Medical-Surgical Nursing | NCM 0112
MODULE 2 FUNCTION OF IMMUNE SYSTEM
§ To remove foreign antigens such as viruses and bacteria to
Concepts in Immunologic Function maintain homeostasis
§ Phagocytosis: monocytes responsible for engulfing and
CHAPTER 35: ASSESSMENT OF IMMUNE FUNCTION
destroying foreign bodies and toxins
§ Inflammatory response:
The Immune System
o Response to injury or invading organisms
• Immunity: the body’s specific protective response to invading
o Chemical mediators minimize blood loss, wall off
foreign agent or organism
invading organisms, activate phagocytes, promote
• Immunopathology: the study of diseases that results from
formation of scar tissue and regeneration of injured tissue
dysfunction of the immune system
• Components of immune system:
Immunity
o Bone marrow: T cells and B cells
1. Natural immunity: nonspecific response to any foreign invader
o Lymphoid tissue: spleen and lymph nodes
- White blood cell action: release cell mediators such as
Question #1: Is the following statement true or false? histamine, bradykinin, and prostaglandins and engulf
Immunity refers to the body’s nonspecific protective response to an (phagocytize) foreign substances
invading foreign agent or organism. - Inflammatory response
False. - Physical barriers, such as intact skin, chemical barriers, and
Rationale: Immunity refers to the body’s specific, not nonspecific, acidic gastric secretions or enzymes in tars and saliva
protective response to an invading foreign agent or organism. 2. Acquired immunity: specific against a foreign antigen
- Result of prior exposure to an antigen
DEVELOPMENT OF CELLS OF THE IMMUNE SYSTEM 1. Active
o Immunologic defenses developed by person’s own body
o Lasts many years; may last a lifetime
2. Passive
o Temporary
o Results from transfer of a source outside of the body that
has developed immunity through previous disease or
immunization
o For example, transfer of antibodies from mother to infant
through breast feeding; receiving immune globulin
through injections
Question #2: Which leukocytes arrive at the inflammation site?
A. Basophils
B. Eosinophils
C. Monocytes
D. Neutrophils
Maturity of Lymphocytes
Rationale: Neutrophils arrive first at a site where inflammation occurs
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§ B lymphocytes mature in the bone marrow
§ T lymphocytes mature in the thymus, where they also differentiate
into cells with various functions
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STAGES OF IMMUNE RESPONSE RESPONSE TO INVASION
§ Phagocytic immune response
- WBCs ingest foreign particles and destroy invading
agents
- Apoptosis; programmed cell death
§ Humoral or antibody response
- Antibody response; B lymphocytes
§ Cellular immune response
- T lymphocytes; cytotoxic killer cells
Humoral Immune Response
• Antigen Recognition
o B lymphocytes respond to antigens by triggering antibody
formation
• Antibodies
o Immunoglobulins: IgA, IgD, IgE, IgG, IgM
o Defend against foreign invaders
o Agglutination, opsonization
1. Recognition Stage
• Antigen–antibody binding
• Recognition of antigens as foreign
o Antigenic determinant
• Use of lymph nodes and lymphocytes for surveillance
• Lymphocytes recirculate from the blood to lymph nodes and from
the lymph nodes back into the bloodstream in a continuous circuit
• Macrophages play an important role in helping the circulating
lymphocytes process antigens
• Both macrophages and neutrophils have receptors for
antibodies and complement; as a result, they coat
microorganisms with antibodies, complement, or both, thereby
enhancing phagocytosis
2. Proliferation Stage
• Circulating lymphocytes containing the antigenic message return to
the nearest lymph node
Cellular Immune Response
• Stimulate some of the resident T and B lymphocytes to enlarge,
• T lymphocytes: cellular immunity
divide, and proliferate
o Attack invaders directly, secrete cytokines, and stimulate
• T lymphocytes differentiate into cytotoxic (or killer) T cells
immune system responses
• B lymphocytes produce and release antibodies
o Helper T cells
o Cytotoxic T cells
3. Response Stage
o Memory cells
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• Begins with the production of antibodies by the B lymphocytes in
o Suppressor T cells (suppress immune response)
response to a specific antigen
• Cellular response stimulates the resident lymphocytes to become
Non-T and Non-B Lymphocytes Involved in Immune Response
cells that attack microbes; (killer) T cells
§ Null cells
• Viral rather than bacterial antigens induce a cellular response
- Destroy antigen coated with antibody
• Most immune responses to antigens involve both humoral and
§ Natural killer cells
cellular responses, although one usually predominates
- Defend against microorganisms and some malignant
cells
4. Effector Stage
• Humoral Immunity: Interplay of antibodies
• Cellular Immunity: Action by cytotoxic T cells
Medical-Surgical Nursing | NCM 0112
COMPLEMENT SYSTEM Question #3: Is the following statement true or false?
