Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 to prevent or ameliorate infections, to recognize self from nonself, to maintain homeostasis. Two basic divisions 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: the spleen, lymph nodes, and lymphoid tissue, cellular elements such as the white blood cells or leukocytes, phagocytes, and natural killer cells. 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 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 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 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 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, or integumentary – systemic lupus erythematosus. HIV, another immune system disease, can affect all organ systems. 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)) 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 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 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 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 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 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 There are no specific laboratory tests for JRA. Laboratory data: – – – – – 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: – – – soft tissue swelling and joint effusion. bony erosions and narrowing of the joint spaces Subluxations and malalignment Treatment of Juvenile Idiopathic Arthritis Multidisciplinary approach Medications Physical and occupational therapy Nutritional considerations Family teaching Systemic Lupus Erythematosus Incidence and etiology: – – – 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 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. – – 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. – – – – – Hematological disorder Immunologic markers ANA (antinuclear antibody) positive Alopecia 4 of the 11 criteria must be present Lupus Erythematosus Treatment – Preventing exacerbations – Treating exacerbations when they occur – Minimizing organ damage and complications – Medications Nursing management Human Immunodeficiency Virus (HIV) Incidence and etiology – HIV infection – HIV disease – Acquired immunodeficiency syndrome (AIDS) – Age-related differences Revised pediatric classification system: clinical categories (continues) Pathophysiology Human Immunodeficiency Virus (HIV) 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 Careful history focusing on risks Timing of transmission from mother to child ELISA Western blot Treatment of HIV Multidisciplinary approach HAART (highly active antiretroviral therapy) Prevention of opportunistic infections Nursing management and family teaching – Home – School – Community Allergic Reactions to Drugs Incidence and etiology Pathophysiology (continues) Allergic Reactions to Drugs Clinical manifestation – – – – – – – Angioedema Urticaria Maculopapular rashes Contact dermatitis Anaphylaxis Erythema multiforme Stevens-Johnson syndrome – Toxic epidermal necrolysis (continues) Allergic Reactions to Drugs Diagnosis Treatment Nursing management Situation: Stevens-Johnson syndrome 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 Glands of the endocrine system – – – – – Anterior pituitary Posterior pituitary Thyroid Parathyroids Adrenal cortex – – – – Adrenal medulla Ovaries Testes Pancreas Disorder of the Anterior Pituitary: Growth Hormone Deficiency Incidence and etiology Pathophysiology Clinical manifestations – – – – Short stature Deteriorating or absent rate of growth Higher weight-for-height ratio Delayed bone age Diagnosis Treatment Nursing Management 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 Outcome identification Planning/implementation Evaluation Family teaching Disorder of the Anterior Pituitary: Precocious Puberty Incidence and etiology Pathophysiology (continues) Disorder of the Anterior Pituitary: Precocious Puberty 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 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 Treatment Nursing management Disorder of the Posterior Pituitary: Diabetes Insipidus 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 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 Treatment – Replacement of antidiuretic hormone or vasopressin – Desmopressin acetate (DDAVP) Nursing management Disorder of the Thyroid Gland: Congenital Hypothyroidism Incidence and etiology Pathophysiology Clinical manifestations – – – – Large posterior fontanel Umbilical hernia Constipation Prolonged jaundice – Other manifestations (continues) Disorder of the Thyroid Gland: Congenital Hypothyroidism Diagnosis Treatment Nursing management Family teaching Disorder of the Thyroid Gland: Acquired Hypothyroidism Incidence and etiology Pathophysiology (continues) Disorder of the Thyroid Gland: Acquired Hypothyroidism Clinical manifestations – – – – – Decreased rate of growth Weight gain Constipation Dry skin, thinning or coarse hair Fatigue (continues) Disorder of the Thyroid Gland: Acquired Hypothyroidism – – – – Cold intolerance Edema of face, eyes, hands Delayed deep tendon reflexes Delayed puberty (continues) Disorder of the Thyroid Gland: Acquired Hypothyroidism 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 Incidence and etiology Pathophysiology (continues) Disorder of the Thyroid Gland: Hyperthyroidism Clinical manifestations – – – – – – – – 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 Diagnosis: serum thyroid tests Treatment – Antithyroid medication – Radioactive iodine therapy – Subtotal thyroidectomy Nursing management Family teaching: home, school, community Disorder of the Adrenal Gland: Congenital Adrenal Hyperplasia Incidence and etiology Pathophysiology (continues) Disorder of the Adrenal Gland: Congenital Adrenal Hyperplasia Clinical manifestations – Male fetus: no physical changes – Female fetus: virilized external genitalia • • • • 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 Incidence and etiology Pathophysiology Clinical manifestations Diagnosis Treatment of Diabetes Mellitus Insulin management Blood glucose management Nutrition Exercise Nursing Management: Diabetes Mellitus 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 Outcome identification Planning/implementation (continues) Nursing Management: Diabetes Mellitus Survival education – Insulin preparation and injection – Blood glucose and urine-ketone monitoring – Hypoglycemia Family teaching: beyond the survival stage – Hyperglycemia – Diabetic ketoacidosis Additional Endocrine Disorders Hypoparathyroidism Addison’s disease Cushing’s syndrome The END. Q & A ?