WEEK 1 LECTURE 16-17 AUGUST 2024

NCM 112 BANUA, NCM 112 ORENSE, NCM 112 GONZALES, NCM 112 BOBIER | Trans by Angela O. Dometita

I. OXYGENATION
A. Healthcare Situation - Global
B. Patient Illnesses
C. Chronic Condition
D. RA 11223 -UHC
II. CELLULAR ABERRATIONS
A. Cancer
‣ Neoplasia
‣ Nomenclature of Neoplasia
B. Review of Normal Cell Cycle
‣ Types of Cells
‣ Cancer Cell Growth
‣ Cell Cycle
C. Carcinogenesis
III. FLUIDS AND ELECTROLYTES
A. Electrolytes
B. Body Fluid Compartments
C. Third Spacing
D. Edema
E. Body Fluid/ Body Fluid Transport
F. Movement of Body Fluid
G. Body Fluid Intake and Output
MEMBERSHIP

OXYGENATION - NCM 112 BANUA

HEALTHCARE SITUATION - GLOBAL

FIRST IN MORTALITY

Ischemic heart disease - world’s biggest killer (16%)

IHD/ CAD Risk Factors

‣ lifestyle practices
‣ heredity/ genetics
‣ environment/ world
FIRST IN MORBIDITY
SYNTHESIS: HEALTH CARE SITUATION
Lower respiratory infections - world’s most deadly communicable
disease (Acute Respiratory Tract Infection) ‣ Patient: unequal access to medical care and resources
‣ Health facilities: unevenly distributed
Upper Respiratory Infections affect: ‣ Resources: shortage in supplies and manpower
✓ nose ‣ Health Services are unaffordable
✓ sinuses
✓ pharynx (throat) Patients/ Clients
✓ larynx (voice box) - Diseases Communicable
- Lifestyle Disease
Lower Respiratory Infections affect:
✓ trachea (windpipe) Financial Risk Protection
✓ bronchi - avail of health services, and reimbursement of health
✓ bronchioles expenditures by PhilHealth
✓ lungs
Improve Access to Quality Hospitals and Health Care
Facilities
- Upgrade government health facilities.
PATIENT ILLNESSES - Improve facility preparedness - for trauma and other
emergencies.
CHRONIC DISEASE - non-communicable diseases, chronic condition, - Treatment packs: HPN, DM
or disorders - DOH licensure and PhilHealth accreditation for
CHRONIC ILLNESS – human experience of living with a chronic hospitals and health facilities .
disease or condition Attainment of Health-related MDGs
- Reduce
• Maternal and child mortality
CHRONIC CONDITION
• Morbidity mortality from tuberculosis and malaria.
• Incidence of HIV/AIDS
• medical conditions or health problems with associated symptoms
that require long- term (3 months or longer) management. Patient Satisfaction: A Quality Metric
• conditions that do not resolve or for which complete cures are rare. - Measurement of Patient’s Satisfaction
• “long lasting condition that can be controlled but not cured” (WHO) • Quality of Nursing care received
• irreversible, have a prolonged course, and unlikely to resolve • Responsiveness of hospital staff
spontaneously (Larsen, 2016) • Quietness of environment
• life-time diseases
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 • Pain management NEOPLASIA
• Communication/Information Medication
• Discharge Instructions Neoplasm - abnormal new growth of tissue which serves no purpose
and which can be highly damaging to the host
Evaluation
- Overall rating of the hospital Tumor - any neoplasm in which cells are permanently altered but have
the capability of growth and reproduction
Differentiation - refers to the extent to which the cells differ from their
cells of origin and to their degree of maturity
Metastasis - the dissemination or spread of malignant cells from the
REPUBLIC ACT NO. 11223 - UNIVERSAL HEALTH CARE primary tumor to distant sites by direct spread of tumor cells to body
cavities or through lymphatic and blood circulation
• Direct Contributors - must contribute to maintain membership Mutation
✓ Migrant workers - unusual change in genetic material occurring spontaneously or by
✓ Business Owners/ Self employed induction; the alteration change the original expression of the gene
✓ Professional practitioners - The initial genetically altered cell forms a clone and begins to
✓ Lifetime members and Dependents proliferate abnormally, evading normal intracellular and extracellular
• Indirect Contributors - can avail w/o income as stated on UHC growth-regulating processes or signals as well as the immune
✓ Indigent members listed in the Department of Social Welfare system defense mechanisms of the body
and Development (DSWD) - may lead to abnormalities in cell signaling transduction processes
✓ Senior Citizens according to Republic Act 10645 (signals from outside and within cells that turn cell activities either
✓ Persons with Disabilities according to RA 11228 on or off) that can in turn lead to cancer development
Benign - noncancerous
Malignant - cancerous
Borderline - low malignant potential tumors (e.g. ovarian tumor,
PCOS)
Anaplasia
- a pattern of growth in which cells lack normal characteristics and
differ in shape and organization with respect to their cells of origin)
- degree of anaplasia is associated with increased malignant
potential

CELLULAR ABERRATIONS - ORENSE

CANCER

• descriptive of the crablike extension of malignant cells into healthy

tissues and the deadly hold or crablike grip that the disease has
upon its victims.
• a large group of disorders with different causes, manifestations,
treatments, and prognoses
• cancer can involve any organ system and treatment approaches
have the potential for multi system effects, cancer nursing also
called as oncology nursing practice overlaps with numerous
nursing specialties.
• cancer nursing practice covers all age groups and is carried out in
various settings, including acute care institutions, outpatient centers,
physician offices, rehabilitation facilities, the home, and long-term
care facilities.
• begins when a cell is transformed by genetic mutations of the
cellular deoxyribonucleic acid (DNA)

Oncologist - a specialist in study and treatment of neoplastic growths • Cancerous cells usually become far different from the tissue from
Oncogenes which they arise.
- genes derived from normal growth-controlling cellular genes which
instruct the cell to behave abnormally
- responsible for vital cell functions, including proliferation and
differentiation

ROOT WORDS ✍

Neo - new A- none

Plasia - growth Ana- lack
Plasm- substance Hyper- excessive
Trophy - size Meta- change The tumour pictured here, an ovarian teratoma, bears no resemblance
+Oma - tumor Dys- bad, deranged to the normal tissue of the ovary. Tumours like these contain such
Statis - location foreign material as bone, hair, skin, or teeth

