Peds Endocrine

Long term complications of diabetes

Vascular changes as early as 2 1/2 to 3 years after diagnosis if poor diabetic control. Intensive insulin therapy delays the onset: Retinopathy, nephropathy, neuropathy.

Why do those with diabetic ketoacidosis experience kussmaul respirations?

When the accumulated ketones exceed the body's capacity to extract them, they overflow into urine (ie, ketonuria). If the situation is not treated promptly, a greater accumulation of organic acids leads to frank clinical metabolic acidosis (ie, ketoacidosis), with a significant drop in pH and bicarbonate [4] serum levels. Respiratory compensation for this acidotic condition results in Kussmaul respirations, ie, rapid, shallow breathing (sigh breathing) that, as the acidosis grows more severe, becomes slower, deeper, and labored (air hunger).

Define precocious puberty

girls less than 8 yo or boys less than 9 yo

Cushing syndrome

Adrenal Cortex - excess (hyper) Excessive circulating free cortisol Uncommon in children. Children with Cushingoid Appearance Caused by excessive or prolonged steroid therapy Reversible once steroids are gradually discontinued "Moon face"

Hypopituitarism - Anterior

Failure of growth hormone (GH) and subsequent failure of secretion of other hormones. Consequences depend on degree of dysfunction.

Issues surrounding growth hormone replacement

Family education related to daily subcutaneous injections. Timing best at bedtime. Need psychological support so child raised normal for age not appearance (Huge Issue) Joint decision on when to stop GH therapy. Epiphyseal closure is a criterion for ending therapy.

Diabetic ketoacidosis: what does the patient look like?

Fatigued, weight loss, nausea and vomiting, thirsty (very dry mouth), drowsiness, rapid breathing, etc.

Hyperthyroidism diagnosis

Increased levels of T4 and T3 TSH is low or undetectable.

Fluid replacement treatment

Initially 0.9% saline solution. Replace deficit at an even rate over 36 to 48 hours Maintenance rate + Fluids needed to replace loss. Need to be careful not to replace too quickly or else cerebral edema may occur.

Which system compensates during diabetic ketoacidosis?

Metabolic acidosis

Treatment of type 1 diabetes

Monitoring: Blood Glucose - 4 times a day. Hemoglobin A1C - every 4 months. Urine Testing - No longer recommended. Nutrition: Snacks. Frequent Meals Exercise: Will lower blood sugar levels.

Hypoglycemia

Most common before meals or when insulin effects are peaking. Triggers include: Vigorous exertion, Gastroenteritis, Error in insulin administration.

Insulin pump requirements

Must check blood glucose at least 4 times/day Be willing to make adjustments in insulin, exercise and food in response to results of tests

Name the 4 intermediate acting insulins, their onset, peak, and duration

NPH, Humulin N, Novolin NPH, and Novolin N Onset: 1-2 hours, Peak: 4-12 hours, Duration: 18-24 hours

Adequate insulin for ketoacidosis

No insulin administration until blood glucose and urine ketones is obtained. Continuous insluin at a dosage of 0.1 units/kg/hr. Goal is to decrease blood glucose levels by 50 to 100 mg/dl/hr. Once below 250 to 300 mg/dl, add dextrose to IV solution. Want blood sugar between 120 to 240 mg/dl.

Symptoms of DM type 1

Often confused with flu or other conditions Recurrent UTI in adolescents Some symptoms may only be present during stress Overt symptoms: Enuresis, irritability and unusual fatigue

Type 1 diabetes mellitus

Onset - abrupt Might be triggered by diet, virus Presenting symptoms: 3 P'- Polyuria, Polyphagia, Polydypsia. Symptoms also include weight loss and lethargy over a few days or weeks.

Hypopituitarism -Anterior - Excess Growth

Overgrowth of long bones - Height 8 feet or more. Excess growth hormone before epiphyseal closure. Acromegaly or gigantism. Excess growth hormone after epiphyseal closure - resulting in widening of bones (transverse).

What are the three options for insulin therapy?

Traditional Carb Counting Insulin Pump Therapy

How is DM type 1 diagnosed?

8 hour fasting blood glucose greater than 126mg/dl Random blood glucose value of 200 mg/dl or more accompanied by classic signs of diabetes. Oral Glucose Tolerance Test finding of 200 mg/dl or more in 2-hour sample.

