The Child with Endocrine Dysfunction

*early recognition of S/S of DI *differentiation of DI from other causes of polyuria and polydipsia (DM) *effective hormone replacement

Outcomes of patients with DI

*early recognition of growth problems *accurate diagnosis of growth hormone deficiency *GH effective in stimulating growth *child & family demonstrate effective coping and diagnosis of treatment

Outcomes of patients with GH deficiency

*early recognition of S/S of hyperthyroidism *physical symptoms managed *regular routine established for child during recovery period *adherence to antithyroid medication as prescribed

Outcomes of patients with Hyperthyroidism (Graves Disease)

*early recognition of S/S of syndrome of inappropriate antidiuretic hormone (SIADH) *fluid overload replacement *seizures prevention

Outcomes of patients with SIADH

*early recognition of S/S of acute adrenal crisis *Hypokalemia or hyperkalemia prevention *fluid balance maintained *sufficient cortisol replacement

Outcomes of patients with acute adrenal insufficiency

The family of a young child has been told the child has diabetes insipidus. What information should the nurse emphasize to the family? 1. One caregiver needs to learn to give the injections of vasopressin. 2. Children should wear Medic alert tags if they are over five years old. 3. Diabetes insipidus is different from diabetes mellitus 4. Overtime, the child may grow out of the need for medication.

Diabetes insipidus is different from diabetes mellitus Rationale: Explaining that DI is very different from DM is crucial to the parents understanding of the management of the disease. DI is a rare disease that affects the posterior pituitary gland, DM is more common condition that affects the pancreas.

What key information should be explained to the family of a 3-year-old who has short stature and abnormal laboratory test results? 1. Because of the diurnal rhythm of the body, growth hormone levels are elevated following the onset of sleep. 2. Exercise can stimulate growth hormone secretion. 3. The initial screening test need to be repeated for accuracy. 4. Growth hormone levels in children are so low that stimulation testing must be done.

Growth hormone levels in children are so low that stimulation testing must be done. Rationale: The need for add'l testing requires explanation. The abnormal IGF-1 and insulin-like growth factor binding protein require a definitive diagnosis when the levels are either abnormally high or low. Very young children do not secrete adequate levels of GH to measure accurately and thus require stimulation testing.

A child with Addison disease takes oral cortisol supplements. What teaching should be done at each visit? SATA 1. Keep an extra month supply of all medications on hand at all times. 2. Wear a medic alert bracelet at all times. 3. The child is less susceptible to infections. 4. Weight gain will occur. 5. Your child is more susceptible to infections.

Keep an extra month supply of all medications on hand at all times. AND Your child is more susceptible to infections. Rationale: An extra monthly supply of all medications, along with a prefilled syringe of hydrocortisone, will enable the family to treat an impending adrenal crisis before it becomes severe. Susceptibility to infections is from long-term use.

· Acute Adrenocortical insufficiency: Monitor serum electrolyte levels and observe for signs of hypokalemia or hyperkalemia (weakness, poor muscle control, paralysis, cardiac dysrhythmias, apnea). The condition is rapidly corrected with IV or oral K+ replacement. · Acute Adrenocortical insufficiency: When an oral K+ preparation is given, mix it with a small amount of strongly flavored fruit juice to disguise its bitter taste. · Cushing Syndrome: Postoperative complications of adrenalectomy are related to the sudden withdrawal of cortisol. Observe for shocklike symptoms (hypotension, hyperpyrexia). · Congenital Adrenal Hyperplasia: Advise parents that there is no physical harm in treating for suspected adrenal insufficiency that is not present, but the consequence of not treating acute adrenal insufficiency can be fatal. · Pheochromocytoma: DO NOT PALPATE MASS. Preoperative palpation of the mass releases catecholamines, which can stimulate severe HTN and tachyarrhythmias.

Nursing Alerts for Disorders of Adrenal function

^DM: Recurrent vaginal & UTI, especially with Candida albicans, are often an EARLY SIGN of Type 2 DM, especially in adolescents. -DM: Vomiting may occur after administration of glucagon; precautions against aspiration must be taken (placing child on side, raising HOB) because the child often becomes unconscious. ^DM: It is a recommendation that urine be tested for ketones q3h during an illness or whenever BG levels are >240 mg/dL when an illness is not present. -DM: Hypoglycemic episodes most commonly occur before meals or when the insulin effect is peaking. ^DKA: K+ must NEVER be given UNTIL the serum K+ level is known to be normal or low AND urinary voiding is observed. All maintenance IV fluids should include 30-40 mEq/L of K+ unless the K+ concentration is elevated or urinary output is absent. NEVER give K+ as a rapid bolus, or cardiac arrest might occur. ^DKA: Caution children NOT to allow anyone to use their lancet, because of the risk of contracting HBV or HIV. ^DKA: Ketonuria in the presence of hyperglycemia is an early sign of ketoacidosis and a CONTRAINDICATION to exercise. -^Ongoing motivation to adhere to a regime is difficult. An older child & parent/caregiver may enjoy negotiating a day off when the responsibility for testing & recording BG is delegated from the child to the caregiver/parent or vice versa.

Nursing Alerts of Disorders of Pancreatic Hormone secretion

· The earliest indication of hypoparathyroidism may be anxiety and mental depression, followed by paresthesia and evidence of heightened neuromuscular excitability, such as the following: o Chvostek sign: facial muscle spasms elicited by tapping the facial nerve in the region of the parotid gland. o Trousseau sign: carpal spasms elicited by pressure of the upper arm. o Tetany: Sharp flexion of wrist and ankle joints, muscle twitching, cramps, seizures, stridor.

