The Child with an Allergy and Immunological Alteration Flashcards by Kaylie Krauzyk

What is the immune system?

* First line defense - internal defense system

> Provides secondary and tertiary protection through nonspecific and specific responses

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

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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

Inflammatory response

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

Complement

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___ - 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

Phagocytosis

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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

Humoral; cell-mediated

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___ - 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)

Lymphocytes

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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

cell-mediated

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B cells are responsible for the ___ response

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

humoral

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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

20-24

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* 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

IgA

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__ 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

Passive

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__ acquired immunity

* Results when the body reacts to an antigen

* Is progressive

Active

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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

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

Radio ALLERGOSORBENT test (RAST)

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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

* 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

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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

* 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)

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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

1-3

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__ 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

moderate

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

mild

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Other signs may include

> bacterial meningitis

> pneumonia, or sepsis (one episode)

> cardiomyopathy

> complicated chickenpox

> herpes zoster

> hepatitis

> nephropathy

> LIP, and

> toxoplasmosis onset before age of one month

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

stage 3

! Diagnostic Evaluation of HIV

* Result of perinatal transmission

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

! 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

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

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

> 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

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

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

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

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

For children greater than 14 days to three years: - 2 NRTIs plus raltegravir or lopinavir/ritinavir

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

For children three years of age or older weighing \> or = 25 kg: - 2 NRTIs plus dolutegravir or 2 NRTIs plus elvitegravir & cobicistat

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***

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

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

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

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

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

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

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

\* 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

\* 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

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

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

\* 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

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

\* Systemic lupus etiology is unknown \* Environmental factors include exposure to the sun, UV light, stress, fatigue, viruses, bacteria, certain medications, and some food activities

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

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

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

\* 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

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

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

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_

Classification of allergic reactions - Classed 1-4

? allergic rhinitis, acute anaphylaxis, hives, eczema, asthma

I. Immediate anaphylactic hypersensitivity

? contact dermatitis, e.g., poison ivy

IV. Delayed cell-mediated hypersensitivity

? transfusion reaction after receiving incompatible blood

II. Cytotoxic hypersensitivity

? serum sickness, glomerulonephritis

III. Arthus hypersensitivity or immune complex

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

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

\* 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

\> 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)

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

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

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

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

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

\* 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