UNIT 5 NURSING CARE OF CHILDREN
WITH ENDOCRINE AND
METABOLIC DISORDERS
Structure
5.0 Objectives
5.1 Introduction
5.2 Classification of Endocrine Disorders
5.2.1
Disorders of Pituitary Function
522
Disorders of Thyroid Function
52.3
Disorder of Parathyroid Function
52.4
Disorder of Adrenal Function
52.5
Disorders of Pancreatic Hormone Function
5.3 Common Endocrine Disorders
5.3.1
Diabetes Mellitus
5.32
Diabetes Insipidus
5.4 Inborn Errors of Metabolism
5.5 Let Us Sum Up
5.6 Answers to Check Your Progress
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;
e
describe the management and nursing care of child with diabetes
mellitus;
formulate a teaching plan for educating the family and child with diabetes
mellitus;
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
edwe \ha\\ bon inborn enorsorsofmetabolism.
These
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5.2 CLASSIFICATION OF END~CRINE
DISORDERS
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The endocrine disorders can be classified as given below:
5.2.1 Disorders of Pituitary Function
The disorders of pituitary function result in following conditions.
Hypopituitarism: Growth Hormone (GH) Deficiency
Hypopituitarism is primarily a disorder associated with deficient secretion of GH
(somatropin). It may be caused by a variety of conditions which may include
developmental defects, destructive lesions such as tumors, trauma, vascular
abnormalities, or surgery, certain hereditary disorders, or functional disorders
such as anorexia nervosa or psychosocial dwarfism. In more than half of
children with hypopituitarism, no lesion is evident and the cause is unknownidiopathic hypopituitarism or idiopathic pituitary growth failure. The children with
hypopituitarism may be normal at birth but later during infancy there is
deviation in growth from normal growth rate. Treatment consists of replacement
of growth hormone and in cases where cause is due to organic lesion then
surgical removal of lesion is done.
Fig. 5.1: Child with Hypopituitarism
Pituitary Hyperfunction
If the excess of Growth Hormone (GH) occurs prior to closure of the
epiphysieal shafts it results in proportional overgrowth of long bones until the
individual reaches a height of 8 feet or more. There is rapid and increased
development of muscles and viscera along with vertical growth. Weight is
increased but is usually in proportion to height. Also there is proportional
enlargement of head circumference which may result in delayed closure of the
fontanels. Children with a pituitary-secreting tumor may also demonstrate signs
of increased intracranial pressure, especially headache. If hypersecretion of GH
occurs after epiphyseal closure, growth takes place in the transverse direction,
producing a condition known as acromegaly. Typical facial features include
sinuses, separation and malocculsion of the teeth in enlarged jaw, disproportion
of the face to the cerebral division of the skull, increased facial hair, and
thickened and deeply creased skin.
Therapeutic treatment includes cryosurgery or hypophysectomy to remove tumor
whenever feasible followed by other therapies such as external irradiation and
radio active implants. Depending upon the insufficiency hormone replacement is
also done.
Diabetes Insipidus
It is a principal disorder of posterior pituitary hypofunction. It is also known as
Neurogenic Diabetes Insipidus (DI). It occurs as a result of hyposecretion of
antidiuretic hormone (ADH), or vasopression, which produces a state of
uncontrolled diuresis. The causes treatment and nursing care is discussed in
detail in section 5.4.2.
Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIAH) This
is a disorder caused by hypersecretion of the posterior pituitary antidiuretic
hormone (ADH, vasopressin). The syndrome of inappropriate Antiduretic.
Hormone secretion occurs with increased frequency in various conditions such
as tumour, infections and trauma of central nervous system. Increased secretion
of ADH causes the kidneys to reabsorb water, which increases the fluid
volume and decreases serum osmolality. When serum sodium levels are lowered
to 120 mEgL, the child presents the symptoms of anorexia, nausea (sometimes
vomiting), stomach cramps, irritability, and personality changes. With progressive
reduction in sodium, child may present other neurologic signs such as stupor
and seizures, etc. The symptoms disappear when the underlying disorder is
corrected. Immediate management consists of restricting fluids.
5.2.2 Disorders of Thyroid Function
The disorders of thyroid function may lead to following problems:
Juvenile Hypothyroidism
Hypothyroidism is one of the most common endocrine problems of childhood. It
may be either congenital or acquired. In this there is a deficiency in secretion
of thyroid hormone (TH). It may present as decelerated growth, dry skin,
puffiness around eyes, sparse hair, constipation, sleepiness and mental decline
Therapeutic treatment consist of replacement of thyroid hormone.
