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 didnt 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
Addisons disease
Cushings syndrome

The END. Q & A ?