endocrine stressors and adaptation. common pediatric endocrine disorders z type i diabetes...

Endocrine Stressors and Adaptation

Common Pediatric Endocrine Disorders

Type I DiabetesCongenital HypothyroidismAcquired Hypothyroidism

(Hashimoto’s Disease)Hyperthyroidism (Graves disease)Growth Hormone Deficiency

The Endocrine SystemGlands-Hormones-Endocrine Disorders are either:

PrimarySecondary

Hypofunction Hyperfunction

Pediatric Differences in the Endocrine System

The endocrine system is less developed at birth than any other body system

Hormonal control of many body functions is lacking until 12-18 months of age

Infants might manifest imbalances in concentration of fluids, electrolytes, amino acids, glucose, and trace substances

Type I Diabetes

Most common endocrine disorder in children

Pancreas becomes unable to produce and secrete insulin

Peak age: 5-7, or at pubertyAbrupt onsetGenetic link

Type 1 Diabetes Beta cells- type of cell found in the Islets

of Langerhans within the pancreas that make and release insulin.

Insulin is a hormone required to move the glucose into cells throughout the body. If no insulin can be produced, the

glucose stays in the blood instead, where it can cause serious damage to all the organ systems of the body.

EtiologyAutoimmune

process causes destruction on insulin-secreting cells in the pancreas

At dx 90% of beta cells are destroyed

Type 1 Diabetes

No cure, but JDRF is funding studies that perfect pancreas transplantation and regeneration the body’s own beta cells without islet transplantation

Serum Glucose Levels

Normal: 70-110mg/dl

Glycosated Hemoglobin Hgb A1C1.8 to 4.0 is normal> 6.0 = DM

Diagnosis:fasting: >126mg/dl Random (non-fasting): ≥ 200mg/dl with classic signs (next slide)

Signs & Symptoms

PolyuriaPolydipsia PolyphagiaFatigue Blurred visionHeadacheShortened attention span

Mood changes

Diabetic Ketoacidosis(DKA)

Medical EmergencyAs glucose levels rise, child will

progress into DKA if not treatedBlood glucose levels > 300

Cellular starvation leads to ketone production Nausea, vomiting, abdominal pain Acetone (fruity) breath odor Dehydration Kussmaul respirations

Coma if untreated

When to Monitor for DKA

Abdominal painNausea and vomiting that persists for over

6 hoursMore than five diarrheal stools in 1 day A 1- or 2-day history of polyuria and

polydipsiaHas illness (e.g., viral or other) and is

unable to eat

Juvenile Diabetes Treatment

MultidisciplineGoal: Normal G & D, optimal glucose

control, minimal complications, adjustment to disease

Treatment consists of: Insulin replacement Diet BG monitoring Exercise

Diet Therapy

Well-balanced, enough caloric intake to support growth and development

Three meals, snacks spaced throughout the day

No diet foodsDon’t omit meals

Diet Therapy

No foods excluded, encourage good nutritional choices

Learn dietary allowances outside of home

Need to have consistent intake & timing of food to correspond to the time & effect of insulin prescribed

Exercise

Encouraged, never restrictedLowers blood glucose levels, by aiding the body’s use of food

Decreases insulin requirements

Proper snack before Add an extra 15- to 30-g

carbohydrate snack for each 45-60 minutes of exercise

BG MonitoringGlucose monitoringUrine testing for ketonesRecord keepingSelf-management at age

appropriate level2-6 choose food, clean finger

for BG4-6 dip own urine6-8 BGM8-10 insulin injections, diary10-14 nutritional decisions12-18 full management

InsulinPrecise dose cannot be predictedAmount is based upon average capillary or serum blood glucose levels

Will change based of G & DCan be administered BID SQ by needle/syringe, pen or by insulin/portable pump

Types of InsulinSynthetic Human Insulin

Rapid acting Lispro (Humalog) Aspart (Novolog)

Fast acting Regular ®

Intermediate NPH (N)

