Nursing Care of Children with Immunologic Alterations By Nataliya Haliyash, MD, BSN Insitute of Nursing, TSMU

Nursing Care of Children with Immunologic Alterations

By Nataliya Haliyash, MD, BSN

Insitute of Nursing, TSMU

Lecture objectivesUpon completion of this chapter you will be able to:Upon completion of this chapter you will be able to: Describe the normal functions of the immune system. Describe the etiology, clinical manifestations, and

medical treatment for the common immune system alterations, juvenile idiopathic arthritis (JIA), systemic lupus erythematosus (SLE), human immunodeficiency virus (HIV), and allergic reaction to drugs.

Identify nursing management of children with immune system alterations, including developmental and psychosocial needs.

Identify the education, resource, and support needs of families who have children with immune system alterations.

Functions of the immune system

to prevent or ameliorate infections, to recognize self from nonself, to maintain homeostasis.

Two basic divisions

The innate immune system acts as the first line of defense against infections, and includes biochemical and physical barriers.

The adaptive immune system produces a specific reaction to each infectious agent, remembers that agent, and can prevent a later infection by the same agent.

The immune system includes:

the spleen, lymph nodes, and lymphoid tissue,

cellular elements such as the white blood cells or leukocytes, phagocytes, and natural killer cells.

Each lymphoid organ plays a role in the production and activation of lymphocytes. Lymphoid organs include:

adenoids (two glands located at the back of the nasal passage)

blood vessels (the arteries, veins, and capillaries through which blood flows)

bone marrow (the soft, spongy tissue found in bone cavities)

lymph nodes (small organs shaped like beans, which are located throughout the body and connect via the lymphatic vessels)

lymphatic vessels (a network of channels throughout the body that carries lymphocytes to the lymphoid organs and bloodstream)

Peyer's patches (lymphoid tissue in the small intestine)

spleen (a fist-sized organ located in the abdominal cavity)

thymus (two lobes that join in front of the trachea behind the breast bone)

tonsils (two oval masses in the back of the throat)

A Lymphocytes Cell at Work

T cell (left) recognizes antigens on the surface of a cell infected with a virus (right), enabling the T cell to bind to and kill the infected cell.

The immune system of neonates and young children is immature.

Because of this immaturity, infants and young children are susceptible to infectious organisms that can cause illness and its associated morbidity.

A child's immune system matures by three to sixthree to six years of age.

Immunity

The term refers to all the processes used by the body to protect against foreign material from environmental sources, including microorganisms or their toxins, foods, chemicals, pollen, dander, or drugs.

Innate or natural immunity Acquired immunity

Innate or natural immunity

nonspecific, function against most threats to the body in a

broad sense. Is represented by physical barriers such as:

– the skin, mucous membranes, – cough reflex; – chemical barriers such as pH of the stomach, fatty acids and

proteolytic enzymes of the small intestine,– fever.

Nonspecific immune cells such as phagocytes (macrophages, neutrophils, natural killer cells), and lymphocytes whose granules release lysing chemicals.

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 of primarily the T lymphocytes

Although immune system alterations occur less commonly in children than other types of alterations, the effects are often disabling or terminal.

In addition, the immune system interacts with other body systems so symptoms may not appear to be immune related but rather primarily musculoskeletal,– juvenile arthritis,

or integumentary– systemic lupus erythematosus.

HIV, another immune system disease, can affect all organ systems.

AUTOIMMUNITY: The inability of the body to distinguish "self" from other, leads to an immune response aimed at parts of one's own body.

INFLAMMATION: Increased blood flow and permeability of blood vessels; results in increased fluid production and attraction of lymphocytes and leukocytes to the area, caused by the release of inflammatory substances called cytokines.

Juvenile Idiopathic Arthritis (Juvenile rheumatoid arthritis (JIA, JRA)) A term used for a group of idiopathic chronic

autoimmune inflammatory diseases affecting joints and connective tissues in children with onset before 16 years of age

JIA 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.