Define correction factor

The pre-meal insulin dose adjustment based upon the pre-meal blood sugar. Usually determined by a Dietician or Diabetes Educator.

Treatment of hypoglycemia

1. Check blood glucose level. 2. If below 70 mg/dL give 10 to 15 g of simple carbohydrate. 3. Recheck blood sugar in 15 minutes 4. If still below 70, give another 10 to 15 g of simple carbohydrate 5. Recheck again in 15 minutes. 6. Once above 80 mg/dL, give a more substantial snack: complex carbohydrate and protein. Ex: Crackers and peanut butter. Especially important if next meal is more than 30 minutes away or if planned physical activity/exercise. If UNCONSCIOUS : Administer Glucagon subcutaneously or intramuscularly

When does hormonal control begin to take place?

12-18 months of age

A 15-year-old adolescent is scheduled for a pelvic ultrasound to evaluate for a possible ovarian cyst. Which instruction by the nurse would be most appropriate? A. "Drink plenty of fluids because you need to have a full bladder." B. "You won't be able to drink any water before or during the test." C. "Limit your level of physical activity for one-half hour before the test." D. "You need to remain very still for the entire test."

A. "Drink plenty of fluids because you need to have a full bladder."

A 9-year-old child with Graves disease is seen at the pediatrician's office reporting sore throat and fever. The nurse notes in the history that the child is taking propylthiouracil. Which of the following would concern the nurse? A. The child may have developed leukopenia. B. The child needs to be started on an antibiotic drug. C. The child may not be taking the medication. D. The child must be participating in sports.

A. The child may have developed leukopenia.

A child with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. Which action would be the priority? A. checking vital signs B. weighing the client C. measuring urine output D. encouraging increased fluid intake

A. checking vital signs

A newborn is born with hypothyroidism. If it is not recognized and treated, what complication is likely? A. cognitive impairment B. dehydration C. muscle spasticity D. blindness

A. cognitive impairment

The nurse is assessing a 1-month-old girl who, according to the mother, doesn't eat well. Which assessment suggests the child has congenital hypothyroidism? A. enlarged tongue B. frequent diarrhea C. warm, moist skin D. tachycardia

A. enlarged tongue

A pediatric client has just been diagnosed with diabetes insipidus. What is the primary consideration for this client? A. fluid replacement B. polydipsia C. weight loss D. headache

A. fluid replacement

The nurse is interpreting the negative feedback system that controls endocrine function. What secretion will the nurse correlate as decreasing while blood glucose levels decrease? A. insulin B. glycogen C. glucagon D. adrenocorticotropic hormone

A. insulin

What are the 6 major hormones of the endocrine system?

Adrenocorticotropic hormone (ACTH) Thyroid stimulating hormone (TSH) Follicle stimulating hormone (FSH) Luteinizing hormone (LH) Growth hormone (GH) Prolactin3

A 10-year-old child is newly diagnosed with type 1 diabetes. The child's hemoglobin A1C level is being monitored. The nurse determines that additional intervention is needed with the child based on which result? A. 7.5 % B. 8.5% C. 6.5% D. 7.0%

B. 8.5%

The parents of a child who was diagnosed with diabetes insipidus ask the nurse, "How does this disorder occur?" When responding to the parents, the nurse integrates knowledge that a deficiency of which hormone is involved? A. Growth hormone B. Antidiuretic hormone C. Thyroxine D. Insulin

B. Antidiuretic hormone

A new mother is concerned about the need to provide medication to a newborn every day for an indefinite period of time. What should the nurse encourage the mother to do to help ensure medication compliance? Select all that apply. A. Make medication administration pleasant such as including it during mealtimes. B. Build medication administration into the general home routine. C. Plan times for medications that fit in with the daily routine. D. Schedule prescription refills at least 1 day before the current amount is used up. E. Check the expiration dates on all medications.

B. Build medication administration into the general home routine. C. Plan times for medications that fit in with the daily routine. E. Check the expiration dates on all medications.