Nursing Alerts of Disorders of parathyroid function

· If an infant is born with a goiter, immediately begin preparations for emergency ventilation, such as supplemental oxygen, and tracheostomy supplies readily available. Hyperextension of the neck often facilitates breathing. · Children treated with propylthiouracil or methimazole must be carefully monitored for side effects. Sore throat and fever often accompany the grave complications of leukopenia, these children should be examined if such symptoms occur. Parents and children should know the S/S and to know when to report symptoms immediately

Nursing Alerts of Disorders of the Thyroid function

ü Children with panhypopituitarism should wear medical identification, such as a bracelet. ü Growth Hormone: Is most effective when it is administered at bedtime. Physiologic release is more normally stimulated as a result of pituitary release of GH during the first 45 to 90 minutes after the onset of sleep. ü The child with DI complicated by congenital absence of the thirst center must be encouraged to drink sufficient quantities of liquid to prevent electrolyte imbalance. ü Small children require close observation during fluid deprivation to prevent them from drinking, even from toilet bowls, flower vases, or other unlikely sources of fluid. ü To be effective, vasopressin must be thoroughly mixed in the oil by being held under warm running water for 10 to 15 minutes and then shaken vigorously before being drawn into this range. If this is not done, the oil may be injected minus the 80 H. Small Brown particles, which indicate drug dispersion, must be seen in the suspension. ü DI: Nausea, vomiting, malaise may precede onset of more severe stages such as disorientation, confusion, coma, seizures.

Nursing Alerts of Disorders of the pituitary function

-Human insulin from various manufacturers might be interchangeable, however, human insulin and pork insulin or pure pork insulin should NEVER be substituted for one another. ^Because insulin can chemically bind to plastic tubing and in-line filters, thereby reducing the amount of medication reaching the systemic circulation, an insulin mixture is run through the tubing to saturate the insulin-binding sites before the infusion is started. -When mixing types of insulin, ALWAYS withdraw the CLEAR , rapid-acting insulin into the syringe FIRST, then the long-acting insulin. This avoids contaminating the short-acting insulin with the long-acting insulin.

Nursing Alerts of Insulin

The nurse is instructing a family on the side effects of oral cortisol. What aspects of administering the medication should the nurse emphasize? 1. Weight gain and dietary management. 2. Bitterness of the taste of the medication. 3. Excitability that results from the medication. 4. Taking the medication with food to decrease gastric irritation.

Taking the medication with food to decrease gastric irritation.

· oxytocin · antidiuretic hormone ADH

These 2 hormones are synthesized in the posterior pituitary?

A nurse is caring for an infant who is very fussy and has a diagnosis of DI. Which parameters should the nurse monitor while the infant is on fluid restrictions? SATA. 1. Oral intake. 2. Urine output. 3. Appearance of the mucous membranes. 4. Change in pulse and temperature. 5. Lethargy and pain.

Urine output. AND Lethargy and pain. Rationale: Infants with DI has hyposecretion of ADH, and fluid restriction has little effect on urine formation. This infant is at risk of dehydration and for fluid and electrolyte imbalances.

At a follow up visit for an 8-year-old who is being evaluated for short stature, the nurse measures and plots the child's height on the growth chart. Which explanation should the nurse give the child and family? 1. We want to make sure you were measured accurately the last two visits. 2. We need to calculate how tall you will be when you grow to adult height. 3. We need to see how much you have grown since her last visit. 4. We need to know your height so that a dosage of medication can be calculated for you.

We need to see how much you have grown since her last visit. Rationale: Height velocity is the most important aspect of a growth evaluation and can demonstrate deceleration in growth if it is present.

-skin mottling: colorless to touch -large anterior fontanel -large swollen tongue: hypotonia -slow reflexes, lethargy -distended abdomen -prolonged jaundice (yellow skin or eyes) -poor or slow growth -umbilical hernia -sleeping longer or more often than usual -constipation

What are clinical manifestations of congenital hypothyroidism?

· Two regulatory systems maintain hemostasis: the endocrine and the autonomic nervous system · Consist of the sympathetic and parasympathetic systems that control nonvoluntary functions -specifically that of smooth muscle, myocardium, and glands · The parasympathetic system primarily regulates the digestive process · The sympathetic system functions to maintain homeostasis during times of stress · Both sympathetic and parasympathetic nerve fibers secrete neurotransmitter substances · The two systems function synergistically because neural impulses transmitted to the CNS stimulate the hypothalamus to manufacture and release several releasing or inhibiting factors · Because of the interdependent relationship the glands, a malfunction in one gland produces effects elsewhere

What are neuroendocrine interrelationships?

-thirst, weakness, fatigue, N/V, abdominal pain, frequent urination -confusion, flushed, rapid respirations, breath odor (fruity)

What are some key points that you as a nurse can review with parents about the S/S of low and high blood sugar?

¶ Increased urination (Polyuria) (early sign) ¶ Oliguria (late sign) ¶ Nausea, vomiting, abdominal pain ¶ Increased thirst ¶ Fatigue ¶ Weight loss (gradual, over several weeks) ¶ Blurred vision ¶ Poor skin turgor ¶ Kussmaul Respirations (deep, rapid) ¶ Diminished reflexes

What are the S/S of hyperglycemia?

· Trembling · Sweating · Tachycardia · Pallor · Cool and Clammy skin . Diplopia

What are the S/S of hypoglycemia?

-oral hypoglycemic agents, insulin -nutrition -physical activity -blood glucose monitoring

What are the additional therapeutic management items of type 2 DM?

§ Emotional lability § Headache § Hunger

What are the alterations in sensorium in hyperglycemia?