Mixed (70/30) Long Acting

Glargine (Lantus) Ultra Lente

Typical ManagementThe peak of the insulin should

occur Post-Prandial (after meal) to avoid hypoglycemia

InsulinAlternate sites Don’t inject

extremity to be used in sports

Give at room temperature

Always draw regular up first if mixing

PumpsDelivers fixed amounts of short-acting

insulin continuouslyWorn on a belt, the tubing & catheter

are changed Q48 hours and taped in place

Should not be removed for > 1-2 hoursSubject to minimal malfunctionSelf-motivated

PumpsAdvantages

Less scar tissue No daily injections Less to carry Private Sense of control

Disadvantages Must wear continuously Need to carry extra

battery Good BGM If insurance dose not

cover $$$$$ Still need emergency

needles, insulin, and remember how to inject

ILLNESSAlters diabetic management

Dosage requirements may increase, decrease, or remain unchanged depending on the severity of the illness & the child’s appetite

Rapid-acting insulin used to manage hyperglycemia associated with illness

Monitor fluids, may require extra oral fluids while ill

“Sick Day” Guidelines Seek medical attention for fever or other signs of infection.

Monitor the blood glucose levels more often than routine (1 to 4 hours).

Test urine ketones when the blood glucose level is greater than 200 mg/dL.

Do not skip doses of insulin.

Large fluid intake (drinks with carbohydrates) is essential if the child cannot eat as usual.

If the child cannot consume adequate amounts of fluids, seek medical attention.

Hyperglycemia BG > 160

Gradual onset Lethargic Polyuria Polydypsia Dulled sensorium, confused Weakness, fatigue, lethargy

Glucose 250 mg/dl Large ketones in blood & urine Blurred vision Ketoacidosis Coma

Hypoglycemia BG < 70

Commonly occurs before meals

when the insulin effect is peaking

burst of physical activity without additional food, delayed, omitted, or incompletely consumed means of snacks

Too much insulin-wrong dose

Signs & Symptomsof HypoglycemiaRapid onsetIrritable, nervousnessDifficulty concentratingShaky feeling, tremors, hungerDiplopiaPallorWeaknessHeadache, dizzinessSweatingUnconsciousness and convulsions

Treatment of Hypoglycemia

Give simple concentrated sugarGlucose gel or SL tablets Hard candySugar cubesLow-fat milk or OJ

Followed by a complex CHO & ProteinSlice of bread or cracker with peanut

butterGlucagon SQ for severe hypoglycemia

(may cause vomiting, prevent aspiration)

Nursing DiagnosisRisk for injury R/T

hypoglycemia or hyperglycemiaFear R/T

diagnosis, insulin injection, negative effect on life style

Risk for ineffective coping R/Tcomplex self-care regimen and uncertain future

Imbalanced nutrition: more than body requirements R/Tintake in excess of activity expenditures

Nursing DiagnosisRisk for non-compliance R/T complexity of regimenRisk for ineffective therapeutic management R/T insufficient knowledge of conditionKnowledge deficit R/T new health condition AEB questions being askedAltered family processes R/T situational crises AEB uncertainty of chronic

disease/disability

Nursing Considerations Begins with survival education Educate child & family regarding

Nature of disease, hypo/hyperglycemia Meal planning (3 spaced meals, 3 snacks) Wearing ID bracelet Effective duration, onset & peak action of

insulin Injection procedure, rotate sites Glucose monitoring, urine testing, record

keeping Exercise regime

Nursing ConsiderationsProvide emotional support

Encourage growth and development

Identify home care needs

Disorders of the Thyroid

Congenital Hypothyroidism

Acquired Hypothyroidism

Hyperthyroidism

CONGENITAL HYPOTHYROIDISM

Disorder at birthBody is producing insufficient thyroid

hormone to meet metabolic needs caused by absent or underdeveloped thyroid gland

If not treated can lead to severe CIDetected in Newborn Screen

Incidence and EtiologyCaused by defect in the embryonic period in

thyroid glad production

Also caused by inborn error of thyroid hormone synthesis (an inherited autosomal recessive trait)

Can be secondary to pituitary dysfunction

Thyroid gland is unable to produce T3 and T4

CONGENITAL HYPOTHYROIDISM

Mottled skinLarge fontanelLarge tongueHypotonia/slow reflexesDistended abdomenLow T4 < 6, High TSH > 40

