Nursing management of children

with endocrine disorder

Dr Marwa Ouda
Objectives

At the end of this lecture the students nurse will able to :

List common physical examination for child with growth hormones

deficiency
Explain Nursing management for child with growth hormones
deficiency
Identify manifestation of DM

Discuss therapeutic management of DM

VARIATIONS IN ANATOMY AND PHYSIOLOGY

Typically, most endocrine glands begin to develop during the first trimester
of gestation, but their development is incomplete at birth. Thus, complete
hormonal control is lacking during the early years of life, and the infant
cannot appropriately balance fluid concentration, electrolytes, amino
acids, glucose, and trace substances
PITUITARY DISORDERS

A- Anterior pituitary primary disorders in children include:

growth hormone deficiency

hyperpituitarism,
B- Posterior pituitary disorders include
diabetes insipidus
Growth hormone deficiency

Growth hormone (GH) is vital for postnatal growth. It is released throughout the
day, with most secreted during sleep.

GH deficiency, is characterized by poor growth and short stature.

This lack of GH impairs the body s ability to metabolize protein, fat, and
carbohydrates.

Causes of Growth hormone deficiency

injury of the anterior pituitary gland or hypothalamus.

Tumor
infection,
Physical examination
the linear height being at or below the third percentile on
standard growth charts,

prominent subcutaneous deposits of abdominal fat; a

child-like face with a large, prominent forehead; high-
pitched voice.

delayed sexual maturation

delayed dentition; delayed skeletal maturation; and
decreased muscle mass
Laboratory and Diagnostic Testing

Pituitary function testing confirms the diagnosis GH levels below 7 to 10

ng/mL in at least two tests confirm the diagnosis.

Therapeutic Management

removal of any tumors that might be the underlying problem,

use of supplemental GH. It is given by subcutaneous injection.Treatment

continues until near final height is achieved
Nursing Management
Measure the child s height at least every 3 to 6 months and plot growth over time
on standardized growth charts

Instruct the family to report headaches, rapid weight gain, increased thirst or
urination, or painful hip or knee joints as possible adverse reaction.

Explain to the family that the child will need to visit the pediatric endocrinologist
every 3 to 6 months to monitor for growth, for potential adverse effects, and for
compliance with therapy
Diabetes Mellitus (DM)

Definition :
is a common chronic disease seen in children and
adolescents. In DM, carbohydrate, protein, and lipid
metabolism is impaired. The cardinal feature of DM is
hyperglycemia.
Classification
The major forms of diabetes are classified as:

Type 1, which is caused by a deficiency of insulin secretion due to pancreatic -

cell damage

Type 2, which is a result of insulin resistance that occurs with different degrees of
-cell impairment

Other types of diabetes secondary to certain conditions such as cystic fibrosis,

glucocorticoid use (as in Cushing syndrome), and certain genetic syndromes such
as Down syndrome,

Gestational diabetes (diabetes during pregnancy)

 The discussion for this Lecture will focus on
type 1 diabetes because it is the most common
type seen in children.
Pathophysiology
in Type 1 DM :
it is an autoimmune disorders that occur in the the genetically susceptible individual who
may also be exposed to one of the several environmental factors, or acquired factors (such
as chemicals, viruses, or other toxic agents ) . the immune system begins damages and
pancreas, resulting in inadequate insulin secretion. This deficiency
of insulin leads to an inability of cells to take up glucose. The end result is hyperglycemia,
glucose accumulation in the blood, and the body s inability to use its main source of fuel
efficiently. The kidneys try to lower blood glucose, resulting in glycosuria and polyuria. Protein
and fat are broken down for energy.
The metabolism of fat leads to a build-up of ketones and
acidosis (diabetic ketoacidosis). resulting in anorexia, nausea
and vomiting, lethargy, stupor,
altered level of consciousness, confusion, decreased skin
turgor, abdominal pain, Kussmaul respirations and air hunger,
fruity (sweet-smelling) or acetone breath odor, presence of
ketones in urine and blood, tachycardia, and, if left untreated,
coma and death.

if
Causes of DM
Genetic: - play an important role in the development of IDDM.
IDDM.
Infection: with certain virus such as mumps and rubella.

Toxins and chemicals: corticosteroids.

Stress.
Assessment criteria:
1. Polyuria (frequent urination).
2. Polydipsia (excessive thirsty).
3. Polyphagia (excessive hunger).
4. Weight loss and anorexia
5. Slow recovery of wounds.
6. Blurring of vision and headache .
7. Weakness, fatigue, pruritus, pain in fingers, and toes.
Laboratory and diagnostic test

Blood
Random Blood Sugar: 200 mg/dl.

