Alteration in Immune Function: Fevers, Sepsis, HIV/AIDS - PDF

ALTERATION IN IMMUNE FUNCTION Part 2 Welcome back students. I have titled this section Alterations in immune function but there are a few things that I want to cover before we jump into those topics. Let’s get started....

ALTERATION IN IMMUNE FUNCTION Part 2 Welcome back students. I have titled this section Alterations in immune function but there are a few things that I want to cover before we jump into those topics. Let’s get started. 1  Fever Physiologic response to an infection Not always bad-- promotes immune response and kills organisms Parents often fearful We have discussed a lot about children having fevers, but we haven’t really defined what it means. Fevers can be a beneficial physiologic response helping to slow the growth of or killing organisms that thrive at lower body temperatures. Fevers are the body’s natural defense again foreign organisms. Even so, fevers, especially in young children can be very scary for parents. Fevers are not typically harmful until they reach 41-degree Celsius ( 105.9 F) but at Akron Children’s we will see orders written to treat fevers greater than or equal to 38.5 degrees Celsius or (101.3 F), sometimes lower in younger children as we will discuss on the next slide. In addition to monitoring the actual temperature, we need to look at how the child is behaving. Are they uncomfortable? Irritable and restless? These behaviors help us determine if the child needs treatment or can allow the fever to do its job. It is also important to be sure to take the child’s temperature with a thermometer – you can tell if a child feels warm, but you need to know how high the temperature. The temporal artery thermometer is the most accurate (if you do it according to the directions) and the least invasive to use for children. 2  Things to Watch For Infant < Child > 2 Other 2 months months signs Stiff Temp 40.1 neck/severe Temp 38 (104.2) (100.4) headache Severe crying or Difficult to inconsolability awaken Call PCP Difficulty Unable to breathing swallow These are some of the things that we would be concerned about when a child has a fever. Any time an infant has a fever greater than 38 or 100.4 F the PCP should be called immediately. I can’t stress that enough. Some other things that you would want to watch for in a child > 2 months old, are things like inconsolability, difficulty breathing, even after you have cleared their nose, a stiff neck or headache, being unable to swallow and drooling saliva. Some additional items, not listed on the slide, are: Purple spots on the skin Any seizure activity And the child won’t drink or has poor output. Some things that can wait 24 hours before calling the doctor would be: The child is 2-4 months old and has a fever within 48 hours of having their DTaP shot without any other symptoms. The child complains of burning or pain with urination, has a fever without a known cause, or a fever went away and then came back. 3  Treatment Acetaminophen 10-15mg/kg/dose q 4-6 hours Ibuprofen 4-10mg/kg/dose* q 6-8 hours NO ASPIRIN Remove all but a light layer of clothing No sponge baths Lots of fluids & rest Fevers are treated with either Acetaminophen, or Ibuprofen – you can see the recommended dosage on the slide, both of which you should be familiar with by now. I want to point out that acetaminophen can now be ordered IV for those who are NPO. However, the side effects are much more extensive with the IV formulation than the oral one. Next time you are on Lexicomp or in your drug guide check it out to see what I mean. We also want to be careful about using the correct unit of measurement when administering either of these meds – also a great teaching point for parents. Caution parents about not using combination products that may have acetaminophen in them in addition to giving their child acetaminophen. We don’t want the child to have an accidental overdose of acetaminophen. Remember No Aspirin. Along with medication administration to help bring the temperature down, we want to unbundle those kids to one single light layer. I think about this every time I have a fever. I want every cover on me because I feel so cold, but I know my temp won’t come down until I take some of the covers off. No sponge baths or alcohol baths. The lukewarm water may increase shivering and discomfort – you can put a cool cloth on their head for comfort, however. The fever will last until the child is recovering from the illness. Remember that illnesses caused by viruses do not respond to antibiotics and should not be given. Most of the URIs children experience are caused by viruses. 