Inflammatory, Wound, and Immune process

Question 1

What do erythrocytes (RBCs) do?

Answer 1

Transport O2 and CO2
- Hemoglobin= Iron + protein
- Oxyhemoglobin= O2 + iron
Helps maintain acid base balance (CO2=O2).

Question 2

What is erythropoeisis?

Answer 2

Stimulated by hypoxia, and controlled by erythropoietin.

It stimulates the creation of RBC.

Its also influenced by nutrient availability.

Question 3

How do you assess the hemotological system?

Answer 3

For things like anemia, sickle cell, etc.
1) Health history
2) Subjective data:
- Demographic data
- Current/past individual and familial history (bleeding, hemophilia)
- Medication/herbs/supplements
- Surgical history (heart valve replacement, gastric bypass)
- Other treatments (previous blood transfusions), anemia
3) Objective data:
- Physical examination (pallor, decreased pulse ox)
- Systems aseessment (Skin, lymphnodes, spleen, and liver)

Question 4

What is pancytopenia?

Answer 4

Suppression of all blood cells.

Question 5

What is a peripheral smear?

Answer 5

A blood test that gives you information about the number and shape of blood cells.

The morphology of blood cells.

Question 6

Who is the universal donor?

Answer 6

O negative!!!

Question 7

What are some diagnostic lab studies for the hemotological system?

Answer 7

RBC:
- Total RBC count (not this alone)
- Hgb/Hct
- RBC indices
- Erythrocyte sedimentation rate (ESR/Sed rate)
Most common ESR tells you about the inflammatory process

Question 8

What test determines Rh status?

Answer 8

Coombs test

Question 9

What is a summary of iron metabolism? What are the steps from ingestion to RBC?

Answer 9

1) Ingestion from diet or suppliment
2) Transported via (serum) transferrin were its put into RBC or stored.
3a) Storage (bone marrow, liver, spleen, macrophages) via ferritin and hemosiderin.
3b) RBC via hemoglobin
4) Recycling via macrophages in liver and spleen

Question 10

What are the laboratory diagnostic studies used to find iron deficient anemia?

Answer 10

Tests for iron metabolism are:
- Serum iron
- Total iron binding capacity (TIBC)
- Serum ferritin
- Transferrin saturation

Question 11

What are the radiologic and biopsy diagnostic studies used to find iron deficient anemia?

Answer 11

Radiologic:
- Computed tomography (CT)
- Magnetic resonance imaging (MRI)

Biopsies:
- Bone marrow examination (RBC iron)
- Lymph node biopsy

Question 12

What are molecular cytogenetics and gene analysis techniques we can do with the biopsies in iron deficient anemia?

Answer 12

From bone and lymph tissue samples:
- Florescent in situ hybridization (FISH)
- Spectral karyotyping (SKY)
lets us know if there a hereditary component to it.

Question 13

What is anemia?

Answer 13

A deficiency in the:
- Number of erythrocytes (RBCs)
- Quantity of hemoglobin
- Volume of packed RBCs (hematocrit)

Question 14

What are the three different characteristic cell types of anemia?

Answer 14

Normocytic (normal)
Microcytic (small)
Macrocytic (large)

Question 15

What are the 6 most common types of anemias? Example of each?

Answer 15

1) Hypochromic- iron or vitamin deficiency
Caused by malabsorption and blood loss.

2) Pernicious- lack of intrinsic factor
B12 deficiency in stomach that effects the intrinsic factor. Large RBC

3) Erythroblastosis fetalis- destruction by the antibodies

4) Secondary- bleeding, leukemia, cancer or CKD

5) Genetic factors- sickle cell anemia or spheroidal

6) Aplastic- malfunctioning bone marrow
Not making enough RBC

Question 16

What clinical manifestations are you going to see with anemia?

Answer 16

*Hgb/hct will be low.

*Hematocrit under 8 will be a POTENTIAL blood transfusion. Under 6 is likely blood transfusion.

*Pallor (Due to low hgb and blood flow to the skin)

*Jaundice (Due to concentration of serum bilirubin)

*Pruritus itching (Due to increased serum and skin bile salt concentrations)

Question 17

What should you assess prior to drawing labs for hematocrit?

Answer 17

Patients hydration status.
If they are overloaded, the blood will be thinner leading to a false low reading.
If they are dehydrated, the blood will be thicker, leading to a false high reading.

Question 18

Trick to determining proper hematocrit range via the hemoglobin level?

Answer 18

Hematocrit percentage should be 3X the hemoglobin level.

Question 19

What are three alterations in erythropoesis that may decrease RBC production?

