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Chapter 28

Chapter 28. Caring for the Child with an Endocrinologic or Metabolic Condition. A & P Review Organs of the Endocrine System. Hypothalamus Pineal body Pituitary gland Thyroid gland Parathyroid glands Adrenal glands Pancreas Gonads.

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Chapter 28

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  1. Chapter 28 Caring for the Child with an Endocrinologic or Metabolic Condition

  2. A & P Review Organs of the Endocrine System • Hypothalamus • Pineal body • Pituitary gland • Thyroid gland • Parathyroid glands • Adrenal glands • Pancreas • Gonads

  3. Pathophysiological Conditions of the Endocrine System Conditions of the Anterior Pituitary

  4. Hypopituitary (Growth Hormone Deficiency) • Signs and symptoms • Growth of less than 2 inches (four to five centimeters) in a year • Delayed closure of the anterior fontanel, delayed dental eruption, decreased muscle mass, delayed puberty, and hypoglycemia • Nursing care • Administer human recombinant growth hormone (GH) • Plot growth measurements on a growth chart • Provide supportive resources • Treat child appropriate to age • Teach parents about condition and treatment

  5. Pituitary Hyperfunction (Precocious Puberty) • Signs and symptoms • Commonly seen in both boys and girls • Arm pit and pubic hair, body odor, acne, mood swings, and growth spurts • Nursing care • Administer gonadotropin-releasing hormone (GnRH) • Keep accurate records of child’s growth • Approach child appropriate to age • Include child in teaching

  6. Acromegaly and Gigantism • Signs and symptoms • Rapid increase in skeletal growth • Nursing care • Assist in providing treatments aimed toward curing the cause • Administer medications (somatostatin analogs, dopamine agonists, or pegvisomant) • Communicate to parents that attempts to slow GH release involves radiation therapy • Accurately assess growth by using correct growth chart and documenting height and weight at each out-patient visit. • Postsurgical care (neurological assessment)

  7. Conditions of the Posterior Pituitary

  8. Diabetes Insipidus • Signs and symptoms • Infant: irritability, poor feeding, failure to grow, vomiting, constipation, and high fevers • Child: polydipsia, polyuria, and enuresis • Nursing care (Central DI) • Administer desmopressin (DDAVP) • Administer chlorothiazide (Diuril) • Give a diet low in solutes • Closely monitor urine output • Monitor daily weights and subtle signs of dehydration or fluid imbalance • Educate patient and parent about replacing fluids and the conditions that increase fluid needs

  9. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) • Signs and symptoms • Nausea and vomiting • Seizures • Personality changes • Increased blood pressure • Weight gain • Decreased urine output • Fluid and electrolyte imbalance • Headache • Nursing care • Maintain fluid restriction and record fluid intake/output • Administer a hypertonic sodium chloride solution (for hyponatremia if neuroloigcal disease is present) • Administer corticosteroids (if adrenal insufficiency is present) • Give medication with meals • Assess nutritional status (provide diet high in sodium and protein) • Assess the neurological system (implement seizure precautions) • Monitor/record all intake and output • Educate parents about fluid balance (hidden sources of water in foods)

  10. Conditions of the Thyroid

  11. Hypothyroidism • Signs and symptoms • Infant: prolonged newborn jaundice, poor feeding, constipation, cool, mottled skin, increased sleepiness, decreased crying, and enlarged tongue • Child: slow heart rate, tiredness, inability to tolerate cold, puffiness in face, impaired memory, depression, and drowsiness • Nursing care • Give thyroid replacement hormone • May also give iodine supplementation (some cases) • Alert family about frequent follow-up blood tests • Educate parents on proper medication administration, monitoring of the child’s growth, weight gain, and developmental milestone progression

  12. Hyperthyroidism (Graves’ Disease) • Signs and symptoms • Goiter • Skin that is raised, thickened, swollen, and reddish in color • Eyes that bulge (exophthalmos) • Nursing care • Physically assess child • Give antithyroid medications (PTU-propylthiouracil or MTZ –methimazole) • Treatments: • Radioactive iodine therapy • Thyroidectomy • Beta-blocking agents (Inderal) • Educate parents on medication, routine blood tests, signs and symptoms of hypothyroidism (low stress environment, bursts of emotions, and school performance)

