Lect.12 - Immunologic and Endocrine Alterations in Children

8/10/2019 Lect.12 - Immunologic and Endocrine Alterations in Children

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Nursing Care of Children withImmunologic Alterations

By Nataliya Haliyash,MD, BSN

Insitute of Nursing,

TSMU


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Lecture objectivesUpon completion o f this chapter you w i l l be able to:

Describe the normal functions of the immune system.

Describe the etiology, clinical manifestations, andmedical treatment for the common immune system

alterations, juvenile idiopathic arthritis (JIA), systemiclupus erythematosus (SLE), humanimmunodeficiency virus (HIV), and allergic reaction todrugs.

Identify nursing management of children with immunesystem alterations, including developmental andpsychosocial needs.

Identify the education, resource, and support needsof families who have children with immune system

alterations.


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Functions of the immune system

to prevent or ameliorate infections,

to recognize self from nonself,

to maintain homeostasis.


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Two basic divisions

The innate immune systemacts as the first

line of defense against infections, and

includes biochemical and physical barriers. The adaptive immune systemproduces a

specific reaction to each infectious agent,

remembers that agent, and can prevent a

later infection by the same agent.


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The immune system includes:

the spleen, lymph nodes, and lymphoid

tissue,

cellular elements such as the whiteblood cells or leukocytes, phagocytes,

and natural killer cells.


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The immune system of neonates andyoung children is immature.

Because of this immaturity, infants andyoung children are susceptible toinfectious organisms that can causeillness and its associated morbidity.

A child's immune system matures bythree to sixyears of age.


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Immunity

The term refers to all the processesused by the body to protect against

foreign material from environmentalsources, including microorganisms ortheir toxins, foods, chemicals, pollen,dander, or drugs.

Innate or natural immunity

Acquired immunity


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Innate or natural immunity

nonspecific,

function against most threats to the body in abroad sense.

Is represented by physical barriers such as: the skin, mucous membranes,

cough reflex;

chemical barriers such as pH of the stomach, fatty acids andproteolytic enzymes of the small intestine,

fever.

Nonspecific immune cells such as phagocytes(macrophages, neutrophils, natural killer cells), andlymphocytes whose granules release lysing

chemicals.


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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 ofprimarily the T lymphocytes


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AUTOIMMUNITY: The inability of the body todistinguish "self" from other, leads to animmune response aimed at parts of one'sown body.

INFLAMMATION: Increased blood flow andpermeability of blood vessels; results inincreased fluid production and attraction oflymphocytes and leukocytes to the area,caused by the release of inflammatorysubstances called cytokines.


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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.


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Pathophysiology of JRA

Current research suggests T cell activationtriggers development of antigen-antibodycomplexes, which cause release of

inflammatory substances called cytokines intargeted organs such as joints and skin.

This causes inflammation of the synovialmembranes and other tissues leading to jointeffusion and swelling.

Chronic inflammation eventually evolves intoerosion of articular cartilage and othersymptoms of inflammatory diseases


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Clinical manifestations

Systemic onset Fever (usually high)

Rash (Salmon-pink, migratory, macular/papular, mostcommon late afternoon or early evening)

Arthralgia/myalgia

Arthritis

Fatigue/malaise

Lymphadenopathy

Hepatosplenomegaly

Possible signs of carditis

(continues)

arthritis is defined as

joint swelling or effusion,

or two of the following:

warmth, pain on motion,or limited range of

motion


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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

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.


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Diagnosis of Juvenile Idiopathic

ArthritisAmerican College of Rheumatology

diagnostic criteria

Onset before 16 years of age

Arthritis of at least 6 weeks duration

(objectively observed)

A defined subtype (by onsetcharacteristics)

Exclusion of other conditions such as

other rheumatic diseases (continues)


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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


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Treatment of Juvenile Idiopathic

Arthritis Multidisciplinary approach

Medications

Physical and occupational therapy

Nutritional considerations

Family teaching


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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 yearsor 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 geneticsusceptibility and probably a viral or bacterial

trigger


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Diagnosis of Lupus

Erythematosus Clinical manifestations (American College of

Rheumatology Ad Hoc Committee ofSystemic Lupus Erythematosus diagnosticcriteria) 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)


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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, renalinsufficiency, and end stage renal disease requiringtransplantation.

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


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Lupus Erythematosus

Treatment

Preventing exacerbations

Treating exacerbations when they occur

Minimizing organ damage and

complications

Medications Nursing management


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Human Immunodeficiency Virus

(HIV) Incidence and etiology

HIV infection

HIV disease

Acquired immunodeficiency syndrome

(AIDS)

Age-related differences Revised pediatric classification system:

clinical categories

Pathophysiology(continues)


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Human Immunodeficiency Virus

(HIV) Clinical manifestations

CD4 counts normal: asymptomatic

Associated symptoms of opportunisticinfections

The younger the child at time of

acquisition, the more severe thesymptoms, faster progression, poorer

prognosis

Variations by age


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Diagnosis of HIV

Careful history focusing on risks

Timing of transmission from mother to

child

ELISA

Western blot


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Treatment of HIV

Multidisciplinary approach

HAART (highly active antiretroviral

therapy) Prevention of opportunistic infections

Nursing management and family teaching

Home School

Community


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Allergic Reactions to Drugs

Incidence and etiology

Pathophysiology

(continues)


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Clinical manifestation

Angioedema

Urticaria

Maculopapular rashes

Contact dermatitis

Anaphylaxis Erythema multiforme

Stevens-Johnson syndrome

Toxic epidermal necrolysis(continues)


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Diagnosis

Treatment

Nursing management


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Situation: Stevens-Johnson

syndrome Twelve-year-old Ron was admitted to the unit withan erythematous papular rash covering his arms,legs, abdomen, the soles of his feet, and the palmsof his hands. His mother Helen said that he had asore throat, headache, fever, and just didnt feelwell a day or two before he broke out with his rash.He also had been on penicillin for five days becauseof a throat infection. He was diagnosed withStevens-Johnson syndrome. What nursing carewould be appropriate?