CONGENITAL HYPOTHYROIDISM

An infant with a low T4 <6 and a TSH value exceeding 40 mU/ml is considered to have primary hypothyroidism until proven otherwise

CONGENITAL HYPOTHYROIDISM

Treated with lifelong thyroid replacement therapy Synthroid 10-15 mcg/kg/day

Administration of increasing amounts over 4-8 weeks to avoid symptoms of hyperthyroidism

Taken 30-60 minutes before meals for optimal absorption

Monitor G&D and Thermoregulation Labs q 2 wks then q 3 mos *** look for upper range of

normal Medication compliance Teach parents to monitor for hyperthyroidism

Signs of Medication induced Hyperthyroidism

Nervousness/anxietyDiarrheaHeat intoleranceWeight lossIncreased HR

OutcomePrevention of cognitive impairment–

newborn screening on all babiesEarly treatment has had significant impact

on morbidityMost children progress to within normal

ranges on developmental assessmentPoor prognosis in more severe cases

Acquired Hypothyroidism (Hashimoto’s disease)

Thyroid produces inadequate levels of thyroid hormone > age 2

T4 decreases, TSH risesAutoimune disorder

Antibodies and developed against thyroid gland

Gland becomes inflamed, infiltrated by antibodies and destroyed

Etiology

Primary (Hashimoto’s thyroiditis)Most commonAutoimmuneChildhood, adolescents,

females>males Secondary

associated with other conditions that affect the thyroid

Pituitary and hypothalmic dysfunction Tertiary

Radiation, surgery, trauma

Acquired Hypothyroidism

GoiterDry, thick skinCoarse but thinning

hairFatigueCold intolerance

Delayed puberty and menses

Decelerated growthEdema around eyes,

face and handsConstipationSleepiness Mental decline-not

permanent cognitive impairment

Acquired Hypothyroidism Treatment

Thyroid hormone replacement-Synthroid Starting dose 10 -15 mcg/kg/day

Administration of increasing amounts over 4-8 weeks to avoid symptoms of hyperthyroidism

Taken 30-60 minutes before meals for optimal absorption

Repeat thyroid function test one month should see normalization of TSH

Requires lifetime follow up Dose and adjustments based on clinical

evaluation & TSH Prognosis is good if kept euthyroid

(normal)

Acquired Hyperthyroidism

(Grave’s Disease)A hyperfunction of the thyroid glandProduces excessive circulating thyroid

hormone (T3 and T4)Four times more common in girlsOccurs between the ages of

12 – 14 yrs. (puberty)Manifestations develop gradually with an

interval between onset & diagnosis of 6 to 12 months

Genetics involvedFollows a viral illness or period of stress

Grave’s Disease

Subjective Signs & Symptoms:Emotional liabilityPhysical restlessness at restDecreased school performanceExcessive appetite without weight gainFatigue

Grave’s DiseasePhysical Signs & Symptoms:

Increased HR PalpitationsWidened pulse pressureExothalmosHair fine, unable to curlDiarrheaPoor attention span

Grave’s DiseasePhysical Signs & Symptoms:

Wide-eyed expression with lid lagFine tremors Increased perspiration/heat intoleranceSystolic murmursEmotional liability Insomnia

Grave’s Disease

Thyroid StormAcute Onset

Severe irritability & restlessness Vomiting and diarrhea Hyperthermia Hypertension Severe tachycardia Prostration May progress to death

Grave’s Disease

Diagnosis: Elevated thyroid function studies,

low TSH, high T4Management:

To suppress thyroxinePTU - propythioracil MTZ – methimazoleSubtotal thyroidectomyAblation with radioiodine