§ Personality change § Irritability § Drunken behavior § Slurred speech § Decreased level of consciousness to total loss of consciousness § Seizure activity

What are the alterations in sensorium in hypoglycemia?

*Too much insulin *Excessive activity without eating extra carbohydrates *Missed or delayed meal *Liver, kidney, and some endocrine disorders

What are the causes of hypoglycemia?

-aplasia or hypoplasia -developmental defects -destructive lesions -idiopathic-(GH deficiency) -trauma-(perinatal: child abuse; basal skull fracture) -hereditary disorders, congenital malformations -autoimmune hypophysitis -vascular-aneurysm, infarct -psychosocial dwarfism -anorexia nervosa -surgery-removal of pharyngeal pituitary, ablation of craniopharyngioma and/or other tumor -deficiency of other pituitary hormones: ACTH/TSH

What are the causes of hypopituitarism?

-idiopathic in 80%-90% of girls, 50% in boys -CNS abnormalities (tumors, head trauma, , infection) 75% of boys -Disorder of the gonads, adrenal glands, or hypothalamic pituitary gonadal axis

What are the causes of precocious puberty?

-polyuria, polydipsia -enuresis is the 1st sign -irritability, severe dehydration, electrolyte imbalance -hyperthermia, potential circulatory collapse, vomiting -constipation, fever, sleep issues, FTT, growth problems -azotemia (Elevated levels of urea & other N compounds in the blood)

What are the clinical manifestations of DI?

· Polyphagia · Polyurea · Polydipsia · Weight loss. · Enuresis or nocturia · Irritability; "non himself/Herself" · Shortened attention span · Lowered frustration tolerance. · Dry skin · Blurred vision · Poor wound healing. · Fatigue. · Flushed skin · Headache · Frequent infections. · Hyperglycemia. o Elevated blood glucose levels. o Glucosuria · Diabetic ketosis. o Ketones and glucose in urine o Dehydration in some cases. · Diabetic ketoacidosis. o Dehydration. o Electrolyte imbalance. o Acidosis o Deep, rapid breathing. (Kussmaul respirations)

What are the clinical manifestations of Type 1 diabetes?

without hormone replacement: -result in disruption of vertical growth -delayed epiphyseal closure -retarded bone age -delayed sexual development -premature aging later in life

What are the complications related to GH deficiency?

-family history, growth patterns, health history -endocrine studies to detect deficiencies; -GH stimulation testing-generally done for children who have a low level of IGF-1 and IGFBP-3, and short stature. -bone age radiograph; -hand and wrist x-rays to evaluate growth potential

What are the diagnostic evaluation for a child with GH deficiency?

· Adrenal cortex secrete three groups of "steroids" o Glucocorticoids (cortisol, corticosterone) o Mineralocorticoids (aldosterone) -glucocorticoids and mineralocorticoids affect metabolism and stress o Sex steroids (androgens, estrogen, progestins) -influence sexual development, not essential · Altered levels of these produce significant dysfunction · Adrenal medulla secrete catecholamines -- epinephrine and norepinephrine · Catecholamines screen tumors are the primary cause of adrenal medullary hyperfunction

What are the disorders of adrenal function?

-thyroid hormone stimulates basal metabolic rate (BMR) -secretes 2 types of hormones: -thyroid hormone made up of: -triiodothyronine (T3) and thyroxine (T4) -thyrocalcitonin -defect in the thyroid can cause hypo- or hyperthyroidism -disturbance secretion of TSH

What are the disorders of thyroid function?

· Pituitary gland · Thyroid gland · Parathyroid glands · Adrenal glands · Ovaries/testes · Hypothalamus · Pineal gland

What are the endocrine glands?

-short stature but proportional height and weight -delayed epiphyseal closure -increased insulin sensitivity -delayed dentition -underdeveloped jaw -delayed sexual development -linear growth velocity consistently less than -1 standard deviation (SD) for age, or an absolute height of less than -2 SD

What are the expected findings of GH?

-risk for injury related to insulin deficiency -risk for injury related to hypoglycemia -deficient knowledge (Diabetes management) related to care of child with newly diagnosed DM

What are the expected nursing diagnoses for a child with DM?

-glucose levels will be maintained within the targeted range. -DKA will be prevented. -Hgb A1C levels will range from 6.5%-8%.

What are the expected outcomes for administering insulin in a child newly diagnosed with type 1 DM?

Parents and child should be able to demonstrate an understanding of the following: -what diabetes is -the need to administer insulin -how to administer insulin -how to monitor glucose -S/S to observe when glucose is low or high -how to promote healthy eating -how to remain physically active

What are the expected outcomes in teaching for a child and family regarding a new diagnosis of type 1 DM?

-the child and parents will understand the S/S of high or low blood sugar levels and will understand the actions needed to take when this occurs.

What are the expected outcomes regarding a family's education needs at a time to assure the child's blood glucose is kept within a target range?

-early recognition of S/S of hyperthyroidism -physical symptoms managed -regular routine established for child during recovery periods -adherence to antithyroid drugs

What are the expected patient outcomes for Graves' disease?

· Growth hormone GH · thyroid hormone TH · thyroid stimulating hormone TSH · adrenocorticotropic hormone ACTH · follicle stimulating hormone FSH · luteinizing hormone LH · prolactin

What are the hormones produced by the anterior pituitary?

§ Increased urination (polyuria) § Nocturia § Increased thirst (polydipsia) § Fluid loss, dehydration § Hypernatremia § Urine specific gravity <1.005 § Elevated serum osmolality (>300 mOsm/kg) § Decreased urine osmolality

What are the indicators of Diabetes insipidus (high and dry)?