Answer 19

1) Decreased hemoglobin synthesis
2) Defective DNA synthesis in RBCs
3) Diminished availability of erythrocyte precursors.

Question 20

What is Procrit?

Answer 20

It is synthetic erythropoeitin, which increases hct and hgb. Used to treat anemia associated with renal failure and chemotherapy.

Watch for hypertension, headache, nausea.

Other names are redicrit, mercera (not for cancer patients)

Question 21

What is leukemia?

Answer 21

A group of malignant disorders affecting the blood and blood forming tissues such as bone marrow, lymph system, and spleen.

Number of adults affected are 10 times that of children patients.

Question 22

What are the two different classifications of leukemia based on cell maturity and nature of disease onset?

Answer 22

1) Acute which comes from the clonal proliferation of immature hematopoetic cells.

2) Chronic which effects come from mature forms of white blood cells and the onset in more gradual.

Question 23

What are the classifications of leukemia based on the type of white blood cell?

Answer 23

1) Acute lymphocytic leukemia (ALL)
2) Acute myelogenous leukemia (AML)
3) Chronic myelogenous leukemia (CML)
4) Chronic lymphocytic leukemia (CLL)

Question 24

Acronym for remembering symptoms of leukemia?

Answer 24

A- Amemia= low Hgb
N- Neutropenia= Risk of Infection
T- Thrombocytopenia= Bleeding

Question 25

What is the eitology and pathophysiology of thrombocytopenia?

Answer 25

Reduction of platelets.
Resuls in abnormal hemostasis.
-Prolonged or spontaneous bleeding
Primarily and acquired disorder.
- Commonly from ingesting certain herbs or drugs.

Question 26

What herbs can be used as a blood thinner?

Answer 26

Garlic
Ginko biloba

Question 27

What pain/fever relievers cause bleeding?

Answer 27

Tylenol (acetametophan) does not make you bleed more

Asprin and NSAID, like ibuprophen (other ‘fen’s) and naproxen do.

Question 28

What are some acquired causes of thrombocytopenia?

Answer 28

Immune thrombocytopenia purpura (ITP)
Thrombotic thrombocytopenia purpura (TTP)
Heparin-induced thrombocytopenia (HIT)

Question 29

What is von Willibrands disease? What are the clinical manifestations and complications?

Answer 29

Von willibrand disease, is a related disorder involving the deficiency of von Willibrands coagulation factor (Factor VIII)

Clinical manifestations:
-Bleeding (may be life threatening).
-Slow, persistant, and prolonged bleeding.
-Delayed bleeding after minor injuries.
-Uncontrollable hemorrhage after dental extraction or irritation with toothbrush.
-Epitaxis
-GI bleed from ulcers and gastritis

Question 30

How would you go about diagnosing Hemophilia/ Von Willibrands?

Answer 30

1) Observing the clinical manifestations such as:
-Hematuria
-Ecchymosis and sub-q hematomas
-Compartment syndrome
-Neurologic signs
-Hemarthrosis

2) Diagnostic studies are:
Factor deficiency within intrinsic system (factor VIII, IX, XI, XII, vWF)

Question 31

How would we go about fixing hemophilia and von willebrand?

Answer 31

3) Interpersonal care:
-Treatment of complications
-Replacement therapy (of that factor)
-Preventative care (prevention of bleeding)

Question 32

What is lymphoma?

Answer 32

1) A malignant neoplasm originating in the bone marrow and lymphatic structures. Metastasizes to non-nodal sites.
-Results in the proliferation of lymphocytes.

2) Fifth most common type of cancer in the united states.

3) Two major types:
- Hodgkin’s Lymphoma- More prevalent in patient 15 to 19 years old.
- Non-Hodgkin’s Lymphoma- More prevalent in children younger than 14 years of age.

Question 33

Explain what hodgkins disease (Hodgkins lymphoma) is?

Answer 33

Neoplastic disease origionating in the lymphoid system. Makes up about 10% of all lymphomas.

Starts in a single location than spreads to adjacent lymphatics.

Often metastasizes to the spleen, liver, bone marrow, lungs, and other tissues.

Classified by histologic type.

Question 34

What is the eitology of Hodgkins Lymphoma?

Answer 34

1) Bimodal age-specific incidence:
-15 to 30 years of age
-Greater than 55 years of age

2) About 8260 new cases each year.

3) Long-term survival exceeds 80% for all stages.

5) Cause remains unknown but there are key factors:
-Infection with Epstein-Barr virus (EBV)
-Genetic predisposition
-Exposure to occupational toxins

6) Incidence increase in those with HIV.

