Download Lect.12 - Immunologic and Endocrine Alterations in Children.

Nursing Care of Children with
Immunologic Alterations
By Nataliya Haliyash,
MD, BSN
Insitute of Nursing,
TSMU
Lecture objectives
Upon completion of this chapter you will be able to:
 Describe the normal functions of the immune system.
 Describe the etiology, clinical manifestations, and
medical treatment for the common immune system
alterations, juvenile idiopathic arthritis (JIA), systemic
lupus erythematosus (SLE), human
immunodeficiency virus (HIV), and allergic reaction to
drugs.
 Identify nursing management of children with immune
system alterations, including developmental and
psychosocial needs.
 Identify the education, resource, and support needs
of families who have children with immune system
alterations.
Functions of the immune system



to prevent or ameliorate infections,
to recognize self from nonself,
to maintain homeostasis.
Two basic divisions


The innate immune system acts as the first
line of defense against infections, and
includes biochemical and physical barriers.
The adaptive immune system produces a
specific reaction to each infectious agent,
remembers that agent, and can prevent a
later infection by the same agent.
The immune system includes:


the spleen, lymph nodes, and lymphoid
tissue,
cellular elements such as the white
blood cells or leukocytes, phagocytes,
and natural killer cells.
Each lymphoid organ plays a role in the
production and activation of
lymphocytes. Lymphoid organs
include:









adenoids (two glands located at the
back of the nasal passage)
blood vessels (the arteries, veins,
and capillaries through which blood
flows)
bone marrow (the soft, spongy tissue
found in bone cavities)
lymph nodes (small organs shaped
like beans, which are located
throughout the body and connect via
the lymphatic vessels)
lymphatic vessels (a network of
channels throughout the body that
carries lymphocytes to the lymphoid
organs and bloodstream)
Peyer's patches (lymphoid tissue in
the small intestine)
spleen (a fist-sized organ located in
the abdominal cavity)
thymus (two lobes that join in front of
the trachea behind the breast bone)
tonsils (two oval masses in the back
of the throat)
A Lymphocytes Cell at Work

T cell (left) recognizes antigens on the
surface of a cell infected with a virus (right),
enabling the T cell to bind to and kill the
infected cell.



The immune system of neonates and
young children is immature.
Because of this immaturity, infants and
young children are susceptible to
infectious organisms that can cause
illness and its associated morbidity.
A child's immune system matures by
three to six years of age.
Immunity



The term refers to all the processes
used by the body to protect against
foreign material from environmental
sources, including microorganisms or
their toxins, foods, chemicals, pollen,
dander, or drugs.
Innate or natural immunity
Acquired immunity
Innate or natural immunity



nonspecific,
function against most threats to the body in a
broad sense.
Is represented by physical barriers such as:
– the skin, mucous membranes,
– cough reflex;
– chemical barriers such as pH of the stomach, fatty acids and
proteolytic enzymes of the small intestine,
– fever.

Nonspecific immune cells such as phagocytes
(macrophages, neutrophils, natural killer cells), and
lymphocytes whose granules release lysing
chemicals.
Acquired immunity



is specific immunity, triggered when a
person has had prior contact with a
foreign agent.
the humoral system, consisting of
primarily B lymphocytes
and/or the cell mediated system of
primarily the T lymphocytes


Although immune system alterations occur less
commonly in children than other types of alterations,
the effects are often disabling or terminal.
In addition, the immune system interacts with other
body systems so symptoms may not appear to be
immune related but rather primarily musculoskeletal,
– juvenile arthritis,

or integumentary
– systemic lupus erythematosus.

HIV, another immune system disease, can affect all
organ systems.


AUTOIMMUNITY: The inability of the body to
distinguish "self" from other, leads to an
immune response aimed at parts of one's
own body.
INFLAMMATION: Increased blood flow and
permeability of blood vessels; results in
increased fluid production and attraction of
lymphocytes and leukocytes to the area,
caused by the release of inflammatory
substances called cytokines.
Juvenile Idiopathic Arthritis
(Juvenile rheumatoid arthritis
(JIA, JRA))



A term used for a group of idiopathic chronic
autoimmune inflammatory diseases affecting
joints and connective tissues in children with
onset before 16 years of age
JIA is the most common pediatric connective
tissue disease with arthritis being the principal
manifestation.
The incidence is 1:1,000. African-American and
Asian children are less likely to suffer from JRA.
Pathophysiology of JRA