A 6-year-old boy has a moon-face, stocky appearance but with thin arms and legs. His cheeks are unusually ruddy. He is diagnosed with Cushing syndrome. What is the most likely cause of this condition in this child? A. Tumor of the thyroid B. Tumor of the adrenal cortex C. Tumor of the parathyroid D. Tumor of the pancreas

B. Tumor of the adrenal cortex

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? A. "Are you saying that hypothyroidism is caused by a problem in the way the thyroid gland develops?" B. "Do you mean that hypothyroidism may be caused by a problem in the way the body makes thyroxine?" C. "So, hypothyroidism can be treated by exposing our baby to a special light, right?" D. "So, hypothyroidism can be only temporary, right?"

C. "So, hypothyroidism can be treated by exposing our baby to a special light, right?"

A school-age child is diagnosed as having Cushing syndrome from long-term therapy with oral prednisone. What assessment finding is consistent with this child's diagnosis and treatment? A. Child appears pale and fatigued. B. The child is excessively tall for chronologic age. C. There are purple striae on the abdomen. D. The child is demonstrating signs of hypoglycemia.

C. There are purple striae on the abdomen.

A nurse should recognize that which laboratory result would be most consistent with a diagnosis of diabetes mellitus? A. proteinuria B. glucose in the urine C. a fasting blood glucose greater than 126 mg/dl D. a fasting blood glucose less than 126 mg/dl

C. a fasting blood glucose greater than 126 mg/dl

Acquired hypothyroidism

Children: Brain growth completed by 2 to 3 years of age. Less impaired growth and development. Treatment: Same as infants Myxedematous skin changes: Dry skin, Puffiness around eyes, Sparse hair, Constipation, Sleepiness, Mental decline

Disadvantages to insulin pump

Constant reminder of the disease More potential for hypoglycemia due to tighter control Infusion site discomfort and infections

A 13-year-old adolescent with hyperthyroidism who takes antithyroid medication has a sore throat and a fever. The parent calls the nurse and asks what to do. Which is the best response from the nurse? A. "Give your child ibuprofen according to the instructions on the box." B. "Offer your child at least 8 ounces of clear fluids and call back tomorrow." C. "Fever and sore throat may be side effects of the medication." D. "Please take your child straight to the emergency department."

D. "Please take your child straight to the emergency department."

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 take? A. Dissolve a piece of candy in the child's mouth. B. Anticipate that the child will need intravenous glucose. C. Request that someone call 911. D. Administer subcutaneous glucagon.

D. Administer subcutaneous glucagon.

A 15-year-old girl is brought to the clinic by her mother because the girl has been experiencing irregular and sporadic menstrual periods and excessive body hair growth. Polycystic ovary syndrome is suspected. Which additional assessment finding would help to support this suspicion? A. Decreased serum levels of free testosterone B. Body mass index as normal C. Short stature D. Darkened pigmentation around the neck area

D. Darkened pigmentation around the neck area

A child presents to the primary care setting with enuresis, nocturia, increased hunger, weight loss, and increased thirst. What does the nurse suspect? A. Syndrome of inappropriate diuretic hormone B. Diabetes insipidus C. Hypothyroidism D. Type 1 diabetes mellitus

D. Type 1 diabetes mellitus

Congenital Adrenal Hyperplasia

Decreased cortisol and increased androgens10th week of fetal development - masculinization of urogenital system. Female (ambiguous genitalia): Enlarged clitoris (small phallus), fusion of labia (resembles scrotum), no abnormal changes in internal. Male: No genital abnormalities at birth

Congenital hypothyroidism

Deficiency in secretion of TH Decreased T4 and increased TSH (T3 normal) Decelerated growth Risk for severe physical and mental retardation Congenital Hypothyroidism: 1 in 4000 to 1 in 3000 newborns. More prevalent in Hispanic and American Indian or Alaskan Native People Treatment: Thyroid hormone replacement (e.g. synthroid) lifelong.

Hyperthyroidism treatment

Delayed rate of hormone excretion Three Options: Antithyroid drugs, Subtotal thyroidectomy, Ablation with radioiodine

Insulin pump

Delivers steady measured dose of rapid acting insulin through a plastic tube inserted through the skin with a needle. Infusion set needs to be changed every 3 days. Pump is worn outside the body, usually attached to a belt.

Hyperthyroidism - Graves Disease characteristics

Emotional lability Physical restlessness, characteristically at rest Decelerated school performance Voracious appetite with weight loss in 50% of cases Fatigue

Name the 2 short acting insulins, their onset, peak, and duration

Humulin R and Novolin R Onset: 30-60 minutes, Peak: 2-4 hours, Duration: 5-7 hours

How is DM type 1 managed?