Question 35

Clinical manifestations of Hodgkin’s Lymphoma?

Answer 35

Clinical manifestations: Typically have a gradual onset…
1) Enlargement of cervical, axillary, or inguinal lymphnodes.
2) Second most common place is the mediastinal node mass.
3) Nodes are movable and non tender.
4) Not painful unless nodes exert pressure on adjacent nerves.

Patient may notice:
- weightloss
- fatigue and weakness
- fever and chills
- tachycardia
- night sweats
Advanced cases:
- hepatomegally
- splenomegally
- anemia
- Other physical signs vary, depending on disease location…
RULE OUT TB

Question 36

How do we treat/manage hodgkins disease?

Answer 36

Irradiation
Chemotherapy (alone or with radiation)
Prognosis
Nursing considerations
-prepare for diagnostic procedure
-prevent side effects if possible; prepare and treat side effects
-child and family support

Question 37

Explain the stages of Hodgkins lymphoma.

Answer 37

Stage 1-Goes to the individual site
Stage 2-Spreads to adjacent sites
Stage 3-More spreading, and liver and spleen enlargement
Stage 4-lung involvement

Question 38

What is the eitology of Non-hodgkin’s lymphoma?

Answer 38

Approx. 60% of pediatric lymphomas are NHLs

Clinical appearance:
-Disease is typically diffuse rather than nodular.
-Cell type is undifferentiated or poorly differentiated.
-Dissemination occurs early, often, and rapidly.
-Mediastinal involvement and invasion of meninges.

Question 39

Explain Non hodgkin’s lymphoma management.

Answer 39

Diagnostic evaluation is similar to that of hodgkins disease with the exception ot the cancer is more diffuse than hodgkins lymphoma.

Irradiation
Chemotherapy (alone or with radiation)
Prognosis
Nursing considerations
-prepare for diagnostic procedure
-prevent side effects if possible; prepare and treat side effects
-child and family support

Question 40

What is the inflammatory process and its purpose?

Answer 40

Its the sequential response to cell injury.
-It neutralizes and dilutes inflammatory agent.
-Removes necrotic materials.
-Establishes an environment suitable for healing and repair.

INFLAMMATION IS ALWAYS PRESENT WITH INFECTION, BUT INFECTION ISN’T ALWAYS PRESENT WITH INFLAMMATION

Question 41

What are the catagories of inflammatory response?

Answer 41

Inflammatory response can be divided into:
1) Vascular response- releases histamine; opens vessels up to allow WBC to move in.

2) Cellular response- Sends out neurophils in phases, than monocytes (5 hours later) they’re the clean up crew and last about 3-7 days.

3) Formation of exudate- sometimes just harmless serum, other times it can become fiberous adhesions that solidifies the wound to everything. Sometimes its purulent…this is infection, absess, and boils. Not to be confused with sebaceous cyst (dead skin cells). There also hemorrhagic blisters and can become infectious.

4) Healing- Comes in primary, secondary, and tertiary. Can also be classified as Stage 1 (intact red, non blanchable), Stage 2 (opening in the skin), Stage 3, Stage 4.

SEE IMMUNE CELL HANDOUT FOR RUNDOWN OF DIFFERENT WBCS.

SEE ALSO: Vascular and cellular response to injury pathophsiology map.

Question 42

What are “bands”

Answer 42

Immature neutrophils. They also get sent out in mass during an invasion. They cant do the job but are ‘clogging up the works’.

Having these bands of neutrophils are called a “shifting to the left”

Question 43

Explain what happens during the Vascular response stage of the inflammatory process.

Answer 43

1) After cell injury, arterioles in the area briefly undergo transient vasoconstriction.

2) After release of histamines and other chemicals by the injured cells, vessels dilate, resulting in hyperemia.

Question 44

Explain what happens during the Cellular response stage of the inflammatory process.

Answer 44

1) The first to the site are neutrophils and they arrive at the site of injury in around 6-12 hours. They are released from the bone marrow. They phagocytize bacteria, other foreign material, and damaged cells.
They have a short lifespan of 24-48 hours.

2) Monocytes are the second type of phagocytic cells to migrate to site of injury from circulating blood. Attracted to the site by chemotactic factors and they arrive within 3 to 7 days after the onset of inflammation.

Monocytes:
On entering tissue spaces, monocytes transform into macrophages and assist in phagocytosis of inflammatory debris. Macrophages have a long lifespan and can multiply.

Macrophage:
Important in cleaning the area before healing can occur. May stay in damaged tissue for weeks. Cells may fuse to form a multineucleated giant cell.

