Chapter 31: The Child with Endocrine group of cells that exerts a physiologic

Dysfunction controlling effect on other cells

Endocrine System Control of Hormone Secretion

- controls and regulates metabolism
● energy production anterior pituitary gland
● growth - located below the hypothalamus
● fluid and electrolyte balance - known as the “master gland”
● response to stress - stimulates and inhibits tropic hormones
● sexual production
pituitary gland
3 components - controlled by either hormonal or
1. cell - sends a chemical message using a neuronal signals from the hypothalamus
hormone
2. target cells/organs - receive the 2 types of substances:
chemical message a. releasing hormones
3. environment - which the chemical is b. inhibitory hormones
transported from the site of synthesis to
the sites of cellular action Neuroendocrine Interrelationships
2 regulatory systems that maintain homeostasis:
a. endocrine
b. ANS
❖ SNS - maintain homeostasis
during times of stress
❖ PNS - regulates the digestive
processes
higher autonomic centers
- located in the hypothalamus and limbic
system
- help control the functioning of both
autonomic systems

DISORDERS OF PITUITARY FUNCTION

2 lobes of pituitary gland:

a. anterior pituitary (adenohypophysis)
- responsible for secreting GH,
TSH, ACTH, FSH, LH, and
prolactin
Hormones
b. posterior pituitary (neurohypophysis)
- a complex chemical substance produced
- secretes ADH and oxytocin
and secreted into body fluids by a cell or
panhypopituitarism
- loss of all anterior pituitary hormones,
leaving only posterior pituitary function
intact

HYPOPITUITARISM
- diminished secretion of one or more
pituitary hormones

Consequences:
● gonadotropin deficiency (decrease LH
or FSH) - children show absence or
regression of secondary sexual
characteristics
● GH deficiency - children display stunted
somatic growth
● TSH deficiency - produces
hypothyroidism
● corticotropin deficiency - adrenal
hypofunction

Other causes of panhypopituitarism:

● encephalitis
● radiation to the head or neck
● traumatic brain injury
● congenital hypoplasia of the
Most common organic cause of pituitary hypothalamic area
undersecretion:
● tumor in the pituitary or hypothalamic ➔ Congenital hypopituitarism can be seen
region in NB infants and run in families,
however, the majority of cases have no
Craniopharyngiomas - tumors that invade the genetic association
regions of the brain and causes
panhypopituitarism Idiopathic hypopituitarism, or idiopathic
pituitary growth failure
● usually related to GH deficiency
● chief complaint is often short stature
 ● can be associated with deficiencies of therapy: recombinant IGF-1 therapy for
other pituitary hormones, such as TSH primary IGF-1 deficiency
and ACTH
Clinical Manifestations
Growth failure
- an absolute height of less than −2 Children with a partial GH deficiency:
standard deviations (SD) for age, or a ● growth retardation is less marked than
linear growth velocity consistently less in children with complete GH deficiency
than −1 SD for age ● height may be stunted more than
- if it occurs without the presence of weight
hypothyroidism, systemic disease, or ● skeletal proportions are normal for the
malnutrition, an abnormality of the age, but these children appear younger
GH–insulin-like growth factor (IGF) axis than their chronologic age
should be considered ● premature aging is common
● bone age is delayed but is closely
Idiopathic short stature (ISS) related to height age;
- a condition in which the height of an ● the degree of growth delay depends on
individual is more than 2 SD below the the duration and extent of the
mean height for his or her age, sex, and hormonal deficiency.
population group, without evidence of ● Because of the underdeveloped jaw,
systemic, endocrine, nutritional, or teeth may be overcrowded and
chromosomal abnormalities malpositioned

3 groups of children with ISS: Children with isolated GH deficiency:

