endocrine disorders

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Endocrine disorders

Diabetes - CretinismNajah QasemQassim University

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Objectives:

• Define the definition for the following endocrine disorders: diabetes insipidus, diabetes mellitus, and critinism.

• List causes for the following endocrine disorders: diabetes insipidus, diabetes mellitus, and critinism.

• Mention diagnostic procedures for DI, DM, Critinism.• Explain clinical assessment findings for DI, DM, Critinism.• Discuss treatment regimen for DI, DM, Critinism.• Discuss nursing management for DI, DM, Critinism.• Numerate acute and long complications for DM.• Compare between hypoglycemia and hyperglycemia.• Formulate nursing care plan for DI, DM.

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Diabetes Inspidus (DI)

Definition:

Diabetes insipidus is a disease in which there is decreased release of antidiuretic hormone (ADH) by the pituitary gland, this causes less reabsorption of fluid in the kidney tubules. Urine becomes extremely dilute, and a great deal of fluid is lost from the body, resulting in increased water intake to compensate.

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Causes:

1. Genetic defect in synthesis of ADH.

2. Due to lesion of hypothalamus:

A- Tumor

B- Trauma

C- Encephalitis

D- Meningitis.

3. Non-specific etiologic factors.

4. In a rare type of diabetes insipidus, pituitary function is adequate, but the kidneys' nephrons are not sensitive to ADH (a kidney-related etiology)

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Clinical Assessment:

The constant (cardinal) signs of Dl are (Polyuria and polydipsia).

1. Polyuria noted in early infancy and even enuresis " involuntary bed wetting".

2. Infant cries excessively and is only quieted by water but not milk.

3. Excessive thirst is disturbed sleep, play, and learning.

4. No perspiration, dry pale skin, hyperthermia.

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Clinical Assessment:

5. Rapid toss of weight.

6. Vomiting, constipation, growth disorder.

7. Dehydration, fluid and electrolyte imbalance lead to brain damage.

8. Urine output of a child with Dl around 4 to 10 litters /day. (normal range, 1 to 2 L, depending on age).

9. The specific gravity of the urine is low (1.001 to 1.005); normal values are more often 1.010 to 1.030)

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Treatment:• Surgery is the treatment of choice if a tumor is

present. • If the cause is idiopathic, the condition can be

controlled by the administration of desmopressin , an arginine vasopressin.

In an emergency, this drug can be given intravenously (IV).

For long-term use, it is given intranasally or orally.

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Treatment: children should use the small tube supplied with

the medication to deposit the prescribed dose well into the nose.

Nasal irritation may result from intranasal administration.

administration will not be effective if the child has an upper respiratory tract infection and swollen mucous membranes.

Caution children that they will notice an increasing urine output just before the time of next dose

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Nursing Diagnoses and Related Interventions

1- Nursing Diagnosis:

Risk for deficient fluid volume related to constant, excessive loss of fluid through urination

2- Outcome Evaluation (Goal):

Child's blood pressure and pulse are within normal limits for age; specific gravity of urine is between 1.003 and 1.030

child states thirst is not excessive.

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3- Nursing interventions: Teach About Long-Term Therapy. If an IM medication is prescribed, the child and at least

one parent must learn the injection technique to ensure adherence.

Explain the difference between diabetes insipidus and diabetes mellitus, so that the family is not confused about differences in therapy.

Help the family establish a routine to ensure that the child receives adequate fluid to discourage a feeling of thirst and has access to bathroom facilities possibly more frequently than others.

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Encourage Communication. parents should always notify health care providers that the child has diabetes insipidus when seeking any type of health care.

Encourage children to wear a medical alert tag. With the child's and parents' permission, inform school

personnel that the child may need to use the bathroom frequently.

Help the child and family plan frequent bathroom stops and adequate fluid intake on long trips or activity-filled days.

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Diabetes Mellitus

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Definition:

DM is a chronic disorder involving primarily carbohydrate metabolism due to an absolute or relative deficiency of insulin.

Classified into three major groups: maturity – onset diabetes of youth : transmitted as an

autosomal – dominant disorder that is characterized by impaired insulin secretion with minimal or no defects in insulin action.

type 1 (previously called insulin – dependent diabetes mellitus): characterized by destruction of the pancreatic beta cells, which produce insulin; this usually leads to absolute insulin deficiency.

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Definition:

type 2 (previously called non - insulin – dependent diabetes mellitus) : usually arises because of insulin resistance, in which the body fails to use insulin properly, combined with relative insulin deficiency.

