NURSING

1. RAKHI DAS
I YEAR MSc NURSING
JUBILEE MISSION COLLEGE OF NURSING
THRISSUR, KERALA, INDIA

2.  In our body the defense mechanism plays the
role of immunity, thus in simple words, the
ability of the body to fight against various
pathogen and protect the body is known as
immunity. Normal immune response is an
innate characteristics of all human being
right from birth though the strength and
intensity may vary due to age advancement
and external environmental features.
 Immune disorders occur when this general
ability is compromised due to varied factors
or disease.

3.  By the end of the seminar, students will gain
adequate knowledge regarding various
immune disorders, its mechanisms, HIV AIDS ,
metabolic syndrome, develop skills of nursing
care of patients with these ailments and
apply this skill in clinical settings with a
positive attitude.

4.  describe about immunity and immune system
 compare and contrast humoral and cell-mediated
immunity, including lymphocytes, types of reactions
and effects on antigens
 list out classifications of immune disorders and its
management
 illustrate causes, symptoms and treatment modalities
 identify types and side effects of immunosuppressive
therapy
 acquire skills in providing quality care
 develop positive attitude towards care of patients
with long term illness and immunodeficiency
syndrome

5.  DEFENSE
 HOMEOSTASIS
 SURVEILLANCE
 ANTIGEN
 AUTOIMMUNITY
 ANERGY
 CELL MEDIATED IMMUNITY

6.  IMMUNO COMPETENCE
 HUMORAL IMMUNITY
 IMMUNODEFICIENCY
 IMMUNOSUPPRESSIVE THERAPY
 SEROCONVERSION
 OPPURTUNISTIC INFECTION
 METABOLIC SYNDROME

7.  Immunity is the ability of the body to fight
against various pathogens and protect the
body. Immune response is the mechanisms
that help an organism to achieve this end.
 Immune system is the system comprising all
the biological structures and the various
processes occurring within the body that
protect against a disease or an antigenic
insult from outside or from within the body
of an organism.

8. DEFENSE
HOMEOSTASIS
SURVEILLANCE

9.  Innate Immunity
 Acquired Immunity
 Active Acquired lmmunity
 Passive Acquired Immunity

10.  Mononuclear Phagocytes
 Lymphocytes
 B lymphocytes (in plasma)
 T lymphocytes (in thymus dependent cells)
 Natural Killer Cells
 Dendritic Cells

11. CHARACTERISTICS HUMORAL IMMUNITY
CELL MEDIATED
IMMUNITY
Cells involved B lymphocytes T lymphocytes, macrophages
Products Antibodies Sensitized T cells, cytokines
Memory cells Present Present
Protection
Bacteria,
virus(extracellular),
respiratory and GI pathogens
Fungus, virus(intracellular),
chronic infectious agents,
tumor cells
Examples
Anaphylactic shock, atopic
diseases, transfusion
reactions
Tuberculosis, fungal
infections, contact dermatitis,
graft rejection, destruction of
cancer cells

12. Four mechanisms in altered immune
responses:
 Immunocompetence
 Hypersensitivity Reactions
 Autoimmunity
 Immunodeficiency syndromes

13.  body’s immune system can identify and
inactivate or destroy foreign substances
 When the immune system is incompetent or
under-responsive, severe infections,
immunodeficiency diseases, and
malignancies may occur
 When the immune system overreacts,
hypersensitivity disorders such as allergies
and autoimmune diseases may develop

14. When the immune response is overreactive against
foreign antigens or reacts against its own tissue,
resulting in tissue damage, responses are termed
hypersensitivity reactions.
 Type I: IgE mediated reaction - Anaphylaxis and
atopic reactions
 Type II: Cytotoxic and cytolytic reactions - hemolytic
transfusion reaction and goodpasture syndrome
 Type III: Immune complex reactions - systemic lupus
erythematosus, acute glomerulonephritis, and
rheumatoid arthritis
 Type IV: Delayed Hypersensitive Reactions - contact
dermatitis and transplant rejections.
 Microbial Hypersensitivity Reactions

