Nursing Assessment of the Endocrine System (Test 2) Flashcards
What are lipid soluble hormones also known as?
Steroid hormones.
Classifications and functions: lipid soluble hormones- ?
Adrenal cortex, sex glands, thyroid
What are water soluble hormones also known as?
Protein base.
Classifications and functions- water soluble hormones?
All other hormones
What is the third group of hormones?
Reproduction/stress/metabolism/growth
Hormone transport
Lipid soluble hormones are bound to plasma proteins for transport
What are the 2 types of hormone receptors?
Steroid “ “ and Protein “ “
Where is the steroid hormone receptor located?
Inside the cell
What does the protein hormone receptor do?
Hormone attaches to receptor on cell membrane “first messenger” which stimulates the production of a “second messenger” that activates intracellular activity
What is simple feedback?
Gland increase/decreases the secretion of a hormone based on feedback (ex: insulin/glucose)
What is positive feedback?
Increases target organ action beyond normal
What is complex feedback?
Communication among several glands to regulate hormone secretion (ex: thyroid)
What is nervous system control?
Initiated by CNS and implemented by sympathetic nervous system (ex: stress/catecholamines)
What are rhythms?
Hormones fluctuate in predictable patterns during 24 hour period (ex: cortisol)
What hormones types make up the hypothalamus?
Inhibiting and releasing hormones
What do inhibiting hormones do?
Inhibit the secretion of hormones from the anterior pituitary.
What are examples of inhibiting hormone?
Somatostatin; prolactin-inhibiting hormone
What do releasing hormones do?
Stimulates the secretion of hormones from the anterior pituitary.
What are examples of releasing hormones?
Corticotropin-releasing hormone; growth hormone-releasing factor
What hormones are in the anterior pituitary?
Tropic hormones, growth hormone, prolactin
What do tropic hormones do?
Control the secretion of hormones by other glands
What are examples of tropic hormones?
Thyroid-stimulating hormone (TSH); adrenocorticotropic hormone (ACTH); follicle-stimulating hormone (FSH)
What hormones are in the posterior pituitary?
Antidiuretic hormone (ADH), and oxytocin
What does ADH do? What is this stimulated by?
Regulates fluid volume by stimulating reabsorption of water in the renal tubules. Stimulated by increased plasma osmolality.
ADH also is…?
A potent vasoconstrictor.
What does oxytocin do?
Stimulates milk secretion and uterine contraction.
What hormones are in the thyroid gland?
Thyroxine (T4), triiodothyronine (T3), and calcitonin
What do T4 and T3 do?
Regulate metabolic rate of all cells and processes of cell growth
What do low levels of T4 and T3 cause?
Stimulate pituitary gland to release TSH
What does calcitonin do?
Inhibits calcium loss from bone, increases calcium storage in bone, and increase renal excretion of calcium and phosphorus
What hormone is in the parathyroid gland?
Parathyroid hormone (PTH)
What does PTH stimulate?
Stimulates bone desorption and inhibits bone formation; stimulates renal conversion of vitamin D
What does PTH increase?
Calcium reabsorption and phosphate excretion in kidneys
What 2 things make up the adrenal gland?
Adrenal medulla and adrenal cortex
What hormones are in the adrenal medulla?
Catecholamines (epinephrine, norepinephrine, dopamine); stress response
What hormones are in the adrenal cortex?
Cortisol, aldosterone, adrenal androgens
What does cortisol do?
Regulates blood glucose concentration, anti-inflammatory action, promotes metabolism
What does aldosterone do?
Maintains extracellular fluid volume, promotes renal reabsorption of sodium and excretion of potassium
What do adrenal androgens?
Promotes masculinization in men and growth and sexual activity in women
What hormones are in the pancreas?
Glucagon and insulin
What does glucagon do?
Increases blood glucose by stimulating glycogenesis, glycogenesis, and ketogenesis
What is insulin stimulated by?
Increased blood glucose level
What does insulin facilitate?
Glucose transport into cells
Normal aging results in what 4 things?
Decreased hormone production and secretion, altered hormone metabolism and biologic activity, decreased responsiveness of target tissue to hormones, alterations in circadian rhythms
*Changes of aging often mimic what?
The manifestation of endocrine disorders
What system is less developed at birth than any other system in the body?
Endocrine
Hormonal control of many body functions is lacking until when?
12-18 months
Infants may manifest what as a result of lack of hormonal development?
Imbalances in fluids, electrolytes, amino acids, glucose, and other trace substances as a result of this lack of development
What things are important to know about past health history?
Previous or current endocrine abnormalities, abnormal patterns of growth and development
What medications are important to know they are taking?
Hormone replacement, insulin, corticosteroids
What is important to know when gathering info about surgery/other treatment?
Neck or brain involvement of increased importance
If kids aren’t getting good growth and weigh percentile numbers, it leads us to what?
Endocrine problems
ADH is released by what?
The pituitary gland
Where is ADH made?
Hypothalamus
What does ADH prevent?
The production of dilute urine
What is something to remember about COPD patients when gathering medication info?
A lot are on long term steroids
In what assessments may you find abnormalities when assessing the system of a person with endocrine problems?
Vital signs, height and weight, mental-emotional status, integument, head, neck, thorax, abdomen, extremities, genitalia (esp. hair distribution)
Common assessment abnormalities?
Changes in skin texture, exophthalmos, moon face, polyuria/polydipsia, goiter, changes in weight, lethargy, thermoregulation
What are the changes in skin texture caused by?
Hypo/hyperthyroidism
What is exophthalmos caused by?
Hyperthyroidism
What is moon face caused by?
Cushing syndrome
What is polyuria/polydipsia caused by?
DM, DI
What are goiters caused by?
Hypo/hyperthyroidism
What are changes in weight caused by?
Hypo/hyperthyroidism; DM
What is lethargy caused by?
Hypothyroidism
What are thermoregulation problems caused by?
Hypo/hyperthyroidism
What are MRIs used for?
Used to find tumors?, measure tumors, and evaluate for metastasis
What should you inform the patient about MRIs?
That the test is painless and noninvasive, and they will need to lie still
What is a computed tomography (CT scan) used for?
To identify tumors or cysts
What do you need to tell the patient about the CT scan?
They will need to lie still
What should you do if an IV contrast will be used?
Check for iodine allergy
Questions to ask for MRIs?
Are you claustrophobic? Do you have on any jewelry? Do you have metal implants or staples? Etc.
What do ultrasounds do?
Evaluates thyroid nodules to determine if they are cysts or tumors
What do you need to explain about ultrasounds?
Explain the painless procedure will take about 15 minutes
Do you need to fast or be sedated for ultrasounds?
No
What is the most sensitive diagnostic test for evaluating thyroid dysfunction?
TSH
What is the normal range of TSH?
0.4-4.2 microunits/milliliter
What should you explain about the TSH test?
Explain blood draw procedure to patient
What is a T4 test used for?
To evaluate thyroid function and monitoring thyroid function
What is the normal range of T4?
4.6-11.0 micrograms/deciliter
What should you explain about the T4 test?
Explain blood draw procedure to patient
What is a T3 test helpful in?