Goiter
A goiter is an enlargement or hypertrophy of the thyroid gland. It can be
congenital or acquired. Congenital disease usually occurs as a result of
antithyroid drugs andlor iodides administered to the mother during pregnancy.
The acquired disease can result from increased secretion of pituitary thyrotropic
hormone in response to decreased circulating levels of TH, neoplastic or
inflammatory processes, or dietary iodine deficiency. The enlargement of thyroid
at birth can cause respiratory distress so immediate surgery is needed to
remove the enlarged part of the gland. The replacement of thyroid hormone is
necessary to treat hypothyrodism.
Lymphocytic Thyroiditis
Lymphocytic throiditis is the most common cause of thyroid disease in children
and adolescents, and it accounts for the largest percentage of juvenile
hypothyroidism. It also accounts for many of the enlarged thyroid glands
formerly designated as thyroid hyperplasia of adolescence, or "adolesecent
goiter". The disease is more common in girls than in boys and in white persons
thgn in black persons. It occurs morr. frequently after age 6, reaching a peak
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incideqce at adolescence there is evidence that the disease is self-limited. A
child with this condition may present various signs and symptoms such as
enlarged thyroid gland, sense of fullness, hoarseness dysphagia, nervousness,
irritability, increased sweating and hyperactivity. Treatment consists of oral
administration of thyroid hormone.
Hyperthyroidism (Graves Disease)
Graves diseases is the most common cause of hyperthyroidism in children and
is usually associated with an enlarged thyroid gland and exophthalmus. The
peak incidence of the disease occurs between 12 and 14 years of age, but it
may be present at birth in children of thyrotoxic mothers, The incidence is five
times higher in girls than in boys. There is no specific cause of this disease but
it is apparently caused by a serum thyroid stimulating immunoglobulin and has
familial association; a large number of persons with the diseAse possess the
histocompatibility antigenc (HLA-B8). The child presents the signs and
symptoms such as; emotional liability, restlessness, low school performance,
fatigue, tachycardia, dyspnea on exertion, exophthalmos tremor, goiter, warm
moist skin, heat intolerance, systolic murmur, thyroid storm such as severe
irritability, anorexia and weightloss vomiting, diarrhoea, hyperthyroidism,
hypertension, severe tachycardia, prostration. This may lead to delirium coma
and death. Therapeutic management consists of anti thyroid drugs, subtotal
thyroidectomy and ablation with radio iodine (13 1 - lodide). The children
should be advised to restrict vigorous exersion until1 thyroid levels are
decreased to normal.
5.2.3 Disorder of Parathyroid Function
The disorders of parathyroid function may either lead to increased production or
decreased production of parathormone.
Hypoparathyroidism
There are two classic forms of hypoparathyroidism which may occur during
childhood as given below.
a) Autoimmune hypoparathyroidism, in which there is decreased
production of parathormone (PTH), usually in relation to auto-immune
phenomena.
b) Familial hypoparathyroidism is inherited as an autosomal recessive trait.
It has early onset, usually in the first month of life. In
pseudohypoparathyroidism there is increased production of PTH but
end-organ responsiveness to the hormone is deficient.
Pseudohypoparathyroidism is also thought to be inherited as an X-linked
dominant trait with variable expressivity. Transient hypoparathyroidism may
also be observed in infants born to mothers with the hypothyrodism or in
infants fed a milk formula with a high phosphate/calcium ratio. The
hypoparathroidism in children may present with dry, scaly, coarse skin with
eruptions, hair often brittle, thin nails with grooves, Tetany, dental and
enamel hypoplasia, muscle crumps or twitching, paresthesia tingling,
diarrhoea, vomiting, headache depression, loss of memory etc. Therapeutic
treatment consists of oral administration of calcium glucosnate and vitamin
D therapy.
Hyperparathyroidism
Hyperparathyroidism is rare in childhood but can be primary or sencondary.
The most common cause of primary hyperparathyroidism is adenoma of the
gland and that of secondary hyperparathyroidism is chronic renal disease, renal
o~teodystrophy,and congenital anomalies of the urinary tract. Hypercalcernia
present in both primary and secondary cases of hyper parathyroidism.
is
5.2.4 Disorder of Adrenal Function
The disorders of adrenal function may lead to acute and chronic .adrenocortical
insufficiency. Let us briefly describe each one as follows.