§ Decreased urination § Excessive thirst § Hypertension § Fluid retention § Hyponatremia § Urine specific gravity >1.030 § Decreased serum osmolality (<280 mOsm/kg) § Increased urine osmolality

What are the indicators of SIADH (wet and low)?

-retinopathy, -blindness -nephropathy, -renal failure -neuropathy, -cardiovascular disease, -HTN, -stroke

What are the long term complications in relation to diabetes mellitus (DM)?

-partial or complete thyroidectomy for CA or thyrotoxicosis -following radiation for Hodgkin or other malignancy -rarely occurs from dietary insufficiency in the United States -Clinical manifestations: -goiter--slow growth, constipation -periorbital edema -weight gain -lethargy -decreased energy and sleepiness -dry skin, sparse hair, and puffiness -cold intolerance and constipation

What is acquired hypothyroidism?

-immediately administer 1/2 cup of fruit juice or a glass of nonfat or 1% milk (to increase blood sugar) -check blood glucose after 15 minutes (to check blood sugar) -give a starch-protein snack (to stabilize blood sugar) -give parents instructions regarding S/S of hypoglycemia vs hyperglycemia (to promote maintaining blood sugar within an acceptable range) -teach parents how to administer IM glucagon if unresponsive, unconscious, or seizing (to increase blood sugar)

What are the most appropriate nursing interventions for a child newly diagnosed with diabetes who is experiencing hypoglycemia?

-obtain blood glucose level before meals and at bedtime (to determine most appropriate dose of insulin) -administer insulin as prescribed (to maintain normal blood glucose level) -understand the action of insulin: differences in composition, time of onset, and duration of action for the various preparations. (to ensure accurate insulin administration) -employ aseptic techniques when preparing and administering insulin. (to prevent infection) -rotate insulin injection sites. (to enhance absorption of insulin)

What are the most appropriate nursing interventions for administering insulin in a child newly diagnosed with type 1 DM?

-shaky feeling, hunger, HA -dizziness, tremors, tachycardia -difficulty concentrating, speaking, and focusing -shallow respirations, can lead to convulsion, shock, and coma

What are the most important S/S of hypoglycemia?

-discuss glucose monitoring (to determine the most appropriate dose of insulin) -teach how to administer insulin (to maintain normal blood glucose levels) -discuss S/S of hypoglycemia and hyperglycemia (to prevent complications) -promote healthy eating patterns (to ensure accurate insulin administration) -encourage physical activity (to enhance absorption of insulin) --treatment consists of glucose monitoring, insulin therapy, observing for common problems, encouraging healthy eating and physical activity.

What are the most important patient teaching for a child and family regarding a newly diagnosis of type 1 DM? Where would you start with patient teaching for a child and family regarding a newly diagnosis of diabetes management?

-polyphagia, polyuria, polydipsia -weight loss, enuresis or nocturia, irritability, "not himself/herself" -shortened attention span, lowered frustration tolerance, fatigue -dry skin, blurred vision, poor wound healing, -flushed skin, headache, frequent infections

What are the most important signs of type 1 diabetes mellitus (DM) that you need to look for in a child?

-monitor blood glucose levels frequently -monitor K+ levels closely (when child receives insulin the serum K+ level changes) might need K+ replacement if K+ level decreases -monitor urine output --make sure child is voiding PRIOR to administration of K+, if child is not producing adequate urine output, hyperkalemia may result -monitor child closely for signs of fluid overload and cerebral edema -if the blood glucose reaches an appropriate level, administer IV dextrose -treat cause of hyperglycemia

What are the nursing interventions for a child with DKA?

-restore circulating blood volume and protection against cerebral, coronary or renal hypo perfusion is necessary. -correct dehydration, need for IV infusion of 0.9% NaCl -PIV infusion of insulin after initial fluid replacement -BS level at or < 250 mg/dL: IV fluid contains dextrose -correct hyperglycemia -monitor VS, urine output, mental status CLOSELY -correct acidosis and electrolyte imbalances -administer oxygen

What are the nursing interventions for a child with DKA?

-assess for adherence to medical therapy -focuses on treating physical symptoms before a response to drug therapy is achieved -limit contact sports during -environment should be unstimulating and quiet -patient and family need help coping with emotional lability associated with disease -Nutrition requirements need to be discussed in order for child to meet metabolic needs -discussion regarding medication side effects (urticarial rash, fever, arthritis, arthralgia) and follow up lab tests (neutropenia, hepatotoxicity, agranulocytosis)

What are the nursing management and client teaching for pediatric Graves' disease?

-administer ADH-antagonizing medication -observe for signs of fluid overload ("breakthrough" urination for prevention) -Measure and record I&O -medical alert identification -allow child to have free access to water and toilet facilities-need at school

What are the nursing management for DI?

Glands located in the female pelvis on each side of the uterus at the fimbriated end of the fallopian tubes

What are the ovaries?

-genetics (type 1 and type 2) -toxins and viruses (type 1) -obesity, physical inactivity, TG ?250 mg/dL, HTN (type 2 DM)

What are the risk factors for Type 1 and Type 2 DM?

§ Management of sick days in children with type one diabetes is critical in preventing diabetic ketoacidosis o Do not stop insulin o Ensure adequate fluid intake o Treat fever o Insulin dose may need to be increased or decreased, based on blood glucose level and food intake. o Blood glucose monitoring should be increased to three or four hours if test strips available o If unable to test blood glucose levels at home, admit child to a local health facility for regular testing. § When vomiting is present, consider this a sign of insulin deficiency and impending DKA.

What are the rules to follow regarding sick day management?

-excessive thirst -nausea -abdominal pain -weakness/fatigue -SOB reports of: blurry vision, excessive urination

What are the subjective data for DKA?