a. those with familial short stature ● have a normal intelligence
b. those with constitutional delay of ● emotional problems are common
growth and puberty especially as they near puberty
c. those with a yet unidentified cause of
short stature Diagnostic Evaluation
● aimed at isolating organic causes (brain
Familial short stature tumor, hypothyroidism, oversecretion of
- healthy children who have ancestors cortisol, gonadal aplasia, chronic illness,
with adult height in the lower nutritional inadequacy, Russell-Silver
percentiles and whose height during dwarfism, or hypochondroplasia)
childhood is appropriate for genetic
background Complete diagnostic evaluation:
● family history
Constitutional delay of growth and puberty ❖ utmost importance in relating
- individuals with delayed linear growth short stature to genetic
and delayed skeletal and sexual background
maturation for age
 ❖ midparental height - an needed to establish diagnosis
important prognosticator of the and localization of brain lesions
child’s ultimate adult height ● endocrine studies
● history of the child’s growth patterns ❖ absent or subnormal
and previous health status reserves of pituitary GH
❖ thorough prenatal history - definitive diagnosis of
❖ compare birth height and GH deficiency
weight with gestational age ❖ measuring serum IGF-1
❖ investigate for evidence of and IGF binding protein
chronic illness 3 (IGFBP3) levels - assist
● physical examination in the decision to
❖ accurate measurement of pursue further testing
height (using a calibrated for GH deficiency
stadiometer) and weight and ❖ GH stimulation tests are
comparison with standard reserved for children
growth charts are essential with low serum IGF-1
❖ crown-to-pubis and and IGFBP3 levels and
pubis-to-heel length to compare poor growth who do
body proportions not have other
❖ sexual development should be endocrine or
assessed and compared with nonendocrine causes
age-appropriate development for short stature
❖ observe the general appearance ❖ GH stimulation testing
❖ funduscopic examination and involves the use of
testing for visual acuity - detect pharmacologic agents
evidence of ocular damage such as levodopa,
from a tumor clonidine, arginine,
● psychosocial evaluation insulin, propranolol, or
glucagon followed by
adiographic SurveysR the measurement of GH
● skeletal survey in children less in the blood
than 3 years of age and
radiographic examination of the Therapeutic Management
hand-wrist for centers of ● directed toward correction of the
ossification (bone age) in older underlying disease process (caused by
children organic lesions)
● epiphyseal maturation is ● recombinant IGF-1 therapy for primary
delayed in GH deficiency but IGF-1 deficiency
consistent with height ● cadaver-derived human growth
● MRI, CT, radionuclear scans, or hormone (HGH) - enhance linear
carotid angiograms may be growth in short children
 ● Children with other hormone - Vertical growth is accompanied by rapid
deficiencies require replacement and increased development of muscles
therapy to correct the specific disorders and viscera.
which may involve administration of - Weight is increased but is usually in
thyroid extract, cortisone, testosterone, proportion to height.
or estrogens and progesterone - Proportional enlargement of head
circumference also occurs and may
Nursing Care Management result in delayed closure of the
● identifying children with growth fontanels in young children.
problems - principal nursing - Children with a pituitary-secreting
consideration tumor may also demonstrate signs of
● investigating clothing sizes is often increasing ICP, especially headache.
helpful in determining growth at - If oversecretion of GH occurs after
different ages epiphyseal closure, growth is in the
● correlate the onset of any positive transverse direction, producing a
findings with the initial evidence of condition known as acromegaly
growth retardation
● Blood samples are usually taken every Typical facial features:
30 minutes for a 3-hour period ● Overgrowth of the head, lips, nose,
● Those receiving glucagon are at risk of tongue, jaw, and paranasal and mastoid
nausea and vomiting. sinuses
● Patients receiving clonidine require ● Separation and malocclusion of the
close blood pressure monitoring. teeth in the enlarged jaw
● Nursing administration of intravenous ● Disproportion of the face to the
(IV) fluids may be required if cerebral division of the skull
hypotension is detected. ● Increased facial hair; thickened, deeply
● The use of arginine is often well creased skin
tolerated by children, but it may cause ● Increased tendency toward
hypoglycemia in some infants and hyperglycemia and diabetes mellitus
toddlers which requires close (DM)
monitoring
Diagnostic Evaluation
Child and Family Support ● based on a history of excessive growth
● give an appropriate emotional support during childhood and evidence of
through an affirmation of each person’s increased levels of IGF-1 concentration
justified feelings, such as anger or guilt ● MRI may reveal a tumor in an enlarged
● emphasis on the treatment plan and sella turcica, normal bone age,
prospects for improvement in the future enlargement of bones (such as the
● Psychologic counseling may be paranasal sinuses), and evidence of
considered joint changes
● Endocrine studies to confirm excess of
PITUITARY HYPERFUNCTION other hormones
Therapeutic Management Causes:
● surgical treatment by cryosurgery or
hypophysectomy - remove the tumor