Acute Adrenocortical Insufficiency
This is a rare disorder and may result from variety of causes such as
haemorrhage in glands from trauma due to difficult labour, meningococcal
infections and or abrupt withdrawal of exogenous sources of cortisone or failure
to increase exogenous supplies during stress or congenital adreno genital
hyperplasia. Management includes replacement of cortisol, body fluids to correct
dehydration and hypovolemia administration of glucose to correct hypoglycemia
and specific antibiotic therapy. Blood transfusion is given if haemorrhage is
severe.
Chronic Adrenocortical Insufficiency (Addison's Disease)
This disorder rarely occurs in children. It is caused by destructive lesion of the
adrenal glands or a neoplasm, or it is idiopathic. The child may present with
neurologic symptoms such as muscular weakness, mental fatigue, irritability
pigmentry changes, palinar creases, hyperpigmentation over pressure points,
dehydration, anorexia weight loss, headache, hunger, sweating and weakness
etc. Therapeutic treatment includes replacement of cotisol and aldosterone.
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:
Pituitary with adrenal hyperplasia, usually attributed to an excess of ACTH
Excessive growth
Swollen face
Red abdominal striae
Poor wound healing
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Adrenal with hypersecretion of glucocorticoids, generally the result of
adrenocortical neoplasms
Ectopic with autonomous secretion of ACTH, most often caused by
extrapituitary neoplasms
Iatrogenic, frequently the result of administration of large amounts of
exogenous coricosterioids
Food dependent, inappropriate sensitivity of adrenal glands to normal
postprandial increases in secretion of gastric inhibitory polypeptide
Therapeutic management involves bilateral adrenalectomy and post operative
replacement of the cortical hormgnes.
Congential Adrenogenital Hyperplasia (CAH)
In the congential adrenogenital hyperplasia there is excessive secretion of
andogens by the adrenal cortex. These conditions are variously known as
congenital adrenogenital hyperplasia (CAH), adrenocortical hyperplasia (AH),
adrenogential syndrome (AGS), and congenital adrenocortical hyperplasia
(CAH). In children most common cause of congenital adrenogenital hyperplasia
(CAH) is hyper function of adrenal gland, an inborn deficiency of various
enzymes necessary for the biosynthesis of cortisol. CAH is inherited as an
autosomal-recessive disorder or may result from a tumor or maternal ingestion
of steroids. The child may present with enlarged clitoris, fusion of labia vaginal
orifice. in females and precocious of genital development, frequent eruptions
and genital enlargement, etc. in male. Therapeutic management includes
cortisone administration to suppress the abnormally high secretion of ACTH.
Reconstructive surgery may be done in females. Since, these children are not
diagnosed at early stages therefore due to masculanisation of the external
genitalia in female may, lead to sex assignment as male so the child should be
reared as male.
5.2.5 Disorders of Pancreatic Hormone Function
The most common disorder of pancreatic hormone secretion results in Diabetes
Mellitus (DM). DM is a most frequent endocrine disorder of childhood, with
the peak incidence during early adolescence.
It is a disease of metabolism characterized by a total or partial deficiency of
the hormone insulin, resulting in a metabolic adjustment or physiologic change in
almost all areas of the body. The details of this disorder are described in subsection 5.4.2
5.3 COMMON ENDOCRINE DISORDERS
We shall focus on two conditions Diabetes mellitus and Diabetes inspidus.
5.3.1 Diabetes Mellitus
Diabetes mellitus (DM) is a disorder of glucose intolerance caused by
deficiency in insulin production and action, resulting in hyperglycemia and
abnormal carbohydrate, protein, and fat metabolism.
It can be classified into three major groups
Insulin Dependent (IDDM), or type I: This is characterized by
catabolism and the development of ketosis in the absence of insulin replacement
therapy. Its onset is typcially in childhood and adolescence but can be at any
age
Non-insulin-dependent (NIDDM), or type 11: It involves resistance to
insulin action and defective glucose-mediated insulin secretion. Its onset is
usually after the age 40. The persons with this type of DM may or may not
require daily insulin injections.
Maturity-onset Diabetes of Youth (MODY): It is transmitted as an
autosomal-dominant disorder in which there is formation of structurally abnormal
insulin that has decreased biologic activity
Type I, formerly called juvenile onset or insulin dependent diabetes mellitus
(IDDM) most commonly occurs in younger children or school aged children.
