The document provides information on caring for children with endocrine or metabolic conditions. It begins with an anatomy and physiology review of the endocrine system and key differences in children. Several pathophysiological conditions are then described, including:
- Growth hormone deficiency causing short stature
- Precocious puberty from premature hormone secretion
- Hypothyroidism impairing growth and development
- Congenital adrenal hyperplasia resulting in virilization of female genitalia if untreated
The summary highlights some of the major conditions discussed and learning objectives covered in the document.
One of lectures presented in our Port said fifth neonatology conference 23-24 October 2014, presented by prof Olfat Fawzy, M.D, M.Sc.,Professor of Endocrinology Al Azhar university
This is a lecture by Ruth S. Hwu, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
One of lectures presented in our Port said fifth neonatology conference 23-24 October 2014, presented by prof Olfat Fawzy, M.D, M.Sc.,Professor of Endocrinology Al Azhar university
This is a lecture by Ruth S. Hwu, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
1. Caring for the Child with an
Endocrinological or Metabolic
Condition
Joyce Buck, PhD(c), MSN, RN-C, CNE
Joy Shepard, PhD, RN-C, CNE
2. 1. Describe the Anatomy and Physiology of the Endocrine
System and Pediatric Differences
2. Identify Functions of Important Hormones
3. Identify Signs and Symptoms that May Indicate an Endocrine
Disorder
4. Identify Conditions for Which Short Stature is a Sign
Learning Outcomes
3. • Distinguish between Nursing Care for
Type 1 Diabetes Mellitus and That for Type 2
• Describe Collaborative Management for the Child with Type 1
diabetes and That for Type 2
• Develop a Nursing Care Plan for the Child with an Inherited
Metabolic Disorder
Learning Outcomes (cont’d)
4. A & P Review
Organs of the Endocrine
System
• Hypothalamus
• Pineal gland
• Pituitary gland
• Thyroid gland
• Parathyroid glands
• Adrenal glands
• Pancreas
• Gonads
6. • Hypothalamic-pituitary system produces releasing & inhibiting
hormones that regulate the function of many endocrine glands
(thyroid, adrenal, reproductive)
• Hypothalamus synthesizes many hormones
• Pituitary gland works by stimulating or inhibiting the release of
these hormones
• Pituitary gland also secretes certain hormones
Anatomy & Physiology
7. • Hormone secretion regulation occurs through a negative
feedback system
• Occurs when an endocrine gland or secretory tissue receives a
message that the target cells have received an adequate
amount of hormone
• Further secretion is inhibited
• Secretion is resumed only when the secretory tissue receives
another message indicating that levels of the hormone are low
A & P cont’d
8. • In children the endocrine system is responsible for stimulating
growth & development during childhood & adolescence
• Multiple hormones in the endocrine system are responsible for
skeletal growth & maturation (growth hormone, thyroid
hormone, adrenal & gonadal androgens & estrogen)
• Skeletal maturity can be detected by examining the child’s bone
age (x-rays of hand & wrist)
Pediatric Differences
9. • During childhood, the production of sex hormones (estrogen,
progesterone, & testosterone) is low
• Puberty (sexual maturation) occurs when gonads begin to
secrete increased amounts of the sex hormones, estrogen &
androgens
• Lasts an average of 4.5 years
• Hypothalamus produces increased amounts of gonadotropin-
releasing hormone (GnRH) at average age of 9 years in girls &
11 years in boys
Pediatric Differences cont’d
10. • Stimulates the anterior pituitary gland to secrete luteinizing
hormone (LH) & follicle-stimulating hormone (FSH)
• In boys, LH stimulates testosterone production & FSH
stimulates sperm production
• In girls, LH & FSH stimulate development & maturation of the
ova & ovulation
Gonadotropin-Releasing Hormone (GnRH)
11. • Onset of adrenal androgen production
• These adrenal hormones lead to the development of acne,
pubic hair & adult body odor
• Pubertal development usually follows a specific sequence
(breast development, pubic hair growth, & menarche in females,
& testicular enlargement, pubic hair growth, appearance of
spermatozoa in seminal fluid, facial hair, & voice change in