Current research suggests T cell activation
triggers development of antigen-antibody
complexes, which cause release of
inflammatory substances called cytokines in
targeted organs such as joints and skin.
This causes inflammation of the synovial
membranes and other tissues leading to joint
effusion and swelling.
Chronic inflammation eventually evolves into
erosion of articular cartilage and other
symptoms of inflammatory diseases
Juvenile
Idiopathic
Arthritis
Patho (arthritis)
– Bone overgrowth
– Inflamed
synovial
membrane
– Excess synovial
fluid
– Thinning
cartilage
Juvenile Idiopathic Arthritis

Clinical manifestations
– Systemic onset
• Fever (usually high)
• Rash (Salmon-pink, migratory, macular/papular, most
common late afternoon or early evening)
• Arthralgia/myalgia
arthritis is defined as
• Arthritis
joint swelling or effusion,
• Fatigue/malaise
or two of the following:
warmth, pain on motion,
• Lymphadenopathy
or limited range of
• Hepatosplenomegaly
motion
• Possible signs of carditis
(continues)
Juvenile Idiopathic Arthritis

Polyarticular onset
– Arthritis in many joints (five or more)
•
•
most particularly the joints of the knees, wrists,
ankles, and proximal interphalangeal joints of the
fingers.
often neck and temporomandibular (TMJ) joints
are affected.
– Low-grade fever

Pauciarticular onset
– Arthritis in a few joints (less than 4)
•
most particularly joints of the knees and ankles.
– Inflammation of the eyes
•
common in anti-nuclear antibody positive
preschool girls.
Diagnosis of Juvenile Idiopathic
Arthritis

American College of Rheumatology
diagnostic criteria
– Onset before 16 years of age
– Arthritis of at least 6 weeks’ duration
(objectively observed)
– A defined subtype (by onset
characteristics)
– Exclusion of other conditions such as
other rheumatic diseases
(continues)
Diagnosis of Juvenile Idiopathic
Arthritis


There are no specific laboratory tests for JRA.
Laboratory data:
–
–
–
–
–


elevated erythrocyte sedimentation rate (ESR),
elevated C-reactive protein (CRP),
elevated white blood count,
decreased hemoglobin,
and increased platelet count.
Antinuclear antibody (ANA) and rheumatoid factor (RF)
are positive in a proportion of children with arthritis
X rays can demonstrate characteristic changes such as:
–
–
–
soft tissue swelling and joint effusion.
bony erosions and narrowing of the joint spaces
Subluxations and malalignment
Treatment of Juvenile Idiopathic
Arthritis





Multidisciplinary approach
Medications
Physical and occupational therapy
Nutritional considerations
Family teaching
Systemic Lupus Erythematosus

Incidence and etiology:
–
–
–

Although systemic lupus erythematosus (lupus
or SLE) can develop at any age, onset in
childhood usually occurs after the age of 5 years
or during adolescence
Peak age of childhood onset is 11 to 15 years
Involving females 8 to 10 times as often as
males
Pathophysiology:
–
is an autoimmune process requiring a genetic
susceptibility and probably a viral or bacterial
trigger
SLE: Uncontrolled Dialog Between
T and B Cells
Diagnosis of Lupus
Erythematosus

Clinical manifestations (American College of
Rheumatology Ad Hoc Committee of
Systemic Lupus Erythematosus diagnostic
criteria)
– Malar rash: Erythematous, flat or raised over the
cheeks.
– Discoid rash: Erythematous raised patches with
scaling.
– Photosensitivity: Skin rash from exposure to sun.
– Oral or nasal ulcers
(continues)

The round or disk shaped (discoid) rash of lupus
produces red, raised patches with scales. The pores
(hair follicles) may be plugged. Scarring often occurs in
older lesions. The majority (approximately 90%) of
individuals with discoid lupus have only skin
involvement as compared to more generalized
involvement in systemic lupus erythematosis (SLE).
SLE: Malar rash