Pathophysiology of JRA

Current research suggests T cell activation triggers development of antigen-antibody complexes, which cause release of inflammatory substances called cytokines in targeted organs such as joints and skin.

This causes inflammation of the synovial membranes and other tissues leading to joint effusion and swelling.

Chronic inflammation eventually evolves into erosion of articular cartilage and other symptoms of inflammatory diseases

Juvenile Idiopathic Arthritis

Patho (arthritis)– Bone overgrowth– Inflamed

synovial membrane

– Excess synovial fluid

– Thinning cartilage

Juvenile Idiopathic Arthritis Clinical manifestations

– Systemic onset • Fever (usually high) • Rash (Salmon-pink, migratory, macular/papular, most

common late afternoon or early evening)• Arthralgia/myalgia• Arthritis• Fatigue/malaise• Lymphadenopathy• Hepatosplenomegaly• Possible signs of carditis

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arthritis is defined as joint swelling or effusion, or two of the following:

warmth, pain on motion, or limited range of

motion

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.

Diagnosis of Juvenile Idiopathic Arthritis American College of Rheumatology

diagnostic criteria – Onset before 16 years of age– Arthritis of at least 6 weeks’ duration

(objectively observed)– A defined subtype (by onset characteristics)– Exclusion of other conditions such as other

rheumatic diseases

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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

Treatment of Juvenile Idiopathic Arthritis Multidisciplinary approach Medications Physical and occupational therapy Nutritional considerations Family teaching

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 years or 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 genetic susceptibility and probably a viral or bacterial trigger

SLE: Uncontrolled Dialog Between T and B Cells

Diagnosis of Lupus Erythematosus Clinical manifestations (American College of

Rheumatology Ad Hoc Committee of Systemic Lupus Erythematosus diagnostic criteria) – 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

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The round or disk shaped (discoid) rash of lupus produces red, raised patches with scales. The pores (hair follicles) may be plugged. Scarring often occurs in older lesions. The majority (approximately 90%) of individuals with discoid lupus have only skin involvement as compared to more generalized involvement in systemic lupus erythematosis (SLE).

SLE: Malar rash

This young woman has a malar rash (the so-called "butterfly" rash because of the shape across the cheeks// Sparing nasolabial fold). Such a rash suggests lupus.

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, renal

insufficiency, and end stage renal disease requiring transplantation.

– 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

Retinal involvement in SLE

Lupus Erythematosus

Treatment– Preventing exacerbations– Treating exacerbations when they occur– Minimizing organ damage and

complications– Medications

Nursing management

Human Immunodeficiency Virus (HIV) - Incidence:

The figures below show the number of children (defined by UNAIDS as under-15s) directly affected by HIV and AIDS:

At the end of 2008, there were 2.1 million children living with HIV around the world.

An estimated 430,000 children became newly infected with HIV in 2008.

Of the 2 million people who died of AIDS during 2008, more than one in seven were children. Every hour, around 31 children die as a result of AIDS.

Most children living with HIV – around 9 out of 10 – live in

Sub-Saharan Africa, the region of the world where AIDS has taken its greatest toll. Large numbers of children with HIV also live in the Caribbean, , Latin America and South/South East Asia.

Around 90% of all children living with HIV acquired the infection from their mothers during pregnancy, birth or breastfeeding.

Effects of HIV on childrenThe direct effects of HIV on children Many children are themselves infected with HIV The effects of HIV on a child’s family Children live with family members who are infected with HIV. Children act as carers for sick parents who have AIDS. Many children have lost one or both parents to AIDS, and are

orphaned. An increasing number of households are headed by children, as

AIDS erodes traditional community support systems. Children end up being their family’s principal wage earners, as

AIDS prevents adults from working, and creates expensive medical bills.

The effects of HIV on a child’s community As AIDS ravages a community, schools lose teachers and

children are unable to access education. Doctors and nurses die, and children find it difficult to gain care

for childhood diseases. Children may lose their friends to AIDS. Children who have HIV in their family may be stigmatized and

affected by discrimination.

