Chapter 25: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder

A nurse is conducting a physical examination of a 12-year-old girl with suspected systemic lupus erythematosus (SLE). How would the nurse best interview the girl?

"Have you noticed any hair loss or redness on your face?" Alopecia and the characteristic malar rash (butterfly rash) on the face are common clinical manifestations of SLE. Rhinorrhea, wheezing, and an enlarged spleen are not hallmark manifestations of SLE. Petechiae and purpura are more commonly associated with hematological disorders, not SLE

The nurse is providing instructions to the parents of a child with a severe peanut allergy. Which statement by the parents indicates a need for further teaching about the use of an epinephrine auto-injector?

"The epinephrine auto-injector should be jabbed into the upper arm." An epinephrine auto-injector should be jabbed into the outer thigh, as this is a larger muscle, at a 90 degree angle, not into the upper arm. The other statements are correct

The nurse is monitoring the CD4 count of an infant who has contracted HIV from the mother in utero. The nurse is concerned that treatment with antiretroviral therapy is not effective when noting which CD4 level?

1300/mm3 The number of CD4 T lymphocytes in the blood helps to determine the effectiveness of antiretroviral therapy. Normal is 1500/mm3 in the infant, so anything below that number may indicate that the therapy is not effective.

The nurse is preparing a care plan for a 3-year-old client diagnosed with severe combined immune deficiency. What is the primary goal for this client?

The client will remain free from infection. While all of these are goals for the client, the highest priority for the immunocompromised client is to remain free from infection since she is at a high risk for development of an infection. In the immunocompromised client any infection can be life threatening

Food allergies have become more and more common in the last few decades. What are some common food allergies of childhood?

• Milk • Peanuts • Eggs Allergies to eggs, peanuts, and milk are common in childhood. Cheerios are made of oats and are not known to be allergenic. Apples also are not allergenic, unlike bananas, which can cause problems for children who have latex allergies.

The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education?

"If we need to use the EpiPen® we will need to notify her physician's office the next business day." If an EpiPen® is used, the child still needs immediate medical attention. EpiPens should be carried with the patient at all times. When administering an EpiPen, the grey safety cap should not be removed until immediately prior to using. Medical alert bracelets or necklaces should be worn by all children with severe allergies

The nurse is observing a child demonstrate the use of an Epipen. The nurse determines that the child has performed the procedure correctly. Place the steps in the proper sequence that was demonstrated by the child.

-Grasps Epipen with black tip pointing downward -Forms a fist around the Epipen -Pulls off the gray safety release -Jabs the Epipen firmly into the outer thigh at a 90-degree angle -Holds Epipen in place for 10 seconds -Massages site for 10 seconds after removing Epipen The steps to using an Epipen are as follows: Grasp the Epipen or Epipen Jr. with the black tip pointing downward, forming a fist; with the other hand, pull off the gray safety release; swing and jab the Epipen firmly into the outer thigh at a 90-degree angle and hold firmly there for 10 seconds; remove the Epipen and massage the thigh for 10 seconds.

school-aged child has a bee-sting allergy. When the child is stung by a bee during a school recess, assuming that all of the following interventions are covered by school protocol, which initial intervention by the school nurse would be most appropriate?

Administer epinephrine immediately. Epinephrine counteracts histamine release to decrease bronchospasm and difficulty breathing.

The parents of an adolescent tell the nurse, "Our child seems to have allergy symptoms every time we visit our favorite cafe. I don't understand since the only allergy indicated in the testing was to eggs?" How should the nurse respond?

"Does your child get a whipped cream or foam topping on their favorite drink?" Albumin, globulin, ovalbumin should be avoided if allergic to eggs. Some foam toppings for drinks contain these substances and would cause an allergic reaction to the person allergic to eggs. This would be important information to ascertain from the family as they would likely not be aware of this.

The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant he gets a rash. It just doesn't make sense to me." How should the nurse respond?

"Has your child ever been tested for a peanut allergy?" Explanation: Enchilada sauce is an unexpected food that may contain a form of peanuts (such as peanut oil) that may be causing an allergic reaction in the child.

A nurse is providing dietary interventions for a 12-year-old with a shellfish allergy. Which response indicates a need for further teaching?

"He will likely outgrow this." Older children and adolescents with allergic reactions to fish, shellfish, and nuts usually continue to have that concern as a life-long problem

The nurse is reviewing the health records of an 18-year-old with Guillain-Barré syndrome (GBS). The nurse anticipates finding what information in the client's health history?