Diagnosing hyperthyroidism in T4 levels are normal
What is the normal T3 range for ages 20-50?
70-204 nanograms/deciliter
What is the normal T3 range for ages 50 plus?
40-181 nonograms/deciliter
What should you explain to the patient about T3 tests?
Explain blood draw procedure to patient
What is a thyroid scan used for?
To evaluate thyroid nodules
What is given during a thyroid scan?
Radioactive isotopes are given orally or IV thyroid is scanned
What does a normal thyroid look like in a scan?
Homogenous pattern
What do benign nodules look like in a scan?
Appear as warm spots
What do malignant nodules look like in a scan?
Appear as cold spots (meaning they won’t absorb meds)
What should you check before doing a thyroid scan?
Check for iodine allergy
What should patients not have before a thyroid scan?
Shouldn’t have supplemental iodine for several weeks before
For what tests should you minimize salt intake (iodine)?
Thyroid scan and radioactive iodine uptake (RAIU)
What do RAIUs provide?
Direct measurement of thyroid activity
What is the patient given for a RAIU?
Radioactive iodine orally or IV
When is the thyroid scanned during a RAIU?
At several time intervals
What should you check for before a RAIU?
Check for iodine allergy
What should be avoided before a RAIU?
No supplemental iodine for several weeks before the test
What can interfere with RAIU results?
Thyroid medications
Which is more common, RAIU or blood draws?
Blood draws, RAIUs aren’t used much
What does cortisol evaluate?
Adrenal cortex function
What is the normal range of cortisol at 8am?
5-23 micrograms/deciliter
What is the normal range of cortisol at 4pm?
3-16 micrograms/deciliter
What time is the most accurate cortisol test collected?
In the morning
What is important to remember to write on the sample?
Mark sample time of specimen vial
What does fasting blood glucose measure?
Measures circulating glucose level
What is the normal range for a fasting blood glucose test?
70-99 milligrams/deciliter
How long should they fast for a FBG test?
4-8 hours
Is water intake allowed for a FBG test?
Yes
What should you ensure when giving a FBG test?
Ensure no dextrose in IV solution
What is a Glycosylated Hemoglobin test also known as?
HGB A 1 C
What does Hgb A1C measure?
Glucose control during previous 3 months
What is the normal range for a Hgb A1C test?
4-6%
Is fasting necessary for an Hgb A1C?
No
What does a ketone test measure?
Amount of acetone secreted in urine as result of incomplete fat metabolism
What does a positive ketone result indicate?
Can indicate lack of insulin and diabetic acidosis
How is a ketone test done?
Completed with freshly voided urine sample
What other test is a ketone test often done with?
Glucose test
When do we usually see ketones?
In diabetics without insulin
How else can ketones be tested for?
Blood
Theories link cause of DM to single/combo of what factors?
Genetic, autoimmune, environmental, viral
What are the two most common types of DM?
Type 1 and 2
What other types of DM are there?
Gestational, prediabetes, secondary diabetes
Normal insulin metabolism is produced by what?
The beta cells (weird B looking letter)
What are the beta cells made of?
Islets of Langerhans (pancreas)
How is normal insulin released?
Released continuously into the bloodstream in small increments with larger amounts released after food intake
What does normal insulin stabilize glucose range to? (Aka what’s the ideal glucose range?)
70-120 mg/dl
What is the average daily secretion of normal insulin?
0.6 units/kg body weight
What does insulin promote? What does this cause?
Glucose transport from bloodstream across cell membrane to cytoplasm of cell. Causes decrease of glucose in the bloodstream.
What does increased insulin after a meal stimulate?
Storage of glucose as glycogen in liver and muscle
What does increased insulin after a meal inhibit?
Gluconeogenesis
What does increased insulin after a meal enhance?
Fat disposition
What does increased insulin after a meal also increase?
Protein synthesis
What are insulin dependent tissue examples?
Skeletal muscles and adipose tissues
What are non insulin dependent tissue examples?
Brain, liver, blood cells
What is the definition of non insulin dependent tissues?
Do not depend directly on insulin for glucose support
What do counterregulatory hormones oppose?
Oppose effects of insulin
What do counterregulatory hormones increase?
Blood glucose levels
What do counter regulatory hormones provide?
A regulated release of glucose for energy
What do counter regulatory hormones help?
Help maintain normal blood glucose levels
What are examples of counterregulatory hormones?
Glucagon, epinephrine, growth hormone, cortisol
What is the incidence rate of DM?
15 per 100,000 people in North America
What are the peak ages of onset for females and males?
Between 10 and 12 for girls, and 12 to 14 for boys (puberty)
What factor increases the risk for DM?
If the child or adolescent has a first degree relative or identical twin with the disease, but it’s not for sure going to happen though
What type of diabetes may show a familial tendency?
Type 1
Theories for DM disease development include?
Genetic components, environmental influences such as viruses, and an autoimmune response that causes the destruction of insulin-secreting cells of the pancreas in the islets of Langerhans
What is type 1 DM formerly known as?
Juvenile onset or insulin dependent diabetes
What age bracket does type 1 usually occur in?
Most often occurs in people under 30 years of age
When is the peak onset of type 1?
10-14
What do the body’s T cells do?
Attack and destroy beta cells which are the source of insulin
What do antibodies to the islet cells cause?
80-90% reduction of normal beta cell function leads to hyperglycemia and diagnosis of type 1 DM
What is the onset of disease like for type 1?
Long preclinical period
What are present before symptoms occur for type 1?
Antibodies present for months to years before symptoms occur
When do manifestations develop for type 1?
When pancreas can no longer produce insulin
After manifestations of type 1, what happens?
Rapid onset of symptoms and present as ER with ketoacidosis
What does type 1 history include?
Recent, sudden weight loss
What are classic symptoms of type 1?
Polydipsia, polyuria, polyphagia
What is polydipsia?
Excessive thirst
What is polyphagia?
Excessive hunger
Does eating more stop the weight loss of type 1 onset?
No, even though you eat a lot, you are still losing weight (15-20 pounds)
What does type 1 diabetes require?
Exogenous insulin to sustain life
When does DKA occur?
Occurs in absence of exogenous insulin (absolutely no insulin)
Is DKA life threatening?
Yes
What does DKA result in?
Metabolic acidosis
When is prediabetes also known as?
Impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)
Fasting blood glucose levels
Higher than normal (over 100 mg/dl, but under 126 mg/dl)
Impaired glucose tolerance 2 hour plasma glucose
Higher than normal (between 140 and 199 mg/dl)
Why is pre diabetes not just diabetes?
Not high enough for diabetes diagnosis
What does having pre diabetes increase your risk for?
Type 2
If no preventative measure is taken about the pre diabetes, what usually happens?
Develop diabetes within 10 years
Does damage occur with pre diabetes?
Long term damage already occurring to heart and blood vessels
How does pre diabetes appear?
Usually present with no symptoms
What do you need to do with a patient that has pre diabetes?
Must watch for diabetes symptoms
What is the most prevalent type of diabetes?
Type 2
What is the percentage of patients with type 2 of all diabetes types?