• Circulating plasma proteins made in the liver and activated when Autoimmune disorders are more common in women than men.
antibody connects to antigen playing an important defense against True.
microbes Rationale: Autoimmune disorders are more common in women than
• Activated by three pathways: classic, lectin, and alternative men.
VARIABLES THAT AFFECT IN IMMUNE SYSTEM FUNCTION
§ Age and gender
§ Nutrition
§ History of infection or immunization
§ Allergies
§ Presence of conditions or disorders: autoimmune disorders,
cancer or neoplasm, chronic illness, surgery or trauma
§ Medications and transfusions
§ Lifestyle
§ Psychoneuroimmunologic factors
ADVANCES IN IMMUNOLOGY
• Genetic engineering: DNA technology
• Stem cells:
o Research shows that stem cells can restore an immune system
that has been destroyed
o Clinical trials using stem cells are under way in patients with a
variety of disorders having an autoimmune component,
including systemic lupus erythematosus, rheumatoid arthritis,
scleroderma, and multiple sclerosis
o Along with these remarkable opportunities, many ethical
challenges arise
ASSESSMENT OF IMMUNE SYSTEM
§ Health history, including nutrition, infections, immunizations,
allergies, autoimmune disorders, cancer, and chronic illness
§ Physical exam, including lymph node assessment in addition
to other body systems
TESTS TO EVALUATE IMMUNE FUNCTION
§ WBC count and differential
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§ Bone marrow biopsy
§ Humoral and cellular immunity tests
§ Phagocytic cell function test
§ Complement component tests
§ Hypersensitivity tests
§ Specific antigen–antibody tests
§ HIV infection tests
NURSE’S ROLE IN EVALUATION OF IMMUNE SYSTEM
§ Offer support
§ Reduce anxiety
§ Provide patient education and counseling
Medical-Surgical Nursing | NCM 0112
MODULE 2 MODES OF TRANSMISSION
- HIV-1 transmitted in body fluids that contain infected cells:
NCM of Adult Patients with § Blood and blood products
Immune Deficiency Disorders § Seminal fluid
§ Vaginal secretions
CHAPTER 36: MANAGEMENT OF PATIENTS WITH § Mother-to-child: Amniotic fluid, breast milk
IMMUNE DEFICIENCY DISORDERS § Not through casual contact
Primary Immune Deficiency Disorders (PIDD) PREVENTION
§ Education on how to eliminate or reduce risks associated with
PATHOPHYSIOLOGY
HIV infections and AIDS
• Genetic
§ Prevention education:
• Majority diagnosed in infancy; some may be diagnosed during
o Behavioral interventions
adolescence
o HIV testing
• Male-to-Female ratio of 5 to 1
o Linkage to treatment and care
• Occasionally, adults may present with persistent, recurrent, or
Strategies to Protect Against HIV Infection
resistant infections
ü Refer to Chart 36-3
o Prevent body from developing normal immune responses
ü Consistent and correct use of condoms: Refer to Chart 36-4
o May affect phagocytic function, B cells or T cells, or the
ü Medical male circumcision
complement system
ü Female condom
ü Harm reduction framework for people who inject drugs
CLINICAL MANIFESTATIONS
• Needle exchange
§ Multiple infection despite treatment • May use bleach to clean used needles and syringes
§ Infection with unusual/opportunistic organisms • Avoid sharing needles and syringes
§ Failure to thrive, poor growth ü Reproduction education
§ Positive family history o Artificial insemination in some cases
o Benefits of ART
Question #1: True or False? o Refrain from breastfeeding
Primary immune deficiency disorders result from external factors such as ü LGTB
infection. o LGTB youth at high risk for HIV infection
False. o Remain nonjudgmental in educating about prevention
Rationale: Primary immune deficiency disorders are genetic.
