Transcript Chapter 24

Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Chapter 28
Caring for the Child with an
Endocrinologic or Metabolic
Condition
Susan Ward
Shelton Hisley
A & P Review
Organs of the Endocrine System
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Hypothalamus
Pineal body
Pituitary gland
Thyroid gland
Parathyroid glands
Adrenal glands
Pancreas
Gonads
Pathophysiological Conditions
of the Endocrine System
Conditions of the Anterior Pituitary
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
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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
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
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Administer gonadotropin-releasing hormone (GnRH)
Keep accurate records of child’s growth
Approach child appropriate to age
Include child in teaching
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)
Conditions of the Posterior
Pituitary
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)
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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
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)
Conditions of the Thyroid
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
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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
child’s growth, weight gain, and developmental milestone progression
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)
Conditions of the Parathyroid
Hypoparathyroidism
 Signs and symptoms
 Poor tooth development, vomiting, headaches, mental deficiency, seizures,
uncontrollable, painful spasms, irritability and rigid muscles
 Nursing care
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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
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)
Conditions of the Adrenals
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 child’s response
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
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
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
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Replace glucocorticoids
Give mineralocorticoid fludrocortisone (Florinef)
Surgical repair
Educate parents about life-long medication, give emotional
support, and reinforce regular check-ups
Hyperaldosteronism
 Signs and symptoms
 Hypervolemia, headache, hypertension, muscle weakness, paresthesia,
polydipsia, and polyuria
 Nursing care
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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
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
Metabolic Conditions
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
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)
Diabetes Mellitus Type I
 Nursing care
 Major components of management and care
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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
Insulin Types
Diet & Nutrition
 Goal for a dietary plan: balance various
foods and include the caloric intake from
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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).
Exercise & Stress Management
 Exercise and extracurricular activities
should not be restricted
 Stressful life events can worsen diabetes
(consult with mental health professionals)
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
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 family’s readiness
to learn
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)
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 >85 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 >200 mg/dL
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
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
Diabetic Ketoacidosis (DKA)
 Diagnosis
 Blood glucose of >200mg/dL
 Ketonuria
 Ketonemia with a serum bicarbonate level of
<15 mEq/L
 pH of the blood (acidosis)
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