Oval-shaped glands situated within the male scrotum

What are the testes?

-surgical treatment to remove tumor -radiation or radioactive implants may be used to destroy GH-secreting tissue -depending on extent of surgical excision & degree of pituitary insufficiency--hormone replacement with thyroid extract, cortisone, sex hormones might be necessary

What are the therapeutic management for pituitary hyperfunction?

-Excessive intake of carbohydrates -Little or no exercise -Inadequate amount of insulin -Increased stress, either emotional or physical -Certain medications mask the symptoms of hypoglycemia (i.e., beta-blockers)

What causes hyperglycemia?

-also called juvenile hypothyroidism -an absent (aplastic), underdeveloped, ectopic thyroid gland -insufficient TSH secretion due to tumors -maternal intake of medications (propylthiouracil (PTU)) -diagnosis: elevated TSH (with or without T4 elevation)

What is congenital hypothyroidism?

§ Chronic adrenocortical insufficiency is rare in children § Causes: infection, destructive lesion of the adrenal gland, autoimmune processes, idiopathic § Onset of symptoms is gradual § Definitive diagnosis is based on measurements of functional cortisol reserve. the fasting serum cortisol and urinary 17-hydroxycorticosteroid levels are low and failed to rise, plasma ACTH levels are elevated with corticotropin stimulation, the definitive test for the disease. § S/S: neurologic symptoms, muscular weakness, anorexia, weight loss, irritability, headache, sweating, intense craving for salt, mental fatigue, acute abdominal pain, pigmentary changes, § Therapeutic management: replacement of glucocorticoids (cortisol) and mineralocorticoids (aldosterone). Dosage adjustments might be needed during stressful situations such as fever, infection or surgery § Nursing considerations: child and parents need guidance concerning drug therapy. Continuous cortisol replacement. Medication termination places child in danger of an acute adrenal crisis. Parents need to be aware of side effects: gastric irritation, increased excitability, sleeplessness, weight gain, and occasionally behavioral changes, including depression or euphoria.

What is Addison disease?

§ Is a characteristic group of manifestations caused by excessive circulating free cortisol § Uncommon in children § Caused by excessive or prolong steroid therapy (iatrogenic) that produces a Cushingoid appearance, is reversible after steroids are discontinued § Abrupt withdrawal will precipitate acute adrenal insufficiency § Etiology: excessive ACTH; hypersecretion of glucocorticoids; extra pituitary neoplasm § Characteristics: excessive hair growth, moon face, pendulous abdomen, poor wound healing, weight gain, bruises, red abdominal striae, ecchymosis, red cheeks, temporal fat, Thin extremities, petechia

What is Cushing syndrome of a child?

§ acute life-threatening condition characterized by hyperglycemia (≥300 mg/dL), and urine and serum ketone tests are present § glycosuria, and acidosis (pH 7.30, bicarbonate 15 mmol/L) § breakdown of body fat for energy § accumulation of ketones from blood, urine, lungs. § Develops over several hours to days, with a high mortality rate § Causes: insufficient insulin, acute stress, poor management of acute illness

What is DKA?

Increased urination (polyuria) Nocturia Increased thirst (polydipsia) Fluid loss, dehydration Hypernatremia Urine specific gravity <1.005 Elevated serum osmolality (>300 mOsm/kg) Decreased urine osmolality

What is Diabetes insipidus?

-most common cause of hyperthyroidism in children; no cure -runs in families and is an autoimmune disorder -most cases occur in adolescence, with a peak incidence at 12-14 yoa, but may be present at birth -higher in girls than boys -excessive secretion of thyroid hormone are produced by enlarged thyroid gland

What is Graves' disease (hyperthyroidism)?

-develop gradually, interval between onset and diagnosis at approximately 6-12 months. -irritability, hyperactivity, short attention span, tremors, insomnia, emotional lability -GI: hyperactivity, vomiting, frequent stooling -Cardiac: tachycardia, widened pulse pressure, systolic murmur, cardiomegaly, dyspnea -Skin: warm, flushed, moist, heat intolerance, diaphoresis -Visual disturbances; exophthalmos: increased blinking, lid lag, lack of convergence, absence of wrinkling of forehead when looking up -Diagnostic evaluation: elevated levels of T4, T3 with TSH levels suppressed; positive autoantibodies and increased-thyroid uptake of radioactive iodine

What is Graves' disease?

-called insulin-like growth factor -a hormone with the help from the GH helps promote normal bone and tissue growth and development. -this test measures amount of IGF-1 from the blood -primarily produced in the liver, skeletal muscles and other tissues in response to GH stimulation

What is IGF-1?

-called insulin like growth factor binding protein 3 -the main carrier of IGF-1 -helps extend the life of IGF-1 in the blood and helps control its effects on body tissues

What is IGFBP-3?

-this medication can treat Graves' disease or hyperthyroidism -anti-thyroid drug that has a similar mechanism of action as methimazole (Tapazole)

What is Propylthiouracil (PTU)?

Decreased urination Excessive thirst Hypertension Fluid retention Hyponatremia (125 mEq/L) Urine specific gravity >1.030 Decreased serum osmolality (<280 mOsm/kg) Increased urine osmolality

What is Syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

· Age: <20 years of age · Type of onset: abrupt · Sex ratio: affects males slightly more than females · Percentage of diabetic population: 5%-8% · Hereditary: o Family history: sometimes o Human leukocyte antigen: associations o Twin concordance: 25% to 50% o Ethnic distribution: primarily whites · Presenting symptoms: the 3-Ps common--polyurea, polydipsia, polyphagia · Nutritional status: underweight · Insulin (natural): o Pancreatic content: usually none o Serum insulin: low to absent o Primary resistance: minimum · Islet cell antibodies: 80% to 85% · Therapy: o Insulin: always o Oral agents: ineffective o Diet only: ineffective · Chronic complications: >80% · Ketoacidosis: common

What is Type 1?

