G HE SHEEHAN’S C YS O PT D N EA I G ADRENAL RT A E PI B N LO E I AN T T SA E A IL S SYNDROME L A MODULE H Heather Anderson, Christen Biddle, Ashley Clontz, Amber Ennis, Kareena Lowery
Gestational Diabetes•Gestational diabetes is a form of diabetes which manifests itself during pregnancy as a result ofhormonally mediated stress on carbohydrate metabolism and familial predisposition to diabetes.•Glucose intolerance may be transitory for the duration of pregnancy , but frequently recurs later in life. Manifestations Clinical manifestations are not always apparent in gestational diabetes. Some manifestations may include:•Blurred vision•Fatigue•Frequent infections ( including ones of bladder, vagina, and skin)•Increased thirst•Increased urination•Nausea and vomiting•Weight loss in spite of increased appetite
Gestational Diabetes Risk Factors: - Previous birth outcome often - History of - Member of high- associated with abnormal glucose risk ethnic group- Overweight gestational tolerance ( Hispanic, African,- Maternal age diabetes - History of Native American,over 25 - Gestational diabetes in ﬁrst- South or East diabetes in degree relative Asian, or Paciﬁc previous Island ancestry) pregnancies
Gestational Diabetes Nursing Diagnoses:• Risk for Ineffective Health Maintenance r/t knowledge deﬁcit• Anxiety r/t threat to self and/or fetus.• Risk for delayed development: fetal r/t endocrine disorder• Risk for disproportionate growth: fetal r/t endocrine disorder• Risk for unstable blood glucose level r/t pregnancy
Gestational Diabetes Interventions:•Educate the patient about a proper diet. She should consume enough calories and nutrients foradequate weight gain, while limiting simple sugars found in sweets. Calories should be divided between3 meals and 3 snacks a day.•Teach the importance of regular exercise. It improves the metabolism of glucose, which helps to lowerblood glucose levels and helps control weight gain.•Demonstrate how to check blood sugar levels and allow patient to perform a return demonstration.•Teach the patient about the different types of insulin.•Teach the patient how to self-inject insulin.•Teach the patient the signs and symptoms of hypo- and hyperglycemia.
Gestational Diabetes Outcomes:•The patient will maintain a balanced diet.•The patient will gain an adequate amount of weight throughout pregnancy.•The patient will demonstrate checking blood sugar level and administering insulin, if needed.•The patient will maintain normal blood glucose levels throughout pregnancy.•The patient will list the signs and symptoms of hypo- and hyperglycemia.•The patient will identify self-care actions to maintain target glucose levels.•The patient will identify actions to take if blood glucose level is too low or too high.
Gestational Diabetes Testing and Treatment:• Generally a test for gestational diabetes is carried out between the 24th and 28th week of pregnancy. If your doctor believes you could be at risk for gestational diabetes (see Risk Factors) he or she could prescribe a glucose test earlier in the pregnancy.• Often, gestational diabetes can be managed through a combination of diet and exercise. If that is not possible, it is treated with insulin(usually 15% need Insulin), in a similar manner to diabetes mellitus.
Gestational Diabetes Diagnosis: A health care team will check the affected persons blood glucose level. Depending on the mothers risk and her test results, she may have one or more of the following tests. Screening Glucose Oral Glucose Fasting Blood Challenge Test Tolerance Test Glucose TestThere are several tests intended to identify gestational Women who are considered at risk for gestational A fasting plasma glucose level >126 mg/dl (7.0 mmol/l)diabetes in pregnant women. The ﬁrst, called the diabetes are given a screening test called a 50 gram or a casual plasma glucose >200 mg/dl (11.1 mmol/l)Screening glucose challenge test, is a preliminary glucose challenge between the 24th and 28th weeks of meets the threshold for the diagnosis of diabetes, ifscreening test performed between 26-28 weeks. If a pregnancy (those with two or more risk factors may be conﬁrmed on a subsequent day, and precludes thewoman tests positive during this screening test, the tested earlier). The glucose challenge is performed by need for any glucose challenge.second test, called the Glucose Tolerance Test, may be giving 50 grams of a glucose drink and then drawing a The following are the values that the American Diabetesperformed. This test will diagnose whether diabetes blood sample one hour later and measuring the level of Association considers to be abnormal during theexists or not by indicating whether or not the body is blood glucose present. Women with a blood sugar level Glucose Tolerance Test:using glucose (a type of sugar) effectively. The Glucose greater than 140 mg/dl may have gestational diabetes,Challenge Screening is now considered to be a and require a follow up test called a 3-hour oral glucose • Fasting Blood Glucose Level≥95 mg/dl (5.33standard test performed during the second trimester of tolerance test (OGTT). mmol/L) • 1 Hour Blood Glucose Level≥180 mg/dl (10pregnancy. mmol/L) • 2 Hour Blood Glucose Level≥155 mg/dl (8.6 mmol/L) • 3 Hour Blood Glucose Level≥140 mg/dl (7.8 mmol/L)
Gestational Diabetes Medications•Most women can treat gestational diabetes by changing the way they eat and exercising more often. Ifthese changes do not keep your blood sugar level within a target range, you may need to take insulin.You may also need to take insulin if your doctor thinks that your baby is getting too large.•Some doctors are using pills called glyburide and metformin to treat women who have gestationaldiabetes.
