Endocrine System


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Endocrine System

  1. 1. ENDOCRINE SYSTEM Ma. Victoria J. Recinto, BSN, RN, USRN Pediatric Intensive Care Nurse University of the Philippines-Manila Philippine General Hospital
  2. 2. PANCREAS <ul><li>Located posterior to the stomach </li></ul><ul><li>Influences CHO metabolism </li></ul><ul><li>Indirectly influences CHON & fat metabolism </li></ul><ul><li>Produces insulin & glucagon </li></ul>
  3. 3. PANCREAS <ul><li>Exocrine gland Endocrine gland </li></ul><ul><li>Acinar cells Islets of Langerhans </li></ul><ul><li>Pancreatic juices  cells  cells </li></ul><ul><li> </li></ul><ul><li>Glucagon Insulin </li></ul><ul><li>(Hypergly) (Hypogly) </li></ul><ul><li>(aids in digestion) </li></ul><ul><li>Pass in pancreatic duct </li></ul>
  4. 4. DIAGNOSTIC STUDIES: Glucose tolerance test <ul><li>Aids in dx of DM: if glucose levels peak at higher than N at 1-2hrs after glucose IV or po & slower than N to return to fasting levels </li></ul><ul><li>Will take 3-5 hrs, pt is given glucose IV or po & multiple blood samples </li></ul>
  5. 5. DIAGNOSTIC STUDIES: Glucose tolerance test- pt. prep <ul><li>Before the test: </li></ul><ul><li>Diet with adequate CHO (3 days) </li></ul><ul><li>No alcohol, coffee & smoking (36 hrs) </li></ul><ul><li>Fast (10-16 hrs) </li></ul><ul><li>Withhold AM insulin or OHA (for DM pt) </li></ul><ul><li>Avoid strenuous exercise (8 hrs, & after the test) </li></ul>
  6. 6. DIAGNOSTIC STUDIES: Glycosylated Hgb A <ul><li>Blood glucose bound to Hgb </li></ul><ul><li>Reflects how well blood glucose levels have been controlled for the past 3-4 mos. </li></ul><ul><li> levels: hyperglycemia in DM pt </li></ul><ul><li>N (DM pt)= ≤7.5% </li></ul><ul><li>N (without DM)=4-6% </li></ul><ul><li>Fasting not needed </li></ul>
  7. 7. Diabetes Mellitus <ul><li>Chronic disorder </li></ul><ul><li>Impaired CHO, CHON & fat metabolism r/t insulin deficiency </li></ul><ul><li>Cx: CAD, cardiomyopathy, HTN, CVA, PVD, infection, retinopathy, nephropathy, neuropathy </li></ul>
  8. 8. Diabetes Mellitus Macronutrient Anabolism Catabolism CHO Glucose Glycogen CHON Amino acid Nitrogen Fats Fatty acids Free fatty acids: Cholesterol & Ketones
  9. 9. Diabetes Mellitus <ul><li>Hyperglycemia </li></ul><ul><li>Osmotic diuresis </li></ul><ul><li>Polyuria Glycosuria </li></ul><ul><li>Cellular dehydration Cellular starvation </li></ul><ul><li>Stimulate thirst center Stimulate satiety center </li></ul><ul><li>Hypothalamus </li></ul><ul><li>Polydipsia Polyphagia </li></ul>
  10. 10. Type 1 Diabetes Mellitus <ul><li>Insulin-dependent/Juvenile Onset </li></ul><ul><li>Nearly absolute deficiency of insulin </li></ul><ul><li>If insulin is not given  fat metabolism  ketonemia (acidosis) DKA </li></ul><ul><li>Incidence rate: 10% of gen. pop. </li></ul><ul><li>Predisposing Factors </li></ul><ul><ul><li>Children, non-obese </li></ul></ul><ul><ul><li>Cause: Unknown </li></ul></ul><ul><ul><li>90%: hereditary, total destruction of  cells </li></ul></ul><ul><ul><li>Viruses </li></ul></ul><ul><ul><li>Toxicity to CCl4 </li></ul></ul><ul><ul><li>Drugs: Furosemide (Lasix) & Pentamide HCl (Pentam) </li></ul></ul>
