Post on 19-Dec-2015
Endocrine Stressors and Adaptation
Common Pediatric Endocrine Disorders
Type I DiabetesCongenital HypothyroidismAcquired Hypothyroidism
(Hashimoto’s Disease)Hyperthyroidism (Graves disease)Growth Hormone Deficiency
The Endocrine SystemGlands-Hormones-Endocrine Disorders are either:
PrimarySecondary
Hypofunction Hyperfunction
Pediatric Differences in the Endocrine System
The endocrine system is less developed at birth than any other body system
Hormonal control of many body functions is lacking until 12-18 months of age
Infants might manifest imbalances in concentration of fluids, electrolytes, amino acids, glucose, and trace substances
Type I Diabetes
Most common endocrine disorder in children
Pancreas becomes unable to produce and secrete insulin
Peak age: 5-7, or at pubertyAbrupt onsetGenetic link
Type 1 Diabetes Beta cells- type of cell found in the Islets
of Langerhans within the pancreas that make and release insulin.
Insulin is a hormone required to move the glucose into cells throughout the body. If no insulin can be produced, the
glucose stays in the blood instead, where it can cause serious damage to all the organ systems of the body.
EtiologyAutoimmune
process causes destruction on insulin-secreting cells in the pancreas
At dx 90% of beta cells are destroyed
Type 1 Diabetes
No cure, but JDRF is funding studies that perfect pancreas transplantation and regeneration the body’s own beta cells without islet transplantation
Serum Glucose Levels
Normal: 70-110mg/dl
Glycosated Hemoglobin Hgb A1C1.8 to 4.0 is normal> 6.0 = DM
Diagnosis:fasting: >126mg/dl Random (non-fasting): ≥ 200mg/dl with classic signs (next slide)
Signs & Symptoms
PolyuriaPolydipsia PolyphagiaFatigue Blurred visionHeadacheShortened attention span
Mood changes
Diabetic Ketoacidosis(DKA)
Medical EmergencyAs glucose levels rise, child will
progress into DKA if not treatedBlood glucose levels > 300
Cellular starvation leads to ketone production Nausea, vomiting, abdominal pain Acetone (fruity) breath odor Dehydration Kussmaul respirations
Coma if untreated
When to Monitor for DKA
Abdominal painNausea and vomiting that persists for over
6 hoursMore than five diarrheal stools in 1 day A 1- or 2-day history of polyuria and
polydipsiaHas illness (e.g., viral or other) and is
unable to eat
Juvenile Diabetes Treatment
MultidisciplineGoal: Normal G & D, optimal glucose
control, minimal complications, adjustment to disease
Treatment consists of: Insulin replacement Diet BG monitoring Exercise
Diet Therapy
Well-balanced, enough caloric intake to support growth and development
Three meals, snacks spaced throughout the day
No diet foodsDon’t omit meals
Diet Therapy
No foods excluded, encourage good nutritional choices
Learn dietary allowances outside of home
Need to have consistent intake & timing of food to correspond to the time & effect of insulin prescribed
Exercise
Encouraged, never restrictedLowers blood glucose levels, by aiding the body’s use of food
Decreases insulin requirements
Proper snack before Add an extra 15- to 30-g
carbohydrate snack for each 45-60 minutes of exercise
BG MonitoringGlucose monitoringUrine testing for ketonesRecord keepingSelf-management at age
appropriate level2-6 choose food, clean finger
for BG4-6 dip own urine6-8 BGM8-10 insulin injections, diary10-14 nutritional decisions12-18 full management
InsulinPrecise dose cannot be predictedAmount is based upon average capillary or serum blood glucose levels
Will change based of G & DCan be administered BID SQ by needle/syringe, pen or by insulin/portable pump
Types of InsulinSynthetic Human Insulin
Rapid acting Lispro (Humalog) Aspart (Novolog)
Fast acting Regular ®
Intermediate NPH (N)
Mixed (70/30) Long Acting
Glargine (Lantus) Ultra Lente
Typical ManagementThe peak of the insulin should
occur Post-Prandial (after meal) to avoid hypoglycemia
InsulinAlternate sites Don’t inject
extremity to be used in sports
Give at room temperature
Always draw regular up first if mixing
PumpsDelivers fixed amounts of short-acting
insulin continuouslyWorn on a belt, the tubing & catheter
are changed Q48 hours and taped in place
Should not be removed for > 1-2 hoursSubject to minimal malfunctionSelf-motivated
PumpsAdvantages
Less scar tissue No daily injections Less to carry Private Sense of control
Disadvantages Must wear continuously Need to carry extra
battery Good BGM If insurance dose not
cover $$$$$ Still need emergency
needles, insulin, and remember how to inject
ILLNESSAlters diabetic management
Dosage requirements may increase, decrease, or remain unchanged depending on the severity of the illness & the child’s appetite
Rapid-acting insulin used to manage hyperglycemia associated with illness
Monitor fluids, may require extra oral fluids while ill
“Sick Day” Guidelines Seek medical attention for fever or other signs of infection.
