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    Infcomdisbw Infcomdisbw Presentation Transcript

    • PEDIATRIC LYMPH/INFECTIOUS/IMMUNE SYSTEM & COMMUNICABLE DISEASES
        • Commensalism: Host provides shelter & food for organism; organism retains ability to exist independently
        • Mutualism: Host provides shelter & food for organism; both benefit
        • Parasitism: Host provides shelter & food; parasite benefits, but host may be harmed.
      MICROORGANISMS & HOST RELATIONSHIPS:
    • IMMUNITY
    •  
    • What we will cover today…
      • Overview: A & P of Immune System
      • Diagnostic Tests and Assessment
      • Nursing Techniques & Procedures
      • Congenital Immunology Health Problems
      • Acquired Immunologic Health Problems
      • Infectious Immunologic Health Problems
    • Overview …
      • Nonspecific immunity (resistance of body to a harmful organism)
      • Functional at birth
      • First line of defense
      • Reacts similarly to all invaders
      • Includes phagocytosis of foreign material by white blood cells
    • Nonspecific immunity ( resistance of body to a harmful organism)
      • Includes phagocytosis of foreign material by white blood cells
      • PMNs or granulocytes , which include basophils, eosinophils, & neutrophils, are most common type of white blood cells & are involved in acute inflammatory process (1 st line of defense)
      • Monocytes migrate to tissues where y become macrophages & have great phagocytic ability, functioning to eliminate foreign invaders & or material
      • Lymphocytes include B lymphocytes (B cells) & T lymphocytes (T cells), are responsible for specific immune response as well as NK cells (Natural Killer cells) concerned w/ viral control as well as autoimmune responses
    • Inflammatory response
      • A NONSPECIFIC RESPONSE to any tissue injury aimed at maintaining body's homeostasis;
      • chemicals are released from injured cells,
      • which cause blood vessels to dilate,
      • bringing large numbers of neutrophils & macrophages to area
      • for phagocytosis of injured cells & foreign material,
      • allowing healing to occur
    • Specific immune response
      • Second line of defense
      • Not functional at birth, must be learned by body
      • Not fully functional until a child is 6 years old
    • Specific Immune Response
      • Humoral immunity depends upon antibody-producing abilities of B-cells
      • In response to antigens (foreign substances that trigger an immune response), B-cells convert into plasma cells & secrete specific antibodies (immune system proteins) to assist body in eliminating foreign proteins
    • Specific Immune Response
      • Five classes of antibodies w/ different functions
      • IgG is antibacterial & antiviral antibody found in large quantities in all body fluids; this antibody can cross placenta; maternal IgG provides passive immunity for first 6 months of infant's life
      • IgA is found in saliva, tears, bronchial secretions, mucous secretions of small intestine, vagina & in breast milk; IgA is not present at birth & reaches normal levels at 6 to 7 years of age
      • IgM is body's primary antibody response to an antigen; IgM levels are low at birth & reach adult levels by 1 year of age
      • IgD's role in unknown but seems to be related to B-cell differentiation
      • IgE is normally found in very small amounts; IgE is associated w/ allergic reactions; elevated levels of IgE are associated w/ allergic individuals & clients infected w/ intestinal parasites; IgE is not present at birth
    • Cellular response
      • T cells are produced in thymus & function to protect individual from intracellular organisms, viruses, & slow growing bacteria
      • Responsible for rejection of foreign grafts
      • Specialized types of T cells include killer T cells, suppressor T cells, & helper T cells
      • Killer T cells kill virus infected cells & depend upon IgG being bound to cell
      • Suppressor T cells inhibit activities of other T & B cells
      • Helper T cells help regulate actions of B cells
    • Complement
      • Enzyme that responds to antigen-antibody reactions causing inflammation & destruction of foreign cells
      • Plays a role in autoimmune diseases (body attacks itself)