· Age at onset: increasingly occurring in younger children · Type of onset: gradual · Sex ratio: females outnumber males · Percentage of diabetic population: 85% to 90% · Hereditary: o Family history: frequently. o Human leukocyte antigen: no Association. o Twin Concordance: 90% to 100%. o Ethnic distribution.: increased incident in American Indians, Hispanics, African Americans. · Presenting symptoms: may be related to long term complications. · Nutritional status: overweight. · Insulin (natural): o Pancreatic content.: >50% normal. o Serum insulin: high or low o Primary resistance: marked · Islet cell antibodies: <5% · Therapy: o Insulin: 20%-30% of patients o Oral agents: often effective o Diet only: often effective · Chronic complications: variable. · Ketoacidosis: infrequent

What is Type 2 diabetes?

-an enlargement or hypertrophy of the thyroid gland -can be congenital or acquired -congenital: as a result of maternal administration of antithyroid drugs or iodides during pregnancy -acquired: result of neoplastic or inflammatory processes, dietary deficiencies (rarely in children), increased secretion of pituitary thyrotrophic hormone -large goiters identified by obvious appearance, small nodules evident only on palpation -Benign enlargement may occur during adolescences (during rapid growth)

What is a goiter?

a complex chemical substance produced by and secreted into body fluids by a cell or group of cells that exerts a physiologic controlling

What is a hormone?

-undersecretion of antidiuretic hormone (ADH) -body's impaired ability to handle fluids -can be accompanied by dehydration and/or hypernatremia -leads to a state of uncontrolled diuresis -primary cause: familial or idiopathic (20%-50% of cases) -2nd causes: trauma (accidental, surgical), tumors, CNS infection, aneurysm

What is diabetes insipidus (DI)?

-naturally occurring substance secreted by the pituitary gland -important for normal growth, development, cellular metabolism -isolated or may be associated with hypopituitarism -deficient secretions of pituitary hormones (primarily GH: somatotropin) inhibits somatic growth and short stature -primary site of dysfunction appears to be in the hypothalamus

What is growth hormone?

random blood glucose concentration of more than 200 mg/dL (or 11 mmol/L) results when insulin deficiency leads to uninhibited gluconeogenesis and prevents the use and storage of circulating glucose.

What is hyperglycemia?

-when glucose is unavailable for cellular metabolism, the body breaks down alternate sources of energy -ketones are release and the excess ketones are eliminated in urine (ketonuria) or by the lungs (acetone breath) -ketones of the blood are strong acids that lower serum pH and produce ketoacidosis

What is ketoacidosis?

-prompt treatment needed for brain growth in infants -oral thyroid hormone replacement: Levothyroxine (Synthroid) -administer gradually over 4-8 weeks to reach euthyroidism -titrated doses to maintain TSH and T4 normal ranges -adherence with medication regimen and follow up labs is essential -teach parents to administer thyroid hormone at the same time each day to ensure adequate levels -infants: mix with water, breast milk or plain formula only -provide reassurance to child and family -newborn screening

What is management of hypothyroidism?

gradual (over days)

What is onset of hyperglycemia?

rapid (within minutes)

What is onset of hypoglycemia?

§ Is a rare tumor characterized by increased secretion of catecholamines, but might mimic other disorders § May occur around the adrenal medulla, along the paraganglia of the aorta, or the thoracolumbar sympathetic chain § They are often bilateral, multiple benign tumors § Often a familial transmission of the condition as an autosomal dominant trait § S/S: HTN, tachycardia, HA, decreased GI activity with resulting Constipation, increased metabolism with anorexia, weight loss, hyperglycemia, polyuria, polydipsia, heat intolerance, diaphoresis, nervousness, hyperventilation

What is pheochromocytoma?

-excess GH before closure of epiphyseal shafts results in overgrowth of long bones -individual height of 8 feet or more; vertical growth and increased development of muscles and viscera -weight is proportional to height -proportional enlargement of head circumference, may delay closure of fontanels in young children -oversecretion of GH AFTER epiphyseal closure -acromegaly -increased risk for hyperglycemia and DM --diagnostic evaluations: radiologic studies, endocrine studies

What is pituitary hyperfunction?

-Boys: BEFORE age 9 -Girls: AGE 8 years -accelerated growth rate and advanced bone maturation -occurs more often in females than in males -might be directly related to obesity, genetic predisposition, stress

What is precocious puberty?

-Dehydration (give fluids and needed electrolytes) -"Korrect" (glucose levels and insulin) -Administer (dextrose) -initial treatment is fluid therapy, w/needed electrolytes, not insulin -with rehydration, glucose levels will start to fall and then insulin will be prescribed -dextrose MUST be given to maintain glucose levels

What is prioritization pearl: DKA?

-oversecretion of ADH -disruption of CNS function: infection, tumor or surgery -side effects of medication -most common cause of hyponatremia -kidneys are unable to reabsorb water -Treatment: goal is to correct the underlying cause and hyponatremia -IV NaCl (at a rate not to exceed 0.5 mEq/L/h to avoid CNS damage) -Nursing care: assess for S/S of fluid overload; initiate seizure precautions in children with serum Na level drops <125 mEq/L; monitor neurological status q2h to q4h

What is syndrome of inappropriate antidiuretic hormone (SIADH)?

Mucosal lining of the gastrointestinal tract containing cells that produce hormones that play important roles in controlling and coordinating secretory and motor activities of digestion

What is the GI glands and sometimes considered an endocrine gland?

