NURSING CARE OF A

FAMILY WHEN A CHILD

HAS AN IMMUNE
DISORDER
FACTUM PER
ANNA IRISH BELEN, RN MSN
• OBJECTIVES
In this lesson you should be able to:
1. Describe the effects of an underactive or overactive immune response as it relates to childhood illnesses.
2. Assess a child with a disorder of the immune system.
4. Formulate nursing diagnoses for a child with a disorder of the immune system.
5. Establish outcomes for a child with a disorder of the immune system that can help the family manage
seamless transitions across different healthcare settings.
6. Competently plan nursing care using the nursing process.
7. Implement nursing care for a child with an immune disorder.
8. Evaluate expected outcomes for achievement and effectiveness of care.
9. Integrate knowledge of immune disorders with the interplay of nursing process, and Family Nursing to
promote quality maternal and child health nursing care.
•The immune system is made up of a variety of
proteins and cell types, which work together to protect the body against
invasion by foreign substances.

• The purpose of the immune system is to provide protection to the body from
invading organisms or antigens. A deficiency in any of the components of
the immune system or alteration in function can limit this protection. An
assessment focuses on the types of illnesses or problems the child is having
in order to target the part of the immune system which is mal- or
nonfunctioning.
• NURSING DIAGNOSES
• Risk for infection related to altered immune response
• Impaired skin integrity and risk for infection related to atopy
• Activity intolerance related to chronic illness
• Risk for delayed or altered growth and development related to chronicity of immune disorder
• Nursing diagnoses specific to the child with allergies focus on the specific symptom.
Examples include:
• Situational low self-esteem related to symptoms of contact dermatitis or atopy
• Ineffective breathing pattern related to bronchospasm of allergic response or anaphylaxis
• Anxiety related to continuing or uncontrolled allergic response
• Powerlessness related to difficulty determining cause of allergy
IMPLEMENTATION
A major nursing intervention in the care of children with immune disorders is child and family teaching.
• Identifying ways to keep the child from contracting life-threatening infections
• Avoid triggers or situations that provoke the allergic response but at the same time not keep the child so
isolated or fearful that the child misses out on important socialization and life experiences.
OUTCOME IDENTIFICATION AND PLANNING
• Outcome identification and planning for a child with an immune disorder should focus both on present and
future concerns. Relief of immediate symptoms is the first priority followed by planning for long-term care
and infection prevention.
• Outcome evaluation with immune disorders must be ongoing because children with allergies can develop
new allergic triggers at any time. Children with immunodeficiencies can similarly develop infections or
related comorbidities at any time. Field of immunology is continually evolving, theories about immune
diseases and associated treatments change year to year.
• ANTIGEN some cells both recognize and react against antigens. Antigens include pathogens
(bacteria, fungi, or viruses), food proteins, and pollens.
• Host defenses include physical protective barriers including the skin, mucous membranes, cilia, and
normal flora.

• Phagocytosis, or the destruction of the invaders, begins.

• Macrophages engulf, ingest, and neutralize the pathogen.
• At the same time, an inflammatory response creates vascular and cellular changes that help to rid the body
of dead tissue and the inactivated antigens.
• Nonspecific responses include complement, phagocytes, and natural killer cells.
• Specific responses include antibody production and cellular immunity.

• Disorders of the immune system can be the result of an underactive or nonfunctional

system (immunodeficiency), an overactive or poorly regulated system (allergy or
hypersensitivity), or an abnormal or excessive response against one’s own cells
(autoimmune disease).
IMMUNE RESPONSE

• Immunogen - an antigen is one that can be readily destroyed by an immune response

(immunity)

• Allergen - mediating substances are released that cause tissue injury and allergic
symptoms.
IMMUNE SYSTEM ORGANS AND CELLS

• The major organs of the immune system are the thymus, liver, bone marrow, spleen, tonsils, lymph nodes, and blood.
All of the cells of the immune system originate in the bone marrow where they develop from stem cells. Lymphocytes,
produced in the bone marrow travel to different parts of the body, where they function. In the thymus, lymphocytes
mature into T cells.
• In other organs, such as the tonsils and spleen, lymphocytes collect and communicate with each other. The liver
synthesizes the proteins of the complement system and contains large numbers of phagocytes to ingest and destroy
bacteria.
B Lymphocytes
• B Cells originate in the bone marrow where they develop from plasma or memory cells.
Their major function is to produce antibodies or immunoglobulins. These
immunoglobulins bind to and destroy specific antigens. When an antibody is formed in
response to a particular antigen, it is specific to that antigen.