  11. 11. Type 1 Diabetes Mellitus <ul><li>S/Sx </li></ul><ul><ul><li>3P’s + glycosuria </li></ul></ul><ul><ul><li>Wt loss, A/N/V </li></ul></ul><ul><ul><li>Blurred vision </li></ul></ul><ul><ul><li> susceptibility to infection </li></ul></ul><ul><ul><li> wound healing </li></ul></ul>
  12. 12. Type 1 Diabetes Mellitus <ul><li>Tx </li></ul><ul><ul><li>Diet </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Insulin tx </li></ul></ul><ul><ul><li>WOF Cx: DKA </li></ul></ul>
  13. 13. Nursing Interventions: Diet <ul><li>The total no. of calories is individualized based on pt’s wt & other existing health problems </li></ul><ul><li>Follows the food exchange from the American Diabetic Association (Food Guide Pyramid) </li></ul><ul><li>Depending on the pt’s needs, lifestyle, cultural & socioeconomic status </li></ul>
  14. 14. Nursing Interventions: Exercise <ul><li>Benefits </li></ul><ul><ul><li> blood glucose & cholesterol </li></ul></ul><ul><ul><li> cardiovascular risks </li></ul></ul><ul><ul><li> circulation & muscle tone </li></ul></ul><ul><ul><li> wt </li></ul></ul><ul><li>Monitor CBG before, during & after exercise (deferred if >250 mg/dL & (+) urine ketones) </li></ul><ul><li>If taking insulin, eat a 15-g CHO snack (a fruit exchange) or complex CHO with CHON before mod. exercise </li></ul>
  15. 15. Insulin Therapy <ul><li>Used when diet & wt control have failed to maintain blood glucose levels </li></ul><ul><li>Sources </li></ul><ul><ul><li>Animal: Pork/Beef- rarely used r/t anaphylaxis </li></ul></ul><ul><ul><li>Human: e.g. Humulin R- less allergic reaction </li></ul></ul><ul><ul><li>Artificial compounds </li></ul></ul><ul><li>ASA, alcohol, warfarin, OHA,  -blockers, TCA, MAOI, tetracycline  severe hypogly </li></ul><ul><li>Steroids, thizide diuretics, thyroid agents, OCP & estrogen  severe hypergly </li></ul><ul><li>Illness, infection & stress  blood glucose &  insulin needs </li></ul>
  16. 16. Insulin Therapy Types Consistency Peak Regular acting: Humulin R Clear 2-4 hrs Intermediate-acting: NPH (Humulin H) Cloudy <ul><ul><li>8-16 hrs </li></ul></ul>Long-acting: Ultralente (Humulin U) Cloudy <ul><ul><li>16-24 hrs </li></ul></ul>
  17. 17. Insulin Therapy Type Onset Peak (hrs) Duration (hrs) Rapid-acting: Lispro (Humalog) 15 min ½-1 ½ 4-5 Insulin aspart (Novolog) 5-10 min 1-3 3-5 Short-acting: Regular (Humulin R, Novolin R) ½-1 hr 2-4 5-7 Intermediate-acting: NPH (Humulin N, Novolin N) 1-2 hrs 6-14 24 Lente (Humulin L, Novolin L) 1-3 hrs 6-14 24
  18. 18. Insulin Therapy Type Onset Peak (hrs) Duration (hrs) Long-acting: Ultralente (Humulin U) 6 hrs 18-24 36 Insulin glargine (Lantus) - - 24 Premixed: 70% NPH/30% regular (Humulin 70/30) ½-1 hr 2-12 18-24 50% NPH/50% regular (Humulin 50/50) ½ hr 3-5 24 75% Lipro Protamine/25% Lispro 10-15 mins 1-6 24