  13. Conditions of the Parathyroid

  14. Hypoparathyroidism • Signs and symptoms • Poor tooth development, vomiting, headaches, mental deficiency, seizures, uncontrollable, painful spasms, irritability and rigid muscles • Nursing care • Teach family about dietary/supplemental calcium and vitamin D • Monitor telemetry for cardiac arrhythmias • Monitor blood pressure for hypotension • Maintain seizure precautions until calcium levels approach normal • Educate families about life-long monitoring of calcium levels and medication • Communicate the importance of an annual renal ultrasound

  15. Hyperparathyroidism • Signs and symptoms • 50% have no symptoms • Attributed to persistently high levels of calcium (bone & joint pain; muscle weakness), abdominal discomfort, kidney stones, excessive thirst and urination, depression, anxiety, memory loss, and fatigue • Nursing care • Parathyroidectomy • Postoperative care (airway management, signs and symptoms of infection and hematoma, fluid management, and electrolyte imbalance) • Teach family signs and symptoms of hypocalcaemia, administering calcium supplements, and about frequent blood draws that may be necessary • Nutritional supplements (Vitamins C & K)

  16. Conditions of the Adrenals

  17. Acute Adrenocortical Insufficiency(Adrenal Crisis) • Signs and symptoms • Weakness, fatigue, nausea, vomiting, loss of appetite, weight loss, low blood pressure, abdominal pain, fever, and confusion or coma • Nursing care • Initially administer steroid IV hydrocortisone (A-hydroCort) and antibiotics • Administer IV fluids to reverse dehydration, electrolyte imbalances and hypovolemia • Constantly assess child and recognize signs and symptoms of adrenal crisis (vital signs q 15 min) • Review lab values often • Understand that cortisone and sodium chloride treatments are given rapidly to rectify an ominous situation • Explain treatment and child’s response

  18. Chronic Adrenocortical Insufficiency (Addison Disease) • Signs and symptoms • Weakness, fatigue, dizziness, and rapid pulse • Dark skin noted on hands and face, weight loss, dehydration, loss of appetite intense salt craving, muscle aches, nausea, vomiting, diarrhea, and intolerance to the cold • Nursing care • Administer oral cortisol (Solu-Cortef) When hospitalized: • Replace fluids and electrolytes • Monitor closely for signs of hypovolemic shock • Educate parents about medications (side effects and administration routinely and regularly), home free of stress, hydration, and medical alert bracelet • Do NOT stop steroids suddenly

  19. Cushing Syndrome • Signs and symptoms • Hypokalemia, hypercalcemia, pendulous abdomen, fatigue, muscle wasting, “moon” face, fragile skin, and depression • Nursing Care: • Surgery (tumor excised) • Give medications to inhibit production of cortisol • Preoperative and post operative care • Teach the family about the disease and medications and “Cushing-like” appearance • Alert parents to watch for signs of adrenal insufficiency

  20. Congenital Adrenal Hyperplasia (CAH) • Signs and symptoms • Male infant: no physical differences until later in childhood • Female infant: malformed external genitalia at birth • Nursing care • Replace glucocorticoids • Give mineralocorticoid fludrocortisone (Florinef) • Surgical repair • Educate parents about life-long medication, give emotional support, and reinforce regular check-ups

  21. Hyperaldosteronism • Signs and symptoms • Hypervolemia, headache, hypertension, muscle weakness, paresthesia, polydipsia, and polyuria • Nursing care • Replace potassium • Administer spironolactone (Aldactone) • Surgical excision of adrenal gland/tumor • Postoperative care may include sodium restricted diet or hypertensive medications • If hypertensive, monitor for hyponatremia and hyperkalemia • Educate parents about medication regimens and subtle signs of electrolyte imbalance