An upper respiratory viral infection GBS is a disorder in which an immune response within the body attacks the peripheral nervous system but does not usually affect the brain or spinal cord. GBS is believed to be an autoimmune condition that most commonly is triggered by a previous viral or bacterial infection, usually described as an upper respiratory tract infection or an acute gastroenteritis with fever, and is more commonly seen in adults rather than children

The nurse is caring for a child who is receiving an intravenous immunoglobulin treatment. The client calls the nurse and reports she vomited. What action should be completed first?

Discontinue the infusion. Clients receiving intravenous immunoglobulin are at risk for anaphylaxis. Vomiting can signal an allergic response. The first action would be to stop the infusion. The remaining activities are appropriate for inclusion in the plan of care but are not of the highest priority

A nurse is caring for an infant whose mother is human immunodeficiency (HIV) positive. The nurse knows that which diagnostic test result will be positive even if the child is not infected with the virus?

Enzyme-linked immunosorbant assay (ELISA) The ELISA test will be positive in infants of HIV-infected mothers because of trans-placentally received antibodies. These antibodies may persist and remain detectable up to 24 months of age, making the ELISA test less accurate in detecting true HIV infection in infants and toddlers than the polymerase chain reaction (PCR). The PCR test is positive in infected infants over the age of 1 month. The erythrocyte sedimentation rate would be ordered for an immune disorder initial workup or ongoing monitoring of autoimmune disease. Immunoglobulin electrophoresis would be ordered to test for immune deficiency and autoimmune disorders

The nurse on a pediatric unit finds a child having extreme shortness of breath, a swollen tongue, and urticaria on her face and neck. The nurse notices her lunch tray to have a half-eaten peanut butter and jelly sandwich. The client is allergic to peanuts. What is the first medication the nurse should be prepared to administer?

Epinephrine The child is demonstrating an anaphylactic reaction. While all of the medications may be necessary, the first medication to be administer is epinephrine to counteract the analphylaxis.

The nurse is monitoring the labs of a child admitted for an exacerbation of juvenile pauciarticular arthritis. Which lab result does the nurse expect to be elevated?

Erythrocyte sedimentation rate (ESR) The erythrocyte sedimentation rate (ESR) is an indicator of inflammation; it would likely be elevated during an exacerbation of arthritis. Immunoglobulin electrophoresis determines the level of individual immunoglobulins; it would not be elevated in an autoimmune disease. Lymphocyte immunophenotyping T-cell quantification measures T-cells; this would be used to monitor immunosuppressive disorders. The radioallergosorbent test measures minute quantities of IgE in the blood; it is used for asthma and food allergy testing.

A child with systemic lupus erythematosus is receiving hydroxychloroquine sulfate. Which instruction would the nurse emphasize when teaching the child and parents about this drug?

Importance of yearly eye examinations When hydroxychloroquine is given, the child should have a fundoscopic eye exam and visual field testing every year. Corticosteroids need to be tapered gradually over time. Cyclosporine A should not be taken with grapefruit juice. Nonsteroidal anti-inflammatory agents should be given with food to decrease gastrointestinal upset

The nurse is caring for a client with HIV who is receiving Ziagen (abacavir) for treatment. What signs and symptoms will require the nurse to notify the physician?

• Muscle weakness • Shortness of breath • Rash • Unusual bleeding Ziagen (abacavir) is a nucleoside analog reverse transcriptase inhibitor given as part of the drug treatment regimen for HIV. Muscle weakness, shortness of breath, headache, insomnia, rash, or unusual bleeding are side effects that must be reported to the physician.

To avoid anaphylactic reactions in children, which question would be most important to ask a parent before administering penicillin to her infant?

"Has she ever had penicillin before?" Penicillin is a drug frequently involved in allergic reactions. The reaction occurs after the child has first been sensitized to the drug

The nurse is providing teaching for the parents of a child with a latex allergy. The nurse tells the client to avoid which food?

Bananas The nurse should instruct children and their families to avoid foods with a known cross-reactivity to latex, such as bananas

The nurse is preparing to administer IVIG to a child who has not received the medication before. What medication should the nurse expect to administer prior to the infusion?

Diphenhydramine Premedication with diphenhydramine or acetaminophen may be indicated in children who have never received IVIG, have not had an infusion in more than 8 weeks, have had a recent bacterial infection, have a history of serious infusion-related adverse reactions, or are diagnosed with agammaglobulinemia or hypogammaglobulinemia. Aspirin, ibuprofen and prednisone would not routinely be administered prior to IVIG

The nurse is explaining to a parent some of the basic aspects of the immune system and its functions. She informs them that B cells, also known as _________ cells, will attack __________ antigens.

