Endocrine

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Endocrine

• Elisa A. Mancuso RNC-NIC, MS, FNS
• Professor of Nursing

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• Hormones
• Regulate growth activity of cells
• Interact with receptors of target tissues
• Regulate metabolism stress response
• Maintain fluid electrolyte balance
• Sexual reproduction
• Feedback mechanism
• ? Blood Level ? Gland Secretion
• ? Blood Level ? Gland secretion

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Thyroid Gland

• Takes up I changes I to react with tyrosine
• I tyrosine ? Thyroid hormones
• T4 T3
• TSH secrets T4 T3
• Dependent on blood levels
• ? T4 or T3 ? TSH
• ? T4 or T3 ? TSH

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Thyroid Hormones

• Thyroxin- T4
• Maintains metabolism in steady state
• Temp Cardiac GI Neuro
• Cellular metabolic activity ? Rate of O2 use
• Stimulates growth and development
• Protein synthesis Tissue Differentiation
• Essential for brain development in first 2 years
• Triidothyronine- T3
• Rapid Intermediate metabolic actions
• Thyrocalcitonin
• Maintain serum Ca PO4 levels
• ?? Ca in serum ? Calcitonin is released
• ?? Ca serum and promote Ca bone deposit

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Hypothyroidism

• Most common pediatric endocrine disorder
• Failure of Thyroid gland development (aplasia)
• ?? T3 and T4
• Initially provides enough T3 T4 for 1st year.
• Then unable to meet rapid body growth needs.
• Anti-thyroid drugs or I deficiency during
  pregnancy
• PKU-Phenylketonuria.
• Genetic defect in synthesis of thyroxin.
• Gunthrie Test (PKU) performed at 48 hours of
  life.
• Unable to convert phenylalanine (amino acid) to
  tyrosine.

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Congenital Hypothyroidism

• Cretinism- Infancy
• Girls 3x more common
• If not tested and untreated displays signs and
  symptoms in 3-6 weeks
• Early DX best prognosis
• Tx before 3 months and baby will grow and develop
  normally.
• No treatment will lead to mental
• retardation

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Clinical Signs

• Very Good Baby
• Lethargic sleeps well
• ? BMR ? weight, cold mottled
• Anorexia Poor feeding
• Hypotonia
• Constipation
• Hoarse cry
• Dry Skin

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Facial Features

• Broad nose
• Wide fontanels and sutures
• Broad, flat nose
• Protruding tongue
• Short thick neck
• Disproportionate Body
• Short arms legs

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Acquired HypothyroidismJuvenile

• Lymphocytic thyroiditis- Hashimotos
• Autoimmune Disease
• Auto-antibodies bind to TSH receptor sites on
  thyroid gland
• ? levels of T3 T4.
• Atrophy of thyroid gland
• Cause of antibody production unknown
• Associated with goiter

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Sign and Symptoms

• ?? Growth
• Edema of face, eyes and hands
• ? Decreased BMR
• Increased weight gain
• ? V/S ? Temp, ? HR and ? BP
• Lethargy
• ? sensitivity to cold
• Forgetfulness
• ? Decreased mental alertness

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Myxedema

• Dry thicken skin
• Fat accumulation
• subcutaneous tissue
• Brittle hair
• coarse and sparse
• Diagnosis
• Thyroid scan
• TSH Radioimmunoassay
• ?TSH with ?T3 and ? T4

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Therapy

• Synthroid (l-thyroxine) 5-10 PO ug/kg/day
• Individualized to pts TSH level
• Initially low dose
• Gradually ? (over 4-8 weeks)
• Allow body time to adjust to changes
• ? BMR ? V/S
• Monitor V/S, HR, Temp BP!
• Lifelong therapy
• v T3 T4 q 6 months

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Nursing Interventions

• Activity
• Accept pts lethargy
• Need ? time to do ADLs
• Skin care
• Oils, lotions
• Frequent position changes
• Prevent chilling
• Encourage layering of clothes
• Diet
• ?Fiber ?Protein ?Vit D ? Bone Growth
• ? Cals ? Fats ? Fluids ? Edema

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Synthroid Toxicity

• Overdose of Medication
• ?Irritable Nervousness
• ? BMR ? Temp ? HR ? BP
• Wide pulse pressure
• Diaphoresis, tremors, V diarrhea
• Therapy
• v serum T3 T4
• Hold med or ?dose

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Hyperthyroidism

• Neonatal hyperthyroidism
• Maternal Graves disease
• Thyroid Stimulating immunoglobulins (TSI),
• autoantibodies passed through the placenta to
  fetus.
• TSI binds to TSH receptors excess thyroid
  hormone production
• Excessive maternal I exposure
• Neonatal thyroid hypertrophy to uptake
• excess I

