The Child with an Allergy and Immunological Alteration

Question 1

What is the immune system?

* First line defense - internal defense system

> Provides secondary and tertiary protection through nonspecific and specific responses

Answer 1

* Major organs and tissues of the immune system - bone marrow, thymus, spleen, lymph nodes, and lymphoid tissue

Question 2

Non-Specific Immune Functions

* Body’s innate immune action

* Made up of protective barriers - not antigen-specific

___ ___ involves vasodilation of small capillaries at the site of invasion
> Redness and edema at the site

Answer 2

Inflammatory response

Question 3

___ - a series of serum proteins that are involved in enzyme action which lead to antigen death

Answer 3

Complement

Question 4

___ - occurs as part of the inflammatory response

* The products of phagocyte antigen death - toxins - fever, pain, and purulence

* These antigens are destroyed, and the toxins are cleared via the lymph nodes - enlarged with inflammation

If this non-specific immune system response is effective, then inflammation subsides

Answer 4

Phagocytosis

Question 5

Specific Immune Functions

* When the non-specific immune response is not effective, and the antigen survives within the phagocyte

2 types of specific immune functions can recognize and destroy it -

___ and __-__ responses

Answer 5

Humoral; cell-mediated

Question 6

___ - sub-classification of leukocytes (white blood cells)

> Function in both types of immune responses - both humoral and cell-mediated

2 classes of lymphocytes are involved in the immune response:

B-lymphocytes (B cells) and T-lymphocytes (T cells)

Answer 6

Lymphocytes

Question 7

T cells are responsible for the __-__response

3 major types

> effector cells or helper T-cells (CD4+) and cytotoxic T-cells (CD8+)

> regulatory T-cells

> memory T-cells

Answer 7

cell-mediated

Question 8

B cells are responsible for the ___ response

> antibodies are classified as immunoglobulins - IgA, IgG, IgM, IgE, and IgD

Answer 8

humoral

Question 9

Development of Immunity

* Fetus can produce IgM by __ to __ weeks gestation

* Neonate’s immune protection comes from prenatal transfer of maternal antibodies IgG and breast milk transfer of IgA

Answer 9

20-24

Question 10

* Normal newborn infant gradually begins to develop their own humoral and cell-mediated response to infections

* IgM, IgE, and IgD are low at birth

* IgM, IgE, __, and IgD do not cross placenta and they approach adult levels at different ages

Answer 10

IgA

Question 11

__ acquired immunity

* Results from antibody transfer from one person to another - mother to her fetus

* The fetus usually receives maternal IgG antibodies across the placenta

* Most maternal antibodies start to dissipate around 6-9 months

* Neonates are susceptible to infections by bacteria - Escherichia coli

Answer 11

Passive

Question 12

__ acquired immunity

* Results when the body reacts to an antigen

* Is progressive

Answer 12

Active

Question 13

Laboratory & Diagnostic Tests

* Laboratory and diagnostic tests of the immune function

> Serum immunoglobulins IgG, IgM, IgA, and IgE

> Serum antibody titer - received antigens in vaccines

> Skin test to candida or tuberculosis

> Differential WBC

Answer 13

* Allergy skin tests
> Anaphylaxis reactions - emergency equipment and medications

Radio ALLERGOSORBENT test (RAST)

Question 14

Human Immunodeficiency Virus (HIV) - Pathophysiology

* HIV is a retrovirus

* CD4 cells primarily enhance cell-mediated immunity

* CD4 helper cells also interact with humoral immune response

Answer 14

* HIV is present in an infected individual in blood or body fluids and can be transmitted by
> sharing of needles and syringes
> engaging in unprotected sexual activity with an infected partner,
> or receiving an infected blood product

* Infected woman can also transmit the virus through
> the fetus across the placenta during pregnancy
> into the infant at delivery
> and into the young child through breastfeeding

Question 15

Manifestations of HIV in Children

* HIV infection in children and adults differ

* Progression of HIV infection to AIDS occurs faster in infants and children younger than 5 years of age - higher viral load

* Physical and developmental failure to thrive

Answer 15

* Early opportunistic infections (chronic oral candidiasis), a greater number of bacterial infections from childhood illness, and lymphoid interstitial pneumonitis (LIP)

> Pneumocystis jirovecii (nee carinii) pneumonia (PCP)

Question 16

CDC classifies clinical manifestations of HIV infection based on CD4 cell counts:

Stage __ - 1st 180 days after infection

Stages __-__ monitor disease progression based on CD4 cell counts according to age group

Answer 16

0

1-3

Question 17

__ signs - important if they persist or reoccur

> like anemia, neutropenia, thrombocytopenia, diarrhea, fever for longer than one month, herpes simplex, and oral candidiasis in children older than 6 months

