UNIT 7: CASE STUDY 6 (Nursing Care of a Family When a Child Note that the course

pack provided to you in

Has an Immune Disorder) any form is intended
only for the use in
connection with the
CASE STUDY: AN ADOLESCENT WITH ATOPIC DERMATITIS course that you are
enrolled in. It is not for
distribution or sale.
Permission should be
Sally is a 13-year-old brought to a dermatology clinic by her obtained from your
grandmother for scaling lesions on her elbows and knees. instructor for any use

CHIEF CONCERN:
“My skin looks like a snake's.”

HISTORY OF CHIEF CONCERN:

Skin condition began with irritation on flexor surfaces at elbows and knees 4 months ago. At first
it was only reddened; then it became scaly and extremely pruritic. Mother tried applying
calamine lotion to areas without improvement. Child is not aware of any new foods eaten in the
last 4 months or any other irritating factor. No such involvement has occurred in other family
members.

FAMILY PROFILE:
Child is oldest of three children (brothers are 10 and 7) of a single parent. Mother lives with
grandmother in two-bedroom apartment. Family is supported by public assistance. Mother is
currently attending school to become a bartender. Grandmother states that money has “always
been a problem”; is hopeful that mother's new job will improve situation. A cousin has severe
asthma: treated with Cromolyn sodium and Zafirlukast (Accolate).

HISTORY OF PAST ILLNESSES:

Child had “constant” upper respiratory infections for first 3 months. Mother was told that child
might have an immune deficiency, but this later proved not to be true. Has had “hay fever” and
allergy to insect stings since 1st grade. Always sneezes and develops stuffy nose around
Christmas trees and goldenrod. Had rubella at 6 years. Head injury at 8 years from fall from
swing; seen in ER; no sequelae.

DAY HISTORY:
Nutrition: Grandmother states child “eats junk food” in preference to table food.
Sleep: Sleeps 7 hours per night but sleeps fitfully because of itching or sneezing at night.
Recreation/Play: Enjoys computer games; writing short stories. Has two tanks of tropical fish she
cares for.
Growth and Development: Child met infant and preschool developmental milestones. Is
presently in 8th grade (age appropriate) but is not doing well with schoolwork. Has been told
that she will not be promoted to high school unless there is a definite improvement in her work.
Child states that “itchiness” interferes with concentration. Has not menstruated yet.

HISTORIES OF FAMILY ILLNESSES:

Mother has sickle cell trait. Maternal grandmother has adult-onset diabetes mellitus. Both
mother and maternal grandmother are obese. Health of child's father is unknown.

REVIEW OF SYSTEMS:
Essentially negative but for chief concern.
Eyes: Has worn eyeglasses since 2nd grade. Tested in school in January. Vision 20/40 (right eye)
and 20/60 (left eye) corrected to 20/20 in both eyes with glasses.
Ears: Tested in school last fall and rated normal.
Extremities: Lesions as described in chief concern.

PHYSICAL EXAMINATION:
Height: 60 inches (50th percentile). Weight: 170 pounds (96th percentile). BMI: 35
Blood Pressure: 120/60.
General Appearance: Obese 13-year-old with obvious lesions on flexor surfaces of both arms.
Head: Normocephalic; scattered reddened papules on chin.
Eyes: Red reflex present. Follows to all fields of gaze. Able to read small print without difficulty.
Ears: TMs pink; landmarks present. Good alignment.
Nose: Midline septum; mucous membrane swollen and pale; clear nasal discharge present;
horizontal crease across nose.
Mouth and Throat: 30 teeth present; one cavity in left lower molar. Geographic tongue
observed.
Neck: Midline trachea; full range of motion present.
Lungs: Occasional rhonchi in upper lobes; respiratory rate: 20 breaths per minute.
Heart: Rate: 80 beats per minute. No murmurs.
Abdomen: Soft; no masses. No tenderness on palpation.
Genitalia: Normal preadolescent female. Tanner 2.
Extremities: Area 3 x 5 on flexor surfaces of both arms and legs at elbows and knees covered by
white scales on erythematous base. Linear abrasions apparently from scratching also present.
Full range of motion in joints present.
Neuro: Patellar reflex 2+. Sensory and motor nerves grossly intact.

Sallyis diagnosed as having both allergic rhinitis and atopic dermatitis. Her pediatrician suggests
that her mother begin some environmental control in their home.

CASE STUDY QUESTIONS:

INSTRUCTION: Select the best answer. For every answer that you choose, write, or indicate the
rationale. You will earn 2 points for every item you answered correctly. Do not forget to include
your references here.