Type 1 diabetes (formerly referred to as juvenile diabetes) most commonly occurs in childhood.

The disease affects as many as 1 in 1,500 children before 5 years of age and increases to 1 in 350 by age 16.

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Causes:

1." Hereditary: play an important role in the development of DM type 1, sibling of client with diabetes have 10 times the risk of developing diabetes over the genera! population.

2. Infection: with certain virus and organism such as streptococcus, these virus and organism attack the islet cells of the pancreas, which renders them useless for producing insulin.

3. Autoimmune: some trigger causes the body to develop islet cell antibodies and anti-- insulin antibodies. These antibodies attack the Beta cell of the pancreas and also the insulin molecules themselves

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Clinical Manifestation:Cardinal signs of Diabetes:

Clinical Manifestation

• Polyuria (frequent urination).

• Polydipsia (excessive thirsty).

Pathophysiological Bases

• Water not reabsorbed from renal tubules because of osmotic activity of glucose in the tubules.

• Polyuria causes severe

dehydration, which causes thirst

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Clinical Manifestation:Cardinal signs of Diabetes:

Clinical Manifestation

• Polyphagia (excessive hunger).

• Weight loss (primarily in type 1).

Pathophysiological Bases

• Tissue breakdown and wasting cause a state of starvation that compels the client to eat excessive amounts of food.

• Glucose not available to cells; thus, the body breaks down fat and protein stores for energy.

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Diagnostic Evaluation:

Blood tests:

A diagnosis of diabetes is confirmed based on finding one of the following three criteria on two separate occasions:

• Symptoms of diabetes with a random blood glucose level greater than 200 mg/dL

• Fasting blood glucose level greater than 126 mg/dL• Two-hour plasma glucose level greater than 200

mg/dL during an oral glucose tolerance test (GTT)

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Diagnostic Evaluation:

• Glycosylated Hemoglobin: As reef blood cells circulate in the blood stream, glucose molecules gradually attach to the Hb. Molecules remain there for the lifetime of red blood cell (120 days). The attachment is not reversible; therefore higher blood glucose level lead to higher glycosylated hemoglobin results, glycosylated Hb is average of blood glucose control over previous 3 months "life span of red blood cell". The sample of this test taken during any time at day. This test is satisfactory method for assessing control, detection incorrect testing, and monitor effective of changes in treatment

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Teacher, school health nurse should be aware of child's illness and manifestation of Hypoglycemia and diabetic coma so they can help in emergency.

Hypoglycemia: Causes• Too much insulin. " insulin shock"• Increase physical activity without additional food.• Delayed or not enough food

Hyperglycemia: Causes• Insufficient insulin.

Acute Complications:

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Comparison of manifestations of hypoglycemia and hyperglycemia

VariableOnset

Mood

Mental status

Inward feeling

HypoglycemiaRapid (minutes)

Labile, irritable, nervous, weepy, combative.

Difficulty concentrating, speaking, focusing, coordinating.

Shaky feeling, hunger, headache, dizziness.

HyperglycemiaGradual (days)

Lethargic.

Dulled sensorium, confused.

Thirst, weakness, nausea and vomiting, abdominal pain.

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VariableSkin

Mucous membrane

Respiration

Pulse

Breath odor

HypoglycemiaPallor, sweating.

Normal

Shallow.

Tachycardia.

Normal.

HyperglycemiaFlushed, signs of dehydration.

Dry, crusty.

Deep, rapid.

Less rapid, weak.

Fruity, acetone.

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Variableneurologic

Omnious signs

Blood: glucoseketonesOsmolarityPhhematocrit

HypoglycemiaTremors, late: hyperreflexia, dilated pupils, seizures.

Shock, coma.

Low: < 60 mg/dl.Negative or traceNormalNormalNormal

HyperglycemiaDiminished reflexes, paresthesia

Acidosis, coma.

High: >= 240 mg/dl.High or largeHighLow (7.25 or less)High

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VariableBlood:HCO3

UrineOutput

GlucoseAcetone

Hypoglycemia

Normal

Normal

NegativeNegative or trace

Hyperglycemia

Less than 15 mEq/L.

Polyuria (early) to oliguria (late).HighHigh

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Hypoglycemia

Nursing care• If client is conscious give simple sugar, candy. • Patient should be instructed to carry out a

piece of candy with him and identification card. • In severe cases of hypoglycemia dextrose

administrated IV.