This young woman
has a malar rash (the
so-called "butterfly"
rash because of the
shape across the
cheeks// Sparing
nasolabial fold).
Such a rash
suggests lupus.
Diagnosis of Lupus
Erythematosus
–
Nonerosive arthritis:
• Two or more peripheral joints with tenderness, swelling, or
effusion.
–
–
Pleuritis or pericarditis
Renal disorder:
• Persistent proteinuria OR cellular casts;
• can progress to hypertension, nephrotic syndrome, renal
insufficiency, and end stage renal disease requiring
transplantation.
–
Neurological disorder:
• Seizures OR psychosis without other cause.
–
–
–
–
–
Hematological disorder
Immunologic markers
ANA (antinuclear antibody) positive
Alopecia
4 of the 11 criteria must be present
Retinal involvement in SLE
Lupus Erythematosus

Treatment
– Preventing exacerbations
– Treating exacerbations when they occur
– Minimizing organ damage and
complications
– Medications

Nursing management
Human Immunodeficiency Virus
(HIV) - Incidence:
The figures below show the number of children (defined by UNAIDS as
under-15s) directly affected by HIV and AIDS:
 At the end of 2008, there were 2.1 million children living with HIV
around the world.
 An estimated 430,000 children became newly infected with HIV in
2008.
 Of the 2 million people who died of AIDS during 2008, more than
one in seven were children. Every hour, around 31 children die as a
result of AIDS.


Most children living with HIV – around 9 out of 10 – live in SubSaharan Africa, the region of the world where AIDS has taken its
greatest toll. Large numbers of children with HIV also live in the
Caribbean, Latin America and South/South East Asia.
Around 90% of all children living with HIV acquired the infection from
their mothers during pregnancy, birth or breastfeeding.
Effects of HIV on children
The direct effects of HIV on children
 Many children are themselves infected with HIV
The effects of HIV on a child’s family
 Children live with family members who are infected with HIV.
 Children act as carers for sick parents who have AIDS.
 Many children have lost one or both parents to AIDS, and are
orphaned.
 An increasing number of households are headed by children, as
AIDS erodes traditional community support systems.
 Children end up being their family’s principal wage earners, as
AIDS prevents adults from working, and creates expensive
medical bills.
The effects of HIV on a child’s community
 As AIDS ravages a community, schools lose teachers and
children are unable to access education.
 Doctors and nurses die, and children find it difficult to gain care for
childhood diseases.
 Children may lose their friends to AIDS.
 Children who have HIV in their family may be stigmatized and
affected by discrimination.
Human Immunodeficiency Virus
(HIV)

Etiology
– HIV infection: Human Immunodeficiency Virus that
attacks the immune system
– HIV disease (4 stages)
– Acquired immunodeficiency syndrome (AIDS): HIV
causes AIDS by damaging the immune system
cells until the immune system can no longer fight
off other infections that it would usually be able to
prevent. It takes around ten years on average for
someone with HIV to develop AIDS.
– Age-related differences


Revised pediatric classification system:
clinical categories
Pathophysiology
How is HIV passed on?
HIV is found in the blood and the sexual fluids of an
infected person, and in the breast milk of an
infected woman. HIV transmission occurs when a
sufficient quantity of these fluids get into
someone else's bloodstream.
There are various ways a person can become
infected with HIV:
 Unprotected sexual intercourse with an
infected person: Sexual intercourse without a
condom carries the risk of HIV infection.
 Contact with an infected person's blood: If
sufficient blood from somebody who has HIV
enters someone else's body, then HIV can be
passed on in the blood.
How is HIV passed on?



Use of infected blood products: Many people in the
past have been infected with HIV by the use of blood
transfusions and blood products which were
contaminated with the virus. In much of the world this is
no longer a significant risk, as blood donations are
routinely tested for HIV.
Injecting drugs: HIV can be passed on when injecting
equipment that has been used by an infected person is
then used by someone else. In many parts of the world,
often because it is illegal to possess them, injecting
equipment or works are shared.
From mother to child: HIV can be transmitted from an
infected woman to her baby during pregnancy, delivery
and breastfeeding. Without treatment, around 15-30% of
babies born to HIV positive women will become infected
with HIV during pregnancy and delivery. A further 5-20%
will become infected through breastfeeding.
HIV and breastfeeding


For most babies, breastfeeding is without question the
best way to be fed, but unfortunately breastfeeding can
also transmit HIV.
Advice for HIV-positive mothers in developed countries
– avoid breastfeeding altogether because the risk of HIV
transmission far outweighs the risks associated with replacement
feeding. Replacement feeding means giving a baby commercial
infant formula (prepared from powder and boiling water)

Advice for HIV-positive mothers in developing countries
– In countries with fewer resources, where replacement feeding can
be much more hazardous, the recommendations for infant feeding
usually depend on a mother's individual situation. When
replacement feeding is acceptable, feasible, affordable,
sustainable and safe, avoidance of all breastfeeding by HIVinfected mothers is recommended. Otherwise, exclusive
breastfeeding is recommended during the first months of life.
– For an overview of detailed information, please see 2009 WHO
guidelines page.

