Endocrine

Question 1

endocrine system

Answer 1

• controls or regulates metabolic processes in the body
  
  • energy production
  • growth
  • fluid and electrolyte balance
  • response to stress
  • sexual reproduction
• most hormones from pituitary gland

Question 2

diabetes insipidus

Answer 2

• pt is not making enough ADH
  
  • ADH helps the body hold onto water
  • so w/o ADH, the body is unable to hold onto water and concentrate the urine, so the pt produces a lot of urine output and the urine is extremely diluted
• causes:
  
  • idiopathic
  • brain tumor/surgery

Question 3

clinical manifestations of DI

Answer 3

• polyuria
• polydipsia
• enuresis: wetting the bed
• infants: irritability relieved with feeding water
  
  • irritable b/c can’t tell us they are thirsty
  • these infants with DI are satiated with water

Question 4

diagnosis and tx of DI

Answer 4

• water deprivation test:
  
  • restrict fluids and check specific gravity ofurine to see if it will concentrate
    
    • if no DI: SG of urine will inc w/o water administered, so it should become more concentrated
    • if have DI: SG of urine will continue to be low and diluted
• often check for brain tumor with MRI b/c can be a cause of DI
• tx:
  
  • desmopressin acetate (vasopressin) is used–DDAVP
    
    • oral tabs: given q 12, but don’t use whole tab so more accurate for the little ones to be on injections
    • intranasal
    • subQ injection
      
      • used for little ones and those who can’t tell us they are thirst (brain injury, developmentally delayed)

Question 5

nursing implications of DI

Answer 5

• closely monitor intake and output in patients after head trauma or neurosurgical procedures
  
  • need to monitor for possible DI w/ these injuries–>would see constantly inc urine output w/ consistent intake
• at school:
  
  • allow child unrestricted use of bathroom
  • water bottle at desk–>need access to water to help control their own sodium levels
  • PRN dosing of desmopressin for breakthrough urination–>occurs when the med wears off and need DDAVP to fix
• don’t often need blood drawn unless very young or developmentally delayed
  
  • we would need to check sodium levels

Question 6

hypothyroidism

Answer 6

• congenital:
  
  • detected on newborn screen
  • prevalent in pts with Down’s syndrome–>screen for this their whole life
• acquired:
  
  • after infection
  • after thyroidectomy
  • after radiation
• high TSH, low T3/T4

Question 7

clinical manifestations and tx of hypothyroidism

Answer 7

• manifestations:
  
  • at birth, >42 weeks
  • sluggish, delayed meconium passage, feeding problems–poor suck, prolonged physiologic jaundice, hypothermia
  • dry skin, coarse hair, constipation, lethargy
    
    • if untreated, brain development affected–>have to tx immediately and consistently to prevent brain damage
      
      • important during 1st year of life to have levels in blood drawn monthly b/c affects brain development, so have to check often
• tx:
  
  • daily thyroid replacement: levothyroxine or synthroid
    
    • no matter what brand, the color for the dosage is the same!
    • changes in medication dosage take 3-4 weeks to be effective
  • blood levels drawn

Question 8

nursing implications of hypothyroidism

Answer 8

• non adherence otmedication will affect physical and brain development
• do not administer thyroid replacement with soy and iron
  
  • don’t want them to mix in the stomach, so just don’t want them given at same time
• education to parents about S/S of hypo and hyperthyroidism
  
  • hypo: may affect school performance–mentally moving “slow”
  • hyper: irritable, jittery, loose stools, high HR
• if you forget a dose, you can take one as soon as you remember or take 2 the next day
  
  • half life of drug is super long

Question 9

type 2 diabetes

Answer 9

• concerned mostly about adolescents
  
  • on the rise in adolescents b/c of obesity, poor diet, and lack of exercise
• genetic predisposition
  
  • lifestyle disorder: based on food, exercise, genetics
• inadequate production and/or inefficient use of insulin
  
  • kids still producing some insulin but either resistant to it or not enough made
    
    • beta cells in the pancreas cant make enough insulin to overcome resistance
  • insulin is necessary for sugar to go from blood stream into cells
• S/S: polydipsia, polyphagia, polyuria, fatigue
  
  • don’t go into DKA b/c still have some insulin, so when they get sick, it is not that obvious at first, so pts often think they don’t need to take their meds
• complications of DM–hyperglycemia:
  
  • kidneys, eyes, heart, nervous system

Question 10

why are kids less active now?