• Memory cells are responsible for retaining the formula or ability to produce specific
immunoglobulins.
T Lymphocytes
• thymus to lymph nodes and spleen

3 subtypes:
• cytotoxic (killer) - ability to bind to the surface of antigens and directly destroy the cell membrane;
secrete lymphokines - prevent the migration of antigens and call other lymphocytes into the area
(chemotaxis). Interferon - preventing viral infections.

• helper T cells (CD4 cells) - stimulates B lymphocytes to divide and mature into plasma cells so
the B cells can begin secreting immunoglobulins. The IgA antibody depends on stimulation by helper T
cells.

• suppressor T cells, are specific cells that reduce the production of immunoglobulins against a
specific antigen and prevent their overproduction
TYPES OF IMMUNITY
• Humoral immunity - immunity created by antibody production or B lymphocyte involvement. Helper T cells
recognize an antigen and activates B lymphocyte. Specific immunoglobulins that mark the antigen for destruction.
(e.g., Escherichia coli)

• specific antigen enters the body and identified by T lymphocytes

• B-cell grows rapidly.
• Within 6 days, IgM present in the bloodstream.
• peaks at 14 days and then declines

• day 10, antigen-specific IgG production begins and remains high for several weeks
• memory cells develop after the first exposure.
• The main type of immunoglobulin produced in a secondary response is IgG
• Complement Activation

• composed of 20 different proteins, when activated by antigen–antibody contact, these molecules

• begin a cascade response that leads to increased vascular permeability, smooth muscle contraction, chemotaxis
(“calling” leukocytes into the area), phagocytosis, and lysis (killing) of the foreign antigen.

• Cell-mediated immunity - is the type of immune response caused by T-lymphocyte activity.

• Cytotoxic T cells attack directly destroy invading antigens

• through the release of chemical compounds onto the antigen membrane,
• through the injection of a toxin directly into the antigen
• through the secretion of lymphokines

• delayed hypersensitivity if the T-lymphocyte activity occurs solely without an accompanying humoral response.
• Autoimmunity

• The result of the immune system being unable to

distinguish self from nonself, causing the immune system
to trigger immune responses against normal cells and
tissue rather than invading antigens.
• Immunodeficiency Disorders

• When any portion of the immune system is missing or not functioning properly, an
immunodeficiency can result. An immunodeficiency can be primary (congenital) or
acquired (secondary to a viral infection, exposure to a toxic substance or some drugs).
PRIMARY IMMUNODEFICIENCY

• comprise over 150 inherited disorders.

• They can present and be diagnosed at various ages and affect all parts of the
immune system, including
humoral defects, cell-mediated defects, complement deficiencies, and
phagocyte disorders
• Humoral Deficiencies
• Children with humoral defects are generally well until 4 to 6 months of age because of the presence of
maternal antibody which crosses the placenta.
• Immunoglobulin can be delivered intravenously every 3 to 4 weeks or subcutaneously every 1 to 2 weeks.
• lack the enzyme
• the B cells are incapable of maturing into antibody

• Low levels of immunoglobulins

• antibody development is impaired
• Selective IgA deficiency

• most common of the humoral immunodeficiencies

• undetectable level of IgA
• Asymptomatic deficiency is noted when the person is being evaluated for another illness,
such as celiac disease.
• May result from an increase in IgA suppressor cells or defect in helper T-cells necessary
for IgA production.
• Possible to see upper respiratory infections or inflammatory bowel disease, atopic
diseases
T-Lymphocyte Deficiencies

• T-Lymphocyte immunodeficiencies involve inadequate numbers or inadequate

functioning of one or more types of T lymphocytes
• affects cell-mediated immunity
• because of helper T-lymphocyte function, possibly humoral immunity as well
• Combined T- and B-Lymphocyte Deficiency

• group of inherited rare disorders associated with large defects in T- and B-cell immunity
• SCID is caused by a developmental abnormality
• prevents the formation of T lymphocytes
• Children cannot respond directly to antigen invasion, and no antibodies are produced.
• correction of the immunologic defect by hematopoietic stem cell transplantation
• SECONDARY (ACQUIRED) IMMUNODEFICIENCY