Over 90%
What age bracket does type 2 usually occur in?
Over 35
How many patients with type 2 are overweight?
80-90%
Type 2 prevalence increases with…?
Age
What type of basis does type 2 have?
Genetic basis
What ethnic populations have an increased rate of type 2?
African Americans, Asian Americans, Hispanic Americans, and Native Americans
What ethnic populations have the highest rate of diabetes in the world?
Native Americans and Alaskan Natives
What are HCPs finding more and more of?
Children with type 2 diabetes, a disease usually diagnosed in adults aged 40 years and older
What may be major contributors to the increase in type 2 diabetes during childhood or adolescence?
The epidemics of obesity and the low level of physical activity among young people
Why is type 2 difficult in children?
It can go undiagnosed for a long time and children often have mild/no symptoms
In type 2 what does the pancreas do?
Continues to produce some endogenous insulin
The insulin produced in a patient with type 2 is…?
Is either insufficient or poorly utilized by tissues
What is the most powerful risk factor for type 2?
Obesity (abdominal/visceral)
???What genetic mutations are related to type 2?
Lead to insulin resistance and increased risk for obesity
What are the 4 major metabolic abnormalities r/t type 2?
Insulin resistance, pancreas’ decreased ability to produce insulin, inappropriate glucose production from liver, and alteration in production of hormones and adipokines
What happens in insulin resistance?
Body tissues don’t respond to insulin and insulin receptors are either unresponsive or insufficient in number
What happens when pancreas has decreased ability to produce insulin?
Beta cells are fatigued from compensating and beta cells mass lost
What happens from inappropriate glucose production from liver?
Liver’s response of regulating release of glucose is haphazard, and it is not considered a primary factor in development in type 2
What does alteration in production of hormones and adipokines do?
Play a role in glucose and fat metabolism and contribute to pathophysiology of type 2; two main adipokines- adiponectin and leptin
What kind of onset is type 2?
Gradual onset
A person may go with with undetected..?
Hyperglycemia
What from hyperglycemia may become severe?
Osmotic fluid/electrolyte loss or hyperosmolar coma
What is probably the number one way people get diagnosed as type 2?
Improper wound healing
What are clinical manifestations of type 2?
Nonspecific conditions (may have classic symptoms of type 1), fatigue, recurrent infections, recurrent vaginal yeast or candida infections, prolonged wound healing, visual changes
When does gestational diabetes develop?
During pregnancy
When is gestational diabetes detected?
At 24 to 28 weeks
Usually normal glucose levels at…?
6 weeks postpartum
What does GD increase risk for?
Increased risk for C section, perinatal (baby) death, and neonatal complications
Why do these increased risks exist?
Because these babies grow at much faster rates and causes those risks
After having GD, it increases risk for what?
Risk for developing type 2 in 5 to 10 years
What is therapy for GD?
1st nutritional, 2nd insulin
What puts you at higher risk for GD?
Excessive weight gain and family diabetes history
Secondary diabetes results from what?
Another medical condition: Cushing syndrome, hyperthyroidism, pancreatitis, parenteral nutrition, cystic fibrosis, hematochromatosis, corticosteroids (Prednisone), thiazides, phenytoin (Dilantin, which is a long term antiseizure)
When does secondary diabetes resolve?
Usually resolves when underlying condition is treated
Diagnosing diabetes- Hgb A1C level
over 6.5%
Diagnosing diabetes- fasting plasma glucose level
Over 126 mg/dl
Diagnosing diabetes- OGTT 2 hour plasma glucose level
200 mg/dl
Diagnosing diabetes- random plasma glucose level
Over 200 mg/dl in a patient with classic symptoms of hyperglycemia
Nursing history type of assessment for DM patients?
Past health history (viral infections, medications (esp. steroids, antibiotics, etc.), recent surgery), positive health history, obesity
If a patient with DM is obese, what will the doctor probably do?
Probably start yearly fasting glucose checks and more often if they have a family history
Stress and sugar relationship?
Stress of illness or injury makes sugar levels increase, if you keep it between 70-120 mg/dl it helps wound healing
What do you say if a patient asks why they are getting fingersticks and they’re not diabetic?
Stress of illness or injury makes sugar levels increase, if you keep it between 70-120 mg/dl it helps wound healing
What do we assess during physical assessment for DM patients?
Weight loss, thirst, hunger, poor healing, Kussmaul respirations (rapid breathing and a sign of DKA)
Nursing diagnoses for DM?
Ineffective therapeutic regimen management, risk for injury, risk for infection, powerlessness, imbalanced nutrition: more than body requirements
What is important to remember about DM as a nurse?
Managing diabetes takes a lot of discipline, so put yourself in your shoes before you judge
What are overall goal examples during the planning period for DM?
Active patient participation (and family and SO’s if applicable), few or no episodes of acute hyperglycemic emergencies or hypoglycemia, maintain normal blood glucose levels, prevent or delay chronic complication, lifestyle adjustments with minimal stress
Health promotion for implementation phase for DM?
Identify those at risk, routine screening for overweight adults over age 45 (FPG is preferred method in clinical settings
Acute intervention for implementation phase for DM?
Hypoglycemia, DKA, Hyperosmolar hyperglycemic nonketotic syndrome
Acute intervention for stress of illness and injury for DM?
Increase blood glucose level, continue regular meal plan, increase intake of noncaloric fluids, continue taking oral agents and insulin, frequent monitoring of blood glucose at least every 4 hours and ketone testing if glucose is over 240 mg/dl
Patients undergoing surgery or radiologic procedures requiring contrast medium should…?
Hold their metformin (glucophage) day of surgery and 48 hours, (begun after serum creatinine has been checked and is normal???)
What is the overall goal of ambulatory and home care?
To enable patient or caregiver to reach an optimal level of independence
When implementing insulin therapy and oral agents in ambulatory and home care what do you need to do?
Provide education of proper administration, adjustment, and side effects; assessment of patient’s response to therapy
When implementing personal hygiene in ambulatory or home care what do you need to do?
Regular bathing with emphasis on foot care, and daily brushing/flossing (dentist should be informed about diabetes diagnosis*)
What is important about medical identification and travel card for DM patients?
Must carry id indicating diagnosis of diabetes
What is important about patient and family teaching for DM?
Educate on disease process, physical activity, medications, monitoring blood glucose, diet, resources; enable patient to become most active participant in his/her care
What is exogenous insulin?
Insulin from an outside source
Who may take exogenous insulin?
Required for type 1, prescribed for type 2 who can’t control blood glucose by other means
What is the only type of insulin used today?
Human insulin
How is human insulin prepared?
Prepared through genetic engineering- common bacteria (Escherichia coli) and yeast cells using recombinant DNA technology
Insulins differ in regard to what 4 things?
Onset, peak, action, and duration
What are insulins characterized as?
Rapid, short, intermediate, and long acting
Different types in insulin may be used for…?
Combination therapy
Examples of rapid acting insulin?
Lispro (Humalog), Aspart (Novolog), and glulisine (Apirdra)
Examples of short acting insulin?
Regular
Examples of intermediate acting insulin?
NPH (cloudy)
Examples of long acting insulin?