Type I DM affects as many as 1 in 500 children.
Type 11diabetes mellitus (formerly called adult onset or non-insulin dependent
diabetes mellitus (NIDDM) was formerly found in only about 2 per cent of
cases of diabetes in children and adolescents. This is rapidly changing, and
occurrence of Type I1 diabetes is increasing among adolscents.
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
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in all cases of diabetes. he excessive urination (water loss) results in a
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
If the child presents the symptoms of ketocidosis then folloking measures are taken:
Nursing Care of Children
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Insulin therapy-to reduce hyperglycemia and inhibit lipolysis and ketogenesis
Fluid therapy to-treat dehydration, increase peripheral perfusion, and replace
sodium and potassium loss due to osmotic diuresis.
Subcutaneous insulin may be given twice a day at a dose usually of a 2:l
ratio of NPH to regular (or lispro) and a 2:l ratio for morning to evening
dose. Initially short-acting insulin is often given four times a day.
Dosage is based on the child's size, diet, and level of activity. Dosages
should be adjusted through daily monitoring of blood glucose levels
DKA treatment - low dose continuous IV infusion of regular insulin only
In many settings insulin pump therapy, consisting of a continuous
subcutaneous infusion of insulin that can be programmed to give bolus and
basal rates, may be used in some children.
Balanced diet should be given which should contain controlled carbohydrates
and adequate protein and fat to meet energy and growth requirement.
Complications
There can be acute, subacute or chronic complications
Acute
Usually reversible
Dabetic ketoacidosis (DKA) accounts for 70 per cent of diabetes-related
deaths in 'children under 10 years of age
Cerebral edema - this may be related to treatment correction and is due to
a rapid decline in blood glucose causing a fluid shift.
Hyperglycemia as a result of under of untreated cases
Hypoglycemia as a result of (insulin reaction)
Subacute
Develops over short period of time
Lipohypertrophy (localized tissue build-up from giving injections in the same
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
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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
If the child is diagnosed as a case of diabetes and is getting treatment for
ketoacidosis then you have to:
a
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Assess for potential cerebral edema (diminished level of consciousness)
when fluid replacement is initiated
Assess cardiac function-There may be tachycardia due to dehydration,
arrhythmias related to potassium imbalances
Assess renal function by checking - urinary output with intake and output,
presence of ketonuria and glucosuria
a
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Watch for hypoglycemia-over treatment of insulin may lower glucose level.
IV replacements frequently contain glucose to prevent large osmotic fluid
shifts leading to cerebral edema.
During treatmentlroutine follow-up:
Assess weight-excessive weight gain may indicate overtreatment of insulin
(child eats due to constant hunger). Loss or lack of weight gain may
indicate underinsulinization (losing calories that are not metabolized).
Review blood glucose daily for level of control and need for insulin
adjustments (check for appropriate adjustments of insulin made by parents).
Obtain history of any hypoglycemic reactions
dietary record and exerciselactivity.
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be specific to time of day,
Assess injection sites-look for sign of lipchypertrophy
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Assess for signs of hyperglycemia-polyuria, polydipsia. Does child need to
get up in the night to go to the bathroom
Nursing Diagnoses
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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
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Maintain fluid balance
Administer IV fluids as ordered
Monitor intake and output, blood pressure, serum electrolyte results and
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
Maintain Adequate Nutritional Status
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
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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
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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.
a
Guidelines for site location:
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Be certain that the measuring scale of the syringe matches the unit
strength on the bottle of insulin. U-100 insulin is preferred because it
allows the smallest possible amount to be given. Other concentrations of
insulin are rarely used.
Use insulin that is at room temperature
- Keep the bottle of insulin in use at room temperature for approximately
1 month without losing appreciable strength
- Extra bottles should be stored in the refrigerator
Before giving insulin mix the solution thoroughly by shaking the bottle
(rolling may not be effective)
Administer insulin subcutaneously
e
Observe the skin closely for signs of irritation and allergic reaction (rash).
Don't give insulin injection on a site if there are signs of irritation
Fig. 5.3: a)
b)
Insulin injection sites are the upper outer portions of the arms, the thighs,
and the abdominal area.
Injection sites are ortated, with subsequent injections given about 2.5 cm
(1 inch) apart.
Fig. 5.3: (C) Inssiin injection by a child.