1. Sally is a child prone to allergies. A term to describe such children is:

a. scleroses.
b. Atrophied
c. atopic
d. stigmatized.
Answer:
Atopic disorders include allergic rhinitis (hay fever), atopic dermatitis, and asthma .

2. Which antibody and white blood cell are most apt to be elevated in children with allergies?
a. IgE and eosinophils
b. IgB and lymphocytes
c. IgM and monocytes
 d. IgA and leukocytes
Answer:
IgE attached to surface of mast cell triggers release of intracellular anaphylaxis granules from
mast cells on contact with antigens. EFFECT: Allergies, asthma, atopic dermatitis. Additionally,
increased number of eosinophils is associated with many allergic disorders, such as atopic
dermatitis, and with parasitic invasion.

3. If Sally had been born with a primary IgA deficiency, assessing for what type of finding would
be most important?
a. A heart murmur.
b. Arthritis symptoms
c. Nervous disorders
d. Respiratory infections
Answer:
Without IgA, infections of surfaces exposed to the external environment and normally protected
by mucus become common. Sinusitis, upper respiratory tract illness, and inflammatory bowel
disease are apt to occur. There are associated atopic diseases (allergies) because without IgA on
the surface mucosa, many more antigens than usual can enter the body, permitting more
antigens to interact with IgE and produce allergic symptoms.

4. If Sally had been born with a primary b-lymphocyte deficiency, she would be unable to do
which of the following?
a. Produce antibodies
b. Directly phagosize cells
c. Produce corticosteroids
d. Develop urticaria
Answer:
B-lymphocyte deficiencies create abnormally low levels of immunoglobulins either selectively
(as in an IgA deficiency).

5. Acquired immunodeficiency syndrome (HIV/AIDS) is an infectious immune disorder. The cell

affected with this disorder is:
a. BBC monocytes.
b. CD4 lymphocytes.
c. eosinophils.
d. involved red cells.
Answer:
The virus acts by attacking the lymphoreticular system, in particular CD4-bearing helper T
lymphocytes.
Moreover, infection results in loss of CD4 lymphocytes and the ability to initiate an effective B-
lymphocyte response. A CD4 cell count in the laboratory determines how many cells are still
present and functioning. Because B-lymphocyte or humoral immune function, which initiates
the production of antibodies, is affected, antibody formation will be decreased
(hypogammaglobulinemia).
6. Children can develop secondary immune deficiencies from which of the following
conditions?
a. Weight above the 90th percentile
b. Intravenous penicillin administration
c. Administration of a corticosteroid
d. Exercising without eating beforehand
Answer:
Secondary immunodeficiency, or loss of immune system response, can occur from factors such
as severe systemic infection, cancer, renal disease, radiation therapy, severe stress,
malnutrition, immunosuppressive therapy, and aging. In stress it appears to alter the immune
response by stimulating the release of corticosteroids from the adrenal gland. This suppresses
the inflammatory response by inhibiting macrophage action.

7. Sally is scheduled for hyposensitization. This means:

a. she will not be allowed to eat any food to which she is allergic.
b. she will receive injections of allergens to which she is sensitive.
c. a course of an immune suppressive will be administered.
d. a course of antibiotics will be started to suppress antibodies.
Answer:
Hyposensitization, or immunotherapy, is done when the child’s allergy symptoms cannot be
controlled by avoidance of an allergen or conventional drug therapy. The procedures is after
specific allergens have been recognized with skin testing, small amounts of the allergy extract
(dilute enough to be clinically subreactive) are injected into the child subcutaneously at 3- to 5-
day intervals.

8. A risk of hyposensitization is that anaphylaxis may occur. This is:

a. sudden pulmonary dilation leading to shortness of breath.
b. a deficiency of immune function resulting from trauma.
c. sudden pulmonary constriction and vasodilatation.
d. high blood pressure reaction resulting from an allergen.
Answer:
Anaphylaxis acute hypersensitivity (type I) reaction characterized by extreme vasodilation that
leads to circulatory shock and extreme bronchoconstriction that decreases the airway lumens
(Lane & Bolte, 2007).

9. The drug of choice you should have available to counteract the risk of anaphylaxis from
hyposensitization is:
a. Prednisone.
b. Ciprocal.
c. Digoxin.
d. Epinephrine.
Answer:
Drug of choice used to counteract the symptoms of anaphylaxis (Karch, 2009).
10. Sarah’s pediatrician suggests her mother begin some environmental control. Which
statement by Sarah’s mother would make you believe she needs further instruction?
a. “I’m proud of Sarah’s tropical fish collection.”
b. “I’ve thrown away everything that was wool.”
c. “I’ve forbidden anyone to smoke in the house.”
d. “I ask Sally to leave the house while I dust.”
Answer:
Environmental control refers to ways to reduce the number of allergens to which children are
exposed.