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 NOMENCLATURE OF NEOPLASIA REVIEW OF NORMAL CELL CYCLE

Tumor is named according to: TYPES OF CELLS

➡Parenchyma, Organ or Cell
• Hepatoma - liver permanent cells - out of the cell cycle
• Osteoma - bone • neurons, cardiac muscle cell
• Myoma - muscle stable cells - dormant/resting (g0)
➡Pattern and Structure, either gross or microscopic • liver, kidney
• Fluid-filled - cyst labile cells - continuously dividing
• Glandular - adeno • git cells, skin, endometrium , blood cells
• Finger-like- papillo
• Stalk - polyp
➡Embryonic Origin CANCER CELL GROWTH
• Ectoderm (usually gives rise to epithelium)
• Endoderm (usually gives rise to glands) In the cell cycle, cancer cells:
• Mesoderm (usually gives rise to connective tissues) • divide too frequently
• are not regulated, uncontrolled
BENIGN TUMORS • are not able to communicate with healthy cells
• do not carry out normal cell functions
✴Use the suffix - “OMA” • can’t anchor themselves
‣ Adipose tissue- LipOMA • have ability to secrete growth hormone that makes blood vessels
‣ Bone- osteOMA divert over to them and supply cancer cells with nutrients intended
‣ Muscle- myOMA for healthy cells
‣ Blood vessels- angiOMA • develop into tumor, some stay put some do not
‣ Fibrous tissue- fibrOMA

MALIGNANT TUMORS RISK FACTORS/ ETIOLOGY OF CANCER CELL GROWTH

named according to:
✓ Physical Agents
✓ embryonic cell origin: • Radiation
➡Ectodermal, Endodermal, Glandular, Epithelial • Exposure to irritants
✴Use the suffix- “CARCINOMA” • Exposure to sunlight
‣ Pancreatic AdenoCarcinoma • Altitude, humidity
‣ Squamos cell Carcinoma ✓ Chemical Agents
• Smoking
✓ connective tissue origin: • Dietary ingredients
➡Mesodermal • Drugs
✴Use the suffix “SARCOMA ✓ Genetics and Family History
‣ FibroSarcoma • Colon Cancer
‣ Myosarcoma • Premenopausal breast cancer
‣ AngioSarcoma ✓ Dietary Habits
• Low-Fiber
OTHERS (“PASAWAY”) • High-fat
• Processed foods
✓ OMA” but Malignant • alcohol
• HepatOMA ✓ Viruses and Bacteria
• lymphOMA • DNA viruses- Hepa B, Herpes, EBV, CMV, Papilloma Virus
• gliOMA • RNA Viruses- HIV, HTCLV
• melanOMA • Bacterium- H. pylori
✓ THREE germ layers ✓ Hormonal agents
• “TERATOMA” • DES
✓ Non-neoplastic but “OMA” • OCP especially estrogen
• Choristoma ✓ Immune Disease
• Hamartoma • AIDS

TREATMENT:

✓ radiation
✓ meds like chemotherapy
• cancer drugs go after cells that divide frequently like hair
follicles cells

CELL CYCLE

INTERPHASE

• growing, replicating DNA, doing cell functions, cells spend more

time here bc some cells don't divide

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I. G1 - normally, these alterations are reversed by DNA repair
➡the cell grows mechanisms or the changes initiate apoptosis
➡has one checkpoint (If a cell has an error like mutation, it will divide (programmed cellular death) or cell senescence
so there are checkpoints) - cells can escape these protective mechanisms with
- Is the cell growing well enough? permanent cellular mutations occurring, but these
- Is its DNA damaged? mutations usually are not significant to cells until the
- does it have the resources it needs? second step of carcinogenesis
II. S (Synthesis)
➡replicates dna II. PROMOTION
III. G2 ✓ repeated exposure to promoting agents (co-carcinogens)
➡grows some more in prep for mitosis causes proliferation and expansion of initiated cells with
increased expression or manifestations of abnormal genetic
➡Checkpoint:
information, even after long latency periods
• replicated correctly - Promoting agents are not mutagenic and do not need to
• growing well enough interact with the DNA
• does have enough resources to continue - Promotion is reversible if the promoting substance is
• divide more cells removed (a key focus in the prevention of cancer)
- Latency periods for the promotion of cellular mutations vary
with the type of agent, the dosage of the promoter, and the
M-PHASE innate characteristics and genetic stability of the target cell.

I. Mitosis III. PROGRESSION

➡ Checkpoint: ✓ the altered cells exhibit increasingly malignant behavior
• checks in the metaphase (mitosis phases: prophase, ✓ cells acquire the ability to stimulate angiogenesis (growth of
metaphase, anaphase, telephase) to make sure chromosomes new blood vessels that allow cancer cells to grow), to invade
are checked correctly made of of dna are lined up in the middle adjacent tissues, and to metastasize
correctly and attached to the spindle correctly bc if they're not, ✓ Cellular proto-oncogenes, such as those for the epidermal
the chromosomes will not be separated correctly growth factor receptor (EGFR), transcription factors such as
II. Cytokineses c-Myc, or cell signaling proteins such as Kirsten ras (KRAS),
act as “on switches” for cellular growth
Apoptosis - happens if the cell self destructs if it doesn't meet the - amplification of proto-oncogenes or overexpression of
requirement of the checkpoint. Cell may have paused to fix an issue. If growth factors, such as epidermal growth factor (EGF), can
not, the cell undergoes apoptosis. lead to uncontrolled cell proliferation. Mutations that
Proteins increase the activity of oncogenes also deregulate cell
- can be sensitive to cues inside and out the cell proliferation.
- are involved to regulate cell cycle - genetic alterations in the gene for KRAS have been
associated with pancreatic, lung, and colorectal cancers
- positive protein allows moving forward - Just as proto-oncogenes “turn on” cellular growth, cancer
‣ cdk (cyclin dependent kinase) - enzyme protein which have suppressor genes “turn off,” or regulate, unneeded cellular
different protein cyclin bound to it proliferation.
‣ cyclin - different types of cyclin rise and fall throughout the cell - When suppressor genes are mutated, resulting in loss of
cycle and this rising and falling is based of signals to determine function or expression, the cells begin to produce mutant
when the cell should move on to the next cell cycle phase cell populations that are different from their original cellular
✓ each cell cycle phase (g1,s, g2, m phase) will tend to have a ancestors
different cyclin binding with the cdk
- negative proteins makes the cycle stop
‣ p53 - initiates apoptosis
FLUIDS AND ELECTROLYTES
Some cells don't go through the phases bc they're in:
ELECTROLYTES
G0
➡a resting phase where cells are doing cell function but are not • An electrolyte is a substance that ionizes on dissolving in solution;
preparing to divide. Although, some cells also go here temporarily if that is, some of its molecules split or dissociate into electrically
there are not enough resources) charged atoms or ions.
➡In neurons and spinal cord cells may stay permanently in G0 can be
a major injury can have challenges with healing Properties Of Electrolytes And Their Three Components
✓Atom
- The smallest part of an element still has the element's
CARCINOGENESIS properties.
- protons (+), neutron, electrons (-)
• must be balanced to maintain homeostasis
• malignant transformation, or carcinogenesis, is thought to be at
✓Molecule
least a three- step cellular process, involving initiation, promotion, - Two or more atoms combine to form a substance.
and progression
✓Ion
- An atom carries an electrical charge because it has gained
Carcinogens or lost electrons
- agents that initiate or promote malignant transformation - Both positive and negative charged
- a complete carcinogen is an agent that both initiates and promotes - active chemicals:
the development of cancer (e.g., cigarette smoking, asbestos ➡cations
fumes, smoke, tobacco, preservatives, exposure to sun can lead to - an ion that has given away or lost electrons,
melanoma) therefore carries a positive charge
- major cations in body fluid are:
MOLECULAR PROCESS ‣ sodium
‣ potassium
I. INITIATION ‣ calcium
✓ cause mutations in the cellular DNA ‣ magnesium