  19. 19. Nursing Interventions: Storing Insulin <ul><li>Avoid exposure to extremes in T, should not be frozen or kept in direct sunlight or hot car </li></ul><ul><li>Administer at room T (esp. if vial will be used up in a mo., otherwise should be refrigerated) to prevent lipodystrophy </li></ul><ul><li>Store prefilled syringes (stable for 1 wk), keep the syringes flat or with needle in upright position to avoid clogging of the needle </li></ul>
  20. 20. Nursing Interventions: Administering Insulin <ul><li>1ml TB syringe= 100 units </li></ul><ul><li>Use G27 or 29 needle, ½ in long </li></ul><ul><li>Gently roll vial between palms, don’t shake not to create bubbles, mix well </li></ul><ul><li>Inject air to insulin vial before aspirating </li></ul><ul><li>Aspirate clear 1 st before cloudy to prevent contamination & to promote proper calibration </li></ul><ul><li>Administer mixed dose of insulin within 5-15 mins to maximize its tx effect </li></ul>
  21. 21. Nursing Interventions: Administering Insulin <ul><li>Administer at either 45-90  angle depending on the pt’s tissue deposit </li></ul><ul><li>Don’t aspirate syringe after injection </li></ul><ul><li>Rotate injection sites </li></ul><ul><ul><li>Main sites: abdomen (even & rapid absorption), posterior arms, anterior thighs, hips </li></ul></ul><ul><ul><li>Do not use same site more than once in 2-3 wks </li></ul></ul><ul><ul><li>Injections should be 1.5 in apart within the anatomical area </li></ul></ul><ul><ul><li>Avoid heat, massage & exercise at the injected area   absorption  hypogly </li></ul></ul><ul><ul><li>Avoid injection into scar tissue   absorption </li></ul></ul>
  22. 22. Nursing Interventions: Administering Insulin <ul><li>WOF Cx and provide tx </li></ul><ul><ul><li>Local allergic reaction esp. during early stages of tx </li></ul></ul><ul><ul><ul><li>Avoid using alcohol for skin prep </li></ul></ul></ul><ul><ul><ul><li>Antihistamine 1 hr before injection </li></ul></ul></ul><ul><ul><li>Lipodystrophy </li></ul></ul><ul><ul><ul><li>Use human insulin, rotate injection sites </li></ul></ul></ul><ul><ul><li>Insulin resistance </li></ul></ul><ul><ul><ul><li>Use pure insulin </li></ul></ul></ul>
  23. 23. Nursing Interventions: Administering Insulin <ul><li>WOF Cx and provide tx </li></ul><ul><ul><li>Dawn phenomenon: develops bet. 5 & 8 am (prebreakfast hypergly), r/t nocturnal release of growth hormone </li></ul></ul><ul><ul><ul><li>Give intermediate-acting insulin at 10 pm </li></ul></ul></ul><ul><ul><li>Somogyi phenomenon: hypogly at 2-3 am with rebound hypergly at 7 am </li></ul></ul><ul><ul><ul><li> intermediate-acting insulin or  bedtime snack </li></ul></ul></ul><ul><ul><li>Insulin waning- progressive hypergly from bedtime to morning </li></ul></ul><ul><ul><ul><li> evening dose of intermediate-acting insulin </li></ul></ul></ul>
  24. 24. Diabetic Ketoacidosis <ul><li>Gluconeogenesis </li></ul><ul><li>CHON breakdown Fat breakdown </li></ul><ul><li>(-) N2 balance FFA ketones </li></ul><ul><li>Tissue wasting Atherosclerosis Ketoacidosis </li></ul><ul><li>Cachexia HTN DKA </li></ul><ul><li>MI CVA </li></ul>
  25. 25. Diabetic Ketoacidosis <ul><li>Acute Cx of IDDM r/t severe hypergly  CNS depression with coma </li></ul><ul><li>Precipitating factors: stress, hypergly, infection, missed or  insulin dose </li></ul>