Gestational Diabetes Nutrition:• Patients with gestational diabetes should most importantly avoid foods that contains sugar.• Counting carbohydrates in each meal is important and the total carbs each meal is about 20-45.• Food combinations is an important idea to consider. Many dieticians believe it is important to mix fruits and milk because both are simple carbohydrates.• Milk, starches, and protein emphasized since the combination can serve as short and long term energy.
Gestational Diabetes Health Promotion:Healthy dieting is the most important goal for gestational diabetes. Thesegoals include:• Eating three small meals a day with two or three snacks at the same time each day. Do not skip any meals or snacks• If the patient has morning sickness, try to eat 1-2 servings of crackers or pretzels before getting out of bed.• Choose foods high in ﬁber such as breads, pasta, cereal, rice, and fruits.• Eat food low in sugar and fat• Drink at least 8 cups of water a day.• Eat less carbohydrates at breakfast than the rest of the day because this is when insulin resistance is the greatest.• Ask health care provider about taking prenatal vitamins and supplements
Gestational Diabetes Health Promotion:Important goals for managing gestational diabetes continued:• Eat at least three servings of food that are rich in iron. This ensures that you are getting 30 mg of iron per day• Choose at least one source of Vitamin C every day. This can include: broccoli, oranges, grapefruit, strawberries, and honeydew.• Choose at least one source of Vitamin A. This includes: carrots, pumpkin, sweet potatoes, spinach, water squash, and cantaloupe.
Congenital Adrenal Hyperplasia (CAH)•CAH is a group of disorders in which the adrenal gland is not able tomanufacture adequate glucocorticoid and, while working to make glucocorticoid,produces excess androgens.•CAH is caused by a defect in the enzymatic pathway of adrenal steroidproduction. Diminished glucocorticoid production prompts increased ACTHproduction, further increasing adrenal androgen excess.• The most life-threatening and most common form of CAH is the “salt- wasting” crisis. This happens when mineralocorticoid production may be normal or low.• Infants with diminished mineralocorticoid production will waste salt through kidneys. This results in hypovolemia, low serum sodium levels, and hyperkalemia.• CAH is a autosomal recessive condition.
Congenital Adrenal Hyperplasia (CAH) Manifestations•CAH is marked by ambiguous genitalia of a newborn female infant, postnatalvirilization in both sexes, and salt-wasting crisis (in the ﬁrst few weeks of life)with low serum sodium, high serum potassium, hypovolemia, and hypotensivecrisis.•Simple virilizing CAH is not associated with salt-wasting crisis and manifestswith a muscular body, advanced bone age, and premature pubic hair. Thisform typically manifest later in infancy or early childhood.•Untreated or poorly treated CAH can result in an advanced bone age withultimate adult short stature.•A milder form of CAH, 3-beta-hydroxysteroid dehydrogenase (3B-HSD), maybecome symptomatic during childhood or adolescence, with the childmanifesting hirsutism, menstrual irregulations, or delayed menses.