Teach the importance of normal activity
Explain that exercises and infection can increase the need for insulin
Explain the patient and be alert for signs of infection and dehydration
Encourage the child to express feelings about the injections.
Nursing Care of Children
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Providing Information about Blood Glucose Monitoring
Teach the child and parents about monitoring the blood glucose. Explain
that the procedure requires a drop of blood (obtained by finger stick a
health care personnel or parents.
Identify and Control Hypoglycemia
Explain family about the causes, of hypoglycemia. Which include.
Overdose of insulin
Reduction in diet or increased exercise without sufficient caloric coverve
Teach Symptoms of hypoglyceiilia which include:
Trembling, shaking, dizziness
Sweating, apprehension
Tachycardia
Hunger, weakness
Drowsitress, unusual behaviour
Seizures, coma
Be prepared to give orange, juice, sugar cubes, or another food containing
readily available simple sugars.
Watch for a patte% of activity or time of day that precedes hypoglycemic
reactions and work with family to alter behaviour to prevent reactions
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
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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.
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Explain about care and managementdm health living
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Community and Home Care Considerations
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
8
Child and parents describe causes, signs and symptoms, and treatment for
hypoglycemia
Child and parents talk freely about diabetes, ask appropriate questions and
display no cryinglfear
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5.3.2 Diabetes Insipidcs
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
Urine specific gravity, sodium and osmolatity are decreased
Serum osmolality and sodium are elevated
Serum measurement of ADH is low in conjuction with high plasma
osmolality
Water deprivation test (potentially dangerious)
- Fluids are restricted, and the urinary volumes and concentrations are
monitored hourly along with the child's weight
- Test is terminated if child loses more than 3 per cent to 5 per cent of
body weight. Serum sodium and osmolality are measured at completion
of test and are high; urine osmolality remains lower
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- Test is completed by giving the child a dose of ADH, which should
Nursing Care of Children
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, ~ r g i c a I problems-II
stop the abnormal diuresis. If it does not, child may have nephrogenic
Dl (renal unresponsiveness).
Assess MRI or CT scan of hypothalamic pituitary region
High incidence of associated anterior pituitary disorders
Treatment
Daily replacement of ADH using desmopression (DDAVP) a synthetic
analogue
In children with cleft lip and palate, sublingual administration has been
shown to be effective
Thiazide diuretics in nephrogenic Dl
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Complications
Dehydration
Hypernatremia
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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
Maintain fluid intake
Assess for and teach Darents about the assessment of dehvdration - which
Administer intravenous (N) fluid as ordered if acutely dehydrated
Monitor intake and output and teach parents to maintain record of fluid
intake and output in child. Reduced output may require restriction of fluids
if overdosage of DDAVP is suspected
Keep record of daily weight.
Administer and teach proper administration of DDAVP. Proper
management should eliminate symptoms
Teach parents to provide free dccess to fluid (water) sources at all times.
However, caution parents that child should be protected fiom water excess
Calculate rough estimated total daily fluid requirements based on body size
to assess fluid replacement versus excess: 100 mL/kg for first 10 kg of
Maintaining Adequate Nutrition
a
Ensure that adequate feeding is given between plain water bottles
a
For older child, provide liquid nutritional supplements.
a
Emphasis on the the importance of providing nutritional requirements with
fluids to ensure adequate calorie intake for growth
a
Help the parents to discuss with dietitian for dietary advise
a
Monitor length and weight and developmental milestones at regular
intervals
Nursing Care of Children
with Endocrine and
Metabolic Disorders
I
I
Normalizing Sleep Pattern
.
a
Ensure adequate evening administration of DDAVP to prevent nighttime
water craving and enuresis
a
Suggest the use of diapers at night and plastic padding on bed to make
bedwetting easier until optimum management of condition is attained
a
Encourage ea'sy access to fluids and toilet or commode for older child
during night
~ a ' m iEducation
l~
and Health Maintenance
Teach to administer correct dosage in a correct way as follows
a
a
Correct dose is measured and drawn up into catheter
is inserted into patient's nostril then other end of cathetric is put
' Catheter
in mouth and then it is blown generally
a
Older children inhale the solution
a
Explain the parents that nostrils should be as clear as possible before
administration of dose
a
Explain the parents that, if dose is thought to be swallowed do not
readminister due to potential overdosage. Split the dose into both nares if
there is swallowing of drug
a
Tell family members to store drug away from heat and direct light and
moisture (not in bathroom)
a
Advise parents that children should wear some identification object
for DI
a
Advise the Parents that school personnel should be informed. about the
condition and symptoms needing attention (water intoxication)
a
Advise routine follow-up; treatment may be temporary or life-long,
depending on cause
Outcome Based
valuation
There are
a
No signs of dehydration and intake equals to output
a
No weight loss, proper growth
a
Child sleeping through out night
I
I
Diagnostic Evaluation
Neonatal Screening consists of an initial filter paper blood spot thyroxine (T,)
measurement followed by measurement of thyroid stimulating hormone (TSH) in
specimens with low T4 values. Screening results that show a low level of T4
and a high level of TSH indicate presence of CH.