Grave’s Disease

Nursing Care: Quiet un-stimulating environment

conducive to rest Maintain a regular routine to

minimizing stress of coping with unexpected demands

Physical activity is restrictedTire easily, experience muscle

weakness and are unable to relax to recoup their strength

Grave’s DiseaseNursing Care

Increased need for calories to meet their metabolic rate

Offer 5-6 moderate meals throughout the day, and vitamin supplements

Stress good hygiene because of excessive sweating

Once therapy is instituted observe for side effects of medications

Monitor for: Neutropenia, Hepatotoxicity, Bone density

Grave’s Disease

Nursing Care: If surgery is planned administer iodine a

few weeks before the procedureMixed in a strong-tasting fruit juice given

through a straw Fear of having throat cut is real Post-op position neck slightly flexed and

observe for bleeding Supplemental thyroid hormone then for life

Hypothyroidism Hyperthyroidism

Tiredness/fatigue Nervousness/anxiety

Constipation Diarrhea

Cold intolerance Heat intolerance

Dry, thick skin Smooth, velvety skin

Edema of face, eyes, hands

Prominent eyes

Decreased growth Accelerated linear growth

Decreased activity/energy Emotional liability

Muscle hypertrophy Muscle weakness

Decreased heart rate Increased heart rate

Growth Hormone Deficiency

Failure of the pituitary to produce growth hormone

Affected boys=girlsBoys tend to be evaluated more75% cause is idiopathicCan be a result of injury and destruction of

anterior pituitary gland from Brain tumor Infection radiation

SymptomsNormal size and weight at birthWithin first few years child will fall

below the 3rd percentile on growth chart

Late onset of pubertyDelayed dentitionHigh-pitched voiceChild-like face with large forehead

Criteria for Suspecting Growth Hormone (GH) Deficiency

Consistently poor growth (<5 cm/yr)

Growth rate more than two standard deviations below the mean for age

Downward deviation from the previous growth curve

Assessment and Diagnosis

Evaluate family historyPrenatal/birth history R/O pituitary tumorGrowth charts

Diagnosis X ray, MRI to study bone age Pituitary function tests

ManagementIM recombinant human growth hormone

2-3 times per weekGiven at bedtime when GH usually peaksGH is a powder that needs to be mixed

with diluentParents/child need teachingRapid growth is often painful, pain

management is needed

Nursing ConsiderationsSpeak to child in age appropriate

manner (be careful not to address as a younger child)

Be discrete when providing step stools, etc

Provide with anticipatory guidance for adolescence Dress in clothing that reflects age not size Choose sports that height is not a requirement

Practice Questions!

A 10-year old type 1 diabetic client tells the school nurse that he has some early signs of hypoglycemia. The nurse recommends that the child:

1. Take an extra injection of regular insulin2. Drink a glass of orange juice3. Skip the next dose of insulin4. Start exercising

An adolescent with Type I diabetes has had several episodes demonstrating lack of diabetic control. The nurse teaches the client by stating: “The best way to maintain control of your disease is to:

1. Check your urine glucose three times a week2. Check the HgA1C every 3 months and every 6

months when stable3. Check your BG QID and HgA1C every 3 months4. Check glucose daily as long as you feel well

A 10-year-old diabetic girl comes to the office of the school nurse after recess. She was just out of school for an extended illness and reports that she returned to her usual insulin dosing schedule today. The nurse notices she is nervous with hand tremors, pale, sweaty, and complaining of sleepiness. The nurse suspects:

1. Exercise-induced hypoglycemia2. Hyperglycemia caused by increased intake at lunch3. Ketoacidosis caused by infection4. The child is avoiding returning to class

After being diagnosed with Hyperthyroidism, a teenager begins taking PTU for treatment of the disease. What symptom would indicate to the nurse that the dose may be too high?

1. Weight loss2. Polyphagia3. Lethargy4. Difficulty with school work

The child’s 7:00 am blood glucose the following morning is 189. At 5:30 pm: the child injected rapid and NPH, then ate dinner and had a 10 pm snack. The nurse concludes (select all that apply)

 1. Rapid insulin dose may be to low2. NPH insulin dose may be to low3. NPH insulin dose may be to high4. The child ate too little dinner5. The child ate too much snack

The nurse is teaching a parent of a child with type 1 diabetes about the different types of insulin. The nurse assumes the parent understands rapid insulin peak times if the parent states that after a 7:00 am injection, be sure the child does not miss:

1. 6:45 AM Breakfast2. 12:30 PM Lunch3. 6:30 PM Dinner4. 10:00 AM Snack