REDUCING THE RISK OF TRANSMISSION
NURSING MANAGEMENT TO HEALTH CARE PROVIDERS
§ Nursing care is meticulous ü Standard precautions
§ Strategies to reduce risk of infection ü Hand hygiene
ü Appropriate hand hygiene ü Post exposure prophylaxis
ü Infection prevention precautions per institution policy § Antiretroviral medications within 72 hours of exposure
ü Continual monitoring for early signs of infection
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§ 2 to 3 drugs prescribed for 28 days
ü Teach patients and caregivers to administer medications
and therapy at home Question #2: Antiretroviral medications as post exposure prophylaxis
ü Provide ongoing education and support for health care workers are started within ____ hours of exposure:
A. 24 hours
Human Immunodeficiency Virus (HIV) B. 72 hours
• Immune deficiency is acquired: C. 36 hours
o Due to medical treatment such as chemotherapy D. 12 hours
o Infection from agents such as HIV
• Despite advances in treating HIV, acquired immune deficiency PATHOPHYSIOLOGY OF HIV
syndrome (AIDS) remains a public health issue • HIV is in the subfamily of lentiviruses and is a retrovirus because it
• Prevention, early detection, and ongoing treatment are important carries its genetic material in the form of ribonucleic acid (RNA)
aspects for care; PLWHA rather than deoxyribonucleic acid (DNA)
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• HIV targets cells with CD4+receptors, which are expressed on the § Neurologic manifestations
surface of T lymphocytes, monocytes, dendritic cells, and brain o Effects on cognition, motor function attention, visual
microglia memory, visuospatial function
o Peripheral neuropathy
STEPS IN THE LIFE CYCLE OF HIV o HIV encephalopathy
1. Attachment/Binding o Fungal infection, Cryptococcus neoformans
2. Uncoating/Fusion o Progressive multifocal leukoencephalopathy
3. DNA synthesis o Depression and apathy
4. Integration § Integumentary manifestations
5. Transcription o Herpes zoster
6. Translation o Seborrheic dermatitis
7. Cleavage § Gynecologic manifestations
8. Budding o Genital ulcers
o Persistent, recurrent vaginal candidiasis
STAGES OF HIV INFECTION o Pelvic inflammatory disease
§ Classified in five stages: 0, 1, 2, 3, unknown o Menstrual abnormalities
§ Stages 1, 2, 3 based on CD4+ T-lymphocyte count
1. Stage O TREATMENT OF HIV AND AIDS
- Early HIV infection; inferred from laboratory testing ü Antiretroviral therapy: ART
2. Stage 1: Primary/acute • Overarching goal to suppress HIV replication
- Period from infection with HIV to the development • Reduce HIV-associated morbidity and prolong duration
of HIV-specific antibodies and quality of life
- Dramatic drops in CD4+T-cell counts normally 500 • Restore and preserve immunologic function
to 1500 cells/mm3 of blood • Maximally and durably suppress plasma HIV viral load
3. Stage 2 • Prevent HIV transmission
- Occurs when T-lymphocyte cells are between 200
and 499 ASSESSMENT OF HIV AND AIDS
4. Stage 3 § Identification of potential risk factors
- CD4+count drops below 200 cells/mm3 of blood § Physical status
- Considered to have AIDS for surveillance purposes § Psychological status
5. Unknown § Immune system functioning
- No information on CD4+ T-lymphocyte count or § Nutritional status
percentage § Respiratory status
§ Neurologic status
CLINICAL MANIFESTATIONS § Fluid and electrolyte balance
§ Refer to Table 36-2 § Knowledge level
§ Asymptomatic during first stage or may exhibit fatigue or
skin rash NURSING DIAGNOSIS IN HIV AND AIDS
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§ Later stages have variety of symptoms related to § Diarrhea related to enteric pathogens
immunosuppressed state § Risk for infection related to immune deficiency
§ Respiratory manifestations § Ineffective airway clearance related to Pneumocystis
o Shortness of breath, dyspnea, cough, chest pain pneumonia, increased bronchial secretions
o Pneumocystis pneumonia, Mycobacterium avium § Imbalanced nutrition: less than body requirements
complex, TB § Deficient knowledge related to means of preventing HIV
§ Gastrointestinal manifestations transmission
o Loss of appetite, N and V, oral candidiasis, diarrhea § Social isolation related to stigma of the disease, withdrawal of