Transsphenoid surgery (TSS)

- most common surgical treatment for
pituitary adenoma
● external radiation (XRT) or radioactive
implants - used to destroy GH-secreting
tissue
● medical therapy using drugs that can
suppress GH may be used in
conjunction with TSS and/or XRT to
treat this disease
● hormone replacement with thyroid
extract, cortisone, and sex hormones
may be necessary depending on the
extent of surgical excision and degree of
pituitary insufficiency - isosexual precocious puberty is more
common among girls than boys
Nursing Care Management
● early identification of children with Central precocious puberty (CPP)
excessive growth rates - pubertal development is activated by
● observe for signs of a tumor, especially the hypothalamic
headache, and evidence of concurrent gonadotropin-releasing hormone
hormonal excesses, particularly the (GnRH) which produces early
gonadotropins, which cause sexual maturation and development of the
precocity gonads, with secretion of sex
● give emotional support hormones, development of secondary
sexual characteristics, and sometimes
PRECOCIOUS PUBERTY production of mature sperm and ova
- manifestations of sexual development
before age 9 years in boys or age 8 Peripheral precocious puberty (PPP)
years in girls - early puberty resulting from hormone
stimulation other than the
hypothalamic-pituitary-gonadal axis: hypothalamic GnRH– stimulated
male: interstitial cell–stimulating hormone pituitary gonadotropin release
stimulates Leydig cells of the testes to secrete - appear without other signs of puberty
testosterone and are probably caused by unusual
female: FSH and LH stimulate the ovarian end-organ sensitivity to prepubertal
follicles to secrete estrogens levels of estrogen or androgen
 ● Treatment is discontinued at a
This includes: chronologically appropriate time,
a. premature thelarche - development of allowing pubertal changes to resume
breasts in prepubertal girls
b. premature pubarche - premature Nursing Care Management
adrenarche, early development of ● Give psychologic support and guidance
sexual hair and of the child and family
c. premature menarche - isolated menses ● GnRH agonists are associated with side
without other evidence of sexual effects such as headache, emotional
development lability, and vasodilation causing hot
flashes
Therapeutic Management ● Provide medical education to the
● children should be evaluated by a patient and family
pediatric endocrinologist ● Dress and activities for the physically
● MRI of the brain - to assess for precocious child should be appropriate
hypothalamic brain tumor to the chronologic age
● CPP can be managed with monthly ● Emphasize to parents that the child may
injections of a synthetic analog of be fertile and usually no form of
luteinizing hormone–releasing contraception is necessary unless the
hormone, which decreases the pituitary child is sexually active
secretion of LH and FSH
DIABETES INSIPIDUS
leuprolide acetate (Lupron Depot) - principal disorder of posterior pituitary
➢ slow-release formulation hypofunction
➢ given in a dosage of 0.2 to 0.3 mg/kg - also known as neurogenic DI
➢ given through IM every 4 weeks - central DI results from the
➢ for longer-lasting preparation, given IM undersecretion of antidiuretic hormone
every 3 months (ADH), also known as vasopressin
- results in the production of large
GnRH analog (GnRHa) histrelin volumes of urine (polyuria), which leads
➢ expensive to a state of uncontrolled diuresis
➢ formulated as a subdermal implant
➢ its effects last for 12 months and may familial or idiopathic
be beneficial for some patients who - primary causes of neurogenic DI
would like to avoid injections
Secondary causes:
● After initiation of treatment, breast a. trauma (accidental or surgical)
development regresses or does not b. tumors
advance, and growth returns to normal c. granulomatous disease
rates, enhancing predicted height d. Langerhans cell histiocytosis (LCH)
e. autoimmune disease
f. infections (meningitis or encephalitis)
 g. cranial malformations ● blood concentration
h. vascular anomalies (aneurysm) ● IV replacement