Glargine (Lantus), detemir (Levemir)
What is a basal-bolus regimen?
Closely mimics endogenous insulin production
What is given for a basal-bolus?
Long acting (basal) once a day and rapid/short acting (bolus) before meals
How are rapid acting (bolus) prepared/onset?
Injected 0-15 minutes before meals, onset of action 15 minutes
How are short acting (bolus) prepared/onset?
Injected 30-45 minutes before meal, onset of action 30-60 minutes
Do patients have to wait to eat after getting insulin?
No????
How are long acting (basal) prepared/peak action?
Injected once a day at bedtime or morning, no peak action
What insulin cannot be mixed with any other insulin or solution?
Long acting (basal)
How may insulin be stored?
In use vials may be left at room temp up to 4 weeks, Lantus only for 28 days, extra insulin should be refrigerated
How should insulin not be stored?
Do not heat/freeze, avoid exposure to direct sunlight
Study graph on page 13
Study graph on page 13
Are oral agents insulin?
No!
What are oral agents?
Work to improve mechanisms by which insulin and glucose are produced and used by the body
What do oral agents work on?
Insulin resistance, decreased insulin production, increased hepatic glucose production
What are examples of oral agents?
Sulfonylureas, meglitinides, biguanides, alpha-glucosidase inhibitors thiazolidinediones
What do sulfonylureas do to insulin production?
Increase production from pancreas
What do Sulfonylureas do to chance of prolonged hypoglycemia?
Decrease chance
How many experience decreased effectiveness after prolonged use of Sulfonylureas?
10%
What are examples of Sulfonylureas?
glipizide (glucotrol), glimepiride (amaryl)
What do Meglitinides do to insulin production?
Increase production from pancreas
When are Meglitinides taken?
30 minutes before each meal up to time of meal
When should Meglitinides not be taken?
If meal is skipped
What are examples of Meglitinides?
Repaglinide (Prandin), Nateglinide (Starlix)
What do Biguanides do to glucose production?
Reduce glucose production by liver
What do Biguanides do to insulin sensitivity?
Enhance it at tissues
What do Biguanides do to glucose transport?
Improve glucose transport into cells
Why are Biguanides popular?
Do not promote weight gain
What is an example of Biguanides?
Metformin (Glucophage)
What are Alpha-Glucosidase Inhibitors also called?
“Starch blockers”
What do AGIs do?
Slow down absorption of carbohydrates in small intestines
What is an example of AGI?
Acarbose (Precose)
What are Thiazolidinediones most effective with?
In those with insulin resistance
What do Thiazolidinediones improve?
Improves insulin sensitivity, transport, and utilization at target tissues
What are examples of Thiazolidinediones?
Pioglitazone (Actos), Rosiglitazone (Avandia)
What is Amylin analog secreted by?
Hormone secreted by beta cells of pancreas
What is Amylin analog cosecreted with?
Insulin
What is Amylin analog indicated for?
Type 1 and 2
How is Amylin analog administered?
Subq in thigh or abdomen
What does Amylin analog do to GI related things?
Slows gastric emptying, reduces postprandial glucagon secretion, increases satiety (fullness)
What is an example of Amylin analog?
Pramlintide (Symlin)
What does post prandial mean?
After meals
What is Incretin mimetic?
Synthetic peptide
What does Incretin mimetic stimulate?
Release of insulin from beta cells
How is Incretin mimetic administered?
Subq injection
What does Incretin mimetic suppress?
Glucagon secretion
What does Incretin mimetic reduce?
Food intake
What does Incretin mimetic slow?
Gastric emptying
Can Incretin mimetic be used with insulin?
No
What is an example of Incretin mimetic?
Byetta
What happened to a lot of people while taking Incretin mimetic?
Lost weight
What do Beta Adrenergic blockers mask?
Symptoms of hypoglycemia
What do Beta Adrenergic blockers prolong?
Hypoglycemic effects of insulin
What can Thiazide/loop diuretics do?
Potentiate hyperglycemia by inducing potassium loss
What is an example of Thiazide/loop diuretics?
Lasix
What is pancreas transplantation used for?
Patients with type 1 who also have end stage renal disease and had/plan to have a kidney transplant
How are pancreas transplants usually done?
With kidney transplants, alone is rare
What does a pancreas transplant eliminate the need for? What else can it also eliminate?
Exogenous insulin; can eliminate hypoglycemia and hyperglycemia
What is the cornerstone of care for a diabetes patient?
Nutritional therapy
What is the most challenging part of therapy for many people?
Nutritional therapy
Who is recommended to be part of a diabetic’s team?
Recommended that diabetes nurse educator and registered dietitian with diabetes experience be members of team
What do American Diabetes Association (ADA) guidelines indicate?
That within context of an overall healthy eating plan, person with diabetes can eat same food as person who doesn’t have diabetes
What is the ADA’s overall goal?
Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control
What is type 1’s meal plan?
Based on individual’s usual food intake and is balanced with insulin and exercise patterns
Type 1 insulin regimen?
Managed day to day
What is type 2’s emphasis on?
Based on achieving glucose, lipid, and blood pressure goals
What is a focus on for type 2’s?
Calorie reduction
What is essential for a diabetic diet?
Nutrient balance
What should be balanced for a type 2?
Nutritional energy intake should be balanced with energy output
How much should carbohydrates and monosaturated fats provide of total energy intake?
45-65%
What kind of diet is not recommended for diabetics?
Decreased carb diet
What does the Glycemic Index term used to describe?
Rise in blood glucose levels after consuming carb containing food
What should be considered when formulating a meal plan?
The GI
What diet systems are based on the GI?
Nutrisystem, weight watcher’s
How much fat should make up a meal plan’s total calories for a diabetic?
No more than 25-30%
How much of the total fat comes from saturated fats?
7%
How much protein should contribute the total energy consumed?
Less than 10%
What kind of intake should be significantly less than the general population?
Protein intake
Does alcohol have any nutritive value?
No
What does alcohol promote?
Hypertrigylceridemia
What does alcohol have a detrimental effect on?
Liver
What can alcohol cause?
Severe hypoglycemia
Who initially provides diet teaching?
Dietician
What should be included during diet teaching?
Family and SO’s
What is an appropriate basic teaching tools for diabetics?
USDA MyPyramid Guide
What is the plate method?
Helps patient visualize the amount of vegetable, starch, and meat that should fill a 9 inch plate
What is an essential part of diabetes management?
Exercise
What does exercise do to insulin receptor sites?
Increase
What does exercise do to blood glucose levels?
Lowers
What contributes to weight loss?
Exercise
What can be taken during exercise?
Several small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia
When is exercise best done?
After meals
When should exercise plans be started?
After medical clearance and slowly with gradual progression
What should exercise be?
Individualized
When should blood glucose levels be monitored r/t exercise?
Before, during, and after
Why do people not follow their glucose plan?
Most don’t because of cost
What does self monitoring of blood glucose (SMBG) enable?
Enables patient to make self management decisions regarding diet, exercise, and medication
What is SMBG important for?
Detecting episodic hyperglycemia and hypoglycemia
What is crucial for SMBG?