Insulin Replacement Glycemic Control: Normal blood glucose levels of less than 126 mg/dl, glycosylated hemoglobin (Hgb A1C) of 7% or less, decreases likelihood of long-term complications. Insulin is administered as 2 or more injections a day or as a continuous subcutaneous infusion (insulin pump).

Name the two long acting insulins, their onset, peak, and duration

Lantus and Levemir Onset: 1-2 hours, Peak: very small, Duration: 20-24 hours

Electrolyte replacement

Potassium may be normal on admission Once fluid and insulin administered, cells will deplete serum potassium Add 20 to 40 mEq/L of potassium to IV fluids once patient is voiding and insulin has been given. Never give rapid IV bolus of Potassium. Place patient on cardiac monitor.

Diabetic ketoacidosis treatment

Rapid Assessment Fluids - Overcome dehydration Adequate Insulin - reduce elevated blood glucose level Electrolyte Replacement - Especially potassium.

Prevention and screening for congenital hypothyroidism

Screen all newborns by 7 days of age (best if between 2 and 6 days of age. If positive (low level of T4 (<10%), obtain TSH levels, if elevated (>40mJ/L), further testing to determine cause.

Post-op thyroidectomy - possible emergencies

Tetany: Hypocalcemia Thyroid storm: Marked increased temperature, Increased pulse, Restlessness and agitation-apathy, stupor, coma, hypovolemic shock Laryngeal Nerve Damage

Carb counting insulin therapy

Treated with Lantus and Novolog/Humalog Insulin Lantus may not be mixed with any other insulins and you do not hold based on blood sugar. Dietary Considerations: Allow patient 45 minutes maximum to finish food. Food items do not need to be replaced if not eaten. When patient finished eating, count the number of carbs eaten. Nursing Considerations: Check blood sugar, give food tray, count carbs eaten, call doctor with blood sugar level and carbs eaten to receive insulin dose, then give insulin.

Traditional insulin therapy

Treated with Novolin/Humulin NPH and Novolog/Humalog Insulin Dietary Considerations: Patient needs to eat meal with in 15 minutes of receiving insulin. Allow patient 45 minutes maximum to finish food. Exchanges: A carbohydrate exchange equals 15 carbs. Patient must eat every carb counting food on the tray. If patient does not want a certain carb item, it must be exchanged for something of equal carb value. Nursing Considerations: Check blood sugar, call doctor with blood sugar level, receive insulin dose order, give insulin, give food tray immediately.

Treatment for excess growth

Tumor - Surgery Other: External radiation and radioactive Implants Hormone Replacement: Thyroid, cortisone, sex hormones If no tumor, can retard further growth. Cannot reduce growth already achieved.

Disorders of the Pancreas: Diabetes Mellitus

Type 1: Destruction of beta cells absolute insulin deficiency (23.6 per 1000 children) Type 2: Insulin resistance - Body fails to use insulin properly More adult onset, over age 45, overweight and sedentary, with family history of diabetes Increasing in adolescents

Hypopituitarism - Posterior - Diabetes Insipidus

Uncontrolled diuresis Symptoms: Polyuria, Polydypsia Treatment: Vasopressin (DDAVP) nasal spray bid. Do not restrict fluids.

Define insulin to carbohydrate ratio

Units of insulin needed to "cover" grams of carbohydrate consumed. Usually expressed as units insulin:grams of carbohydrates○ e.g., 1:10 = 10; 3:12 = 4

Treatment for congenital adrenal hyperplasia

Untreated: Early Sexual Maturation Confirm diagnosis and Assign a Sex, Usually according to genotype Female - Diagnosed at Birth: Treat with cortisone. Signs and symptoms in female gradually disappear, and excessive early linear growth is slowed. Fertility depends on degree of deficiency and compliance with therapy. Male: Typically no signs and symptoms. Diagnosed when puberty begun early. If testicular masses - infertile Female - Raised Male - Diagnosed when virilism appears. Continue raising child as male. Hormone replacement to permit linear growth and initiate male pubertal changes. Surgery to remove female organs and reconstruct the phallus - infertile.