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Endocrine Stressors and Adaptation

Endocrine Stressors and Adaptation. Common Pediatric Endocrine Disorders. Type I Diabetes Congenital Hypothyroidism Acquired Hypothyroidism (Hashimoto’s Disease) Hyperthyroidism (Graves disease) Growth Hormone Deficiency. The Endocrine System. Glands- Hormones-

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Endocrine Stressors and Adaptation

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  1. Endocrine Stressors and Adaptation

  2. Common Pediatric Endocrine Disorders • Type I Diabetes • Congenital Hypothyroidism • Acquired Hypothyroidism (Hashimoto’s Disease) • Hyperthyroidism (Graves disease) • Growth Hormone Deficiency

  3. The Endocrine System • Glands- • Hormones- • Endocrine Disorders are either: • Primary • Secondary • Hypofunction • Hyperfunction

  4. 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

  5. Type I Diabetes • Most common endocrine disorder in children • Pancreas becomes unable to produce and secrete insulin • Peak age: 5-7, or at puberty • Abrupt onset • Genetic link

  6. 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.

  7. Etiology • Autoimmune process causes destruction on insulin-secreting cells in the pancreas • At dx 90% of beta cells are destroyed

  8. 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

  9. Serum Glucose Levels • Normal: 70-110mg/dl • Glycosated Hemoglobin Hgb A1C 1.8 to 4.0 is normal > 6.0 = DM • Diagnosis: • fasting: >126mg/dl • Random (non-fasting): ≥ 200mg/dl with classic signs (next slide)

  10. Polyuria Polydipsia Polyphagia Fatigue Blurred vision Headache Shortened attention span Mood changes Signs & Symptoms

  11. Diabetic Ketoacidosis(DKA) • Medical Emergency • As glucose levels rise, child will progress into DKA if not treated • Blood glucose levels > 300 • Cellular starvation leads to ketone production • Nausea, vomiting, abdominal pain • Acetone (fruity) breath odor • Dehydration • Kussmaul respirations • Coma if untreated

  12. When to Monitor for DKA • Abdominal pain • Nausea and vomiting that persists for over 6 hours • More than five diarrheal stools in 1 day • A 1- or 2-day history of polyuria and polydipsia • Has illness (e.g., viral or other) and is unable to eat

  13. Juvenile Diabetes Treatment • Multidiscipline • Goal: Normal G & D, optimal glucose control, minimal complications, adjustment to disease • Treatment consists of: • Insulin replacement • Diet • BG monitoring • Exercise

  14. Diet Therapy • Well-balanced, enough caloric intake to support growth and development • Three meals, snacks spaced throughout the day • No diet foods • Don’t omit meals

  15. 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

  16. Exercise • Encouraged, never restricted • Lowers 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

  17. BG Monitoring • Glucose monitoring • Urine testing for ketones • Record keeping • Self-management at age appropriate level • 2-6 choose food, clean finger for BG • 4-6 dip own urine • 6-8 BGM • 8-10 insulin injections, diary • 10-14 nutritional decisions • 12-18 full management

  18. Insulin • Precise dose cannot be predicted • Amount is based upon average capillary or serum blood glucose levels • Will change based of G & D • Can be administered BID SQ by needle/syringe, pen or by insulin/portable pump

  19. Types of Insulin Synthetic Human Insulin • Rapid acting • Lispro (Humalog) • Aspart (Novolog) • Fast acting • Regular ® • Intermediate • NPH (N) • Mixed (70/30) • Long Acting • Glargine (Lantus) • Ultra Lente

  20. Typical Management • The peak of the insulin should occur Post-Prandial (after meal) to avoid hypoglycemia

  21. Insulin • Alternate sites • Don’t inject extremity to be used in sports • Give at room temperature • Always draw regular up first if mixing

  22. Pumps • Delivers fixed amounts of short-acting insulin continuously • Worn on a belt, the tubing & catheter are changed Q48 hours and taped in place • Should not be removed for > 1-2 hours • Subject to minimal malfunction • Self-motivated

  23. Advantages 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 Pumps

  24. ILLNESS Alters 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

  25. “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.