      • Levels of proteins lower in newborns than older children & adults
    • Diagnostic Tests & Assessments of Immune System
      • Bone marrow aspiration : fluid-containing bone marrow cells are aspirated from iliac crest to provide information about hematologic & immunologic disorders
        • Usually performed under local anesthesia
        • Post-procedure complications include bleeding & infection
    • Diagnostic Tests & Assessments of Immune System
      • White cell differentials (differential blood count ): compare % of types of white cells against whole; by evaluating ∆ in types of WBCs, information can be obtained related to type of infection
        • Neutrophils  in response to acute infections
        •  eosinophil counts are associated w/ allergies & parasitic infections as well as skin diseases such as eczema & psoriasis
        • Basophil counts may  in response to chronic infection & stress; white blood cells contribute to inflammatory process & allergic reactions because they release histamine
    • Allergy testing
      • Determines reactions to specific antigens
      • Four types of allergy tests available
        • Scratch tests can test many antigens at once; although less sensitive than or allergy tests, results can be obtained in about 30 minutes
        • Prick test is similar to scratch test in that antigens are placed on skin; tends to be slightly more sensitive than scratch test
    • Allergy testing
      • More types of allergy tests available…
        • Intradermal testing injects antigen into dermis; reactions are noted by redness & swelling
        • Radioallergosorbent testing (RAST) looks for allergen-specific IgE antibodies in a blood sample; it is no more sensitive than other methods but does not involve risk of anaphylaxis or allergic reactions
    • Common Nursing Techniques & Procedures for Immune System
      • Immunity from disease can be acquired either from exposure to disease or by immunization (introducing an antigen into body)
        • Active immunity involves body's formation of antibodies in response to exposure to an antigen
        • Passive immunity is temporary immunity achieved by administration of antibodies produced by another individual; when antibodies pass from mother to fetus, passive immunity is acquired
    • Vaccines
      • Contain antigens to specific diseases; they cause body to respond w/ development of antibodies & active immunity
      • Vaccines may contain killed virus, live virus, or toxoids;
        • live vaccines have weakened virus but still carry risk of infection;
        • killed virus & toxoid vaccines do not carry this risk;
        • live vaccines should be avoided in immunocompromised or pregnant client
    • Vaccines
      • Childhood vaccinations are currently recommended for hepatitis B, diphtheria, tetanus, pertussis, hemophilus influenzae B, polio, measles, mumps, rubella, & varicella; vaccinations for hepatitis A are also recommended in certain areas
      • Vaccination schedules allow initial vaccination to occur after passive immunity from mother has disappeared; some vaccinations do not provide lifelong immunity & should be repeated
    • Vaccines
      • American Academy of Pediatrics provides current recommendations on vaccination schedule
      • Prior to administering vaccinations, absence of allergic reaction history should be verified
      • Instruct parents to maintain vaccination schedule; if vaccinations are delayed, follow AAP recommendations for completing vaccination program
    • Congenital Immunologic Health Problems
      • Severe combined immunodeficiency disease
        • Description
          • Severe combined immunodeficiency disease (SCID) is most severe of several different congenital disorders of immune system yielding susceptibility to infections
          • Other forms of immunodeficiency include B cell & T cell deficiencies
    • Congenital Immunologic Health Problems
        • Etiology & pathophysiology
          • SCID occurs as a result of x-linked recessive or autosomal recessive inheritance, as well as because of a spontaneous mutation
            • Characterized by absence of both humoral & cellular immunity
            • Maternal antibodies may protect infant for a short period of time, but chronic infections become apparent around 3 months of age
