Endocrine disorders


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Endocrine disorders

  1. 1. Najah QasemQassim University 1
  2. 2. 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. 2
  3. 3. 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. 3
  4. 4. Diabetes Inspidus (DI)Causes:1. Genetic defect in synthesis of ADH.2. Due to lesion of hypothalamus:A- TumorB- TraumaC- EncephalitisD- 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) 4
  5. 5. Diabetes Inspidus (DI)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. 5
  6. 6. Diabetes Inspidus (DI)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) 6
  7. 7. Diabetes Inspidus (DI)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. 7
  8. 8. Diabetes Inspidus (DI)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 8
  9. 9. Diabetes Inspidus (DI)Nursing Diagnoses and Related Interventions1- Nursing Diagnosis:Risk for deficient fluid volume related to constant, excessive loss of fluid through urination2- Outcome Evaluation (Goal):Childs blood pressure and pulse are within normal limits for age; specific gravity of urine is between 1.003 and 1.030child states thirst is not excessive. 9
  10. 10. Diabetes Inspidus (DI)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. 10
  11. 11. Diabetes Inspidus (DI) 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 childs 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. 11
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  13. 13. 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. 13
  14. 14. 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. 14
  15. 15. 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 15
  16. 16. Clinical Manifestation: Cardinal signs of Diabetes:Clinical Manifestation Pathophysiological Bases• Polyuria (frequent • Water not reabsorbed urination). from renal tubules because of osmotic activity of glucose in the tubules. • Polyuria causes severe• Polydipsia dehydration, which (excessive thirsty). causes thirst 16
  17. 17. Clinical Manifestation: Cardinal signs of Diabetes:Clinical Manifestation Pathophysiological Bases• Polyphagia (excessive • Tissue breakdown and hunger). wasting cause a state of starvation that compels the client to eat excessive amounts of food.• Weight loss • Glucose not available to (primarily in type 1). cells; thus, the body breaks down fat and protein stores for energy. 17
  18. 18. 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) 18
  19. 19. 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 19
  20. 20. Acute Complications: Teacher, school health nurse should be aware of childs 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 foodHyperglycemia: Causes• Insufficient insulin. 20
  21. 21. Comparison of manifestations of hypoglycemia and hyperglycemiaVariable Hypoglycemia HyperglycemiaOnset Rapid (minutes) Gradual (days)Mood Labile, irritable, Lethargic. nervous, weepy, combative.Mental Difficulty concentrating, Dulled sensorium,status speaking, focusing, confused. coordinating.Inward Shaky feeling, hunger, Thirst, weakness, nauseafeeling headache, dizziness. and vomiting, abdominal pain. 21
  22. 22. Comparison of manifestations of hypoglycemia and hyperglycemiaVariable Hypoglycemia HyperglycemiaSkin Pallor, sweating. Flushed, signs of dehydration.Mucous Normal Dry, crusty.membraneRespiration Shallow. Deep, rapid.Pulse Tachycardia. Less rapid, weak.Breath Normal. Fruity, acetone.odor 22
  23. 23. Comparison of manifestations of hypoglycemia and hyperglycemiaVariable Hypoglycemia Hyperglycemianeurologic Tremors, late: Diminished reflexes, hyperreflexia, dilated paresthesia pupils, seizures.Omnious Shock, coma. Acidosis, coma.signsBlood:glucose Low: < 60 mg/dl. High: >= 240 mg/dl.ketones Negative or trace High or largeOsmolarity Normal HighPh Normal Low (7.25 or less)hematocrit Normal High 23
  24. 24. Comparison of manifestations of hypoglycemia and hyperglycemiaVariable Hypoglycemia HyperglycemiaBlood:HCO3 Normal Less than 15 mEq/L.UrineOutput Normal Polyuria (early) to oliguria (late).Glucose Negative HighAcetone Negative or trace High 24
  25. 25. HypoglycemiaNursing 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. 25
  26. 26. Hyperglycemia "Diabetic coma " , diabetic ketoacidosisNursing 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 andmeasurement or collection bag. 26
  27. 27. 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. 27
  28. 28. Therapeutic Management:1. Diet2. Insulin.3. Exercise.4. Identification.5. Hygiene.6. Regular eye and dental check up. 28
  29. 29. Therapeutic Management: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". 29
  30. 30. Therapeutic Management: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. 30
  31. 31. Therapeutic Management: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. 31
  32. 32. Therapeutic Management: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. 32