Human Immunodeficiency Virus (HIV) Etiology

– HIV infection: Human Immunodeficiency Virus that attacks the immune system

– HIV disease (4 stages)– Acquired immunodeficiency syndrome (AIDS): HIV

causes AIDS by damaging the immune system cells until the immune system can no longer fight off other infections that it would usually be able to prevent. It takes around ten years on average for someone with HIV to develop AIDS.

– Age-related differences Revised pediatric classification system:

clinical categories Pathophysiology

How is HIV passed on?HIV is found in the blood and the sexual fluids of an

infected person, and in the breast milk of an infected woman. HIV transmission occurs when a sufficient quantity of these fluids get into someone else's bloodstream.

There are various ways a person can become infected with HIV:

Unprotected sexual intercourse with an infected person: Sexual intercourse without a condom carries the risk of HIV infection.

Contact with an infected person's blood: If sufficient blood from somebody who has HIV enters someone else's body, then HIV can be passed on in the blood.

How is HIV passed on? Use of infected blood products: Many people in the

past have been infected with HIV by the use of blood transfusions and blood products which were contaminated with the virus. In much of the world this is no longer a significant risk, as blood donations are routinely tested for HIV.

Injecting drugs: HIV can be passed on when injecting equipment that has been used by an infected person is then used by someone else. In many parts of the world, often because it is illegal to possess them, injecting equipment or works are shared.

From mother to child: HIV can be transmitted from an infected woman to her baby during pregnancy, delivery and breastfeeding. Without treatment, around 15-30% of babies born to HIV positive women will become infected with HIV during pregnancy and delivery. A further 5-20% will become infected through breastfeeding.

HIV and breastfeeding For most babies, breastfeeding is without question the

best way to be fed, but unfortunately breastfeeding can also transmit HIV.

Advice for HIV-positive mothers in developed countries– avoid breastfeeding altogether because the risk of HIV

transmission far outweighs the risks associated with replacement feeding. Replacement feeding means giving a baby commercial infant formula (prepared from powder and boiling water)

Advice for HIV-positive mothers in developing countries– In countries with fewer resources, where replacement feeding can

be much more hazardous, the recommendations for infant feeding usually depend on a mother's individual situation. When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life.

– For an overview of detailed information, please see 2009 WHO guidelines page.

An HIV positive mother and her HIV positive baby in India and an African HIV positive woman breastfeeding her baby

An HIV-positive Ukrainian mother practices cup feeding her infant.

Human Immunodeficiency Virus (HIV)

Clinical manifestations CD4 counts

• To judge whether an HIV-positive person requires treatment, a CD4 test is usually carried out. This measures the number of T-helper cells – white blood cells that are attacked by HIV – in an individual’s blood. It can either measure the absolute number of CD4 cells, or the percentage of white blood cells that are CD4 cells, in a sample of blood.

• Normal count: asymptomatic • A falling CD4 count is a sign that HIV is progressing

Associated symptoms of opportunistic infections

The younger the child at time of acquisition, the more severe the symptoms, faster progression, poorer prognosis

Variations by age

Diagnosis of HIV Careful history focusing on risks Timing of transmission from mother to

child Antibody tests are inexpensive and

very accurate. – ELISAELISA (antibody test (enzyme-linked

immunoabsorbent) also known as EIA (enzyme immunoassay)

– Western blot Western blot assayassay – One of the oldest but most accurate confirmatory antibody tests. It is complex to administer and may produce indeterminate results if a person has a transitory infection with another virus.

– An indirect immunofluorescence assayAn indirect immunofluorescence assay – Like the Western blot, but it uses a microscope to detect HIV antibodies.

– A line immunoassayA line immunoassay - Commonly used in Europe. Reduces the chance of sample contamination and is as accurate as the Western Blot.

