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NURSING THERAPEUTICS

FOR CHILDREN AND ADOLESCENT II

Prepared by: Sarah Jane L. Racal RN,MAN Christian University of Thailand

Love your calling with passion; it is the meaning of your life- Sir Pagsi

THE ENDOCRINE SYSTEM

Controls

or regulates metabolic processes, governing energy production, growth, fluid and electrolyte balance, response to stress, and sexual reproduction.

THE ENDOCRINE SYSTEM

Hormones
Target organ Cells

Environment ( blood, lymph, extracellular fluids

GLANDS OF THE ENDOCRINE SYSTEM

DISORDERS OF PITUITARY FUNCTION


Hypopituitarism Pituitary

Hyperfunction Precocious Puberty Diabetes Insipidus Syndrome of Inappropriate Antidiuretic Hormone ( SIADH)

HYPOPITUITARISM

Growth hormone (GH) Short stature Delayed epiphyseal closure Retarded bone age Premature aging Increased insulin sensitivity Thyroid Stimulating Hormone ( TSH ) Short stature with infantile proportions Dry, coarse skin, yellow discoloration, pallor Cold Intolerance Constipation Somnolence Bradycardia Dyspnea on exertion Delayed dentition, loss of teeth

Is diminished or deficient secretion of pituitary hormones.

HYPOPITUITARISM : MANIFESTATIONS
Gonadotropins Absence of sexual maturation/loss of secondary sex characteristics Atrophy of genitalia, prostate gland, breasts Amenorrhea without menopausal symptoms Decreased spermatogenesis Adrenocorticotropic Hormone ( ACTH) Severe anorexia, weight loss Hypoglycemia Hypotension Hyponatremia, Hypokalemia

Anidiuretic Hormone ( ADH ) Polyuria Polydipsia Dehydration MelanocyteStimulating Hormone ( MSH ) Decreased pigmentation

HYPOPITUITARISM : CAUSES
Aplasia or Hypoplasia Idiopathic Trauma Surgery Anorexia Nervosa Autoimmune Hypophysis Irradiation

Media file 1: The left photograph shows an untreated 21-monthold girl with congenital hypopituitarism. The right panel depicts the same child aged 29 months, following 8 months of growth hormone therapy.

HYPOPITUITARISM: MANAGEMENT
Medications: Somatropin Levothyroxine Hydrocortisone Vasopressin Desmopressin Androgen
Hormone replacement and Surgical Intervention

PITUITARY HYPERFUNCTION
Gigantism ( Before epiphyseal closure)

Elevated growth hormone

Acromegaly ( After epiphyseal closure) Causes: Congenital Adrenal Hyperplasia Adenoma/Carcinoma Glucocorticoid resistance Idiopathic Trauma Post- Inflammation Facial features ( overgrowth head, lips, nose, tongue, jaw, increased facial hair), increased tendency toward DM

TREATMENT

Treatment is directed toward the specific cause of the disorder.

Injection of a specific analog of Luteinizing Hormone ( regulates Pituitary secretion) Leuprolide acetate given 0.2-0.3 mg/kg
Management

Psychological

DIABETES INSIPIDUS ( POSTERIOR PITUITARY HYPOFUNCTION )


also known as Neurogenic Diabetes Insipidus Familial Idiopathic Trauma Infection Alcohol Phenytoin

Decreased ADH/Vasopr essin/Pitress in

Uncontrolled Diuresis

Polyuiria Polydipsia First sign : Enuresis

DIABETES INSIPIDUS

Infants

Irritability

Feeding with Water and Not Milk

ALERT! For dehydration, electrolyte imbalance, elevated temperature, azotemia, potential circulatory collapse
ALERT! Encourage patient to drink more liquids to prevent electrolyte imbalance ( special precaution to those with trauma/under anesthesia)

TREATMENT
Hormone

replacement

IM/SC vasopressin Tannate ( 48-72 hours )

Nasal Spray of aqueous lysine vasopressin ( every 8-12 hours)


Overdosage

effect: SIADH symptoms

NURSING CARE MANAGEMENT


Body weight Serum Electrolyte Blood Urea Nitrogen Hematocrit Urine Specific Gravity Intake and Output