            • Death usually occurs w/in first 2 years of life
    • Congenital Immunologic Health Problems
        • Assessment
          • Initial infection often persistent thrush (oral candidiasis)
          • Followed by chronic infections
          • Organisms causing infection may include cytomegalovirus & Pneumocystis carinii
          • Failure to thrive also accompanies diagnosis
          • Leukocyte counts are usually reduced
    • Congenital Immunologic Health Problems
        • Priority nursing diagnoses
          • Risk for infection related to immunodeficiency
          • Altered growth & development
          • Altered nutrition: less than body requirements
          • Risk for ineffective coping
    • Congenital Immunologic Health Problems
        • Planning & implementation
          • Protecting child from infection is of primary importance; careful hand-washing is essential, as well as preventing contact w/ infected individuals
          • Live plants & fresh flowers should be avoided as they harbor mold & bacteria
          • While hospitalized, care should be taken in planning room assignment to reduce exposure to infection
          • Bone marrow transplant offers best hope for survival
    • Medication Therapy
      • Intravenous immune globulin (IVIG) (see Box 11-1)
      • Immunizations should be administered 14 days prior to or 3 months after IVIG administration
      • Antibiotic therapy when indicated; monitor for overgrowth of non-susceptible organisms
      • Maintain intact skin & mucous membranes
    • Client education
      • Teach family ways to protect child from infection
      • Provide emotional support & support group referrals
      • Genetic counseling provides family w/ information about transmission
    • Evaluation:
      • Client remains free of infection; family demonstrates appropriate coping methods related to diagnosis & prognosis
    • Acquired Immunologic Health Problems
      • Allergies
        • Description
          • Hypersensitivity to a foreign protein
          • Antigen-antibody reaction causes release of histamine & or chemicals into body; chemicals are responsible for allergic symptoms
          • Broad group of disorders; symptoms vary dependent on body cell that has been sensitized
    • Acquired Immunologic Health Problems
      • Allergies
        • Etiology & pathophysiology
          • First exposure to antigen causes production of antibodies (usually IgE)
          • Subsequent exposure to same antigen causes an antigen-antibody reaction w/ cell damage causing release of histamine & or chemicals
          • Chemicals travel through bloodstream causing allergic symptoms
    • Acquired Immunologic Health Problems
      • Allergies
        • Etiology & pathophysiology
          • Most allergens are large molecular weight proteins
            • Common inhalant allergens include mold, pollen & house dust, pet dander
            • Common food allergens include cow's milk, eggs, wheat, chocolate, citrus fruits
            • Drugs including oral & injectables
            • Animal serum/venom & insect stings
            • Contact allergens include plants, dyes, & chemicals
    • Assessment
      • Family history of allergies
      • History of reactions: allergy symptoms can be numerous
        • Respiratory system: allergic rhinitis, asthma, serous otitis media, allergic croup
        • Skin: eczema, atopic dermatitis, angioedema, urticaria
        • Gastrointestinal system: diarrhea, constipation, colic
    • Assessment
      • History of reactions: allergy symptoms can be numerous
        • Neurologic system: headache, tension-fatigue, convulsions
        • Genitourinary system: dysuria, enuresis
        • Miscellaneous: serum sickness & anaphylaxis
      • Elevated eosinophil counts
    • Assessment
      • Allergy testing: Skin or RAST test
        • Skin testing can involve a scratch or intradermal injection of small amounts of suspected allergens; scratch test is often an initial diagnostic tool as it allows for testing a large number of allergens quickly w/ results in about 30 minutes; if child is allergic to allergen, a reddened wheal will form in 15 to 30 minutes; anaphylaxis during testing; it is more expensive & felt to be less sensitive.
