Download Lect.12 - Immunologic and Endocrine Alterations in Children

Nursing Care of Children with
Immunologic Alterations
By Nataliya Haliyash,
MD, BSN
Insitute of Nursing,
TSMU
Lecture objectives
Upon completion of this chapter you will be able to:
 Describe the normal functions of the immune system.
 Describe the etiology, clinical manifestations, and
medical treatment for the common immune system
alterations, juvenile idiopathic arthritis (JIA), systemic
lupus erythematosus (SLE), human
immunodeficiency virus (HIV), and allergic reaction to
drugs.
 Identify nursing management of children with immune
system alterations, including developmental and
psychosocial needs.
 Identify the education, resource, and support needs
of families who have children with immune system
alterations.
Functions of the immune system
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to prevent or ameliorate infections,
to recognize self from nonself,
to maintain homeostasis.
Two basic divisions
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The innate immune system acts as the first
line of defense against infections, and
includes biochemical and physical barriers.
The adaptive immune system produces a
specific reaction to each infectious agent,
remembers that agent, and can prevent a
later infection by the same agent.
The immune system includes:
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the spleen, lymph nodes, and lymphoid
tissue,
cellular elements such as the white
blood cells or leukocytes, phagocytes,
and natural killer cells.
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The immune system of neonates and
young children is immature.
Because of this immaturity, infants and
young children are susceptible to
infectious organisms that can cause
illness and its associated morbidity.
A child's immune system matures by
three to six years of age.
Immunity
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The term refers to all the processes
used by the body to protect against
foreign material from environmental
sources, including microorganisms or
their toxins, foods, chemicals, pollen,
dander, or drugs.
Innate or natural immunity
Acquired immunity
Innate or natural immunity
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nonspecific,
function against most threats to the body in a
broad sense.
Is represented by physical barriers such as:
– the skin, mucous membranes,
– cough reflex;
– chemical barriers such as pH of the stomach, fatty acids and
proteolytic enzymes of the small intestine,
– fever.

Nonspecific immune cells such as phagocytes
(macrophages, neutrophils, natural killer cells), and
lymphocytes whose granules release lysing
chemicals.
Acquired immunity
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is specific immunity, triggered when a
person has had prior contact with a
foreign agent.
the humoral system, consisting of
primarily B lymphocytes
and/or the cell mediated system of
primarily the T lymphocytes
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Although immune system alterations occur less
commonly in children than other types of alterations,
the effects are often disabling or terminal.
In addition, the immune system interacts with other
body systems so symptoms may not appear to be
immune related but rather primarily musculoskeletal,
– juvenile arthritis,
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or integumentary
– systemic lupus erythematosus.

HIV, another immune system disease, can affect all
organ systems.
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AUTOIMMUNITY: The inability of the body to
distinguish "self" from other, leads to an
immune response aimed at parts of one's
own body.
INFLAMMATION: Increased blood flow and
permeability of blood vessels; results in
increased fluid production and attraction of
lymphocytes and leukocytes to the area,
caused by the release of inflammatory
substances called cytokines.
Juvenile Idiopathic Arthritis
(Juvenile rheumatoid arthritis
(JRA))
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A term used for a group of idiopathic chronic
autoimmune inflammatory diseases affecting
joints and connective tissues in children
JRA is the most common pediatric connective
tissue disease with arthritis being the
principal manifestation.
The incidence is 1:1,000. African-American
and Asian children are less likely to suffer
from JRA.
Pathophysiology of JRA
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Current research suggests T cell activation
triggers development of antigen-antibody
complexes, which cause release of
inflammatory substances called cytokines in
targeted organs such as joints and skin.
This causes inflammation of the synovial
membranes and other tissues leading to joint
effusion and swelling.