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Hyperglycemia "Diabetic coma " , diabetic ketoacidosis

Nursing Care.• Check v/s.• Insulin as doctor order.• Fluid and electrolyte therapy.• Monitor blood glucose and keton level.• Gastric suction in unconscious child to prevent

aspiration.• Antibiotic is given to febrile children after

appropriate specimen are obtained for culture.• Insert a Foley catheter for urine .sample and

measurement or collection bag.

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Long-Term Complications:

1. Stunted growth, lack of development of secondary sex character, amenorrhea.

2. Cataracts, ganagrene, arteriosclerosis.

3. Infection, especially skin, urinary.

4. Nephropathy, neuropathy.

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Therapeutic Management:

1. Diet

2. Insulin.

3. Exercise.

4. Identification.

5. Hygiene.

6. Regular eye and dental check up.

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1. Diet:

1. They need sufficient calories to balance daily expenditure for energy to satisfy the requirement for growth and development.

2. Concentrated sweats are eliminated, and because of the increase risk for arteriosclerosis in persons with D.M., fat is reduced.

3. Dietary fiber is encourage because of its influence on digestion, absorption and metabolism of many nutrient" it found decrease blood glucose level after meat".

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1. Diet:

4. The time of food consumption must be regulated to correspond to the time and action of insulin prescribed.

5. Have all diabetic children eating together as they encourage each other.

6. Diet should be attractive and varied according to limits.

7. Child should understand that if he reports breaks in dietary rules, he will not be punished or scolded, but unreported breaks may cause sudden sickness.

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2. Insulin Therapy:

Insulin lowers blood glucose by:

a- Promoting the transport of glucose into the cells.

b- inhibiting the conversion of glycogen and amino acid to glucose, insulin therapy should be stabilized according to the child needs.

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2. Insulin Therapy:

Several factors vary the need for insulin:

- Diet: As in excess carbohydrate intake.

- Exercise: Children need exercise. But diabetic children should have specific amount of exercise. Since exercises caused a low blood sugar level.

- Infection: Increase the need for insulin.

- Emotional disturbances: increase the need insulin.

- Body growth: Puberty and adolescences, there is an increased need for insulin.

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Common Types of Human Insulin

Preparation Onset (hr) Peak Effect (hr)

Duration of Effect (hr)

Lispro (Humalog)

Immediate ½–1 3–4

Regular (Humulin-R)

0.5–1.0 2–4 5–7

Lantus 1 5 24 Humulin-N 1–2 4–12 24+ Humulin-L 1–3 6–14 24+ Humulin-U 6 16–18 36+ Karch, A.M. (2004). Lippincott's nursing drug guide. Philadelphia: Lippincott Williams & Wilkins.

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3. Exercise:

Benefits: Lower blood sugar by increasing CHO

metabolism. Facilitate weight reduction. "Decrease stress

and tension.

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3. Exercise:

1. Exercise is encouraged and never restricted unless indicated by other health condition.

2. Exercise should be planned around child's capabilities.

3. Because insulin is absorbed more quickly from exercise extremities, many patients are more stable when injection is given in abdomen on day of exercise.

4. Unplanned exercise can cause hypoglycemia and that can be compensatory by giving extra snacks.

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4. Identification:• The child must wear some of medical

identification "stainless steel, silver identification bracelet that is visible and immediate recognizable."

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5. Hygiene: Foot Care:• Inspect feet carefully and routinely.• Use a small mirror to check bottom of each feet.• Bath feet daily in warm water.• Dries feet careful especially between toes.• Message the feet with lubricating lotion except

between toes.• Wear well-filling non-compressive shoes. • Avoid heat, chemicals or injury to feet.• Avoid wearing sandals, walking barefoot.• Correct nail.

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6. Regulate eye and dental check up.• Eyes-should be checked once a year unless the

child wears lenses, and then as directed by the ophthalmologist.

• Regular dental care is emphasize and periodic check up.

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• Nursing Diagnosis:

Health-seeking behaviors related to self-administration of insulin, balanced exercise, and hygiene

• Outcome Evaluation (Goal): Child demonstrates insulin injection technique to

nurse, describes steps correctly.Child discusses plans for an exercise and hygiene

program.

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• Related Interventions• Self-Administration of Insulin:

Children aged 8 years or more can be taught to administer their own insulin. Many children younger than this do not have the dexterity to handle a syringe or an understanding of the importance of sterile technique and proper dosage. They may skip injections if they are tired or busy.