Loss of immune system response

• severe systemic infection
• cancer
• radiation therapy
• severe stress
• Malnutrition
• monoclonal antibody therapy targeted at B cells
• aging
• Anything that causes the body to lose protein such as renal disease or protein-losing enteropathies
• HIV Infection and AIDS

• substitutes its own RNA and DNA for the cell’s DNA, and begins to replicate, destroying the lymphocytes
in the process as well as their ability to initiate an effective B-lymphocyte response.
• There is no effective way to destroy the HIV, so it remains in the body for life and can activate if the
immune system becomes depressed.
• When monocytes and macrophages become affected, the person with HIV infection cannot resist usual
infections such as the common cold.
• The final result is that both the immune response and the ability to screen and remove malignant cells from
the body are lost.
• Transmission
• Assessment
• incubation period of about 10 years in adults.
• children are usually HIV positive by 6 months and develop clinical signs of the disease by 1 to 3 years of
age.
• Children who receive the virus from another source usually convert to HIV positivity by 2 to 6 weeks or at
least by 6 months after exposure.
• poor resistance to infection, fever, swollen lymph nodes, respiratory tract infections, and oral candidiasis.
• All infants born to infected mothers test positive for antibodies to the virus at birth because of passive
antibody transmission (which persists for about 18 months)
• polymerase chain reaction (PCR) - antigen
• enzyme-linked immunosorbent assay (ELISA) or Western blot confirmation - antibodies
• Allergy

• abnormal antigen–antibody responses.

• they can disrupt a child’s life and development and the life
of the family
• HYPERSENSITIVITY

• The underlying cause of all allergic disorders appears to be an excessive antigen–

antibody response when the invading organism is an allergen rather than an immunogen.
This is termed a type I response, or a hypersensitivity response, when it happens
immediately.
• SKIN TEST
• EPINEPHRINE HYDROCHLORIDE (ADRENALIN)
• Classification: Epinephrine is a sympathomimetic drug.
• Action: Acts on both α- and β-receptor sites of sympathetic receptor cells to cause increased blood
pressure and heart rate. It also relaxes the smooth muscles of the bronchi. It is used to counteract the
symptoms of anaphylaxis Possible Adverse Effects:
• Anxiety, restlessness, headache, nausea, arrhythmias, hypertension, palpitations, pallor
THERAPEUTIC MANAGEMENT

• Environmental Control
• Pharmacologic Therapy
• Intranasal steroids can be used prophylactically to prevent inflammation
• antihistamines, block histamine release and, as a result, control itching, sneezing, and rhinorrhea
• Decongestants
• Immunotherapy
• Hyposensitization, Small amounts of allergens are introduced to the child until the child produces a state
of increased tolerance (a state of not responding) to the allergen.
• Immunotherapy
• hyposensitization, is done when the child’s allergy symptoms cannot be controlled by avoidance of an allergen or
conventional drug therapy.
• subcutaneous immunotherapy (SCIT) or by tablets that are given sublingually.
• Immunotherapy works by increasing the plasma concentration of IgG antibodies, which then act to prevent or block
IgE antibodies from coming in contact with an allergen.
• AFfter specific environmental allergens have been determined with skin testing, small amounts of allergy extracts are
injected subcutaneously at weekly intervals.
• The dose of antigen is increased in strength each time until the peak concentration, called “maintenance,” is reached
• periodic injections every 3 to 4 weeks to maintain maintenance to the allergen. threat of significant anaphylaxis.

• Sublingual immunotherapy (SLIT); painless, can be self- or parent administered,

• observed for a minimum of 30 minutes after an allergy shot
• this therapy will not “cure” their child. It can reduce allergy symptoms
•Common Allergic
Reactions
• ANAPHYLACTIC SHOCK

• An immediate, life-threatening, type I hypersensitivity reaction that occurs after

exposure to an allergen.
• Anaphylaxis can be caused by exposure to foods such as milk, egg, peanut, and tree
nuts; stinging insects including yellow jackets, honeybees, paper wasps, hornets, and fire
ants; certain drugs, primarily antibiotics, nonsteroidal anti-inflammatory drugs
(NSAIDs), and neuromuscular blocking agents; and latex.
• Assessment of Anaphylaxis
Emergency Measures for Anaphylactic Shock
• Epinephrine, injected intramuscularly, is the standard of care for the treatment of
Anaphylaxis. This relieves laryngeal edema and severe bronchospasm by widening the airway.
• Oxygen
• Anticipate the need for an intravenous (IV) fluid line
• Tourniquet
• Bronchodilator
• corticosteroid
URTICARIA

