chapter 19 immune disorders copyright © 2012 by saunders, an imprint of elsevier, inc

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


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


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


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


Juvenile Idiopathic Arthritis

• Meeting emotional needs– Parents should avoid overindulgence and

preferential treatment– Assist families in understanding the chronic

nature of the disease


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



• 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



• 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


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



• 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



• 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



• 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


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


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


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


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


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


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


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


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


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


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


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


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


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


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 mildCopyright © 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


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


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


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


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


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


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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