Alterations with

Infectious,
Inflammatory and
Immunologic
Responses
Learning Objectives
At the end of the course unit (CU), learners will be able to:
Cognitive:
1. Identify and understand the different alterations with infectious, inflammatory and immunologic
responses in children.
2. Verbalize the importance and relevance of these topics to nursing practice
Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.
Psychomotor:
1. Participate actively during class discussions and group activities
2. Express opinion and thoughts in front of the class
Juvenile Idiopathic
Arthritis(JIA)
A chronic autoimmune inflammatory disease causing inflammation
of joints and other tissue with an unknown cause.
Juvenile Idiopathic Arthritis (JIA)

+ Starts before age 16 years with a peak onset between 1

and 3 years of age
+ Cause unknown
+ Factors (Hypothesized):
Immunogenic susceptibility
Environmental or external trigger such as a virus
Pathophysiology
+ Characterized by chronic
inflammation of the synovium
with joint effusion
+ Eventual erosion, destruction,
and fibrosis of the articular
cartilage
+ If inflammatory process
persists, adhesions between
joint surface and ankylosis of
joints occur
Clinical
Manifestations
+ Joint deformity
+ Functional disability
Classification of Juvenile Idiopathic
Arthritis (JIA):
+ Systemic Arthritis
+ Oligoarthritis
+ Polyarthritis Rheumatoid factor negative
+ Polyarthritis Rheumatoid factor positive
+ Psoriatic Arthritis
+ Enthesitis-related Arthritis
+ Undifferentiated Arthritis
Diagnostic Evaluation
+ Diagnosis of exclusion (no definitive tests)
Clinical criteria:
• Age of onset before age 16 years
• Arthritis in one or more joints for 6 weeks or longer
• Exclusion of other causes

+ Laboratory tests (supporting evidence)

Leukocytosis
ESR
Antinuclear antibody
Radiograph
Slit lamp eye examination
Therapeutic Management
+ Medications
Non-Steroidal Antiinflammatory Drugs (NSAID)
Methotrexate
Corticosteroids
Biologic agents (Etanercept, Adalimumab, and Abatacept)

+ Physical and Occupational Therapy

PT directed toward specific joints, focusing on strengthening muscles, mobilizing
restricted joint motion, and preventing or correcting deformities.
OT for generalized mobility and performance of activities of daily living.
Nursing Management
+ Relieve pain
Behavioral therapy and relaxation techniques
+ Promote general health
Well-balanced diet with sufficient calories
Sleep and rest are essential
Nighttime splints instructions to parents
Prevent URTI
Effective communication among family, primary care provider and
rheumatology team for care coordination
Nursing Management
+ Facilitate adherence
Involve family in therapeutic plan
Know the purpose and correct use of splints and appliances and
medication regimen
Regular administration of medication schedule
+ Encourage heat and exercise
Moist heat (bath tub with warm water), paraffin bath, hot packs
Pool therapy (swimming)
ADL (activities of daily living)
Nursing Management
+ Support child and family
Encourage family to pursue their normal activities
Recognize signs of stress and counterproductive coping and
provide the necessary support to maximize adaptation.
Allergic Rhinitis

+ Caused by a type I or
immediate
hypersensitity immune
response
+ Occurs in 10% to 40%
of children
Assessment
+ Main Symptoms:
Sneezing
Nasal engorgement
Profuse watery nasal discharge
+ Pale mucous membrane of the nose
+ Nasal congestion
+ Watery eyes
+ Pruritic conjunctiva
+ Full frontal headache (>6 years old)
Therapeutic Management
+ Avoidance of allergen
+ Pharmacologic agents:
Antihistamines
Leukotriene inhibitors
Corticosteroids (Intranasal)
+ Immunotherapy
Atopic Dermatitis
(Eczema)
A type of pruritic eczema that usually begins during infancy
and is associated with an allergic contact dermatitis with a
hereditary tendency (atopy)
Infantile form (Infantile Eczema)
+ Usually begins at 2 to 6 months of age
+ Undergoes spontaneous remission by
3 years of age
+ Generalized, especially cheeks, scalp,
trunk, and extensor surfaces of
extremities
+ Appearance of lesions:
• Erythema
• Vesicles/ Papules
• Weeping/ Oozing/ Crusting/ Scaling
• Often symmetric
Childhood form
+ May follow the infantile form
+ Occurs at 2 – 3 years of age
+ 90% of children have manifestations by age 5
years
+ Flexural areas (antecubital and popliteal fossae,
neck), wrists, ankles, and feet
+ Appearance:
Symmetric involvement
Clusters of small erythematous or flesh-colored papules or
minimally scaling patches
Dry and may be hyperpigmented
Lichenification (thickened skin with accentuation of creases)
Keratosis pilaris (follicular hyperkeratosis) common
Preadolescent and Adolescent form
+ Begins at about 12 years of age
+ May continue into the early adult years or
indefinitely
+ Face, sides of neck, hands, feet, face, and
antecubital and popliteal fossae (to a lesser
extent)
+ Appearance of lesion
Same as childhood manifestations
Dry, thick lesions (lichenified plaques) common Confluent
papules
Intense itching
Unaffected skin dry and rough
Therapeutic Management
+ Hydrate the skin
+ Relieve pruritus
+ Reduce flare-ups or inflammation
+ Prevent and control secondary infection
+ Avoid exposure to skin irritants or allergens
+ Avoid overheating
+ Administration of medications:
Antihistamines, topical immunomodulators, topical steroids, and mild sedatives
Nursing Management
+ Prevent and minimize scratching
Cut fingernails and toenails short, keep it clean and filed
Gloves or cotton stockings can be placed over hands and pinned to shirtsleeves
One-piece outfits with long sleeves and long pants decreases direct contact
with the skin
Remove woolen clothes or blankets, rough fabrics, and furry stuffed animals
from the child’s environment
Proper dress for climatic conditions
Prevent exposure to certain components of soaps, detergents, fabric softeners,
perfumes, and powders
Use soft cotton fabrics
Nursing Management
+ Prevent infections
Tepid baths
Avoid bubble baths, oils, and powders
Skinfolds and diaper areas need frequent cleansing with plain water
Room humidifier or vaporizer
Assess for signs of infection (honey-colored crusts or pustules with
surrounding erythema)
ASTHMA
+ Inflammatory process of the large airways, which results in
heightened airway reactivity.
+ Chronic inflammatory disorder of the airway
+ Most common chronic disease of childhood
+ Boys, before 4 y/o & 5 y/o
+ Airflow limitation or air obstruction
+ Caused by physical and chemical irritants, that lead to
obstruction after initial exposure
Risk factors:
+ Age
+ Hereditary
+ Gender
+ Mother <20 y/o
+ Smoking
+ Ethnicity
+ Previous life-threatening attacks
+ Lack of access in medical care
+ Psychological & physiologic problem
Pathophysiology
+ Irritants
+ Release of inflammatory
mediator
+ Migration & activation of
inflammatory cell
+ Alteration in epithelial integrity
& autonomic neutral control of
airway
+ Smooth muscle responsiveness,
wheezing, dyspnea
+ Obstruction
Clinical manifestations

