NCMA219 - FINALS

• Juvenile Rheumatoid Arthritis (JIA)


  Chronic childhood arthritis, a group of heterogeneous chronic autoimmune diseases that cause inflammation in the synovium, joints, and surrounding tissue
• Cause of JIA is unknown
• Pathophysiology of JIA


  1. Chronic synovial inflammation causing joint effusion and eventual erosion, destruction, and fibrosis of the articular cartilage

  2. Adhesions between joint surfaces and ankylosis of joints occur if the process persists
• Clinical Manifestations of JIA


  • Stiffness, swelling, and loss of motion develop in the affected joints
  • Swelling results from soft tissue edema, joint effusion, and synovial thickening
  • Affected joints may be warm and tender to touch, but pain not commonly reported
  • Limited motion early is due to muscle spasm and joint inflammation, later due to ankylosis or soft tissue contracture
  • Morning stiffness of the joint(s) is characteristic
  • Functional change may be an obvious limp that protects the involved joint
  • In severe, long-standing cases, growth is significantly restricted
• Course and Prognosis of JIA


  • Outcome is variable and unpredictable
  • Rarely life threatening, significantly different from adult rheumatoid arthritis
  • Onset before 16 years of age
  • Negative rheumatoid factor in 90% of cases
  • Classic symptoms of systemic arthritis including quotidian fever, rash, pericarditis
  • Development of uveitis as a complication in 8-20% of cases
  • Tendency for the arthritis to become inactive
• Physical Management of JIA


  1. Physical therapy programs individualized to preserve function and prevent deformity

  2. Focus on strengthening muscles, mobilizing restricted joints, and preventing/correcting deformities

  3. Occupational therapists evaluate and improve performance of activities of daily living

  4. Muscle strength frequently lost around involved joints, inactivity leads to generalized weakness

  5. Exercising in a pool allows freedom of movement with support

  6. When joints inflamed, heavy resistance aggravates pain so isometric exercises tolerated

  7. Range-of-motion exercises continued after disease disappears to detect recurrence

  8. Nighttime splinting to help maximize pain and prevent/reduce flexion deformity

  9. Vigilance required to detect loss of motion, vigorous attention to passive stretching, positioning, and resting splints to prevent deformity
• Surgical Management of JIA


  1. Synovectomy used primarily in pauciarticular disease when other therapy unsuccessful

  2. Intraarticular steroid injection an alternative to synovectomy

  3. Joint replacement successful in older fully grown children
• Nursing Care Management of JIA


  • Assessment of general health, status of involved joints, and emotional responses to disease
  • Effects manifest in physical activities, social experiences, and personality development
  • Children's adjustment related to reaction and support from family and healthcare professionals
• Nursing Care Plan for JIA


  1. Relieve pain

  2. Promote general strength (diet, exercise, sleep, rest)

  3. Encourage school attendance
• Allergic Rhinitis


  • Increased risk in children exposed to tobacco smoke and early introduction of whole milk and solid foods
  • Classified as seasonal (SAR) or perennial (PAR)
• Pathophysiology of Allergic Rhinitis


  1. Requires familial predisposition to allergy and exposure to allergen

  2. Inhalants bind to submucosal mast cells, triggering release of mediators like histamine

  3. Histamine causes vasodilation, mucosal edema, and increased mucus production

  4. Cytokines summon cells, causing late-phase inflammation and destruction of mucosal surface

  
• Clinical Manifestations of Allergic Rhinitis


  • Watery rhinorrhea, nasal obstruction, sneezing, itchy throat, nasal pruritus
  • Symptoms may be chronic, recurrent, or acute
  • Nasal itching causes "allergic salute"
  • Dark circles under eyes ("allergic shiners"), open mouth breathing ("allergic gape")
  • Horizontal nasal crease, extra wrinkles below lower eyelids
  • Tearing, soreness of eyes, gelatinous conjunctival discharge, irritability, fatigue, depression, loss of appetite
• Asthma


  Chronic inflammatory disorder of the airways characterized by recurring symptoms, airflow limitation/obstruction that is reversible, and bronchial hyperresponsiveness
• Allergy influences both the persistence and severity of asthma in children
• Asthma episodes are associated with airflow limitation or obstruction that is reversible either spontaneously or with treatment
• Inflammation causes an increase in bronchial hyperresponsiveness to a variety of stimuli
• Difficulty of breathing and wheezing upon auscultation are characteristic of asthma
• Fluticasone (Flovent)