Patient training
What does SMBG supply?
Immediate info about blood glucose levels
What is more common than diabetes in elderly? (???)
Hypoglycemia unawareness
What must you consider for the elderly?
Patient’s own desire for treatment and coexisting medical problems
What elderly limitations must you recognize?
Physical activity, manual dexterity, and visual acuity
What could interfere with treating hypoglycemia in the elderly?
Presence of delayed psychomotor function
What should education for the elderly be based on?
Their individual needs, using slower pace
What main things do you need to do for pediatric DM illness management?
Continue insulin treatment, stay close to the meal plan, give plenty of liquids, choose meds wisely, check blood glucose and ketone levels frequently
What does illness often do to diabetic kids?
Increase the amount of insulin the body needs
What should you instruct parents?
Insulin should never be withheld
What should you do if the child has an upset stomach and can’t eat?
Give clear liquids that contain carbohydrates (sports drinks, juices, gelatin, broth, frozen fruit bars, regular pop)
What should you encourage the child to do?
Drink as much water and other non-caffeinated beverages as possible (caffeine dehydrates you
Many OTC meds contain what?
Sugar and alcohol
What in meds can rapidly add up?
Glucose
What should parents look for in meds? What if that’s unavailable?
Parents should look for a glucose free version of the medication. If unavailable, carbs must be accounted for in the meal plan.
What can meds that contain alcohol do? What should you ensure?
Lower blood glucose levels; ensure the child eats something to prevent hypoglycemia
What medicines are better?
Alcohol free rather than including it
Many decongestants can do what?
Raise blood glucose levels
What should you check frequently?
Blood glucose and ketone levels
What becomes a danger when the child is sick?
DKA
To prevent DKA or catch it early, what should you do?
Check the child’s blood glucose levels often (every few hours) while sick
How often should you check ketones for kids? When do you need to do it more often?
Check urine several times a day; more for when vomiting or diarrhea is present
5 facts about infants?
Very rapid growth, trusting relationship with the parents, erratic eating habits (food can become a power struggle), erratic sleep patterns, treatment schedule is difficult to keep
Why is a treatment schedule difficult to keep for infants?
Because of erratic feeding and sleeping patterns
When do peer issues begin to emerge?
Preschool age
When can kids begin to understand rules?
Preschool
What can preschool kids do about care?
Can perform more self care, including blood tests under parental supervision
Preschool eating behavior is…?
Less erratic
Preschoolers are at risk for what? Because?
Hypoglycemia because they are very energetic
How are preschoolers’ sleeping patterns?
Regular
What is a challenge when dealing with preschoolers and food?
May be more challenging to provide snacks and meals that match what siblings and friends eat
What do school age kids fear?
Being different from other kids
What can school age kids do?
Can perform most self care, including blood tests and insulin injections
What are school age kids eager to do?
Learn
What are school age kids beginning to do?
Understand consequences of their actions
What do school age kids test?
Independent decision making
Where is most of school age kids’ time spent?
Away from home
When is puberty well under way?
Adolescence
What are adolescents concerned with?
Physical appearance
What do adolescents have a clearer sense of than school age kids?
Clearer sense of self (can set goals)
What is increased in adolescence?
Autonomy
What are diabetic related adolescent risk taking behaviors?
Not taking insulin and not performing blood sugar tests
What is unpredictable about adolescents?
Many social activities are unpredictable
What counseling do adolescents need?
Regarding contraception, alcohol, and smoking
What is DKA caused by?
Profound deficiency of insulin
What is DKA characterized by?
Hyperglycemia, ketosis, acidosis, dehydration
In what type does DKA most likely occur?
Type 1
What are precipitating factors of DKA?
Illness, infection, inadequate insulin dosage, undiagnosed type 1, poor self management, neglect
What happens when supply of insulin is insufficient?
Glucose cannot be properly used for energy and body breaks down fat stores
What are ketones?
By products of fat metabolism
What do ketones/fat metabolism affect?
Alters pH balance which causes metabolic acidosis, ketone bodies excreted in urine, electrolytes become depleted
What are signs and symptoms of DKA?
Lethargy/weakness, dehydration, abdominal pain, Kussmaul respirations
What are the early symptoms of DKA?
Lethargy/weakness
What does dehydration lead to/cause?
Poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension
What are related to the abdominal pain symptom of DKA?
N/V
What do Kussmaul respirations include?
Rapid deep breathing, attempt to reverse metabolic acidosis, sweet fruity odor
They may or may not need hospitalization depending on what?
Signs and symptoms
Laboratory findings of DKA: blood glucose-
Over 300 mg/dl
Laboratory findings of DKA: arterial blood pH-
Below 7.30
Laboratory findings of DKA: serum bicarbonate level-
Under 15 mEq/l
Laboratory findings of DKA: What’s the 4th finding?
Ketones in blood and urine
What may be included in treatment of DKA and signs and symptoms
Airway management- oxygen administration
What IV will be used to correct fluid/electrolyte imbalance for DKA? What does it do?
0.45% or 0.9% NaCl; Restore urine output and raise blood pressure
When blood glucose levels approach what, what do you do?
When they approach 250 mg/dl, 5% dextrose is added to regimen and the point is to prevent hypoglycemia
What electrolyte needs to be replaced?
Potassium
When do patients with DKA need sodium bicarbonate?
If it less than 7
What insulin therapy is used with DKA?
Withheld until fluid resuscitation has begun, bolus followed by insulin drip
Is Hyperosmolar hyperglycemic syndrome (HHS) life threatening?
Yes
Which is more common, HHS or DKA?
DKA
In what patient type does HHS often occur in?
Over 60 with type 2
Does ketoacidosis occur in HHS? Why?
Patient has enough circulating insulin so ketoacidosis doesn’t occur
HHS earlier stages have…?
Less symptoms
Why do neurologic manifestations occur in HHS?
Due to increased serum osmolality
HHS patients usually have a history of what?
Inadequate fluid intake, increasing mental depression, polyuria
HHS laboratory values: blood glucose-
Over 400 mg/dl
HHS laboratory values: What is increased?
Serum osmolality
HHS laboratory values: What is absent/minimal?
Ketone bodies
What administrations of DKA and HHS patients should be closely monitored?
IV fluids, insulin therapy, electrolytes
What assessments of DKA and HHS patients should be closely monitored?
Renal status, cardiopulmonary status, level of consciousness
What else should the patient be closely monitored for?
Signs of potassium imbalance, cardiac monitoring, vital signs
Does HHS have a low mortality rate?
No, high
What is HHS therapy similar to?
DKA therapy, except HHS requires greater fluid replacement
Hypoglycemia is…?
Low blood glucose
Hypoglycemia occurs when?
Too much insulin in proportion to glucose in the blood and blood glucose level is less than 70 mg/dl
Hypoglycemia common manifestations?
Confusion, irritability, diaphoresis, tremors, hunger, weakness, visual disturbances, and can mimic alcohol intoxication
Untreated hypoglycemia can progress to what?
Loss of consciousness, seizures, coma, and death
What is hypoglycemia unawareness?