  26. 26. Diabetic Ketoacidosis: S/Sx <ul><ul><li>3Ps + 1 g </li></ul></ul><ul><ul><li>CBG: 300-800 mg/dL </li></ul></ul><ul><ul><li>A/N/V </li></ul></ul><ul><ul><li>Wt. loss, dehydration </li></ul></ul><ul><ul><li>Acetone breath (fruity odor) </li></ul></ul><ul><ul><li>Kussmauls’ respiration: rapid, shallow breathing </li></ul></ul><ul><ul><li> LOC  coma </li></ul></ul><ul><ul><li> FBS, BUN, crea, Hct, ABG: metabolic acidosis </li></ul></ul>
  27. 27. Nursing Interventions: Diabetic Ketoacidosis <ul><li>Assist in mech. vent. </li></ul><ul><li>Administer as ordered </li></ul><ul><ul><li>Rapid IVF: 0.9NaCl followed by 0.45NaCl (to counter DHN), then D5 0.45 NaCl when CBG= 250-300 mg/dL (WOF  ICP r/t cerebral edema) </li></ul></ul><ul><ul><li>Regular Insulin: only given IV, prime the IV tubing then discard the 1 st 50 cc solution or given with albumin to prevent sticking to the IV tubing </li></ul></ul><ul><ul><li>NaHCO3, K+ supplements (WOF for hypoK esp. within the 1 st hr of tx) </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul>
  28. 28. Type 2 Diabetes Mellitus <ul><li>Non-insulin dependent/Adult or Maturity Onset </li></ul><ul><li>Resistant to action of insulin </li></ul><ul><li>Insulin is enough to stabilize fat & CHON but not CHO </li></ul><ul><li>Incidence rate: 90% of gen. pop. </li></ul><ul><li>Predisposing Factors </li></ul><ul><ul><li>>40 y/o </li></ul></ul><ul><ul><li>90%: Obese (lack of insulin receptor binding sites) </li></ul></ul>
  29. 29. Type 2 Diabetes Mellitus <ul><li>S/Sx </li></ul><ul><ul><li>Asymptomatic at first then: 3 P’s + glycosuria </li></ul></ul><ul><li>Tx </li></ul><ul><ul><li>Oral Hypoglycemic agents </li></ul></ul><ul><ul><li>Diet </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>WOF Cx: Hyper Osmolar Non-Ketotic Coma (HONKC) </li></ul></ul>
  30. 30. Oral Hypoglycemic Agents <ul><li>Action: stimulates pancreas to secrete insulin </li></ul><ul><li>Sulfonylureas </li></ul><ul><li>1 st gen. </li></ul><ul><ul><li>Chlorpropamide (Diabinese) </li></ul></ul><ul><ul><li>Tolbutamide (Orinase) </li></ul></ul><ul><ul><li>Tolazamide (Tolinase) </li></ul></ul><ul><li>2 nd gen. </li></ul><ul><ul><li>Glucotrol (Glipizide) </li></ul></ul><ul><ul><li>Glyburide (Diabeta, Micronase) </li></ul></ul><ul><li>Biguanide: Metformin (Glucophage) </li></ul><ul><li>OHA should not be taken with Aluminum hydroxide, alcohol, ASA, OCP, sulfonamide, MAOI  severe hypogly </li></ul><ul><li>Steroids, thiazide diuretics & estrogen  severe hypergly </li></ul>
  31. 31. Hyper Osmolar Non-Ketotic Coma <ul><li>Slow onset of severe hypergly (CBG=600-1,200 mg/dL) </li></ul><ul><li>Hyperosmotic  severe DHN </li></ul><ul><li>Non-Ketotic  (-) ketones in urine & blood, no acidosis </li></ul><ul><li>HA, irritability, agitation, sz,  LOC  Coma </li></ul><ul><li>Tx: same as in DKA except NaHCO3 & insulin </li></ul>