o Wasting syndrome support systems, isolation procedures, fear of infecting others
§ Oncologic manifestations
o Kaposi sarcoma
o AIDS-related lymphomas
Medical-Surgical Nursing | NCM 0112
COLLABORATIVE PROBLEMS / POTENTIAL COMPLICATIONS § Hospice nursing during terminal stages
§ Opportunistic infections ü Provides physical and emotional support
§ Impaired breathing or respiratory failure
§ Wasting syndrome and fluid and electrolyte imbalance Question #3: _______ is a clinical syndrome that is characterized by a
§ Adverse effects of medications progressive decline in cognitive, behavioral, and motor functions as a
direct result of HIV infection:
PLANNING AND GOALS IN HIV AND AIDS A. Cryptococcalmeningitis
§ Resumption of usual bowel patterns B. Neuropathy
§ Absence of infection oImproved airway clearance C. Progressive multifocal leukoencephalopathy
§ Improved nutritional status D. HIV encephalopathy
§ Increased socialization and expression of grief
§ Increased knowledge regarding disease prevention and self-
care
§ Absence of complications
NURSING INTERVENTIONS FOR HIV AND AIDS
§ Promoting usual bowel patterns
ü Assess for diarrhea
ü Avoid foods that are irritating to bowel
ü Administer medications
§ Preventing infection
ü Monitor for signs and symptoms of infection
ü Monitor lab test results for changes
ü Culture wound drainage, urine, stool , sputum, etc.
ü Educate patient and family in prevention of infection
§ Improving airway clearance
ü Respiratory assessment
ü Pulmonary therapy every 2 hours
ü Semi-or high Fowler
ü Oxygen as needed
§ Improving nutritional status
ü Monitor weight, dietary intake, serum albumin
ü Dietary consult as needed
ü Instruct ways to supplement nutrition
§ Improving knowledge of HIV
ü Instruct patient and family about routes of transmission
and prevention
ü Avoid sexual contact with multiple partners
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
ü Use condoms
ü Do not use IV/injection drugs
§ Decreased sense of social isolation
ü Assess pattern of social interaction
ü Observe for behaviors indicative of social isolation
ü Assist with identifying resources
RESOURCES IN THE COMMUNITY
§ Home healthcare nursing
ü Monitor adherence to therapeutic regimen
ü Complex wound care
ü Respiratory care
§ Community programs that help with transportation, shopping,
legal and financial assistance
Medical-Surgical Nursing | NCM 0112
MODULE 2
CHEMICAL MEDIATORS
NCM of Adult Patients with 1. Primary (preformed found in mast cells or basophils)
Allergic Disorders o Histamine -*1stchem mediator to be released in immune and
inflammatory response; peaks at 5-10min after contact with
CHAPTER 36: ASSESSMENT AND MANAGEMENT OF PATIENTS antigen (H1 in bronchiolar and vascular smooth muscles & H2
WITH ALLERGIC DISORDERS in gastric parietal cells)
§ H1 receptors – bronchoconstriction, vasodilation
Allergy § H2 receptors – acidity, diarrhea
• An inappropriate, often harmful response of the immune system to o Eosinophil chemotactic factor of anaphylaxis –mov’tor
normally harmless substances eosinophils to site of allergens
• Hypersensitive reaction to an allergen initiated by immunologic o Platelet-activating factor –initiate platelet aggregation &
mechanisms that is usually mediated by IgE antibodies leukocyte infiltration
• Allergen: the substance that causes the allergic response o Prostaglandins –smooth muscle contrxn, vasodilation,
• Atopy: refers to IgE-mediated diseases, such as allergic rhinitis, increased capillary permeability (heat, pain & swelling)
that have a genetic component 2. Secondary (inactive precursors formed or released in response to
primary mediators)
Allergic Reaction o Leukotrienes
• Manifestation o Bradykinin
• of tissue injury resulting from interaction between an antigen and o Serotonin
an antibody
• Body encounters allergens that are types of antigens Question #1: True or False?
• Body's defenses recognize antigens as foreign An antigen is a protein substance developed by the body in response to
• Series of events occurs in an attempt to render the invaders and interacting with a specific antibody
harmless, destroy them, and remove them from the body False.