Chronic inflammation eventually evolves into
erosion of articular cartilage and other
symptoms of inflammatory diseases
Juvenile Idiopathic Arthritis
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Clinical manifestations
– Systemic onset
• Fever (usually high)
• Rash (Salmon-pink, migratory, macular/papular, most
common late afternoon or early evening)
• Arthralgia/myalgia
arthritis is defined as
• Arthritis
joint swelling or effusion,
• Fatigue/malaise
or two of the following:
warmth, pain on motion,
• Lymphadenopathy
or limited range of
• Hepatosplenomegaly
motion
• Possible signs of carditis
(continues)
Juvenile Idiopathic Arthritis
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Polyarticular onset
– Arthritis in many joints (five or more)
•
•
most particularly the joints of the knees, wrists,
ankles, and proximal interphalangeal joints of the
fingers.
often neck and temporomandibular (TMJ) joints
are affected.
– Low-grade fever
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Pauciarticular onset
– Arthritis in a few joints (less than 4)
•
most particularly joints of the knees and ankles.
– Inflammation of the eyes
•
common in anti-nuclear antibody positive
preschool girls.
Diagnosis of Juvenile Idiopathic
Arthritis
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American College of Rheumatology
diagnostic criteria
– Onset before 16 years of age
– Arthritis of at least 6 weeks’ duration
(objectively observed)
– A defined subtype (by onset
characteristics)
– Exclusion of other conditions such as
other rheumatic diseases
(continues)
Diagnosis of Juvenile Idiopathic
Arthritis
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There are no specific laboratory tests for JRA.
Laboratory data:
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elevated erythrocyte sedimentation rate (ESR),
elevated C-reactive protein (CRP),
elevated white blood count,
decreased hemoglobin,
and increased platelet count.
Antinuclear antibody (ANA) and rheumatoid factor (RF)
are positive in a proportion of children with arthritis
X rays can demonstrate characteristic changes such as:
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soft tissue swelling and joint effusion.
bony erosions and narrowing of the joint spaces
Subluxations and malalignment
Treatment of Juvenile Idiopathic
Arthritis
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Multidisciplinary approach
Medications
Physical and occupational therapy
Nutritional considerations
Family teaching
Systemic Lupus Erythematosus
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Incidence and etiology:
–
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Although systemic lupus erythematosus (lupus
or SLE) can develop at any age, onset in
childhood usually occurs after the age of 5 years
or during adolescence
Peak age of childhood onset is 11 to 15 years
Involving females 8 to 10 times as often as
males
Pathophysiology:
–
is an autoimmune process requiring a genetic
susceptibility and probably a viral or bacterial
trigger
Diagnosis of Lupus
Erythematosus
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Clinical manifestations (American College of
Rheumatology Ad Hoc Committee of
Systemic Lupus Erythematosus diagnostic
criteria)
– Malar rash: Erythematous, flat or raised over the
cheeks.
– Discoid rash: Erythematous raised patches with
scaling.
– Photosensitivity: Skin rash from exposure to sun.
– Oral or nasal ulcers
(continues)
Diagnosis of Lupus
Erythematosus
–
Nonerosive arthritis:
• Two or more peripheral joints with tenderness, swelling, or
effusion.
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Pleuritis or pericarditis
Renal disorder:
• Persistent proteinuria OR cellular casts;
• can progress to hypertension, nephrotic syndrome, renal
insufficiency, and end stage renal disease requiring
transplantation.
–
Neurological disorder:
• Seizures OR psychosis without other cause.
