Chapter 26: Nursing Care of the Child With an Alteration in Metabolism/Endocrine Disorder

After explaining the causes of hypothyroidism to the parents of a newly diagnosed infant, the nurse should recognize that further education is needed when the parents ask which question?

"So, hypothyroidism can be treated by exposing our baby to a special light, right?" Congenital hypothyroidism can be permanent or transient and may result from a defective thyroid gland or an enzymatic defect in thyroxine synthesis. Only the last question, which refers to phototherapy for physiologic jaundice, indicates that the parents need more information.

When discussing congenital adrenal hyperplasia with a child's parents, you would advise them that administration of which drug will probably be indicated?

Hydrocortisone The basic defect in congenital adrenal hyperplasia is the lack of cortisol. Administering hydrocortisone supplements this

A 7-year-old is diagnosed as having type 1 diabetes. One of the first symptoms usually noticed by parents when this illness develops is:

Loss of weight. Lack of insulin reduces the ability of body cells to use glucose; this leads to starvation of cells and loss of weight as an early symptom.

In interpreting the negative feedback system that controls endocrine function, the nurse correlates how _______ secretion is decreased as blood glucose levels decrease.

Insulin Feedback is seen in endocrine systems that regulate concentrations of blood components such as glucose. Glucose from the ingested lactose or sucrose is absorbed in the intestine and the level of glucose in blood rises. Elevation of blood glucose concentration stimulates endocrine cells in the pancreas to release insulin. Insulin has the major effect of facilitating entry of glucose into many cells of the body; as a result, blood glucose levels fall. When the level of blood glucose falls sufficiently, the stimulus for insulin release disappears and insulin is no longer secreted.

The school nurse notes that a child diagnosed with diabetes mellitus is experiencing an insulin reaction and is unable to eat or drink. Which action would be the most appropriate for the school nurse to do?

Administer subcutaneous glucagon If the child having an insulin reaction cannot take a sugar source orally, glucagon should be administered subcutaneously to bring about a prompt increase in the blood glucose level. This treatment prevents the long delay while waiting for a physician to administer IV glucose or for an ambulance to reach the child

The nurse is seeing a new client in the clinic who reports polyuria and polydipsia. These conditions are indicative of which endocrine disorder?

Diabetes insipidus The most common symptoms of central DI are polyuria (excessive urination) and polydipsia (excessive thirst). Children with DI typically excrete 4 to 15 L per day of urine despite the fluid intake. The onset of these symptoms is usually sudden and abrupt. Ask about repeated trips to the bathroom, nocturia, and enuresis. Other symptoms may include dehydration, fever, weight loss, increased irritability, vomiting, constipation, and, potentially, hypovolemic shock

Reva is an 8-year-old who is being seen today in the clinic for moodiness and irritability. She has begun to develop breasts and pubic hair and her parents are concerned that she is at too early an age for this to begin. The nurse knows that the possible prognosis is:

Precocious puberty. The prognosis for a child with precocious puberty depends on the age at diagnosis and immediate treatment. Appropriate treatment can halt, and sometimes even reverse, sexual development and can stop the rapid growth that results in severe short adult stature caused by premature closure of the epiphysis. Treatment for precocious puberty allows the child to achieve the maximum growth potential possible. Mental development in children with precocious puberty is normal, and developmental milestones are not affected; however, the behavior may change to that of a typical adolescent. Girls may have episodes of moodiness and irritability, whereas boys may become more aggressive

The nurse working with the child diagnosed with type 2 diabetes mellitus recognizes that most often the disorder can be managed by:

Taking oral hypoglycemic agents If the child presents with diabetic ketoacidosis, initial treatment is insulin administration, but then oral hypoglycemic agents such as metformin are often effective for controlling blood glucose levels. Lifestyle changes such as weight loss and increased exercise are important aspects of treatment for the child

The nurse has told the 14-year-old diabetic that the doctor would like them to have their hemoglobin A1C test performed. Which comment by the client indicates that she understands what this test is for?