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• Related Interventions Teach the child how to handle syringe correctly. Teach the child how to prepare the proper dose . Teach the child how to keep sterile technique

during all steps of preparing and giving insulin. Explain to parents that at least one adult in the

family should be taught to give insulin injection. sometimes child refuses to administer his or her own insulin or is not feeling well.

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• Related Interventions• Exercise: Exercise is an important component of

care, because it uses up carbohydrates and helps reduce hyperglycemia. No type of exercise is restricted for children with diabetes .

Teach the child to choose the injection site that is least likely to be exercised, or to eat additional carbohydrate, or decrease the regular insulin injection according to an established protocol before exercise because exercise lead to increased absorption of insulin from the injection site

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• Related Interventions Teach children to design a consistent daily

exercise program (e.g., 10 minutes of aerobics every day before school).

Explain to the child the importance to continue this type of exercise every day (including weekends) to avoid becoming hyperglycemic on days of no exercise.

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• Related Interventions• Hygiene: Teach the child to cut his/her toenails straight

across, to prevent ingrown toenails. Inform child the importance of wearing properly

fitting shoes. Reminded Girls to practice a good perineal care

to prevent vaginal infection.

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Parental anxiety related to newly diagnosed diabetes mellitus in a child

• Outcome Evaluation (Goal): Parents accurately describe their child's illness

and treatment and ways in which the disease will affect their lifestyle.

Parents state a specific plan for daily routine child care and identify potential problems in the schedule and ways they can be handled.

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• Related Interventions Ensure that parents have the telephone number of the

health care facility, most parents appreciate having someone to consult before they give insulin, for reassurance that they are giving the correct dose during the first days.

Encourage expression of Feelings. Encourage the parents and the child to describe their

perceptions of diabetes. Misconceptions need to be corrected before the child can begin to accept the diagnosis and view himself or herself as basically well except for faulty insulin release.

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Risk for imbalanced nutrition, less than body requirements, related to decreased insulin level

• Outcome Evaluation (Goal): Child's growth follows percentile curve on standard

growth chart. Serum glucose is between 70 and 110 mg/dL,

fasting. Child states that nutrition and exercise program is

being followed.

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Related Interventions Plan Nutrition Program: teach the parents to:• Plan well-balanced and appealing meals. Caloric content

should be appropriate for child's age group.• Provide three meals throughout the day, plus snacks. Total

daily caloric intake is divided to provide 20% as breakfast, 20% as lunch, 30% as dinner, and 10% as morning, afternoon, and evening snacks. Distribution of calories should be 55% carbohydrate, 30% fat, and 15% protein.

• Not to use dietetic food. This food is expensive and not necessary.

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Related Interventions:• Urge child not to omit meals. Getting him to eat at every

meal calls for creative planning so the child likes the foods served and eats readily.

• Maintain a positive outlook by stressing the foods your child is allowed to eat, not those he must avoid.

• Steer clear of concentrated carbohydrate sources, such as candy bars; be sure to include foods with adequate fiber, such as broccoli, because fiber helps prevent hyperglycemia.

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• Related Interventions:• Keep complex carbohydrates available to be eaten

before exercise, such as swimming or a softball game, to provide sustained carbohydrate energy sources.

• Teach children about meal planning so they can wisely select what to eat at school or at a friend's home. This teaching will promote independent self-care.

• Teach Hypoglycemic Management. Parents and children, as soon as they are old enough to understand, need to be aware of the reasons for hypoglycemia and what measures they must take to counteract it if it occurs.

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Related Interventions conscientious diet modification is necessary,

because chronic hyperglycemia can lead to vascular disease in later years. The American Diabetes Association recommend that children follow a nutrition pattern consistent with their lifestyle and cultural preferences.

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CRETINISM

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Disorders of Thyroid Gland:

The main function of thyroid gland is to synthesize the thyroid hormones

• T4 (thyroxin).• T3 (triiodothyroxin).

Which are essential for; Regulates the rate of body metabolism, thereby affecting body temperature, growth, cardiovascular function, gastrointestinal mobility, neurologic reflex, muscle tone, and respiratory rate

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Disorders of Thyroid Gland:

• Thyroid gland traps iodine from ingested food to produce the thyroid hormone.

• Thyroid hormones are necessary from early fetal life for normal growth and development of all tissue' particularly for brain development. This is particularly rapid in fetal and first two years of postnatal life so untreated hypothyroidism in first few years of life can result in severity impaired growth and irreversible mental retardation.

