Transcript Endocrine/Metabolic Alterations

Endocrine/Metabolic
Alterations
NUR 264
Pediatrics
Angela Jackson, RN, MSN
Developmental Differences
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The endocrine system is incompletely developed
at birth
Less mature than any other body system
Pituitary gland is formed by the 4th month of
gestation and measurable amounts of hormone
can be detected
Newborn’s level of TSH is 10 times higher than
levels seen in older children. Initial thyroid
function tests cannot be interpreted using
normal standards of childhood or adults
Endocrine Glands
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Anterior pituitary
Posterior pituitary
Thyroid
Parathyroid
Adrenal cortex
Adrenal medulla
Ovaries
Testes
Pancreas
Growth Hormone Deficiency
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Characterized by poor growth and short
stature
Occurs equally in both sexes
May result from injury, destruction of the
anterior pituitary gland by a brain tumor,
infection, or irradiation, but is usually
idiopathic
GHD: Pathophysiology
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Hypothalamus secretes growth hormonereleasing hormone (GRH)
Production of growth hormone (GH) by
the pituitary is stimulated
In GHD, the pituitary is unable to respond
to the GRH, and GH is not produced
GHD: Clinical Manifestations
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Short stature
Deteriorating or absent rate of growth
Higher weight to height ration
Delayed bone age (Determined by x-ray of the hand and
wrist)
Increased fat in trunk area
Childlike face with a large, prominent forehead
High-pitched voice
Hypoglycemia
Micropenis and small testes in males
Delayed sexual maturation
Delayed dentition
GHD: Diagnosis
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Family history
Review of previous growth records
Physical examination
Determination of growth rate
Radiographic bone studies
Baseline blood testing
Pituitary function testing
GHD: Treatment
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Goal of treatment is to promote normal
growth rates by administration of growth
hormone
Growth hormone is given IM or SC
Treatment is discontinued once the
epiphyseal growth plates have fused
Treatment is expensive ($20,000 to
$30,000 / year, depending on dosage)
GHD: Potential Complications of
Treatment
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Slipped femoral epiphysis
Pseudotumor cerebri
Edema
Sodium retention
GHD: Nursing Management
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Monitor growth
Maintain growth chart
Provide teaching to family concerning
normal growth and development
Teach family proper medication
administration techniques and side effects
Monitor medication dosages
Provide emotional support
Precocious Puberty
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Breast development before the age of 7 in
Caucasian girls and before the age of 6 in
African-American girls
Development of secondary sex
characteristics in boys less than 9 years
old
Five times more common in girls
Idiopathic in girls, related to central
nervous system abnormalities in boys
Precocious Puberty:
Pathophysiology
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Results from premature activation of the
hypothalamic-pituitary-gonadal axis
Hypothalamus secretes gonadatrophin
releasing hormone, which stimulates the
pituitary to produce leutinizing hormone
and follicle stimulating hormone. Estrogen
or testosterone is also produced
Precious Puberty: Clinical
Manifestations
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Accelerated growth rate
Advanced bone age
Secondary sex characteristics
Acne
Body odor
May be emotionally labile, aggressive, and
mood swings may occur
Potentially fertile
Precocious Puberty: Diagnosis
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Physical exam and history
Tanner staging
Measurement of height and weight
X-rays for bone age, pelvic ultrasound for
females to identify size of uterus and ovaries,
CT, MRI or skull film to detect CNS lesions for
males
Lab tests for LH, FSH, estradiol or testosterone
GnRH stimulation testing
Precocious Puberty: Treatment
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Administration of luteinizing hormone – releasing
hormone (Lupron) SC on a monthly basis
Surgery, radiation or chemotherapy if caused by
CNS tumor
Treatment results in a decrease in growth rate,
stabilization or regression of secondary sex
characteristics
Puberty resumes when therapy is discontinued
Precocious Puberty: Nursing
Management
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Monitor growth
Provide psychological support
Teach parents about normal growth and
development
Instruct parents that child’s mental age is
congruent with chronologic age
Teach parents about medication
administration and potential side effects
Diabetes Insipidus (DI)
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Disorder of water regulation
Deficiency of ADH results in excretion of
large amounts of dilute urine
Most often seen as a complication
following head injury or cranial surgery to
remove tumors of the hypothalamicpituitary region
Other causes include vascular anomalies,
infection, and genetic defect
DI: Clinical Manifestations
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Polyuria
Polydipsia
Nocturnal enuresis
Urine output can range from a few liters
to eighteen liters a day
Urine specific gravity is 1.005 or less,
urine osmolarity is <200mmol/l
Serum sodium concentration and plasma
osmolarity are elevated
DI: Diagnosis
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UA for osmolarity, specific gravity, and
sodium
Serum osmolarity, sodium and creatinine
levels
Water deprivation test. Requires several
hours to complete with close monitoring
(I&O, weight, vital signs, hydration
assessment, and urine and blood samples)
DI: Treatment
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Goals of treatment include: antidiuresis,
uninterrupted sleep, and increased ability
to participate in school and other
programs
Treated with daily replacement of ADH
Drug of choice is DDAVP, which is given
intranasally or orally
DI: Nursing Management
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Strict I&O and daily weight
Teach parents about the condition
Teach parents about lifelong need for
medication and medication administration
Teach parents to monitor I&O and daily
weights
Congenital Hypothyroidism (CH)
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Present at birth
Reduced rate of metabolism caused by a low
concentration of circulation thyroid hormones
(T3 and T4)
More females than males are affected
Caused by a defect in the embryonic
development of the thyroid gland, inborn error
of thyroid hormone synthesis, and pituitary
dysfunction
Thyroid gland is unable to produce T3 and T4 in
response to increasing elevated levels of TSH
secreted by the pituitary gland
CH: Clinical Manifestations
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Asymptomatic at birth
Large posterior
fontanel
Umbilical hernia
Constipation
Prolonged jaundice
Pallor hypothermia
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Enlarged tongue
Hypotonia,
hypoactivity
Feeding difficulties
Delayed mental
responsiveness
Cool, dry, scaly skin
Swollen eyelids
CH: Diagnosis
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Mandatory newborn screening
Low T4 and a high TSH indicate CH
Thyroid scan to evaluate for absence or
ectopic placement of the thyroid gland
CH: Treatment
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Goal of therapy is to quickly normalize thyroid
function
Maintain the level of T4 in the upper half of the
normal range and TSH in the normal range
Thyroid replacement with synthroid is initiated
as soon as possible, starting dose of 10-15
mcg/kg/day
Close monitoring of thyroid function
Lifelong replacement is necessary to maintain
normal metabolism
CH: Nursing Management
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Monitor growth and development
Monitor lab values: every 2-4 weeks until thyroid
function is within target range and medication
dose is stabilized, every 3-4 months for first
several years of life, every 6-12 months in
adolescence
Teaching parents proper medication
administration, side effects, importance of
continuing medication for rest of child's life and
importance of regular blood tests to monitor
thyroid function
Questions??