UNIT 12. Immune System. Self Tolerance PROBLEMS OF PROTECTION. Purpose. Immune cells distinguish self from non self. Neutralize. Eliminate.

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1 UNIT 12 PROBLEMS OF PROTECTION Purpose Neutralize Immune System Eliminate Destroy Chp. 12 pages Self Tolerance Immune cells distinguish self from non self Infected cells Cancer cells Organisms

2 Organization of the Immune System Some immune cells mature in the bone marrow then release to circulation Other immune cells leave the bone marrow and mature in different body sites Cell Mediated Immunity Many antigens hide inside the normal cells Cellular immunity recognizes them T-Cells are 70-80% of lymphocytes Effector cells (killer T cells) Regulator cells (helper T cells) Humeral Immunity B Cells Make-up 10-15% of circulating lymphocytes Spleen (await activation) Lymph nodes Identify foreign antigens

3 Focused Health History Past history of allergies Family history Social history Physical Assessment General Appearance Age, fatigue, weight, height body type Mucous Membranes Color and condition Skin color, temperature and moisture Pallor, rashes or lesions Inspect and palpate lymph nodes Tenderness or swelling Musculoskeletal system Palpate joints for swelling, tenderness or deformity Focused Physical Exam Since immunologic diseases can involve many organ systems, a complete physical exam is warranted Liver Spleen Thymus Lymphatic system

Diagnostics Carcinoembryonic antigen test (CEA) C reactive Protein (CRP) Calcium

4 Physiological Changes in Aging With age, white cells or lymphocytes become less active, making the body more vulnerable to bacteria, viruses and other pathogens. Diagnostics Carcinoembryonic antigen test (CEA) C reactive Protein (CRP) Calcium Red blood cells Hematocrit and Hemoglobin Estrogen BUN ALT/AST White blood cells

5 Neoplasms Types Lung Breast Prostate Colon Skin Testis Cervix Ovary Pathophysiology Cumulative alteration in a cell s genes Three stage theory of cell transformation Initiation Promotion Progression Invasion Neovascularzation Metastasis

6 Neoplasms Mass of new tissue that grows independently of its surrounding structures. Used interchangeably with the word tumor Require a blood supply with nutrients and oxygen to sustain growth Classified as Benign or Malignant Benign Neoplasm Localized, slow growths Solid mass with well-defined borders Frequently encapsulated Stop growing when they reach boundaries of other tissues Often easily removed and do not reoccur Can be destructive if they obstruct surrounding organs, i.e. brain and spinal cord Grow aggressively Irregular shape Malignant Neoplasm Does not stop at tissue border Do not crowd other tissue but cut thru them causing bleeding, inflammation and necrosis Metastasizes to different sites Not always easy to remove Can recur

7 Clinical Manifestations Change in bowel and bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or a lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging cough or hoarseness Pain Sleep/rest patterns Assessment Fatigue/shortness of breath Vital signs especially temperature Intake and output (diarrhea) Weight loss Agitation and restlessness WBC, platelets and serum electrolytes Complications Cancer treatments often too expensive for many Promising drugs raise dilemma of whether benefits outweigh the risks Toxic side effects of chemotherapy

8 Collaborative Management Surgery Radiation Biologic therapy Chemotherapy Nursing Interventions Encourage screenings Implement pain control measures Encourage/maintain nutrient intake Prevent infections Listen to client concerns Avoid false reassurance Allow time for client to discuss feelings regarding loss and to grieve Integument

9 Anatomy and Physiology Anatomy of the skin 1 st layer Epidermis 2 nd layer Dermis 3 rd layer Subcutaneous tissue Function of the skin Protection infection Regulate body temperature Maintain fluid and electrolyte balance Cushion/heat insulation Protect internal organs Malignant Skin Disorders Melanoma Squamous Cell Carcinoma Actinic Keratosis Chapter 16 pages

10 Actinic Keratosis Also called solar keratosis Epidermal skin lesion Directly related to sun exposure Highest prevalence in fair skin, rare in dark skin people Classified as premalignant but may progress to squamous cell Erythematous rough macules Squamous Cell Carcinoma Malignant tumor of the epithelium of the skin or mucous membranes Occurs on areas of frequent sun exposure Aggressive and metastasizing growth Invades surrounding tissue Ulcerates, bleeds and is painful when it grows May occur from pre-existing skin lesions (scars, burns, actinic keratosis) Malignant Melanoma Deadly Skin Cancer Accounts for 4% of skin cancer but causes 79% of skin cancer deaths Highest incidence is in caucasions More than 6mm in size and are asymmetric Considered benign until they penetrate the dermis Poor prognosis if they are on the hands, feet and scalp

11 Precursor Lesions Congenital Nevi Dysplastic Nevi Lentigo Maligna Classification of Melanoma Superficial Spreading Melanoma: most common; flat, scaly and crusty come from nevi Lentigo Melanoma: comes from precursor lesion, appear in shades of brown Nodular Melanoma: may look like a blood blister, arise in unaffected skin Acral Lentiginous Melanoma: more common in dark skin, found on palms of hands and soles of feet. Women and men in their s The ABCD Rule A = asymmetry (one half of the nevus does not match the other B = border irregularity (edges are ragged, blurred, or notched C = color variation or dark black color D = diameter greater than 6mm (size of a pencil eraser)