Humoral; bacterial B cells are also called humoral cells and typically attack bacterial organisms. Another term for T cells is killer cells, and they most commonly attack viral organisms.

A group of nursing students are reviewing information about the immune system. The students demonstrate understanding of the information when they identify what as being produced by the thymus?

Lymphocyte T cells The thymus is responsible producing lymphocyte T cells. The bone marrow produces stem cells that are capable of differentiating into various blood cells. White blood cells arise from the stem cells in the bone marrow. Antibodies are formed by the B cells

The nurse is providing teaching about food substitutions when cooking for the child with an allergy to eggs. Which response indicates a need for further teaching?

"I can use the egg white when baking, but not the yolk." The parents must understand that their child cannot consume any part of an egg in any form. The other statements are accurate.

What would best identify foods to which a child is allergic?

Elimination diet Elimination diets involve adding foods slowly to a child's diet so foods to which the child is allergic can be identified.

Which drug should be available for emergency treatment of a child who goes into anaphylactic shock?

Epinephrine Epinephrine (adrenaline) reverses the effects of histamine (severe bronchospasm and edema).

The nurse is preparing to administer an intravenous immunoglobulin infusion. While reconstituting the product according the manufacturer's instructions, the nurse knows to take which step for proper preparation?

Gently roll the vial to mix the medication. The nurse knows not to shake the intravenous immunoglobulin, as this may lead to foaming and may cause the immunoglobulin protein to degrade. Reconstituted intravenous immunoglobulin can be refrigerated overnight but should be brought to room temperature prior to administration. The nurse does not need to reconstitute the medication 2 hours prior to administration

A nursing student correctly identifies what to be the most serious of all of the immunologic disorders?

Human immunodeficiency virus (HIV) Of the immunologic disorders, HIV infection is the most serious, not only because it is still fatal but also because its spread has been difficult to contain

The mother of a child with myasthenia gravis inquires about thymus gland removal. She reports she has read that this is a possible cure for her child. What response by the nurse is indicated?"

"Removal of this gland may not improve your child's symptoms." Myasthenia gravis is an autoimmune condition. It is characterized by progressive weakness and fatigue. There is not cure. Removal of the thymus gland is recommended by some professionals but the thymus gland and its relationship to this disease are not clear. Removal of the gland may not improve the child's condition

The nurse is speaking with a teenager who has requested HIV testing. Which is the best statement by the nurse regarding HIV testing?

"The ELISA method detects antibodies so a person may have a false negative test for up to six months after exposure. ELISA method detects only antibodies, so the test may remain negative for several weeks up to 6 months (false-negative) after exposure. A false-positive may result with autoimmune disease. The ELISA test requires serial testing. HIV test results are confidential

The mother of a child with a possible food allergy asks the nurse for information about how to test for it. Which response by the nurse would be most appropriate?

"The best way is to eliminate the food from the diet and then look for improvement." Food allergies are best identified by eliminating a suspected food from the diet and observing whether symptoms improve. After a time of improvement, the food is reintroduced and if the child is allergic to the food, the symptoms will return. Skin testing with either a patch or intracutaneous injection is ineffective for determining food allergies. Serum antibody levels can be measured but are not specific in helping to determine food allergies.

A nursing student correctly identifies the inability to distinguish self from nonself, causing the immune system to carry out immune responses against normal cells:

Autoimmunity Autoimmunity results from an inability to distinguish self from nonself, causing the immune system to carry out immune responses against normal cells and tissue. Delayed hypersensitivity is when T-lymphocyte activity occurs without an accompanying humoral response. Immunity is the ability to destroy like antigens. An allergen is any mediating substance that when released causes tissue injury and allergic symptoms.

The nurse is assessing a child with a complex medical history that includes fatigue, Raynaud phenomenon, anemia and photosensitivity. The nurse should anticipate that this child may require which treatment?

Corticosteroid therapy This child's symptoms are consistent with systemic lupus erythematosus (SLE), which is usually treated with corticosteroids. Antiretrovirals, IVIG and phototherapy are of no benefit in the treatment of SLE

A child is in the emergency department after a bee sting and experiencing bouts of nausea and vomiting. The client's blood pressure is 68/40; pulse is 48. The child is hypoxic and dyspneic. Which medication should the nurse prepare to give this client?

Epinephrine Epinephrine is the drug of choice to treat anaphylaxis.

