Nursing Management of Children with Endocrine Disorders (PDF)

# Nursing Care to Children with Endocrine System Disorders ## Objectives - After this lecture, the student should be able to: - Define congenital hypothyroidism, hyperthyroidism, diabetes insipidus and diabetes mellitus - Discuss their different etiology - List their specific signs and...

# Nursing Care to Children with Endocrine System Disorders ## Objectives - After this lecture, the student should be able to: - Define congenital hypothyroidism, hyperthyroidism, diabetes insipidus and diabetes mellitus - Discuss their different etiology - List their specific signs and symptoms - Describe their treatment and nursing care ## Introduction The endocrine system is made up of glands that produce and secrete hormones which are chemical substances produced in the body that regulate the activity of cells or organs. These hormones regulate the body's growth, metabolism, and sexual development and function. The hormones are released into the bloodstream and may affect one or several organs throughout the body. Hormones are chemical messengers created by the body. They transfer information from one set of cells to another to coordinate the functions of different parts of the body. Functions of endocrine glands: they secrete chemical substances in the blood, the hormone whose function is to: 1. Regulate the metabolism. 2. Stimulate and control growth and development. 3. Stimulate and control sexual maturity and fertility. ## Disorders of the Thyroid Gland ### Function of Thyroid Gland: The main function of the thyroid gland in to synthesize the thyroid hormones, of which thyroxinT₄ and triodothyronimineT₃ are essential as they regulate the body metabolism. The thyroid gland needs to retain iodine from the blood and incorporate it into molecules to form the main hormones. Thyroid hormones are necessary from early fetal life for normal growth and development of all tissues, particularly for the brain development. This is particularly rapid in fetal and the first 6 months of postnatal life. That is why if thyroid hormones are deficient in the first 6 months, the child will have permanent brain deficiency. Early diagnosis and treatment is of greatest importance. ### Congenital Hypothyroidism **Definition:** It is a condition that is present at birth. This occurs when the thyroid gland makes too little or no thyroid hormone which turns result in generalized slowing down metabolic process and slowing growth and development with serious permanent consequences including mental retardation. **Etiology:** 1. Absent or hypo plastic thyroid gland due to an embryonic defect. 2. Lack of enzymes involved in the formation of the thyroid gland. 3. Endemic hypothyroidism in areas where iodine is lacking. 4. Pregnant women with hyperthyroidism receive anti-thyroid medication. The drug cross the placenta and destroyed the thyroid in their babies. **Clinical Manifestations:** 1. Feeding difficulties (e.g. chocking) 2. Prolongation of physiological jaundice. 3. Constipation from hypo-tonic abdominal muscles and even umbilical hernia 4. Little sweating resulting in dry and scaly skin. 5. Lethargy, little cry, poor appetite, mostly sleeping all time. 6. Subnormal temperature and slow pulse. 7. Peculiar face appearance: Eyes far apart, bridge is broad, nose is flat, eyelids swollen, open mouth, protruded tongue. 8. Poor bone development: Anterior fontanel wide-open, dentition delayed thick short neck; teeth decay rapidly, arms and leg short. 9. Physical motor development: slow (in sitting, walking, etc.). 10. Delayed mental development. 11. Delayed sexual maturation. **Diagnostic Evaluation:** - **Thyroid function:** SerumT₄ is low - **High TSH:** If the defect is primarily in thyroid. **Treatment:** If the treatment is started within 1-3 months of birth, the mental development is usually excellent. 1. Oral administration of L-thyroxin for life. 2. Levels of T₄ and TSH should be monitored and maintained in normal range. **Nursing Care:** 1. **Observe symptoms of over dosage from dissociated thyroid:** - **Signs of over-dosage from thyroid therapy:** - Rapid pulse - Increase in temperature - Loss of weight - Cramps - Vomiting - Diarrhea - Personality changes (irritability - excitability) - **Because of tendency to tooth decay, good dental care.** Teach tooth brushing. - **Because of slow mental development, neither the nurse nor the parents should push child beyond his capacity, or compare him with others.** - **Health teaching about diet with high protein foods, cereals and lots of milk (vitamin D and calcium).** **Nursing Diagnosis and Planning:** 1. **Knowledge deficit** R/T congenital disorder. **Expected Outcomes:** The parents will demonstrate the ability to monitor the infant for signs and symptoms of hypo/hyper thyroid sum; verbalize an understanding of normal growth and development milestone; give thyroid medication. 2. **Altered Growth and Development** R/T disease process. **Expected Outcome:** The infant will demonstrate growth and development milestone appreciate for age. 3. **Ineffective thermoregulation** R/T decrease basal metabolic rate. **Expected Outcome:** the infant will maintain body temperature. **Implementation:** 1. **Education is directed to the parents.