Congenital Adrenal Hyperplasia Nursing Diagnoses:•Risk for disproportionate growth r/t congenital disorder•Risk for electrolyte imbalance r/t endocrine dysfunction
Congenital Adrenal Hyperplasia Interventions:•Assess newborn girls for abnormal genital characteristics, such as fused labia, enlarged clitoris, orabnormal location of urethral opening.•Assess newborn boys with unexplained dehydration and low sodium levels for adrenal insufficiency.•Assess older children who are taking glucocorticoids for excessive growth and signs of early puberty.•Measure height regularly.•Monitor renin levels closely.•Monitor blood pressure closely if receiving mineralocorticoid replacement therapy.•Instruct parents about the correct timing of medications and what to do when their child is sick.•Teach parents how to prepare sodium supplements if they are needed.
Congenital Adrenal Hyperplasia Outcomes:·•The patient will maintain normal serum sodium levels.·•The patient will maintain an average height for age and sex.·•The parents will be able to explain how and when to give medications.
Congenital Adrenal Hyperplasia Prenatal Testing• Doctors have the tools to screen and diagnose congenital adrenal hyperplasia in fetuses. These tools are used most often when siblings have the disease or family members are known to carry the gene defect. If youre pregnant and have the condition or a family history of the condition, your doctor may recommend one of the following tests:• Amniocentesis. This procedure uses a needle to withdraw a sample of cells from the amniotic ﬂuid in the womb and determine in the laboratory whether the condition is present.• Chorionic villus sampling. This test involves withdrawing cells from the placenta for analysis in the laboratory.If the condition is diagnosed before birth, treatment can be started in the womb. Prenatal diagnosis andtherapy may be able to reduce the risk of complications. Testing to determine a childs sex After birth, your child may have ambiguous external genitalia, so you may not sure of your childs sex. In that case, genetic blood tests can analyze chromosomes — in a test called karyotyping — to determine the sex of your child.In addition, a pelvic ultrasound can be used to produce images of female reproductive structures — thecervix, uterus and fallopian tubes — to conﬁrm whether your child is a girl.
Congenital Adrenal Hyperplasia Diagnosis • Physical exam. Your childs doctor will examine your child and evaluate symptoms. If, based on these ﬁndings, the doctor suspects congenital adrenal hyperplasia, the next step is to conﬁrm the diagnosis with blood and urine tests. • Blood and urine tests. Tests used to diagnose congenital adrenal hyperplasia measure levels of hormones manufactured by the adrenal glands — cortisol, aldosterone and androgens. A diagnosis can be made when there are abnormal levels of these hormones.In many states, doctors are required to conduct hormonal tests for congenital adrenal hyperplasia innewborns during the ﬁrst few days of life. Blood is drawn with a heel prick of the newborn andanalyzed.
Congenital Adrenal Hyperplasia Medications:•In most cases, your childs doctor will prescribe replacement hormone medication to boost the levelsof deﬁcient hormones in your child and restore them to normal levels. For example, your child may takean oral drug — such as hydrocortisone or dexamethasone to replace cortisol and ﬂudrocortisone toreplace aldosterone — on a daily basis. At times, children with congenital adrenal hyperplasia needmultiple drugs, with even higher doses prescribed during periods of illness or severe stress, includingsurgery
Congenital Adrenal Hyperplasia Nutrition: Patients with congenital adrenal hyperplasia should remain on an unrestricted diet. Patients should be able to have access to as salt because salt wasting is common in congenital adrenal hyperplasia Monitoring caloric intake is important and should be restricted if excess weight gain occurs. Weight gain can occur because glucocorticoids stimulate appetite.Foods with high salt content should be emphasized, these foods include: Ketchup, Salad Dressings, Baking soda and Baking powders, Broths, soups, and Gravies, Soy sauce, Salami, Bacon, and cured meats
Congenital Adrenal Hyperplasia Health Promotion: Parents with a family history of congenital adrenal hyperplasia or has a newborn diagnosed with the disease should consider genetic counseling. New born screening is very important, the screening is performed using a routine heel stick, obtaining blood from the infant. Check-ups for the disease should be emphasized to educate and monitor the disease in the patient. Patients should be equip to recognized new symptoms and changes. Patients should also understand the importance of adhering to medication and treatment of the disease
Sheehan’s Syndrome•Sheehan’s is a deﬁciency of various hormones the pituitary gland controls ; thyroid, adrenal, breast milkproduction, and menstrual function.•Postpartum hemorrhage is the most common cause of pituitary infarction, which results in decreasedhormone secretion.•The pituitary gland normally enlarges during pregnancy, and when hypotension results from hemorrhage,ischemia and necrosis of the gland occur. Usually this condition develops immediately after delivery, althoughsome cases have occurred several years later.