Place in correct order the steps in the anaphylactic response.

Exposure to allergen Rapid immune response Vasodilation Bronchoconstriction Circulatory collapse Anaphylaxis typically is a very rapid response to exposure to an allergen. Vasodilation leads to potential circulatory collapse. Bronchospasm occurs simultaneously with other system reactions, also contributing to the life-threatening possibility.

What advice would be most appropriate for the child with a stinging-insect allergy?

Obtain a medical alert ID bracelet so the presence of the allergy can be identified easily. Stinging-insect allergy can lead to anaphylactic shock. Alerting health care personnel to the possibility of an insect sting is important.

The nurse is reviewing the medical history of a 4-year-old child. What would the nurse identify as potentially indicative of a primary immunodeficiency?

• Acute otitis media, one episode every 3 to 4 weeks over the past year. • Recurrent deep abscess of the thigh • Oral thrush, persistent over the past 6 to 7 months Warning signs associated with primary immunodeficiency include four or more new episodes of acute otitis media in 1 year, recurrent deep skin or organ abscesses, persistent oral thrush or skin candidiasis after 1 year of age. A history of infections requiring IV antibiotics to heal and two or more episodes of pneumonia in 1 year are also warning signs.

The nurse is caring for a child who is beginning to show signs and symptoms of anaphylaxis. Which intervention would be the priority?

Assessing patency of the airway The priority nursing intervention is to assess patency of the airway and breathing. If the child is stable, the next step would be to obtain a brief history of allergen exposure. If epinephrine is required, it would be administered prior to diphenhydramine. Corticosteroids would be used to prevent late-onset reactions.

When describing anaphylaxis to a group of parents whose children have experienced anaphylaxis from insect stings, the nurse integrates knowledge that this response is related to which immunoglobulin?

IgE Anaphylaxis is an acute IgE-mediated response to an allergen that involves many organ systems and may be life-threatening

The parents of a 10-year-old with HIV have never told their child that he has the virus. The child asks the nurse why he is "on so many medications." What action should the nurse take?

The nurse should encourage the child to talk with his parents about his medications Generally, children older than 6 years of age will eventually need to have their diagnosis disclosed to them in an age-appropriate manner. They begin to ask questions and often seem to sense that something is going on other than what they've been told so far. Encouraging discussion with the parents is the best first step

The nurse is working with a pregnant client with HIV who is receiving oral zidovudine. What is the primary rationale for this intervention?

To help prevent transmission of the disease to the fetus A goal of therapy during pregnancy is to maintain the CD4 cell count at greater than 500 cells/mm3 by administering oral zidovudine which helps halt maternal/fetal transmission dramatically along with one or more protease inhibitors, such as ritonavir (Norvir) or indinavir (Crixivan), in conjunction with an NRTI. If P. carinii pneumonia develops, a woman is treated with trimethoprim with sulfamethoxazole. Kaposi's sarcoma is normally treated with chemotherapy. Women may need a platelet transfusion close to birth to restore coagulation ability.

A nurse is assisting with skin testing for allergies in a 14-year-old girl. What should the nurse do to ensure an accurate test?

Be certain that the child has not received an antihistamine in the past 8 hours. Skin testing is done to detect the presence of IgE in the skin, or to isolate an antigen (allergen) to which the IgE is responding or to which a child is sensitive. When an allergen is introduced into the child's skin and the child is sensitive to that allergen, a wheal or flare response will appear at the site of the test from the release of histamine, which leads to local vasodilation. Because this reaction appears quickly, the test should be read in 20 minutes, not 40 minutes. Systemic or aerosol administration of an antihistamine will inhibit the flare response, so be certain the child has not received these drugs for 8 hours before skin testing. Because intracutaneous injections are given just below the epidermal layer of skin (not in the muscle), they are almost painless; thus, no anesthetic is needed.

The nurse is planning to administer IVIG to a child for the first time. What actions related to this therapy are indicated?

• After mixing, roll the vial of medication. • Store the vial in the refrigerator until use. • Promote hydration prior to administration. • Medicate with acetaminophen prior to administration. IVIG must be reconstituted. After the diluent is added to the powder, gently roll the vial between your hands to mix. Shaking will damage the medication. Reconstituted IVIG may be refrigerated overnight but should be brought to room temperature prior to infusion. Premedication with acetaminophen may be indicated in children who have never received IVIG. The child should be well hydrated prior to the administration. Adverse reactions should be monitored for within 15 minutes of the initiation of the infusion

A nurse is preparing a presentation for a group of new parents and is planning to discuss nutrition during the first year. As part of the presentation, the nurse is planning to address foods that should be avoided to reduce the risk of possible food allergies. Which foods would the nurse most likely include? Select all that apply.