  33. 33. Common Types of Human Insulin Peak Duration ofPreparation Onset (hr) Effect (hr) Effect (hr)Lispro Immediate ½–1 3–4(Humalog)Regular 0.5–1.0 2–4 5–7(Humulin-R)Lantus 1 5 24Humulin-N 1–2 4–12 24+Humulin-L 1–3 6–14 24+Humulin-U 6 16–18 36+Karch, A.M. (2004). Lippincotts nursing drug guide.Philadelphia: Lippincott Williams & Wilkins. 33
  34. 34. Therapeutic Management:3. Exercise:Benefits: Lower blood sugar by increasing CHO metabolism. Facilitate weight reduction. "Decrease stress and tension. 34
  35. 35. Therapeutic Management:3. Exercise:1. Exercise is encouraged and never restricted unless indicated by other health condition.2. Exercise should be planned around childs 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. 35
  36. 36. Therapeutic Management:4. Identification:• The child must wear some of medical identification "stainless steel, silver identification bracelet that is visible and immediate recognizable." 36
  37. 37. Therapeutic Management: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. 37
  38. 38. Therapeutic Management: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. 38
  39. 39. Nursing Diagnoses and Related Interventions• 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. 39
  40. 40. Nursing Diagnoses and Related Interventions• 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. 40
  41. 41. Nursing Diagnoses and Related Interventions• 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. 41
  42. 42. Nursing Diagnoses and Related Interventions• 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 42
  43. 43. Nursing Diagnoses and Related Interventions• 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. 43
  44. 44. Nursing Diagnoses and Related Interventions• 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. 44
  45. 45. Nursing Diagnoses and Related Interventions• Nursing Diagnosis:Parental anxiety related to newly diagnosed diabetes mellitus in a child• Outcome Evaluation (Goal): Parents accurately describe their childs 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. 45
  46. 46. Nursing Diagnoses and Related Interventions• 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. 46
  47. 47. Nursing Diagnoses and Related Interventions• Nursing Diagnosis:Risk for imbalanced nutrition, less than body requirements, related to decreased insulin level• Outcome Evaluation (Goal): Childs 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. 47
  48. 48. Nursing Diagnoses and Related Interventions Related Interventions Plan Nutrition Program: teach the parents to:• Plan well-balanced and appealing meals. Caloric content should be appropriate for childs 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. 48
  49. 49. Nursing Diagnoses and Related Interventions 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. 49
  50. 50. Nursing Diagnoses and Related Interventions• 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 friends 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. 50
  51. 51. Nursing Diagnoses and Related InterventionsRelated 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. 51
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  53. 53. 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 53
  54. 54. 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. 54
  55. 55. 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" 55
  56. 56. 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) 56
  57. 57. Congenital Hypothyroidism:• 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. 57
  58. 58. Congenital Hypothyroidism:• 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) 58
  59. 59. Congenital Hypothyroidism:• 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 weeksafter birth his movement become sluggish.And both his physical and mental growthare greatly retarded. Coarse facial features 59
  60. 60. Congenital Hypothyroidism:• Clinical Assessment: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. 60
  61. 61. Congenital Hypothyroidism:• Clinical Assessment: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. 61
  62. 62. Congenital Hypothyroidism:• Clinical Assessment: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. 62
  63. 63. Infant with congenital hypothyroidism,notice short, thick neck and enlargedabdomen 63
  64. 64. Congenital Hypothyroidism:• 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 casesDiagnosis is confirmed by demonstrating decreased levels of serum thyroid hormone (total or free T4) and elevated levels of thyroid- stimulating hormone (TSH) . 64
  65. 65. Congenital Hypothyroidism:• 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. 65
  66. 66. Congenital Hypothyroidism:• 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. 66
  67. 67. Congenital Hypothyroidism: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). 67
  68. 68. Congenital Hypothyroidism: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). 68
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