Week 13: Inflammatory, Infectious and Immunologic Response

• Juvenile Idiopathic Arthritis


  Chronic childhood arthritis; chronic autoimmune disorder that causes inflammation of synovial joints and surrounding tissues
• Probable causes of Juvenile Idiopathic Arthritis (JIA)

  • Genetic predisposition
  • Environmental factors (Exposure to radiation, viruses)
• Pathophysiology of Juvenile Idiopathic Arthritis (JIA)

  1. Synovial inflammation

  2. Joint effusion

  3. Erosion, destruction and fibrosis of articular cartilage

  4. Adhesion and ankylosis (stiffness) of the joints
• Clinical manifestations of Juvenile Idiopathic Arthritis (JIA)

  • Stiffness, swelling and loss of motion in the affected joint
  • Soft tissue edema
  • Joint effusion
  • Synovial thickening
  • Warm and tender to touch
  • Warm, erythematous and painful edema may signify infections
• Prognosis of Juvenile Idiopathic Arthritis (JIA)

  Onset usually start less than 16 y/o
• Diagnostics of Juvenile Idiopathic Arthritis (JIA)

  • Diagnosis of exclusion (onset before 16 y/o, arthritis in one or more joints for more than 6 weeks)
  • C-reactive protein may or may not be present
  • CBC features leukocytosis
  • Antinuclear Antibodies is common
  • Rheumatoid factor is negative in 90% of cases
• Therapeutic management for Juvenile Idiopathic Arthritis (JIA)

  • Non-steroidal anti-inflammatory drug (NSAIDs)
  • Disease modifying anti-rheumatic drug (DMARDs)
  • Glucocorticoids
  • Surgery is no recommended for children (Synovectomy), intra articular steroid injection is the alternative for synovectomy
• Physical therapy of Juvenile Idiopathic Arthritis (JIA)

  • Pool exercise is HIGHLY preferred and recommended
  • Isometric or tensing exercises can be done
  • Nighttime splinting may be done to avoid unnecessary movement during sleep
• Nursing management of Juvenile Idiopathic Arthritis (JIA)

  1. Assess the general health, status of affected joints, emotional response to all ramification of the disease, pain, physical restriction, therapies and self-concepts

  2. Promote general strength through diet and exercise, sleep and rest

  3. Day time naps are discouraged as it hampers daily activities and sleep cycle

  4. Encourage child school attendance

  5. Relieve pain
• Allergic Rhinitis


  Also known as Hay Fever, inflammation of the inner nose canal due to exposure of irritants
• Risk factors for Allergic Rhinitis

  • Exposure to tobacco smoke
  • Feeding of whole milk and solid food before 4-6 months of age
• Pathophysiology of Allergic Rhinitis: Early Phase Response (10-30 mins after allergen exposure)

  1. Allergen enters upper respiratory tract

  2. Binds to submucosal mast cells in the respiratory tract = immunoglobulin E (IgE) mediate symptoms

  3. Triggers rapid release of mast cells mediators (histamine, prostaglandins and leukotrienes)

  4. Histamine acts directly on local receptors to produce vasodilation, mucosal edema and increase production of mucus

  5. Cytokines summon cells slows allergic reaction of inflammation and destruction of the mucosal surface = chronic nasal obstruction
• Pathophysiology of Allergic Rhinitis: Late Phase Response (4-8 hours after exposure to allergens)

  Antigen exposure migrates neutrophils, eosinophils, basophils, macrophages and lymphocytes into nasal mucosa
• Clinical manifestations of Allergic Rhinitis

  • Watery rhinorrhea
  • Nasal obstruction
  • Sneezing
  • Itchy throat, nose, eyes or palate
  • Allergic salute- rubbing of nose
  • Allergic shiners- dark circles under the eyes due to lymphatic drainage outflow
  • Allergic gape- due to obligate mouth breathers secondary to nasal obstruction
  • Peak symptoms: tearing and soreness of eyes, gelatinous conjunctival discharges in morning, irritability, fatigue, depression and loss of appetite
• Diagnostics for Allergic Rhinitis

  • Physical and thorough history assessment
  • Skin test
• Therapeutic management of Allergic Rhinitis


  • AVOIDANCE of allergens
  • Immunotherapy: constant exposure to allergens until tolerance is established
  • Nasal corticosteroids is first line of drugs
  • Antihistamines
• Topical corticosteroids for Allergic Rhinitis

  • 1st generation: Beclomethasone (Vancenase and Beconase), Flunisolide (Nasalide), Budesonide (Rhinocort or Pulmicort)
  • Second generation: Fluticasone (Flovent), Mometasone (Nasonex)
• Topical corticosteroids are safe and effective than oral antihistamines for Allergic Rhinitis
• Nursing Management for Allergic Rhinitis

  • When nurses suspect allergic rhinitis, obtain information regarding clinical signs of related disorder such as middle ear disease, speech delay, wheezing, urticaria, cough etc.
• Asthma


  Chronic inflammatory disorder of the airways characterized by recurring symptoms, airway obstruction, bronchial hyperresponsiveness
• Risk factors for asthma

  • Atopy
  • Heredity
  • Gender (boys more affected than girls until adolescence)
  • Smoking
  • Ethnicity (African-Americans)
  • Low-birth weight
  • Overweight
• Pathophysiology of asthma

  1. Antigen enters the airway

  2. Mast cell degranulation and release of mediators

  3. Mediator effect (airway constriction, mucus secretion, vascular fluid leak)
• Clinical manifestations of asthma

  • Dyspnea
  • Wheezing
  • Coughing
  • Chest tightness and pain (older children)
  • Prodromal itching localized at front of neck
  • Increase restlessness due to nocturnal attacks/episodes
  • Hacking paroxysmal irritative non productive cough
  • Accumulated secretions become more profuse, frothy, clear and gelatinous sputum
  • Accessory muscles while breathing (infants)
• Diagnostics for asthma

