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Endocrine Stressors and Adaptation Common Pediatric Endocrine Disorders Type I Diabetes Congenital Hypothyroidism Acquired Hypothyroidism (Hashimoto’s Disease) Hyperthyroidism (Graves disease) Growth Hormone Deficiency The Endocrine System GlandsHormonesEndocrine disorders Hypofunction Hyperfunction Primary Secondary 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 puberty Abrupt onset Genetic 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. Etiology Autoimmune 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 A1C 1.8 to 4.0 is normal > 6.0 = DM Diagnosis: fasting: >126mg/dl Random (non-fasting): ≥ 200mg/dl with classic signs (next slide) Signs & Symptoms Polyuria Polydipsia Polyphagia Fatigue Blurred vision Headache Shortened attention span Mood changes Diabetic Ketoacidosis(DKA) Medical Emergency As glucose levels rise, child will progress into DKA if not treated Blood glucose levels > 300 Cellular starvation leads to ketone production Nausea, vomiting, abdominal pain Acetone (fruity) breath odor Dehydration Kussmaul respirations Coma if untreated Juvenile Diabetes Treatment Multidiscipline Goal: 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 foods don’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 restricted Lowers 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 Monitoring Glucose monitoring Urine testing for ketones Record keeping Self-management at age appropriate level 2-6 choose food, clean finger for BG 4-6 dip own urine 6-8 BGM 8-10 insulin injections, diary 10-14 nutritional decisions 12-18 full management Insulin Precise dose cannot be predicted Amount is based upon average capillary or serum blood glucose levels Will change based of G & D Can be administered TID SQ by needle/syringe, pen or by insulin/portable pump Types of Insulin Synthetic Human Insulin Rapid acting Lispro (Humalog) Aspart (Novolog) Fast acting Regular ® Intermediate NPH (N) Mixed (70/30) Long Acting Glargine (Lantus) Ultra Lente Typical Management The peak of the insulin should occur Post-Prandial (after meal) to avoid hypoglycemia Insulin Alternate sites Don’t inject extremity to be used in sports Give at room temperature Always draw regular up first if mixing Many are using insulin pens Pumps Delivers fixed amounts of short-acting insulin continuously Worn on a belt, the tubing & catheter are changed Q48 hours and taped in place Should not be removed for > 1-2 hours Subject to minimal malfunction Self-motivated Pumps Advantages 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 ILLNESS alters diabetic management Dosage requirements may increase, decrease, or remain unchanged depending on the severity of the illness & the child’s appetite Short-acting insulin used to manage hyperglycemia associated with illness Monitor fluids, may require extra oral fluids while ill 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 & Symptoms of Hypoglycemia Rapid onset Irritable, nervousness Difficulty concentrating Shaky feeling, tremors, hunger Diplopia Pallor Weakness Headache, dizziness Sweating Unconsciousness and convulsions Treatment of Hypoglycemia Simple concentrated sugar Glucose gel or SL tablets Hard candy Sugar cubes Low-fat milk or OJ Followed by a complex CHO & Protein Slice of bread or cracker with peanut butter Glucagon SQ for severe hypoglycemia (may cause vomiting, prevent aspiration) Honeymoon Period Blood glucose level initially regulated by insulin then the child may not need any insulin from one month to one year Confuses child and parent Some MD’s continue to give a very small amount of insulin during this time period so that a routine is established Consequences of Poor Management Cardiovascular more likely to have high cholesterol and hypertension, CAD Nephropathy slow deterioration of kidney function, can eventually result in kidney failure, also known as end-stage renal disease, or ESRD. Neuropathy nerve damage can range from slight inconvenience to major disability and even death. Retinopathy progressive disease that destroys small blood vessels in the retina, eventually causing vision problems The CDE A diabetes nurse-educator role is as a resource for information on diabetes "Certified Diabetes Educator" (CDE) indicates that the RN has received board certification. Helps patients and families develop a management plan based child’s age, work/school schedule, activity level, and usual eating patterns Education 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 Diagnosis Risk for injury R/T:____________________ Fear R/T :____________________________ Risk for ineffective coping R/T:___________ _______________________________________ Imbalanced nutrition: more than body requirements R/T_________________________________________ Nursing Diagnosis Risk for non-compliance R/T _______________ Risk for ineffective therapeutic management R/T ____________________________________________ Knowledge deficit R/T_______________________ Altered family processes R/T __________________ Future Diabetic Management Insulin inhalers Mouth sprays Patches Pills Implantable pumps Disorders of the Thyroid Congential