Answer 10

• overall activity levels of kids has decreased due to:
  
  • dec time spent in PE/recess
  • dec play time at home
  • inc time with TV, computer, video games, etc

Question 11

characteristics of adolescents at diagnosis w/ Type 2 DM

Answer 11

• obesity
• sedentary lifestyle
• diet high in calories and fat
• minorities: African American, American Indian, Hispanic
• female
• average age: 13 yo
• majority have hx of DM in first degree relative
• majority have physical evidence of insulin resistance: acanthosis nigricans–darkening of skin folds usually on neck and underarms
• frequent co-existing medical problems: HTN, elevated cholesterol and lipids, sleep apnea

Question 12

tx of Type 2 DM

Answer 12

• usually started on insulin
• may be able to switch to oral diabetes pills
  
  • important to remember that the oral pills are NOT insulin, they just help the pt use the insulin they are making, SO only works if the pt is making some insulin
  • oral pills are medicines that make the person more sensitive to their own insulin or make the pancreas release extra amounts of insulin
  • usually we use metformin (glucophage) on kids

Question 13

Metformin (glucophage)

Answer 13

• lowers blood sugar
• may help w/ weight loss
• usually started on 1 (500 mg) pill once a day for 7 days
  
  • then inc to 1 pill (500 mg) BID
  • then 1 g in AM and 500 mg in PM
  • then 1 g in AM and 1 g in PM
    
    • this regimen helps to dec SEs
• SEs: upset stomach, diarrhea
• metformin XR: longer acting form taken only in the morning
  
  • 1500 mg–>only take once per day
  • easier to remember
  • better adherence this way

Question 14

lifestyle changes for Type 2 DM

Answer 14

• dietary tx is very important: cut calories and cut carbs
  
  • low calories, fat, and carbs but still need balanced diet b/c growing
  • recommend 60 g of carbs/meal
• exercise is important
  
  • goal is at least 60 min of moderate exercise every day
• goal is A1C <7%

Question 15

Type 1 DM

Answer 15

• insulin dependent b/c not making insulin
  
  • usually diagnosed before 25 yo
  • often have a genetic predisposition, but usually an environmental trigger causes the dz to start
    
    • often starts after a viral illness
  • autoimmune rxn: body attacking its own pancreas
• onset is during childhood
• tx: insulin

Question 16

honeymoon phase of Type 1 DM

Answer 16

• pt is given injectable insulin in hospital
  
  • the cells start feeling a little better, less tired, so they may start producing some insulin
    
    • so now, they are being given synthetic insulin and insulin is being made in the body, so need to watch for hypoglycemia and take away some of the insulin being injected
  • this phase may not occur or may last for a few years
    
    • once this ends, they have to go back on insulin subQ

Question 17

tx of type 1 DM

Answer 17

• insulin injections are necessary
• diet
• exercise

Question 18

target blood sugar

Answer 18

• normal blood sugar: 60-125
  
  • gold standard for dx of type 1 DM: fasting blood sugar of greater than or equal to 126
  • hypoglycemia=<70
• goal for infants: 100-200
  
  • infants can’t tell you that they are hypoglycemic, so we run them a tad higher to hopefully prevent a hypoglycemic event
• goal for children: 80-180
• goal for teenagers: 70-150
  
  • blood sugar logs: write down and track blood sugar at least 4 times/day (before meals and bed)
    
    • of 28 blood sugars per week, we would want 100% in target range, but this is not reality, so we just want >50% in range

Question 19

goals for children with DM

Answer 19

• to achieve and maintain blood sugar control
• to grow and develop normally
• to maintain emotional wellbeing
• to optimize their learning potential and success in school

Question 20

3 class of insulin

Answer 20

• short acting:
  