4  Mononucleosis Causes: S&S: RX: EBV* Fever, HA, Supportive Human Painful sore Corticosteroids Herpesvirus throat, FATIGUE No antibiotics type 4 HSM, increase Spread via LFTs direct contact* I have included Mono in this section because it didn’t really fit in the section with all the vaccine preventable diseases, even though it is also an infectious and communicable disease. Main difference is, there is no vaccine to prevent mono. Mono is caused by either the Epstein-Barr virus or EBV for short or the human herpesvirus type 4. It used to be called the “kissing disease” because the virus infects the oral mucosa and salivary glands. It is transmitted by direct contact with saliva or exposure to body fluids (blood or semen). The course of the illness usually lasts for 2-4 weeks but the fatigue can continue beyond that. In addition to the S&S on the slide, patient’s infected with mono may also experience anorexia, abd pain, malaise, and lymphadenopathy. HSM stands for hepatosplenomegaly, and LFT stands for liver function tests, which will be increased. Treatment is supportive – pain and fever meds, warm saltwater for gargling, Bed Rest during the acute phase. These kids can go back to school when their fever is gone and swallowing is back to normal, Remind them about no sharing food or kisses, or other bodily fluids, no contact sports for approx 4 wks due to the enlarged liver and spleen, and no alcohol until LFTs back to normal. This is to protect the liver. Corticosteroids may be used to control tonsillar swelling, impending airway obstruction, the enlargement of the liver and spleen, and myocarditis We don’t use antibiotics, specifically Ampicillin or Amoxicillin, to treat this because they cause a nonallergic rash. 5  Sepsis – Case Study Ruby is 1-week old female Brought in for feeding problems, some subtle changes in her color, change in tone, and activity. She has no fever, feels cool to the touch. Her HR is elevated, and she is tachypneic Diagnosis- rule out sepsis What can sepsis lead to if untreated? Now let's discuss Sepsis. I mentioned it several times as a consequence of some of the vaccine preventable diseases, but we need to do a closer look, especially because it is so serious in children. Sepsis is a systemic inflammatory response syndrome in relation to an infection, such as bacteria in the blood from an infected mediport, or PICC line, Group B strep from mom during delivery, for example. Infants and children who are at high risk include those who have chronic conditions, require invasive catheters like mediports or other central lines, burn victims, kids who have undergone many invasive procedures, have a compromised immune system or are on long term antibiotics. This brings us to our case regarding Ruby. Go ahead and take a minute to read through the information if you haven’t already done so. (Pause) We see that she is very young, is having some feeding problem and some behaviors that are concerning to her parents. The weird thing is she has no fever and feels cool to the touch. They are ruling out sepsis for her. As you may have noticed, the symptoms of sepsis may be nonspecific as in Ruby’s case. Something just seems off and parents are concerned. Other kids with sepsis may also present with abdominal distention, vomiting and diarrhea. Before the docs can start ordering tests or prescribing meds, they need to do a little history taking. What about those feeding problems? What do parents mean when they tell us this? Feeding problems may be described as decreased intake, poor suck or lack of interest and parents may describe the child’s color as being “off”. As sepsis progresses, the child may appear grey. Newborns with sepsis will also have hypothermia, as opposed to a fever and their HR and respirations will be elevated. What do you think sepsis can lead to if untreated? (pause) Sepsis can lead to septic shock and death. Rapid diagnosis and treatment are important because these little ones can go downhill very quickly. It can be missed because of the subtle symptoms in the early stages. 6  Sepsis – Case study In addition to her clinical While waiting for the signs and symptoms, cultures to come back, what diagnostic tests will Ruby is started on the need to be run on Ruby? following: Blood and urine cultures O2 CSF IV fluids Culture any skin lesions IV antibiotics CBC with differential So what do you think they will need to do for Ruby to #1 diagnose her, and #2 support her if she indeed has sepsis? (pause)They will order us to draw blood and urine cultures, a LP (lumbar puncture) will be performed to collect cerebrospinal fluid, and any skin lesions if present will be cultured. While we are waiting for those results, she will be started on O2, IV fluids, and IV antibiotics – all of these are done to preserve her vital organ function. They may add other meds depending on the symptoms that she is demonstrating, for example she may receive red blood cells to maintain her Hgb or vasopressor meds to manage hypotension. 