Answer 17

moderate

Question 18

__ signs - nonspecific: lymphadenopathy, hepatomegaly, splenomegaly, dermatitis, parotitis, and recurrent or persistent upper respiratory infection, sinusitis, or otitis media

Answer 18

mild

Question 19

Other signs may include

> bacterial meningitis

> pneumonia, or sepsis (one episode)

> cardiomyopathy

> complicated chickenpox

> herpes zoster

Answer 19

> hepatitis

> nephropathy

> LIP, and

> toxoplasmosis onset before age of one month

Question 20

Most common indicators of ___ ___ include bacterial infections, LIP, PJP, opportunistic infections, encephalopathy, lymphomas, Kaposi sarcoma, severe nutritional deficits with fall off on growth percentiles (wasting syndrome) without evidence of another cause

Answer 20

stage 3

Question 21

! Diagnostic Evaluation of HIV

* Result of perinatal transmission

* Universal testing for all pregnant women unless they “opt out”, and HIV counseling

Answer 21

! Diagnosing HIV-exposed infants

* Virologic assay tests - HIV deoxyribonucleic acid polymerase chain reaction (PCR) or HIV ribonucleic acid (RNA) assay

* Virologic testing is performed when the infant is 14-21 days old, at 1-2 months, and again at 3-6 months for those infants who have been exposed to HIV

* 2 positive virologic assays obtained on 2 separate occasions can establish a positive diagnosis

Question 22

! Ongoing diagnostic monitoring includes CD4+ lymphocyte counts and HIV RNA assays

Question 23

Therapeutic management of HIV

* HIV-exposed infants

> During labor an HIV positive mother should be given Ziovudine (ZDV)

> All infants should also receive oral ZDV therapy within 6-12 hrs after birth

> Cesarean section at 38 weeks

> Treatment options and recommendations

> More prone to acquiring opportunistic infections

Answer 23

> More at risk for PCP, certain strains of TB, bacterial and viral infections, and fungal infections

> CDC recommends testing for TB at 3 mos of age or if exposed to contagious TB

> CDC recommends for varicella-zoster immunoglobulin to be given to unimmunized infants within 96 hours of exposure

Question 24

Pneumocystis jirovecii (carinii) pneumonia (PCP) is the most serious infection acquired by HIV-exposed infants

Answer 24

Treatment is directed towards
> suppressing viral load
> having the greatest effect while minimizing toxicity
> having an administration routine

Treatment - is multidisciplinary

Highly active antitretroviral therapy (HAART)

Test for antiretroviral drug resistance

Adherence ability

Question 25

Medications - drug classes include

• nucleoside analogue reverse transcriptase inhibitors (NRTIs and NtRTIs)
• non-nucleoside reverse transcriptase inhibitors (NNRTIs)
• protease inhibitors (PIs)
• entry and fusion inhibitors
• pharmacokinetic enhancers
• integrase inhibitors

Answer 25

Preferred drug combination for initial treatment

For NEONATES 42 weeks gestation and 14 days to younger than 3 years of age:

• 2 NRTIs plus raltegravir or nevirapine

Question 26

For children greater than 14 days to three years:

• 2 NRTIs plus raltegravir or lopinavir/ritinavir

Answer 26

For children three years of age and older or weighing <25 kg:

• 2 NRTIs plus raltegravir or 2 NRTIs plus atazanavir/ritinovir or darunavir/ritonavir

Question 27

For children three years of age or older weighing > or = 25 kg:

• 2 NRTIs plus dolutegravir or 2 NRTIs plus elvitegravir & cobicistat

Answer 27

For adolescent age greater than 12 years and weighing > or = 25 kg:

• 2 NRTIs plus bictegravir or 2 NRTIs plus dolutegravir 4/2 and NRTIs plus elvitegravir & cobicistat

Doses are individualized according to age and growth

Question 28

Nursing Care Plan

Nursing care plan for a child with HIV infection in the community

* Assessment

> Always child development and well care

> Assess the understanding of HIV and related spectrum

> During hospital admission - always assess

• hydration status
• respiratory status
• mucous membranes
• skin lesions
• pain

Answer 28

Nursing diagnosis

* Deficient knowledge about the natural history of pediatric HIV infection, potential complications associated with HIV infection, and current treatment modalities related to an emotional reaction to the diagnosis

* Ineffective therapeutic regimen management nonadherence related to lack of support systems or denial of the illness

Question 29

How to care for a child with HIV infection

* Nurses should provide information at the time of initial testing and in subsequent visits