• Peanuts • Eggs • Shrimp Foods that should be avoided in children younger than 1 year of age include cow's milk, eggs, peanuts, tree nuts, sesame seeds, and fish and shellfish (i.e., shrimp). Carrots, potatoes, and bananas are not considered problematic.

The most accurate screening test for the presence of HIV antigen in young children is:

PCR PCR tests directly for the HIV antigen. ELISA and the Western blot test detect the presence of HIV antibodies. The CD4 count is used as a measure of disease status and progression

The nurse is assessing children in a physician's office. Which children may have a primary immunodeficiency?

• Child diagnosed with six episodes of acute otitis media during the previous year • Child with oral thrush that is unresolved with treatment • Child admitted to the hospital three times within the last year with pneumonia • Child who has taken antibiotics for the last 3 months without evidence of clearing of the infection The following children may have a primary immunodeficiency: a child with a persistent case of oral candidiasis, a child who has been diagnosed with pneumonia at least twice during the previous year, and a child who has taken antibiotics for 2 months or longer with little effect

The nurse is assessing a child who is experiencing renal complications as a result of lupus. Which finding is of the greatest concern?

Elevated blood pressure Renal complications may result from lupus. This may be accompanied by hypertension making monitoring of blood pressure of the highest importance.

A mother, who is HIV positive, is distraught when she learns that her 6-month-old baby is also human immunodeficiency virus (HIV) positive. The child had undergone open heart surgery as a newborn and had received numerous blood transfusions. The nurse recognizes that the most likely means of transmission of the disease to this child was:

Placental spread during pregnancy Although it is decreasing in incidence, transmission of HIV from mother to child by placental spread is still the most common reason for childhood HIV infection in the United States. Children with hemophilia no longer have a high incidence of the disease because blood products are now screened for the virus. HIV is not transmitted by animals or through usual casual contact, such as shaking hands or kissing, or in households, day care centers, or schools. Infection via breast milk is possible but less likely that via placental spread

Susie is a 3-year-old with a history of neonatal transmission of HIV and recent diagnosis of AIDS, as manifested by M. tuberculosis infection. To date, Susie has been relatively healthy with few illnesses associated with high fever; she has been developing appropriately and is at the 5th percentile for height and weight. Susie is at risk for all of the following diagnoses. Prioritize the order of urgency of these diagnoses based on the scenario provided.

-Altered family coping related to new presentation of significant illness -Altered comfort related to severity of new illness -Inadequate adherence to medication regimen related to side effects -Inadequate nutrition related to side effects of medication -Delayed growth and development related to frequent infections Because Susie has been relatively healthy since she was diagnosed with HIV, the change in her status is likely to cause changes in family coping mechanisms and dynamics that will have implications for the entire family. Next, the nurse needs to address the specific symptoms of the child. With the increased degree of illness and altered coping strategies, the child may have more difficulty with medication adherence, as well as other complications of AIDS-related illness and treatment, such as poor nutritional intake and delayed growth and development

A nurse is giving a talk to high school students about preventing the spread of human immunodeficiency virus (HIV). What does the nurse identify as ways in which HIV is spread?

• Perinatally from mother to fetus • Sharing contaminated needles • Transfusion of contaminated blood • Through breastfeeding • Exposure to blood and body fluids through sexual contact HIV is spread by exposure to blood and other body fluids through sexual contact, sharing of contaminated needles for injection, transfusion of contaminated blood, perinatally from mother to fetus, and through breastfeeding

The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education?

"Humoral immunity is generally functional at birth." Normal immune function is a complex process involving phagocytosis (process by which phagocytes swallow up and break down microorganisms), humoral immunity (immunity mediated by antibodies secreted by B cells), cellular immunity (cell-mediated immunity controlled by T cells), and activation of the complement system. Cellular immunity is generally functional at birth, and as the infant is exposed to various substances over time, humoral immunity develops.

The nurse is instructing a group of women of childbearing age about human immunodeficiency virus (HIV) during pregnancy. What would be a priority recommendation in this setting?

Screening for HIV No screening mandate has been put forth for HIV, but all pregnant women should be encouraged to undergo this test. Prophylactic treatment would be initiated only once the woman has been screened. Screening for STIs and ensuring proper nutrition are also part of health promotion for women in this age group, but they are of lower priority than identifying HIV-positive individuals