An HIV positive mother and her HIV
positive baby in India and an African HIV
positive woman breastfeeding her baby
An HIV-positive Ukrainian mother
practices cup feeding her infant.
Human Immunodeficiency Virus
(HIV)
Clinical manifestations
 CD4 counts
•
•
•



To judge whether an HIV-positive person requires
treatment, a CD4 test is usually carried out. This
measures the number of T-helper cells – white blood
cells that are attacked by HIV – in an individual’s
blood. It can either measure the absolute number of
CD4 cells, or the percentage of white blood cells that
are CD4 cells, in a sample of blood.
Normal count: asymptomatic
A falling CD4 count is a sign that HIV is progressing
Associated symptoms of opportunistic
infections
The younger the child at time of acquisition,
the more severe the symptoms, faster
progression, poorer prognosis
Variations by age
Diagnosis of HIV



Careful history focusing on risks
Timing of transmission from mother to
child
Antibody tests are inexpensive and
very accurate.
–
–
–
–
ELISA (antibody test (enzyme-linked
immunoabsorbent) also known as EIA
(enzyme immunoassay)
Western blot assay – One of the oldest
but most accurate confirmatory
antibody tests. It is complex to
administer and may produce
indeterminate results if a person has a
transitory infection with another virus.
An indirect immunofluorescence assay
– Like the Western blot, but it uses a
microscope to detect HIV antibodies.
A line immunoassay - Commonly used Using a rapid oral HIV test
in Europe. Reduces the chance of
sample contamination and is as
accurate as the Western Blot.
Rapid HIV tests




An OraQuick HIV-1/2 rapid test kit
These tests are based on the
same technology as ELISA tests,
but instead of sending the sample
to a laboratory to be analysed, the
rapid test can produce results
within 20 minutes.
Rapid tests can use either a blood
sample or oral fluids. They are
easy to use and do not require
laboratory facilities or highly
trained staff.
All positive results from a rapid
test must be followed up with a
confirmatory test, the results of
which can take from a few days to
a few weeks.
OraQuick HIV-1/2 test kit
Diagnosis of HIV



PCR test
A PCR test (Polymerase Chain Reaction test) can detect the
genetic material of HIV rather than the antibodies to the virus,
and so can identify HIV in the blood within two or three weeks of
infection. The test is also known as a viral load test and HIV
NAAT (nucleic acid amplification testing).
Babies born to HIV positive mothers are usually tested using a
PCR test because they retain their mother's antibodies for
several months, making an antibody test inaccurate.
Blood supplies in most developed countries are screened for
HIV using PCR tests. However, they are not often used to test
for HIV in individuals, as they are very expensive and more
complicated to administer and interpret than a standard antibody
test.
Collection of dried blood spots from an
infant for HIV testing at the Lapolagang
Clinic in Botswana.
Treatment of HIV


HIV develops very
rapidly among infants
and children, and,
without treatment, a
third of infected children
will die of AIDS before
their first birthday, with
half dying before they
are two.
In 2008, there were
280,000 deaths
attributed to HIV in
under-15s, most of
which could have been
prevented through early
diagnosis and effective
treatment.





Approaches:
Multidisciplinary
approach
HAART (highly active
antiretroviral therapy)
Prevention of
opportunistic infections
Nursing management
and family teaching
– Home
– School
– Community
Treatment of HIV


The most effective treatment for HIV-positive children
is antiretroviral therapy. This requires several
antiretroviral drugs (ARVs) be taken every day.
Starting antiretroviral treatment in children
– There is ongoing debate about when it is best to start
antiretroviral treatment in HIV-positive children. There is a
complex balance between the immediate benefits of
providing treatment to children who are not showing any
symptoms of AIDS-related illness, and concerns about longterm resistance and antiretroviral drug side effects if
treatment is started too early.