• Allergen triggers the B cell to make IgEantibody, which attaches to Rationale: An antibody, not an antigen, is a protein substance
the mast cell. When that allergen reappears, it binds to the IgEand developed by the body in response to and interacting with a specific
triggers the mast cell to release its chemicals. antigen, not antibody. Antigen is a substance that induces the production
of antibodies
1. B cells; also known as B lymphocyte
- Programmed to produce one specific antibody Hypersensitivity
- Stimulates production of plasma cells; antibody production • Abnormal heightened reaction to a stimulus of any kind
- Results in outpouring of antibodies • Types:
2. T cells; also known as T lymphocyte 1. Type I: Anaphylactic Reaction (most severe)
- Assist B cells - An anaphylactic reaction is characterized by vasodilation,
- Secrete substances that destroy target cells and stimulate increased capillary permeability, smooth muscle
macrophages contraction, and eosinophilia. Systemic reactions may
- Digest antigens and remove debris involve laryngeal stridor, angioedema, hypotension, and
bronchial, GI, or uterine spasm; local reactions are
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
IMMUNOGLOBULINS AND ALLERGIC RESPONSE characterized by hives.
§ Antibodies (IgE, IgD, IgG, IgM, and IgA) formed by lymphocytes and - Examples of Type I reactions include extrinsic asthma,
plasma cells allergic rhinitis, systemic anaphylaxis, and reactions to
§ IgE antibodies are involved in allergic disorders insect stings.
§ IgE molecules bind to an allergen and trigger mast cells or basophils 2. Type II: Cytotoxic
§ These cells then release chemical mediators such as histamine, - A cytotoxic reaction, which involves binding either the IgG
serotonin, kinins, SRS-A, and neutrophil factor or IgM antibody to a cell-bound antigen, may lead to
§ These chemical substances cause the reactions seen in allergic eventual cell and tissue damage. The reaction is the result
response of mistaken identity when the system identifies a normal
constituent of the body as foreign and activates the
complement cascade.
Medical-Surgical Nursing | NCM 0112
- Examples of Type II reactions are myasthenia gravis, MEDICATIONS TO TREAT ALLERGIC REACTIONS
Goodpasture syndrome, pernicious anemia, hemolytic § Oxygen, if respiratory assistance is needed
disease of the newborn, transfusion reaction and § Epinephrine used for anaphylactic reactions
thrombocytopenia. § Anti-Histamines
3. Type III: Immune Complex § Corticosteroids
- An immune complex reaction is marked by acute § Refer to Tables 37-2 and 37-3 for list of medications
inflammation resulting from formation and deposition of
immune complexes. The joints and kidneys are Anaphylaxis
particularly susceptible to this kind of reaction, which is • Mild, moderate, and severe systemic reactions
associated with systemic lupus erythematosus, serum • Symptoms are sudden in onset and progress in severity over
sickness, nephritis and rheumatoid arthritis. Some signs minutes to hours
and symptoms include urticaria, joint pain, fever, rash, § Flushing
and adenopathy (swollen glands). § Urticaria
4. Type IV: Delayed Type § Angioedema
- A delayed, or cellular, reaction occurs 1 to 3 days after § Hypotension
exposure to an antigen. The reaction, which results in § Bronchoconstriction
tissue damage, involves activity by lymphokines, § Antibiotics most common; penicillin
macrophages, and lysozymes. Erythema and itching are
common; a few examples include contact dermatitis, COMMON CAUSES OF ANAPHYLAXIS
graft-versus-host disease, Hashimoto’s thyroiditis, and § Foods
sarcoidosis. o Peanuts, tree nuts (e.g., walnuts, pecans, cashews,
almonds), shellfish (e.g., shrimp, lobster, crab), fish, milk,
ASSESSMENT OF PT WITH ALLERGIC DISORDERS eggs, soy, wheat
§ History and manifestations; comprehensive allergy history § Medications
§ Diagnostic tests o Antibiotics, especially penicillin and sulfa antibiotics,
o CBC: eosinophil count allopurinol, radiocontrast agents, anesthetic agents
o Total serum IgE (lidocaine, procaine), vaccines, hormones (insulin,