• Urticaria, or hives, refers to macular wheals surrounded by erythema arising from the
chorion layer of skin; they are intensely pruritic (often described as having a burning
sensation). Hives may occur so closely together that they tend to coalesce (blend
together); dilatation of capillaries and venules with increased permeability occurs around
the lesions. The cause of urticaria is a type I or immediate hypersensitivity reaction
created by the release of histamine from an antibody–antigen reaction,
• ANGIOEDEMA

• edema of the skin and subcutaneous tissue

• frequently on the eyelids, hands, feet, genitalia, and lips
• With severe angioedema, the larynx may be involved
• Drugs, foods, and insect stings
• Exposure to hot or cold
• intramuscular epinephrine injection or the administration of an oral antihistamine.
•Atopic Disorders

1. allergic rhinitis
2. eczema (atopic dermatitis)
3. asthma
• Higher production of IgE antibodies, which makes them more responsive to allergens
• Familial tendencies with these diseases
• ALLERGIC RHINITIS

• Allergic rhinitis is associated with an IgE-mediated inflammatory response to allergen

exposure.
• It is a risk factor for the development of asthma.
• frontal headache
• lethargic and do not function well in school.
• Recurrent otitis media may occur because of swollen pharyngeal tissue causing eustachian tube blockage.
• prone to allergic conjunctivitis.

• The triggers that usually cause allergic rhinitis are pollens, molds, or irritants rather than foods or drugs.
• PERENNIAL ALLERGIC RHINITIS
• Allergic rhinitis becomes perennial (year round) when the allergen is one that is present in the environment
year round, such as house dust mites or pet hair.
• Serous otitis media can accompany the disorder as a long-term consequence. Because the agent that causes
perennial allergic rhinitis is often something in the house, environmental control as well as SLIT can play a
big role in the control of the allergic symptoms
• ATOPIC DERMATITIS (INFANTILE ECZEMA)
• pruritic
• chronic inflammatory skin
• develop allergic rhinitis and asthma
• Food allergy is a major trigger
• intense pruritus and associated scratching that disturbs sleep
• Sweating, heat, tight clothing, and contact irritants such as soap tend to increase the pruritus
associated with eczema.
• Symptoms may be more annoying in the winter when the skin dries out and heavier clothing is
worn.
• Other children have eczema triggered by sweating and find the humid, summer months more
difficult
• Assessment
• epidermal barrier defect
• papular and vesicular skin eruptions with surrounding erythema.
• The vesicles rupture and exude yellow, sticky secretions that form crusts on the skin as
they dry.
• linear excoriations
• As the infected lesions heal, the skin becomes depigmented and lichenified (shiny), and
dry, flaky scales form.
• may have a low-grade fever and pus-filled lesions
• uncomfortable, fussy and irritable.
• They may not eat well because of this generalized discomfort.
• The combination of poor sleep patterns, poor intake
A child with seborrheic dermatitis needs little therapy than soaking the
scales in mineral oil and then lifting them away; infants with infantile atopic
dermatitis must be referred for long-term
therapy.
• ATOPIC DERMATITIS IN THE OLDER CHILD