males)
Adrenarche
12. • Onset of menstruation in females
• Occurs at average age of 12.1 years in African American girls &
12.6 years in White girls
Menarche
14. • The release of growth hormone from the anterior pituitary gland
is controlled by the hypothalamus, which secretes releasing &
inhibitory factors
• Growth hormone (GH) stimulates linear growth & bone mineral
density, as well as growth of all body tissues
• GH also stimulates synthesis of proteins in the liver, including
somatomedins or insulin-like growth factors (IGF’s) which
promote glucose utilization by the cells
Etiology
15. • Anything that interferes with the production or release of growth
hormone (GH)
• Infarction of pituitary (SCD)
• Infection (CNS)
• Tumors (pituitary or hypothalamus)
• Cranial radiation of chemotherapy
• Psychosocial deprivation (psychosocial dwarfism)
Pituitary Hypofunction (Hypopituitarism)
Growth Hormone Deficiency (Causes)
16. • Familial
• Hypothyroidism
• Turner Syndrome
• Late Pubertal Growth Spurt
• Chronic Renal Failure
• Down’s Syndrome
• Other
Other Causes of Short Stature
17. Pituitary Hypofunction
Growth Hormone Deficiency
• Signs and symptoms
• Growth of <2 inches or 4-5 centimeters
in a year (< 3rd % by one year of age)
• Delayed closure of the anterior fontanel,
delayed dental eruption, decreased muscle
mass, delayed puberty & hypoglycemia, micropenis,
undescended testes, “cherubic” appearance
18. Familial Short Stature – Family has
adults or children who are also short
Growth Hormone Deficiency – Bothlength
andweightaresignificantlyaffected
Growth Hormone Deficiency vs Inherited
Short Stature
20. • Nursing care
• Administer human recombinant growth
hormone (GH) SQ
• Plot growth measurements on a growth chart
• Provide supportive resources
• Treat child appropriate to age
• Teach parents about condition & treatment ($$$)
• Adequate nutrition
Pituitary Hypofunction
Growth Hormone Deficiency
21. • Subcutaneous injections 6-7 times per week
• Continues for several years until growth is complete
• Increase growth velocity occurs for the first year, followed by a
gradual decrease in growth for subsequent months or years
• Treatment is continued until an acceptable height occurs or
growth velocity decreases to < 2 cm (1 in.) per year
• In addition, bone age of > 14 years (girls) or > 16 years (boys)
is reached
Growth Hormone Replacement
22. • Central precocious puberty occurs when the hypothalamus is
prematurely activated to secrete gonadotropin-releasing
hormone (GnRH)
• Other causes: tumors of the ovary, adrenal gland, & pituitary
gland
Precocious Puberty
23. • Definition: Any secondary sex characteristics before age 8
(girls); breast & pubic hair
• Any secondary sex characteristics before age 9 (boys), pubic
hair or genital development
• May be unusually tall for age
• However, growth ceases prematurely because the hormones
stimulate closure of the epiphyseal plates, resulting in short
stature
• Behavioral changes, such as mood swings & emotional lability
may occur
Precocious Puberty
26. • Conditions of the Thyroid
• Hypothyroidism
Other Endocrine Disorders
27. • Congenital or acquired
• Congenital occurs ~ 1 in 4,000 births
• Twice as common in females
Hypothyroidism
28. • Thyroid hormones are important for growth & development & for
metabolizing nutrients & energy
• When unavailable to stimulate other hormones or specific target
cells, growth is delayed & intellectual disability develops
Pathophysiology of Hypothyroidism
29. • Signs & Symptoms
• Few in 1st few weeks of life
• *Metabolic screening of newborn
• Cretinoid features
• Thick protuberant tongue
• Thick lips
• Dull appearance
Hypothyroidism
30. • Difficulty feeding
• Constipation
• Hoarse cry
• Intellectual disability
(cretinism)
• *Irreversible if not treated early
• Hypotonia
• Cool extremities
• Umbilical hernia
• Lethargy
Hypothyroidism
31. • Older Children (Acquired)
• Decreased appetite
• Cool skin
• Hair loss or thinning
• Decreased DTR’s
• Bradycardia
• Constipation
• Goiter (nontender enlarged thyroid)
Hypothyroidism
32. • Manifestations unique to children:
• Change in past normal growth patterns with weight
• height velocity
• Delayed bone & dental age
• Hypotonia with poor muscle tone
• Delayed or precocious puberty
Hypothyroidism
33.