Assess

Health Education

Wear medical alert bracelet

SIADH ( SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE )


Increased ADH
Fluid retention Hypotoniciy Low serum Osmolality High urine osmolality

Stupor Convulsions

Anorexia, Nausea, Stomach cramps Irritability Personality changes

Immediate Management: RESTRICT FLUIDS ( -1/2 maintenance)

NURSING CARE MANAGEMENT


Monitor

Intake and Output Seizure precautions Long term ADH antagonizing medication Observe for signs and symptoms of fluid overload Weight Health education

THYROID DISORDERS
T4 (Throxine)

Thyroid Hormone
Calcitonin

T3 ( Triiodothyronine )

Regulates calcium levels by decreasing its concentration PTH

Controls Basal Metabolic Rate

JUVENILE HYPOTHYROIDISM
Congenital Hypoplastic Thyroid Radiotherapy Infection Low dietary intake of iodine

Decreased circulatory thyroid hormones

Poor growth Constipation Sleepiness Mental decline Myxedematous skin ( dry skin, puffiness, sparse hair)

HYPOTHYROIDISM

TREATMENT
Thyroid Hormone Replacement Increasing amounts of Levothyroxine ( 4-8 weeks )

Nursing Care Management Early recognition of disorder Health Education Encourage compliance to therapy

GOITER

Enlargement or Hypertrophy of the Thyroid gland


Can occur in deficient, excessive and normal TH secretion

Decrease circulating TH Low dietary intake of Iodine

Increased secretion of Pituitary TSH

Enlargement of Thyroid

ALERT! If an infant is born with goiter, prepare for emergency ventilation. Hyperextension of neck can improve ventilation.

LYMPHOCYTIC THYROIDITIS
Hashimoto disease/ Juvenile Autoimmune Thyroiditis - Most common cause of thyroid disease in children. Accounts for the largest percentage in juvenile hypothyroidism - After age 6

Strong genetic predisposition

Lymphocytic infiltration of the gland

Symmetrically enlarged gland

TREATMENT
Oral Replacement of Thyroid Hormone Surgery is NOT RECOMMENDED

Nursing Care Management


Reasure the child that the condition is temporary Compliance to thyroid therapy Health education

HYPERTHYROIDISM

Graves Disease

Autoimmune response to TSH receptors; no specific etiology identified


Clinical Manifestations: irritability, hyperactivity, short attention span, tremors, insomnia and emotional lability, warm, flushed and moist skin; hair is fine and unable to hold a wave; exophthalmos; increased blinking; absence of wrinkles in the forehead;visual disturbances.

TREATMENT
DRUG

THERAPY (PTU: propylthiouracil and Methimazole)

THYROIDECTOMY

(subtotal thyroidectomy)
RADIATION

THERAPY (ablation with radioiodine)

TREATMENT
Drug

therapy: Most serious side-effect: Agranulocytosis ( severe leukopenia ) Thyroidectomy complications: - Possible incidence of hypothyroidism - Laryngeal nerve palsy - Permanent hypothyroidism

THYROTOXICOSIS
Occur

from sudden release of hormones-LIFE THREATENING!

THYROID

STORM: Clinical Manifestations: severe irritability, hyperthermia,hypertension, severe tachycardia, prostration

NURSING CARE MANAGEMENT


Early

Identification Children: Need quiet, unstimulating environment conducive to rest.

ALERT : children taking propylthiouracil or methimazole must be monitored for sideeffects: Sore throat + Fever ( leukopenia)= early detection is important. See a doctor immediately.

SURGICAL CARE
Iodine

( given few weeks before surgery)=unpalatable.


Mix with a strong tasting fruit juice (grape/punch flavors) Use straw Compliance is essential to avoid thyroid crisis.

Psychological

preparation

Health education

Assess

for bleeding ( damage to laryngeal nerves: severe stridor, hoarseness )

LARYNGOSPASM
Can occur and is life-threatening. Characterized by stridor, hoarseness and feeling of tightness in the throat. Tracheostomy set Observe for signs of hypothyroidism and hypocalcemia especially in the immediate post operation period.