15.  an immune response against self in which the
immune system no longer differentiates self from
oneself
 auto antibodies and autoumitized T cells cause
pathophysiologic tissue damage
 a type of hypersensitivity response where the body
fails to recognize self-proteins and reacts against
self-antigens.
Principal factors in the development of autoimmunity:
 Inheritance of susceptibility genes, which may
contribute to the failure of self-tolerance
 Initiation of autoreactivity by triggers (infections that
activate self-reactive lymphocytes)
 Other factors

16.  exists when the immune system does not
adequately protect the body
Primary immunodeficiency disorders - the
immune cells are improperly developed or
absent; rare and often serious
 Basic categories of primary
immunodeficiency disorders are:
 Phagocytic defects
 B cell deficiency
 T cell deficiency
 A combined B cell and T cell deficiency

17. Secondary immunodeficiency disorders - the
deficiency is caused by illnesses or
treatment; common and less severe
 Basic categories of secondary
immunodeficiency disorders are:
 Drug induced immunodeficiency disorders
 Age factors and malnutrition related disorders
 Stress disorders
 System disorders - AIDS, Cirrhosis, Chronic Renal
disease, Trauma, burns, Hodgkin’s lymphoma,
malignancies

18.  Sequestered or hidden antigens
 Neo antigens
 Cessation of tolerance
 Cross reacting antigens
 Loss of immune regulation

20. APHERESIS
 used for the collection of donor blood
components
 removal of parts of the blood that might
contain disease-provoking elements
 a procedure in which the components of
whole blood - red cells, white cells, and
plasma - are separated into layers using a
machine called a Cell Separator
 procedure is used to collect blood stem cells
from donors or autologous transplant
patients

21. PLASMAPHERESIS
 a process including removal of plasma, that
filters the blood and removes harmful
antibodies
 procedure done similarly to dialysis;
however, it specifically removes antibodies
from the plasma portion of the blood

22.  recommended treatment for control of
allergic symptoms when the allergen cannot
be avoided and drug therapy is not effective
 Relatively few patients with allergies have
symptoms so intolerable that they require
allergy immunotherapy
 involves administration of small titers of an
allergen extract in increasing strengths until
hyposensitivity to the specific allergen is
achieved.

23. Subcutaneous immunotherapy
 involves the subcutaneous injection of
titrated amounts of allergen extracts
biweekly or weekly
 The dose is small at first and is increased
slowly until a maintenance dosage is reached
 takes 1 to 2 years of immunotherapy to reach
the maximal therapeutic effect

24. Sublingual immunotherapy
 involves allergen extracts taken under the
tongue
 lower risk of severe adverse reaction than
the traditional subcutaneous administration.

26.  Rejection of organs occurs as a normal
immune response to foreign tissue
 can be prevented by using
immunosuppression therapy
 prevented by performing ABC and HLA
matching, and ensuring that the crossmatch
is negative
TYPES OF REJECTION:
 Hyperacute rejection
 Acute rejection
 Chronic rejection

27. Hyperacute rejection
 rare and occurs minutes to hours after
transplantation because the blood vessels are
rapidly destroyed
 occurs because the person had preexisting
antibodies against the transplanted tissue or
organ
 no treatment for hyperacute rejection, and
the transplanted organ is removed

28. Acute rejection
 commonly manifests in the first 6 months after
transplantation
 usually mediated by the recipient’s lymphocytes,
which have been activated against the donated
(foreign) tissue or organ
 when the recipient develops antibodies to the
transplanted organ
 To combat acute rejection, all patients with
transplants require long-term use of immune-
suppressants

29. Chronic rejection
 a process that occurs over months or years
and is irreversible
 can occur for unknown reasons or from
repeated episodes of acute rejection
 results in fibrosis and scarring
 no definitive therapy for this type of
rejection
 Treatment is primarily supportive
 difficult to manage and is not associated
with the optimistic prognosis of acute
rejection

