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5.0 OBJECTIVES
After completing this unit, you should be able to:
classify various endocrine disorders;
explain the diabetes insipidus;
differential between the various categories of diabetes mellitus;
describe the management and nursing care of child with diabetes
mellitus;
formulate a teaching plan for educating the family and child with diabetes
mellitus;
e describe inborn errors of metabolism; and
discuss nursing care of a child with inborn errors of metabolism.
5.1 INTRODUCTION
In the previous unit we have discussed about pediatric emergencies. Now we
shall focus on endocrine and metabolic disorders. Endocrine dysfunction in
children fiequently leads to altered growth and development. The accurate
identification and assessment of children is important to detect any deviation in
growth and developmental patterns and identify the factors that cause any
alteration in normal functioning of the body. In this unit we shall focus on
general classification of endocrine disorders. We shall also discuss about
common conditions such as diabetes insipidus and diabetes mellitus in detail. At
Surgical Problems-I1
The endocrine disorders can be classified as given below:
Cushing Syndrome
Cushings syndrome is uncommon in children. It is a characteristic group of
manifestations caused by excessive circulating free cortisol. (Fig. 5.2). It may
occur due to one or more of the following causes:
Excessive growth
Swollen face
Etiology
The factors responsible for the diabetes mellitus are
genetic, environmental or acquired factors
abnormal immune responses, including autoimmune reactions.
0 Morbid obesity, sedentary life style, high calorie intake and family history of
diabetes.
Pathophysiology
As you'know insulin is needed to support the metabolism of carbohydrates, fats,
and proteins, primarily by facilitating the entry of these substances'into the cell,
with the exception of nerve cells and vascular tissue. Due to deficiency of
insulin, glucose is unable to enter the cell, and its concentration in the blood
stream increases. The increased concentration of glucose produces an osmotic
gradient that causes the movement of body fluid from the intracellular space to
the extravcelluar space, from there the body fluid is excreted by the kidneys.
When the serum glucose level exceeds the renal threshold (+ 180 mgldl),
glucose "spills" into the urine leading to glycosuria, and there is an osmotic
diversion of water called Polyuria which is a cardinal sign of diabetes. The
urinary fluid losses cause the excessive thirst called Pblydipsia which is present
Nursing Care or Children in all cases of diabetes. he excessive urination (water loss) results in a
with Medical and
Surgical Problems-I1 depletion of other essential chemicals in the body.
Clinical Manifestations
A child with diabetes myellitus may present with following symptoms:
1) Rapid onset (usually over a period of a few weeks)
2) Major symptoms:
- Increased thirst
- Increased urination, enuresis
- Increased food ingestion
- Weight loss
- Fatigue
Minor symptoms:
- Skin infections
- Dry skin, poor wound healing
- Monlial vaginitis in adolescent girls
If there is diabetic ketoacidosis then following symptoms may occur because
the patient may go into shock.
3) Diabetic ketoacidosis (DKA) The symptoms at precomatose state and
comatose state are given below:
Precomatose state:
- Drowsiness
- Dryness of skin
- Cherry red lips
- Increased respirations
- Nausea
- Vomiting
- Abdominal pain
Comatose state:
- Extreme hyperpnea (kussmaul breathing)
- Acetone breath
- So% sunken eyeballs
- Rigid, weak pulse
- Decreased temperature
- Decreased blood pressure
Circulatory collapse and renal failure may follow, resulting from the combination
of lowered PH, electrolyte deficiency and dehydration
Diagnostic Evaluation
The diabetes myellilus may be diagnosed by following:
- Presence of symptoms as already discussed
*
- Glycosuria on routine examination of urine
- Random blood glucose which shows blood glucose level higher than the
200 mg/dl
- Ketonuria
- Metabolic acidosis (pH less than 7.3 and bicarbonate less than 14 mEq/L)
Treatment Nursing Care of Children
with Endocrine and
If the child presents the symptoms of ketocidosis then folloking measures are taken: Metabolic Disorders
Subacute
Develops over short period of time
Lipohypertrophy (localized tissue build-up from giving injections in the same
I
site) - repeated injections in the same area; can cause abnormal absorption
Skeletal and joint abnormalities - limited joint mobility
Growth failure and delayed sexual maturation due to underinsulinization
Chronic
These are Very rarely seen in children which include:
Retinopathylcataracts - may cause blindness
Neuropathy-peripheral and autonomic
Nephropathy-proteinuriahenal failure
Cardiooathv-connestive cardiac failure
Surgical Problems-I1
Nursing Assessment
You have to make assessment during the onset of symptoms after the diagnosis
and during the treatment.