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Neonatal Graves Disease

• Irritability
• Tachycardia
• Hypertension
• Voracious appetite with FTT (? Weight)
• Flushing
• Prominent eyes
• Goiter
• Tracheal compression
• ? Respiratory distress ? asphyxia

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Graves Disease

• Autoimmune condition
• Thyroid stimulating immunoglobulin rxn ? T3 T4
• Hyperplasia of thyroid gland
• Develops gradually over 6 -12 months
• Suppression of TSH No Feedback mechanism
• Peak incidence is 11 and 15 years
• Girls 5 times gt boys
• Family history of thyroid disease

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Signs and Symptoms

• Goiter
• Exopthalmos
• ?? risk corneal abrasion
• ?? Appetite ?? weight
• (-) N balance
• ?? VS _at_ rest
• HRgt 160 Palpitations
• ? BP ? CHF
• ? Temp Heat intolerance
• Peripheral vasodilation
• Flushed skin
• ?? Attention span
• Emotional liability cry easily

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Medications

• Propylthiouracil (PTU) 50 100mg/day bid
• Interferes with I conversion to thyroxine
• Prevents T3 and T4 synthesis
• Takes 3 - 4 weeks, No effect on available T3 T4
• Side Effects
• Skin rash-urticaria,
• Agranulocytosis- S/S of infection STOP med!
• Monitor for overdose
• ? VS ? Lethargy Sleepiness
• Methimazole (Tapazole) 0.2mg/kg q12H
• Blocks formation of new T3 and T4.
• Available T3 and T4 must be used up

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Medications

• Potassium Iodine SSKI (Lugols solution)
• ? pituitary TSH ? Thyroxin ? T3 T4
• ? glands vascularity
• used a surgery ?bleeding
• Side Effects
• Swelling of salivary glands
• Metallic taste, burning of mouth throat.
• Sore teeth gums, skin rash
• v serum K

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Surgery

• Sub Total Thyroidectomy
• Removes majority of gland 5/6 (leave isthmus.
• Gradually takes over bodys needs
• Hormone replacement initially
• Then gradually taper off
• Post-op complications
• Hemorrhage
• v blood behind neck ?VS
• Respiratory distress-
• Laryngeal edema v stridor (trach at bedside)
• Dysphasia
• Laryngeal nerve damage v speech

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Thyroid Storm

• Life Threatening Crisis
• Acute infection or Post-op
• Manipulation of thyroid
• ?? release of thyroxin ?? BMR
• Abrupt onset
• ?? Temp 106 ?? BP
• ?? Apical gt200 Fatal arrhythmia's
• Severe irritability/restlessness
• Electrolyte imbalances
• Vomiting
• Delirium ? coma ? death

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Therapy

• Medications
• Tylenol No ASA (? T4 and T3 )
• MSO4 ? CNS VS
• Lugols Solution (SSKI) PTU
• ? vascularity and ? thyroxine
• Cortisone ? inflammation
• Propranol ? CO
• ?? Temp via Hypothermia blanket
• O2 for ? BMR demands

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Nursing Interventions

• Environment
• Open windows Keep away from heat
• Frequent rest periods
• Consistent routine and ? stimulation
• Diet
• Meet metabolic needs
• Small frequent meals
• ? Protein, ? Carb, ? Calories
• No Junk food!

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Hypersecretion of Pituitary

• Gigantism
• 12 year old boy 6 ft 5 in
• ?? Growth via ?? STH
• ?? muscles viscera
• ?? ICP ?? HA
• Death _at_ age 30
• Cardiac unable to sustain CO
• Therapy
• Irradiation Hypophsectomy

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Hyposecretion of Pituitary

• Dwarfism (Vertically challenged)
• Lesion, trauma or idiopathic
• ? STH ? GH
• ?Growth lt 10
• Disproportionate growth
• Hands feet short chubby
• adult male _at_ 4ft
• Therapy
• Surgery Hormone Replacement
• STH, ACTH, TSH, FSH, LH, MSH,
• Thyroxin, Synthroid
• Reinforce Age appropriate behaviors

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Insulin Dependent Diabetes Mellitus

• Type I - IDDM Juvenile Onset
• Genetic Predisposition or virus
• causes an autoimmune process
• destroys pancreatic insulin secreting B cells
• ??? Insulin Production
• Glucose unable to enter the cells Hyperglycemia
• Glucose unavailable for cell metabolism
• cellular starvation

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IDDM

• Fatty Acids
• Fats break down ? fatty acids ? Ketones
• Ketones used as source of energy release H
• Metabolic Acidosis (Ketoacidois)
• Remaining ketones accumulate in tissues
• Excreted via urine (ketonuria)
• Exhaled via lungs (Acetone/fruity breath)
• Gluconeogenesis
• Proteins break down ? to glucose in liver
• ? Glucose circulating in blood ? hyperglycemia