> Transmission
> Prevention
> Testing
> AIDS illness
> Medications

Answer 29

Home care

* Offering a high calorie, high protein diet if there’s a growth problem

* Home care instructions - include basic infection control measures - follow standard precautions

* Immunization information

* Give prophylaxis against PCP and anti-retroviral drugs as ordered

Question 30

Corticosteroid Therapy

Corticosteroids are usually given as part of a treatment regimen

> Topical steroids are applied to the skin and mucous membranes

> Systemic steroids reduce the inflammatory symptoms of generalized allergic reactions

> Inhaled corticosteroids produce very strong local action

Answer 30

Pathophysiology

* Corticosteroids possess anti-inflammatory and immunosuppressive properties

* Usually, the higher the dose and the longer the medication is taken = more serious side effects

* Long-term use of steroid therapy may be associated with adverse effects

Question 31

Manifestations of excess corticosteroid therapy

* Excess topical administration of steroids

• Skin atrophy, delayed wound healing, telangiectasis, dilation of cheek blood vessels, striae, and excess absorption which can lead to any of the clinical manifestations of systemic use

Answer 31

* Excess systemic administration

• Edema (especially in the face), GI irritation with bleeding, bruising and delayed wound healing, susceptibility to infections, growth limitations, HTN, loss of muscle mass, increased appetite and weight gain, amenorrhea, pancreatitis, joint pain and osteoporosis that can lead to bone fractures and cataracts

Question 32

* Goal is to prevent corticosteroid excess

> Short-term high dose therapy is preferred over long-term therapy

> If long-term therapy is necessary, alternate - day administration is preferred

> At the time of an acute infection or surgery - supplementary steroids are indicated for children who have received them over a long period of time

> Killed-virus vaccines are substituted for live-virus vaccines for children receiving high-dose or long-term steroids

Answer 32

Nursing diagnosis

* Ineffective therapeutic regimen management nonadherence related to associated complications; disturbed body image related to changes caused by the treatment

* Risk for infection related to amino suppression for injury adrenal insufficiency delayed wound healing related to insufficient knowledge

* Risk for delayed growth and development related to growth suppression and muscle wasting

Question 33

Interventions

* Written instructions
* Never discontinued abruptly
* The child should take medications with food and milk
* Encourage eating low calorie snacks throughout the day
* Avoid salt intake
* Liquid forms of corticosteroids can seem unpalatable
* Emphasize that changes in appearance are temporary and reversible

Answer 33

* Mask infections
* Skin should be inspected routinely
* Family should not be treating child with OTC products
* Avoid others who are sick
* Can impact growth and bone density
* Accidents should be prevented

VERY IMPORTANT NOTE

* Long-term corticosteroid use causes adrenal insufficiency
* Supplemental glucocorticoids may be necessary

Question 34

Systemic Lupus Erythematosus (SLE)

* Chronic autoimmune disease characterized by inflammation of connective tissue marked by remissions and exacerbations

* Pathophysiology - autoantibodies or anti-nuclear antibodies (ANA’s) act against DNA and other cell nucleus components - leading to damaged tissues and organs including the skin, joints, heart, lungs, kidneys, brain, and circulatory vessels

Answer 34

* Systemic lupus etiology is unknown

* Environmental factors include exposure to the sun, UV light, stress, fatigue, viruses, bacteria, certain medications, and some food activities

Question 35

SLE Manifestations

* Frequent early manifestations - malaise, arthralgia, and recurrent fever of unknown etiology

S&S depend on the organs affected by the immune complexes

• Malar butterfly rash
• Discoid rash
• Photo sensitivity
• Oral and nasal ulcers
• Arthritis
• Pleuritis, pericarditis, or peritonitis

Answer 35

• Renal disorder
• Neurologic disorders
• Hematologic disorders - anemia, leukopenia, lymphopenia, or thrombocytopenia
• Immunologic disorders
• Positive antinuclear antibody (ANA) assay

Question 36

SLE Therapeutic Management

* Targeted at organ system or systems affected - aimed at preventing exacerbations and complications

* The goal is to use the least amount of pharmacological intervention

* Systemic corticosteroids

* Non-steroidal anti-inflammatory drugs (excluding ibuprofen)

* Anti-convulsants and antihypertensive therapy

Answer 36

* Antimalarial drugs such as hydroxychloroquine (Plaquenil)

* Killed virus vaccines are always given over live vaccines

* Low salt diet

* Adverse outcomes include delayed growth and onset of puberty, decreased bone mass, atherosclerosis, and decreased quality of life

Question 37

SLE Nursing Diagnosis

* Disturbed body image related to change is secondary to the disease process and treatments