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Hematological disorder
Immunologic markers
ANA (antinuclear antibody) positive
Alopecia
4 of the 11 criteria must be present
Lupus Erythematosus
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Treatment
– Preventing exacerbations
– Treating exacerbations when they occur
– Minimizing organ damage and
complications
– Medications
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Nursing management
Human Immunodeficiency Virus
(HIV)
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Incidence and etiology
– HIV infection
– HIV disease
– Acquired immunodeficiency syndrome
(AIDS)
– Age-related differences
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Revised pediatric classification system:
clinical categories
(continues)
Pathophysiology
Human Immunodeficiency Virus
(HIV)
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Clinical manifestations
– CD4 counts normal: asymptomatic
– Associated symptoms of opportunistic
infections
– The younger the child at time of
acquisition, the more severe the
symptoms, faster progression, poorer
prognosis
– Variations by age
Diagnosis of HIV
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Careful history focusing on risks
Timing of transmission from mother to
child
ELISA
Western blot
Treatment of HIV
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Multidisciplinary approach
HAART (highly active antiretroviral
therapy)
Prevention of opportunistic infections
Nursing management and family teaching
– Home
– School
– Community
Allergic Reactions to Drugs
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Incidence and etiology
Pathophysiology
(continues)
Allergic Reactions to Drugs
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Clinical manifestation
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Angioedema
Urticaria
Maculopapular rashes
Contact dermatitis
Anaphylaxis
Erythema multiforme
Stevens-Johnson syndrome
– Toxic epidermal necrolysis
(continues)
Allergic Reactions to Drugs
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Diagnosis
Treatment
Nursing management
Situation: Stevens-Johnson
syndrome
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Twelve-year-old Ron was admitted to the unit with
an erythematous papular rash covering his arms,
legs, abdomen, the soles of his feet, and the palms
of his hands. His mother Helen said that he had a
sore throat, headache, fever, and “just didn’t feel
well” a day or two before he broke out with his rash.
He also had been on penicillin for five days because
of a throat infection. He was diagnosed with
Stevens-Johnson syndrome. What nursing care
would be appropriate?
Answer: Ron and his parents will need to be
provided with education about his sensitivity to the
penicillin. Ron will be on a liquid diet. The nurse will
need to provide comfort measures, including use of
topical lidocaine prn for his sore mouth, frequent
skin care, and administration of pain medications as
needed. He also will need a nutritious diet, adequate
fluids, and excellent skin care.
Endocrine Alterations
Anatomy and Physiology
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Glands of the endocrine system
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Anterior pituitary
Posterior pituitary
Thyroid
Parathyroids
Adrenal cortex
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Adrenal medulla
Ovaries
Testes
Pancreas
Disorder of the Anterior Pituitary:
Growth Hormone Deficiency
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Incidence and etiology
Pathophysiology
Clinical manifestations
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Short stature
Deteriorating or absent rate of growth
Higher weight-for-height ratio
Delayed bone age
Diagnosis
Treatment
Nursing Management
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Assessment
Nursing diagnoses
– Delayed growth and development related
to inadequate growth hormone secretion
– Disturbed body image related to short
stature
– Deficient knowledge related to treatment
(continues)
Nursing Management
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Outcome identification
Planning/implementation
Evaluation
Family teaching
Disorder of the Anterior Pituitary:
Precocious Puberty
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Incidence and etiology
Pathophysiology
(continues)
Disorder of the Anterior Pituitary:
Precocious Puberty
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Clinical manifestations
– Accelerated growth rate
– Advanced bone age
– Evidence of secondary sexual
characteristics
– Acne
– Adult body odor
– Possible behavior changes
(continues)
Disorder of the Anterior Pituitary:
Precocious Puberty
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Diagnosis
– Complete history
– Physical exam
• Sexual maturation staging (Tanner staging)
• Height, weight, span (fingertip to fingertip),
upper/lower body ratio
– Radiological exams
– Laboratory screening
(continues)
Disorder of the Anterior Pituitary:
Precocious Puberty
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Treatment
Nursing management
Disorder of the Posterior Pituitary:
Diabetes Insipidus
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Incidence and etiology
