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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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-2 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-3 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-4 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-5 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-6 Juvenile Idiopathic Arthritis • Meeting emotional needs – Parents should avoid overindulgence and preferential treatment – Assist families in understanding the chronic nature of the disease Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-7 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-8 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-9 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-10 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-11 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-12 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-13 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-14 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-15 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-16 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-17 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-18 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-19 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-20 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-21 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-22 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-23 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 19-24 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-25 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-26 Immunizations • Contraindications to immunization – – – – – – 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-27 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-28 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-29 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-30 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-31 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-32 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-33 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-34 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-35 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 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-36 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) Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 18-37