12 Risk Factors for Non-Melanoma Fair skin, blue or green eyes, blond or red hair Family history Sun exposure or UV radiation (natural or artificial) Radiation treatment Occupational exposures to coal, tar, arsenic or radium Severe sunburns as a child Risk factors for Malignant Melanoma High number of moles or large moles Fair skin, freckles, blond hair and blue eyes Family history (close relative) Exposure to sun or UV radiation (tanning beds) Over 50 Past history of melanoma Treatment Non-maligant Melanoma Malignant Melanoma Surgical excision Mohs surgery Curettage and Electrodesication Radiation therapy Surgery Immunotherapy Radiation therapy New methods of treatment

13 Nursing Assessment Interview questions Nursing Diagnosis Physical Assessment (next slide) Focused Physical Exam Inspection Color Lesions Moisture Edema Vascular markings Intactness Cleanliness Palpation Lesions Excess moisture Skin temperature Texture Turgor Hair Nails Changes with Aging Subcutaneous tissue decreases Fat Pad production decreases Seborrheic keratosis Senile lentigines (liver spots) Cherry angiomas

14 Diagnostics Cultures Skin Biopsy Wood light examination Diascopy Skin testing SLE-Systemic Lupus Erythematousus Pathophysiology Altered immune system Production of pathologic tissue damage

15 Genetic influence Environmental Etiology No known cure Risk factors include: females between African American, Asian, Native American Incidence drops in women following menopause Discoid Classifications Primarily affects skin, butterfly rash over nose and cheeks, self-limiting Systemic Affects connective tissues of multiple organ systems, can lead to major organ failure Drug-induced Procanimide, hydralazine, isoniazid; symptoms resolve when drug is discontinued. Does not cause organ failure How is Lupus diagnosed? (ANA )Antinuclear Antibody.. 95%-98% of patients with SLE will have a positive ANA test, ESR CRP CBC UA BUN/Creat Kidney Bx Positive Syphilis test (RPR)

16 Sun What makes Lupus worse? Stress Menses Fever/malaise Butterfly rash Symptoms Alopecia Anorexia/Weight loss Anemia Lymphadenopathy Depression Joint pain/swelling, tenderness Cutaneous Clinical Manifestations Joint Central Nervous System Cardio-pulmonary Hematologic

17 Antimalarial drugs Treatment Corticosteroids Immunosuppressive agents (Imuran) Complications Kidney CNS Blood and Blood vessels Lungs Heart Infection Cancer Bone and Tissue death (avascular necrosis) Pregnancy Collaborative Management Physical therapy Dietician Pharmacy Dialysis

18 Nursing Interventions Patient teaching Avoid UV and sun exposure Use mild protein shampoo Steroid creams for rash Report peripheral or periorbital edema ASAP Report signs of infection Small frequent meals Limit salt intake Medication management Support groups Nursing diagnosis for the client with Lupus Case Study Sondra Lee Evan is a 30-year-old female who presented for an obstetrics follow-up 6 weeks post-miscarriage. She was 10 weeks pregnant at the time of her miscarriage. She has been off work since the miscarriage and complains of arthralgia and extreme fatigue as well as feeling "blah." She is not on any medications. She does take a multivitamin. Her other complaints include decreased appetite, joint swelling and stiffness, and difficulty sleeping.

19 Mrs. Evan is of African American/American Indian descent. Her parents are alive and in good health. Her mother has type 2 diabetes mellitus that is controlled with lifestyle changes and oral medications. Her father has hypertension that is controlled by lifestyle changes (dietary changes, exercise, and weight loss) and medication. Both sets of grandparents have died from a motor vehicle accident, or from complications from diabetes mellitus or heart disease. Mrs. Evan describes her sleeping pattern as follows: difficulty falling asleep, waking after 2 to 3 hours followed by difficulty returning to sleep for 1 or more hours after waking, then feeling like her sleep was not restful when she gets out of bed in the morning. Mrs. Evan describes pain, swelling and stiffness in her joints as progressing over the past 3 months. Mrs. Evan explains that her appetite remained decreased after her morning sickness subsided 2½ months ago. Height: 64" Weight: 108 lbs Temperature: 99.6 F HR: 82 bpm Resp: 20/min. BP: 112/70 Mrs. Evan exhibits the following signs: joint stiffness and swelling especially noted in her hands and wrists bilaterally. Her right knee is also noted to have some swelling along with decreased range of motion (ROM). It is also noted that her weight had decreased by 10 pounds since her miscarriage.

20 Work-up Diagnosis? Type of disease What other s/s could be assessed What lab tests would be anticipated to get ordered Medical interventions Nursing interventions Patient Teaching

Clinical characteristics

Skin Cancer Fernando Vega, MD Seattle Healing Arts Clinical characteristics Precancerous lesions Common skin cancers ACTINIC KERATOSIS Precancerous skin lesions Actinic keratoses Dysplastic melanocytic