7  Sepsis – Case study In addition to drawing labs, what other interventions will nurses perform for Ruby? CRM Frequent VS Strict I & O Daily weights Perfusion checks Ok, we’ve drawn our labs and started our fluids, and have her admitted to the PICU. What else do you expect to be part of Ruby’s active orders? We would want to put her on Cardiac and resp monitor along with a pulse ox since she is on O2, paying close attention and responding to any alarms that she may have, do frequent VS – alerting the provider for abnormals, do Strict I & O along with daily weights. Frequent perfusion checks would be important as well as doing a good skin assessment, looking for petechiae or purpua, which could indicate DIC (disseminated intravascular coagulation). All of these would be done in addition to her IV meds, fluids and O2 therapy. Supporting the parents through this extremely stressful time would also be important as the child may have disabilities or even die as a result of sepsis. 8  HIV/AIDS AIDS caused by human immunodeficiency virus (HIV) Develops if HIV not treated Most cases in children = perinatal transmission – Blood, amniotic fluid, genital track secretions – Breast milk Adolescents: – Unprotected sex – IV drug abuse Next up, I would like to discuss a few of the diseases in which there is an alteration in immune function, the first one being AIDS. Acquired immune deficiency syndrome is caused by the HIV -1 primarily. In the disease process, HIV destroys the body’s ability to fight infection allowing opportunistic infections to sneak in and destroy the immune system. It does this by destroying the T-cells which eventually eliminates cellular immunity. You can see by the slide how most cases in children and adolescents are acquired. With more effective identification and treatment of HIV + mothers, the incidence of perinatally acquired HIV infection has decreased by 41% from 2012-2016. Those women who are HIV+ and pregnant receive antiretroviral medications and are advised not to breastfeed. 9  AIDS NONSPECIFIC FINDINGS AS DISEASE PROGRESSES: Lymphandenopathy Recurrent bacterial infections Hepatosplenomegaly LIP Oral candidiasis FTT and weight loss Progressive neurological Delayed development deterioration Swelling of parotid glands Chronic diarrhea The time interval between the HIV infection to full blown AIDS is shorter in children than adults. Babies who are born with HIV are asymptomatic at first but will begin to present with nonspecific findings in the early stages of the infection. You can see those listed on the left- hand side of the slide. As the disease progresses, we will see recurrent bacterial infections, LIP Lymphoid interstitial pneumonitis, and progressive neuro, neurological deterioration, all of which are more common in kids than adults. I am not going to expect you to know all of these things, but I want you to see the progression. If you didn’t know the child’s history of exposure, you could be scrambling to find out what is making the child sick. The preferred tests for finding out if someone is HIV + are the HIV DNA (PCR) test or the HIV RNA Assay. This assay looks at the child’s viral load. Any positive results are confirmed by retesting. If a child has been exposed because mom is HIV +, they will have antibody testing done regularly. Two negative tests at age 6 months or older means the child is HIV -. 10  TREATMENT Antiretroviral drugs All infants of infected mothers should receive P. jiroveci pneumonia prophylaxis at age 4-6 weeks old In the child diagnosed with HIV – Combination Antiretroviral drugs – Monitor for toxicity and side effects – Frequent lab work While there is no cure for HIV or AIDS, the treatment has come a long way. It involves the use of antiretroviral drugs. We want to prevent children from getting HIV from their mothers, so as I stated earlier, the mom is started on these antiretrovirals as early in the pregnancy as possible. Infants who are born to infected mother are then put on this PJP prophylaxis. PJP stands for pneumocystis jiroveci pneumonia. The prophylaxis would be started at 4-6 wks of age through the first year of life, unless the child tests negative twice. Children who are diagnosed with HIV are put on a combination of Antiretroviral drugs. These combinations are made up of at least three oral antiretroviral drugs from a minimum of two different categories.(Garzon, 2025) These children need to be monitored closely for toxicity and side effects of the drugs. They also require frequent labs before and during treatment to help with this monitoring. 