CD4 counts in children
– In healthy, uninfected adults, absolute CD4 count is usually
between 500 and 1500 cells per cubic millimetre of blood
– Absolute CD4 counts vary with age, and younger children
usually have a much higher CD4 count than adults. This
makes it difficult to judge the health of a child's immune
system based on CD4 count. Percentage CD4 count does
not vary in the same way as absolute CD4 count, and is
therefore recommended for children under five.
Which antiretroviral drugs should
be used?


As with adults, antiretroviral therapy with at
least three drugs is recommended for
children as this prevents HIV from becoming
resistant to any single drug.
It is usually recommended that this therapy
should consist of
– two nucleoside reverse transcriptase inhibitors
(NRTIs: Epivir (lamivudine), Retrovir (zidovudine),
Viread (tenofovir)) combined with
– either one non-nucleoside reverse transcriptase
inhibitor (NNRTI): Intelence (etravirine)
– or a protease inhibitor (PI): Aptivus (tipranavir),
Reyataz (atazanavir).
Dosing and drug formulations in
children
“Since there are still no
available, easy-to-use triple
 The dose of antiretroviral drugs
given to children
is
drug combinations
for children,
do what or
most
doctors
are
generally based on either Iweight
body
surface
doing: I try to show caregivers
area.
such as grandparents how to
break adult tablets,
hopingdrug
that
 As children’s bodies are constantly
changing,
themake
childrensure
will get
theadoses
doses need to be altered to
that
child is
they need.”

not given too much, or too little, of a drug.
- Dr to
Fasineh
Malawi
Healthcare workers also need
take Samura,
into account
that children under the age of six metabolise drugs
faster than adults, so even after adjusting for body
weight, they may need to be given higher quantities
of ARVs to achieve the same effect that the drugs
would have in adults.
Side effects of paediatric HIV
treatment



Because children’s bodies are still developing,
and they are likely to be exposed to treatment for
prolonged periods of time, they may be
particularly vulnerable to some complications.
Side effects can occur at various stages of a
child’s course of treatment.
They may be
– acute (occurring directly after drug administration),
– sub-acute (within one or two days after administration)
– late (after prolonged drug administration).
Side effects of paediatric HIV
treatment: Diarrhoea


is a common side effect of many antiretroviral drugs – especially
protease inhibitors. Other possible causes include HIV, other
infections and antibiotics. Sometimes an antiretroviral drug
causes diarrhoea for only the first few weeks; in other cases this
side effect lasts for as long as the drug is taken.
Changing diet may reduce the severity of diarrhoea. Good
advice includes:
– Eat less insoluble fibre (raw vegetables, fruit skins, wholegrain
bread or cereal, seeds and nuts)
– Eat more soluble fibre (white rice, pasta, oat bran tablets,
psyllium/isphagula)
– Cut down on caffeine, alcohol and the sweetener sorbitol
– Avoid greasy, fatty, spicy and sugary foods
– Consider reducing dairy products in case of lactose intolerance
– Consult a dietician
– Over-the-counter medicines such as Imodium (loperamide), Lomotil
(diphenoxylate and atropine) and calcium supplements are
sometimes all that is needed to control diarrhoea.
Side effects of paediatric HIV
treatment:Nausea and vomiting


Almost all antiretroviral drugs can cause nausea (feeling sick)
and vomiting, especially during the first few weeks of treatment.
Although this side effect can reduce appetite, it is important to
keep eating when possible, and to replace lost fluids and
electrolytes (as with diarrhoea). The following measures may
help:
–
–
–
–
–
–