Monitor the blood glucose levels more often than routine (1 to 4 hours).
Test urine ketones when the blood glucose level is greater than 200 mg/dL.
Do not skip doses of insulin.
Large fluid intake (drinks with carbohydrates) is essential if the child cannot eat as usual.
If the child cannot consume adequate amounts of fluids, seek medical attention.
Hyperglycemia BG > 160
Gradual onset Lethargic Polyuria Polydypsia Dulled sensorium, confused Weakness, fatigue, lethargy
Glucose 250 mg/dl Large ketones in blood & urine Blurred vision Ketoacidosis Coma
Hypoglycemia BG < 70
Commonly occurs before meals
when the insulin effect is peaking
burst of physical activity without additional food, delayed, omitted, or incompletely consumed means of snacks
Too much insulin-wrong dose
Signs & Symptomsof HypoglycemiaRapid onsetIrritable, nervousnessDifficulty concentratingShaky feeling, tremors, hungerDiplopiaPallorWeaknessHeadache, dizzinessSweatingUnconsciousness and convulsions
Treatment of Hypoglycemia
Give simple concentrated sugarGlucose gel or SL tablets Hard candySugar cubesLow-fat milk or OJ
Followed by a complex CHO & ProteinSlice of bread or cracker with peanut
butterGlucagon SQ for severe hypoglycemia
(may cause vomiting, prevent aspiration)
Nursing DiagnosisRisk for injury R/T
hypoglycemia or hyperglycemiaFear R/T
diagnosis, insulin injection, negative effect on life style
Risk for ineffective coping R/Tcomplex self-care regimen and uncertain future
Imbalanced nutrition: more than body requirements R/Tintake in excess of activity expenditures
Nursing DiagnosisRisk for non-compliance R/T complexity of regimenRisk for ineffective therapeutic management R/T insufficient knowledge of conditionKnowledge deficit R/T new health condition AEB questions being askedAltered family processes R/T situational crises AEB uncertainty of chronic
disease/disability
Nursing Considerations Begins with survival education Educate child & family regarding
Nature of disease, hypo/hyperglycemia Meal planning (3 spaced meals, 3 snacks) Wearing ID bracelet Effective duration, onset & peak action of
insulin Injection procedure, rotate sites Glucose monitoring, urine testing, record
keeping Exercise regime
Nursing ConsiderationsProvide emotional support
Encourage growth and development
Identify home care needs
Disorders of the Thyroid
Congenital Hypothyroidism
Acquired Hypothyroidism
Hyperthyroidism
CONGENITAL HYPOTHYROIDISM
Disorder at birthBody is producing insufficient thyroid
hormone to meet metabolic needs caused by absent or underdeveloped thyroid gland
If not treated can lead to severe CIDetected in Newborn Screen
Incidence and EtiologyCaused by defect in the embryonic period in
thyroid glad production
Also caused by inborn error of thyroid hormone synthesis (an inherited autosomal recessive trait)
Can be secondary to pituitary dysfunction
Thyroid gland is unable to produce T3 and T4
CONGENITAL HYPOTHYROIDISM
Mottled skinLarge fontanelLarge tongueHypotonia/slow reflexesDistended abdomenLow T4 < 6, High TSH > 40
CONGENITAL HYPOTHYROIDISM
An infant with a low T4 <6 and a TSH value exceeding 40 mU/ml is considered to have primary hypothyroidism until proven otherwise
CONGENITAL HYPOTHYROIDISM
Treated with lifelong thyroid replacement therapy Synthroid 10-15 mcg/kg/day
Administration of increasing amounts over 4-8 weeks to avoid symptoms of hyperthyroidism
Taken 30-60 minutes before meals for optimal absorption
Monitor G&D and Thermoregulation Labs q 2 wks then q 3 mos *** look for upper range of
normal Medication compliance Teach parents to monitor for hyperthyroidism
Signs of Medication induced Hyperthyroidism
Nervousness/anxietyDiarrheaHeat intoleranceWeight lossIncreased HR