30.  Immunosuppressive therapy requires a balance
 the immune response needs to be suppressed to
prevent rejection of the transplanted organ
 adequate immune response needs to be
maintained to prevent overwhelming infection
and the development of malignancies
 Many of the drugs used to achieve
immunosuppression have significant side effects.
Because transplant recipients must take
immunosuppressant for life, the risk of toxicity
continues for the rest of their lives

31. AGENT ROUTE MECHANISM OF
ACTION
SIDE EFFECTS
Corticosteroids
Prednisolone,
methylprednisolone
PO, IV Suppress inflammatory
response. Inhibit
cytokine production and
T cell activation,
proliferation
Peptic ulcers,
hypertension,
osteoporosis, sodium
and water retension
Calcineurin inhibitors
Cyclosporin, tacrolimus
PO, IV Acts on T helper cells,
inhibit production of
cytotoxic lymphocytes
and b cells
Nephrotoxicity,
neurotoxicity tremors,
hepatotoxicity,
leukopenia
Cytotoxic
(antiproliferative) drugs
Mycophenolate mofetil
mycophenolate acid
Cyclophosphamide
Azathioprine
Sirolimus
everolimus
PO,IV
PO
PO
Inhibit purine synthesis
Cross links DNA
leading to cell injury
Blocks purine synthesis
Blinds to mammalian
target of rapamycin
Diarrhea, naussea,
vomiting, neutrepenia,
trombocytopenia
Hemorrhagic cytosis
Bone marrow
suppression, anemia
Risk for infection

32. Monoclonal
antibodies
IV Binds to CD3
receptors causing
cell lysis
Fever, chills,
dyspnea, chest
pain
Polyclonal
antibody
Lymphocyte
immune globulin
IV Depleting T cells Serum sickness,
tachycardia, back
pain, fever, chills
Other
Belatacept
IV Prevents
activation of T
cells
Anemia,
constipation,
urinary tract
infection,
peripheral edema

35.  Human immunodeficiency virus (HIV)
infection is caused by HIV, which is a
retrovirus that causes immunosuppression.
The viral infection causes the person to be
susceptible to infections that would normally
be controlled through immune responses.
The term HIV disease is used interchangeably
with HIV infection or AIDS

37.  contact with infected blood, semen, vaginal
secretions, or breast milk
 Sexual Transmission - The most common mode of
HIV transmission is unprotected sexual contact
with an HIV-infected partner
 Contact with Blood and Blood Products -
equipment that may be contaminated with HIV
and other blood-borne organisms, and sharing
that equipment
 Puncture wounds are the most common means of
work related HIV transmission
 Perinatal transmission - from an HIV infected
mother to her infant can occur during pregnancy,
delivery, or breastfeeding

38. HIV is not spread casually
 The virus cannot be transmitted through
hugging, dry kissing, shaking hands, sharing
eating utensils, using toilet seats, or casual
encounters in any setting. It is not spread by
tears, saliva, urine, emesis, sputum,
feces, sweat, respiratory droplets, or enteric
routes

41. According to the CDC definition, a patient
has AIDS if they are infected with HIV and
have either:
 CD4+ T-cell count below 200 cells/µL
 One of the following opportunistic infection:
 Fungal – candidiasis of bronchi, trachea, lungs, or
esophagus, pneumocystic jiroveci pneumonia
 Viral- cytomegalovirus infection of liver, spleen, eyes,
Herpes simplex virus
 Protozoal- toxoplasmosis of brain, isosporiasis
 Bacterial- mycobacterium tuberculi, M. kansasii,
salmonella septicemia

42.  One of the following opportunistic cancers
 Invasive cervical cancer
 Kaposis sarcoma
 Burkitts lymphoma
 Immunoblastic lymphoma
 Primary lymphoma of brain
 Wasting syndrome – defined as loss of 10%
or more of ideal body mass
 AIDS dementia complex

43.  Laboratory studies - The enzyme-linked
immunosorbent assay (ELISA), also known
as an enzyme immunoassay (EIA),
detects HIV antibodies and antigens in the
blood (2 and 12 weeks after becoming
infected with HIV)
 A rapid HIV antibody test can
detect HIV antibodies in blood or oral
fluid in less than 30 minutes – a simplified
version of ELISA