Small clusters of endocrine cells within the pancreas situated between the acinar or exocrine-secreting portions of the gland

What is the Islet of Langerhans

Pyramid-shaped glands situated atop the kidneys, fitting like caps over these organs

What is the adrenal glands?

· Located below the hypothalamus · often referred to as the master gland · primarily responsible for stimulation an inhibition of Tropic hormones · regulate the secretion of hormones from various target organs · as blood concentrations of the target hormones reached normal levels, a negative message is sent to this gland to inhibit release of the Tropic hormones

What is the anterior pituitary gland?

-is characterized by the destruction of the pancreatic beta cells, which produce insulin; this results in absolute insulin deficiency.

What is the definition of type 1 DM?

usually arises because of insulin resistance, in which the body fails to use insulin properly, combined with relative (rather than absolute) insulin deficiency

What is the definition of type 2 DM?

-8 hour fasting plasma glucose (FPG) >126 mg/dL (7.0mmol/L) -2 hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) -in patients with classic symptoms of hypoglycemia or hyperglycemia crisis, a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L)

What is the diagnostic criteria for diabetes with a pediatric client with DM?

-consistent increased linear growth rate -biosynthetic GH injection (somatropin) -continues until the child's growth plates are closer or the acceptable final height is reached -other hormone replacement as needed -thyroid extract: cortisone -testosterone or estrogen and progesterone

What is the therapeutic management for GH deficiency?

§ Confirm excess cortisol levels o X Rays, which produce images of bones on film, evaluate for osteoporosis and skull films to look for enlargement of sella turcica o Dexamethasone suppression test: child is given synthetic glucocorticoid medication, blood is drawn to determine the cortisol level in the blood. This measures whether the pituitary gland is producing too much adrenocorticotrophic hormone (ACTH). § Labs: fasting blood glucose, serum electrolytes, 24-hour urinary test. § Treatment depends on the cause; surgery might be needed and replacement of GH, TH, ADH, gonadotropins, steroids may be necessary indefinitely § Nursing management: depends on the cause; if cushingoid features are caused by steroid therapy—give medication early in the morning with an alternate day basis; postoperative complications can be hypotension, hyperpyrexia; compliance with therapy should be discussed with client and parents.

What is the diagnostic evaluation, therapeutic management and nursing management for a child with Cushing Syndrome?

the child's blood sugar will return to the targeted range

What is the expected outcome for a child who is experiencing hypoglycemia?

-early recognition of growth problems -accurate diagnosis of GH deficiency -GH effective in stimulating growth -child and family demonstrate effective coping mechanisms with diagnosis and treatment

What is the expected patient outcome for a child with GH deficiency?

-A1c ≥ 6.5% indicates DM (expected reference ranges 4% - 5.9%) -Acceptable target for children with DM is 6.5%-8% with a target goal of <7%.

What is the expected reference ranges for HbA1c?

Blood glucose >160 mg/dL; usually >250mg/dl

What is the laboratory data for hyperglycemia?

Blood glucose <60 mg/dL

What is the laboratory data for hypoglycemia?

-early identification of children with excessive growth rates -early treatment for improved outcomes -emotional support for child and family; body image issues

What is the nursing care management for pituitary hyperfunction?

Factors helping establish GH diagnosis -identify growth problems -serial height and weight records -question parents about growth -prepare child and family for diagnostic tests Discuss GH replacement therapy -ensure patients and family that GH replacement therapy is a priority -discuss administration of GH -prepare child for daily injections -discuss adherence to therapy -GH is most effective when administered at bedtime. -when pituitary release of GH during 1st 45-90 minutes after onset of sleep -monitor and assess the effectiveness of therapy -provide support of child and family regarding psychosocial concerns regarding altered body image, depression -follow up appointments with endocrinologist every 3-4 months --treatment is very expensive - up to $52,000 per year depending on dosage or $35,000 per inch.

What is the nursing care management of GH deficiency?

-enlargement of the thyroid gland at birth can cause severe respiratory distress -TH replacement is necessary for treatment of hypothyroidism and can reverse the TSH effect on the gland -For lifesaving situations removal of the gland might be necessary

What is the nursing management of a goiter in a child?

-frequent urination -vomiting -fruity-scented breath -confusion -hyperglycemia, usually ->400 mg/dL -high urine ketone levels -Kussmaul respirations -metabolic acidosis with elevated anion gap

What is the objective data for DKA?

Four or five (more or less) small round bodies attached to the posterior surfaces of the lateral lobes of the thyroid gland

What is the parathyroid glands?

Ø With a deficiency of insulin, glucose is unable to enter the cell and remains in blood, causing hyperglycemia Ø When serum glucose exceeds the renal threshold, glucose spills into urine (glycosuria) Ø Cells break down protein for conversion to glucose by the liver (glucogenesis)

What is the pathophysiology of DM?

-early recognition of S/S of SIADH -fluid overload prevention -seizures prevention **N/V and malaise may precede the onset of more severe stages such as disorientation, confusion, coma and seizures.

What is the patient outcome and alert for SIADH?

A gland located in the cranial cavity behind the midbrain and third ventricle, the functions of which are largely speculative

What is the pineal body (epiphysis cerebri) and sometimes considered an endocrine gland?

a pea sized gland that lies within a deep bony depression of the cranium (the sella turcica) and is attached to the hypothalamus on the undersurface of the brain by a slender infundibulum, or pituitary stalk

What is the pituitary gland (hypophysis cerebri)?

· controlled by either hormonal or neuronal signals from the hypothalamus · two types of substances secreted from the hypothalamus: · releasing hormones or inhibitory hormones --> they stimulate the secretion of Tropic hormones · the hormones that lack feedback control the product of a target tissue require hypothalamic inhibitors and stimulators for their control

What is the pituitary gland?