11. Sally was diagnosed as having allergic rhinitis. A common finding on her physical exam that
suggests this is:
a. linear lacerations on her arms.
b. a horizontal crease across her nose.
c. eyesight of 20/40 and 20/60.
d. an upper respiratory infection.
Answer:
Children constantly rub their noses in an upward motion, termed an allergic salute. Over a long
period, rubbing the nose this way leads to a horizontal crease across the tip of the nose, called
an allergic crease.

12. Sally is prescribed an antihistamine. What is a common side effect of antihistamines that
you would want to alert Sally may occur?
a. Irritation and short temper
b. Lethargy or sleepiness
c. Petechiae on skin surfaces
d. Tingling of extremities
Answer:
Caution children and parents that antihistamines tend to cause sleepiness.

13. What is a common drug you could anticipate Sally will be prescribed to reduce her atopic
dermatitis symptoms?
a. An aminoglycoside antibiotic
b. A glucose-based nasal spray
c. A hydrocortisone cream.
d. A glycerin suppository
Answer:
Application of hydrocortisone cream can make a big difference in helping lesions improve.

14. If Sally is allergic to insect stings, which would be the best household chore for her?
a. Taking out the trash or garbage
b. Mowing the lawn in summer
c. Weeding the flower garden
d. Washing the evening dishes
Answer:
They should not be assigned household chores such as mowing the lawn or weeding the garden,
actions that might stir up bees. Because insects tend to cluster around garbage containers,
taking out the trash is also an inappropriate chore for these children.
15. Sally is scheduled for allergy testing. This is done by:
a. implanting suspected allergens into the mucous membrane.
b. instructing her to avoid all exposure to offending allergens.
c. injecting suspected allergens under the child’s skin.
d. rubbing her skin with oil to induce an allergic reaction.
Answer:
Skin testing is done by introducing an allergen into the child’s skin and the child is sensitive to
that allergen, a wheal or flare response appears at the site of the test.

16. Contact allergies result from lymphocyte activity. If Sally contacted poison ivy from a hiking
trip, what symptoms would you expect to see?
a. Linear strings of blisters on her arms
b. Constant sneezing and coughing
c. Irregular reddened blotches all over
d. Petechiae on her legs or thighs
Answer:
The first reaction is generally erythema, followed by intensely pruritic papules and then vesicles.
Poison ivy usually appears on the hands and arms where the child brushed against the plant.

17. When you take a history of Sally’s illness, it would be most important to ask if:
a. there are pollens she might be exposed to.
b. there is a source of metal she frequently touches.
c. the family owns a pet such as a dog or a cat.
d. Sally knows to keep lesions lubricated.
Answer:
Hydrating the skin by bathing or applying wet dressings (wet with tap water or Burow’s solution)
for 15 to 20 minutes, followed by application of a hydrating emollient such as petroleum jelly
(Vaseline) or even vegetable shortening (Crisco), is helpful.

18. When bathing, the midwife would tell Sally to have the bathwater:
a. As hot as the child can tolerate
b. Hot to touch on the inner wrist
c. Tepid
d. Cool
Answer:
Hot water can aggravate inflamed skin and draw moisture from your skin. Tepid water is way
more comfort than cool water.

19. What would be an appropriate nursing goal for Sally with eczema of the elbows, hands, and
face?
a. Pain will be managed
b. Spread of infection will be prevented
c. Well-hydrated skin will be maintained
d. Dietary restriction will be maintained
Answer:
Maintaining the skin to be well hydrated will prevent the need to scratch your dry skin rat may
lead to excoriation.
20. Sally keeps on scratching herself with her fingernails. To lessen the pruritus, you tell her
mother to avoid:
a. Covering the child’s hands
b. Administering antipruritics
c. Using elbow restraints
d. Keeping the skin dry
Answer:

The most common cause of pruritus is dry skin. This is the r Aston why you should apply
moisturizer daily.

REFERENCE:
Pilliterri, A. (2010). Nursing Care of a Family When a Child Has an Immune Disorder. In
Lippincott, Williams & Wilkins (Ed). Maternal and Child Health Nursing: Care of the Childbearing
and Childrearing Family 6th Edition (pp. 1230-1255) Philadelphia: Wolters Kluwer Health

Adapted from:
Pillitteri, A. (2010). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family (6th Edition). Lippincott Williams & Williams.

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 Submit this requirement by uploading this file on Canvas or via my email address at
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