11  PATIENT TEACHING Prevent spread! Prevent and treat infections Immunizations Promote medication compliance Regular physical exercise Monitor growth – GT feeds, TPN? Protect abdomen – avoid injury to liver and spleen Our number one priority with HIV is to prevent its spread, both vertically from mother to child and from person to person as with the adolescent population. Standard precautions should be used at home to prevent spread via body fluids. If an infant or child is unfortunate enough to have contracted HIV, it is important to reinforce the teaching points I have listed on the slide. Because their immune system is compromised, we should teach about the importance of antibiotic therapy for treatment of infections, and the need for immunizations. We also want to limit the child’s exposure to people with known infections or groups of people (who may have infections). For example, we would council parents not to take their child out to the mall to see Santa at Christmas. Great place to pick up an infection. We also want to promote the child’s compliance to the medication regimen. It may take several tries to find the right combination of drugs to treat the virus while not causing the child to experience severe side effects or toxicity. Bottom line is, they don’t take the meds, the disease will progress. But it can be challenging, especially due to cost. Just because these kids have HIV, they are still kids and need to have regular exercise to keep their lungs functioning properly due to their increased risk of pneumonia and other respiratory infections. We would also Monitor growth; do they need supplements added to their diet to improve their nutrition? Are they able to take them orally or do they need a G tube placed or TPN? Because of the progressive neurological deterioration, we need to monitor their development as well– are they meeting their developmental milestones or are they experiencing developmental delays? It is also important to Assess abd frequently, since the child may have HSM, and teach about safe transport in car seats or seat belts to avoid injury to the liver and spleen. 12  Juvenile Idiopathic Arthritis Inflammation involving one or more joints Lasts longer than 6 weeks Diagnosed prior to 16 years Cause is unknown – autoimmune? Alright the last disease we are going to discuss is Juvenile idiopathic arthritis or JIA for short. The definition of Juvenile idiopathic arthritis includes all the criteria I have listed on the slide. This disease results in decreased mobility, swelling, and pain which may impact normal growth and development. Because it affects joints and surrounding tissues, it also has potential effects on other organs such as the heart, lungs, liver and eyes. Females experience it 2x more often than males. The cause of JIA is unknown, and it is thought to have an autoimmune basis. 13  JIA Here we can see the pathophysiology of the disease. Inflammation starts in the joints and leads to pain and swelling. Over time, scar tissue develops, reducing the ROM in the joint. This can lead to early closure of the epiphyseal plates, small joint contractures, and synovitis which means that there is swelling and inflammation in the synovial membrane that lines some of the joints. JIA may be restricted to a few joints or be systemic with symptoms like a fever, rash, Lymphandenopathy, Splenomegaly, hepatomegaly. The child with JIA may develop a limp or obviously favor one extremity over the other. The disease is frequently chronic, extending over several years. Remissions and exacerbations are characteristic. 14  JIA Treatment Relieve pain, NSAIDS control DMARDs inflammation Preserve joint PT & OT function, prevent Surgery (occasionally) deformities Promote adequate Eat well-balanced diet Maintain healthy weight for height nutrition – monitor growth The overall goal of treatment for JIA is to achieve remission. This is done by focusing on the more specific goal of relieving pain and controlling the inflammation. This is accomplished by administering NSAIDS and possibly DMARDS if they don’t respond to the NSAIDS. DMARDs – stands for disease modifying antirheumatic drugs such as methotrexate and sulfasalazine. There are other meds used for the more severe types of JIA but I am not going to go into those. You’re welcome. They are in your text if you are interested. The next piece of the picture focuses on preserving joint function and preventing those contractures which can lead to deformities. This is done through PT & OT treatments which would include things like– ROM exercises, stretching, hydrotherapy, and swimming. Swimming is great for this as it is easy on the joints but still works them. We want the child to strengthen those muscles, increase their tone and maintain a good body alignment. Surgery may be done to release contractures if needed One additional item that is important to address is nutrition. If a child has decreased mobility, they have a lower metabolic rate and can put on weight if they don’t maintain a healthy diet. Any excess weight, as those of us know who have ever battled with our weight, is hard on the joints. We want to keep a close eye on these kid’s growth charts to watch for changes. 15  End of Part 2 This concludes this section of content. Take a break, stretch your legs, email me with any questions you may have. When you come back, we will cover Alterations in skin integrity. BTW this picture has nothing to do with what we just covered. It just makes me happy to look at it. 16