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Chapter 19
Immune Disorders
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
The Immune System
• Protective processes eliminate foreign antigens
through function of specific cells
• Antibodies fight infections
– IgG is the only antibody that crosses the placenta
• Full-term infants receive adult levels, providing protection from
bacterial infections
• Immune responses are humoral or cell-mediated
– Humoral: B lymphocytes produce antibodies and memory
cells
– Cell-mediated: Involves T lymphocyte cells
• Helper cells, killer cells, suppressor cells
• Autoimmune disorders: Abnormal, excessive
response to self
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Kawasaki Disease (KD)
• Description
– Acute, severe vasculitis of all blood vessels
• Leading cause of acquired heart disease in children
• Signs and symptoms
•
Diagnosis: Clinical signs, lab tests, 2D echocardiogram
– Three stages
• Acute: prolonged high fever, strawberry tongue, irritability
• Subacute: Desquamation of hands/feet, arthritis, coronary aneurysms
• Convalescent: All signs have disappeared
– Treatment and nursing care
• Reduce inflammation via IV-IG and high-dose aspirin
• Provide symptom-specific relief
• Extreme irritability is the most challenging nursing issue
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Stevens-Johnson Syndrome
• Description
– A severe form of erythema multiforme involving
lesions of the skin and mucous membranes
• Signs and symptoms
– Flu-like symptoms
– Mucosal lesions in eyes, mouth, and GI tract
• Treatment and nursing care
– Ophthalmologist monitors for corneal scarring
– Care of topical and oral lesions as needed
– Medication allergies should be noted in order to
prevent future incidents
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Juvenile Idiopathic Arthritis (JIA)
• Description
– JIA syndromes affect joints, connective tissue, viscera
– Chronic, with remissions and exacerbations
• Signs and symptoms
–
–
–
–
Joint stiffness in the morning or after a period of inactivity
Osteopenia: low bone mass
Diagnosis: clinical manifestations, radiographs, lab tests
JIA is categorized by method of onset
• Systemic: acute febrile
• Oligoarticular: involving five or fewer joints
– Risk for iridocyclitis, inflammation of the iris and ciliary body (risk of
blindness)
• Polyarticular: involving more than five joints
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Juvenile Idiopathic Arthritis
• Treatment and nursing care
– Drug therapy and exercise to reduce pain and stiffness
• Continued monitoring of medications is important
– Intra-articular long-acting corticosteroid injections preserve
joints
• Home care
–
–
–
–
Moist hot packs lessen stiffness
Firm mattresses prevent sagging joints
Encourage swimming
Avoid weight gain
• Facilitating school attendance
– Provide unobtrusive access to the school health office
– Excess absence may suggest preoccupation with illness
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Juvenile Idiopathic Arthritis
• Meeting emotional needs
– Parents should avoid overindulgence and
preferential treatment
– Assist families in understanding the chronic
nature of the disease
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Infectious Mononucleosis
• Description
– A global disease caused by a herpes type of
Epstein-Barr virus (EBV)
– Studies suggest that the organism is
transmitted by contact with saliva, either
directly or from contaminated eating utensils;
however, its communicability is considered
low
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Infectious Mononucleosis
• Signs and symptoms
– Low-grade fever, sore throat, headache,
fatigue, skin rash, and general malaise
– The lymph glands enlarge
– Splenomegaly develops in approximately half
the patients
– Liver involvement with mild jaundice occurs in
a small number of persons
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Infectious Mononucleosis
• Treatment and nursing care
– Acetaminophen or NSAIDs given as needed
– An antipyretic is given to reduce fever and
discomfort
– An initial period of rest or restricted activities is
usually needed; returning to usual activities is
based on the child’s energy level
– Gargling with warm saline solution and sucking
on throat lozenges can be helpful for pharyngitis
– Adequate fluid intake is necessary
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Diabetes Mellitus (Type 1)
• Description
– Failure to metabolize carbohydrates, fats, and
proteins properly due to lack of insulin
• Incidence
– Frequency increases with age
• Highest rate of new cases among 5- to 7-year-old
children
– Risk factors include history of Type1 DM in
the family, psychosocial stress, obesity, viral
infections
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Diabetes Mellitus (Type 1)
• Signs and symptoms
– 3P’s: Polyuria (excretion of large amounts of urine),
polydipsia (excessive thirst), and polyphagia
(constant hunger)
– Fatigue, anorexia, nausea, lethargy, weakness
– Dry skin
– Vaginal yeast infections
– Urine accidents in a previously trained child
– Hyperglycemia, glycosuria, ketoacidosis
– Diabetic ketoacidosis (DKA) when conditions demand
an increase insulin to maintain blood sugar levels
• Kussmaul breathing
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Diabetes Mellitus (Type 1)
• Treatment and nursing care
– Diabetic ketoacidosis