A body that secretes ovarian hormones and chorionic gonadotropin during gestation; only a temporary endocrine gland

What is the placenta?

-in 80% of affected children GH replacement therapy is successful -growth rate treatment: -growth rate is 3.5-4 cm/year before treatment -growth rate is 8-9 cm/year after treatment -responses are based on age, length of treatment, frequency of doses, dosage, weight, and GH receptor amount

What is the prognosis of GH deficiency?

§ Surgical removal of tumor is the definitive treatment § May require bilateral adrenalectomy and lifelong glucocorticoid and mineralocorticoid therapy § Do not palpate the mass. Preoperative palpation of the mass releases catecholamines, which can stimulate severe hypertension and tachyarrhythmias § Pre- and post-operative care.

What is the therapeutic and nursing management of pheochromocytoma?

-identification of disorder -treatment of central DI-maintaining fluid balance -hormone replacement DDAVP (Desmopressin) -intranasal and oral forms for children; IM or SQ -twice daily: -at bedtime to allow child to sleep through night -in the morning to allow fewer interruptions -treatment is lifelong

What is the therapeutic management for DI?

-insulin therapy--injections and/or pumps -glucose monitoring is essential to management of diabetes -glucose monitoring -- goal range should be 80-120 mg/dL -lab measurement of HbA1c (goal is < 7% or 7.5%) -urine testing for ketones: not routinely used except to test q3h or q4h during an illness -blood glucose level is over 240 mg/dL when illness is not present -nutrition therapy and physical exercise -teach patient and family how to manage hypoglycemic episodes -most commonly occur before meals or when the insulin effect is peaking -illness management--sickness will increase BS levels -management of DKA -"cool and clammy skin give me some candy"

What is the therapeutic management of type 1 and type 2 DM?

A gland situated behind the sternum and below the thyroid gland; plays an important role in immunity but only during fetal life and early childhood

What is the thymus gland and sometimes considered an endocrine gland?

Two large lateral lobes and a connecting portion, the isthmus, situated on the anterior aspect of the neck just below the larynx

What is the thyroid gland?

§ Insulin § Exercise § Increased oral fluids

What is the treatment for hyperglycemia?

§ 15 g of carbohydrate (ideally with a source of protein) § For loss of consciousness or seizure activity: Glucagon subcutaneous or intramuscular § Intravenous (IV) dextrose

What is the treatment for hypoglycemia?

-goal is retard rate of hormone secretion -Methimazole: 1st-line drug for children -Propylthiouracil is used as a last resort to decrease risk for liver toxicity in children -subtotal thyroidectomy (ablation of thyroid) -radioiodine therapy-choice in young patients who relapse after medical treatment

What is the treatment of Graves' Disease?

-Central: treatment of GnRH (hypothalamic gonadotropin-releasing hormone) -Peripheral: focuses on correcting the underlying cause -goal of therapy: preservation of final adult height; regress or stop the development of secondary sexual characteristics --nursing care: medication regimen with adherence; psychological support and coping strategies

What is the treatment of precocious puberty?

-due to an endogenous insulin deficiency -most common in children -pancreatic beta-cells fail to produce necessary amounts of insulin -An autoimmune condition, might be associated with other autoimmune diseases -onset typically in childhood and adolescences but can occur at any age -need exogenous insulin for prevention of ketoacidosis -EXOGENOUS INSULIN IS THE 1ST-LINE OF TREATMENT

What is type 1 diabetes mellitus (DM)?

-due to a tissue-level insulin resistance -pancreas produces a high level of insulin, but the tissues do not respond accordingly -family history can predispose -can be present at any age, not only adults (common age is 40) -less likely to develop ketoacidosis -African American, Hispanic and Native American at increased risk -recurrent vaginal and UTI, especially with candida albicans, are often and early sign, especially in adolescents -DIET AND EXERCISE ARE THE 1ST LINE OF TREATMENT

What is type 2 diabetes mellitus (DM)?

-review how to recognize high and low blood sugar levels to prevent glucose levels that lead to medical emergencies (to ensure prompt and appropriate treatment) -reinforce the importance of keeping the blood sugar within a target range (to keep blood glucose levels stable) -discuss when to contact the doctor, including fever for 2 days, vomiting and diarrhea, unable to keep fluids down, and glucose levels above target range (to ensure prompt and appropriate treatment) -discuss that exercise and increased activity will affect blood glucose levels, so increased monitoring will be necessary (to keep blood glucose levels stable)

What should a nurse focus on regarding a family's education needs at a time to assure the child's blood glucose is kept within a target range?

§ Nature of the disease and management § Nutrition--Meal planning § Insulin therapy --types of insulin, duration, onset and peak action, myxine of insulin, administration of insulin, rotation of injection sites (lipohypertrophy) § Insulin pump therapy (in some cases) § Glucose monitoring and glucose record keeping § Hygiene and family support § Recognition and treatment of hypoglycemia and hyperglycemia § Management of "minor" illnesses § Sick day management § Importance of medical identification bracelet § When to notify provider or team member o Nausea, vomiting, fruity odor to the breath, deep rapid respirations, decreasing LOC, moderate or high urine ketones, persisted hyperglycemia § Follow-up care: yearly vision, foot exam, dental care, health care, immunizations

What to cover for patient and family teaching for a patient regarding DM and insulin therapy?

Why would the nurse monitor the fluid and electrolyte balance in a child with DKA?

electrolyte deficiencies can lead to further complication and cardiac arrhythmias

Regulation of hormonal secretion is often based on:

negative feedback.