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Clinical Signs

• Polyphagia
• ? appetite but unable to use glucose
• Protein lipid catabolism body is starving!!
• Muscle wasting with rapid weight loss () N
  balance
• Polyuria (enuresis is the 1st sign!!)
• Glucose acts as a diureticgt Renal Threshold
  (180mg/100cc)
• Excrete ? urine to remove glucose ketones
• ? Loss of electrolytes (Na, Cl, Ca, Mg, PO4)
• Polydipsia
• ? Thirst due to polyuria
• ? Intake gt 2-3 Liters/day
• Hyperglycemia
• ? serum glucose
• glucose adheres to vaginal wall ? vaginal
  yeast infections

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Diagnosis

• Fasting Blood Sugar (FBS) gt120mg/dl
• May miss 85 early chemical diabetes
• Post-prandial-gt150mg/dl
• Eat ?? carbohydrate meal (75-100 gm)
• v BS p 2H
• Glucose Tolerance Test (GTT) gt 200
• FBS Urine S A
• Drink Glucola (75 gm carb)
• v BS urine S A q ½ H (x 4)
• Glycosylated Hemoglobin (GHB, HbA1c)
• Reflects BS for last 3-4 months
• WNL 5.5 8 Poorly controlled gt11.5
• Ketoacidosis gt15

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Treatment

• Insulin
• ?? Uptake utilization of glucose by muscle
  fat cells. Inhibits release of glucose in
  liver
• Rapid Acting- Regular, Humulin R or Lispro
• Onset 30 mins Peak 2-4H Duration 6-8H
• Intermediate- NPH, Lente
• Onset 2H Peak 6-8H Duration 12-16H
• Long Acting- Ultralente, PZI
• Onset 4-8H Peak 16-24H Duration 30-36H
• Insulin Glargine-Lantus (rDNA origin)
• Steady concentration over 24H No peaks.
• Cannot be mixed with other insulin's

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Insulin

• Pediatric Dosages
• Combination of Regular, NPH or Lantus 2 doses
• AM (2/3 daily dose) ½ H a breakfast
• PM (1/3 daily dose) ½ H a dinner
• Administration
• v Brand v Type
• clear to cloudy 1st draw up Regular
• SQ _at_ 90 angle
• Rotate sites (Abd ? Arms ? Thighs)
• Coverage
• Based on BS (200-250 -2u R)
• Additional regular insulin added to daily dose
• Insulin Pump
• Consistent coverage
• No need for multiple daily injections
• ? Independence control

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Diet Therapy

• Maintain adequate calories for growth spurt.
  Need food for metabolism with insulin
• NCS No Concentrated Sweets ? fats
• ADA exchange diet
• 3 meals 3 snacks/day
• ? Flexibility c exchanges 75 kcal 1point
• Meal planning
• Consider school, activities sports
• Pt. preferences
• Exercise
• ? food intake 10-15gm complex carbs
• for q 30 mins activity

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Patient Teaching

• Essential for optimal health
• ? knowledge ?compliance ?control ?health
• Short sessions 15 -20 mins
• Practice using equipment/supplies a D/C
• Pathophysiology
• S/S Therapy
• Long term sequella
• ? Infections, Retinopathy, Glomerulonecrosis, ?
  BP
• Separate teaching for Pt Family
• Adolescents need to be empowered and independent

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Hypoglycemia (Insulin Shock)

• ? Insulin ? Food ? Exercise
• Rapid Onset
• Sympathetic NS activated (Cool Clammy)
• Hungry, irritable, tremors, dizzy
• Diaphoresis, pale skin, flushed cheeks
• HA, blurred vision, slurred speech,
• ? HR, shallow respirations, seizures
• Therapy v BS q 15 mins
• Mild milk or OJ
• Moderate Simple sugar (Lifesaver)
• Severe Glucagon IM/IV

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Ketoacidosis (Diabetic Coma)

• ? Food ? Stress/Infection ?Insulin
• Gradual onset days weeks
• Kussmauls Respirations
• Deep rapid sighing breaths
• Exhale release ?CO2, H ? pH
• Acetone Breath (fruity, sweet odor)
• Metabolic Acidosis? pH ? HCO3 ? PO2
• Hyperkalemia ? K
• K follows glucose from cells ? blood
• Muscle weakness Cardiac arrhythmias
• Dehydration (Hot Dry)
• ? Temp, skin hot dry, lethargic, mallar flush
• ? Turgor sunken eyeballs

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DKA Therapy

• ICU NPO
• v V/S BS Continuously
• C/R monitor v arrhythmias
• Pulse ox ABG
• v Neuro for cerebral edema
• Electrolytes (v K)
• Rebound Hypokalemia
• K follows glucose ? cells
• v I O
• IV NaCl Regular Insulin (0.1u/kg)IVPB
• NaHCO3 IVPB for metabolic acidosis
• Constantly assess Pts response to RX!