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 ‣ hydrogen ions • Sodium ions, which are positively charged, far outnumber the other
➡anions cations in the ECF
- an ion that has gained electrons, therefore carries a ➡ Because sodium concentration affects the overall concentration
negative charge of the ECF, sodium is important in regulating the volume of body
- major anions are: fluid.
‣ chloride ➡Water follows movement of sodium in the body fluids.
‣ bicarbonate ➡Retention of sodium is associated with fluid retention
‣ phosphate ➡Excessive loss of sodium is usually associated with decreased
‣ sulfate volume of body fluid
‣ negatively charged protein ions • one of the major electrolytes in the ICF is potassium
• the ECF has a low concentration of potassium, and patients can
Measurement: tolerate only small changes in potassium concentration
‣ the metric system is used to measure volumes of fluids- liters (L) ➡Changes in potassium within the ECF can cause cardiac rhythm
or milliliters (mL) disturbances and hyperkalemia can cause cardiac arrest.
‣ the unit of measure that expresses the combining activity of an Therefore, the release of large stores of intracellular potassium,
electrolyte is the milliequivalent (mEq) typically caused by trauma to the cells and tissues, can be
‣ 1 mEq of anion = 1 mEq of cation extremely dangerous.
• in any given solution, the total positive charges (cations) • The body expends a great deal of energy maintaining the high
must balance the total negative charges (anions) to maintain extracellular concentration of sodium and the high intracellular
electrical neutrality. This balance is crucial for proper concentration of potassium. It does so by means of a cell membrane
physiological function. pump that exchanges sodium and potassium ions, termed the
sodium–potassium pump
➡These active chemicals unite in varying combinations.
Therefore, electrolyte concentration in the body is expressed in
terms of milliequivalents (mEq) per liter, a measure of chemical THIRD SPACING
activity, rather than in terms of milligrams (mg), and a unit of
weight. • due to disease or injury, accumulation of trapped extracellular fluid
• Fluid in each of the body compartments contain electrolytes where in an actual or potential body space (pericardial, peritonial,
abdomen, joints)
• the trapped fluid represents a volume loss and is unavailable for
BODY FLUID COMPARTMENTS normal physiological processes.
• Intake ≠ output means there is a kidney abnormality if not balanced
each compartment has a particular composition of electrolytes • No definite gauge for assessing third space
which differ from that of other compartments.
➡intravascular - fluid within blood vessels
➡intracellular - fluid inside cells , most fluids found EDEMA
➡extracellular - fluid outside cells, found in connective tissue;
lymph; blood; bones; interstitial fluid (fluid b/w • An excess accumulation of fluid in the interstitial space; occurs as a
cells and sometimes called third space fluid result of alterations in oncotic pressure, hydrostatic pressure,
shift if there is disruption/ injury) capillary permeability, and lymphatic obstruction.
• Edema can occur as a result of increased capillary fluid pressure,
decreased capillary oncotic pressure, or increased interstitial oncotic
RULING FOR FLUIDS AND ELECTROLYTES pressure, causing expansion of the interstitial fluid compartment
For every loss, there must be a replacement. Body cells must • Edema can be localized (e.g., in the ankle, as in rheumatoid arthritis
be in the right compartment in the right amount to achieve - causative factors can be injury, surgery or bodily response) or
balance generalized (as in cardiac failure and kidney injury) (Sterns, 2018b).
Severe generalized edema is called anasarca.
• Edema occurs when there is a change in the capillary membrane,
increasing the formation of interstitial fluid or decreasing the removal
of interstitial fluid
• Ascites is a type of edema in which fluid accumulates in the
peritoneal cavity; it results from heart failure, nephrotic syndrome,
cirrhosis, and some malignant tumors.
• Treatments may include diuretic therapy, restriction of fluids and
sodium, elevation of the extremities, application of anti-embolic
stockings, paracentesis (pulling fluid out of the peritoneal cavity
using a needle and syringe), dialysis, and continuous renal
replacement therapy in cases of kidney injury or life- threatening
fluid volume overload

BODY FLUID/ BODY FLUID TRANSPORT

• Body fluids transport nutrients to the cells and carry waste products
from the cells. Total body fluid (intracellular and extracellular)
amounts to:
➡60% of body weight in the adult
➡55% in the older adult
➡80% in the infant
- Infants and older adults need to be monitored closely
for fluid imbalances - Hindi pwede madeplete ang older
• Electrolyte concentrations in the ICF differ from those in the ECF adults, hindi pwede masobrahan ang infants
• Because special techniques are required to measure electrolyte
concentrations in the ICF, it is customary to measure the electrolytes • Constituents of body fluids: Consists of water and dissolved
in the most accessible portion of the ECF—namely, the plasma substances. The largest single fluid constituent of the body is water.

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• Normal movement of fluids through the capillary wall into the tissues
depends on Starling’s Laws of Capillary Forces
• Capillary forces are the two forces at every capillary membrane:
hydrostatic pressure (also called hydraulic pressure) and osmotic
pressure.

Hydrostatic Pressure Osmotic Pressure

pressure exerted by fluid on pressure exerted by the

the walls of the blood vessel solutes within the plasma
pushes fluid out of the pulls fluid into the capillary
capillary toward the ICF from the ICF
force that draws the solvent
from a less concentrated
solute through a selectively Osmosis
permeable membrane into a - force that draws the solvent from a less concentrated solute
more concentrated solute, through a selectively permeable membrane into a more
thus tending to equalize the concentrated solute, thus tending to equalize the concentration of
concentration of the solvent the solvent.
- osmolality and osmolarity are terms that describe the concentration
of solutes or dissolved particles in a solution
‣ These forces oppose each other at every capillary ‣ osmolality
membrane and balance each other out in healthy • the number of milliosmoles of solute (the standard
(homeostatic) conditions. unit of osmotic pressure) per kilogram of solvent; it is
‣ The direction of fluid movement depends on the differences expressed as milliosmoles per kilogram (mOsm/kg)
in the two opposing forces of hydrostatic and osmotic • the term osmolality is used more often than
pressure (Fig. 10-3). osmolarity to evaluate the solutes in the blood or
‣ If hydrostatic pressure is greater than osmotic pressure, urine
then the movement of fluid is from ECF toward the ICF. ‣ osmolarity
• number of milliosmoles (the standard unit of osmotic
LECTURE NOTES ✍
pressure) per liter of solution; it is expressed as
milliosmoles per liter (mOsm/L).
arterial end - hydrostatic pressure is higher than osmotic
pressure, causes solutes to go out of capillary
venous end of capillary - osmotic is higher than hydrostatic Filtration
pressure, enables solutes to go in the capillary - the movement of solutes and solvents by hydrostatic pressure. The
movement is from an area of higher pressure to an area of
lower pressure.
- Hydrostatic pressure in the capillaries tends to filter fluid out of the
intravascular compartment into the interstitial fluid. Movement of
water and solutes occurs from an area of high hydrostatic pressure
to an area of low hydrostatic pressure. The kidneys filter
approximately 180 L of plasma per day. Another example of
filtration is the passage of water and electrolytes from the capillary
bed to the interstitial fluid; in this instance, the hydrostatic pressure
results from the pumping action of the heart (Hall, 2016).