+ Wheezing
+ Breathlessness
+ Dyspnea
+ Chest tightness
+ Cough (-)respiratory
infection = night & early
morning
+ Activity induced
cough/wheeze
Asthma Severity Classification
MILD MILD MODERATE SEVERE
INTERMITTEN PERSISTENT PERSISTENT PERSISTENT
T ASTHMA ASTHMA ASTHMA ASTHMA

Symptoms Symptoms Daily symptoms Continual

<2x/week >2x/week but symptoms
<1/day

Nighttime Nighttime Nighttime Frequent

symptoms <2x/mo symptoms >1x/mo symptoms nighttime
>1x/week symptoms

Meds for acute Daily meds Daily meds Daily meds

exacerbation Long term Long term Long term
Diagnostic Examination:
+ Laboratory assessment
ABG
CBC (elevated Eosinophil count)
Elevated IgE levels
Pulmonary function tests (most accurate test for asthma)

•Peak expiratory flow rate

Highly suggestive of asthma when >15% increase in
PEFR after inhaled short acting B2 antagonist and
When <15% decrease PEFR after exercise
Therapeutic Management:
+ GOAL
Maintain normal activity level
Normal pulmonary function
Prevent symptoms
Drug therapy
Exacerbation
+ Episode of progressively shortness of
breath
+ Cough
+ Wheezing
+ Chest tightness
+ Mucus plugging

+ AIRWAY TRAP >>> HYPOXEMIA

Asthmatic episode
+ Begin with irritability, restlessness,
headache, feeling tired, or chest tightness
+ Accumulation of secretion – gelatinous
sputum
+ Lips deep red – cyanosis
+ Tripod position
+ (+) retraction
Interventions:
+ Assess airway

+ Meds

+ Monitor respiratory status

+ IV line to correct electrolytes

Therapeutic Management:
+ Allergen control
+ Drug therapy
Bronchodilators
Corticosteroid (Anti-inflammatory)
Cromolyn & Nedocromil Na
B-adrenergic agents
Methylxanthines
Anticholinergic
(Heliox & MgSO4)
Therapeutic Management:
+ Chest physiotherapy (not in episode)
+ Hyposensitization
+ Exercise – swimming
+ Avoid cool environment
+ Recognize early symptoms
Bronchodilators
Side effects:
+ Chest pain or discomfort
+ Irregular or fluttery heartbeat
+ Unusual bruising
+ Hives or rash
+ Swelling
+ Wheezing or other breathing problems
+ Numbness in the hands or feet
+ Blurred vision
Bronchodilators
+ ᵝ2 agonist ˗ Monitor for SE:
Albuterol (Ventolin) excessive cardiac &
Bitolterol
CNS stimulation (Check
BP & pulse)
Pirbuterol
Salmeterol
Formterol + Cholinergic antagonist
+ Methylxanthines Ipratropium (Atrovent)

Theophylline, aminophylline,
Oxtriphylline
Anti-inflammatory agents
+ CORTICOSTEROIDS
Oral (Prednisolone, Prednisone)
Inhaler (Budesonide, Fluticasone,
Beclomethasone, Triamcinolone, Flunisolide)
+ MAST CELL STABILIZER
Cromolyn sodium (Intal)
Helps prevent atopic asthma attacks (prevent
mast cell membranes from opening when an
allergen binds to IgE)
Anti-inflammatory agents

+ Monoclonal Antibodies
Omalizumab (Xolair)
Binds to IgE receptor sites on mast cells & basophils
preventing the release of chemical mediators for
inflammation
Nursing care management:
+ Recognize sign & symptoms
+ Position: sitting upright or leaning forward
+ Ask questions that requires few words
+ Reassure that they are safe & will be cared for during
stressful situation
+ Avoid allergen; encourage to cough
+ Administer meds as ordered
Nursing care management:
+ Clean devices used- oral candidiasis
+ Increase fluid, inform condition, encourage self
care
+ Influenza vaccination annually
Client Education Guide:
•Avoid factors that triggers asthma attack
•Use bronchodilator 30 minutes before exercise to prevent
or reduce exercise-induced asthma
•Proper technique & correct use of metered dose inhalers
•Adequate rest & sleep, reduce stress & anxiety; learn
relaxation techniques
•Failure of medications to control worsening symptoms,
seek immediate emergency care
Thank you!