Therapeutic Management
Treatment involves lifelong thryroid hormone replacement therapy as soon as
possible after diagnosis to subside all signs of hypothyroidism and reestablish
normal physical and mental development. The drug of choice is synthetic
levothyroxine sodium (Synthroid or Levothroid). Regular measurement of
thyroxine levels is important in ensuring optimum treatment. Home based
surveys are also performed to ensure optimum growth.
Nursing Considerations
The most important nursing objective is
Ensure early identification and screening of the disorder
Nurses need to be aware of the earliest signs of the disorder
Be aware about the parental remarks about the child being an unusually
"quite and good" baby coupled with any of the early physical
manifestations which helps to suspect hypothyroidism a,ld refer the child
for specific tests.
Unfortunately, many parents harbor guilt about their impressions of the
infant before the diagnosis because the child's inactivity may not have
alerted them to a problem with the result that treatment is delayed but you
should resure the parents.
Explain necessity of lifelong treatment. The importance of compliance with
the drug regimen must be emphasized for the child to achieve normal
growth and development. Since the drug is tasteless, it can be crushed and
added to milk feed, water, or food. If a dose is missed, twice the dose
Check the signs of overdose, such as rapid pulse, dyspnea, irritability,
insomnia, fever, sweating, and weight loss. Ideally they should know how to
count the pulse and be instructed to withhold a dose and consult their
doctor if the pulse rate is increased to a certain value. Signs of inadequate
treatment are fatigue, sleepiness, decreased appetitite and constipation.
Phenyle Ketoneuria
It is a disorder of amino acid metabolism. It is either due to deficiency of the
enzyme Phenylalaninehydroxylase or in the synthesis or recyling of the
biopterm in cofactor for this enzyme. It presents with infantile spasm and
developmental dealy at 6-12 months of age. There may be a musty odour due
to the metabolitic phenylacetic acid. Some children may develop eczema and
most of the children have blue eyes and jelly hair. The condition can be
detected by raised level of phenylalanine levels in blood which is detected at
5-7 days when milk feeding has been established.
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
Nursing Care o f Children
with Endocrine and
Metabolic Disorders
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
1.
i) Administer IV fluids as ordered
i i Monitor intake and output, blood pressure, serum electrolyte results and
daily weight report any abnormality
iiii Assess for signs of dehydration - dry skin and mucous membranes,
constipation
iv) Encourage to take oral fluids when the child is able to take orally
2. i) Arms
ii) Thighs
iiii Abdomen
iv) Buttocks
3. Precomatose state:
Drowsiness
Dryness of skin
Cherry red lips
Increased respirations
Nausea
Vomiting
Abdominal pain
Comatose state:
Extreme hyperpnea (kussmaul breathing)
Acetone breath
121
• Soft, sunken eyeballs
Nursing Care of Children
wlth Medical and
Surgical problems-11
• Rigid weak pulse
Decreased temperature
Decreased blood pressure
Check Your Progress 4
1.
Signs and Symptoms
a Sudden onset of excessive thirst and polyuria
a The infants may present with following symptoms:
a Excessive crying - quieted with water more than milk feeding
a Rapid weight loss - caloric loss due to water preference over feedings
Constipation
a Growth failure - failure to thrive
a Sunken fontanel with dehydration
Children may have following symptoms:
a Excessive thirst and drinking
Polyuria with nocturia and enuresis
a Pale, dry skin with reduced sweating
2. Complications
a Dehydration
a Hypernatremia
Check Your Progress 5
1.
9
ii)
iii)
iv)
v)
Congenital Hypothydoidism (CH)
Phenyle Ketoneuria
Galactosemia
Hypoglycemia
Hypocalcemia