  • humalog
  • novolog
• intermediate acting:
  
  • NPH
• long acting:
  
  • lantus (glargine)
  • levemir (detemir)

Question 21

short acting insulin

Answer 21

• humalog and novolog
• match up to carb content of food
• starts working: 10-15 min
• peak: 60-90 min
• lasts: 3-4 hours

Question 22

intermediate acting insulin

Answer 22

• NPH
  
  • starts working: 2-3 hours
  • peak: 6-9 hours
  • lasts: 12-15 hours

Question 23

long acting insulin

Answer 23

• lantus (glargine):
  
  • no peak!
  • starts working: 1-2 hours
  • lasts: 24 hours
    
    • take once daily
• levemir (detemir):
  
  • no peak!
  • starts working: 1-2 hours
  • lasts: 20 hours
    
    • take BID b/c doesn’t last a full day

Question 24

explain the “old” insulin regimen

Answer 24

• 2 injections per day:
  
  • mix of humalog/novolog and NPH
  • taken only prior to breakfast and prior to dinner
    
    • BUT, this has an inc risk of hypoglycemia b/c NPH peaks when not eating, so if on this, have to be no prescribed snack regimen

Question 25

advantages of lantus and levemir insulin

Answer 25

• less variability in absorption and activity
• reduction in risk of hypoglycemic events
  
  • b/c no peak!
• clear insulin: does not need to be rooled to mix
  
  • no settling and insulin concentrations do not vary from one shot to the next

Question 26

disadvantages of lantus insulin

Answer 26

• no other insulin can be mixed in the same syringe
  
  • if mixed, both lose activity
• when using lantus, 3 or more shots per day of a short acting insulin are needed, so total of 4 shots per day
• can be confused with humalog b/c both are clear insulins with purple caps
  
  • if give humalog by accident instead of NPH, eat carbs to reverse the insulin intake and check sugar
• acidic and at lower pH, so it may sting/burn

Question 27

disadvantages of levemir insulin

Answer 27

• in type 1 patients, doses are given twice a day to get full 24 hour coverage
• cannot be mixed with other insulins, so pt takes 5 shots a day
  
  • 3 for meals, 2 of levemir
• neutral pH–>less likely to have burning at injection site

Question 28

why do we need long acting insulin?

Answer 28

• blood sugar will still have ups and downs even w/o food b/c of the production of glucose with gluconeogenesis
• still need long acting insulin, even if sick, b/c gluconeogenesis does not stop
• lantus and levemir need to be given on time every day (NOT based on food, based on time)

Question 29

pen devices for diabetes

Answer 29

• able to give units of insulin in 1/2 unit dosages which is often needed for little kids
• refillable with 300 unit cartridge that should be discarded if not used in 30 days
• a new needle tipe should be used each time
• a priming dose of 2 units should be performed before EVERY injection
  
  • need to teach pt/parents this
  • want to clear the air out of the needle, and if you don’t the pt may not get any insulin

Question 30

limitations of injected insulin

Answer 30

• there is >30% daily variability in absorption of intermediate and long acting insulin
• regional differences in absorption:
  
  • abdomen>arm>thigh>hip
  • have to pinch fat over area and inject at 90 deg
  • can’t use same area over and over b/c of risk of lipohypertrophy
    
    • if this occurs, have to avoid that area for 3-4 weeks and see if it heals
• very large insulin doses have unpredictable absorption kinetics
• once injected, it cannot be removed

Question 31

insulin pumps

Answer 31

• catheter is inserted into fatty tissue
• w/ a pump, not on regular injections, so need a basal rate of insulin, but only have short acting insulin in the pump, so get a little bit every hour, and get a bolus at meal time dependent on what you are eating/sugar level
• pt needs to know how to look through the pump to see when the last bolus was given and when site changed (site should be changed every 3 days)
• carb counting features w/in the pump
• if pump malfunctions, pt doesn’t replace insulin, or problem w/ catheter, blood sugar will inc!
  