Sheehan’s Syndrome Manifestations:•Slowed mental function, weight gain, & difficulty staying warm•Difficulty breastfeeding or inability to beast feed•No menstrual period (amenorrhea) or infrequent menstruation (oligomenorrhea)•Loss of pubic or underarm hair•Low blood pressure•Fatigue•Weight loss Some may not realize they have Sheehan’s syndrome until they need treatment for thyroid or adrenal insufficiency.
Sheehan’s Syndrome Nursing Diagnoses:·•Risk for bleeding r/t postpartum complications·•Deficient fluid volume r/t active fluid loss·•Risk for shock r/t hypovolemia
Sheehan’s Syndrome Interventions·•Prevent postpartum hemorrhage.·•Assess for signs of bleeding, such as excessive bruising and petechiae.·•Administer blood transfusions as needed.·•Provide oxygen as ordered.·•Administer IV fluids as prescribed.
Sheehan’s Syndrome Outcomes• The patient will remain oriented to person, place, andtime.• The patient will maintain oxygen saturation above 95%.• The patient will have adequate levels of hemoglobin andhematocrit.• The patient will have no bruising or petechiae.• The patient will maintain a systolic blood pressure above90 mm Hg.
Sheehan’s Syndrome Diagnosis:Upon a general investigation symptoms may include: an inability to breast-feed(breast milk never "comes in"), Fatigue, Loss of pubic and axillary hair,amenorrhea, or lack of menstrual bleeding and low blood pressureIf your history and signs and symptoms suggest pituitary insufficiency, youllhave blood tests to check your pituitary hormone levels. You may needspecialized stimulation testing of the pituitary hormones, which typically isdone after consulting an endocrinologist.You may also need imaging tests, such as magnetic resonance imaging orcomputerized tomography, to check the size of your pituitary and to look forother possible reasons for your symptoms, such as a pituitary tumor.
Sheehan’s Syndrome Medications: Treatment for Sheehans syndrome is lifelong hormone replacement therapy. Your doctor may recommend one or more of the following medications: Corticosteroids. • Levothyroxine Estrogen Growth hormoneYour endocrinologist is likely to test your blood regularly to make sure that youre getting adequate— but not excessive — amounts of any hormones that you take. Generally, hormone levels arechecked every few weeks or months at the beginning of treatment and then once a year thereafter
Sheehan’s Syndrome Nutrition: Because Sheehan’s is a postpartum syndrome, there are no speciﬁc changes needed in the diet or nutrition. Health Promotion:• The severe bleeding from childbirth that can cause Sheehans Syndrome can often be avoided by health management and prenatal care during the pregnancy.• To make sure one is managing their health during pregnancy, the following can be included:• Ask about pre-appointment restrictions, in case tests need to be performed• Even if they seem unrelated, write down any symptom changes.• Make a list of important medical information, such as medications and past surgical procedures.• Take a family member or friend to each appointment to soak up more information.
NCLEX Questions: 1.) A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes. Which statement made by the client indicates a need for further teaching?A.) “I should stay on the diabetic diet.”B.) “I should perform glucose monitoring athome.”C.) “I should avoid exercise because of thenegative effects on insulin production.”D.) “I should be aware of any infections and reportsigns of infection immediately to my doctor.”
ANSWER: CExercise is safe and lowers bloodglucose levels.
2.) An infant is born with ambiguous genitalia. Tests are being done to assist in gender assignment. The parents tell the nurse that family and friends are asking what caused the baby to be this way. What should the nurse’s intervention include?A.) Explain the disorder so that parents can explainit to others.B.) Help parents understand that no one knowshow this occurs.C.) Suggest that parents avoid family and friendsuntil the gender is assigned.D.) Encourage parents not to worry while the testsare being done.
ANSWER: A This is the most therapeutic approachwhile the parents await the genderassignment.
3.) The best evaluation for the client outcome of accurate insulin administration is that she will:A.) Repeat the taught steps of the technique.B.) Accurately withdraw, mix, and inject insulin.C.) Have normal fasting and postprandial glucoselevels.D.) State that she understands the teaching given.
ANSWER: B A return demonstration is the best way to evaluatethat teaching has been effective.