Eat several small meals instead of a few large meals
Avoid spicy, greasy and rich foods; choose bland foods
Eat cold rather than hot meals
Don’t drink with a meal or soon after
Avoid alcohol, aspirin and smoking
Avoid cooking smells
Some antiretroviral drugs can be taken with food, and doing so
may lessen their harmful effects. It may also be possible to alter
drug dosage or frequency.
Various treatments, known as anti-emetics, are available for
nausea and vomiting, some of which do not require a
prescription. There is some evidence that ginger and
peppermint may help against nausea.
Side effects of paediatric HIV
treatment: Rash
Rashes often appear as a side effect of antiretroviral treatment.
 These may be itchy but are usually harmless and short-lived.
However, severe rashes can occur with nevirapine, and more
rarely with some other drugs. Any rash occurring during the first
few weeks of treatment should be reported to a doctor
immediately, as should any rash accompanied by fever,
blistering, facial swelling or aches. A rash occurring with
abacavir may indicate a very dangerous hypersensitivity
reaction.
Tips for coping with rashes include:
 Avoiding hot showers or baths
 Using milder toiletries and laundry detergents
 Wearing cool fibres such as cotton, and avoiding wool
 Humidifying the air
 Trying moisturisers / emollients or calamine lotion
Antihistamine tablets can sooth rashes and are generally available
without a prescription. However, because these may interact
with antiretroviral medications, patients should check with their
doctors before using them. More severe skin problems may be
treated with steroids.

Allergic Reactions to Drugs


Incidence and etiology
Pathophysiology
(continues)
Allergic Reactions to Drugs

Clinical manifestation
–
–
–
–
–
–
–
Angioedema
Urticaria
Maculopapular rashes
Contact dermatitis
Anaphylaxis
Erythema multiforme
Stevens-Johnson syndrome
– Toxic epidermal necrolysis
(continues)
Allergic Reactions to Drugs



Diagnosis
Treatment
Nursing management
Situation: Stevens-Johnson
syndrome


Twelve-year-old Ron was admitted to the unit with
an erythematous papular rash covering his arms,
legs, abdomen, the soles of his feet, and the palms
of his hands. His mother Helen said that he had a
sore throat, headache, fever, and “just didn’t feel
well” a day or two before he broke out with his rash.
He also had been on penicillin for five days because
of a throat infection. He was diagnosed with
Stevens-Johnson syndrome. What nursing care
would be appropriate?
Answer: Ron and his parents will need to be
provided with education about his sensitivity to the
penicillin. Ron will be on a liquid diet. The nurse will
need to provide comfort measures, including use of
topical lidocaine prn for his sore mouth, frequent
skin care, and administration of pain medications as
needed. He also will need a nutritious diet, adequate
fluids, and excellent skin care.

Erythema multiforme major, also referred to as StevensJohnson syndrome, is a toxic or allergic rash in response
to the smallpox vaccine, use of drugs that can take
various forms, and range from moderate to severe.
Endocrine Alterations
Anatomy and Physiology

Glands of the endocrine system
–
–
–
–
–
Anterior pituitary
Posterior pituitary
Thyroid
Parathyroids
Adrenal cortex
–
–
–
–
Adrenal medulla
Ovaries
Testes
Pancreas
Disorder of the Anterior Pituitary:
Growth Hormone Deficiency



Incidence and etiology
Pathophysiology
Clinical manifestations
–
–
–
–


Short stature
Deteriorating or absent rate of growth
Higher weight-for-height ratio
Delayed bone age
Diagnosis
Treatment
Nursing Management


Assessment
Nursing diagnoses
– Delayed growth and development related
to inadequate growth hormone secretion
– Disturbed body image related to short
stature
– Deficient knowledge related to treatment
(continues)
Nursing Management




Outcome identification
Planning/implementation
Evaluation
Family teaching
Disorder of the Anterior Pituitary:
Precocious Puberty


Incidence and etiology
Pathophysiology
(continues)
Disorder of the Anterior Pituitary:
Precocious Puberty

Clinical manifestations
– Accelerated growth rate
– Advanced bone age
– Evidence of secondary sexual
characteristics
– Acne
– Adult body odor
– Possible behavior changes
(continues)
Disorder of the Anterior Pituitary:
Precocious Puberty

Diagnosis
– Complete history
– Physical exam
• Sexual maturation staging (Tanner staging)
• Height, weight, span (fingertip to fingertip),
upper/lower body ratio
– Radiological exams
– Laboratory screening
(continues)
Disorder of the Anterior Pituitary:
Precocious Puberty


Treatment
Nursing management
Disorder of the Posterior Pituitary:
Diabetes Insipidus



Incidence and etiology
Pathophysiology
Clinical manifestations
– Infants: failure to thrive, fevers, vomiting,
constipation, dehydration, poor growth
– Children: polyuria, polydipsia
(continues)
Disorder of the Posterior Pituitary:
Diabetes Insipidus