MOVEMENT OF BODY FLUID

• Cell membranes and capillary walls separate body compartments.

Cell membranes are selectively permeable; that is, the cell
membrane and the capillary wall allow water and some solutes free
passage through them.
‣ semipermeable membrane - not all substances can pass
through (prevent movement of solute)
‣ permeable membrane - all substances can pass through
(allows selective passage of solutes through them)
➡water is permeable to all membranes
Diffusion
- The process whereby a solute (a substance that is dissolved) may Tonicity
spread through a solution or solvent (solution in which the solute is - ability of solutes to cause an osmotic driving force that promotes
dissolved). water movement from one compartment to another.
- Diffusion of a solute spreads the molecules from an area of higher - Movement of water is either from ICF to ECF or ECF to ICF.
concentration to an area of lower concentration. - The tonicity of a solution can be used to drive water movement
- the natural tendency of a substance to move from an area of higher between compartments to change the state of cellular hydration
concentration to one of lower concentration (Fig. 10-4). and cell size.
- It occurs through the random movement of ions and molecules. - Tonicity most commonly refers to the NaCl content of the solution.
- Examples of diffusion are the exchange of oxygen (O2) and carbon - The tonicity of a solution is determined by how it compares to
dioxide (CO2) between the pulmonary capillaries and alveoli and physiologic fluid which is 0.9% NaCl (Sterns, 2017b). Fluids can be
the tendency of sodium to move from the ECF compartment, isotonic, hypotonic, or hypertonic compared to physiologic fluid of
where the sodium concentration is high, to the ICF, where its 0.9% NaCl.
concentration is low (Hall, 2016). - Tonicity commonly pertains to intravenous (IV) solutions. IV
solutions of different tonicities can be infused into the bloodstream
to produce movement of water from one compartment to the other.

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 cell. For every 3 Na+ pumped out of the cell, 2 K+ ions
✓ Isotonic solutions are pumped into the cell (Pirahanchi & Aeddula, 2019).
‣ are composed of 0.9% NaCl; the same sodium and chloride ‣ The sodium–potassium pump uses energy to maintain
concentration as the bloodstream and the same water this electrolyte gradient and is powered by the enzyme
concentration as the bloodstream
‣ do not provoke water movement between ICF or ECF termed Na+K+-ATPase.
compartments. ‣ The sodium– potassium pump performs active transport
‣ Isotonic solutions expand the plasma volume of the blood which actively moves sodium from the ICF into the ECF
(Sterns, 2017b). and actively moves potassium from the ECF to the ICF.
‣ When the solutions on both sides of a selectively permeable ‣ Active transport is the use of energy to create movement
membrane have established equilibrium or are equal in against a concentration gradient (Hall, 2016; Norris,
concentrations, they are isotonic. 2019).
‣ Isotonic to human cells; thus very little osmosis occurs.
‣ Isotonic solutions have the same osmolality as body fluids.
‣ must be monitored when used IN IV bc it can put the pt in a BODY FLUID INTAKE AND OUTPUT
hypervolemic state or fluid excess
BODY FLUID INTAKE
✓ Hypotonic solutions • Water enters the body through three sources: ingested liquids,
‣ are composed of less sodium chloride concentration compared water in foods, and water formed by oxidation of foods. About
to the blood; for example, 0.45% NaCl or 0.225% NaCl. 10 mL of water is released by the metabolism of each 100 calories
‣ contain less solute but more water than the bloodstream. of fat, carbohydrates, or proteins.
‣ IV hypotonic solution infusions can be used to move water from • Water (in a measurement cup) , parentheral, medications but not all
the ECF into the ICF. are considered an intake ( tablet no, but water used yes), IV meds,
‣ IV hypotonic solutions can be used to hydrate a patient as they Blood transfusion, IV fluids are measured
contain high water concentration (Sterns, 2017b). • 1kg = 1L of intake
‣ When a solution contains a lower concentration of salt or solute
than another, more concentrated solution, it is considered
hypotonic. BODY FLUID OUTPUT
‣ Has less salt or more water than an isotonic solution; these • The kidneys play a major role in regulating fluid and electrolyte
solutions have lower osmolality than body fluids. balance and excrete the largest quantity of fluid. Normal kidneys
can adjust the amount of water and electrolytes leaving the body.
• Urine(not estimated, must be exact), vomitous, liquid feces,
✓ Hypertonic solutions
drainage, suction liquid
‣ are composed of greater concentration of NaCl compared to
blood (e.g., 3% NaCl).
‣ contain more solute concentration and less water than the
bloodstream.
‣ IV hypertonic solution can be infused into the bloodstream to
pull water from the ICF into the ECF.
‣ The movement of water from ICF to ECF will cause dehydration
of the cells.
‣ This is useful in disorders of severe edema; particularly cerebral
edema, which requires immediate treatment.
‣ Sodium, glucose, and mannitol are examples of solutes capable
of affecting water movement from ICF to ECF. Mannitol, a
nonresorbable sugar alcohol, in water is an IV solution that can
be used to move water from ICF to ECF rapidly. IV mannitol can • Insensible fluid loss: unmeasurable, cannot be seen
induce a condition termed osmotic diuresis; it is most commonly • Sensible fluid loss: measurable, can be seen
used to decrease cerebral edema (Brater & Ellison, 2019). (See
discussion of parenteral therapy later in this chapter.)
‣ solution that has a higher concentration of solutes than another,
less concentrated solution is hypertonic
‣ these solutions have a higher osmolality than body fluids.
‣ Lesser percentage of hypertonic saline (0.20 -0.23 percent)

Active Transport
- If an ion is to move through a membrane from an area of lower
concentration to an area of higher concentration, an active
transport system is necessary. An active transport system moves
molecules or ions against concentration and osmotic pressure.