44. Goals of drug therapy is to:
 Decrease viral load
 Maintain or increase CD4+Tcells counts
 Prevent HIV related symptoms and
oppurtunistics disease
 Delay disease progression
 Prevent HIV transmission

45.  Entry inhibitors
eg: Enfuvirtide, Maraviroc
 Reverse transcriptase inhibitors
eg: Zidovudine, didanosine, lamivudine,
emtricitabine
 Fixed dose combination products
eg: Combivir, Trizivir, Truvada, Stribild

46. Nursing interventions can help the patient
 adhere to drug regimens
 adopt a healthy lifestyle that includes avoiding
exposure to other sexually transmitted infections and
blood-borne diseases
 protect others from HIV
 maintain or develop healthy and supportive
relationships
 maintain activities and productivity
 explore spiritual issues
 Decreasing risks of perinatal transmission by
educating HIV infected woman have family planning
methods. Health education to adolescent and
vulnerable women for prevention of HIV

47.  Improving adherence to antiretroviral
therapy
 END-OF-LIFE CARE - Despite new
developments in the treatment of HIV
infection, many patients eventually
experience disease progression, disability,
and death. Sometimes these occur because
treatments do not work for the patient.
Sometimes the patient’s HIV becomes
resistant to all available drug therapies. In
addition, ART is now allowing people living
with HIV to live longer and to develop
diseases of aging, such as cardiovascular and
endocrine problems that lead to death

48. Evaluation
The expected outcomes are that the
patient at risk for HIV infection will
 Analyze personal risk factors
 Develop and implement a personal plan to
decrease risks
 Get tested for HIV
 Describe basic aspects of the effects of HIV
on the immune system
 Compare and contrast various treatment
options for HIV disease
 Work with a team of health care providers
to achieve optimal health
 Prevent transmission of HIV to others

49.  ETHICAL/LEGAL DILEMMAS
Be familiar with the state law concerning
mandated reporting for domestic partner
abuse and infectious diseases.
Laws regarding protection of privacy in HIV
testing are federal and apply everywhere.
Be familiar with crisis counseling services.

50.  INFORMATICS IN PRACTICE
 Use of Internet and Mobile Devices to Manage
HIV
 The Internet offers resources and support for
patients that can assist them in coping with
their illness and educate them about signs
and symptoms
 By monitoring their health and quickly
spotting warning signs of serious illnesses,
patients are able to alert their physicians
and receive earlier treatment. “
 These systems can help the patient manage
antiretroviral therapy by sending medication
reminders by text or e-mail.

51. As a nurse in an HIV clinic, you are counseling
Patient, a 25-year-old gay man, and his partner.
He is on antiretroviral therapy. His viral load is
low, and his CD4+ T cell count is normal. He tells
you that since the medications are working, he
and his partner (who is not infected with HIV)
have decided to forgo the use of condoms. They
tell you that they are in a committed
relationship and have no other partners. You
spend time explaining to both of them the risks
of unprotected sex: his partner may get infected
with HIV even with a low viral load (although the
risk is decreased)

52.  BEST AVAILABLE EVIDENCE
 CLINICIAN EXPERTISE
 PATIENT PREFERENCES AND VALUES
 YOUR DECISION AND ACTION

55.  Metabolic syndrome is characterized by a
cluster of health problems including obesity,
hypertension, abnormal lipid levels and high
blood glucose level.
 OTHER NAMES
 Syndrome X
 Insulin resistance syndrome
 Dysmetabolic syndrome

56. Measure Criteria
Waist circumference
≥40 inches (102cm) in male
≥35 inches (89cm) in female
Triglycerides
>150mg/dl (1.7mmol/L) ( or)
Drug treatment for elevated triglycerides
High Density
Lipoprotein
<40 mg/dl (0.9mmol/L) in male
<50 mg/dl (1.1mmol/L) in female
( or)Drug treatment for reduced cholesterol
Blood pressure
≥130mmHg systolic or
≥85mmHg diastolic BP
(or) treatment for hypertension
Fasting blood sugar
≥110mg/dl (or)
Treatment for elevated glucose