PARATHYROID DISORDERS
Function:

Homeostasis in serum calcium


Parathyroid Hormone + Vitamin D + Calcium

Parathyroid gland

PTH Increases serum calcium Bone demineralization

Calcitonin Decreases serum calcium Bone formation

HYPOPARATHYROIDISM: DEFICIENT PTH


Deficient in the synthesis or cellular processing of PTH Aplasia/Hypoplasia of the gland

Congenital Hypothyroidism

Decreased Calcium

Post thyroidectomy

Hypoparathyroidism

Clinical Manifestations: Numbness, tingling in hands and feet, + Chvosteks sign,+trousseaus sign, larygospasm. Convulsion may occur.

HYPOPARATHYROIDISM
Treatment goal: Maintain normal serum calcium and phosphorus levels with minimal complications.

Acute/sever tetany: IV/PO Calcium gluconate Vitamin D- prolonged onset; long half life Long term management- massive doses of vitamin D; Oral calcium supplementation

NURSING CARE MANAGEMENT

of Hypocalcemia convulsions, irritability, GI symptoms, seizures Establish seizure and safety precautions and reduce environmental stimuli. Observe for signs of larygospasm Always prepare calcium gluconate for emergency.
Recognition

HYPERPARATHYROIDISM

A rare condition in children


Nausea, vomiting, abdominal discomfort, vague bone pain, polyuria, polydipsia

Primary:
Gland adenoma

Hyperparathyroidism

Secondary: Chronic renal disease; Renal osteodystrophy; congenital anomalies of urinary tract; hypercalcemia

TREATMENT: DEPENDING ON THE CAUSE

Primary : Surgical removal of tumors or hyperplasic tissue

Secondary: Calcium and Vitamin D

NURSING CARE MANAGEMENT

1. Early recognition of the disorder

2.

Assess complications : Bone pain/fracture 3. Assess for unexplained GI symptoms and cardiac irregularities 4. Hydration to minimize renal calculi formation 5. Take fruit juices to decrease urinary PH ( cranberry or apple juice

NURSING CARE MANAGEMENT


6. Strain urine 7. Keep side rails in place and assist in ambulation. 8. Take vital signs and pulse for one full minute ( report bradycardia and cardiac arrest ) 9. Health education re diet ( Calcium and Vitamin D ) 10. Surgery may lead to hypocalcemia ( observe for signs of tetany, instituting seizure precautions. Have calcium gluconate ready for emergency

ADRENAL GLAND
Adrenal Medulla : catecholamines ( Epinephrine and Norepinephrine

Adrenal Cortex :
Steroids Glucocorticoid ( cortisol, corrtisone) Mineralocorticoid ( aldosterone ) Sex steroids ( androgen, estorgen, and progestine )

MINERALOCORTICOID

Aldosterone

Sodium and water retention and Potassium excretion

Renin-angiotension Aldosterone system

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM

Catecholamines

ADRENAL MEDULLA
Activity Vasoconstriction
Respiration Bronchial dilation Heightened sensory awareness Pupillary dilation Metabolic rate

ADRENAL

ACUTE ADRENOCORTICAL INSUFFICIENCY


Hemorrhage into the gland from trauma ( prolonged difficult labor, fulminating infections meningococcemia ,abrupt withdrawal of cortisone)

AAI

Increased Irritability Headache Diffuse abdominal weakness, nausea, vomiting, diarrhea

CRISIS

TREATMENT

Cortical Replacement Administer glucose solution Replace body fluids Antibiotic if with infection

NURSING CARE MANAGEMENT


Prompt

recognition is essential VS and BP every 15 minutes ( hyperpyrexia; shocklike state) MIO Monitor response to treatment

Rapid administration of fluids : heart failure High dosage of cortisol: sudden fall in blood pressure and temperature. Increased sodium and cortisol tx: decreased potassium---flaccif paralysis

ALERT!
Monitor

electrolyte level especially a decrease or increase in potassium ( weakness, poor muscle control, paralysis,cardiac dysrhythmias, apnea

Intravenous or oral Potassium- mixed with fruit juice

CHRONIC ADRENOCORTICAL INSUFFICIENCY ADDISONS DISEASE


Rare

in children Adrenal Gland Destruction

Generalized TB Destructive lesion in Adrenal gland Neoplasm Idiopathic

TREATMENT
Glucocorticoid

replacement

mineralocorticoid=== liberal salt intake BUT: Fever, infection, emotional upset, surgery= triple dose ( if not, may lead to ACUTE CRISIS
1.
Monthly

injections of desoxycorticosterone Implantation of desoxycorticosterone acetate pellets SC every 12 months.

