Endocrine

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

2. 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

3. 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

4. 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

5. 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.

6. 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

7. Clinical Signs “Very Good Baby” • Lethargic & “sleeps well” • ↓ BMR ↑ weight, cold & mottled • Anorexia & Poor feeding • Hypotonia • Constipation • Hoarse cry • Dry Skin

8. Facial Features • Broad nose • Wide fontanels and sutures • Broad, flat nose • Protruding tongue • Short thick neck Disproportionate Body • Short arms & legs

9. Acquired HypothyroidismJuvenile • Lymphocytic thyroiditis- “Hashimoto’s” • 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

10. 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

11. Myxedema • Dry thicken skin • Fat accumulation • subcutaneous tissue • Brittle hair • coarse and sparse Diagnosis • Thyroid scan • TSH Radioimmunoassay • ↑TSH with ↓T3 and ↓ T4

12. Therapy Synthroid (l-thyroxine) 5-10 PO ug/kg/day • Individualized to pt’s 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 • √ T3 & T4 q 6 months

13. Nursing Interventions • Activity • Accept pt’s 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

14. Synthroid Toxicity Overdose of Medication • ↑Irritable & Nervousness • ↑ BMR & ↑ Temp ↑ HR ↑ BP • Wide pulse pressure • Diaphoresis, tremors, V & diarrhea • Therapy • √ serum T3 T4 • Hold med or ↓dose

15. Hyperthyroidism Neonatal hyperthyroidism • Maternal Grave’s 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

16. Neonatal Graves Disease • Irritability • Tachycardia • Hypertension • Voracious appetite with FTT (↓ Weight) • Flushing • Prominent eyes • Goiter • Tracheal compression • ↑ Respiratory distress → asphyxia

17. Grave’s 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 > boys • + Family history of thyroid disease

18. Signs and Symptoms • Goiter • Exopthalmos • ↑↑ risk corneal abrasion • ↑↑ Appetite & ↓↓ weight • (-) N balance • ↑↑ VS @ rest • HR> 160 Palpitations • ↑ BP → CHF • ↑ Temp = Heat intolerance • Peripheral vasodilation • Flushed skin • ↓↓ Attention span • Emotional liability & cry easily

19. 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

20. Medications Potassium Iodine SSKI (Lugol’s 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 • √ serum K+

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

22. Thyroid Storm Life Threatening Crisis • Acute infection or Post-op • Manipulation of thyroid • ↑↑ release of thyroxin ↑↑ BMR • Abrupt onset • ↑↑ Temp 106 ↑↑ BP • ↑↑ Apical >200 Fatal arrhythmia's • Severe irritability/restlessness • Electrolyte imbalances • Vomiting • Delirium → coma → death

23. Therapy Medications • TylenolNo ASA (↑ T4 and T3 ) • MSO4 =↓ CNS & VS • Lugol’s Solution (SSKI) & PTU • ↓ vascularity and ↓ thyroxine • Cortisone↓ inflammation • Propranol↓ CO • ↓↓ Temp via Hypothermia blanket • O2 for ↑ BMR demands

24. 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!

25. Hypersecretion of Pituitary • Gigantism • 12 year old boy 6 ft 5 in • ↑↑ Growth via ↑↑ STH • ↑↑ muscles & viscera • ↑↑ ICP ↑↑ HA • Death @ age 30 • Cardiac unable to sustain CO • Therapy • Irradiation & Hypophsectomy

26. Hyposecretion of Pituitary Dwarfism (Vertically challenged) • Lesion, trauma or idiopathic • ↓ STH ↓ GH • ↓Growth < 10% • Disproportionate growth • Hands & feet short & chubby • adult male @ 4ft • Therapy • Surgery & Hormone Replacement • STH, ACTH, TSH, FSH, LH, MSH, • Thyroxin, Synthroid • Reinforce Age appropriate behaviors

27. 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

28. 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

29. 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 diuretic> Renal Threshold (180mg/100cc) • Excrete ↑ urine to removeglucose & ketones • ↑ Loss of electrolytes (Na+, Cl+, Ca+, Mg, PO4) • Polydipsia • ↑ Thirst due to polyuria • ↑ Intake > 2-3 Liters/day • Hyperglycemia • ↑ serum glucose • glucose adheres to vaginal wall = ↑ vaginal yeast infections

30. Diagnosis • Fasting Blood Sugar (FBS) >120mg/dl • May miss 85% early chemical diabetes • Post-prandial->150mg/dl • Eat ↑↑ carbohydrate meal (75-100 gm) • √ BS p 2H • Glucose Tolerance Test (GTT) > 200 • FBS & Urine S & A • Drink Glucola (75 gm carb) • √ 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 >11.5 • Ketoacidosis >15

31. 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

32. 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 • √ Brand √ Type • “clear to cloudy” 1st draw up Regular • SQ @ 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 • ↓ Ketoacidosis

33. 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

34. 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

35. 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 √ BS q 15 mins • Mild: milk or OJ • Moderate: Simple sugar (Lifesaver) • Severe: Glucagon IM/IV

36. Ketoacidosis (Diabetic Coma) ↑ Food ↑ Stress/Infection ↓Insulin • Gradual onset days – weeks • Kussmaul’s 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

37. DKA Therapy • ICU & NPO • √ V/S & BS Continuously • C/R monitor √ arrhythmias • Pulse ox & ABG • √ Neuro for cerebral edema • Electrolytes (√ K+) • Rebound Hypokalemia • K+ follows glucose → cells • √ I & O • IV NaCl & Regular Insulin (0.1u/kg)IVPB • NaHCO3 IVPB for metabolic acidosis • Constantly assess Pt’s response to RX!