lect.12 - immunologic and endocrine alterations in children
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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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Juvenile Idiopathic Arthritis
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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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.
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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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Allergic Reactions to Drugs
Clinical manifestation
Angioedema
Urticaria
Maculopapular rashes
Contact dermatitis
Anaphylaxis Erythema multiforme
Stevens-Johnson syndrome
Toxic epidermal necrolysis(continues)
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Allergic Reactions to Drugs
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
Clinical manifestations
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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Disorder of the Anterior Pituitary:
Precocious Puberty
Incidence and etiology
Pathophysiology
(continues)
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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)
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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)
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Disorder of the Anterior Pituitary:
Precocious Puberty
Treatment
Nursing management
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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)
i d f h i i i
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Disorder of the Posterior Pituitary:
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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Disorder of the Posterior Pituitary:
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
Incidence and etiology
Pathophysiology
Clinical manifestations
Large posterior fontanel
Umbilical hernia
Constipation
Prolonged jaundice
Other manifestations (continues)
Di d f h Th id Gl d
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Disorder of the Thyroid Gland:
Congenital Hypothyroidism
Diagnosis
Treatment
Nursing management
Family teaching
Di d f h Th id Gl d
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Disorder of the Thyroid Gland:
Acquired Hypothyroidism
Incidence and etiology
Pathophysiology
(continues)
Di d f h Th id Gl d
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Disorder of the Thyroid Gland:
Acquired Hypothyroidism
Clinical manifestations
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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Disorder of the Thyroid Gland:
Acquired Hypothyroidism
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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Disorder of the Thyroid Gland:
Acquired Hypothyroidism
Diagnosis
Treatment
Nursing management
Assessment
(continues)
Di d f th Th id Gl d
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Disorder of the Thyroid Gland:
Acquired Hypothyroidism
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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Disorder of the Thyroid Gland:
Hyperthyroidism
Incidence and etiology
Pathophysiology
(continues)
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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)
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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
Di d f th Ad l Gl d
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Disorder of the Adrenal Gland:
Congenital Adrenal Hyperplasia
Incidence and etiology
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
Incidence and etiology
Pathophysiology
Clinical manifestations
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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Nursing Management: Diabetes
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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Nursing Management: Diabetes
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 ?
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