  26. 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

  27. 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 Hypoglycemia BG < 70

  28. Rapid onset Irritable, nervousness Difficulty concentrating Shaky feeling, tremors, hunger Diplopia Pallor Weakness Headache, dizziness Sweating Unconsciousness and convulsions Signs & Symptomsof Hypoglycemia

  29. Treatment of Hypoglycemia Give simple concentrated sugar • Glucose gel or SL tablets • Hard candy • Sugar cubes • Low-fat milk or OJ Followed by a complex CHO & Protein • Slice of bread or cracker with peanut butter • Glucagon SQ for severe hypoglycemia (may cause vomiting, prevent aspiration)

  30. Nursing Diagnosis • Risk for injury R/T hypoglycemia or hyperglycemia • Fear R/T diagnosis, insulin injection, negative effect on life style • Risk for ineffective coping R/T complex self-care regimen and uncertain future • Imbalanced nutrition: more than body requirements R/T intake in excess of activity expenditures

  31. Nursing Diagnosis • Risk for non-compliance R/T complexity of regimen • Risk for ineffective therapeutic management R/T insufficient knowledge of condition • Knowledge deficit R/T new health condition AEB questions being asked • Altered family processes R/T situational crises AEB uncertainty of chronic disease/disability

  32. 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

  33. Nursing Considerations • Provide emotional support • Encourage growth and development • Identify home care needs

  34. Disorders of the Thyroid • Congenital Hypothyroidism • Acquired Hypothyroidism • Hyperthyroidism

  35. CONGENITAL HYPOTHYROIDISM • Disorder at birth • Body is producing insufficient thyroid hormone to meet metabolic needs caused by absent or underdeveloped thyroid gland • If not treated can lead to severe CI • Detected in Newborn Screen

  36. Incidence and Etiology • Caused 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

  37. CONGENITAL HYPOTHYROIDISM • Mottled skin • Large fontanel • Large tongue • Hypotonia/slow reflexes • Distended abdomen • Low T4 < 6, High TSH > 40

  38. 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

  39. 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

  40. Signs of Medication induced Hyperthyroidism • Nervousness/anxiety • Diarrhea • Heat intolerance • Weight loss • Increased HR

  41. Outcome • Prevention of cognitive impairment– newborn screening on all babies • Early treatment has had significant impact on morbidity • Most children progress to within normal ranges on developmental assessment • Poor prognosis in more severe cases

  42. Acquired Hypothyroidism (Hashimoto’s disease) • Thyroid produces inadequate levels of thyroid hormone > age 2 • T4 decreases, TSH rises • Autoimune disorder • Antibodies and developed against thyroid gland • Gland becomes inflamed, infiltrated by antibodies and destroyed

  43. Etiology • Primary (Hashimoto’s thyroiditis) • Most common • Autoimmune • Childhood, adolescents, females>males • Secondary • associated with other conditions that affect the thyroid • Pituitary and hypothalmic dysfunction • Tertiary • Radiation, surgery, trauma

  44. Goiter Dry, thick skin Coarse but thinning hair Fatigue Cold intolerance Delayed puberty and menses Decelerated growth Edema around eyes, face and hands Constipation Sleepiness Mental decline-not permanent cognitive impairment Acquired Hypothyroidism

  45. Acquired HypothyroidismTreatment • 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)

  46. Acquired Hyperthyroidism (Grave’s Disease) • A hyperfunction of the thyroid gland • Produces excessive circulating thyroid hormone (T3 and T4) • Four times more common in girls • Occurs between the ages of 12 – 14 yrs. (puberty) • Manifestations develop gradually with an interval between onset & diagnosis of 6 to 12 months • Genetics involved • Follows a viral illness or period of stress

  47. Grave’s DiseaseSubjective Signs & Symptoms: • Emotional liability • Physical restlessness at rest • Decreased school performance • Excessive appetite without weight gain • Fatigue

  48. Grave’s DiseasePhysical Signs & Symptoms: • Increased HR • Palpitations • Widened pulse pressure • Exothalmos • Hair fine, unable to curl • Diarrhea • Poor attention span

  49. Grave’s DiseasePhysical Signs & Symptoms: • Wide-eyed expression with lid lag • Fine tremors • Increased perspiration/heat intolerance • Systolic murmurs • Emotional liability • Insomnia

  50. Grave’s DiseaseThyroid Storm • Acute Onset • Severe irritability & restlessness • Vomiting and diarrhea • Hyperthermia • Hypertension • Severe tachycardia • Prostration • May progress to death

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