NURSING CARE MANAGEMENT


Health

education- continued need for cortisol replacement Drug side-effect:


Gastric Irritation ( ingest food or use antacid ) Increased excitability and sleeplessness May require dietary management to prevent obesity.

ALERT!
Taste

different preparations of cortisone. Smaller volume of liquid to ingest is also the most bitter. Effects of Mineralocorticoid generalized edema ( eyes, headache. Cardiac arrhythmias, signs and symptoms of decreased potassium)

Side

CUSHING SYNDROME
Excessive circulating free cortisol
Adrenal Hyperplasia Adrenocortical neoplasm Extra pituitary neoplasms Administration of large amounts of exogenous corticosterone

Glucocorticoid/cortisol

Poor wound healing Excessive hair growth Moon face Buffalo hump Pundulum abdomen Ecchymosis Red abdominal Striae Bruises Weight gain

CUSHING SYNDROME

TREATMENT
Depending Surgery:

on the case

Bilateral Adrenalectomy (postop replacement of cortical hormones)

NURSING CARE MANAGEMENT


Depending

on the cause To decrease cushingoid features = give during early am to maintain normal diurnal pattern of cortisol secretion. = at night: decrease level of cortisol ( more pronounced effect if with increased supply of medication)

ALERT!
Post

operation complications of adrenalectomy ( sudden withdrawal of cortisol)


Observe for shock-like symptoms ( hypotension, hyperglycemia )

CONGENITAL ADRENAL HYPERPLASIA


Family

of disorders caused by a decreased enzyme activity required for cortisol production in the adrenal cortex.

21-hydroxylase deficiency : most common defect ( 90% of all cases of CAH) 1/12000-15000 births
Causes over production of the adrenal androgen = virilization of female fetus

CONGENITAL ADRENAL HYPERPLASIA

Interference in the biosynthesis of cortisol during fetal life

Increased production of ACTH

Hyperplasia of adrenal gland

SIGNS AND SYMPTOMS

Girls will usually have normal female reproductive

organs (ovaries, uterus, and fallopian tubes). They may also have the following changes: Abnormal menstrual periods Deep voice Early appearance of pubic and armpit hair Excessive hair growth and facial hair Failure to menstruate Genitals that look both male and female (ambiguous genitalia), often appearing more male than femal

SIGNS AND SYMPTOMS


Boys won't have any obvious problems at birth. However, they may appear to enter puberty as early as 2 - 3 years of age. Changes may include: Deep voice Early appearance of pubic and armpit hair Early development of male characteristics Enlarged penis Small testes Well-developed muscles

SIGNS AND SYMPTOMS


Both

boys and girls will be tall as children but much shorter than normal as adults. Some forms of congenital adrenal hyperplasia are more severe and cause adrenal crisis in the newborn due to a loss of salt. Newborns with these forms develop severe symptoms shortly after birth, including: Cardiac arrhythmias Dehydration Electrolyte changes Vomiting

TREATMENT
Protecting

normal growth

Androgen blockade (sprinolactone) Inhibition of estrogen synthesis ( testosterone ) GH therapy Lupon therapy

Cortisol

replacement choices

Dexamethasone day at low dosage


Laboratory

assessments of control

Androstenedione emphasis in adolescent females

PHEOCHROMOCYTOMA

Pheochromocytomas

are a type of tumor of the adrenal glands that can release high levels of epinephrine and norepinephrine

WHAT ARE SYMPTOMS OF PHEOCHROMOCYTOMA?


Sweating
Classic symptoms

Palpitations

Headache

OTHER CONDITIONS THAT MAY ACCOMPANY THE CLASSIC SYMPTOMS ARE:

Anxiety Nausea Tremors Weakness Abdominal pain Weight loss

TREATMENT
Surgery

is the definitive treatment until the tumor is removed.