  Dry powder preparation
• Mometasone (Nasonex)


  Dry powder preparation
• Beclomethasone furoate


  Dry powder preparation
• Ciclesonide


  Dry powder preparation
• Immunotherapy


  Exposing the patient slowly to the allergen so that the body will be used to it
• Asthma


  • Chronic inflammatory disorder of the airways
  • Characterized by recurring symptoms, airway obstruction, and bronchial hyperresponsiveness
  • In susceptible children, inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough, especially at night or in the early morning
• The inflammation also causes an increase in bronchial hyperresponsiveness to a variety of stimuli
• You will have difficulty of breathing and wheezing upon auscultation in the lung fields
• Allergy


  • Influences both the persistence and the severity of asthma
  • Atopy, or the genetic predisposition for the development of an IgE-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma
  • 20% to 40% of children with asthma have no evidence of allergic disease
  • The allergic reaction in the airways can cause an immediate reaction, with obstruction, and it can precipitate a late bronchial obstructive reaction several hours after the initial exposure
• Allergic rhinitis


  Allergic reaction that causes predisposition for the development of asthma
• Risk Factors for Asthma


  • Atopy (includes a history of allergies or atopic dermatitis)
  • Heredity (e.g., parent/sibling with asthma)
  • Gender (boys are affected more frequently than girls until adolescence, when the trend reverses)
  • Smoking or exposure to secondhand smoke
  • Maternal smoking during pregnancy
  • Ethnicity (African-Americans at greatest risk)
  • Low birth weight
  • Being overweight
• Pathophysiology of Asthma


  • Inflammation contributes to heightened airway activity
  • Multiple mechanisms contribute to airway inflammation involving a number of different pathways
  • Asthma is unlikely to be caused by either a single cell or single inflammatory mediator, rather it appears that asthma results in complex interactions between inflammatory cells, mediators, and the cells and tissues present in the airway
  • Recognition of the importance of inflammation has made the used of anti-inflammatory agent such as steroids, a key component of asthma therapy
  • Bronchospasm and obstruction are also important components of asthma
  • Mechanisms responsible for the obstructed symptoms include respiratory response stimuli, airway edema and accumulation of secretions of mucous
  • Spasm of the bronchi and bronchioles, and airway remodeling which causes permanent cellular changes
  • Airflow is determined by the size of the airway lumen, degree of the bronchial wall edema, mucous production, smooth muscle contraction and muscle hypertrophy
  • Bronchial constriction is a normal reaction to the foreign stimuli but in childhood asthma it is abnormally severe producing impaired respiratory function
  • The smooth muscles arranged the spinal bundle around the airway causing narrowing and shortening of the airway which significantly increases airway resistance to airflow
  • The respiratory difficulty is more pronounced due to expiratory phase of respiration
  • Increase resistance in the airway causes forced expiration through the narrowed lumen, the volume of air trapped in the lungs increases as airways are functionally closed at the point between the alveoli and the lobar bronchi
  • The trapping of gas forces the individual to breath at higher and higher volumes, causing fatigue, decreased respiratory effectiveness, and increased oxygen consumption
  • The inspiration occurring at higher lung volumes hyperinflates the alveoli and reduces the effectiveness of the cough
  • As the severity of the obstruction increases, there is reduced alveoli ventilation with carbon dioxide retention, hypoxemia respiratory acidosis and eventually respiratory failure

  
• Asthma attack


  1. Antigen entry to the airway

  2. Mast cell degranulation and release of mediators in the airway

  3. Mediator effects (IgE) leading to mucus secretion, vascular leak of fluid and airway smooth muscle constriction

  4. Accumulation of RBC/WBC differential counts, with increased eosinophil and neutrophil, increasing mucus production and constricting the airway

