Endocrine disorders

Najah Qasem
Qassim University

1

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

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


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)
4


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


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


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


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


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.

9

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


 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.
11

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

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

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

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

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

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

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

Acute Complications:
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.
20

Comparison of manifestations of
hypoglycemia and hyperglycemia
Variable Hypoglycemia Hyperglycemia
Onset 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, nausea
feeling headache, dizziness. and vomiting, abdominal
pain. 21

Skin Pallor, sweating. Flushed, signs of
dehydration.

Mucous Normal Dry, crusty.
membrane

Respiration Shallow. Deep, rapid.

Pulse Tachycardia. Less rapid, weak.

Breath Normal. Fruity, acetone.
odor
22

neurologic Tremors, late: Diminished reflexes,
hyperreflexia, dilated paresthesia
pupils, seizures.

Omnious Shock, coma. Acidosis, coma.
signs

Blood:
glucose Low: < 60 mg/dl. High: >= 240 mg/dl.
ketones Negative or trace High or large
Osmolarity Normal High
Ph Normal Low (7.25 or less)
hematocrit Normal High 23

Blood:
HCO3 Normal Less than 15 mEq/L.

Urine
Output Normal Polyuria (early) to oliguria
(late).
Glucose Negative High
Acetone Negative or trace High

24

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.

25

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.
26

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

Therapeutic Management:

1. Diet
2. Insulin.
3. Exercise.
4. Identification.
5. Hygiene.
6. Regular eye and dental check up.

28


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


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


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


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

Common Types of Human
Insulin
Peak Duration of
Preparation 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 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.
33


3. Exercise:
Benefits:
 Lower blood sugar by increasing CHO
metabolism.
 Facilitate weight reduction. "Decrease stress
and tension.

34


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. 35


4. Identification:
• The child must wear some of medical
identification "stainless steel, silver
identification bracelet that is visible and
immediate recognizable."

36


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


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

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

• 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

 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

• 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

 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

• 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

Parental anxiety related to newly diagnosed
diabetes mellitus in a child
 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.

45

 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

Risk for imbalanced nutrition, less than body
requirements, related to decreased insulin level
 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.
47

 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.
48

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

• 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.
50

 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

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

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

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

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


• 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


• 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


• 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
59


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


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


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

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

63


• 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) .
64


• 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


• 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


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


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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