a Obtain history of onset of signs and symptoms
Assess for levels of dehydration and weight loss and level of appetite
a Check for sores that slowly heal
Identify any fruity smell to breath-acetone breath due to ketosis
I e
Assess injection sites-look for sign of lipchypertrophy
Assess for signs of hyperglycemia-polyuria, polydipsia. Does child need to
get up in the night to go to the bathroom
I Nursing Diagnoses
I These may be
Deficit of fluid volume which is related to osmotic diuresis and vomiting
Altered nutrition: Less than body requirements due to metabolic catabolism
due to lack of insulin
a Lack of Knowledge related to insulin management and to blood glucose
monitoring
Risk for injury related to hypoglycemia
Fearlanxiety of child and family related to diagnosis, treatment and
management procedures
Nursing Interventions
110 Maintain fluid balance
Administer IV fluids as ordered Nursing Care of Ct~ildren
with Endocrine and
Monitor intake and output, blood pressure, serum electrolyte results and Metaholic Disorders
daily weight Report any abnormality
Assess for signs of dehydration-dry skin and mucous membranes,
constipation
Encourage to take oral fluids when the child is able to take orally
1) Provide an adequate diet for the child and teach the family about the diet
i) Explain that the diet should contain 55 per cent carbohydrate, 30 per cent
fat, and 15 per cent protein
ii) Approximately 70 per cent of the carbohydrate content should be
derived from complex carbohydrates such as starch
iii) Foods with high fiber content should be encouraged
iv) All diets must supply sufficient caloric intake for activity and growth,
sufficient protein for growth, and the required vitamins and minerals
- Provide and distribute Foods throughout the day to accommodate
varying peak action of insulin and adjust the foods according to
increased or decreased amounts of exercise
- Include fluids containing sugar (sodas, juices, milk) in carbohydrate
count.
2) Include the child and parents in meal planning as soon as possible
3) During hospitalization allow the child normal activity so that the observed
result of the dietary control will be valid.
4) Allow the child to eat with other children
5) Make certain that the child adheres to the prescribed diet and understands
the rationale for it
6) Refer family to a dietitian for additional planning and education
Teach About Administration of Insulin
a Insulin should be given as directed. Lispro (Humalog) insulin begins to
work immediately and should be given right before the meal. If taking
regular insulin, the child should wait 20-30 minutes before eating.
a Be aware of the major types of insulin and their effects .
Develop a systematic plan for injections that emphasizes rotation of sites to
avoid ulceretion or wound Fig. 5.3.
Fig. 5.3: a) Insulin injection sites are the upper outer portions of the arms, the thighs,
and the abdominal area.
b) Injection sites are ortated, with subsequent injections given about 2.5 cm
(1 inch) apart.
If glucagons cannot be given and the child is unresponsive, honey orcorn syrup
can be rubbed inside a cheek while positioning the child to prevent aspiration
Reduce Fear and Anxiety
I
procedures on yourself first (e.g. finger, sticks for glucose testing, allow
parent to give saline injection for practice of insulin injection).
Allow parents to verbalize feelings related to the expectations of their
performance. Assist the parents in performing the needed tasks (finger
sticks, insulin injections) to build their confidence. Instruct home
management
,
Caution the parents that the focus on the diabetic child may cause sibling
rivalry.&
) E n c them
~ to~involveall
~ ~ family
~ members in care and give K,ttentian to other
children
Prevent the child fmm developing pilty feeling for oc,~unenclof disease. pt'A
-
Explain about care and managementdm health living - 11'
Nursing Care of Children Community and Home Care Considerations
with Medical and
Surgical Problems-I1 Perform home assessment for adequate nutritional resources
Review and reteach family 's adherence to insulin administration blood
glucose monitoring and ability to respond to hypoglycemia
Ensure that school is able to follow through with management plan for
insulin administration, planned exercise and meal times, and responding to
hypoglycemia
Teach family how to monitor condition, maintain insulin coverage, and
notify the health care provider when child is ill, evaluate for dehydration,
hyperglycemia, and ketonuria.