"This will tell my doctor what my average blood glucose level has been over the last 2 to 3 months." Hemoglobin A1C (HbA1C) provides the physician or nurse practitioner with information regarding the long-term control of glucose levels, as it provides an average of what the blood glucose levels are over a 2 to 3 month period. No fasting is required. Desired levels for children and adolescents 13 to 19 years is less than 7.5%.

The physician has ordered a thyroid scan to confirm the diagnosis. Before the procedure the nurse should:

Assess the client for allergies. A thyroid scan uses dye, so a client should be assessed for allergies to iodine and shellfish to prevent a possible reaction. The client will not be asleep, have a catheter, or receive a bolus of fluids

A newborn is born with hypothyroidism. A complication of this disorder if it is not recognized and treated is:

Cognitive impairment. Congenital hypothyroidism can lead to extreme cognitive challenge impairment if not treated.

In the salt-losing form of congenital adrenal hyperplasia, the most important observation you would make in a newborn would be for:

Dehydration. With this form of the disorder, children are unable to produce aldosterone. This leads to the inability to retain sodium and fluid.

A 10-year-old boy is upset and reports he is the shortest boy in his class. He reports he is done with school and wants to just stay at home. When reviewing the plan of care, which nursing diagnosis would be most appropriate for this concern?

Disturbed body image All of the listed nursing diagnoses may be appropriate for a child experiencing a growth hormone deficiency. The child is voicing feelings of personal devaluation. This is consistent with a lack of self-esteem making a disturbed body image the greatest concern in this scenario

A child is prescribed glargine (Lantus) insulin. What information would the nurse include when teaching the child and parents about this insulin?

Do not mix this insulin with other insulins. Glargine (Lantus) is not to be mixed with other insulins. Glargine is usually given in a single dose at bedtime. Insulin should be kept at room temperature; insulin that is administered cold may increase discomfort with the injection. Any vial of insulin that is opened should be discarded after 1 month

A child is admitted to the pediatric medical unit with the diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Based on the typical signs and symptoms of this disorder, which nursing diagnosis will the nurse identify as relating to this client?

Excess fluid volume Syndrome of inappropriate antidiuretic hormone (SIADH) occurs when ADH (vasopressin) is secreted in the presence of low serum osmolality because the feedback mechanism that regulates ADH does not function properly. ADH continues to be released, and this leads to water retention, decreased serum sodium due to hemodilution, and extracellular fluid volume expansion; thus, Excess fluid volume from edema is the highest priority.

A child is diagnosed with hyperthyroidism. What finding would the nurse expect to assess?

Heat intolerance Hyperthyroidism is manifested by heat intolerance, nervousness or anxiety, diarrhea, weight loss and smooth, velvety skin. Constipation, weight gain, and facial edema are associated with hypothyroidism

Rank the different types of insulin based on their duration of action beginning with the shortest to the longest duration.

Lispro Humulin R Humulin N Lantus Lispro is a rapid-acting insulin. Humulin R is a short-acting insulin. Humulin N is an intermediate-acting insulin. Lantus is a long-acting insulin.

A child has been prescribed Stimate (esmopressin) acetate for the treatment of diabetes insipidus. The client and the parents ask the nurse how this drug works. What is the correct response by the nurse?

Stimate (esmopressin) acetate is a synthetic antidiuretic hormone that will slow down your urine output Stimate (esmopressin) acetate is a synthetic antidiuretic hormone that promotes reabsorption of water by action on renal tubules; it is used to control diabetes insipidus by decreasing the amount of urine produced

The nurse measures the client's blood glucose level prior to breakfast. The measurement obtained is 130 mg/dL. The orders read to administer 2 units of Humalog insulin for a blood glucose of 100 to 150mg/dL. How soon should the nurse ensure that the client eats their breakfast after receiving their insulin?

