Endocrine/Metabolic Conditions Flashcards
1. Assess and plan care for the child with type 1 diabetes. 2. Describe conditions resulting from hyposecretion of the pituitary gland. 3. Assess alterations in growth and development from the hyposecretion of thyroid hormones.
The pituitary gland
The pituitary gland releases growth hormone.
1. It is called the master gland because it controls the release of other hormones.
2. The anterior lobe affects growth (growth hormone), sexual development (FSH, LH, prolactin), thyroid function (TSH), adrenal funcition (adrenocorticotropic hormone [ACTH]), and skin pigment (melanocyte-stimulating hormone).
3. The posterior lobe influences uterine contractions (oxytocin) and produces antiduretic hormone (vasopressin), which has its effect on the kidneys.
Insulin production release is NOT controlled by the pituitary gland.
Altered Posterior Pituitary Function
Syndrome of inappropriate antidiuretic hormone (SIADH) may be due to brain tumor, head trauma or surgery, or brain infection and causes hypersecretion of ADH.
1. SIADH causes an increased release of antidiuretic hormone (ADH) that tells the kidneys to reabsorb too much water; this reults in decreased output, expanded fluid volume in the vessels, and diluted sodium concentration (hyponatremia).
2. Assessment: edematous, risk of seizures and cerebral edema, I & O
3. Intervention: fluid restriction, vasopressin antagonist, seizure precautions.
Diabetes Insipidus due to undersecreiton of ADH results in massive fluid loss, hypernatremia
1. Assessment: polyuria (increased urination), polydipsia (thirst), risk for dehydration
2. Interventions: hourly fluid replacement, vasopressin
Deficient Anterior Putuitary Hormone: Pituitary Dwarfism
Introduction
1. Hypopituitarism results in decreased growth hormone.
2. The cause can be idiopathic or from brain tumor, trauma, or lesions.
3. Decreased pituitary function can decrease the release of precursors for thyroid, adrenal, and gonadotropin functions.
Assessment
1. Review the child’s history for normal birth length, then assess for gradual decrease in height compared with peers.
2. Observe for short stature but normal body proportions.
3. Note that, physically, the child appears younger than expected; the child is usually well nourished.
4. Note that bone age studies reveal growth retardation.
5. Note that mental age approximates chronologic age; the child has normal intelligence.
6. Assess for delayed but normal pubertal development.
7. Assess the teeth; dental anomalies may occur when permanent teeth erupt because of growth retardation of the jaw.
8. Review the family’s history to rule out a genetic reason for the lag in height.
Interventions
1. Administer growth hormone to help the child catch up physically to peers.
2. Treat the child according to mental age, not bone age or height.
3. Provide social and psychological support to help the child cope.
Hypersecretion of Anterior Pituitary Hormone: Gigantism or Acromegaly
Overview
1. May be from hyperplasia of the pituitary cells or a pituitary tumor.
2. May present different symptoms depending on whether hypersecretion of growth hormone occurs before or after the epiphyseal plates close.
Assessment
1. Note that bone age studies are normal.
2. Assess for signs and symptoms of gigantism if the increased release of growth hormone occurs before the closure of the epiphyseal plates.
a. Elongation and enlargement of the long bones, facial bones, and accompanying body tissue
b. Late closure of the fontanels
c. Proportional body growth
3. Assess for signs and symptoms of acromegaly if the increased release of growth hormone occurs after the closure of the epiphyseal plates.
a. Enlargement of the hands, feet, nose, tongue, and jaw
b. Thickening of the skin and coarseness of facial features
Interventions
1. Be aware that radiation may be used to retard growth.
2. Provide social and emotional support to help the child (especially the female) deal with large size.
Hyposecretion of Thyroid Gland Hormone: Hypothyroidism
Overview
1. The thyroid regulates the basal metabolic rate.
2. The decreased secretion of thyroid hormones results from the decreased development of the thyroid gland or from medicaitons that suppress hormone production; the thyroid depends on diety iodine and tyrosine to function normally.