** They should have understanding of importance of compliance with therapy. 2. **Parents should be aware of the correct dose and timing of the medication their infant is to receive.** The medication may be dissolved in a small amount of water and given by syringe. 3. **When the infant is older, the medication may be given by spoon.** The infant vomits within 1 hour of taking medication, the dose should be given again. 4. **Frequently missed dose may lead to developmental delays and poor growth.** 5. **Because this is lifelong condition, school -age child and teenager should be made aware of the importance of taking his/her medication and keeping regular follow-up visits** **Evaluation:** 1. Has the infant exhibited any signs and symptoms of hypo/hyper thyroidism. 2. Is the child developing appropriately for age? 3. Dose the child has normal results on thyroid function tests. ## Disorders of Pancreas ### Diabetes Mellitus **Definition:** Chronic metabolic syndrome characterized by hyperglycemia and glycosuria associated with abnormal metabolism of carbohydrate, protein and fat, caused by partial or complete deficiency of insulin. It is called "Juvenile Diabetes" if it occurs, before 15 years of age. **Etiology:** - It is a hereditary disease: siblings of client with diabetes have 10 times risk to develop diabetes. - Infections: virus and organism may attack islet cells of the pancreases and affect insulin secretion. **Clinical Manifestations:** - **Polyuria** (frequent urination) due to water not absorbed from renal tubules because of osmotic activity of glucose in the tubules. - **Polydipsia** (excessive thirst) - **Polyphagia** (excessive hunger) - **Weight loss** because glucose is not available to cells, thus the body breaks down fat and protein stores for energy. - **Enuresis.** **Diagnostic Evaluation:** Glucosuria and ketonuria plus Fasting blood glucose level ≥ 126 mg/dl or random blood glucose ≥ 200 mg/ dl or two hours plasma glucose during oral glucose tolerance test ≥ 200 mg/dl. **Laboratory features of diabetic ketoacidosis include:** - Blood glucose level more than 300mg/dl - PH level less than 7.3 - Serum bicarbonate less than 15 mmol/l **Complications:** 1. **Acute Complications:** teacher, school health nurse should be aware of child illness and manifestation of hypoglycemia and diabetic coma so they can help in emergency. **Signs and symptoms of hypoglycemia:** nervousness, pallor, tremors, palpitation, numbness, sweeting, hunger, weakness, dizziness, irritability, dilated pupils, loss of coordination, seizure and coma. **Signs and symptoms of diabetic coma:** - polyuria, polydipsia - nausea, vomiting, abdominal pain - increased pulse, slow blood pressure - dehydration, oliguria - acetone odor in mouth, ketone body in urine - Coma and death **Chronic complications:** Retinopathy, nephropathy, neuropathy, dwarfism, infection gangrene, cataracts, atherosclerosis **Therapeutic management:** 1. Diet 2. Insulin 3. Exercise 4. Foot care 5. Regular eye and dental checkup. **Diet:** 1. Diet should be attractive and varied according to limits. 2. All restricted food should be kept as far as possible. But later on child should learn self-control. 3. Child should understand that if he reports breaks in dietary rules, he will not be punished, but unreported breaks may cause sudden sickness. 4. Three meals + 2-3 snacks (55% carbohydrates, 15% fat, 30% protein), high fiber content 5. Have all diabetic children eat together as they encourage each other. **Insulin:** 1. Insulin regimen should be adapted according to lifestyle, diet, age, general health, self-management, social and financial circumstances. - 0.5-1 units/kg/day - 1.5 units/kg/day during puberty - During infection insulin should be increased by 10-15% of the calculated dose - With exercise, insulin should be decreased by 10-15% of the calculated dose 2. Child should be encouraged to express his feelings towards disease and treatment (as he may feel he is punished, because of food restriction and injections). 3. Teach child self-administration of insulin (7-10 years). Make explanation easy. Let him practice frequently under supervision. Use rotating sites of injection (thigh, upper arm and abdomen). Teach also urine analysis (when and how) e.g. pre-meal and bed time urine testing. A chart to determine the used site of injection, time given, date, dosage, and nurse's signature should be made and posted in the child's room. Also, a chart to record the urine testing results. **Insulin injection sites:** - Outer arm - Abdomen - Hip area - Thigh **Exercises:** - Exercise is encouraged and never restricted - Exercise lower blood glucose levels and insulin should be reduced by 10-15%. - Exercise should be planned around child capabilities **Foot care:** 1. Inspect feet carefully and routinely by small mirror 2. Bath feet daily in warm water and dry carefully 3. Wear well- fitting and non-compressive shoes, avoid wearing sandals and walking barefoot 4. Avoid heat, chemicals or injury to feet 5. Correct nail straight **Prognosis:** Depends upon accuracy of control measures. **Nursing care plan:** Apply nursing care plan for a child with Diabetes mellitus (Refers to Wong DL (2015): Whaley & Wong; Essentials of nursing.