34. • Diagnosis:
• Newborn screening of Thyroxine (T4) & Thyroid-Stimulating Hormone
(TSH)
• ↓ T4, normal T3 & ↑TSH
• Treatment:
• Levothyroxine (Synthroid)
Hypothyroidism
35. Conditions of the Adrenals
• Congenital Adrenal Hyperplasia (CAH)
Other Endocrine Disorders
36. • Autosomal recessive
• Enzyme deficiency for synthesis of cortisol & aldosterone &
overproduction of androgen
• Considered to be an inborn error in metabolism
• Occurrence~ 1 in 10,000-20,000 births
• 90-95% have 21-hydroxylase deficiency
Congenital Adrenal Hyperplasia
37. • 2 Forms:
• Salt-Losing (75%) caused by aldosterone deficiency & overproduction
of androgen
• Non-Salt-Losing (25%) with virilization (production of mascular
secondary sexual characteristics in females)
• Both forms: increased secretion of adrenocorticotropic hormone (ACTH
) occurs in response to decreased cortisol levels
Congenital Adrenal Hyperplasia, cont’d
38. • During fetal development the lack of cortisol triggers the
pituitary to continue secretion of ACTH
• This stimulates overproduction of the adrenal androgens
• Virilization of the female external genitalia begins in week 10 of
gestation
• If untreated, overproduction of androgens results in accelerated
height, early closure of epiphyseal plates, & premature sexual
development with pubic & axillary hair
Congenital Adrenal Hyperplasia, cont’d
39. • CAH is the most common cause of pseudohermaphroditism
(ambiguous genitalia) in newborn girls
• S/S
•
Enlarged clitoris & partial or complete labial fusions
• Vagina usually has a common opening with urethra
• May be mistaken for males with cryptorchidism, hypospadias or
micropenis
• Uterus, ovaries & fallopian tubes normal
Congenital Adrenal Hyperplasia
40.
41. • Male infants may look normal at birth or may have slightly
enlarged penis & hyperpigmented scrotum
• Boys may have be tall with an adult-sized penis by school-age
Congenital Adrenal Hyperplasia, cont’d
42. • As child grows precocious puberty may develop in males &
females:
• Other S/S
• Tall stature
• Acne
• Excessive muscle development
• Shorter adult stature (due to early epiphyseal fusion)
Congenital Adrenal Hyperplasia
45. • Treatment:
• Dexamethosone ↓ genital masculinization in females
• Lifelong use of glucocorticoids ( ACTH)
• Dexamethasone, prednisone or hydrocortisone
• Adrenalectomy if medical treatment ineffective
• Salt-wasting form: salt added to formula & Florinef (mineralocorticoid)
Congenital Adrenal Hyperplasia
46. • Reconstruction surgery of enlarged clitoris (females) in 1st year
• Several surgeries may be required prior to age 2
• Surgery may also be required during adolescence to dilate the vagina
• Optional: delay tx til adolescence & allow girl to decide
• Genetic counseling for child during adolescence
Treatment cont’d
47. • During acute illness, may become dehydrated quickly & need
IVF’s & electrolyte replacement
• Higher doses of hydrocortisone (double or triple)
• Teach parents to administer hydrocortisone IM
Treatment (salt-wasting)
48. • Always follow prescribed schedule
• Never abruptly discontinue
• Medical alert bracelet
• Have emergency kits available
• Check expiration dates frequently
• Administer injections if unable to take PO
Hydrocortisone Administration
49. 49
• Sit down if you have pre-diabetes, any kind of diabetes, or a first
degree relative with any kind of diabetes.