A hemoglobin A1C greater than 6.5%,

A1C
Fasting Blood glucose :, 126 mg/dl, and a 2-hour plasma
glucose level above 200 mg/dL
Therapeutic management

1- Insulin Replacement Therapy:

Types of insulin include rapid acting, short acting, intermediate acting,
and long actin. most children will use more than one type this
depends on the needs of the child.
Often, the regimen consists of three injections of intermediate-acting
insulin, with the addition of rapid-acting insulin before breakfast and
dinner. Insulin doses are typically ordered on a sliding scale related to
the serum glucose level and how the insulin works.

Insulin doses and frequency are based on the needs of the child utilizing
information gained from blood glucose testing.

Regulating glucose can be challenging in children due to continual

growth, onset
of puberty, varying activity levels with unpredictable
schedules, unpredictable eating habits, and the inability
to always verbalize the way they are feeling.
Factors increase need to Insulin:
Excess carbohydrate intake.
During Puberty and adolescences.
Emotional disturbances.
Infection.
Exercise

Injection Procedure:
1. Insulin is administered daily by subcutaneous injections into adipose tissue over
large muscle masses using a traditional insulin syringe or a subcutaneous injector .

2. Systemic rotation of injection sites is necessary to enhance absorption. Each

injection should be separated from the previous injection 2.5 cm .
2- Diet:
The food choices should provide sufficient energy and nutrients for optimal
growth and development,

Give small frequent meals (6 meals per day).

Encourage eating a bedtime snack.

Concentrated sweets are eliminated, and fat is reduced.

Dietary fiber is encouraged because of it found decrease blood glucose level

after meal .

The time of food consumption must be regulated to correspond to the

time and action of insulin prescribed.
3. Exercise:
Exercise is encouraged and never restricted unless indicated by
other health condition.

If exercise unplanned can cause hypoglycemia and that can be

compensatory by giving extra snacks.

4. Identification:
The child must wear medical identification identification
bracelet' that is visible.
5-Screening for Complications and Associated Conditions:

Regular dental examinations (every 2 years) are recommended.

Eye examination by ophthalmologist

(with expertise in diabetes) once child is 10 and
had diabetes for 3 to 5 years; annual examinations
unless different recommendation by professional.

Investigation of the state of injection sites at each clinic visit.

The height and weight measured and plotted on an appropriate growth chart and their body mass
index calculated at each clinic visit.

Annual screening for micro-albuminuria (which occurs when the kidneys leak small
amounts of albumin into the urine) once child is 10
and has had diabetes for 5 years
 Acute Complications:

1-Hypoglycaemia:
Causes:
Too much insulin.
Increase physical activity without additional food.

Delayed or not enough food.

Signs and symptoms:
Nervousness, pallor, tremors.
Palpitation, numbness, sweating, hunger, weakness, dizziness,
irritability, dilated pupils, loss of coordination, seizures, and
coma.
Management (NO SEVERE hypoglycemia )

Give the child rapidly absorbed simple carbohydrate it will raise blood
glucose levels within 5 to 15 minutes.

As symptoms improve or normoglycaemia is restored, additional complex

long-acting carbohydrate should be given orally to maintain blood
glucose levels.

Blood glucose levels should be rechecked within 15 minutes.

Management (SEVERE hypoglycemia )

50 % intravenous glucose should be used when rapid intravenous

access is possible.

Blood glucose levels should respond within 10 minutes.

As symptoms improve or normoglycaemia is restored, in children who

are sufficiently awake, additional complex long-acting carbohydrate
should be given orally to maintain blood glucose levels.
 2- Hyperglycemia (Diabetic Ketoacidosis):
Management (SEVERE hypoglycemia )

Signs and symptoms:

-Polyuria, polydipsia.
- Nausea, vomiting, abdominal cramps, increased pulse and low blood pressure.

- Dehydration and oliguria.

- Acetone odor in mouth, keton body in urine.
- Coma and death.
Nursing management:
Check v/s.
Insulin as doctor order.
Fluid and electrolyte therapy to prevent dehydration .
Monitor blood glucose urine glucose, serum electrolyte, ECG, urea, creatinine. keton
level
Long-term complication:

Delay growth, lack of development of secondary sex

character, amenorrhea.
Long-term complication:
Retinopathy , gangrenes, arteriosclerosis.

Recurrent infection especially skin

Nephropathy, neuropathy.
Foot problems.
Dental decay.