3. Hypothyroidism can be congenital or acquired.
Assessment
1. For congenital hypothyroidism:
a. Evaluate for intellectual disability that develops as the disorder progresses if treatment is not initiated.
b. Observe for short stature with the persistence of infant proportions; legs shorter in relation to trunk size.
c. Short thick neck
d. Observe for an enlarged tongue.
e. Assess for hypotonia.
f. Assess for delayed dentition.
2. For acquired hypothyroidism:
a. Assess for signs and symptoms of slow basal metabolic rate (e.g., easy weight gain).
b. Cool body and skin temperature
c. Slow pulse
d. Dry, scaly skin
e. Decreased perspiration
f. Constipation
g. Fatigue and tiredness
3. Signs for both types of hypothyroidism:
a. Assess for goiter.
b. Note that blood tests show low serum T3 and T4 levels.
Interventions
1. Administer oral thyroid hormone (thyroxine), especially to infants with hypothyroid funciton to prevent intellectual disability.
2. Administer supplemental vitamin D to prevent rickets resulting from rapid bone growth.
3. Monitor growth and development.
Hypersecretion of Thyroid Gland Hormone: Graves’ Disease
Overview
1. May be due to autoimmune response
Assessment
1. Tachycardia, nervousness/tremors (symptoms may resemble the hyperactivity of ADHD), heat intolerance with increased sweating, weight loss, insomnia, exophthalmos (protruding eyes), and presence of a goiter.
Interventions
1. Treatments aim to decrease rate of thyroid secreiton, including drug therapy, subtotal thyroidectomy, and ablation with radiodine.
2. Refer child if not currently being treated.
NOTE: thyroid storm is a rare emergency due to sudden release of thyroid hormone; this results in an acute onset of high fever and tachycardia. Seek immediate medical attention.
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Hyperfunction of the Adrenal Gland: Cushing Syndrome
Overview
1. Also called hyperadrenocorticism
2. High cortisol levels produced, resulting in the decreased secretion of ACTH
3. Often due to a tumor in the pituitary gland
4. Can also be due to prolonged or excessive use of cortiocosteroids for other conditions
Assessment
1. Central obesity: increased accumulation of fat on chest, upper back, and face (moon face); weigh daily.
2. Increased gluconeogenesis; decreased glucose tolerance; test sugar levels.
3. Increased protein catabolism leads to muscle weakness and atrophy.
4. Assess skin daily for purplish striae on skin; easy bruising.
5. Be aware of possibility of osteoporosis with susceptibility to bone fractures.
6. Assess for acne.
7. Assess for facial hair growth/hirsutism.
8. Assess for decreased linear growth, as ACTH inhibits the action of growth hormone.
9. Assess blood pressure for hypertension.
10. Assess for mood disorders.
11. Assess for poor wound healing.
Interventions
1. Prepare for surgery, if needed to remove a tumor.
2. Work with m edical staff to slowly taper exogenous corticosteroids, depending on the condition for which they are given; abrupt withdrawal will precipitate acute adrenal insufficiency.
3. Promote a clean environment because of decreased immunity to infection.
4. If steroids are needed, administer them early in the morning and on an alternate-dy basis, if possible.
5. Anorexia and nausea may be relieved by nasogastric decompression.
6. Be supportive related to the child’s mood changes, as these may not improve for months.
Type 1 Diabetes Mellitus (DM)
Overview
1. It is the most common type of diabetes in children (previously called juvenile diabetes).
2. It is a chronic systemic disorder most commonly diagnosed between ages 10 and 14 but can occur at any age from infancy to young adulthood.
3. Predisposition to the disease may be genetically passed by human leukocyte antigen in 20% of cases.
4. An autoimmune attack occurs against the beta cells of the oancreas approximately 1 week after an immune insult, such as an upper respiratory tract infection, although autoantibodies may be present up to 9 years before onset of clinical symptoms.
a. No insulin is produced, and the cells cannot use glucose; excess glucose in the blood spills into the urine.
b. The increased blood glucose can act as an osmotic diuretic, resulting in polyuria (increased urination), dehydration, polydipsia (thirst), hypotension, and renal shutdown.
c. Without glucose, the cells are starving (resulting in signals of hunger and increased food intake polyphagia]).
d. The body attempts to compensate for lost energy by converting triglycerides to fatty acids, which then form ketones with resulting metabolic acidosis.