Pathophysiology
Clinical manifestations
– Infants: failure to thrive, fevers, vomiting,
constipation, dehydration, poor growth
– Children: polyuria, polydipsia
(continues)
Disorder of the Posterior Pituitary:
Diabetes Insipidus
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Diagnosis
– First morning urine sample: osmolarity,
specific gravity, sodium
– Serum osmolarity, sodium and creatinine
levels
– Water deprivation test
(continues)
Disorder of the Posterior Pituitary:
Diabetes Insipidus
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Treatment
– Replacement of antidiuretic hormone or
vasopressin
– Desmopressin acetate (DDAVP)

Nursing management
Disorder of the Thyroid Gland:
Congenital Hypothyroidism
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Incidence and etiology
Pathophysiology
Clinical manifestations
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Large posterior fontanel
Umbilical hernia
Constipation
Prolonged jaundice
– Other manifestations
(continues)
Disorder of the Thyroid Gland:
Congenital Hypothyroidism
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Diagnosis
Treatment
Nursing management
Family teaching
Disorder of the Thyroid Gland:
Acquired Hypothyroidism
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Incidence and etiology
Pathophysiology
(continues)
Disorder of the Thyroid Gland:
Acquired Hypothyroidism
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Clinical manifestations
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Decreased rate of growth
Weight gain
Constipation
Dry skin, thinning or coarse hair
Fatigue
(continues)
Disorder of the Thyroid Gland:
Acquired Hypothyroidism
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Cold intolerance
Edema of face, eyes, hands
Delayed deep tendon reflexes
Delayed puberty
(continues)
Disorder of the Thyroid Gland:
Acquired Hypothyroidism
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Diagnosis
Treatment
Nursing management
– Assessment
(continues)
Disorder of the Thyroid Gland:
Acquired Hypothyroidism
– Nursing diagnosis
• Delayed growth and development related to
the absence or deficiency of thyroid hormone
synthesis
• Hypothermia related to decreased BMR
• Constipation related to decreased motility of
the GI tract
• Activity intolerance related to fatigue and
decreased endurance
Disorder of the Thyroid Gland:
Hyperthyroidism
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Incidence and etiology
Pathophysiology
(continues)
Disorder of the Thyroid Gland:
Hyperthyroidism
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Clinical manifestations
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Increased rate of growth
Weight loss despite excellent appetite
Warm, moist skin
Tachycardia
Ophthalmic changes
Heat intolerance
Emotional lability
Insomnia, fine tremors
(continues)
Disorder of the Thyroid Gland:
Hyperthyroidism
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Diagnosis: serum thyroid tests
Treatment
– Antithyroid medication
– Radioactive iodine therapy
– Subtotal thyroidectomy
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Nursing management
Family teaching: home, school,
community
Disorder of the Adrenal Gland:
Congenital Adrenal Hyperplasia
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Incidence and etiology
Pathophysiology
(continues)
Disorder of the Adrenal Gland:
Congenital Adrenal Hyperplasia
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Clinical manifestations
– Male fetus: no physical changes
– Female fetus: virilized external genitalia
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•
•
•
Enlarged clitoris
Fusion of the labial folds
Rugate appearance to labia
Pseudohermaphroditism
– Children (often toddlers present): adrenarche,
accelerated growth velocity, advanced bone
age, acne, hirsutism
Disorder of the Pancreas:
Diabetes Mellitus
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Incidence and etiology
Pathophysiology
Clinical manifestations
Diagnosis
Treatment of Diabetes Mellitus
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Insulin management
Blood glucose management
Nutrition
Exercise
Nursing Management: Diabetes
Mellitus
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Assessment
Nursing diagnoses
– Risk for injury related to insulin
insufficiency and deficiency
– Risk for injury related to hypoglycemia or
hyperglycemia
– Disturbed body image related to
developing a chronic disease
(continues)
Nursing Management: Diabetes
Mellitus
– Deficient knowledge related to
management of both types of diabetes
– Interrupted family processes related to
management of a chronic illness
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Outcome identification
Planning/implementation
(continues)
Nursing Management: Diabetes
Mellitus
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Survival education
– Insulin preparation and injection
– Blood glucose and urine-ketone
monitoring
– Hypoglycemia
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Family teaching: beyond the survival
stage
– Hyperglycemia
– Diabetic ketoacidosis
Additional Endocrine Disorders
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Hypoparathyroidism
Addison’s disease
Cushing’s syndrome
The END. Q & A ?