3) Lymphocytes arrive later at the site and their primary role involves:
- Cell-mediated immunity (Cell-mediated immunityorcellular immunityis an immune response that does not involveantibodies)
- Humoral immunity (Humoral immunityis an antibody-mediatedresponse that occurs when foreign material - antigens - are detected in the body)
They are major medicators of the inflammatory response.

*Pus is the exudate composed of dead neutrophils, digested bacteria, and other cell debris.

Question 45

What are the two stages of inflammation?

Answer 45

*Bacterial infection of 2 weeks or less is considered ACUTE inflammation and presents with:
-Pain
-Redness
-Swelling
-Heat
-Loss of function

*Bacterial infection of longer than 2 weeks or more is considered CHRONIC inflammation and presents with no symptoms.

Persistant onslaught of bacteria= exaggerated host inflammatory response.

Question 46

What is the complement system and what are its major functions?

Answer 46

The complement system is the major medicator of the inflammatory response. Its the enzyme cascade (C1-C9) consisting of pathways to mediate inflammation and destroy invading pathogens.

Major functions of the complement system:
-Enhances phagocytosis
-Increased vascular permiability
-Chemotaxis
-Cellular lysis

C8 and C9, the final components of the complement system, pierce the cell surface, causing rupture of the cell membrane and lysis.

Question 47

What is the clinical manifestations of local response to inflammation? What can we do to treat it?

Answer 47

Local response to inflammation is:
- Redness
- Heat
- Pain
- Swelling
- Loss of function

Treatment is:
Rest
Ice
Compression
Elevation

Question 48

What are some clinical manifestations of the inflammatory response?

Answer 48

Systemic response:
-Increased WBC count with shift to the left
-Malaise
-Nausea and anorexia
-Increased pulse and respiratory rate
-Fever: Onset is triggered by release of cytokines. Cytokines cause fever by initiating metabolic changes in temperature regulating center in hypothalamus. Epinephrine released from the adrenal medulla increasing metabolic rate.

Systemic response to inflammation:
- The causes of systemic response are pooprly understood. Probably due to complement activation and the release of cytokines.
-Some cytokines are IL-1,IL-6, and tumor necrosis factor.

Question 49

What happens in the healing stage of the inflammatory response?

Answer 49

Final phase of the inflammation process is healing.
Two major components:
-Regeneration of tissue
-Repair of that tissue. More common than regeneration and more complex and happens by primary, secondary, and tertiary.

*Primary intention includes three phases:
1) Initial phase: lasts 3-5 days. Edges of insicion are aligned. Blood fills the incision area, which forms a matrix for WBC migration. Acute inflammatory reaction occurs
2) Granulation phase: Fibroblasts migrate to the site and secrete collagen. Wound is pink and vascular. Surface epithelium begins to regenerate.
3) Maturation phase and scar contraction: Begins 7 days after injury and continues for several months to years. Fibroblasts disappear as wound becomes stronger. Mature scar forms (can be interrupted by excess cell formation).

*Secondary intention is wounds that occure with trauma, ulceration, and infections that have large amount of exudate and wide, irregular wound margins with extensive tissue loss. Edges cannot be appoximated. Results in more debris, cells, and exudate.

*Tertiary intention is a delayed intention due to delayed suturing of the wound. Occures when a contaminated wound is left open and sutured closed after the infection is controlled. (Cat bites and dog bites)

Question 50

What are some complications of healing?

Answer 50

Dehiscence- can happen due to stress/strain on wound, infection, inflammation (becomes friable, or fragile and shreds open)

Hypertrophic scarring- excess cells building up, looks very similar to keloid. More common in whites than blacks, deeper.

Keloid scar-less common, and more superficial. This is more comon in blacks than whites.

Question 51

Three functions of the immune response?

Answer 51

Defense
Homeostasis (cell balance)
Surveillance

Question 52

What are the types and subtypes of immunity?

Answer 52

1) Innate which is present at birth and is first-line defense against pathogens.

2) Acquired or developed immunity:
-Active: response to actual attack OR vaccination; Lasts longest.
-Passive: Protected from pathogen by immunity gained from someone else like mom to baby or serum injection; Doesnt last as long due to lack of memory cells.

Question 53

What are antigens and antibodies?

Answer 53

1) Antigens are substances the body recognizes as foreign that illicit a response. Does not always have to start out as pathogens, can be lipoproteins, glycoproteins etc. and get pissed and turn on you!! The body can actually create these AND your body can become tolerant of them and ignore them…fuckin. crazy.

2) Antibodies are immune globulins produced by lymphocytes in response to antigens.

Question 54

What are our organs of immunity?