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Congenital Hypothyroidism (Cretinism)

• Definition:

Congenital hypothyroidism or "cretinism" is a condition produced by congenital insufficiency of thyroxin hormone." it is the most common-endocrine disorders in childhood"

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Congenital Hypothyroidism:

• Incidence Data from most countries with well-established

newborn screening programs indicate an incidence of congenital hypothyroidism of about 1 per 3000-4000. Some of the highest. incidences (1 in 1400 to 1 in 2000) have been reported from various locations in the Middle East.

It seems to be that girls contracting this condition more than boys (female-to-male ratio of a 2:1)

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• Causes:

1. Inborn errors of thyroid hormones synthesis and secretion.

2. Dysgenesis of the thyroid gland, including agenesis (i.e, complete absence of thyroid gland) and ectopy (lingual or sublingual thyroid gland).

3. Pregnant women with hyperthyroidism receive antithyroid medication, the drug cross the placenta and disrupt fetal thyroid hormone production.

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• Causes:

4. In maternal autoimmune disease, transplacental passage of antibodies cause transient or permanent hypothyroidism.

5. Radioactive iodine therapy of pregnant women may cause permanent congenital hypothyroidism.

6. Endemic cretinism is caused by iodine deficiency.

(The thyroid gland uses tyrosine and iodine to manufacture T4 and T3)

http://emedicine.medscape.com/article/122714-overview

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• Clinical Assessment:

1. A newborn baby without sufficient amount of a thyroid hormone may have normal appearance and functions because he has supplied with some thyroid hormone by mother while in utero. But a few weeks

after birth his movement become sluggish.

And both his physical and mental growth

are greatly retarded.

Coarse facial features

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2. In hypothyroid infants a mental development is retarded (the change are irreversible if replacement therapy is not begun soon after birth).

3. Physical retardation is manifested by anterior "fontanel wide, delayed eruption of teeth (teeth decay rapidly), delay sitting and later walking.

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4. Skeletal growth in the cretinism is characteristically more inhibited than is soft tissues growth. As a result of this disproportionate rate of growth, the soft tissues are likely to enlarge excessively, giving the cretinism child the appearance" of obese and short stature. Arms and legs are short.

5. Peculiar face appearance: eye far apart, bridge of board nose is flat, eyelid swollen, open mouth and tongue protruded.

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6. Feeding difficulties.

7. Pallor "anemia".

8. Constipation from “hypotonic abdomen muscle” and even umbilical hernia.

9. Little sweating resulting in dry and scaly skin.

10. Lethargy, little cry, poor appetite, mostly sleeping all times.

11. Subnormal temperature, pulse is slow.

12. Later on, sexual maturation is slow.

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Infant with congenital hypothyroidism, notice short, thick neck and enlarged abdomen

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• Diagnosis:• Neonatal screening:

For all newborns, a cord blood or newborn blood. Sample " by heal prick" should be used to estimate TSH and /or T4. this is very successful to diagnosis more than 95% of cases

Diagnosis is confirmed by demonstrating decreased levels of serum thyroid hormone (total or free T4) and elevated levels of thyroid-stimulating hormone (TSH) .

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• Treatment:If treatment is started within 1-4 months of birth the

mental development is usually excellent.1. Replacement therapy with oral levothyroxine in the

following dose:•Newborn: 10-15 mcg /kg /day.•6-12 month: 6-8 mcg/ kg/ day.•1-5 years: 5 mcg/ kg/ day.•6-12 years: 4mcg/ kg /day.2. Vitamin D (thyroid stimulates bone growth and

rickets may occurs as child will utilize more than his supply of vit. D.

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• Nursing Care:

1. Periodic monitoring of T4 and T3 to ensure an appropriate medication dosage. If the is low, the T4 level will remain low, and there will be few signs of clinical improvement. If the dose is too high, the T4 level will rise, and the child will show signs of hyperthyroidism: irritability, fever, rapid pulse, and perhaps vomiting, diarrhea, and weight loss.

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Nursing Care:

2. Because of tendency to teeth decay, good dental care is needed, teach tooth brushing.

3. Because of slow mental development, neither the nurse nor the parents should push child beyond his capacity, or compare him with others.

4. Health teaching about diet with high protein foods, cereals and lots of milk (vit. D and calcium).

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Nursing Care:

5- Be certain that parents know the rules for long-term medication administration with children, particularly the rule about not putting medicine in a large amount of food (thyroxine tablets must be crushed and added to food or a small amount of formula or breast milk).

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THANK YOU

endocrine disorders

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