o Skin tests: prick, scratch, and intradermal vasopressin, adrenocorticotropic hormone), aspirin,
§ Intradermal testing nonsteroidal anti-inflammatory drugs
§ Other Pharmaceutical/Biologic Agents
o Animal serums (tetanus antitoxin, snake venom
antitoxin, rabies antitoxin), antigens used in skin testing
§ Insect Stings
o Bees, wasps, hornets, yellow jackets, ants (including fire
ants)
§ Latex
o Medical and nonmedical products containing latex
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
PREVENTION AND MANAGEMENT OF ANAPHYLAXIS
ü Screen and prevent
ü Treat respiratory problems, oxygen, intubation, and
MANAGEMENT OF PT WITH ALLERGIC DISORDERS
cardiopulmonary resuscitation as needed
§ Two types of reactions: ü Epinephrine 1:1000 subcutaneously
1. Atopic – the genetic predisposition to mount an IgEresponse ü Auto injection system: EpiPen
to inhaled or ingested innocuous proteins ü May follow with IV epinephrine
o Asthma, allergic rhinitis, atopic dermatitis ü IV fluids
o Familial
2. Nonatopic – lack the genetic component and organ specificity
of the atopic disorders
o Latex allergy
o Contact dermatitis
Medical-Surgical Nursing | NCM 0112
Allergic Rhinitis Latex Allergy
• Hay fever, seasonal allergic rhinitis • Allergic reaction to natural rubber proteinsImplicated in rhinitis,
• A common respiratory allergy presumed to be mediated by a type I conjunctivitis, contact dermatitis, urticarial, asthma, anaphylaxis
hypersensitivity • Prevalence has been decreasing due to the use of nonlatex
• Affects 12% of adults gloves8% to 17% of healthcare workers affected
• Major symptoms: copious amounts of serous nasal discharge, nasal • Different types of reactions, refer to Table 37-6
congestion, sneezing, nose and throat itching
• May affect the quality of life, sleep disturbance, impairment of daily OTHER TYPES OF ALLERGIC DISORDERS
activities, and missed school and work 1. Contact dermatitis
2. Atopic dermatitis
ASSESSMENT OF PT WITH ALLERGIC RHINITIS 3. Drug reactions (dermatitis medicamentosa)
§ Health history includes personal and family history 4. Urticaria and angioneurotic edema
§ Allergy assessment 5. Hereditary angioedema and cold urticaria
§ Subjective data include symptoms and how the patient feels 6. Food allergy: peanut most common
before symptoms become obvious
§ Note relationship between symptoms and seasonal changes, Question #2: When could a “rebound” anaphylactic reaction occur after
emotional problems, or stress an initial attack even when epinephrine has been given?
§ Identify nature of antigens, seasonal changes in symptoms, A. 1 hour
and medication history B. 2 hours
C. 3 hours
DIAGNOSIS OF PT WITH ALLERGIC RHINITIS D. 4 hours
§ Ineffective breathing pattern related to allergic reaction Rationale: A “rebound” anaphylactic reaction can occur 4 to 10 hours
§ Deficient knowledge about allergy and the recommended after an initial attack even when epinephrine has been given.
modifications in lifestyle and self-care practices Patients who have experienced anaphylactic reactions and received
§ Ineffective individual coping with chronicity of condition and epinephrine should be transported to the local emergency department
need for environmental modifications (ED) for observation and monitoring because of the risk for a “rebound”
or delayed reaction 4 to 8 hours after the initial allergic reaction.
COLLABORATIVE PROBLEMS / POTENTIAL COMPLICATIONS
§ Anaphylaxis
§ Impaired breathing
§ Nonadherence to therapeutic regimen
PLANNING AND GOALS IN ALLERGIC RHINITIS
§ Restoration of normal breathing pattern
§ Increased knowledge about the causes and control of allergic
symptoms
§ Improved coping with alterations and modifications
§ Absence of complications
G.M.M.E. | A.J.E.F. | T.A.M.M. – MARILAG
INTERVENTIONS FOR ALLERGIC RHINITIS
§ Breathing
ü Modify the environment to reduce allergens
ü Reduce exposure to people with URI
ü Take deep breaths and cough frequently
§ Teaching
ü Instruction to minimize allergens
ü Use of medications
ü Importance of keeping appointments
ü Desensitization procedures