• Atopic dermatitis that occurs at later ages is prominent on the flexor surface of the
extremities and on the dorsal surfaces of the wrists and ankles.
• It often occurs in the eyebrows; if the child scratches the lesions, hair loss and scant
eyebrows can result.
• Depigmentation or hyperpigmentation is usually noticed as lesions fade lichenification
can be marked.
• child’s fingernails have a glossy sheen caused constant rubbing and scratching.
• “itch–scratch cycle” ; children who are rub their skin, a nervous, comforting mannerism
• Therapeutic Management
• reducing the amount of allergen exposure
• reducing pruritus so children do not irritate lesions
• antimicrobial treatment.
• Hydrating the skin by bathing or applying wet dressings for 15 to 20 minutes, and
application of a barrier to seal in the moisture is helpful.
• Antihistamine
• steroids can be used for maintenance
• topical steroids should not be applied to face, eyelids, or genitalia, and they need to be
used sparingly in young infants
• take a shower to remove perspiration so
• Avoiding tight clothing at the flexor portions of the extremities
Drug and Food Allergies
• DRUG ALLERGIES
• when the drug combines with body protein, it becomes an allergen, which is why allergic
responses occur not with the initial administration of a drug but only after the protein interaction
(hapten formation or sensitivity) has occurred
• toxic reaction is one that occurs when a child has received too much of a drug.
• Side effects of drugs are those that are known to occur in addition to a therapeutic effect.
• allergic effect occurs, a range of unpredictable symptoms occurs.
• exception of antibiotics, acetylsalicylic acid (aspirin), and NSAIDs, allergies rarely occur to
orally administered drugs.
• Children with atopic diseases appear to be most prone to allergic drug reactions
• Respiratory symptoms include wheezing or rhinitis
• Skin manifestations include urticaria, angioedema, allergic contact dermatitis, flushing, pruritus,
and/or purpura.
• Thrombocytopenia and hemolytic anemia may develop.
• FOOD ALLERGIES
• abnormal immune response caused by exposure to a particular food protein.
• They can be IgE-mediated, cell-mediated, or mixed reactions, although IgE-mediated
(type I hypersensitivity) reactions account for most food reactions
• Symptoms of food allergies: reactions to foods including urticaria, angioedema, flushing,
and pruritus
• Additional symptoms may develop over a period of 2 hours, often making the offending
food difficult to recognize.
• Although not every food allergic reaction develops into anaphylaxis, food is the number
1 cause of anaphylaxis, and prior reaction severity does not predict future reactions.
• Children with milk and egg allergy may be able to tolerate baked good that contain
milk and/or egg because the exposure to high heat destroys the conformational
epitopes
• Assessment
• Sensitization can occur as food protein cross the placenta or via breast milk.
• immediate type I response such hives, swelling, and vomiting. These reactions can be
anaphylactic.
• increase in atopic dermatitis
• An elimination diet can be an effective tool to detect mild food allergies.
• Therapeutic Management
• eliminate offending foods
• child’s nutrition
• Urge parents to become conscientious shoppers and read labels carefully
• Supplement vitamin D and calcium.
• VACCINES

• Mild local reactions and fever after vaccinations are common and do not contraindicate
future doses.
• Anaphylactic reactions to vaccines are rare.
• Children who are egg allergic can and should receive injectable influenza as well as the
MMR vaccine.
• The yellow fever (Flavivirus) vaccine requires special precautions for children with egg
allergy.
• MILK INTOLERANCE

• Milk is one of the leading causes of type I reactions to foods but not all milk reactions
are IgE-mediated reactions.
• Milk intolerance usually presents in infancy and is typified by failure to gain weight,
diarrhea, perhaps vomiting, and abdominal pain.
• Because these symptoms also occur in gastrointestinal disorders, infants with colic
(characterized by abdominal pain, no change in stools, and no failure to gain weight),
those with lactase deficiency, or those with a gastroenteritis infection (have nausea and
vomiting) may be incorrectly diagnosed as having a milk allergy.
• Stinging Insect Hypersensitivity
• Children may have severe hypersensitivity reactions to stings from bees, wasps, hornets,
or yellow jackets
• Although a serum sickness reaction may occur, the usual reaction to these stings is an
immediate type I hypersensitivity reaction (anaphylaxis).
• THERAPEUTIC MANAGEMENT
• immunotherapy extract of venom
• self-administer epinephrine
• antihistamine should never be taken in place of epinephrine.
• Ice applied to the site minimizes the amount of venom absorbed.
• ways to avoid; using scented preparations such as hair spray, deodorants, lotions,
or perfume because these attract insects.
• should not be assigned household chores
• fast-acting insecticide handy to use on flying insects
• refrain from drinking out of open soda cans at outside activities because bees and
wasps are drawn to the sugar in the soda, but the child may be unaware that an
insect has entered the open can.
• Contact Dermatitis
• example of a delayed or type IV hypersensitivity response
• a reaction to skin contact with an allergen
• The first reaction is generally erythema, followed by the development of intensely
pruritic papules and then vesicles.
• For example, dermatitis from a diaper-washing compound appears in the diaper area.
Allergy to cosmetics appears on the face. Oozing at the site of pierced ears suggests an
allergy to the nickel used in earring posts. Poison ivy appears on the hands and arms
where the child brushed against the plant.
•THANK YOU!
•THANK YOU!
References

• https://www.niaid.nih.gov/diseasesconditions