Person does not experience warning signs/symptoms, increasing risk for decreased blood glucose levels, and this is related to autonomic neuropathy
Causes of hypoglycemia?
Mismatch in timing- food intake and peak action of insulin or oral hypoglycemic agents
At first sign of hypoglycemia what should you do?
Check blood glucose
Blood glucose level actions-
If under 70 mg/dl begin treatment, if over 70 investigate further for cause of signs/symptoms
What should done if blood glucose monitoring equipment is not available and there is a sign of hypoglycemia?
Treatment should be initiated
What is used for treatment of hypoglycemia?
If alert enough to swallow, 15 to 20 grams of a simple carb (ex: pb on graham crackers) with 4-6 ounces of fruit juice or regular soft drink
What food should be avoided with a hypoglycemic patient?
Foods with fat, it decreases absorption of sugar
Important things to do/remember about hypoglycemic treatment:
Do not overtreat, recheck blood sugar 15 min after treatment, repeat until blood sugar is under 70 mg/dl, patient should eat regularly scheduled meal/snack to prevent rebound hypoglycemia, check blood sugar again 45 min after treatment
If no improvement after 2 or 3 doses of simple carbohydrate or patient not alert enough to swallow, what treatment should you use?
Administer 1 mg of glucagon IM or subq
What side effect does glucagon have?
Rebound hyperglycemia
After recovery of hypoglycemia, what should you have the patient do?
Ingest a complex carb after recovery
In acute care settings what would you use for treatment?
25-50 ml of 50% dextrose IV push
What is macrovascular disease?
Diseases of large and medium sized blood vessels
Macrovascular disease and diabetes relationship?
Occurs with greater frequency and with an earlier onset in diabetics
What is macrovascular disease development promoted by?
Altered lipid metabolism common to diabetes
What can tight glucose control do for macrovascular disease?
May delay atherosclerotic process
Risk factors for macrovascular disease?
Obesity, smoking, hypertension, high fat intake, sedentary lifestyle
What should patients with diabetes be screened for?
Dyslipidemia at diagnosis of macrovascular disease
What does microvascular disease result from? In response to what?
Result from thickening of vessel membranes in capillaries and arterioles; in response to chronic hyperglycemia
Which is specific to diabetes: microvascular or macro vascular?
Microvascular is specific
Areas most noticeably affected by microvascular?
Eyes (retinopathy), kidneys (nephropathy), skin (dermopathy)
When do clinical manifestations of microvascular appear?
Usually after 10-20 years of diabetes
What is diabetic retinopathy?
Microvascular damage to retina, result of chronic hyperglycemia
What is diabetic retinopathy the most common cause of?
New cases of blindness in people ages 20 to 74
What is the most common form of diabetic retinopathy?
Nonproliferative
What is non pro. DR?
Partial occlusion of small blood vessels in retina
What does non pro. DR cause?
Causes development of microaneurysms
What happens in non pro. DR?
Capillary fluid leaks out, which leads to retinal edema and eventually hard exudates or intraretinal hemorrhages occur
What is the most severe form of DR?
Proliferative
What does pro. DR involve?
Retina and vitreous
When does pro. DR occur?
When retinal capillaries become occluded
What happens when retinal capillaries become occluded?
Body forms new blood vessels, vessels are extremely fragile and hemorrhage easily (produces vitreous contraction), and retinal detachment can occur
The earliest and most treatable stages of DR often?
Often produces no changes in vision
People with DR must get what yearly?
Annual dilated eye exams
Treatment types for DR?
Photocoagulation, Cryotherapy, Vitrectomy
What is photocoagulation?
Most common, laser destroys ischemic areas of retina which prevents further visual loss
What is Cryotherapy?
Used to treat peripheral areas of retina, probe creates frozen area until reaches specific point on retina
What is Vitrectomy?
Aspiration of blood, membrane, fibers from inside eye through small incision
When is Vitrectomy used?
Vitreal hemorrhage doesn’t clear in 6 months and/or threatened or actual retinal detachment
What is diabetic neuropathy associated with?
Damage to small blood vessels that supply the glomeruli of the kidney
What is the leading cause of end stage renal disease?
Diabetic neuropathy
What are critical factors for prevention/delay of diabetic neuropathy?
Tight glucose control, blood pressure management, and yearly screening
What is involved in blood pressure management?
Angiotensin-converting enzyme (ACE inhibitors) (used even when not hypertensive), and angiotensin II receptor antagonists
What is the yearly screening for diabetic neuropathy consist of?
Microalbuminuria in urine and serum creatinine
How many patients with diabetes have some degree of neuropathy?
60-70%
What is diabetic neuropathy related nerve damage due to?
Metabolic derangements of diabetes
Which is more common- sensory or autonomic neuropathy?
Sensory
What is a part of sensory neuropathy?
Distal symmetric
What does sensory neuropathy affect?
Hands and/or feet bilaterally
Characteristics of sensory neuropathy?
Loss of sensation, abnormal sensations, pain, and paresthesias
When is sensory neuropathy usually worse?
At night
What can occur with sensory neuropathy?
Foot injury and ulcerations can occur without feeling pain
What is the treatment for sensory neuropathy?
Tight glucose control and drug therapy
What does drug therapy for sensory neuropathy include?
Topical cream, Tricyclic antidepressants, Selective serotonin and norepinephrine reuptake inhibitors, and antiseizure meds
What can autonomic neuropathy affect?
Nearly all body systems
What complications can be caused by autonomic neuropathy?
Gastroparesis (delayed gastic emptying), cardiovascular abnormalities, sexual functions, neurogenic bladder
What is the most common cause of hospitalization in diabetes?
Foot complications
What do foot complications result from?
Combination of microvascular and macro vascular disease
What are risk factors for foot complications?
Sensory neuropathy and peripheral artery disease
Other contributors to foot complications are?
Smoking, clotting abnormalities, impaired immune function, autonomic neuropathy
What integumentary complications can occur with diabetes?
Acanthosis nigricans and necrobiosis lipoidica diabeticorum
What is acanthosis nigricans?
Dark, coarse, thickened skin
What is necrobiosis lipoidica diabeticorum associated with?
Type 1
What does necrobiosis lipoidica diabeticorum appear as?
Red yellow lesions and skin becomes shiny, revealing tiny blood vessels
Diabetics are more susceptible to what?
Infections
What is the definition of infection?
Defect in mobilization of imflammatory cells and impairment of phagocytosis by neutrophils and monocytes
What may loss of sensation cause?
May delay detection of infection
Treatment of infections in diabetics must be what?
Prompt and vigorous
What is acromegaly caused by?
Caused by an overproduction of growth hormone usually caused by a benign pituitary tumor
What does acromegaly present as?
Presents as a thickening of bone and soft tissue
How many people have acromegaly?
Very rare, 3 out of 1 million in US
What is the onset of acromegaly?
Gradual onset, 7 to 9 years between onset of symptoms and final diagnosis
What are clinical manifestations of acromegaly?
Enlargement of hands and feet, joint pain, thick leathery oily skin, visual disturbances, headaches
What is the treatment of choice for acromegaly? What will the patient need?