Top Priority!!!! Control Blood Pressure

In rare cases, rediation therapy or chemotherapy may be required after surgery

DIABETES MELLITUS

Diabetes is an autoimmune disorder that occurs in children that have a certain genetic predisposition. It is not yet known what triggers or causes the autoimmune reaction to occur in these kids

At about 6-7 years old: Type I Insulin Dependent Diabetes Mellitus ( more common in children )

MAIN SYMPTOMS
Polyuria Weight loss Polydipsia Polyphagia

TYPE I AND TYPE II DIABETES MELLITUS


Type I IDDM Type II NIDDM

Completely unable to produce insulin Autoimmune disease of insulin-producing beta cells of the pancreas.

Almost 10% of diabetic children More common in adults Usually overweight May have acanthosis nigricans Produce insulin but cells dont respond to it.

POPULATION AT RISK OF DEVELOPING TYPE II DIABETES MELLITUS


people who are overweight or obese (more than 20 percent above their ideal body weight) people who have a parent or sibling with type 2 diabetes those who belong to a high-risk ethnic population (African-American, Native American, Asian-American, Hispanic, or Pacific Islander) people who live a sedentary lifestyle (i.e., exercise less than three times a week) women who have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg) people with high blood pressure (140/90 mmHg or above) people with high density lipoprotein cholesterol (HDL, or "good" cholesterol) level less than or equal to 35 mg/dl and/or a triglyceride level greater than or equal to 250 mg/dl

MANAGEMENT
When

to call a doctor?
Any child displaying symptoms of diabetes should be taken to a doctor or emergency care facility for evaluation immediately.

MANAGEMENT
Diagnosis

Suspected based on symptoms and confirmed by blood tests that measure the level of glucose in blood plasma

BLOOD TESTS
Fasting Plasma Glucose Test

Random Plasma Glucose Test

Oral Glucose Tolerance Test

FASTING PLASMA GLUCOSE TEST


Blood

is drawn from a vein in the child's arm following an eight-hour fast (i.e., no food or drink), usually in the morning before breakfast. The red blood cells are separated from the sample and the amount of glucose is measured in the remaining plasma. A fasting plasma glucose level of 126 mg/dl (7.0 mmol/l) or higher indicates diabetes (with a confirming retest on a subsequent day).

RANDOM PLASMA GLUCOSE TEST


Blood

is drawn at any time of day, regardless of whether the patient has eaten. A random plasma glucose concentration of 200 mg/dl (11.1 mmol/l) or higher in the presence of symptoms indicates diabetes.

ORAL GLUCOSE TOLERANCE TEST


Blood

samples are taken both before and several times after a patient drinks 75 grams of a glucose-based beverage. If plasma glucose levels taken two hours after the glucose drink is consumed are 200 mg/dl (11.1 mmol/L) or higher, the test is diagnostic of diabetes (and should be confirmed on a subsequent day if possible).

MANAGEMENT OF DIABETES MELLITUS

Diet

Medication

Exercise

TREATMENT

Type I Diabetes

insulin injections or infusions operate a home blood glucose monitor

Insulin

height, weight, age, food intake, and activity level given subcutaneously upper arm, abdomen, or upper thigh.

INSULIN
Insulin Onset of action
15 to 30 minutes 1 to 3 hours

Peak of action/Durati on
Two hours ( 4-6 hrs) 18 to 26 hours

Regular Insulin Intermediate Acting Insulin ( NPH and Lente) Ultra-lente

4 to 8 hours

28 to 36 hours

Basal action insulin ( peakless insulin)glargine or Lantus

15 minutes

Duration : 18-26 hours

INSULIN INJECTION SITE

ADMINISTRATION OF INSULIN

INSULIN AND INSULIN SYRINGE

NUTRITIONAL CONCERNS
50 to 60 % of calories from carbohydrates

10 to 20 % of calories from protein


Less than 30% of calories from fats

ORAL MEDICATIONS
Metformin

(Glucophage) Only medication approved by the U.S. FDA for use in children over age ten

Works by reducing the amount of glucose the liver produces and the amount of circulating insulin in the body.

METFORMIN

"WHATEVER THE MIND OF MAN CAN CONCEIVE AND BELIEVE, IT CAN ACHIEVE." NAPOLEON HILL

Have a healthy day ahead of all of you!