5. Two fasting plasma glucose levels of >126 mg/dl or two random plasma glucose levels >200 mg/dl are grounds for diagnosis of DM.
6. Prediabetes is oncsidered a fasting blood sugar of 100-125 mg/dl.
7. The child appears thin and possibly malnouished.
8. The child with type 1 DM is insulin dependent.
a. Hyperglycemia can result from increased intake of sugar, decreased use of insulin, decreased exercise with no decrease in food intake, increased stressors, infeciton, or cortisone use.
b. Hypoglycemia (insulin shock) can result from increased insulin use, excessive exercise, or failure to eat.
9. If it cannot be determined whether a stuporous diabetic is suffering from hypoglycemia or hyperglycemia, treat for hypoglycemia, as hypoglycemia is life threatening.
10. Illness, especially with fever, increases blood surgar and insulin needs; exercise decreases blood sugar and insulin needs.
11. Schools and parents need a Diabetes Action/Care Plan that stipulates amount of insulin needed based on blood sugar and a correction factor; specific treatment measures for hypoglycemia are also included.
Assessment for hyperglycemia
1. Ask about polyuria, polydipsia, and polyphagia; these are cardinal signs and symptoms.
2. Note wekaness, fatigue, headache, nausea, vomiting, and abdominal cramps.
3. Test blood sugar.
4. Test for glycosuria (when glucose reaches 200 mg/dl, renal tubules cannot absorb all of the sugar, causing it to spill into the urine) and ketonura using dipstick.
a. Note hyperglycemia is measured by finger stick or blood glucose test.
5. Observe for dry, flushed skin.
6. Note “fruity”/acetone breath odor.
7. Long-term control of blood sugar is monitored by the glycosylated hemoglobin A1 (hgbA1c); hemoglobin in RBCs attaches to sugar; RBCs live for 90 to 120 days; HgbA1c measures the average amount of blood sugar over the past 90 to 120 days. Below 7% is the goal.
8. Continuous Glucose Monitor may be used in addition to a standard glucose monitor.
Interventions for hyperglycemia
1. Administer rapid-acting insulin for fast action.
2. Give fluids without sugar to flush out ketones; this includes all IV fluids with Dextrose.
3. Follow treatment for acidosis.
4. Monitor blood sugar.
Assessment for hypoglycemia
1. Definition: blood sugar < 70 mg/dl
2. Note time when insulin was administered and if it is the peak time of its action (rapid acting insulin peaks in 30-90 minutes, regular insulin peaks 2-4 hours after administration; intermediate insulin (NPH) peaks approximately 8 hours after administration).
3. Has the child eaten or exercised? Assure food at peak of insulin.
4. Assess for increased vital signs.
5. Observe for sweating.
6. Note tremors.
7. Observe for behavior changes (slow thinking, confusion, irritability, poor coordination).
Interventions for hypoglycemia
1. Give 15 grams of fast-acting carbohydrate such as a small tube of gel for cake icing, 1/2 cup orange juice, or 1/2 cup regular soda pop, followed later by a protein source, such as crackers with peanut butter or cheese; avoid complex sugars, such as a candy bar.
2. Administer glucagon to an unconscious child; glucagon may cause vomiting so the child should be placed on their side to prevent aspiration.
3. Follow seizure precautions.
Insulins
Type 1 DM
- Lispro/Humalog (clear, rapid acting): onset 10 to 15 minutes, peaks in 30 to 90 minutes.
- Regular (clear, fast acting): onset 30 minutes, peeaks in 2 to 4 hours. (Note: this is no longer used much with children.)
- NPH (cloudy, intermediate acting): onset 2 to 4 hours, peaks in approximately 8 hours.
- Lantus, a clear, long-acting insulin is used only for basal needs; it has no peaks and it is not related to meals (do not mix Lantus with other insulins).