Within 15 to 30 minutes Humalog is a rapid-acting insulin. The onset of Humalog insulin is within 15 minutes and the peak level is achieved within 30 to 90 minutes; therefore, the client should eat within 15 to 30 minutes to avoid a hypoglycemic reaction

In a child with diabetes insipidus, which characteristic would most likely be present in the child's health history?

Abrupt onset of polyuria, nocturia, and polydipsia Diabetes insipidus is characterized by deficient secretion of antidiuretic hormone leading to diuresis. Most children with this disorder experience an abrupt onset of symptoms, including polyuria, nocturia, and polydipsia. The other choices reflect symptoms of pituitary hyperfunction

During a visit to the clinic the adolescent client with hypothyroidism tells the nurse that she takes her Synthroid (levothyroxine) "whenever I think about it...sometimes I miss a dose, but not very often." What is the best response by the nurse?

"I know it's hard to remember medicines, but it is really important for you to take it before breakfast each day to control your hypothyroidism." Synthroid (levothyroxine) is thyroid hormone replacement used to treat hypothyroidism. It is important to maintain a level thyroid hormone level by taking the medication at the same time each day (preferably 30 prior to breakfast for best absorption). Toxicity can occur if the dose is doubled. Suggesting the client "do something" to remember does not highlight the importance of taking it correctly

The nurse is speaking with the parents of a school-aged child recently diagnosed with diabetes mellitus regarding the differences between hypoglycemia and hyperglycemia. Which statement by a parent indicates a need for further teaching?

"If I notice changes in my son like tearfulness or irritability, his blood sugar may be high." Behavior changes such as tearfulness, irritability, confusion and slurred speech are indications of hypoglycemia, not hyperglycemia. Tremors and diaphoresis are also indications of low blood sugar. Dry flushed skin, fatigue, weakness, nausea, vomiting and fruity breath odor are all symptoms of hyperglycemia

Kate and her parents are being seen in the office after discharge from the hospital with a new diagnosis of type 2 diabetes. Which statement by the nurse is true?

"Kids can usually be managed with an oral agent, meal planning, and exercise." Treating type 2 diabetes in children may require insulin at the outset if the child is acidotic and acutely ill. More commonly, the child can be managed initially with oral agents, meal planning, and increasing activity. Telling the child that she is lucky she did not have to learn how to give a shot might scare her so it will inhibit her from seeking future health care. The condition will not rectify itself if all orders are followed. A weight-loss program might need to be implemented but that is not always the case

The nursing is caring for a child recently admitted with an endocrine disorder. The child's mother asks the nurse what the term metabolism means. Which is the best response by the nurse?

"Metabolism refers to all physical and chemical reactions occurring in the body's cells that are necessary to sustain life."

When discussing care of an infant with congenital hypothyroidism, you would stress that the infant will need:

Administration of levothyroxine for a lifetime. Hypothyroidism occurs because the thyroid is not producing adequate thyroxine. The child will need a supplemental source for a lifetime.

Insulin deficiency, increased levels of counter regulatory hormones, and dehydration are the primary causes of:

Diabetic ketoacidosis. Insulin deficiency, in association with increased levels of counter regulatory hormones (glucagon, growth hormone, cortisol, catecholamines) and dehydration, is the primary cause of diabetic ketoacidosis (DKA), a life-threatening form of metabolic acidosis that is a frequent complication of diabetes. Liver converts triglycerides (lipolysis) to fatty acids, which in turn change to ketone bodies. The accumulation and excretion of ketone bodies by the kidneys is called ketonuria. Glusosuria is glucose that is spilled into the urine

The nurse is teaching a child with type 1 diabetes mellitus to administer her own insulin. The child is receiving a combination of short-acting and long-acting insulin. The nurse knows that the child has appropriately learned the technique when she:

Draws up the short-acting insulin into the syringe first. Drawing up the short-acting insulin first prevents mixing a long-acting form into the vial of short-acting insulin. This maintains the short-acting insulin for an emergency. Insulin is given subcutaneously

Which nursing objective is most important when working with neonates who are suspected of having congenital hypothyroidism?