Family Education and Health Maintenance
Educate the family about:
Influence of exercise, emotional stress, and other illness on both insulin and
diet needs
how to recognise the symptoms of insulin shock and diabetic acidosis and
related emergency management
Prevention of infection:
- Attend to regular body hygiene, with special atte:lc;on to foot care
- Report any breaks in the skin. Treat them promptly.
- Use only properly fitted shoes; do not wear vinyl or plastic, which do
not permit ventilation. Avoid calluses and blisters
- Dress the child appropriately for the weather
- See that the child receives regular dental checkups and maintenance
every 6 months
- Follow routine immunizations according to the recommended schedule
Precautionary measures:
a) Instruct the child to carry an identification card that states that he or
she has diabetes and includes name, address, telephone number, and
health care provider's name and telephone number
b) Suggest a simple, convenient source of sugar that can be easily carried
by the child or parents in a pocket, purse, or backpack to have
available for hypoglycemic symptoms. A good example is five sugar
cubes or cake decorating gel that comes as a tube, such as Cake
Mate.
Follow up with care provider or pediatrician for immunizations, at regular
health check-ups, and growth and development evaluation.
Outcome B p e d Evaluation
Intake equals output, blood pressure is stable, sodium and potassium within
normal limits
Parents and child describe a meal plan that is followed consistently
Child and parents demonstrate correct insulin administration technique and
correct glucose monitoring technique
8 Child and parents describe causes, signs and symptoms, and treatment for
hypoglycemia
8 Child and parents talk freely about diabetes, ask appropriate questions and
display no cryinglfear
5.3.2 Diabetes Insipidcs I
Diabetes insipidus (DI) is failure of the body to conserve water due to a '
deficiency of Antidiuretic Hormone (ADH), decreased renal sensitivity to ADH,
or suppression of ADH secondary to excessive ingestion of fluids (primary
polydipsia).
Signs and Symptoms
Sudden onset of excessive thirst and polyuria
The infants may present with following symptoms:
Excessive cryingquieted with water more than milk feeding
Rapid weight loss-caloric loss due to water preference over feedings
Constipation
Growth failure-failure to thrive
Sunken fontanel with dehydration
Children may have following symptoms:
a) Excessive thirst and drinking
b) Polyuria with nocturia and enuresis
c) Pale, dry skin with reduced sweating
Diagnostic Evaludtion
I Nursing Assessment
Assess hydration status and assess the appropriate intake of medicine and
accurate dosage
Assess children with complaints of polyuria and polydipsia and dehydration
Obtain a detailed history of symptoms and behavic~ss- specific attention
to changes in sleep patterns (may be caused by enuresis) and choices
(drinking of fluid, fiom toilet bowls or dog dishes)
Evaluate height and weight as weight boss may be caused by excessive drinking
Y
Nursing Diagnosis
The child with Dl has,
Deficit of fluid volume due to disease process
Altered nutrition: low intake of food less than body requirhents due to
fluid preference over food
Disturbance in sleep pattern due to nocturia and enuresis
Nursing Interventions
Restriction of dietary phenylananine but you have to ensure that the restriction
does not effect normal growth and development (both physical and neurological)
of the child. The dietary management is done for at least 10 years.
Educate the parents regarding the diseases and role of diet in the disease.
Teach the family regarding dietary restrictions. Advise the family to give low
Check Your Progress 1
1. i) Disorders of pituitary function
ii) Disorders of thyroid function
iii) Disorder of parathyroid function
iv) Disorder of adrenal{unction
v) Disorders of pancreatic hormone function
Check Your Progress 2
1. i) Insulin dependent (IDDM) or type I
iii Non-insulin-dependent (NIDDM), or type I1
iiii Maturity-onset diabetes of youth (MODY)
2. Major symptoms
Increased thirst
Increased urination, enuresis
1ncreas:d food ingestion
Weight loss
Fatigue
Minor symptoms
Skin infections
Dry skin, poor wound healing
Montial vaginitis in adolescent girls
Check Your Progress 3