* Powerlessness related to memory and emotional alterations

* Activity intolerance related to the effects of the disease process

* Chronic pain related to arthritis and numbness of the hands and feet

* Ineffective therapeutic regimen management nonadherence related to associated complications and developmental level

Answer 37

Interventions

* Explain the importance of drug therapy and activity restriction

* Identify and avoid triggers

* Prevent Raynaud’s phenomenon
> Some areas of the body feel numb and cool in certain circumstances

* Document episodes of fatigue along with associated activities

* In adolescents wearing makeup can mask rashes and improve appearance

* Refer to national SLE organizations

Question 38

Allergic Reactions

An allergy is an immune response to an antigen also called an allergen

The hypersensitivity reaction with the second exposure to the antigen - immediate or delayed

Allergic rhinitis is an immediate hypersensitivity reaction to allergens trapped by the hairs and mucous that line the inside of the nose

Anaphylaxis is a life-threatening immediate allergic response

Allergic reactions are related to the antibody IgE

Answer 38

Classification of allergic reactions

• Classed 1-4

Question 39

?

allergic rhinitis, acute anaphylaxis, hives, eczema, asthma

Answer 39

I. Immediate anaphylactic hypersensitivity

Question 40

?

contact dermatitis, e.g., poison ivy

Answer 40

IV. Delayed cell-mediated hypersensitivity

Question 41

?

transfusion reaction after receiving incompatible blood

Answer 41

II. Cytotoxic hypersensitivity

Question 42

?

serum sickness, glomerulonephritis

Answer 42

III. Arthus hypersensitivity or immune complex

Question 43

Anaphylaxis

Severe immediate hypersensitivity reaction to an excessive release of chemical mediators that affects entire body

Food allergies are the major cause of anaphylaxis
> peanuts (including peanut butter), tree nuts (cashews, almonds, walnuts, pecans, pistachios)
> other food allergies include milk, eggs, wheat, shellfish, and other fish

Answer 43

Other causes = penicillin or other antibiotics, insect stings, immunizations, allergy, immunotherapy, chemotherapeutic agents, blood products, diagnostic contrast media

Latex-containing products can lead to anaphylactic reactions

Question 44

* sudden onset

* Initial symptoms include

> Sneezing
> Tightness or tingling of the mouth or face with swelling of lips and tongue
> Severe flushing, urticaria, itching of the skin - especially the head and upper trunk
> Rapid development of erythema
> Sense of impending doom
> May be followed by GI or respiratory symptoms
- Nausea, vomiting, diarrhea, cramping, as well as rhinorrhea, stridor, wheezing, and hoarseness

Answer 44

> Most serious symptoms of anaphylaxis include laryngospasm and edema, cyanosis, hypotensive shock, vascular collapse, cardiac arrest

* Biphasic reaction can occur (the recurrence of anaphylaxis symptoms within 72 hrs of the initial anaphylactic event, without re-exposure to the trigger)

Question 45

Therapeutic Management of Anaphylaxis - treatment must begin immediately

If in the community:

* Immediately activate the emergency response system

* Inject epinephrine - epinephrine (0.1 mg/kg/dose of 1:1000 concentration)

* EpiPen (0.3 mg) - weigh more than 25 kg

* EpiPen Junior (0.15 mg) - weigh 10-25 kg

* May administer oral diphenhydramine, a histamine inhibitor (ranitidine or cimetidine), and oral corticosteroids

* Transfer by ambulance to an emergency facility and observe for 4-6 hours

Answer 45

If in a hospital or emergency setting, to manage anaphylactic shock:

* Establish adequate airway (may even have endotracheal intubation)

* Administer epinephrine, oxygen

* Administer corticosteroids and antihistamines

* Keep the child warm and lying flat or with feet slightly elevated

* Start an IV line

Question 46

Nursing Care of the Child with Anaphylaxis

Assessment

* Observe airway patency, respiratory rate and effort, heart rate, peripheral pulses, capillary refill, oxygen saturation, urine output, level of consciousness

Answer 46

Nursing diagnosis

* Ineffective breathing pattern and decreased cardiac output related to an excessive hypersensitive reaction to an allergen

* Deficient knowledge about allergens and prevention through risk reduction related to inexperience

Question 47

Interventions

* Maintain a patent airway with adequate oxygenation

* A laryngoscope and intubation tray, a tracheostomy kit and a code cart should always be available

* Insect sting or injected medication - use a tourniquet to confine allergen

* Establish IV access

Answer 47

* Administer IV fluids, epinephrine, corticosteroids, antihistamines

* Look for signs of palpitations and tachycardia - assure child

* Teach the child who has experienced an anaphylactic reaction how to use an injectable epinephrine