  32. 32. Nursing Interventions: DM <ul><li>Monitor VS, I/O, CBG </li></ul><ul><li>Monitor for peak action of insulin </li></ul><ul><li>Monitor for S/Sx of hypo (or hypergly) </li></ul><ul><ul><li>T-remors, tachycardia </li></ul></ul><ul><ul><li>I-rritability </li></ul></ul><ul><ul><li>R-estlessness </li></ul></ul><ul><ul><li>E-xcessive hunger, weakness </li></ul></ul><ul><ul><li>D-epression, diaphoresis </li></ul></ul>
  33. 33. Nursing Interventions: DM <ul><li>During mild (CBG<60 mg/dl) to moderate hypogly (CBG<40 mg/dl) : give 10-15 g fast-acting simple sugar (check CBG after 15 mins. then give a regular meal or food with CHON & CHO e.g. milk & cheese within 1 hr </li></ul><ul><ul><li>Commercially prepared glucose tab. </li></ul></ul><ul><ul><li>6-10 Life Savers or hard candy </li></ul></ul><ul><ul><li>4 tsp of sugar </li></ul></ul><ul><ul><li>4 sugar cubes </li></ul></ul><ul><ul><li>1 tbs honey or syrup </li></ul></ul><ul><ul><li>½ cup fruit juice or regular softdrink </li></ul></ul><ul><ul><li>8 oz low-fat milk </li></ul></ul><ul><ul><li>6 saltin crackers </li></ul></ul><ul><ul><li>3 graham crackers </li></ul></ul>
  34. 34. Nursing Interventions: DM <ul><li>During severe hypogly (CBG<20 mg/dl): give glucagon SQ or IM up to a 2 nd dose after 10 mins. if pt is still unconscious, or 25-50 cc D50W IV </li></ul>
  35. 35. Nursing Interventions: DM <ul><li>Provide diabetic diet: alternative food products & not to skip meals </li></ul><ul><li>Encourage exercise after meals </li></ul><ul><li>Encourage annual eye & kidney exam </li></ul>
  36. 36. Nursing Interventions: DM <ul><li>Meticulous Skin & Foot care (r/t peripheral neuropathy) </li></ul><ul><ul><li>Inspect feet & between toes OD, keep it dry (no foot soaks) </li></ul></ul><ul><ul><li>Wear well-fitting socks to keep feet warm, Change socks OD </li></ul></ul><ul><ul><li>Don’t wear same pair of shoes 2 days in a row </li></ul></ul><ul><ul><li>Don’t wear open-toed shoes or with a strap across toes </li></ul></ul>
  37. 37. Nursing Interventions: DM <ul><li>Meticulous Skin & Foot care (r/t peripheral neuropathy) </li></ul><ul><ul><li>Check shoes for cracks/tears/foreign objects before wearing </li></ul></ul><ul><ul><li>Don’t walk barefooted </li></ul></ul><ul><ul><li>Cut toenails straight, smooth nails with an emery board </li></ul></ul><ul><ul><li>Apply lanolin lotion but not in between toes </li></ul></ul><ul><ul><li>Avoid restrictive garments, leg crossing, heating pads, hot water & baths </li></ul></ul>
  38. 38. Nursing Interventions: DM <ul><li>Monitor for U/A: ketones/glucose (since Tape-test method & Clinistix may cause inaccurate results), 2 nd voided urine is most accurate </li></ul><ul><li>Assist in surgical wound debridement, BKA, AKA </li></ul>
  39. 39. Nursing Interventions: DM <ul><li>WOF Cx </li></ul><ul><ul><li>Atheroslerosis, HTN, MI, CVA </li></ul></ul><ul><ul><li>Microangiopathy </li></ul></ul><ul><ul><li>Eyes: Retinopathy, premature cataract, retinal detachment, blindness </li></ul></ul><ul><ul><li>Kidneys: Nephropathy, Recurrent pyelonephritis, ARF </li></ul></ul><ul><ul><li>Peripheral neuropathy  PVD, sexual impotence </li></ul></ul><ul><ul><li>Shock r/t DKA & HONKC </li></ul></ul><ul><ul><li>Gangrene formation </li></ul></ul>