• Correction of depleted fluids, stabilization of vital signs
• Low doses of IV insulin; check K+ levels
• Response to treatment is gradual
– Long-term management
• Promote normal growth and development through
metabolic control
• Enable a happy childhood
• Prevent complications
• Planned educational programs provide a consistent
body of information to families
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Diabetes Mellitus (Type 1)
• Treatment and nursing care (continued)
– Insulin administration
• Goal: simulate the fluctuations in insulin levels
normally seen in non-diabetic individuals
• Human insulin is frequently used; lesser incidence
of allergies
• A 100-unit (U-100) insulin is standard in the United
States
• Administered subcutaneously at a 90-degree angle
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Hypoglycemia
• Low blood glucose, also known as insulin shock
• Symptoms appear suddenly
• Immediate treatment consists of administering
sugar, such as orange juice, hard candy, or a
commercial product such as Glutose PO
• If the child begins to feel better within a few
minutes and blood glucose level exceeds 70
mg/dL, eat a small amount of protein or starch to
prevent another reaction
• Severe hypoglycemia is treated with Glucagon IM
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Hypoglycemia
• Blood glucose self-monitoring
– Home glucose monitoring should be taught to all
young patients and/or their caretakers
– Blood specimen obtained with capillary blood-letting
devices
– A drop of blood is put on a chemically treated reagent
strip, and a meter reads the blood glucose level
• Nutritional management
– Elimination of concentrated carbohydrates (simple
sugars) and refined sugars
– The two major approaches to nutritional management
include the use of exchange lists and the constant
carbohydrate monitoring diet
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Hypoglycemia
• Exercise
– Causes the body to use sugar and promotes
good circulation
• Sick day rules –
• chart for controlling sugar on days you don’t feel
well, so exercise less and eat less
• Infections raise the need for insulin
• Skin care
– Bathe daily, dry well especially feet
– The patient should be instructed to inspect skin
for cuts, rashes, abrasions, cysts, or boils
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Hypoglycemia
• Foot care
– Instruct the patient to wash and dry the feet well
each day
– Instruct the patient to trim the nails straight across
• Infections
– Obtain immunizations against communicable
diseases
– Cystitis, subcutaneous nodules, and monilial
vulvitis occur with greater frequency in patients
with diabetes
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Hypoglycemia
• Urine checks
– Routine urine checks for sugar are replaced by glucose
blood monitoring
– May be used to test for acetone
– Quantitative urine collection is sometimes ordered
• Glucose-insulin imbalances
– Patient should recognize signs of insulin shock and
ketoacidosis
– Carry a ready source of glucose for emergencies
– Medic-Alert bracelets, wallet cards
– Adults involved in caring for the child (i.e., coaches,
teachers) should have parent/physician phone numbers
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Hypoglycemia
• Psychosocial aspects
– Parents and patients must understand that although insulin
dose needs may vary, the child will need lifelong insulin
administration
– Because children grow in spurts, dosing may be irregular
– School-age children may use illness to gain attention or
avoid responsibilities
– Rebellion against treatment regimen
– Impact of disease on the rest of the family should be
considered
• Other issues
– Planning is needed for travel
– Surgery is typically well-tolerated
– Regular eye and dental exams are especially important
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Hypoglycemia
• Role of the nurse
– Preparing the child for meals
– Checking blood glucose
– Observing the types and amounts of foods that
the patient refused and charting them in the
nurse’s notes
– Reinforcing the interaction among nutrition,
insulin requirements, and exercise and answering
questions from the child or family
• The future of research on diabetes
– Genetics, viruses, pancreas transplantation, beta
cell transplantation, and artificial pancreas
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Type 2 Diabetes (T2DM)
• One-third to one-half of all newly diagnosed
diabetes patients are younger than 18 years
of age
• Insulin receptor resistance combined with
insulin deficiency
• Symptoms similar to T1DM
• Nutritional education and improved exercise
• Insulin may be reduced or discontinued within
a few weeks of treatment if sugar is stable
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Communicable Diseases
• Transmitted by direct/indirect contact, vector,
or airborne
• Children’s immune systems are not fully
developed until 6 years of age
• Nursing care focuses on disrupting the chain
of infection to prevent disease
–
–
–
–
Reservoir: environment where organism exists and multiplies
Portal of exit: route by which organisms leave the reservoir
Portal of entry: route by which the organism enters the host
Prodromal symptoms indicate the onset of a disease
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Immunizations
• Stimulate the body to produce antibodies in
defense against weakened/killed microorganisms
in the vaccine
– Immunizations prevent epidemics