  • Pulmonary function test
  • Peak expiratory flow rate
• Therapeutic management of asthma

  • Regular contact with healthcare provider to control symptoms and prevent exacerbations
  • Avoiding triggers and allergens
  • Using medications
  • Reducing inflammation
  • Relieving or preventing symptomatic airway narrowing
  • Patient education
  • Environmental control
  • Pharmacologic management
  • Monitoring severity and course of therapy
• Allergen control measures

  • Cover pillows and mattresses with dust proof covers
  • Wash bedding in hot water once a week and dry completely
  • Avoid using feather or down filled pillow and mattresses
  • Keep child indoors when pollen count is high or during gardening activities
  • Keep windows and doors closed during pollen season; use aircon if possible
  • Child should not be present during cleaning activities
  • Vacuum carpet and fabric-covered furnitures every week to reduce dust build up
  • Limit or prevent exposure to tobacco or wood smoke
  • Use air conditioner with high efficiency particulate air filters
  • Use indoor air purifiers
  • Choose stuffed toy that can be washed in hot water; dry completely before using
• Drug therapy for asthma

  • Inhaled corticosteroids such as cromolyn sodium and nedocromil
  • Long acting B2 agonist methylxanthines and leukotrienes modifiers use for long term management
  • Short acting B2 agonists, anticholinergics and systemic corticosteroids are used as quick relief (rescue drugs) medications
• Asthma medications are given in inhalation with nebulizer or metered dose inhaler
• Nursing management of asthma

  • Acute asthma care
  • General care
  • Avoid allergens
  • Relieve bronchospasms
  • Maintain health and prevent complications
  • Promote self-care and normalization
  • Provide the child and the family support
• Atopic Dermatitis (Eczema)


  A descriptive category of dermatologic disease and not to a specific etiology. A type of pruritic skin lesion usually begins in infancy and associated with allergic contact dermatitis with hereditary tendency (atopy)
• Types of Atopic Dermatitis

  • Infantile eczema - onset 4-6 mos. Spontaneous remissions by 3 y/o
  • Childhood eczema - onset 2-3 y/o, manifestation by 5 y/o
  • Preadolescent and adolescent - begins at 12 y/o may continue until adulthood
• Therapeutic management (Atopic Dermatitis)

  • Hydrate skin, Relieve pruritus, Prevent and minimize inflammation
  • Prevent or control infection
  • Avoiding exposure to possible or known skin irritants
  • Administration of medication such as antihistamine, topical immunomodulators and topical steroids
  • Tepid bath with mild soap (dove or neutrogena) followed immediately by application of an emollient (within 3 mins) in assisting trapping moisture
  • Oral antihistamine Hydroxyzine or Diphenhydramine, non-sedating antihistamine such as Loratidine (Claritin) or Fexofenadine (Allegra) is preferred in day time
• Nursing management


  1. Assess family history for evidence of atopy, environmental and dietary factors associated with exacerbations

  2. Explore family feelings and methods of coping

  3. Fingernails and toenails should be kept short, clean and filed

  4. Gloves and cotton stockings can be place to protect from excessive scratching

  5. Skin lesions are examined for type, distribution and evaluated for infection

  6. Control pruritus and conditions that increases itching

  7. Avoid woolen clothes and products; soft cotton fabrics are worn next to the skin

  8. Wear proper dress for climatic conditions as heat intensify pruritus

  9. Exposure to latex product should be avoided

  10. Clothes and sheets are washed in a mild detergent and rinsed thoroughly

  11. Bath are given as prescribed; water is kept tepid, soaps, oils and powders are avoided

  12. Skinfolds and diaper areas are washed frequently with plain water

  13. Room humidifier and vaporizer can be used to prevent drying of skin

  14. Report signs of infection to the physician (honey-colored crusts or pustules surrounded by erythema)
• Wilms Tumor


  Also known as nephroblastoma, most common intra abdominal and kidney tumor of childhood. Most of the time is malignant
• Clinical manifestations of Wilms Tumor

  • Mass within abdomen (firm, tender, confined)
  • Secondary anemia
  • Weight loss
  • Hypertension
• Diagnostics of Wilms Tumor

  1. History and clinical examination

  2. Radiograph (Ultrasound, MRI, CT-scan)

  3. Hematologic studies shows Polycythemia
• Stages of Wilms Tumor

  • Stage 1- one kidney is affected, can be resected
  • Stage 2- tumor extends beyond the kidney but can still be resected. NO lymph node affected
  • Stage 3- residual tumor confined to the abdomen with affected lymph nodes
  • Stage 4- metastasized to the lungs, liver, bones or distant nodules
  • Stage 5- upon diagnosis, tumor is already present in both kidneys
• Therapeutic management of Wilms Tumor

  1. Surgery: Nephrectomy

  2. Radiation therapy

  3. Chemotherapy (Actinomycin D, Vincristine)
• Nursing management of Wilms Tumor

  • Prevent/Avoid palpation of the abdomen, put do not palpate sign on the bedside to prevent other healthcare worker team to palpate
  • Prepare the child and family for operations
  • Post op care: Advise to avoid high-risk activities, prevent UTI, report any gastrointestinal disturbances, signs and symptoms. Watch out for hypertension
• Leukemia


  A broad term given to a group of malignant diseases of the bone marrow, blood and lymphatic system