  5. Difficulty of breathing, wheezes and eventual collapse of the lungs

  
• Clinical Manifestations of Asthma


  • The classic manifestations are dyspnea, wheezing, and coughing
  • Children may experience symptoms ranging from acute episodes to a relatively continuous pattern of chronic symptoms
  • Older children may complain of chest tightness and an intermittent generalized chest pain
  • Children may experience a prodromal itching localized at the front of the neck or over the upper part of the back
  • Respiratory symptoms include hacking, paroxysmal, irritative, and nonproductive cough caused by bronchial edema
  • Bronchial spasm and mucosal edema reduce the size of the bronchial lumen, and the bronchi may be occluded by mucous plugs
  • Coughing in the absence of respiratory tract infection, especially at night, may disrupt sleep
  • Wheezing may be mild or discernible only on auscultation at the end of expiration, or severe enough to be audible
  • Younger children have a tendency to assume the tripod sitting position, whereas older children have a tendency to sit upright with shoulders hunched over
  • Infants may display supraclavicular, intercostal, suprasternal, subcostal, and sternal retractions, but clinical symptoms may be less obvious in infancy
• Diagnostic Evaluation of Asthma


  • Pulmonary Function Tests (PFTs) provide an objective method in identifying the presence and degree of the lung disease and its response to therapy
  • Peak Expiratory Flow Rate (PEFR) can be measured using a peak expiratory flow meter
• Therapeutic Management of Asthma


  • The overall goals are to maintain normal activity levels, maintain normal pulmonary function, prevent chronic symptoms and recurrent exacerbations, provide optimum drug therapy with minimum or no adverse effects, and assist the child in living as normal and happy a life as possible
  • Regular contact with the health care provider is necessary to control symptoms and prevent exacerbations
  • Prevention of exacerbations includes avoiding triggers, avoiding allergens, and using medications as needed
  • Therapy includes efforts to reduce underlying inflammation and relieve or prevent symptomatic airway narrowing
  • Therapy includes patient education, environmental control, pharmacologic management, and the use of objective measures to monitor the severity of disease and guide the course of the therapy
• Allergen Control Measures


  • Cover pillows and mattresses with dustproof covers
  • Wash bedding in hot water once a week. Dry completely
  • Avoid using feather- or down-filled pillows and mattresses
  • Keep child indoors while lawn is being mowed, bushes and trees are being trimmed, or pollen count is high
  • Keep windows and doors closed during pollen season; use air conditioner if possible, or go to places that are air conditioned
  • Wet-mop bare floors weekly; wet-dust and clean child's room weekly
  • Vacuum carpet and fabric-covered furniture every week to reduce buildup, using a high-efficiency particulate air filter
  • Limit or prevent child's exposure to tobacco and wood smoke
  • Use air conditioners with high-efficiency particulate air filters
  • Use indoor air purifiers with high-efficiency particulate air filters
  • Choose stuffed toys than can be washed in hot water. Dry completely before the child plays with the toy
• Drug Therapy for Asthma


  • Quick-relief medications: Short-acting β2-agonists, anticholinergics, and systemic corticosteroids
  • Long-term control medications: Inhaled corticosteroids, cromolyn sodium and nedocromil, long-acting β2-agonists, methylxanthines, and leukotriene modifiers
  • Bronchodilators that relax bronchial smooth muscle and dilate the airway: β2-agonists, methylxanthines, and anticholinergics
  • Many asthma medications are given by inhalation with a nebulizer or a metered-dose inhaler (MDI), with a spacer when using inhaled corticosteroids
• Nursing Care Management for Asthma


  • Acute Asthma Care
  • General Care
  • Avoid Allergen
  • Relieve Bronchospasm
  • Maintain Health and Prevent Complications
  • Promote Self-Care and Normalization
  • Child and Family Support
• 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)
  • Manifests in three forms based on the child's age and the distribution of lesions: Infantile, Childhood, and Preadolescent and adolescent
• Therapeutic Management of Atopic Dermatitis


  • The major goals are to hydrate the skin, relieve pruritus, reduce flare-ups or inflammation, and prevent and control secondary infections
• Atopic dermatitis (AD)


  A type of pruritic eczema that usually begins during infancy and is associated with an allergic contact dermatitis with a hereditary tendency (atopy)
• Forms of AD based on age and lesion distribution


  • Infantile (infantile eczema) - Usually begins at 2 to 6 months of age; generally undergoes spontaneous remission by 3 years of age
  • Childhood - May follow the infantile form; occurs at 2 to 3 years of age; 90% of children have manifestations by age 5 years
  • Preadolescent and adolescent - Begins at about 12 years of age; may continue into the early adult years or indefinitely