Sodium-Potassium Pump
‣ sodium concentration is greater in the ECF than in the
ICF; because of this, sodium tends to enter the cell by
diffusion. To maintain cellular function, more potassium
needs to be inside the cell and more sodium needs to be
outside the cell.
‣ The sodium–potassium pump maintains the electrolyte
gradient of high extracellular Na+ compared to low
intracellular Na+, and high intracellular K+ compared to
low extracellular K+. The pump maintains the different
concentrations of cations Na+ and K+ in and out of the

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 17 AUGUST 2024 ANATOMY AND PHYSIOLOGY REVIEW OF THE IMMUNE SYSTEM
I. IMMUNOLOGY AND INFECTIOUS DISEASES (page 2696)
‣ Immunity EPITOPES (antigenic determinants) - participate in specific
‣ Anatomy & Physiology Review of the Immune System
interactions with molecules and cells present on foreign materials,
‣ Unique characteristics of the Immune System
‣ Cells involved in Immune Response initiating a series of actions in a host, including:
‣ Humoral vs. Cell Mediated Immunity - Inflammatory response
- Lysis of microbial agents
- Disposal of foreign toxins
IMMUNOLOGY AND INFECTIOUS DISEASES
MAJOR COMPONENTS OF THE IMMUNE SYSTEM
IMMUNITY ✓central and peripheral organs
✓tissues
• A state of responsiveness to foreign substances such as ✓cells - called immune cells
microorganisms and tumor proteins
• body’s specific protective response to a foreign agent or organism

IMMUNE SYSTEM

• body’s defense mechanism against invasion and allows a rapid

response to foreign substances in a specific manner
• genetic and cellular responses result
• any qualitative or quantitative change in the components of the
immune system can produce profound effects on the integrity of the
human organism
• function is affected by a various factors central nervous system
integrity; general physical and emotional status; medications; dietary
patterns; and the stress of illness, trauma, or surgery.
• dysfunctions can be genetically based while others are acquired

IMMUNE MEMORY - is a property of the immune system that provides

protection against harmful microbial agents despite the timing of re-
exposure to the agent
TOLERANCE - the mechanism by which the immune system is
programmed to eliminate foreign substances such as microbes, toxins,
and cellular mutations but maintains the ability to accept self-antigens
IMMUNOPATHOLOGY - refers to the study of diseases that result
from dysfunctions within the immune system

IMMUNE RESPONSE THREE FUNCTIONS TWO MAIN ORGANS INVOLVED IN THE IMMUNE SYSTEM
DEFENSE - body protects itself against invasions by microorganisms
and prevents the development of infection by attacking foreign I. BARRIERS TO INFECTION
antigens and pathogens. (involves resisting infection)
HOMEOSTASIS - Damaged cellular substances are digested and • activation of the natural immunity response is enhanced by
removed. Through this mechanism, the body’s different cell types processes inherent in physical and chemical barriers
remain uniform and unchanged. (involves removing worn
out “self-components”) PHYSICAL BARRIERS
SURVEILLANCE - the immune system is in a perpetual state of Your skin and mucous membranes are the first line of defense against
vigilance, screening and rejecting any invader that is recognized as germs entering from outside the body.
foreign to the host (deals with the identification and destruction of SKIN
mutant cells) ‣ bars invading microorganisms unless it is physically disrupted
example: arthropod vectors, injury, IV catheters, surgical
incision
Disorders of the immune system may stem from:
MUCOUS MEMBRANES
1. excesses or deficiencies of immunocompetent cells
2. alterations in the function of these cells ‣ many mucous membranes are bathed in secretions that have
antimicrobial properties
3. immunologic attack on self-antigens
example: cervical mucus, prostatic fluid, and tears containing
4. inappropriate or exaggerated responses to specific antigens lysozyme, which splits the muramic acid linkage in bacterial
cell walls, especially in gram-positive organisms

CROSS SECTION OF THE MUCUS MEMBRANE

Below this barrier are many immune cells (lymphocytes, dendritic cells, and macrophages) that attack any pathogens
that get past the mucus.

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BARRIERS IN THE RESPIRATORY SYSTEM
๏ If invading organisms reach the tracheobronchial tree, the
mucociliary epithelium transports them away from the lung.
Coughing also helps remove organisms.
๏ If the organisms reach the alveoli, alveolar macrophages and tissue
histiocytes engulf them.
๏ These defenses can be overcome by large numbers of organisms,
by compromised effectiveness resulting from air pollutants (eg,
cigarette smoke), interference with protective mechanisms (eg,
endotracheal intubation, tracheostomy), or by inborn defects (eg,
cystic fibrosis).
๏ The cilia of the respiratory tract, along with coughing and sneezing
responses, filter and clear pathogens from the upper respiratory
tract before they can invade the body further.

➡Chemical barriers (mucus, acidic gastric secretions, enzymes

in tears and saliva, and substances in sebaceous and sweat
secretions) - act in a nonspecific way to destroy invading bacteria
and fungi
➡Viruses are countered by other means, such as interferon

BARRIERS IN THE DIGESTIVE SYSTEM

๏ barriers include the acid ph of the stomach and the antibacterial ✓ THYMUS
activity of pancreatic enzymes, bile, and intestinal secretions. - located behind the breastbone above the heart. This gland-like
๏ peristalsis and the normal loss of epithelial cells remove organ reaches full maturity only in children, and is then slowly
microorganisms. transformed to fatty tissue
๏ if peristalsis is slowed (eg, because of drugs such as belladonna or - Immature lymphocytes are produced in the marrow from the
opium alkaloids), this removal is delayed and prolongs some lymphoid stem cells. A second major source of production for
infections, eg symptomatic shigellosis. lymphocytes is the thymus.
๏ compromised GI defense mechanisms may predispose patients to - special types of immune system cells called thymus cell
particular infections (eg, achlorhydria predisposes to salmonellosis). lymphocytes (T cells) mature in the thymus
๏ normal bowel flora can inhibit pathogens - alteration of this flora with - cells derived from the thymus are known as T lymphocytes (or T
antibiotics can allow overgrowth of inherently pathogenic cells); those derived from the marrow can also be T cells but are
microorganisms. more commonly B lymphocytes (or B cells)
- Stem cells continuously migrate from the bone marrow to the
thymus gland, where they develop into T cells. Despite the partial
II. LYMPHOID ORGANS
degeneration of the gland at puberty, T cells continue to develop in
the thymus gland.
PRIMARY LYMPHOID ORGANS - create special immune system
cells called lymphocytes. These organs include:

✓ Bone Marrow
✓ Thymus

SECONDARY LYMPHOID ORGANS - It is in these organs where the

cells of the immune system do their actual job of fighting off germs and
foreign substances. These organs include:
✓ Lymph nodes
✓ Spleen
✓ Tonsils
✓ Certain tissue in various mucous membrane layers in the body (for
instance in the bowel)

PRIMARY LYMPHOID ORGANS

✓ BONE MARROW
- a sponge-like tissue found inside the bones.
- It is where most immune system cells are produced and then also
multiply. These cells move to other organs and tissues through the
blood.
- Where white blood cells (WBCs) involved in immunity are produced
- Like other blood cells, lymphocytes are generated from stem cells
(undifferentiated cells). There are two types of lymphocytes—B SECONDARY LYMPHOID ORGANS
cells, also called B lymphocytes, and T cells, also called T
lymphocytes
✓ LYMPH NODES
- small bean-shaped tissues found along the lymphatic vessels.
- act as filters. Various immune system cells trap germs in the lymph
nodes and activate the creation of special antibodies in the blood.
- swollen or painful lymph nodes are a sign that the immune system
is active, for example to fight an infection.
- connected by lymph channels and capillaries, are distributed
throughout the body