Using a rapid oral HIV test

Rapid HIV tests An OraQuick HIV-1/2 rapid test kit These tests are based on the

same technology as ELISA tests, but instead of sending the sample to a laboratory to be analysed, the rapid test can produce results within 20 minutes.

Rapid tests can use either a blood sample or oral fluids. They are easy to use and do not require laboratory facilities or highly trained staff.

All positive results from a rapid test must be followed up with a confirmatory test, the results of which can take from a few days to a few weeks.

OraQuick HIV-1/2 test kit

Diagnosis of HIV

PCR testPCR test A PCR test (Polymerase Chain Reaction test) can detect the

genetic material of HIV rather than the antibodies to the virus, and so can identify HIV in the blood within two or three weeks of infection. The test is also known as a viral load test and HIV NAAT (nucleic acid amplification testing).

Babies born to HIV positive mothers are usually tested using a PCR test because they retain their mother's antibodies for several months, making an antibody test inaccurate.

Blood supplies in most developed countries are screened for HIV using PCR tests. However, they are not often used to test for HIV in individuals, as they are very expensive and more complicated to administer and interpret than a standard antibody test.

Collection of dried blood spots from an infant for HIV testing at the Lapolagang

Clinic in Botswana.

Treatment of HIV HIV develops very

rapidlyrapidly among infants and children, and, without treatment, a third of infected children will die of AIDS before their first birthday, with half dying before they are two.

In 2008, there were 280,000 deaths attributed to HIV in under-15s, most of which could have been prevented through early diagnosis and effective treatment.

Approaches: Multidisciplinary

approach HAART (highly active

antiretroviral therapy) Prevention of

opportunistic infections Nursing management

and family teaching– Home– School– Community

Treatment of HIV The most effective treatment for HIV-positive children

is antiretroviral therapy. This requires several antiretroviral drugs (ARVs) be taken every day.

Starting antiretroviral treatment in children– There is ongoing debate about when it is best to start

antiretroviral treatment in HIV-positive children. There is a complex balance between the immediate benefits of providing treatment to children who are not showing any symptoms of AIDS-related illness, and concerns about long-term resistance and antiretroviral drug side effects if treatment is started too early.

CD4 counts in children– In healthy, uninfected adults, absolute CD4 count is usually

between 500 and 1500 cells per cubic millimetre of blood – Absolute CD4 counts vary with age, and younger children

usually have a much higher CD4 count than adults. This makes it difficult to judge the health of a child's immune system based on CD4 count. Percentage CD4 count does not vary in the same way as absolute CD4 count, and is therefore recommended for children under five.

Which antiretroviral drugs should be used? As with adults, antiretroviral therapy with at

least three drugs is recommended for children as this prevents HIV from becoming resistant to any single drug.

It is usually recommended that this therapy should consist of – two nucleoside reverse transcriptase inhibitors

(NRTIs: Epivir (lamivudine), Retrovir (zidovudine), Viread (tenofovir)) combined with

– either one non-nucleoside reverse transcriptase inhibitor (NNRTI): Intelence (etravirine)

– or a protease inhibitor (PI): Aptivus (tipranavir), Reyataz (atazanavir).

Dosing and drug formulations in children

The dose of antiretroviral drugs given to children is generally based on either weight or body surface area.

As children’s bodies are constantly changing, drug doses need to be altered to make sure that a child is not given too much, or too little, of a drug.

Healthcare workers also need to take into account that children under the age of six metabolise drugs faster than adults, so even after adjusting for body weight, they may need to be given higher quantities of ARVs to achieve the same effect that the drugs would have in adults.

“Since there are still no available, easy-to-use triple drug combinations for children, I do what most doctors are doing: I try to show caregivers such as grandparents how to break adult tablets, hoping that the children will get the doses they need.”

- Dr Fasineh Samura, Malawi

Side effects of paediatric HIV treatment

Because children’s bodies are still developing, and they are likely to be exposed to treatment for prolonged periods of time, they may be particularly vulnerable to some complications.