58.  Cardiovascular disease, coronary artery disease
 Central obesity
 Stroke
 Diabetes mellitus
 Sedentary lifestyle
 Clotting disorders
 Hypertension
 Genetic factor
 Environmental factor
 smoking
 Asian race

60.  Impaired fasting blood glucose level
 Hypertension
 Abnormal cholesterol level, dislipidemia
 Non alcoholic fatty liver disease
 Dementia
 Obesity
 Medical problems develop over time if
remains untreated
 Higher risk to develop heart disease, stroke,
renal disease, polycystic ovarian syndrome,
cancer

61. The initial management of metabolic syndrome
involves lifestyle modifications, including
changes in diet and exercise habits. Diet,
exercise, and pharmacologic interventions
may inhibit the progression of metabolic
syndrome to diabetes mellitus.

62.  Treatment and control of diabetes
mellitus
 Treatment and control of hypertension
 Treatment and control of blood
cholesterols

63.  Very rare, but if the condition is extensive,
and lifestyle modifications fails- Liposuction
is an option which is a cosmetic surgery but
can help reduce excess belly and central fat
deposition.
 Not recommended if patient have health
problems with blood flow or have heart
disease, diabetes or a weak immune system.

66.  JulieSP, Isabelle L, Marie-ClaudeV, PatriceG,
Pierre J. Contribution of abdominal obesity
and hypertriglyceridemia to impaired fasting
glucose and coronary artery disease. The
American Journal of Cardiology. 90(1); 1
July 2002. Pages 15-18

67.  Osoti A, Tecla MT, Nicholas K, Edmond KN,
Jemima HK, Stephanie P et al. Metabolic
Syndrome Among Antiretroviral Therapy-
Naive Versus Experienced HIV-Infected
Patients Without Preexisting Cardio-
metabolic Disorders in Western Kenya. AIDS
patient care and STDs 32 (6), 215-222, 2018

69.  Books:
 Lewis SL, Dirksen SR, Heitkemper ML, Bucher L. Lewis
Medical Surgical Nursing- assessment and management of
clinical problems. Second south Asian Edition. VolumeI.
New Delhi:Elsevier; 2016
 Lewis SL, Dirksen SR, Heitkemper ML, Bucher L. Lewis
Medical Surgical Nursing- assessment and management of
clinical problems. Second south Asian Edition. VolumeII.
New Delhi:Elsevier; 2016
 Joyce MB & Jacob EM. Luckmann Medical Surgical Nursing,
A psychophysiologic approach. Fourth edition. Saunders
International edition.2005
 Chugh SN. Textbook of Medical Surgical Nursing part II.
New Delhi: Avichal Publishing Company; 2013
 Hinkle JL & Cheever KH. Brunner and Suddarths textbook
of Medical surgical nursing. Volume I 13th edition.New
Delhi: Wolters Kluwer; 2014

70.  Journals:
 JulieSP, Isabelle L, Marie-ClaudeV, PatriceG,
Pierre J. Contribution of abdominal obesity and
hypertriglyceridemia to impaired fasting glucose
and coronary artery disease. The American
Journal of Cardiology. 90(1); 1 July 2002. Pages
15-18
 Osoti A, Tecla MT, Nicholas K, Edmond KN,
Jemima HK, Stephanie P et al. Metabolic
Syndrome Among Antiretroviral Therapy-Naive
Versus Experienced HIV-Infected Patients
Without Preexisting Cardiometabolic Disorders in
Western Kenya. AIDS patient care and STDs 32
(6), 215-222, 2018

71.  Internet:
 www.nhlbi.nih.gov/health/dci/Diseases/ms/
ms_diagnosis.html
 www.wedMD.com
 www.googlescholar.com
 Cohen MS. McCauley M, Gamble RT: HIV
treatment as prevention and HPTN 052, Curr
Open HIV AIDS 7(2):99, 2012

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