Hypothyroidism Acquired Hypothyroidism Hyperthyroidism CONGENITAL HYPOTHYROIDISM Disorder at birth Body is producing insufficient thyroid hormone to meet metabolic needs caused by absent or underdeveloped thyroid gland If not treated can lead to MR Detected in Newborn Screen Incidence and Etiology Caused 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 skin Large fontanel Large tongue Hypotonia/slow reflexes Distended abdomen Low 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 Monitor G&D and Thermoregulation Labs q 2 wks then q 3 mos *** look for upper range of normal Med compliance Teach parents to monitor for hyperthyroidism Outcome Prevention of mental retardation – newborn screening on all babies Early treatment has had significant impact on morbidity Most children progress to within normal ranges on developmental assessment Poor prognosis in more severe cases Signs of Medication induced Hyperthyroidism Nervousness/anxiety Diarrhea Heat intolerance Weight loss Increased HR Acquired Hypothyroidism (Hashimoto’s disease) Thyroid produces inadequate levels of thyroid hormone > age 2 T4 decreases, TSH rises Autoimune disorder Antibodies and developed against thyroid gland Gland becomes inflamed, infiltrated by antibodies and destroyed Etiology Primary (Hashimoto’s thyroiditis) Most common Autoimmune Childhood, adolescents, females>males Secondary associated with other conditions that affect the thyroid Pituitary and hypothalmic dysfunction Tertiary Radiation, surgery, trauma Acquired Hypothyroidism Goiter Dry, thick skin Coarse but thinning hair Fatigue Cold intolerance Delayed puberty and menses Decelerated growth Edema around eyes, face and hands Constipation Sleepiness Mental decline but mental retardation or neurologic sequelae are not problem 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 gland Produces excessive circulating thyroid hormone (T3 and T4) Four times more common in girls Occurs between the ages of 12 – 14 yrs. (puberty) Manifestations develop gradually with an interval between onset & diagnosis of 6 to 12 months Genetics involved Follows a viral illness or period of stress Grave’s Disease Cardinal Signs & Symptoms: Emotional liability Physical restlessness at rest Decreased school performance Excessive appetite without weight gain Fatigue Grave’s Disease Physical Signs & Symptoms: Increased HR Palpitations Widened pulse pressure Exothalmos Hair fine, unable to curl Diarrhea Poor attention span Grave’s Disease Physical Signs & Symptoms: Wide-eyed expression with lid lag Fine tremors Increased perspiration/heat intolerance Systolic murmurs Emotional liability Insomnia Grave’s Disease Thyroid Storm Acute 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 T4 Management: To suppress thyroxine PTU - propythioracil MTZ – methimazole Subtotal thyroidectomy Ablation 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 restricted Tire easily, experience muscle weakness and are unable to relax to recoup their strength Grave’s Disease Nursing 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 procedure Mixed 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=girls Boys tend to be evaluated more 75% cause is idiopathic Can be a result of injury and destruction of anterior pituitary gland from Brain tumor Infection radiation Symptoms Normal size and weight at birth Within first few years child will fall below the 3rd percentile on growth chart Late onset of puberty Delayed dentition High-pitched voice Child-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 history Prenatal/birth history R/O pituitary tumor Growth charts Diagnosis X ray, MRI to study bone age Pituitary function tests Management IM recombinant human growth hormone 2-3 times per week Given at bedtime when GH usually peaks GH is a powder that needs to be mixed with diluent Parents/child need teaching Rapid growth is often painful, pain management is needed Nursing Considerations Speak 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 Case Study A 14-year-old female with Type I diabetes mellitus, has the flu and stayed home from school today. Her mother reports that she doesn’t have much of an appetite and can only get her to eat toast and drink a little tea. She calls the nurse in the pediatric office. If you were the nurse… What questions will you ask the mother to assure a complete assessment? What instructions would you give regarding insulin dose? If urinary ketones were present, what advice would you offer the client? 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. 2. 3. 4. Take an extra injection of regular insulin Drink a glass of orange juice Skip the next dose of insulin 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. 2. 3. 4. Check your urine glucose three times a week Check the HgA1C every 3 months and every 6 months when stable Check your BG QID and HgA1C every 3 months 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. 2. 3. 4. Exercise-induced hypoglycemia Hyperglycemia caused by increased intake at lunch Ketoacidosis caused by infection 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. 2. 3. 4. Weight loss Polyphagia Lethargy Difficulty with school work