- DI may be an early sign of an evolving Diagnostic Evaluation

cerebral process ● water deprivation test
- simplest test used to diagnose
Clinical Manifestations this condition
cardinal signs: - restricts oral fluids and
1. polyuria observes changes in urine
2. polydipsia volume and concentration
- if positive, the child should be
Older children: given a test dose of injected
● signs can include excessive urination aqueous vasopressin
accompanied by insatiable thirst so (Pitressin), which should
intense that the child does little more alleviate the polyuria and
than go to the toilet and drink fluids polydipsia

enuresis - frequently the first sign nephrogenic DI: unresponsive to exogenous

vasopressin
Infant central DI: rise in urine osmolality after
prone to: vasopressin administration
➔ severe dehydration
➔ electrolyte imbalance ● MRI to look for secondary causes of
➔ hyperthermia central DI such as a tumor or central
➔ azotemia brain anomaly
➔ potential circulatory collapse ● kidney function tests, urine osmolality
irritability tests, blood electrolyte levels, and
- initial symptom specific endocrine studies are sent to
- relieved with feedings of water but not isolate associated problems
milk
Therapeutic Management
symptoms: ● hormone replacement using DDAVP
➔ vomiting - usual treatment
➔ constipation - a synthetic analog of the
➔ fever endogenous hormone arginine
➔ irritability vasopressin (AVP)
➔ sleep issues - given orally, intranasally, or
➔ failure to thrive parenterally
➔ growth problems ❖ intranasal and oral
forms are most
To prevent dehydration: commonly used in
● careful monitoring of urine volumes children
 ❖ oral form has few SYNDROME OF INAPPROPRIATE ANTIDIURETIC
complications and is HORMONE (SIADH)
easier to give, which - cause by an oversecretion of the
likely increases posterior pituitary antidiuretic hormone
compliance (ADH)
- usually administered twice daily—at - occurs with increased frequency in a
bedtime to allow the child to sleep variety of conditions that disrupt CNS
through the night and in the morning to function such as infection, tumor, or
allow fewer interruptions in the school surgery
day - can also be the side effect of a variety of
- signs of overmedication are similar to medications
manifestations associated with the - most common cause of hyponatremia in
syndrome of inappropriate ADH (SIADH) hospitalized patients

Nursing Care Management ● Excess ADH causes free water to be

● identification of the disorder reabsorbed from the kidneys. As
- initial objective increased free water circulates, serum
● persistent irritability and crying in an osmolality goes down, and urine
infant that is relieved only by osmolality inappropriately increases.
bottle-feedings of water - another clue
● Assessment includes measurement of Clinical signs:
body weight, serum electrolytes, blood a. fluid retention
urea nitrogen (BUN), hematocrit, and b. hyponatremia
urine specific gravity taken before
surgery and every other day after the ● When hyponatremia occurs acutely,
procedure swelling of the brain occurs.
● carefully measure and record the fluid I
and O Clinical manifestations for children who has a
● After confirmation of the diagnosis, serum sodium levels of 120 mEq/L:
parents need a thorough explanation ➔ anorexia
regarding the condition ➔ nausea
● If children are to receive DDAVP, ideally ➔ vomiting
two caregivers should learn the correct ➔ stomach cramps
procedure for preparation and ➔ irritability
administration of the drug ➔ personality changes
● children should wear medical alert
identification fluid restriction - immediate management of
choice

❖ some children may be treated with oral

sodium replacement
 ❖ Severe SIADH may require hypertonic 2. Calcitonin
saline infusion that is only given in the - helps maintain blood calcium
hospital setting under close supervision levels by decreasing the calcium
concentration
Nursing Care Management - inhibits skeletal
● recognition of SIADH symptoms demineralization and promotes
- primary nursing goal calcium deposition in the bone
● pay close attention to measurements of
I&O, weight, and monitoring for the
development of neurologic symptoms JUVENILE HYPOTHYROIDISM
● seizure precautions are implemented in
children at high risk Hypothyroidism
● provide the child as well as the family - one of the most common endocrine
education and support regarding the problems of childhood
rationale for fluid restrictions - may be either congenital or acquired
● rare child with chronic SIADH is placed - represents a deficiency in secretion of
on long-term ADH-antagonizing TH
medication
● give instruction regarding medication Cases that could lead to hypothyroidism:
administration ● Radiotherapy for Hodgkin disease or
other malignancies
● infectious processes
DISORDERS OF THYROID FUNCTION ● deficient dietary iodine

two types of hormones secreted by thyroid Characteristics of congenital hypothyroidism:

gland: ● Low levels of circulating thyroid
1. thyroid hormone (TH) hormones
- made up of the hormones ● raised levels of TSH at birth
thyroxine (T4) and
triiodothyronine (T3) Clinical Manifestations
- controlled by the anterior ● Thyromegaly (enlarged thyroid gland)
pituitary hormone TSH ( which and growth deceleration
is regulated by the ● dry skin
hypothalamic hormone ● puffiness around the eyes
thyrotropin-releasing factor ● sparse hair
(TRF) as a negative feedback ● constipation
response) ● sleepiness
● lethargy
main physiologic action of TH: ● mental decline
- to regulate metabolism and control ● growth failure
the processes of growth and tissue ● delayed puberty
differentiation ● excessive weight gain
Adolescents may demonstrate problems with: Clinical Manifestations
● memory ● Enlargement of the thyroid gland may
● attention be mild and noticeable only when there
● visuospatial processing is an increased demand for TH
● Enlargement of the thyroid at birth can
Therapeutic Management be sufficient to cause severe respiratory
● TH Replacement distress.
● Administration of increasing amounts of
l-thyroxine over a period of 4 to 8 weeks Sporadic goiter
(for children with severe symptoms) - usually caused by lymphocytic
thyroiditis, and intrinsic biochemical
Nursing Care Management defects in synthesis of the hormones
● Growth deceleration in a child whose are associated with goiters
growth has previously been normal
should alert the observer to the ❖ ​TH replacement is necessary to treat
possibility of hypothyroidism. hypothyroidism and reverse the TSH
● Treatment is daily oral TH replacement. effect on the gland.
● The importance of daily compliance and
the need for periodic monitoring of Nursing Care Management
serum thyroid levels should be stressed ● Nurses in ambulatory settings need to
to patients and their families be aware of the possibility of goiter and
report such findings.
● Include questions regarding exposure to
GOITER radiation in the assessment.
- an enlargement or hypertrophy of the ● Immediate surgery to remove part of
thyroid gland the gland may be lifesaving in infants
- may occur with deficient (hypothyroid), born with a goiter.
excessive (hyperthyroid), or normal ● When thyroid replacement is necessary,
(euthyroid) TH secretion parents have the same needs regarding
- can be congenital or acquired its administration as discussed for the
parents of children who have
Congenital disease - usually occurs as a hypothyroidism.
result of maternal administration of
antithyroid drugs or iodides during
pregnancy CHRONIC LYMPHOCYTIC THYROIDITIS