  22. Pheochromocytoma • Signs and symptoms • Hypertension, tachycardia, arrhythmias, headache, dizziness, poor weight gain, growth failure, polydipsia, and polyuria • Nursing care • Preoperatively administer dibenzyline • Preoperatively document history of symptoms, assess for hypertension, CHF, and hyperglycemia • Postoperative care after tumor removal • If both adrenal glands are removed, administer mineralocorticoids and glucocorticoids (life-time) • Observe for signs and symptoms of shock (frequent vital signs) • Provide calm environment (use play) • Teach parents about condition and factors that cause stress • Do not touch or palpate the mass

  23. Metabolic Conditions

  24. Diabetes Mellitus Type I • Signs and symptoms • Polyuria, polydipsia, polyphagia, and unintended weight loss • High glucose levels (blood and urine) • Nausea, vomiting, abdominal pain, excessive fatigue, susceptibility to infection, dehydration, blurred vision, and irritability

  25. Diabetes Mellitus Type I • Diagnosis • Elevated blood glucose levels (usually in excess of 200 mg/dL) • Elevated hemoglobin A1C level (greater than 7.0) • Increase sugar and ketones in urine • Diabetic ketoacidosis (DKA)

  26. Diabetes Mellitus Type I • Nursing care • Major components of management and care • Insulin types (dose and frequency) • Diet and nutrition • Exercise • Stress management • Blood glucose and ketone monitoring • Long-term treatment • Patient/lfamily teaching that optimize outcomes

  27. Insulin Types

  28. Diet & Nutrition • Goal for a dietary plan: balance various foods and include the caloric intake from • Carbohydrates (50 – 60%) • Fats (20 – 30%) • Proteins (10 – 20%) • Goal is to maintain normal glucose levels. AIC levels are indicative of the average blood glucose over the past 2 to 3 months (see Tables 28-4 and 28-5).

  29. Exercise & Stress Management • Exercise and extracurricular activities should not be restricted • Stressful life events can worsen diabetes (consult with mental health professionals)

  30. Blood Glucose &Ketone Monitoring • Monitor blood glucose levels 3 – 6 times per day • Monitor urine ketones whenever blood glucose readings exceed 240 mg/dL, when the child experiences unexplained weight loss, or if the child is ill

  31. Long-term Treatments • The focus is on reducing symptoms and preventing complications • The emphasis is placed on teaching the child and family about the chronic illness and its management • The nurse assesses the family’s readiness to learn

  32. Patient/Family Teaching that Optimizes Outcomes • Education is the route by which a family achieves the best glucose control for the child • Education focus on insulin administration and schedule, meal planning, physical exercise, blood glucose monitoring, and extremity care • Alternative therapies (see Where Research and Practice Meet: Alternative to Injectable Insulin)

  33. Diabetes Mellitus Type 2 • Signs and symptoms • High blood glucose levels • Sometimes symptoms may mimic type 1 diabetes • Diagnosis • Criteria for type 2 diabetes in children • BMI >85 percentile for age, sex, and weight plus 2 of the following risk factors • Family history of type 2 diabetes • Race/ethnicity • Insulin resistance • Maternal history or gestational diabetes • Diagnosis is confirmed with 2 fasting glucose results that exceed 125 mg/d: or 2 random readings >200 mg/dL

  34. Diabetes Mellitus Type 2 • Nursing care • Provide nutrition teaching (decreasing calories) • Encourage behavioral changes: increasing activity • Lifestyle modification to the entire family to ensure compliance • Teach family about oral hypoglycemic agent • Monitor for complications

  35. Diabetic Ketoacidosis (DKA) • Signs and symptoms • Toddlers: classic manifestations often absent • Altered mental status, tachycardia, tachypnea, Kussmaul respirations, normal or low blood pressure, poor perfusion, lethargy and weakness, and fever and acetone breath

  36. Diabetic Ketoacidosis (DKA) • Diagnosis • Blood glucose of >200mg/dL • Ketonuria • Ketonemia with a serum bicarbonate level of <15 mEq/L • pH of the blood (acidosis)

  37. Diabetic Ketoacidosis (DKA) • Nursing care • Four essential physiologic principles • Restore fluid volume • Return child to a glucose utilization state by inhibiting lipolysis • Replace body electrolytes • Correct acidosis and restore acid-base balance

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