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- remove foreign material from the lymph system before it enters the - The tonsils also contain a lot of white blood cells, which are
bloodstream responsible for killing germs.
- also serve as centers for immune cell proliferation

UNIQUE CHARACTERISTICS OF THE IMMUNE SYSTEM

I. SELF OR NON-SELF RECOGNITION

- normally recognizes host cells as non-antigenic and
responds only to foreign and potentially harmful agents, living
or non-living as antigens
✓ SPLEEN
- located in the left upper abdomen, beneath the diaphragm II. ANTIBODY PRODUCTION
- It is responsible for different kinds of jobs: - produces specific antibodies for specific antigens for
‣ It stores various immune system cells. When needed, they destruction
move through the blood to other organs. Scavenger cells III. MEMORY
(phagocytes) in the spleen act as a filter for germs that get - remembers antigens that have invaded the body in the past,
into the bloodstream. allowing a quicker response
‣ It breaks down red blood cells (erythrocytes).
IV. SELF-REGULATION
‣ It stores and breaks down platelets (thrombocytes), which - monitors its own performance, turning itself on when
are responsible for the clotting of blood, among other
antigens invade and turning itself off when infection is
things.
eradicated
- The spleen is the site of activity for most macrophages.
- Most of the spleen (75%) is made of red pulp; here, the blood
enters the venous sinuses through capillaries that are surrounded CELLS INVOLVED IN IMMUNE RESPONSE
by macrophages. Within the red pulp are tiny aggregates of white
pulp, consisting of B and T lymphocytes.
- The spleen sequesters newly released reticulocytes from the ✓ MONONUCLEAR PHAGOCYTES
marrow, removing nuclear fragments and other materials (e.g., • The mononuclear phagocyte system includes monocytes in the
denatured hemoglobin, iron) before the now fully mature blood and macrophages found throughout the body.
erythrocyte returns to the circulation. Although a minority of • Responsible for capturing, processing, and presenting the antigen to
erythrocytes (less than 5%) pool in the spleen, a significant the lymphocytes.
proportion of platelets (20% to 40%) pool here (Doherty, 2015). ➡This stimulates a humoral or cell-mediated immune
- If the spleen is enlarged, a greater proportion of red cells and response. Capturing is accomplished through phagocytosis.
platelets can be sequestered.
- The spleen is a major source of hematopoiesis in fetal life. It can
resume hematopoiesis later in adulthood if necessary, particularly
when marrow function is compromised (e.g., in bone marrow
fibrosis).
- It forms substances called opsonins that promote the phagocytosis
of neutrophils; it also forms the antibody immunoglobulin M (IgM)
after exposure to an antigen.

✓ LYMPHOCYTES
• mature, infection-fighting cells that develop from lymphoblasts, a
type of blood stem cell in the bone marrow.
• main cells that make up lymphoid tissue, a major part of the immune
system.

✓ TONSILS
- Because of their location at the throat and palate, they can stop
germs entering the body through the mouth or the nose.

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• Mature lymphocytes are small cells with scanty cytoplasm ➡ T – Helper Cells
• Immature lymphocytes are produced in the marrow from the ‣ (CD4)Involved in the regulation of cell-mediated immunity and
lymphoid stem cells. the humoral antibody response.
• Lymphocytes complete their differentiation and maturation primarily ‣ They are effective against parasites and are also involved in
in the lymph nodes and in the lymphoid tissue of the intestine and allergic responses.
spleen after exposure to a specific antigen. ‣ activated on recognition of antigens and stimulate the rest of the
• Mature lymphocytes are the principal cells of the immune system, immune system. When activated, helper T cells secrete
producing antibodies and identifying other cells and organisms as cytokines, which attract and activate B cells, cytotoxic T cells,
“foreign.” NK cells, macrophages
TYPES OF LYMPHOCYTES

➡ B- Lymphocytes
‣ Differentiate into plasma cells when activated. Plasma cells
produce antibodies (immunoglobulins)
‣ They are capable of differentiating into plasma cells. Plasma
cells, in turn, produce antibodies called immunoglobulins (Igs),
which are protein molecules that destroy foreign material by
several mechanisms. This process is known as humoral
immunity

➡ Natural Killer Cells (Nk)

‣ Involved in cell-mediated immunity
‣ They are large lymphocytes with numerous granules in the
cytoplasm
‣ Involved in recognition and killing of virus-infected cells, tumor
cells, and transplanted grafts
‣ NK cells have a significant role in immune surveillance for
malignant cell changes
‣ Like other lymphocytes, NK cells accumulate in the lymphoid
➡ T- Lymphocytes tissues (especially spleen, lymph nodes, and tonsils), where
they mature.
‣ Primarily responsible for immunity to intracellular viruses, tumor ‣ When activated, they serve as potent killers of virus-infected
cells, and fungi. T-cells account for long-term immunity. and cancer cells.
‣ Kills foreign cells directly or releases lymphokines, substances ‣ They also secrete cytokines to mobilize the T and B cells into
that enhance the activity of phagocytic cells. T lymphocytes are action.
responsible for delayed allergic reactions, rejection of foreign
tissue (e.g., transplanted organs), and destruction of tumor cells.
This process is known as cellular immunity.

➡ Dendritic Cells
‣ These primarily function to capture antigens at sites of contact
➡ T- Cytotoxic Cells
with the external environment (e.g., skin, mucous membranes)
‣ capable of direct destruction of cancer cells and then transport an antigen until it encounters T-cell with
‣ Involved in attacking antigens on the cell membrane of foreign specificity for the antigen.
pathogens and releasing cytolytic substances that destroy the ‣ cells that present antigens to the immune system
pathogen.
‣ These cells have antigen specificity and are sensitized by
exposure to the antigen.
‣ killer T cells) attack the antigen directly by altering the cell
membrane, causing cell lysis (disintegration), and releasing
cytolytic enzymes and cytokines.

➡ Cytokines
‣ proteins produced by leukocytes that are vital to regulation of
hematopoiesis, apoptosis, and immune responses
‣ cytokines are soluble factors secreted by WBCs and a variety of
other cells in the body.

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 ‣ cytokines instruct cells to alter their proliferation, differentiation,
secretion or activity.