Acquired disease - result from Chronic lymphocytic thyroiditis (Hashimoto

increased secretion of pituitary TSH in disease)
response to decreased circulating levels - most common cause of thyroid disease
of TH or from infiltrative neoplastic or in children and adolescents and
inflammatory processes accounts for the largest percentage of
juvenile hypothyroidism
 - occurs more frequently after age 6, HYPERTHYROIDISM
with peak incidence occurring during
adolescence Graves disease (GD)
- most common cause of hyperthyroidism
Clinical Manifestations in children
● enlargement of the thyroid gland - runs in families and is autoimmune
● entire gland is enlarged symmetrically - most cases occur in adolescence, with a
(but may be asymmetric) and is firm, peak incidence at 12 to 14 years of age
freely movable, and nontender - higher in girls than boys
● moderate tracheal compression (sense
of fullness, hoarseness, and dysphagia hyperthyroidism of GD
- caused by the generation of
Others have signs suggestive of autoantibodies to the TSH receptor
hyperthyroidism, such as:
● nervousness Currently, there is no cure for GD.
● irritability
● tachycardia Clinical Manifestations
● increased sweating ● irritability
● hyperactivity ● hyperactivity
● short attention span
Diagnostic Evaluation ● tremors, insomnia
● TSH levels may be slightly or moderately ● emotional lability
elevated ● Gradual weight loss despite a voracious
● T4 decreases, followed by a decrease in appetite occurs in half the cases
T3 levels and an increase in TSH ● Linear growth and bone age are usually
● abnormalities in radioactive iodine accelerated
uptake ● muscle weakness
● vomiting and frequent stooling (caused
Therapeutic Management by hyperactivity of GI tract)
● Oral administration of TH
Cardiac manifestations
Surgery is contraindicated in this ● rapid pulse at rest
disorder. ● widened pulse pressure
● systolic murmur
Nursing Care Management ● cardiomegaly
● Identifying the youngster with thyroid
enlargement Dyspnea may occur during slight exertion, such
● Reassuring the child that the condition as climbing stairs.
is probably only temporary
● Reinforcing instructions for thyroid Other symptoms
therapy ● warm skin, flushed, and moist
 ● heat intolerance may be severe and is disadvantages:
accompanied by diaphoresis ● recurrent laryngeal nerve palsy
● hair is unusually fine and unable to hold ● permanent hypoparathyroidism
a wave ● keloid formation
● Exophthalmos (protruding eyeballs) ● surgical morbidity and mortality
● blurred vision and loss of visual acuity
Surgery
Diagnostic Evaluation - reserved for children who fail ATD
● increased levels of T4 and T3 therapy or who are prone to recurrence
● TSH is suppressed to unmeasurable
levels Radioiodine
- may be a therapy of choice in young
Therapeutic Management patients with GD who relapse after
❖ Therapy for hyperthyroidism is medical treatment
controversial, but the end goal is the - relapse rate is high in this case and may
same: to decrease circulating TH require multiple doses throughout life
- should be avoided in very young
three available treatments for children: children due to the increased risk of
1. antithyroid drugs (ATD) cancer
- first-line treatment for
hyperthyroidism (in most potential long-term side effects:
centers) ● thyroid cancer
disadvantages include: ● hyperparathyroidism
a. drug reactions (e.g., rash, hives) ● high mortality rates
b. chronic dependency on the drug
Thyrotoxicosis (thyroid “crisis” or thyroid
agranulocytosis (severe leukopenia) “storm”)
- most serious side effect of ATDs - may occur from sudden release of TH
- usually accompanied by a sore - unusual in children but it can be life
throat and fever threatening
- Treatment involves immediate
discontinuation of the drug and Clinical signs of thyroid storm
the administration of antibiotics ● acute onset of severe irritability and
and glucocorticoids restlessness
● vomiting
2. subtotal thyroidectomy ● diarrhea
3. ablation with radioiodine ● hyperthermia
● hypertension
surgical ablation of the thyroid (thyroidectomy) ● severe tachycardia
- has the advantage of being a ● prostration
long-lasting form of therapy ● there may be rapid progression to
delirium, coma, and death
Nursing Care Management Surgical Care
● Nurses in ambulatory settings, ● If surgery is anticipated, iodine is
particularly schools, need to be alert to administered for a few weeks before
signs that suggest this disorder the procedure
● mix iodine with a strong-tasting fruit
Weight loss despite an excellent juice, such as grape or punch flavors,
appetite, inattention, hyperactivity, using straw
unexplained fatigue, sleepiness, and
difficulty with fine motor skills may be Postoperative care involves:
seen ● positioning with the neck slightly flexed
to avoid strain on the sutures and
Exophthalmos, infrequent blinking, and observation for bleeding and
impairment of convergence are complications
common presenting signs.
Laryngospasm
● Nursing care focuses on treating - spasmodic contraction of the larynx,
physical symptoms before a response to can be a life-threatening complication
drug therapy is achieved in a quiet, of thyroidectomy
unstimulating environment that is
conducive to rest. Signs of laryngospasm:
● Nurse can help parents understand the - stridor
medical reason for behavior changes - hoarseness
and offer ways to minimize them - feeling of tightness in the throat
● Consultation with the child’s teachers
is important to provide education and DISORDERS OF PARATHYROID FUNCTION
suggest ways of helping the child adjust
at school. Parathyroid Hormone
● Use of light cotton clothing in the - regulates the homeostasis of serum
home, good ventilation, air conditioning calcium concentrations
or fans, frequent baths, and adequate
hydration is helpful in providing comfort
● Nurses should know the side effects of
ATD therapy, including urticarial rash,
fever, arthritis, or arthralgia
● Parents should also be aware of the
signs of hypothyroidism, which can
occur from overdose of the drugs

most common indications are lethargy

and somnolence
HYPOPARATHYROIDISM ● bone radiographs may demonstrate
- a spectrum of disorders that result in increased bone density and suppressed
deficient PTH growth