• Sit down if you have any relative with diabetes.
• Sit down if you have a close or not-so-close friend with diabetes.
• Sit down if you personally know anybody with diabetes.
• Sit down if, as a nurse or student, you have ever cared for anyone
with diabetes or a blood glucose issue.
Anybody left standing?
Everybody stand up!
51. • Incidence ~ 1 in every 400-600 children (Type 1)
• Peak age 7-15 years
• But Type 1 can present @ any age
• Caucasions & adolescents ↑ Type 1
Diabetes
52. • Pathophysiology:
• Autoimmune (Type 1)
• Destruction of pancreatic islet beta cells→ fail to secrete insulin*
• Familial (child inherits susceptibility not disease)
• Believed that event (virus or toxin) triggers inflammatory
process→ development of islet cell serum antibodies
Diabetes
53. • Insulin helps transfer glucose into cells so body can use it
• As destruction cont’s, insulin secretion ↓
• As insulin ↓ blood glucose level ↑ and glucose in cells ↓
• As serum glucose reaches 180 mg/dL, renal tubules cannot
reabsorb all glucose, so spilled in urine
• Lg. amts electrolytes (Na, K, Ca, Ph, & Mg) excreted too
(polyuria & dehydration)
• Polydipsia- attempt to relieve dehydration
Pathophysiology of Diabetes cont’d
54. • Polyphagia- attempt to compensate for calories lost during
polyuria
• Insulin deficiency ↑catabolism of protein results in ↑ production
of amino acids
• Liver converts triglycerides to fatty acids (lipolysis)→ketone
bodies
• Ketone bodies accumulate & excreted via kidneys (ketonuria)
• Ketones produce ↑ free Hydrogen ions → metabolic acidosis (↓
serum pH)
Pathophysiology of Diabetes cont’d
55.
56. Diabetes Mellitus Type I
• Signs and symptoms
• Polyuria, polydipsia, polyphagia, and unintended weight loss
• High glucose levels (blood and urine)
• Nausea, vomiting, abdominal pain, excessive fatigue, susceptibility to
infection, dehydration, blurred vision, and irritability
57.
58. Diabetes Mellitus Type I
• Diagnosis
• Elevated blood glucose levels (usually in excess of 200 mg/dL)
• Elevated hemoglobin A1C level (greater than 6.5%)
• Increase sugar and ketones in urine
• Diabetic ketoacidosis (DKA)
59. • Insulin dose too low for food eaten
• Illness, injury, or stress
• Too many CHO’s eaten
• Meals/ snacks too close together
• Insulin injected just under the skin or injected into hypertrophied
areas
• Decreased activity
Hyperglycemia Causes
61. • Give additional insulin at usual injection time
• Give correction scale insulin doses for specific blood glucose
levels when ill or injured
• Give extra injections if hyperglycemia & moderate to large
ketones
• Increase fluids
Treatment of Hyperglycemia
62. Diabetes Mellitus Type I
• Nursing care
• Major components of management and care include family education on:
• Insulin types (dose and frequency)
• Diet and nutrition
• Exercise
• Stress management
• Blood glucose and ketone monitoring
• Long-term treatment
• Patient/family teaching that optimize outcomes
63. 63
• Many children use insulin pumps.
• Pros:
• Convenience
• Better quality of life and control
• Mimics insulin dosage of a pancreas with bolus and basal
rates
• Cons:
• VERY Expensive!
• DKA may occur due to pump or user error
• Overall, more insulin is required and wasted due to priming
Insulin Pump Therapy
73. • FSBS AC
• Provide meal
• Calculate CHO’s consumed
• Administer insulin (rapid-acting) based on:
• CHO count
• +
• FSBS (sliding scale)
• ______________
• Total insulin
Pediatric Protocol for Insulin Administration
74. • Insulin lispro (Humalog Luxura) 100 unit/ml pen/cartridge 0.5 Units:
Dose 0.5 Units: Subcutaneous: 5 times a day insulin
• Administer 15 minutes before or after meal administration. HOLD if NPO or patient is not
eating.
