NUR2349 Exam 3 Review
Anatomy of the Immune System
• Physical barriers
• Leukocytes- normal level: 4500-1100
• Monocyte-macrophages
• Dendritic cells
• Neutrophils- can cause overwhelming bacterial infection, large number
may indicate early inflammation.
• Mast cells
• Granulocytes
• Natural killer cells
• Lymphocytes
• B lymphocytes and antibodies
• T lymphocytes
Physiology of the Immune System
• Inflammation response: s/s- edema, heat, erythema (redness), pain.
• Innate immune response: present at birth
• Local
• Systemic
• Adaptive immunity
• Cell-mediated immune response
• Humoral mediated immunity
• Total immune response
• Immunological memory
• Mechanisms of immunization
Inflammation Nursing Diagnosis
• Risk for infection
• Thermoregulation: ineffective
• Acute pain
• Nutrition: imbalanced
Assessment of the Immune System
• Age and developmental considerations
o Older adults: altered nutrition intake, failure of immune system
to differentiate self from nonself, increased hematuria
• Immunizations and infections
• Allergies
• Autoimmune disorders
• Cancer
• Chronic illness
, 2
• Physical examination
o Integumentary system
o Eyes, ears, nose, and throat
o Lymph nodes
o Respiratory system
o Cardiovascular system
o Neurological system
Diagnostic Tests
• Complete blood count (CBC) with differential
• Radiological tests
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein
• Total complement (CH50)
Interventions
• Nursing management
• Aseptic technique
• Wound care
• Stress management
• Do not “prediagnose”
• Education
Stages of Infection
Classification of Infections
The Spread of Infection
Factors That Increase Infection Risk
Factors That Support Host Defenses
Healthcare-Related Infection
• Exogenous Healthcare-Related Infection