Early identification The most important nursing objective is early identification of the disorder. Nurses caring for neonates must be certain that screening is performed, especially in neonates who are preterm, discharged early, or born at home. Promoting bonding, allowing rooming in, and encouraging fluid intake are all important but are less important than early identification.

A nurse is teaching a child with type 1 diabetes mellitus how to self-inject insulin. Which method should she recommend to the child for regular doses?

Subcutaneously in the outer thigh Insulin is always injected SC except in emergencies, when half the required dose may be given IV. SC tissue injection sites used most frequently in children include those of the upper outer arms and the outer aspects of the thighs. The abdominal SC tissue injection sites commonly used in adults can be adequate sites but most children dislike this site as abdominal skin is tender.

A 10-year-old boy has been diagnosed with type 1 diabetes mellitus. He is curious about what the cause of his disease is and asks the nurse to explain it to him. What should the nurse say to the boy?

"Special cells in a part of your body called the pancreas can't make a chemical called insulin, which helps control the sugar level in your blood." Type 1 diabetes is a disorder that involves an absolute or relative deficiency of insulin, in contrast to type 2 where insulin production is only reduced. Insulin is produced by beta islet cells in the pancreas. Diabetes insipidus is caused by the pituitary gland not producing enough ADH and is characterized by extreme thirstiness and polyuria. Insufficient growth hormone is also related to dysfunction of the pituitary gland

The nurse is preparing a child suspected of having a thyroid disorder for a thyroid scan. What information regarding the child should the nurse alert the doctor or nuclear medicine department about?

The child is allergic to shellfish Allergies to shellfish should be reported because shellfish contains iodine; the dye used for a nuclear medicine scan is iodine based and could cause an anaphylactic reaction. The other information about the child would not need to be reported to the staff

During an assessment of an adolescent child, the nurse notes that the child has a protuberant tongue, fatigued appearance, poor muscle tone and exophthalmos. What medical diagnosis would the nurse expect the child to have?

Graves disease Symptoms of Graves disease include an increased rate of growth; weight loss despite an excellent appetite; hyperactivity; warm, moist skin; tachycardia; fine tremors; an enlarged thyroid gland or goiter; and ophthalmic changes including exophthalmos.

Which results would indicate to the nurse the possibility that a neonate has congenital hypothyroidism?

Low T4 level and high TSH level Screening results that show a low T4 level and a high TSH level indicate congenital hypothyroidism and the need for further tests to determine the cause of the disease.

A 6-year-old child is being evaluated for growth hormone dysfunction. Which tests will be employed in the diagnostic workup?

• CT scan • MRI • Pituitary function test The child will undergo laboratory tests to rule out chronic illnesses such as renal failure or liver and thyroid dysfunction. Laboratory and diagnostic tests used in children with suspected GH deficiency include CT and MRI to assess for structural abnormalities. A pituitary function test will be used to confirm a diagnosis of growth hormone dysfunction.

A 12-year-old boy arrives at the emergency room experiencing nausea, vomiting, headache, and seizures. He is diagnosed with bacterial meningitis. Other findings include a decrease in urine production, hyponatremia, and water intoxication. Which pituitary gland disorder would be most associated with these symptoms?

Syndrome of inappropriate antidiuretic hormone Syndrome of inappropriate antidiuretic hormone (SIADH) is a rare condition in which there is overproduction of antidiuretic hormone by the posterior pituitary gland. This results in a decrease in urine production and water intoxication. As sodium levels fall in proportion to water, the child develops hyponatremia or a lowered sodium plasma level. It can be caused by central nervous system infections such as bacterial meningitis. As the hyponatremia grows more severe, coma or seizures occur from brain edema. Diabetes insipidus is characterized by polyuria, not decreased urine production. Hyposecretion of somatotropin, or growth hormone, results in undergrowth; hypersecretion results in overgrowth.