Hypophysectomy (removal of pituitary gland) and the patient will require hormone supplements for life
What may a large tumor require?
Radiation or drug therapy in addition to hypophysectomy
Bone growth and soft tissues r/t acromegaly
Bone growth can usually be stopped and soft tissue hypertrophy reversed
What does SIADH stand for?
Syndrome of Inappropriate Antidiuretic Hormone
When does SIADH occur?
When ADH is released despite normal or low plasma osmolarity
What are causes of SIADH?
Most common is malignancy, the rest is on table 50-1
What does SIADH lead to?
Fluid retention, serum hypoosmolality, hyponatremia, hypochloremia, and concentrated urine
Pathophysiology map of SIADH?
- Increased diuretic hormone leads to 2. increased water reabsorption in renal tubules which leads 3. to increased intravascular fluid volume which leads 4. to dilution hyponatremia and decreased serum osmolality
What are clinical manifestations of SIADH?
Muscle cramping, pain, and weakness (caused by hyponatremia); decreased urinary output; increased body weight; and lethargy, seizures, and coma (severe, late stage)
How is SIADH diagnosed?
Through measurement of urine and serum osmolality
Nursing and collaborative management for SIADH (Table 50-2, p. 1260)?
Restrict fluid intake to no more than 1000 mL a day (includes IV fluids too), position head of bed to flat, seizure precautions, and frequent oral care
What is diabetes insipidus?
Decrease in ADH production, secretion, or renal response
What are the 3 types of diabetes insipidus?
Central, nephrogenic, and primary
What is central diabetes insipidus caused by?
Caused by lesion of the hypothalamus or pituitary (most common cause)
What is nephrogenic diabetes insipidus? What is it caused by?
There is adequate ADH but the kidneys do not respond appropriately. Caused by meds (ex: Lithium which is long term usually)
What is primary diabetes insipidus associated with?
Associated with excessive water intake
What are clinical manifestations of diabetes insipidus?
Polydipsia and polyuria (5-20 L/day)
What is the diagnostic study for diabetes insipidus?
Water restriction test
What nursing and collaborative management is needed for diabetes insipidus?
Fluid and hormone replacement
What does DI fluid and hormone replacement include?
IV fluid titrated to replace urinary output (0.45% NS; D5W) and desmopressin acetate (DDACP)- chemical replacement for ADH
How many thyroid nodules are benign?
95%
What are clinical manifestations of thyroid cancer?
Painful, palpable nodule in an enlarged thyroid gland
What are diagnostic studies for thyroid cancer?
Ultrasound, Cat Scan or MRI
Nursing and Collaborative management for thyroid cancer?
Surgical removal of the tumor with or without radiation treatment (and the thyroid gland?) and monitor patient for hypocalcemia after surgery
Is true thyroid cancer common?
No it’s rare
What is hyperthyroidism?
Increase in synthesis and release of T3, T4, or both
Does hyperthyroidism occur more often in males or females?
Females
What age is the highest frequency of hyperthyroidism?
20-40 years old
What is the most common type of hyperthyroidism?
Grave’s Disease
What is Grave’s Disease?
Autoimmune disease of unknown etiology; patient develops antibodies to TSH receptors. The antibodies then attach to the receptors and stimulate the thyroid gland to secrete T3, T4, or both
Clinical manifestations of hyperthyroidism?
Table 50-5 pg. 1264, increased appetite, weight loss, hair loss, thin brittle nails, fatigue, insomnia, menstrual irregularities
Complications of hyperthyroidism?
Thyrotoxic crisis
What is thyrotoxic crisis?
(When it releases way too much hormone?) It is life threatening and can cause serve tachycardia, heart failure, shock, hyperthermia, and coma
Why do we especially not palpate thyroids as student nurses?
We can cause thyrotoxic crisis
Diagnostic studies of hyperthyroidism?
Decreased TSH levels, and increased free T4 levels
Collaborative care for hyperthyroidism?
Antithyroid meds, radioactive iodine therapy, subtotal thyroidectomy (common), nutritional therapy
What does hyperthyroidism nutritional therapy include?
High calorie diet (4000-5000 calories a day) may be needed to satisfy hunger and prevent tissue breakdown
Nursing implementation for hyperthyroidism?
Elevate HOB to promote fluid drainage from periorbital area
Nursing implementation after thyroidectomy?
Assess patient every 2 hours for first 24 hours for signs of hemorrhage or tracheal compression, position patient’s head to avoid tension on the suture line, monitor vital signs, monitor of signs and symptoms of hypocalcemia, control post op pain
Why does hypothyroidism occur?
Insufficient circulating thyroid hormones
How many people does hypothyroidism affect?
Approximately 1 in 50 women and 1 in 300 men
Clinical manifestations of hypothyroidism?
Onset of symptoms may occur over months to years, fatigue, lethargy, impaired memory, cold intolerance, muscle weakness, weight gain
Diagnostic studies for hypothyroidism?
High TSH indicates a defect in the thyroid gland, low TSH indicates a defect in the pituitary or hypothalamus
Collaborative care for hypothyroidism?
Levothyroxine (Synthroid) is very common, they are started on a low dose and increased every 4 to 6 weeks as needed and they need to have blood work checked
What is hyperparathyroidism?
Oversecretion of PTH
What is hyperparathyroidism most commonly caused by?
A benign tumor in the parathyroid gland
What does hyperparathyroidism lead to?
Hypercalcemia and hypophosphatemia
Clinical manifestations of hyperparathyroidism?
Muscle weakness, loss of appetite, constipation, fatigue, shortened attention span
What are diagnostic studies for hyperparathyroidism?
Elevated PTH and calcium levels
Collaborative care for hyperparathyroidism?
Surgical removal of parathyroid gland or nonsurgical therapy
What does hyperparathyroidism non surgical therapy include?
Fosamax- normalizes calcium levels; oral phosphate replacement
What is hypoparathyroidism?
Inadequate levels of PTH
What does hypoparathyroidism lead to?
Hypocalcemia and hyperphosphatemia
What are clinical manifestations of hypoparathyroidism?
Irritability, abdominal cramps, fatigue, weakness
What are hypoparathyroidism diagnostic studies?
Low PTH and calcium levels
What are hypoparathyroidism nursing and collaborative management?
Treat complications such as tetany, IV calcium may be needed, instruct patient on management of long term drug therapy and nutrition
What is Cushing Syndrome?
Spectrum or abnormalities caused by an excess of corticosteroids
What is the most common cause of Cushing Syndrome?
Administration of exogenous corticosteroids (ex: Prednisone)
What can Cushing Syndrome also be caused by?
ACTH secreting tumor
What are clinical manifestations of Cushing Syndrome?
Truncal obesity, “moon face”, purplish red striae on abdomen, hirsutism in women, menstrual disorders, hypertension, unexplained hypokalemia, buffalo hump, and increase in axillary, chest, etc. hair in abnormal places
What are diagnostic studies for Cushing Syndrome?
Plasma cortisol levels may be increased, 24 hour urine for free cortisol is often done
What is collaborative care for Cushing Syndrome?
Treatment depends on underlying cause and medication adjustments may be necessary if caused by corticosteroids by decreasing dose and alternate day dosing
What is Addison’s Disease?