• BS < 150, no sliding scale needed
• BS 150-200 = 0.5 unit
• BS 201-250 = 1 unit
• BS 251-300 = 1.5 units
• BS 301-350 = 2 units
• BS 351-400 = 2.5 units
• BS > 400 = 3 units, call MD
Sliding Scale Insulin
75. • Insulin lispro (Humalog Luxura) 100 unit/ml pen/cartridge 0.5
Units: Dose 0.5 Units: Subcutaneous: 5 times a day insulin
• Administer 15 minutes before or after meal administration. HOLD if NPO or patient is not
eating.
• CARB COVERAGE
• Administer 1 unit per 15 grams of carbohydrates
Carb Coverage
76. Diet & Nutrition
• Goal for a dietary plan: balance various foods and include the
caloric intake from
• Carbohydrates (50 – 60%)
• Fats (20 – 30%)
• Proteins (10 – 20%)
• Goal is to maintain normal glucose levels. AIC levels are indicative of
the average blood glucose over the past 2 to 3 months
77. Exercise & Stress Management
• Exercise and extracurricular activities should not be restricted
• Stressful life events can worsen diabetes (consult with mental
health professionals)
79. Blood Glucose &
Ketone Monitoring
• Monitor blood glucose levels 3 – 6 times per day
• Monitor urine ketones whenever blood glucose readings exceed
240 mg/dL, when the child experiences unexplained weight
loss, or if the child is ill
80. • Blood glucose < 70 mg/dL
• Caused by:
• Insulin dose too high for food eaten
• Insulin injection into muscle
• Too much exercise for insulin dose
• Too long between meals/snacks
• Too few CHO’s eaten
• Illness or stress
Hypoglycemia
83. • Children are at high risk for hypoglycemia due to their rapid
growth rates and unpredictable eating habits & physical activity
• Severe hypoglyemic episodes may occur at night in children
who receive 2 or more injections of insulin per day
Hypoglycemia cont’d
84. • S/S of nocturnal hypoglycemia:
• Awakening with headache
• Unprovoked sleep disturbance
• Feeing unusually tired
• Awakening with damp bed clothes & sheets from sweating
• To prevent:
• Don’t skip meals (dinner)or snacks (HS snack)
• Avoid excessive exercise at night
Hypoglycemia cont’d
85. • If signs of hypoglycemia (pallor, sweating, tremors, dizziness,
numb lips or mouth, confusion, irritability or altered MS) check
BG
• If BG < 70 mg/dL give glucose rapidly
• Wait 15 minutes and recheck BG
• Repeat 15 gms CHO if still < 70mg/dL
• Recheck BG in 15 minutes
• Once BG is at least 80 mg/dL give snack with a protein such as
cheese & crackers or peanut butter and crackers
Treating Hypoglycemic Episodes
86. • If conscious:
• Give 15 gms CHO’s
• Wait 15 minutes and recheck BS
• Give another 15 gms CHO’s if 70mg/dL or below
• If unconscious:
• Give glucagon by injection IM or SC or rub glucose paste on
gums
• Call 911
15.15.15 Rule
87. • Half cup juice or non-diet soda
• 3-4 glucose tablets or hard candy
• Small box of raisons
15 grams of CHO’s
88.
89. Long-term Treatments
• The focus is on reducing symptoms and preventing
complications
• The emphasis is placed on teaching the child and family about
the chronic illness and its management
• The nurse assesses the family’s readiness to learn
90. Patient/Family Teaching that
Optimizes Outcomes
• Education is the route by which a family achieves the best glucose
control for the child
• Education focus on insulin administration and schedule, meal
planning, physical exercise, blood glucose monitoring, and
extremity care
• Alternative therapies
92. • Emphasize good foot care
• Clean cotton socks
• Change socks & shoes when damp
• Washing & drying feet
• Keep toenails short
Patient/Family Teaching that
Optimizes Outcomes
93. •Individualized school health plan
• Glucose monitoring
• Insulin injections (order from HCP)
Patient/Family Teaching that
Optimizes Outcomes
94. Diabetic Ketoacidosis (DKA)
• DKA is an acute life threatening condition characterized by
hyperglycemia. It results in the breakdown of body fat for
energy leading to ketosis and acidosis.