Side effects can occur at various stages of a child’s course of treatment.

They may be – acute (occurring directly after drug administration), – sub-acute (within one or two days after administration) – late (after prolonged drug administration).

Side effects of paediatric HIV treatment: Diarrhoea is a common side effect of many antiretroviral drugs – especially

protease inhibitors. Other possible causes include HIV, other infections and antibiotics. Sometimes an antiretroviral drug causes diarrhoea for only the first few weeks; in other cases this side effect lasts for as long as the drug is taken.

Changing diet may reduce the severity of diarrhoea. Good advice includes:– Eat less insoluble fibre (raw vegetables, fruit skins, wholegrain

bread or cereal, seeds and nuts) – Eat more soluble fibre (white rice, pasta, oat bran tablets,

psyllium/isphagula) – Cut down on caffeine, alcohol and the sweetener sorbitol – Avoid greasy, fatty, spicy and sugary foods – Consider reducing dairy products in case of lactose intolerance – Consult a dietician – Over-the-counter medicines such as Imodium (loperamide), Lomotil

(diphenoxylate and atropine) and calcium supplements are sometimes all that is needed to control diarrhoea.

Side effects of paediatric HIV treatment:Nausea and vomiting Almost all antiretroviral drugs can cause nausea (feeling sick)

and vomiting, especially during the first few weeks of treatment. Although this side effect can reduce appetite, it is important to

keep eating when possible, and to replace lost fluids and electrolytes (as with diarrhoea). The following measures may help:– Eat several small meals instead of a few large meals – Avoid spicy, greasy and rich foods; choose bland foods – Eat cold rather than hot meals – Don’t drink with a meal or soon after – Avoid alcohol, aspirin and smoking – Avoid cooking smells

Some antiretroviral drugs can be taken with food, and doing so may lessen their harmful effects. It may also be possible to alter drug dosage or frequency.

Various treatments, known as anti-emetics, are available for nausea and vomiting, some of which do not require a prescription. There is some evidence that ginger and peppermint may help against nausea.

Side effects of paediatric HIV treatment: Rash Rashes often appear as a side effect of antiretroviral treatment. These may be itchy but are usually harmless and short-lived.

However, severe rashes can occur with nevirapine, and more rarely with some other drugs. Any rash occurring during the first few weeks of treatment should be reported to a doctor immediately, as should any rash accompanied by fever, blistering, facial swelling or aches. A rash occurring with abacavir may indicate a very dangerous hypersensitivity reaction.

Tips for coping with rashes include: Avoiding hot showers or baths Using milder toiletries and laundry detergents Wearing cool fibres such as cotton, and avoiding wool Humidifying the air Trying moisturisers / emollients or calamine lotion Antihistamine tablets can sooth rashes and are generally available

without a prescription. However, because these may interact with antiretroviral medications, patients should check with their doctors before using them. More severe skin problems may be treated with steroids.

Allergic Reactions to Drugs

Incidence and etiology Pathophysiology

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Clinical manifestation – Angioedema– Urticaria– Maculopapular rashes– Contact dermatitis– Anaphylaxis– Erythema multiforme– Stevens-Johnson syndrome

– Toxic epidermal necrolysis (continues)


Diagnosis Treatment Nursing management

Situation: Stevens-Johnson syndrome

Twelve-year-old Ron was admitted to the unit with an erythematous papular rash covering his arms, legs, abdomen, the soles of his feet, and the palms of his hands. His mother Helen said that he had a sore throat, headache, fever, and “just didn’t feel well” a day or two before he broke out with his rash. He also had been on penicillin for five days because of a throat infection. He was diagnosed with Stevens-Johnson syndrome. What nursing care would be appropriate?

Answer: Ron and his parents will need to be provided with education about his sensitivity to the penicillin. Ron will be on a liquid diet. The nurse will need to provide comfort measures, including use of topical lidocaine prn for his sore mouth, frequent skin care, and administration of pain medications as needed. He also will need a nutritious diet, adequate fluids, and excellent skin care.

