Assessments • Fever/chills • Hypothermia • Altered LOC/confusion • Break in skin integrity • Foley catheter • Wound or incision • Tachycardia • HR >100 • What if elderly or on beta blockers?

  47. Key Nursing Assessments • Tachypnea • RR >20 • Hypotension • SBP <90 • SBP drop of >20-30mm/Hg Decreasing urine output…<30cc/hr • Labs • WBC • Neutrophils • Creatinine

  48. Nursing Diagnosis statements w/infection/sepsis? • Ineffective breathing pattern • Decreased cardiac output • Ineffective tissue perfusion…manifested by: • Altered mental status • Behaviorial changes (restlessness) • Renal…creatinine • Acute confusion

  49. Why is the older adult at risk for infection and cancer development? Inflammation and immunity are provided primarily through what body cells? Differentiate the 5 types of leukocytes and what each type does to protect the body from micro-organisms Which leukocyte is elevated in bacterial infection? Why… What body cell is able to recognize and destroy non-self cells? What vital sign changes are seen in sepsis? What assessment findings are seen in sepsis? NCLEX Concepts of Emphasis

  50. Passive Acquired Immunity Present at birth Short lived Body needs to develop own Active Acquired Immunity After birth Active Long-term Exposure to micro-organisms immunizations Immune Response

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