OutcomePrevention of cognitive impairment–
newborn screening on all babiesEarly treatment has had significant impact
on morbidityMost children progress to within normal
ranges on developmental assessmentPoor prognosis in more severe cases
Acquired Hypothyroidism (Hashimoto’s disease)
Thyroid produces inadequate levels of thyroid hormone > age 2
T4 decreases, TSH risesAutoimune disorder
Antibodies and developed against thyroid gland
Gland becomes inflamed, infiltrated by antibodies and destroyed
Etiology
Primary (Hashimoto’s thyroiditis)Most commonAutoimmuneChildhood, adolescents,
females>males Secondary
associated with other conditions that affect the thyroid
Pituitary and hypothalmic dysfunction Tertiary
Radiation, surgery, trauma
Acquired Hypothyroidism
GoiterDry, thick skinCoarse but thinning
hairFatigueCold intolerance
Delayed puberty and menses
Decelerated growthEdema around eyes,
face and handsConstipationSleepiness Mental decline-not
permanent cognitive impairment
Acquired Hypothyroidism Treatment
Thyroid hormone replacement-Synthroid Starting dose 10 -15 mcg/kg/day
Administration of increasing amounts over 4-8 weeks to avoid symptoms of hyperthyroidism
Taken 30-60 minutes before meals for optimal absorption
Repeat thyroid function test one month should see normalization of TSH
Requires lifetime follow up Dose and adjustments based on clinical
evaluation & TSH Prognosis is good if kept euthyroid
(normal)
Acquired Hyperthyroidism
(Grave’s Disease)A hyperfunction of the thyroid glandProduces excessive circulating thyroid
hormone (T3 and T4)Four times more common in girlsOccurs between the ages of
12 – 14 yrs. (puberty)Manifestations develop gradually with an
interval between onset & diagnosis of 6 to 12 months
Genetics involvedFollows a viral illness or period of stress
Grave’s Disease
Subjective Signs & Symptoms:Emotional liabilityPhysical restlessness at restDecreased school performanceExcessive appetite without weight gainFatigue
Grave’s DiseasePhysical Signs & Symptoms:
Increased HR PalpitationsWidened pulse pressureExothalmosHair fine, unable to curlDiarrheaPoor attention span
Grave’s DiseasePhysical Signs & Symptoms:
Wide-eyed expression with lid lagFine tremors Increased perspiration/heat intoleranceSystolic murmursEmotional liability Insomnia
Grave’s Disease
Thyroid StormAcute Onset
Severe irritability & restlessness Vomiting and diarrhea Hyperthermia Hypertension Severe tachycardia Prostration May progress to death
Grave’s Disease
Diagnosis: Elevated thyroid function studies,
low TSH, high T4Management:
To suppress thyroxinePTU - propythioracil MTZ – methimazoleSubtotal thyroidectomyAblation with radioiodine
Grave’s Disease
Nursing Care: Quiet un-stimulating environment
conducive to rest Maintain a regular routine to
minimizing stress of coping with unexpected demands
Physical activity is restrictedTire easily, experience muscle
weakness and are unable to relax to recoup their strength
Grave’s DiseaseNursing Care
Increased need for calories to meet their metabolic rate
Offer 5-6 moderate meals throughout the day, and vitamin supplements
Stress good hygiene because of excessive sweating
Once therapy is instituted observe for side effects of medications
Monitor for: Neutropenia, Hepatotoxicity, Bone density
Grave’s Disease
Nursing Care: If surgery is planned administer iodine a
few weeks before the procedureMixed in a strong-tasting fruit juice given
through a straw Fear of having throat cut is real Post-op position neck slightly flexed and
observe for bleeding Supplemental thyroid hormone then for life
Hypothyroidism Hyperthyroidism
Tiredness/fatigue Nervousness/anxiety
Constipation Diarrhea
Cold intolerance Heat intolerance