Diagnosis
– First morning urine sample: osmolarity,
specific gravity, sodium
– Serum osmolarity, sodium and creatinine
levels
– Water deprivation test
(continues)
Disorder of the Posterior Pituitary:
Diabetes Insipidus

Treatment
– Replacement of antidiuretic hormone or
vasopressin
– Desmopressin acetate (DDAVP)

Nursing management
Disorder of the Thyroid Gland:
Congenital Hypothyroidism



Incidence and etiology
Pathophysiology
Clinical manifestations
–
–
–
–
Large posterior fontanel
Umbilical hernia
Constipation
Prolonged jaundice
– Other manifestations
(continues)
Disorder of the Thyroid Gland:
Congenital Hypothyroidism




Diagnosis
Treatment
Nursing management
Family teaching
Disorder of the Thyroid Gland:
Acquired Hypothyroidism


Incidence and etiology
Pathophysiology
(continues)
Disorder of the Thyroid Gland:
Acquired Hypothyroidism

Clinical manifestations
–
–
–
–
–
Decreased rate of growth
Weight gain
Constipation
Dry skin, thinning or coarse hair
Fatigue
(continues)
Disorder of the Thyroid Gland:
Acquired Hypothyroidism
–
–
–
–
Cold intolerance
Edema of face, eyes, hands
Delayed deep tendon reflexes
Delayed puberty
(continues)
Disorder of the Thyroid Gland:
Acquired Hypothyroidism



Diagnosis
Treatment
Nursing management
– Assessment
(continues)
Disorder of the Thyroid Gland:
Acquired Hypothyroidism
– Nursing diagnosis
• Delayed growth and development related to
the absence or deficiency of thyroid hormone
synthesis
• Hypothermia related to decreased BMR
• Constipation related to decreased motility of
the GI tract
• Activity intolerance related to fatigue and
decreased endurance
Disorder of the Thyroid Gland:
Hyperthyroidism


Incidence and etiology
Pathophysiology
(continues)
Disorder of the Thyroid Gland:
Hyperthyroidism

Clinical manifestations
–
–
–
–
–
–
–
–
Increased rate of growth
Weight loss despite excellent appetite
Warm, moist skin
Tachycardia
Ophthalmic changes
Heat intolerance
Emotional lability
Insomnia, fine tremors
(continues)
Disorder of the Thyroid Gland:
Hyperthyroidism


Diagnosis: serum thyroid tests
Treatment
– Antithyroid medication
– Radioactive iodine therapy
– Subtotal thyroidectomy


Nursing management
Family teaching: home, school,
community
Disorder of the Adrenal Gland:
Congenital Adrenal Hyperplasia


Incidence and etiology
Pathophysiology
(continues)
Disorder of the Adrenal Gland:
Congenital Adrenal Hyperplasia

Clinical manifestations
– Male fetus: no physical changes
– Female fetus: virilized external genitalia
•
•
•
•
Enlarged clitoris
Fusion of the labial folds
Rugate appearance to labia
Pseudohermaphroditism
– Children (often toddlers present): adrenarche,
accelerated growth velocity, advanced bone
age, acne, hirsutism
Disorder of the Pancreas:
Diabetes Mellitus




Incidence and etiology
Pathophysiology
Clinical manifestations
Diagnosis
Treatment of Diabetes Mellitus




Insulin management
Blood glucose management
Nutrition
Exercise
Nursing Management: Diabetes
Mellitus


Assessment
Nursing diagnoses
– Risk for injury related to insulin
insufficiency and deficiency
– Risk for injury related to hypoglycemia or
hyperglycemia
– Disturbed body image related to
developing a chronic disease
(continues)
Nursing Management: Diabetes
Mellitus
– Deficient knowledge related to
management of both types of diabetes
– Interrupted family processes related to
management of a chronic illness


Outcome identification
Planning/implementation
(continues)
Nursing Management: Diabetes
Mellitus

Survival education
– Insulin preparation and injection
– Blood glucose and urine-ketone
monitoring
– Hypoglycemia

Family teaching: beyond the survival
stage
– Hyperglycemia
– Diabetic ketoacidosis
Additional Endocrine Disorders



Hypoparathyroidism
Addison’s disease
Cushing’s syndrome
The END. Q & A ?