• DKA is the presenting complaint in almost ¼ of all newly
diagnosed pediatric patients with D.M.
• DKA is the leading cause of death in these children.
95. • Signs and symptoms
• Toddlers: classic manifestations often absent
• Altered mental status, tachycardia, tachypnea, Kussmaul respirations,
normal or low blood pressure, poor perfusion, lethargy and weakness,
fever, and acetone or “fruity" breath.
• C/O nausea, vomiting, abdominal pain
• S/S dehydration
Diabetic Ketoacidosis (DKA)
96. Diabetic Ketoacidosis (DKA)
• Diagnosis
• Blood glucose of >200mg/dL
• Ketonuria
• Ketonemia with a serum bicarbonate level of <15 mEq/L
• pH of the blood (acidosis)</= 7.3
97. Diabetic Ketoacidosis (DKA)
• Nursing care
• Four essential physiologic principles
• Restore fluid volume
• Return child to a glucose utilization state by inhibiting lipolysis
• Replace body electrolytes
• Correct acidosis and restore acid-base balance
98. • Signs of DKA:
• Change in mental status
• BG > 250 mg/dL
• Moderate to large ketones in
urine
• Fruity breath odor
• Evidence of a bacterial infection
(eg. UTI)
• Difficulty breathing
• Decrease urine output
• When to monitor for DKA:
• Abdominal pain
• Nausea & vomiting that persists
for > 6 hours
• > 5 diarrhea episodes per day
• 1-2 day history of polyuria &
polydipsia
• Has illness (eg. virus) and
unable to eat
Prevention of DKA
99.
100. 100
•Remember, we are human and we make
mistakes!
•Puberty is a very crazy time for teenagers and
blood sugar control.
•Treat us as a person, not a disease.
Advice from a Type 1 Diabetic …
102. 102
• Type 2 Diabetes is growing at an alarming rate for children.
• You must approach them differently than a Type 1 patient.
•Education and prevention is KEY!
Children with Type 2
103. • Characterized by insulin resistance
• In response to increased body weight, the visceral fat produces
a cytokine hormone (tumor necrosis factor) that desensitizes
cellular insulin receptors to insulin
• The pancreatic cells produce more insulin to try to overcome
insulin resistance & facilitate glucose transfer
• This results in hyperinsulinemia
• The child maintains a balance between hyperinsulinemia &
insulin resistance and a normal glycemic state
Pathophysiology of Type 2 Diabetes
104. • As insulin resistance worsens, the islets of Langerhans beta
cells fail in their ability to hypersecrete insulin
• This leads to glucose tolerance and overt diabetes develops
• The onset of puberty and increased secretion of growth
hormone are believed to be contributing factors in the
development of insulin resistance
Pathophysiology of Type 2 Diabetes
cont’d
105. Diabetes Mellitus Type 2
• Signs and symptoms
• High blood glucose levels
• Sometimes symptoms may mimic type 1 diabetes
• Diagnosis
• Criteria for type 2 diabetes in children
• BMI >85 percentile for age, sex, and weight
• Two of the following risk factors
• Family history of type 2 diabetes
• Race/ethnicity
• Insulin resistance
• Maternal history or gestational diabetes
• Diagnosis is confirmed with 2 fasting glucose results that exceed 125
mg/d: or 2 random readings >200 mg/dL
106.