Different Types of Cytokines

• Interleukines
‣ have immunomodulatory effects on other components of the
immune response
• Colony Stimulating Factor
‣ act as growth regulating factors for hematopoietic cells
‣ group of naturally occurring glycoprotein cytokines that
regulate production, differentiation, survival, and activation
of hematopoietic cells.
• Interferons
‣ are antiviral and immunomodulatory
‣ cytokines with antiviral, antitumor, and immunomodulatory
(inhibition or stimulation of the immune system) properties
‣ proteins formed when cells are exposed to viral or foreign
agents; capable of activating other components of the
immune system
‣ one type of biologic response modifier, is a nonspecific
viricidal protein that is naturally produced by the body and
capable of activating other components of the immune
system. Interferons
‣ These substances have antiviral and antitumor properties.
‣ produced by T-lymphocytes, B-lymphocytes, and
macrophages in response to antigens.
‣ They are thought to modify the immune response by
suppressing antibody production and cellular immunity.
‣ They also facilitate the cytolytic role of macrophages and NK
cells. Interferons are used to treat immune-related disorders
(e.g., multiple sclerosis) and chronic inflammatory conditions HUMORAL IMMUNITY VS CELL- MEDIATED IMMUNITY
(e.g., chronic hepatitis).

(Page 2706)

HUMORAL IMMUNITY

• B-lymphocytes differentiate into plasma cells. Plasma cells, in turn,

produce antibodies called immunoglobulins (Igs), which are protein
molecules that destroy foreign material by several mechanisms.
• synonym: antibody response
• Begins with the B lymphocytes, which can transform themselves
into plasma cells that manufacture antibodies. An antibody is a
protein substance developed by the body, transported in the
bloodstream, and attempts to disable invaders.

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 CELLULAR MEDIATED IMMUNITY 17 AUGUST 2024
I. IMMUNOLOGY AND INFECTIOUS DISEASES
• involves the T lymphocytes, which can turn into special cytotoxic (or ‣ Types of Immunity
‣ 5 classes of Antibodies
killer) T cells that can attack the pathogens ‣ Types of Antigen - Antibody Reactions
• The T lymphocytes are primarily responsible for cellular immunity. ‣ Immunization
• Stem cells continuously migrate from the bone marrow to the ‣ Diagnostic Tests
thymus gland, where they develop into T cells. Despite the partial
degeneration of the gland at puberty, T cells continue to develop in
the thymus gland. Several types of T cells exist, each with
TYPES OF IMMUNITY
designated roles in the defense against bacteria, viruses, fungi,
parasites, and malignant cells. T cells attack foreign invaders
directly rather than by producing antibodies. Classified as INNATE (Natural) or ACQUIRED (Adaptive)
• Cellular reactions are initiated, with or without the assistance of
macrophages, by the binding of an antigen to an antigen receptor
located on the surface of a T cell. The T cells then carry the
antigenic message, or blueprint, to the lymph nodes, where the
production of other T cells is stimulated. Some T cells remain in the
lymph nodes and retain a memory for the antigen. Other T cells
migrate from the lymph nodes into the general circulatory system
and ultimately to the tissues, where they remain until they bind with
their respective antigens or die

ANTIGEN

• the structural part of the invading or attacking organism that is

responsible for stimulating antibody production INNATE IMMUNITY
• Also called immunogen
• an antigen can be a small patch of proteins on the outer surface of a • Exists in a person without prior contact with an antigen
microorganism • This type of immunity involves a nonspecific response, and
• Not all antigens are naturally immunogenic; some must be coupled neutrophils and monocytes are the primary WBCs involved
to other molecules to stimulate the immune response • It is considered the first line of host defense following antigen
• A single bacterium or large molecule, such as a diphtheria or exposure, because it protects the host without remembering prior
tetanus toxin, may have several antigens, or markers, on its surface, contact with an infectious agent
thus inducing the body to produce many different antibodies • coordinates the initial response to pathogens through the production
• Once produced, an antibody is released into the bloodstream and of cytokines and other effector molecules, which either activate cells
carried to the attacking organism. There, it combines with the for control of the pathogen (by elimination) or promote the
antigen, binding with it like an interlocking piece of a jigsaw puzzle development of the acquired immune response
• Cells involved in this response:
➡ monocytes
ANTIBODIES
➡ macrophages
➡ dendritic cells
• Antibodies are large proteins, called immunoglobulins, that consist ➡ natural killer (NK) cells
of two subunits, each containing a light and a heavy peptide chain ➡ basophils
held together by a chemical link composed of disulfide bonds.
➡ eosinophils
• Each subunit has one portion that serves as a binding site for a
➡ granulocytes.
specific antigen and another portion that allows the antibody
molecule to take part in the complement system.
• defend against foreign invaders in several ways, and the type of
defense used depends on the structure and composition of both the
antigen and the immunoglobulin.
• The antibody molecule has at least two combining sites, or Fab
fragments (Fig. 31-6). One antibody can act as a cross-link between
two antigens, causing them to bind or clump together.
• This clumping effect, referred to as agglutination, helps clear the
body of the invading organism by facilitating phagocytosis.
• Some antibodies assist in the removal of offending organisms
through opsonization. In this process, the antigen–antibody
molecule is coated with a sticky substance that also facilitates
phagocytosis.

• Natural immune mechanisms can be divided into two stages:

immediate (generally occurring within minutes) and delayed
(occurring within several days after exposure)

ACQUIRED IMMUNITY

• The development of immunity, either actively or passively

• usually develops due to prior exposure to an antigen through
immunization (vaccination) or by contracting a disease, both of
which generate a protective immune response

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• Weeks or months after exposure to a disease or vaccine, the body IgA (IMMUNOGLOBULIN A)
produces an immune response that is sufficient to defend against
the disease on re-exposure
• Located in the saliva, tears, colostrum, and mucus of the respiratory,
• In contrast to the rapid but nonspecific natural immune response,
digestive, and urinary tracts
this form of immunity relies on the recognition of specific foreign
antigens • Adds protection against enteric viruses in the breastfed infant
• broadly divided into two mechanisms:
(1) the cell-mediated response, involving T-cell activation
(2) effector mechanisms, involving B-cell maturation and
production of antibodies

TWO TYPES OF ACQUIRED IMMUNITY IgM (IMMUNOGLOBULIN M)

I. Active Acquired Immunity - refers to immunologic defenses • The largest of the immunoglobulins in molecular size
developed by the person’s own body. This immunity typically lasts • Second most abundant antibodies
many years or even a lifetime. Two types: • First to appear in fetal life
• First to form during viral or bacterial infection
Active Natural Immunity: Natural contact with antigen
through clinical infection.
➡Recovery from chicken pox, measles, mumps
Active Artificial Immunity: Immunization with antigens
➡Immunization with live and killed vaccines

II. Passive Acquired Immunity - is temporary immunity transmitted

from a source outside the body that has developed immunity
through previous disease or immunization.
examples: IgE (IMMUNOGLOBULIN E)
‣ immunity resulting from the transfer of antibodies from
the mother to an infant in utero • Responsible for some allergic responses, triggers release of
‣ through breast-feeding or receiving injections of immune histamine
globulin.
Two Types:

Passive Natural Immunity: Transplacental and colostrum

transfer from mother to child
➡Maternal immunoglobulins in neonates
Passive Acquired Immunity:
➡Injection of human gamma globulin
IgD (IMMUNOGLOBULIN D)

• Minute amounts
• Possibly a regulatory antibody, acts as an antigen receptor of B cells