Caused by a lack of adrenal corticosteroids (glucocorticoids, mineral corticoids, androgens)
What is Addison’s Disease most commonly caused by?
An autoimmune response
In what population is Addison’s Disease most common?
White females under 60
Addison’s Disease is often (blank) before diagnosis is made?
Advanced
Clinical manifestations of Addison’s Disease?
Progressive weakness, fatigue, weight loss, anorexia, skin hyper pigmentation (especially around joints of arms, legs and knuckles and it looks like a bad self tanner)
Complications of Addison’s Disease?
Addisonian crisis- acute adrenal insufficiency
Diagnostic studies for Addison’s Disease?
Decreased cortisol levels
Collaborative care for Addison’s Disease?
Replacement therapy with hydrocortisone usually through IV, increased salt in diet, increase in hydrocortisone dose during periods of high stress (surgery; hospitalization)
Effects of Corticosteroids?
Anti-inflammatory action, immunosuppression, maintenance of normal BP, carbohydrate and protein metabolism
Side effects of Corticosteroids?
Table 50-20 pg. 1283
Patient teaching guide for Corticosteroids?
Table 50-21 pg. 1283 (delayed wound healing, infections, can increase BP and blood sugar)
What is hyperaldosteronism?
Excessive secretion of aldosterone causing sodium retention and potassium excretion
What is hyperaldosteronism most commonly cause by?
Adrenocortical tumor in adrenal cortex
What are clinical manifestations of hyperaldosteronism?
Hypertension, headache, muscle weakness, cardiac dysrhythmias
What is Pheochromocytoma?
Excessive catecholamine production due to tumor of the adrenal medulla
What are clinical manifestations of Pheochromocytoma?
Severe hypertension, pounding headache, tachycardia with palpitations, profuse sweating, chest pain
Treatment for Pheochromocytoma includes what?
Surgical removal of the tumor and good BP management
When does Growth Hormone Deficiency occur?
WHen GH is absent or produced in inadequate amounts
What is hypopituitarism?
If other pituitary hormones are lacking + GHD
What is an important part of determining normal growth?
The child’s growth pattern
When can GHD occur?
At any age
What are signs of GHD?
Growth of less than 2 inches per year between the ages of 2 and 11 years in girls or 2 and 13 years in boys; leveling off and slowing of growth progress; growth below the 5th percentile on standardized growth charts
Etiology of GHD?
Can be congenital, acquired, or idiopathic; tends to run in families but may occur with no family history,
What may congenital GHD be associated with?
An abnormal pituitary gland or be a part of another syndrome
What are acquired GHD causes?
Brain tumors (or other disorders), cranial irradiation, infections, trauma (head)
What are clinical manifestations of GHD?
Short height for child’s age, increased amount of fat around waist and in face, emotional feelings about height or weight, younger appearance than children of same age, decreased muscle mass, delayed skeletal maturation, delayed onset of puberty, delayed tooth development, hypoglycemia
What are GHD diagnostic studies?
Thyroid panal, serum electrolytes, blood urea nitrogen, creatinine, complete blood count, insulin-like growth factor 1, insulin-like growth factor binding protein 3, karotyping (form of genetic testing), bone density scan
Management of GHD?
If the cause is a tumor, surgical removal or radiation therapy may be indicated. Replacement of deficient hormones is often required even after successful treatment of a pituitary tumor
What kind of injection is GH?
Most children receive subq injection
How often are GH injections given?
Daily or 3 to 4 times per week and have increased growth velocity at bedtime
Does GH need refrigerated?
Yes
How does growth need to be monitored?
Close monitoring of growth with endocrinology visits every 3 to 4 months and pediatric follow up
How long is GH replacement therapy given?
Continued until the child achieves an acceptable height or growth velocity drops to less than 1 inch per year
Nursing implications for GHD?
Assess compliance with medication regimen, assess and address issues of self esteem, monitor growth (accurate is impt), teach the child and family about the disorder, teach proper technique for administering meds (shots), educational resources for parents
What are educational resources for parents about GHD?
Magic Foundation www.magicfoundation.org/wwww, Human Growth Foundation www.hgfound.org, Child Growth Foundation www.childgrowthfoundation.org/ghd.htm
When is the onset of precocious puberty?
Before age 7 or 8 and before age 9 in boys
What is precocious puberty accompanied by?
The appearance of secondary sexual characteristics, advanced growth rate, and bone maturation
What does precocious puberty cause?
Short stature as an adult from premature closure of epiphyseal ends of the long bones
What is the etiology for precocious puberty?
Hormone-secreting tumors, brain injury caused by head trauma, infection, thyroid dysfunction, ovarian dysfunction, idiopathic
What is the most common etiology for precocious puberty?
Idiopathic
Clinical manifestations of precocious puberty in females?
Females: breast development, axillary hair, pubic hair, adult body odor, onset of menses, acne, deepening voice
Clinical manifestations of precocious puberty in males?
Testicular enlargement, acne, penile enlargement, axillary and chest hair, pubic hair, adult body odor, facial hair
Diagnostic studies for precocious puberty?
Bone density scan, gonadotropin0releasing hormone simulation test, pelvic and abdominal ultrasound, computed tomographic scan or MRI, Blood work of testosterone levels and estrogen fraction test
What is the treatment for precocious puberty?
Involves the suppression of puberty
What are clinical manifestations of Congenital Hypothyroidism?
Large for age despite having poor feeding habits and increased birth weight, puffy face, swollen tongue, hoarse cry, poor muscle tone, cold extremities, persistent constipation, bloated or full to the touch, lack of energy and sleeps most of the time, appears tired even when awake, little to no growth, often appears perfectly normal at birth
Why is screening forCongenital Hypothyroidism vital at birth?
They often appear perfectly normal at birth
What are Congenital Hypothyroidism diagnostic studies?
State required screening of TSH and T4 for every baby born, Low T4, elevated TSH, or both indicate hypothyroidism, positive test results ay be followed by scan for bone age, blood tests before 48 hours after birth may be falsely interpreted because of the rise in TSH immediately after birth
What indicates hypothyroidism in babies?
Low T4, elevated TSH, or both
What should you monitor in an infant with Congenital Hypothyroidism?
Monitor growth and development of the infant (serial measurements of height, weight, and head circumference and screens for developmental milestones)
What should you assess for in children with Congenital Hypothyroidism?
Assess for retarded physical growth and slow intellectual development, if cognitive impairment has occurred then provide support to the family
What should you teach the family about Congenital Hypothyroidism?
Teach importance of daily admin of meds, drug therapy is needed for life
When do we stop measuring head circumference?
18 months to 2 years because fontanelles close around 18 months
How can meds for infants with Congenital Hypothyroidism be prepared?
Crushed and added to a small amount of formula, food, or water, or can be offered mixed with formula through a syringe or a nipple
How must meds for infants never be prepared?
Never put in a full bottle of formula in case they don’t finish it
What should you include instructions of about Congenital Hypothyroidism in kids?
Include instructions on taking pulse in the teaching plan to monitor for signs of drug overdose