Answer: Ron and his parents will need to beprovided with education about his sensitivity to thepenicillin. Ron will be on a liquid diet. The nurse willneed to provide comfort measures, including use oftopical lidocaine prn for his sore mouth, frequentskin care, and administration of pain medications as

needed. He also will need a nutritious diet, adequatefluids, and excellent skin care.


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Endocrine Alterations


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Anatomy and Physiology

Glands of the endocrine system

Anterior pituitary

Posterior pituitary

Thyroid

Parathyroids

Adrenal cortex

Adrenal medulla

Ovaries

Testes

Pancreas


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Disorder of the Anterior Pituitary:

Growth Hormone Deficiency Incidence and etiology

Pathophysiology


Short stature

Deteriorating or absent rate of growth

Higher weight-for-height ratio

Delayed bone age

Diagnosis

Treatment


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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)


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Nursing Management

Outcome identification

Planning/implementation

Evaluation

Family teaching


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Precocious Puberty


Pathophysiology

(continues)


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Precocious Puberty


Accelerated growth rate

Advanced bone age

Evidence of secondary sexual

characteristics

Acne Adult body odor

Possible behavior changes(continues)


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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)


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Precocious Puberty

Treatment

Nursing management


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Disorder of the Posterior Pituitary:

Diabetes Insipidus


Pathophysiology

Clinical manifestations Infants: failure to thrive, fevers, vomiting,constipation, dehydration, poor growth

Children: polyuria, polydipsia

(continues)

i d f h i i i


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Diabetes Insipidus

Diagnosis

First morning urine sample: osmolarity,

specific gravity, sodium

Serum osmolarity, sodium and creatininelevels

Water deprivation test

(continues)

i d f h i i i


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Diabetes Insipidus

Treatment

Replacement of antidiuretic hormone or

vasopressin

Desmopressin acetate (DDAVP)

Nursing management

Di d f h Th id Gl d


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Disorder of the Thyroid Gland:

Congenital Hypothyroidism


Pathophysiology


Large posterior fontanel

Umbilical hernia

Constipation

Prolonged jaundice

Other manifestations (continues)

Di d f h Th id Gl d


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Congenital Hypothyroidism

Diagnosis

Treatment

Nursing management

Family teaching

Di d f h Th id Gl d


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Acquired Hypothyroidism


Pathophysiology

(continues)

Di d f h Th id Gl d


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Decreased rate of growth

Weight gain Constipation

Dry skin, thinning or coarse hair

Fatigue

(continues)

Di d f h Th id Gl d


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Cold intolerance

Edema of face, eyes, hands Delayed deep tendon reflexes

Delayed puberty

(continues)

Di d f th Th id Gl d


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Diagnosis

Treatment

Nursing management

Assessment

(continues)

Di d f th Th id Gl d


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Nursing diagnosis

Delayed growth and development related to

the absence or deficiency of thyroid hormonesynthesis

Hypothermia related to decreased BMR

Constipation related to decreased motility of

the GI tract Activity intolerance related to fatigue and

decreased endurance


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Hyperthyroidism


Pathophysiology

(continues)


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Hyperthyroidism


Increased rate of growth

Weight loss despite excellent appetite Warm, moist skin

Tachycardia

Ophthalmic changes

Heat intolerance

Emotional lability

Insomnia, fine tremors (continues)


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Hyperthyroidism

Diagnosis: serum thyroid tests

Treatment

Antithyroid medication

Radioactive iodine therapy

Subtotal thyroidectomy

Nursing management

Family teaching: home, school,

community

Di d f th Ad l Gl d


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Disorder of the Adrenal Gland:

Congenital Adrenal Hyperplasia


Pathophysiology

(continues)

Di d f th Ad l Gl d


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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


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Disorder of the Pancreas:

Diabetes Mellitus


Pathophysiology


Diagnosis


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Treatment of Diabetes Mellitus

Insulin management

Blood glucose management

Nutrition

Exercise


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Nursing Management: Diabetes

MellitusAssessment

Nursing diagnoses

Risk for injury related to insulin

insufficiency and deficiency

Risk for injury related to hypoglycemia or

hyperglycemia

Disturbed body image related todeveloping a chronic disease

(continues)


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Mellitus

Deficient knowledge related to

management of both types of diabetes

Interrupted family processes related tomanagement of a chronic illness

Outcome identification

Planning/implementation

(continues)


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Mellitus

Survival education

Insulin preparation and injection

Blood glucose and urine-ketonemonitoring

Hypoglycemia

Family teaching: beyond the survivalstage

Hyperglycemia

Diabetic ketoacidosis


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Additional Endocrine Disorders

Hypoparathyroidism

Addisons disease

Cushings syndrome


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The END. Q & A ?

Lect.12 - Immunologic and Endocrine Alterations in Children

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