Answer 54

Tonsils
Thymus gland
Bronchial-associated lymphoid tissue
Lymphnodes
Spleen (major organ of immune response)
Gut-associated lymphoid tissue
Bone marrow (Where all WBC are made)
Lymphnodes
Genital-associated lymphoid tissue

Question 55

What are the various lymphoid organs?

Answer 55

Central (primary) lymphoid organs:
1) Thymus gland: Shrinks with age and is involved with the differentiation and maturation of T lymphocytes.
2) Bone marrow: Produces red blood cells, white blood cells, and platelets. They migrate all over.

Peripheral lymphoid organs:
1) Lymph nodes
2) Tonsils
3) Spleen
4) Lymphoid tissues associated with the gut, genitals, bronchi, and skin.

Question 56

Humoral vs. Cell-mediated immunity.

Answer 56

Humoral immunity and cell-mediated immunity are two types of anadaptive immune responsethat enable the human body to defend itself in a targeted way against harmful agents such as bacteria, viruses and toxins. Whilst there is some overlap between these arms of the immune response - both rely on the functions of lymphoid cells - there are also some important differences.

Humoral immunityis an antibody-mediated response that occurs when foreign material -antigens- are detected in the body. This foreign material typically includes extracellular invaders such as bacteria. This mechanism is primarily driven byB cell lymphocytes, a type of immune cell that produces antibodies after the detection of a specific antigen. *Antibodies produced by plasma cells (differentiated B lymphocytes) Primary immune response is evident 4-8 day s after initial exposure to antigen.

Unlike humoral immunity,cell-mediated immunitydoes not depend on antibodies for its adaptive immune functions. Cell-mediated immunity is primarily driven by mature T cells, macrophages, and the release of cytokines in response to an antigen.

Question 57

What are the cells of the immune response and what are their roles?

Answer 57

*Mononuclear phagocytes: Initiates the immune response
1) Include monocytes in the blood and macrophages found throughout the body.
2) Capture, process, and present antigens to lymphocytes to initiate an immune response.
3) Capture antigens by phagocytosis

*Lymphocytes:
1) Produced in bone marrow
2) Eventually migrate to peripheral organs
3) Differentiate into B and T lymphocytes
-T cytotoxic cells- they attack the antigen.=> memory cells
-T helper cells- help produce cytokines
-Natural killer cells (large lymphocytes) recognizing and killing viruses, tumor cells, and transplanted grafts.

*Cytokines:
1) Soluble factors secreted by the WBCs and a variety of other cells in the body.
2) Acts as messengers among cell types
3) Instructs other cells to alter their proliferation, differentiation, secretion or activity.
4) Currently at least 100 different cytokines
5) Have a beneficial role in hematopoeis and immune function.
6) Can have detrimental effects:
-Chronic inflammation
-Autoimmune diseases
-Sepsis

Question 58

What are different types of cytokines?

Answer 58

Interleukins
Interferons (common ones, used in cancers)
Tumor necrosis factor
Colony-stimulating factor
Erythropoietin

A-Interferon and B-interferon:
- Inhibit viral replication
- Activate NK cells and macrophages
- Antiproliferative effects on tumor cells
y-Interferon: (used with MS)
-Activates macrophages, neutrophils, and NK cells
-Promotes B-cell maturation
-Inhibits viral replication

Question 59

What are the 5 classes of immune globulins and their specific characteristics?

Answer 59

IgG- Secondary exposer responder. When a person is exposed to an antigen for a second time, the response is faster (1 to 3 days) and lasts longer. Main product of secondary response is IgG rather than IgM. Largest component of total immunoglobulin in body. Can cross placenta and plasma etc. Memory cells account for more rapid prodcution of IgG.

IgA- Found in body secretions such as saliva and tears, breast milk and colostrum, lines mucus membranes.

IgM- Largest immunoglobulin. Also found in the plasma. Rsponsible for primary immune response. This forms antibodies in the ABO blood cell proteins.

IgD- Found in the plasma. Its on the lymphocytes surface. Assists in differentiation of B cells.

IgE- found also in the plasma. Also in interstitial fluid. Responsible for allergic reactions.

IgM (1st to react) AND IgG (2nd to react) are the predominant primary immunoglobulins in primary response to antigens. In subsequent exposure, IgG will be first to respond and it will be more rapid, and severe. IgM willstay the same.

Question 60

What are some of the effect of aging on the immune system?

Answer 60

Higher incidences of tumors
Greater suseptibility to infection
Increased autoantibodies (antibodies made against our own body)
Lower cell-medicated immunity
Thymic involution