  • so these pts have to be able to check blood sugar often and rapidly
• more likely to go into DKA on the pump

Question 32

hyperglycemia

Answer 32

• blood sugar level >240
• increases gradually
• usually can be tolerated for a longer period of time
• causes:
  
  • not enough insulin or missed injections
  • eating too much
  • illness or infection
  • emotional/physical stress
  • lack of exercise or activity

Question 33

symptoms and effects of hyperglycemia

Answer 33

• polydipsia
• polyuria
• dry, flushed skin
• HA, stomachache
• feeling tired or not well
• vision problems
• dec ability to focus, dec energy level, frequent trips out of classroom–>dec school performance

Question 34

ketones

Answer 34

• form when sugar is high for too long
  
  • form b/c body is breaking down fat for energy
• occur due to a lack of insulin
• build up of ketones can lead to DKA
• when to check for ketones: by peeing on stick
  
  • blood sugar >300
  • child feels sick–esp vomiting
  • notify parents if moderate of large ketones present–need insulin

Question 35

diabetic ketoacidosis (DKA)

Answer 35

• occurs due to lack of insulin and inc blood sugar
  
  • body breaks down fat for energy and produces ketones
• S/S: fruity breath, HA, abdominal pain, vomiting, lethargy, changes in K+, dec pH
  
  • dec bicarb (or total CO2):
    
    • if <5: severe DKA–>coma
    • if 5-15: moderate DKA–>ICU
    • if 15-19: mild–>need insulin injections
• tx:
  
  • insulin IV drip–continuous regular insulin
  • bolus of fluids
  • electrolytes: potassium, dextrose
• complication: cerebral edema b/c of high fluids
  
  • give mannitol to fix this
  • do neuro checks

Question 36

hypoglycemia

Answer 36

• blood sugar <70
• occurs quickly and needs immediate attention
• causes:
  
  • too much insulin
  • meals or snacks are late or missed
  • extra or extreme exercise
  • excitement in young children (start and finish of school year, christmas break)
  • alcohol experimentation (older children)
    
    • alcohol stunts liver, so gluconeogenesis can’t occur, so eat and take less insulin

Question 37

symptoms of hypoglycemia

Answer 37

• shakiness
• pallor
• hunger
• irritability
• HA/stomachache
• behavior/personality changes
• confusion
• sweatiness
• fatigue
• sleepiness
  
  • parents have to teach child how they feel when sugar decreases

Question 38

tx of hypoglycemia

Answer 38

• 1st line: 3-4 glucose tablets or 1/2 cup of juice
• can also use: 1/2 cup regular soda, carton of milk, small tube of glucose gel
• rule of 15s:
  
  • give 15 g of glucose, and recheck sugar in 15 min
  • if still <70, then repeat
  • if above 70, give follow up protein snack
    
    • 2-4 cheese or peanut butter crackers
    • 1/2 cup of milk and graham cracker square

Question 39

glucagon

Answer 39

• if unconscious, having a seizure or unable to swallow, then give glucagon
  
  • given IM–>powder and diluent–>put diluent in powder, mix and draw up
• give thru the pants b/c it is an emergency
• not based on sugar level, based on LOC
• should work w/in 5 min
• place pt on his/her side in case of vomiting
• if in school, call 911 and notify parents

Question 40

nutrition and DM

Answer 40

• keep blood sugars in target range
• provide calories and energy for growth and development
• promote good health
• carbs:
  
  • most effect on blood sugar levels
  • includes: fruit, milk, starches (bread, pasta, cereal, starchy veggies)
  • teach anyone taking care of child how to count carbs

Question 41

how does DM affect children?

Answer 41

• toddlers:
  
  • testing and injections
  • activity levels
    
    • activity + insulin–>hypoglycemia, so if lots of activity, dec insulin OR if already gave insulin, give an extra shot
  • diet
• school age:
  
  • participation and control
    
    • start taking over own care around age 10, but still need supervision
  • social activities: let child be normal for age
• adolescents:
  
  • falsifying logbook
  • diabulemia: insulin omission–>mostly in adolescent girls b/c when they don’t take insulin, they lose weight
  • risk taking behaviors