Erythema multiforme major, also referred to as Stevens-Johnson syndrome, is a toxic or allergic rash in response to the smallpox vaccine, use of drugs that can take various forms, and range from moderate to severe.

Endocrine AlterationsEndocrine Alterations

Anatomy and Physiology Glands of the endocrine system

– Anterior pituitary– Posterior pituitary– Thyroid– Parathyroids– Adrenal cortex

– Adrenal medulla– Ovaries– Testes– Pancreas

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

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

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Nursing Management

Outcome identification Planning/implementation Evaluation Family teaching

Disorder of the Anterior Pituitary: Precocious Puberty


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Clinical manifestations – Accelerated growth rate– Advanced bone age– Evidence of secondary sexual

characteristics– Acne– Adult body odor– Possible behavior changes

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Diagnosis – Complete history– Physical exam

• Sexual maturation staging (Tanner staging)

• Height, weight, span (fingertip to fingertip),

upper/lower body ratio – Radiological exams– Laboratory screening

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Treatment Nursing management

Disorder of the Posterior Pituitary: Diabetes Insipidus


– Infants: failure to thrive, fevers, vomiting, constipation, dehydration, poor growth

– Children: polyuria, polydipsia

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Diagnosis – First morning urine sample: osmolarity,

specific gravity, sodium– Serum osmolarity, sodium and creatinine

levels– Water deprivation test

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Treatment – Replacement of antidiuretic hormone or

vasopressin– Desmopressin acetate (DDAVP)

Nursing management

Disorder of the Thyroid Gland: Congenital Hypothyroidism


– Large posterior fontanel– Umbilical hernia– Constipation– Prolonged jaundice

– Other manifestations (continues)

Disorder of the Thyroid Gland: Congenital Hypothyroidism

Diagnosis Treatment Nursing management Family teaching

Disorder of the Thyroid Gland: Acquired Hypothyroidism


(continues)


Clinical manifestations – Decreased rate of growth– Weight gain– Constipation– Dry skin, thinning or coarse hair– Fatigue

(continues)


– Cold intolerance– Edema of face, eyes, hands– Delayed deep tendon reflexes– Delayed puberty

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Diagnosis Treatment Nursing management

– Assessment

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– Nursing diagnosis• Delayed growth and development related to

the absence or deficiency of thyroid hormone synthesis

• Hypothermia related to decreased BMR• Constipation related to decreased motility of

the GI tract• Activity intolerance related to fatigue and

decreased endurance

Disorder of the Thyroid Gland: Hyperthyroidism Incidence and etiology Pathophysiology

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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

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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

Disorder of the Adrenal Gland: Congenital Adrenal Hyperplasia


(continues)

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

Disorder of the Pancreas: Diabetes Mellitus Incidence and etiology Pathophysiology Clinical manifestations Diagnosis

Treatment of Diabetes Mellitus

Insulin management Blood glucose management Nutrition Exercise

Nursing Management: Diabetes Mellitus Assessment Nursing diagnoses

– Risk for injury related to insulin insufficiency and deficiency

– Risk for injury related to hypoglycemia or hyperglycemia

– Disturbed body image related to developing a chronic disease

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Nursing Management: Diabetes Mellitus

– Deficient knowledge related to management of both types of diabetes

– Interrupted family processes related to management of a chronic illness

Outcome identification Planning/implementation

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Nursing Management: Diabetes Mellitus Survival education

– Insulin preparation and injection– Blood glucose and urine-ketone monitoring– Hypoglycemia

Family teaching: beyond the survival stage– Hyperglycemia– Diabetic ketoacidosis

Additional Endocrine Disorders

Hypoparathyroidism Addison’s disease Cushing’s syndrome

The END. Q & A ?

Documents

Nursing Care of Children with Immunologic Alterations By Nataliya Haliyash, MD, BSN Insitute of Nursing, TSMU