107. • Hyperpigmentation and thickening of the skin
• Occurs on the back of the neck, medial aspects of thighs and
axillae
• Associated with insulin resistance
• Present in up to 90% of children with Type 2 Diabetes
Acanthosis Nigrans
108. • Metformin is used when diet and exercise is inadequate
• Improves the sensitivity of target cells to insulin, slows the GI
absorption of glucose & reduces hepatic and renal glucose
production
• SE’s: nausea, vomiting, & diarrhea
• Sulfonylureas may be used if metformin is no adequate or
contraindicated
• Insulin may be needed for periods of increased stress or illness
and may ultimately be requires for glycemic control
Medical Management of Type 2 Diabetes
109. Diabetes Mellitus Type 2
• Nursing care
• Provide nutrition teaching (decreasing calories)
• Encourage behavioral changes: increasing activity
• Lifestyle modification to the entire family to ensure compliance
• Teach family about oral hypoglycemic agent
• Monitor for complications
Eg: Hypothalamus produces GnRH (gonadotropin-releasing hormone) @ puberty which stimulates the anterior pituitary gland to secrete LH (luteinizing hormone) & FSH (follicle-stimulating hormone)
Normal puberty: girls 8-13
boys 9 ½-14
Growth hormone is secreted by the anterior pituitary gland during stage 4 of sleep.
Infant born with normal weight & length
GHD usually detected earlier in males due to concerns about short stature
IGF-1 (insulin-like growth factor); IGFBP-3 (insulin-like growth factor- binding protein 3) screens for growth hormone deficiency
Provocative growth hormone testing: medications such as arginine, clonidine, glucagon, insulin, l-dopa, are given to stimulate release of growth hormone and is used to confirm growth hormone deficiency
MRI: detects malformation, tumor or infarct of pituitary
Bone age: identifies skeletal maturation compared to chronological age
> $52,000; insurance may not cover
Occurs more often in females
Normal puberty : 8-13 (girls)
9 ½ to 14 (boys)
GnRH agonist: continued stimulation desensitizes the pituitary to secretion of LH & FSH until a more normal age for puberty is reached
S/S similar to adults
Newborn screening is mandatory in all 50 states
Levothyroxine: recommended dose is 10-15 mcg/kg/day
Dose is increased gradually as child grows to ensue a euthyroid state
Periodic evaluation of T4 & TSH levels, bone age & growth parameters is required
Children with acquired hypothyroidism usually have normal growth following a period of catch-up growth
Aldosterone ’s sodium reabsorption & ’s potassium & hydrogen ion excretion
Androgen stimulates bone development & secondary sexual characteristics
ACTH (adrenocorticotropic hormone)
Signs of adrenal insufficiency may be the first indication of the disorder
*Mandatory in all 50 states
The goal of treatment is to suppress adrenal secretion of androgens by replacing deficient hormones
In the newborn nursery the child should referred to as “Your beautiful baby” vs. “your son” or “your daughter” until gender identity is confirmed
Multifactoral; genetic-predisposition; the child develops a susceptibility to the disease rather than the disease itself
It is estimated that at least 80% of the beta cells are destroyed prior to the onset of signs & symptoms
Islet cell antibodies can be detected in the blood months to years before the onset of beta cell destruction
Free fatty acids provide an alternate source of energy since glucose is unavailable to the cells
Polyuria may present in a child as a loss of bladder control, especially at night after having been potty trained.
Vaginitis (Candida) in females
Diagnostic criteria for D.M includes presence of classic symptoms & one of the following:
A1c >/= 6.5%
BS>/= 200
A fasting BS >/=126
A two hour BS >/= 200 with an oral glucose tolerance test
Education will include the primary caregivers but also the child depending on his age or maturity.
Long-term treatment includes eye care, foot care, etc.
Children as young as 3 or 4 are being placed on insulin pumps that are controlled by the parents.
The pump allows the child to have flexibility with eating due to the ability to bolus insulin right before they eat. They also receive a basal rate which mimics the natural insulin release of the pancreas.
Pump users tend to have lower H1ACs, better control, and overall better quality of life.
Pumps are very expensive. Reservoirs, infusion sets, and other supplies are just as expensive with or without insurance.
If the patient doesn’t know how to use the pump, or doesn’t realize that it is not delivering insulin, this could lead to DKA. The pump may also appear to be working but may not deliver insulin due to the site being bad and this will require a set change. This is expensive and problematic if it happens often.