TYPES OF ANTIGEN - ANTIBODY REACTIONS

5 CLASSES OF ANTIBODIES
AGGLUTINATION
• The body can produce five different types of immunoglobulin (Ig). • Clumping together
Each of the five types, or classes, is identified by a specific letter of • clumping effect occurring when an antibody acts as a cross-link
the alphabet, IgA, IgD, IgE, IgG, and IgM. Classification is based on between two antigens
the chemical structure and biologic role of the individual PRECIPITATION
immunoglobulin. • Antibodies react with soluble antigens resulting in an insoluble
complex which then precipitates
NEUTRALIZATION
IgG (IMMUNOGLOBULIN G) • Antibodies combine with all the toxin
LYSIS
• most abundant antibodies • Antibodies attack all membrane and cause cell rupture
• can cross the placenta, responsible for immunity in the newborn OPSONIZATION
• Neutralizes toxins and viruses • Antibodies coat bacteria and increase their susceptibility to
phagocytosis

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 IMMUNIZATION • Patient preparation includes a careful explanation of the procedure,
which may be done at the patient’s bedside (for a hospitalized
patient) or in the outpatient setting.
IMMUNIZATION • Some patients may be anxious, thus an antianxiety agent may be
- Process of rendering an organism immune to the effects of specific prescribed.
harmful substances. • It is always important for the physician or nurse to describe and
explain to the patient the procedure and the sensations that will be
VACCINE experienced.
- A biologically derived substance designed to produce a protective • The risks, benefits, and alternatives are also discussed. A signed
immune response when administered to humans. informed consent is needed before the procedure is performed.
• Before aspiration, the skin is cleansed using aseptic technique.
VACCINATION • Then, a small area is anesthetized with a local anesthetic agent
- the act of introducing a vaccine into the body. The desired outcome through the skin and subcutaneous tissue to the periosteum of the
is to produce immunity against a specific infection or disease bone. It is not possible to anesthetize the bone itself. The bone
marrow needle is introduced with a stylet in place.
• When the needle is felt to go through the outer cortex of bone and
enter the marrow cavity, the stylet is removed, a syringe is attached,
and a small volume (5 mL) of blood and marrow is aspirated.
• Patients typically feel a pressure sensation as the needle is
advanced into position.
• The actual aspiration always causes sharp but brief pain, resulting
from the suction exerted as the marrow is aspirated into the syringe;
the patient should be warned about this. Taking deep breaths or
using relaxation techniques often helps ease the discomfort
• If a bone marrow biopsy is necessary, it is best performed after the
aspiration and in a slightly different location, because the marrow
structure may be altered after aspiration (Ryan, 2015).
• A special biopsy needle is used. Because these needles are large,
the skin may be punctured first with a surgical blade to make a 3- to
4-mm incision. The biopsy needle is advanced well into the marrow
cavity. When the needle is properly positioned, a portion of marrow
DIAGNOSTIC TESTS is cored out. The patient feels a pressure sensation but should not
feel actual pain. The nurse should assist the patient in maintaining a
BONE MARROW ASPIRATION comfortable position and encourage relaxation and deep breathing
throughout the procedure. The patient should be instructed to inform
the physician if pain occurs so that an additional anesthetic agent
• Low WBC indicates bone marrow depression can be given.
• Low lymphocytes (1500-3000/cu mm) indicates defective cellular
immunity

• are crucial when additional information is needed to assess how a

patient’s blood cells are being formed and to assess the quantity
and quality of each type of cell produced within the marrow
• also used to document infection or tumor within the marrow.
• Other specialized tests can be performed on the marrow aspirate,
such as cytogenetic analysis or immunophenotyping (i.e., identifying
specific proteins expressed by cells), which are useful in further
identifying certain malignant conditions and, in some instances,
establishing a prognosis
• Normal bone marrow is in a semifluid state and can be aspirated T CELL (CELLULAR DEFICIENCY)
through a special large needle.
• In adults, bone marrow is usually aspirated from the iliac crest and • Cell function can be screened by delayed hypersensitivity
occasionally from the sternum. The aspirate provides only a sample • Skin testing to common antigen
of cells.
a. PPD – Purified Protein Derivative
• Aspirate alone may be adequate for evaluating certain conditions,
b. DNCB – Dinitrochlorobenzene
such as anemia. However, when more information is required, a
biopsy is also performed. Biopsy samples are taken from the
posterior iliac crest; occasionally, an anterior approach is required. A B CELL (HUMORAL DEFICIENCY) THE IMMUNE
marrow biopsy shows the architecture of the bone marrow as well
as its degree of cellularity.

Page 15
• Electrophoresis – the movement of colloid (protein) particles in an ALLERGY TEST
electrical field
• Identifies immune-globulins IgG, IgA, IgM in a serum
I. INTRADERMAL SKIN TEST
• It assesses the effectiveness of chemotherapy or radiation therapy,
detects hypogammaglobulinemias and hypergammaglobulinemias
and diagnose paraproteinemias A. TINE TEST

QUANTITATIVE IMMUNOGLOBULIN TEST

IgG → 600 – 1600 mg/100 mL

IgA → 20 – 500 mg/100mL
IgM → 60 – 200 mg/100mL
IgE → present in amounts too small to measure
IgD → present in amount too small to measure

SPECIFIC ANTIGEN – ANTIBODY TEST SYSTEM B. MANTOUX TEST

RADIOIMMUNOASSAY TEST (RIA) – consists of the unknown

antigen to the antibody followed by incubation

IMMUNO-FLOURESCENCE TEST – consists of attaching fluorescein

dye to antibodies and then mixing with the antigen to be tested

AGGLUTINATION TEST – determines the presence of antigens

located in the surfaces of RBC’s or on microorganisms, the antigen
and antibody react by clumping of cells

COMPLEMENT FIXATION TEST – a standard amount of complement

is added to a mixture of an antigen and its corresponding antibody
II. PATCH AND ALLERGY TEST

A. PATCH TEST
ELISA (ENZYME-LINKED IMMUNOSORBENT ASSAY)
• The test is read 20 – 30 minutes after the patch is removed.

• Designed to screen blood or plasma for the presence of antibodies

of HTLV-3 (human -T lymphocytes virus 3) + = erythema only; doubtful reaction; negative or anergic
++ = erythema and papules; weak (nonvesicular) reaction
+++ = erythema, papules and small vesicles; strong
(edematous or vesicular) reaction
++++ = all of the above plus bullae or ulceration; extreme
reaction

B. SCRATCH TEST
• Involves scratching the patient’s skin with a special tool or
needle and introducing the allergens into the scratched area
• Test sites are examined 30 – 40 minutes later and compared
with the control site
• Erythema or edema indicates a positive reaction

Page 16
 CONJUCTIVAL TEST

1 drop of test extract is instilled in the eye → redness and tearing will
appear within 5-15 minutes.

USE TEST

• Substances such as foods, cosmetic or fabrics to which a person is

suspected of being allergic are eliminated from use and then added
individually according to set schedule.

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