Dry, thick skin Smooth, velvety skin
Edema of face, eyes, hands
Prominent eyes
Decreased growth Accelerated linear growth
Decreased activity/energy Emotional liability
Muscle hypertrophy Muscle weakness
Decreased heart rate Increased heart rate
Growth Hormone Deficiency
Failure of the pituitary to produce growth hormone
Affected boys=girlsBoys tend to be evaluated more75% cause is idiopathicCan be a result of injury and destruction of
anterior pituitary gland from Brain tumor Infection radiation
SymptomsNormal size and weight at birthWithin first few years child will fall
below the 3rd percentile on growth chart
Late onset of pubertyDelayed dentitionHigh-pitched voiceChild-like face with large forehead
Criteria for Suspecting Growth Hormone (GH) Deficiency
Consistently poor growth (<5 cm/yr)
Growth rate more than two standard deviations below the mean for age
Downward deviation from the previous growth curve
Assessment and Diagnosis
Evaluate family historyPrenatal/birth history R/O pituitary tumorGrowth charts
Diagnosis X ray, MRI to study bone age Pituitary function tests
ManagementIM recombinant human growth hormone
2-3 times per weekGiven at bedtime when GH usually peaksGH is a powder that needs to be mixed
with diluentParents/child need teachingRapid growth is often painful, pain
management is needed
Nursing ConsiderationsSpeak to child in age appropriate
manner (be careful not to address as a younger child)
Be discrete when providing step stools, etc
Provide with anticipatory guidance for adolescence Dress in clothing that reflects age not size Choose sports that height is not a requirement
Practice Questions!
A 10-year old type 1 diabetic client tells the school nurse that he has some early signs of hypoglycemia. The nurse recommends that the child:
1. Take an extra injection of regular insulin2. Drink a glass of orange juice3. Skip the next dose of insulin4. Start exercising
An adolescent with Type I diabetes has had several episodes demonstrating lack of diabetic control. The nurse teaches the client by stating: “The best way to maintain control of your disease is to:
1. Check your urine glucose three times a week2. Check the HgA1C every 3 months and every 6
months when stable3. Check your BG QID and HgA1C every 3 months4. Check glucose daily as long as you feel well
A 10-year-old diabetic girl comes to the office of the school nurse after recess. She was just out of school for an extended illness and reports that she returned to her usual insulin dosing schedule today. The nurse notices she is nervous with hand tremors, pale, sweaty, and complaining of sleepiness. The nurse suspects:
1. Exercise-induced hypoglycemia2. Hyperglycemia caused by increased intake at lunch3. Ketoacidosis caused by infection4. The child is avoiding returning to class
After being diagnosed with Hyperthyroidism, a teenager begins taking PTU for treatment of the disease. What symptom would indicate to the nurse that the dose may be too high?
1. Weight loss2. Polyphagia3. Lethargy4. Difficulty with school work
The child’s 7:00 am blood glucose the following morning is 189. At 5:30 pm: the child injected rapid and NPH, then ate dinner and had a 10 pm snack. The nurse concludes (select all that apply)
1. Rapid insulin dose may be to low2. NPH insulin dose may be to low3. NPH insulin dose may be to high4. The child ate too little dinner5. The child ate too much snack
The nurse is teaching a parent of a child with type 1 diabetes about the different types of insulin. The nurse assumes the parent understands rapid insulin peak times if the parent states that after a 7:00 am injection, be sure the child does not miss:
1. 6:45 AM Breakfast2. 12:30 PM Lunch3. 6:30 PM Dinner4. 10:00 AM Snack