Caring for the Child with an Endocrinologic or Metabolic Condition

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 childs 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 childs 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 childs 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

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Insulin Types
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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).

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Exercise Stress Management

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

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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 familys readiness to learn

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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 gt85 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 gt200 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 gt200mg/dL
• Ketonuria
• Ketonemia with a serum bicarbonate level of lt15
  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