    • Assessment
      • Allergy testing: Skin or RAST test
        • RAST test is a blood test looking for specific IgE antibodies; used in individuals who have a history of a strong reaction, as this test allows no opportunity for anaphylaxis during testing; it is more expensive & felt to be less sensitive
    • Priority nursing diagnoses
      • Risk for injury
      • Altered tissue perfusion: cardiopulmonary
      • Impaired skin integrity
      • Diarrhea
      • Knowledge deficit
    • Planning & implementation
      • Interventions are aimed at reducing exposure to allergen
        • Food. once food allergens are identified, all labels of prepared food should be carefully read to avoid allergens
        • Environment: create surface that's easily cleaned; focus in particular on child s bedroom; no carpet, bedroom curtains & bedding should be washable; avoid dust-collecting items in bedroom; avoid live plants & flowers; keep animals out of bedroom; no stuffed toys in bedroom
        • Inhalant: avoid cigarette smoking in child's presence & environment
    • Planning & implementation
      • Interventions are aimed at reducing exposure to allergen
      • Immunotherapy aims at increasing child's tolerance of allergen; also called hyposensitization or allergy shots, this rapy provides for introduction of allergen in small but increasing amounts by subcutaneous injections
    • Planning & implementation
        • Injections are given in controlled environment because of risk of systemic reaction or anaphylaxis
        • Child remains in controlled environment for 15 minutes post-injection to allow for monitoring of side effects
        • Emergency treatment must be readily available in case anaphylaxis occurs
    • Medication Therapy
      • Antihistamines are given prior to or early in reactive phase; antihistamines compete w/ histamine on receptor sites, refore if given late in reaction, will be ineffective
      • Bronchodilators may be given for lower-respiratory symptoms
    • Medication Therapy
      • Corticosteroids may be administered systemically or topically, depending upon symptoms
      • Cromolyn sodium is a preventive medication for asthma; it is not useful during an acute attack
      • Epinephrine is administered for anaphylaxis
    • Client education
      • Parents & child should be taught to manage symptoms, control environmental exposure, & recognize medical emergencies
      • Obtain medic alert bracelets, especially for drug allergies
      • Safe administration of medications
    • Evaluation:
      • Child & Parents verbalize medication understanding, demonstrate their use correctly, & verbalize environmental control of allergens
    • Infectious Immunologic Health Problems
      • TORCH is an acronym for a group of infections, which when acquired in utero, cause teratogenesis
        • T is for toxoplasmosis: toxoplasmosis is an infectious disease by organism Toxoplasma gondii & is usually contracted from cat feces & undercooked meats
        • 0 is for other, which includes syphilis & hepatitis; congenital syphilis is caused by spirochete Treponema pallidum
    • Infectious Immunologic Health Problems
      • TORCH is an acronym for a group of infections, which when acquired in utero, cause teratogenesis
        • R stands for rubella; also called German measles
        • C refers to cytomegalovirus or CMV a member of herpes family
        • H is for herpes simplex virus
    • Etiology & Pathophysiology
      • Maternal exposure to organism allows fetal exposure through placenta
      • The earlier in gestation that infection occurs, greater damage that may occur
      • Mother may be asymptomatic during pregnancy & syndrome may not be recognized until after baby is born
    • Assessment
      • Assessment of newborn is comprehensive, reviewing all systems
      • Maternal history during pregnancy
      • Intrauterine growth retardation may be apparent at birth
    • Assessment
      • Symptoms including hydrocephalus, blindness, microcephaly, mental retardation, as well as FTT, suggest TORCH infection; depending upon organism involved, infant may also display jaundice, rash, deafness, cardiac defects
      • Serologic blood sampling for toxoplasmosis, rubella, CMV; & herpes; VDRL for syphllis & a hepatitis profile
    • Priority nursing diagnoses
      • Altered nutrition: less than body requirements
      • Risk for altered parent attachment
      • Altered growth & development
    • Planning & implementation
      • The child should be isolated as virus may be shed for up to a year after birth; pregnant women are at increased risk
      • Parents may grieve at loss of normal newborn; emotional support must be available
    • Planning & implementation
      • Physical care supporting infant's needs will be individualized
      • Nutritional support will be needed to support intake of food; child may require a nasogastric or gastric tube or utilize a "premie" nipple to make sucking easier
    • Medication Therapy
      • Depends upon infectious organism