The patient must adjust to using the pump just like they adjust to taking SubQ insulin shots. Each method of insulin delivery has its pros and cons and the patient must decide for themselves which is the best way to take their insulin.
Early Insulin Pumps
The Omnipod tubeless pump system
The pods hold the insulin.
The PDM “speaks” to the pod wirelessly and tells it how much insulin to deliver for basal and bolus rates.
Medtronic Insulin Pump with Infusion Set & Site on right and Continuous Glucose Monitoring (CGM) Sensor on left.
Medtronic is one of the most popular tubed insulin pumps systems on the market.
1st pump similar to the one seen in picture debuted in 1983.
The pump holds a reservoir of insulin that is delivered via the tubing through the infusion site in the body.
The CGM is checking the blood glucose levels at a set interval of time.
The new Medtronic pumps now “speak” to the CGM and will stop delivering insulin if the patient’s blood sugar drops below a set level (ex: 70 mg/dL), preventing further hypoglycemia.
Examples of site rotations on the stomach.
The picture on the right is of a man who only put insulin in the same sites and induced “insulin hypertrophy”. Fat and scar tissue builds up at the injection sites and if not rotated, will build up and create masses that DO NOT absorb insulin properly!
HgbA1c goal is < 7.0%
HgbA1c is the component of HgbA1 that combines most strongly with glucose
It contains the majority of glycosylated hgb
The amount of glycosylated hgb depends on the amount of glucose available in the bloodstream over the RBC’s 120-day lifespan
Confusion, headache, blurred vision: same as hyperglycemia
Parents of children may need to check glucose while child is sleeping
Glucagon is a hormone produced by the alpha cells of the pancreas that helps release stored glucose from the liver
If glucagon unavailable, rub cake icing, jelly or other sweet substance on gums
In hospital Dextrose IV
Actual patient labs: glucose 884
HCO3 <5
pH 6.81
Patient was obtunded and treated with mannitol
Normal bicarb (20-28)
With DKA: hyperkalemia, hyperchloremia, hyponatremia, hypophosphatemia, hypocalcemia, & hypomagnesemia
With administration of insulin: potassium shifts into the cells, causing hypokalemia; potassium supplements may be needed
Most common cause of DKA-related deaths is cerebral edema (keep mannitol on standby)
Often times, T1s feel that Dr. appointments are a time for judgment and their blood sugar booklets/diaries/print outs are viewed as a “grade” of how well they are taking care of themselves. Instead of treating it as such, use it as an educational opportunity with your patients. Encourage them to find patterns (depends on patient’s age/maturity level), see how certain foods and activities impact their blood sugars, etc. You want to EMPOWER the patient to take care and control of their diabetes. This is their life and they need to understand what is happening.
Puberty can really mess up blood sugars. Patient who were diagnosed younger may have had pretty good control and then they seemingly lose it all during puberty. Remind the patient to try their best to control their blood sugars but not to let bizarre highs discourage them. There are many factors that impact blood sugar levels and during this time, the patient is not entirely in control of it. Ideally, their sugars will be easier to control once they pass through puberty into adulthood.
Treat you patient holistically. Understand that there are many factors that impact their blood sugars, such as school, stress, family, relationships, etc. This varies on the patient’s age, but ask them what is going on their life and see if you can figure out what is causing weird blood sugars beyond food, not taking medication, etc. Get to know your patient as it will help you get a better picture of where they are coming from and why they are/are not taking care of themselves.
Type 2 used to be referred to as adult onset, but now children as young at 10 are being diagnosed with it due to lack of exercise, healthy food choices, etc.
Type 2 CAN be managed with diet and exercise alone. These children CAN reverse their problems by taking care of themselves. Educate them on how they can turn this around and resolve their issues.
Education! Education! Education!
This goes for both the child and the parent. Teach them ALL healthy lifestyles as the child depends upon the parent to provide their meals. Encourage the entire family to exercise together. More than likely, they all need it!
American Indians have the highest incidence of Type 2 DM in childhood
The onset of puberty and increased secretion of growth hormone are thought to contribute to insulin resistance