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Administration
a. When giving two types, draw up clear insulin first to prevent contamination (remember, Lantus cannot be mixed with other insulins).
b. To prevent air bubbles, do not shake the vial; intermediate forms are suspensions and should be gently rotated.
c. Rotate injection sites to prevent lipodystrophy; lipodystrophy will alter the rate at which insulin is abdorbed.
d. Make sure the child eats when insulin peaks; in young children, it is acceptable to admin insulin immediately after eating to accurately determine what the child ate.
e. Insulin requirement may be altered with illness, stress, growth, food intake, and exercise; blood glucose measurements are the best way to determine insulin adjustment.
f. Insulin may be given by syringe and needle, an insulin pen, or an insulin pump.
(1) Insulin pump delivers basal insulin (Lispro/Humalog) continuously. A Bolus is needed to cover carbohydrates in meals with a correction formula if needed. Disconnect for water activities and showering but test every hour and have fast-acting insulin available to administer while the pump is not being worn. - Insulin is administered twice a day, at a minimum (before breakfast and dinner); administration may be more frequent.
- Dosage is based on either amount of carbohydrates consumed or blood sugar.
- Store upopened vials in refrigerator; open vials may be stored at room temperature and are good for 1 m onth; insulin pens are good for 14 to 30 days, depending on the type of insulin.
Meal planning
Type 1 DM
May require prescribed number of carbohydrates (one carbohydrate choice is 15 g carbohydrate) or an exchange list for carbohydrates.
Example:
Give 15 grams of fast-acting carbohydrate such as a small tube of gel for cake icing, 1/2 cup orange juice, or 1/2 cup regular soda pop, followed later by a protein source, such as crackers with peanut butter or cheese; avoid complex sugars, such as a candy bar.
Complications of diabetes
- Life expectancy is shortened by one third.
- Nephropathy is the primary cause of death.
- Premature atherosclerosis with vascular insufficiency (leading to heart disease and stroke) and renal failure are possible.
- Retinopathy may lead to blindness.
- Poor wound healing is characteristic.
- Predisposition to infection is characteristic.
Honeymood period
Type 1 DM
- This is one-time remission of the symptoms, which occurs shortly after insulin treatment is started.
- It is a final effort by the pancreas to produce insulin.
- The child can be insulin free for up to 1 year but may need oral hypoglycemics.
- Symptoms of hyperglycemia will reappear, and the child will be insulin dependent for life.
Type 2 Diabetes Mellitus
Overview
1. Typically seen in obese and overweight children who are physically inactive.
2. Increasing in epidemic proportions; 30% to 45% of DM in children is type 2.
3. Caused by both genetic and environmental factors; 50% to 80% have a parent with a family history of diaetes
4. Will be the biggest cause of morbidity and early mortality for the next generation of adults
5. Occurs as a result of insulin resistance plus some insulin deficiency; insulin resistance results in diminished liver, muscle, and adipose tissue sensitivity to insulin
Assessment
1. Assess for acanthosis nigricans, a thickening and hyperpigmentation of the skin at the neck and axillary areas.
2. Assess for hypertension, hyperlipidemia.
3. Assess for sleep apnea.
Interventions
1. Intervention includes a comination of activity, weight loss, and medication (if needed).
2. Metformin (Glucophage) decreases glucose production by the liver.
An adolescent, newly diagnosed with diabetes is receiving education on Humalog insulin. Which of the following should be included in the education?
a. Give the injection 30 minutes before breakfast.
b. Have a mid- afternoon snack.
c. Check her urine after each meal.
d. Give the injection immediately before her meal.
d
Humalog insuline is immediate-acting and has its peak effect 5-10 minutes after administration. It should be taken immediately prior to a meal. The afternoon snack is used to cover the peak effect of long-acting NPH insulin. Checking urine after each meal is not necessary.
Which of the following would be expected in the history of a 5-year-old, newly diagnosed with Type 1 diabetes?
a. HgbA1C of 5
b. Clammy, diaphoretic skin
c. A history of anorexia
d. Dry, flushed skin
d
Children with newly diagnosed diabetes typically have dry, flushed skin. Clammy, diaphoretic skin is seen in a child who is hypoglycemic. Newly diagnosed diabetics have a history of greatly increased appetite. A HgbA1C of 5 is considered within normal limits and would not typically be found in a new diabetic.