      • For toxoplasmosis, an extended course of pyrimethamine (Daraprim) & sulfadiazine (generic) may be given; leucovorin may be added to reduce bone marrow suppression
    • Medication Therapy
      • Treatment for congenital syphllis is usually a 10 to 14 day course of penicillin
      • Acyclovir (Zovirax) is used to treat infants w/ congenital herpes infection
    • Client education
      • Parents are educated to meet physical needs of their handicapped infant; nutrition support is of primary importance
      • Infant stimulation to promote physical development of child; special instructions need to be given to assist parents working w/ blind or deaf child
      • Instructions must be given about potential viral shedding; parents are instructed to avoid contact w/ pregnant women
    • Evaluation:
      • Parents verbalize & demonstrate appropriate child care measures including nutritional support;
      • Parents express confidence in their ability to care for their child;
      • Parents demonstrate safe medication administration
    • Sepsis
      • Description: sepsis is systemic bacterial infection spread through bloodstream
      • Etiology & pathophysiology
        • Neonates are at high risk because of inability to localize an infectious organism; low birth weight is a risk factor for sepsis
    • Sepsis
      • Etiology & pathophysiology
        • Immunocompromised children at high risk
        • Children w/ skin defects/injuries or w/ invasive devices at high risk
        • Organisms involved include Escherichia coli, pseudomonas, enterococcus, staphylococcus
    • Assessment
      • Monitor clients for risk factors for sepsis
      • Hypothermia or hyperthermia
      • Lethargy, poor feeding
      • Jaundice or hepatosplenomegaly
      • Respiratory distress
      • Vomiting
    • Priority nursing diagnoses
      • Hypothermia
      • Hyperthermia
      • Ineffective infant feeding pattern
    • Planning & implementation
      • Maintain temperature w/in normal range w/ antipyretics as ordered, tepid sponge bath, appropriate clothing
      • Monitor blood glucose; support nutrition; lethargy, hypoglycemia, & hyperthermia can all contribute to poor feeding
      • Maintain antibiotic therapy on schedule, monitor for side effects
    • Medication therapy
      • Antibiotic therapy based on culture and sensitivity
      • Antipyretics such as acetaminophen (Tylenol) for elevated temperature
    • Client education
      • Teach the parents how to monitor temperature and means of maintaining a neutral body temperature
      • Instruct parents on the purpose of the antibiotics and potential side effects
    • Evaluation
      • Harmful sequelae of sepsis will be prevented
      • Parents are able to describe the purpose of the antibiotics and can list side effects for which the child is being monitored
    • Acquired immunodeficiency syndrome (AIDS)
      • Description: infection with retrovirus human immunodeficiency virus (HIV)
      • Etiology and pathophysiology
        • Virus transmitted through blood and body fluids of infected person
        • Most common source of infection in children is perinatally, from an infected mother to her infant
          • Across the placenta
          • At the time of birth
          • Possibly through breast milk
    • Acquired immunodeficiency syndrome (AIDS)
      • Etiology and pathophysiology
        • Also could be contracted from transfusions with infected blood or blood products
        • Once in the body, the HIV enters the T lymphocytes, particularly the CD4 cell
        • The CD4 cell begins synthesis of the HIV DNA
        • Leads to death of CD4 cell
        • Infected child is susceptible to infection caused by deficiency in cell-mediated and humoral immunity
    • Assessment
      • Diagnostic tests for HIV start at birth; the child of the HIV-positive mother is followed up to 18 months before infection can be determined; tests are divided into early (birth, 3, and 6 months) and later (12, 15, and 18 months)
      • Early tests to detect the HIV antigen (p24 antigen), HIV (HIV culture and polymerase chain reaction [PCR])
      • After maternal antibodies have disappeared, ELISA test (enzyme-linked immunosorbent assay)
    • Assessment
      • CBC and CD4 levels
      • Presenting symptoms include chronic diarrhea, failure to thrive, delayed development
      • Frequent infections including candidiasis, Streptococcus pneumoniae, Hemophilus influenzae , Staphylococcus aureus , and herpes simplex
      • Opportunistic infections including pneumocystis carinii
    • Priority nursing diagnoses
      • Risk for infection related to immunosuppression secondary to HIV infection
      • Altered nutrition: less than body requirements
      • Ineffective family coping
    • Planning and implementation
      • Focus on preventing infection
        • Normal health precautions including handwashing, avoiding contact with infected persons, maintaining nutritional status, good skin care, promoting a hygienic environment.