• Immunizations recommended in the U.S. by age 2:
– Polio, diphtheria, tetanus, pertussis (whooping
cough), hepatitis A, hepatitis B, Haemophilus
influenzae type b, mumps, measles, rubella, varicella
(chickenpox), rotavirus, and Streptococcus
pneumoniae (pneumococcus)
• Other vaccines with varying age groups are
influenza, varicella, HPV/HPV4, rotavirus,
meningococcal conjugate
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Immunizations
• Contraindications to immunization
–
–
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Acute febrile conditions
Some chronic diseases
Recent blood transfusion
Injection of immune serum globulin
Severe allergy to a vaccine component
Severe reaction after previous administration of
an immunization
– Malignant disease
– Chemotherapy
– Steroid therapy
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Immunizations
• Precautions/side Effects
– Benefits of protection greatly outweigh the
risks
– Notify a health care provider if the child
experiences
•
•
•
•
Persistent high fever
Continued crying
Decreased responsiveness
Seizure activity
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Immunizations
• Hepatitis B (Hep B) vaccine
– Intramuscular
– Given to newborns before discharge
– Three doses total
• HBIG also, if mother has a positive surface antigen for Hep B
– Injection site tenderness/mild temperature common
• Rotavirus vaccine
– Oral
– Not recommended with previous history of
intussusception, or if antibody-containing blood
products have been administered in the past 42 days
– Irritability, mild diarrhea/vomiting
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Immunizations
• Diphtheria-tetanus-pertussis vaccine (DTP) and
diphtheria-tetanus-acellular pertussis vaccine (DTaP)
– Requires excellent intramuscular injection technique
– Contraindications
• Encephalopathy within 7 days of administering a previous dose
– Side effects: mild fever, swelling at injection site,
fussiness, decreased appetite
– Tdap: Licensed in 2005, recommended as a once-only
booster for adolescents
• Haemophilus influenzae type b (Hib) vaccine
– Intramuscular
– Side effects are usually mild
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Immunizations
• Pneumococcal vaccine (PCV)
– Intramuscular
– Can cause fever, fussiness, local erythema
• Polio vaccine
– Oral in the past; now subcutaneous or
intramuscular
– Contraindications: anaphylactic reaction to
neomycin/streptomycin/polymyxin B, pregnancy
– Side effects are rare
• Mild soreness at injection site
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Immunizations
• Influenza vaccine
– Intramuscular
• Live attenuated influenza vaccine (LAIV) intranasal alternative for persons
aged 5-49 years
– Contraindication: anaphylactic hypersensitivity to eggs
• Mumps, measles, and rubella vaccine (MMR)
– Subcutaneous
– Contraindications: pregnancy, anaphylactoid reaction to neomycin or
gelatin, immunodeficiency
– Precautions: administration of antibody-containing blood products,
thrombocytopenia
– Possible side effects
• Measels vaccine: fever/rash 7-12 days after vaccination
• Rubella vaccine: rash within a few days, joint pain/swelling 2 weeks after
vaccination
• Combination MMR: mild fever, rash, mild swelling of cheek/neck glands
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Immunizations
• Varicella vaccine
– Subcutaneous
– Contraindications: immunocompromised, pregnancy, children
receiving steroids, previous anaphylactic reaction to neomycin
or gelatin
– Precautions: recent administration of antibody-containing
blood products
– Reactions: Mild vaccine-associated maculopapular or varicella
rash, soreness/edema at the injection site, mild fever
• Hepatitis A vaccine
– Intramuscular
– Contraindication: Sensitivity to alum or 2-phenoxyethanol
– Possible side effect: Local redness may occur
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Immunizations
• Meningococcal vaccine (MCV)
– Intramuscular
– Contraindications: hypersensitivity to any
component of the vaccine
– Possible side effect: Pain/redness at injection site
• Human papillomavirus (HPV)
– Possible side effects: Pain, redness, swelling at
injection site
• Because syncope can occur, children should be
observed for 15-20 minutes after administration
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Health Problems and Immunizations
• Children with asthma, lung/heart/kidney disease,
metabolic/blood disorders should not receive
LAIV
– Administer inactivated influenza vaccine
• Children with cancer, leukemia, AIDS, or other
immune system problems should not receive
live-virus vaccines
– LAIV, MMR, varicella, rotavirus
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Importance
• Community outreach projects sponsored
by the Public Health Department provide
immunizations for children
• Accurate records are important
• Administration of multiple vaccines in one
visit does not increase intensity or number
of side effects
• EMLA cream or topical vapocoolant sprays
may decrease pain at injection site
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Concerns
• Thimerosal, a mercury-containing
preservative, has been eliminated from
childhood immunizations
• Some investigators believe that MMR
vaccine is associated with autism
– Multiple studies fail to support an association
between MMR vaccine and autism
• See Price et al. (2010)
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