        • Immunizations on schedule; the child and all household contacts should avoid immunization with live virus vaccines
        • Following medical orders on prophylactic drugs
    • Management of symptoms
        • Diarrhea management, monitoring hydration and nutrition status, maintaining skin integrity
        • Monitoring for infection including pneumonia, meningitis, otitis media and others
        • Support of family coping
          • Encourage participation in parent support groups
          • Demonstrate acceptance of child during everyday contact
          • Utilize communication skills to allow parents to verbalize feelings
    • Medication therapy
      • Prophylaxis treatment
        • Against HIV: zidovudine (AZT)
        • Against pneumocystis cari nii: trimethoprim-sulfamethoxazole (Bactrim or Septra)
        • Against bacterial infections: intravenous immune globulin (IVIG)
          • Infections: appropriate antimicrobial therapy; for antibiotic therapy, see Table 11-1
    • Client education
      • Information is presented on preventing the spread of HIV to other members of the household and those having contact with the child
      • Parents are taught to maintain a clean home environment and ways to reduce bacterial exposure
      • Information about nutritional support, diarrhea, and skin management as well as medication regimen is given
      • Developmental stimulation information is shared with the parents
      • Infection monitoring information is given to the parents
    • Evaluation:
      • Parents :
      • Verbalize medication regimen, describe safety measures to prevent infection,
      • Identify symptoms of infection to be reported to physician,
      • Discuss their concerns about caring for this child, and join a support group
    • Childhood communicable diseases
      • Description: a group of diseases common during childhood
      • Etiology and pathophysiology
        • Variety of diseases spread from person to person
        • Infectious organism often viral
      • Mode of transmission describes how the organism moves from one individual to another
      • Incubation period describes the time between exposure to the disease and disease outbreak; during this time, the child may be contagious
      • Period of communicability is the time period when the organism can move from the host to another individual
    • Assessment
      • in contact with children should be constantly alert to the appearance of symptoms associated with the childhood diseases and take measures to prevent the spread the infection to other children
      • Client history will include record of vaccinations as well as history of exposure to children with communicable diseases
      • Regardless of the reason the child is seeking treatment, all children should be assessed for symptoms of communicable diseases including rashes, temperature, and swollen glands
      • The period of time between the initial symptoms and the presence of the full-blown disease is called the prodromal period
    • Priority nursing diagnoses
      • Hyperthermia
      • Risk for injury secondary to complications of childhood diseases
      • Body image disturbance
      • Risk for impaired skin integrity related to scratching secondary to itch
      • Social isolation
    • Planning and Implementation
      • Immediate steps are taken to reduce exposure of other children to the possibly infected child
      • Monitor temperature and use temperature control measures to reduce hypertbermia
        • Tepid baths
        • Limit clothing and bed coverings
        • Give NSAIDs as ordered; avoid aspirin as aspirin intake with a viral infection may contribute to the development of Reye syndrome
        • Increase liquid intake
    • Medication therapy
      • Antibiotic therapy usually not recommended unless secondary bacterial infection occurs
      • Antipyretics, analgesics, and anti-inflammatory drugs may be ordered; aspirin is usually contraindicated in acute viral infections
    • Client education
      • Instructions should be given regarding available vaccines to prevent the development of childhood contagious disease
      • Information should be given regarding isolation precautions for the illness
      • Parents should be aware of symptoms that indicate the development of complications of the specific illness
    • Evaluation:
      • Client receives vaccinations on schedule;
      • Client develops no complications of childhood communicable disease;
      • Parents describe isolation precautions for their child with a communicable disease
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    • Lymph System
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    •