Congenital hypoparathyroidism Therapeutic Management

- may be caused by a specific defect in ● objective of treatment is to maintain
the synthesis or cellular processing of normal serum calcium and phosphate
PTH or by aplasia or hypoplasia of the levels with minimum complication
gland ● IV and oral administration of calcium
gluconate and follow-up doses
Clinical manifestations ● vitamin D therapy (when diagnosis is
● Muscle cramps (early symptom) confirmed)
progressing to numbness, stiffness, and ● Long-term management administration
tingling in the hands and feet of massive doses of vitamin D and oral
● positive Chvostek or Trousseau sign or calcium
laryngeal spasms ● Blood calcium and phosphorus are
● Convulsions with loss of consciousness monitored frequently until the levels
(may be preceded by abdominal have stabilized
discomfort, tonic rigidity, head ● Renal function, blood pressure, and
retraction, and cyanosis) serum vitamin D levels are measured
● Headaches and vomiting with increased every 6 month
intracranial pressure and papilledema ● Serum magnesium levels are measured
● dry, scaly, coarse skin and horizontal every 3 to 6 months
lines in the nails (​​children with
long-standing hypoparathyroidism) Nursing Care Management
● Mucocutaneous eruptions caused by ● initial objective is recognition of
Candida organisms hypocalcemia
● Dental and enamel hypoplasia ● Initial nursing care includes institution
● cataracts of seizure and safety precautions and
● skeletal remodeling and bone turnover observation for signs of laryngospasm
are diminished such as stridor, hoarseness, and a
feeling of tightness in the throat
● tracheostomy set and injectable calcium
Diagnostic Evaluation gluconate should be located near the
● diagnosis is made on the basis of clinical bedside for emergency use
manifestations associated with
decreased serum calcium and increased
serum phosphorus HYPERPARATHYROIDISM
● Levels of plasma PTH are low in - rare in childhood but can be primary or
idiopathic hypoparathyroidism but high secondary
in pseudohypoparathyroidism
● kidney function tests
most common cause of primary ● surgical removal of the tumor or
hyperparathyroidism: radioactive iodine is used
● adenoma of the gland
Parathyroidectomy
most common causes of secondary - may cause
hyperparathyroidism: a. recurrent laryngeal nerve damage
● chronic renal disease b. voice impairment
● renal osteodystrophy c. hypoparathyroidism
● congenital anomalies of the urinary
tract ● oral administration of calcium salts, high
doses of vitamin D to enhance calcium
common symptom of hyperparathyroidism: absorption
hypercalcemia. ● a low-phosphorus diet, and
administration of a
Clinical Manifestations phosphorus-mobilizing aluminum
hydroxide to reduce phosphate
absorption

Nursing Care Management

initial nursing objective: recognition of

hyperparathyroidism
● Encourage the child to drink fruit juices
that maintain a low urinary pH, such as
cranberry or apple juice.
● Children with renal rickets
(osteodystrophy) may wear braces to
Diagnostic Evaluation minimize skeletal deformities.
● Blood studies to identify elevated ● If the child is confined to bed, the nurse
calcium and decreased phosphorus consults with the physical therapist
levels regarding proper use of orthopedic
● Measurement of PTH appliances.
● Imaging using ultrasound ● Vital signs are taken frequently, and the
● sestamibi nuclear substraction study pulse should be counted for 1 full
● electrocardiography and radiographic minute to detect irregularities
bone survey
Clues to the possibility of hyperparathyroidism
Therapeutic Management ● change in behavior, especially inactivity
● treatment of primary ● unexplained gastrointestinal symptoms
hyperparathyroidism is initially ● cardiac irregularities
medication (but no effect)
Since hypocalcemia is a potential complication:
 observing for signs of tetany
instituting seizure precautions
having calcium gluconate available for
emergency use

DISORDERS OF ADRENAL FUNCTION

ADRENAL HORMONES

two distinct portions of adrenal glands:

a. cortex, or outer section aldosterone
- secretes hormones, called - most important mineralocorticoid
steroids, that are essential to - promotes sodium retention and
life potassium excretion in the renal tubules

b. medulla, or inner core ADRENAL MEDULLA

- produces the catecholamines - secretes the catecholamines
epinephrine and norepi- epinephrine and norepinephrine
nephrine
Epinephrine
ADRENAL CORTEX - has a greater effect on cardiac activity
- secretes three groups of hormones that than norepinephrine
are classified according to their biologic - causes only weak constriction of the
activity: blood vessels of muscles in comparison
(1) glucocorticoids (cortisol, with the effect of norepinephrine
corticosterone) - increases the metabolic rate to a much
(2) mineralocorticoids (aldosterone) greater extent than norepinephrine
(3) sex steroids (androgens, estrogens,
and progestins) Norepinephrine
- elevates blood pressure
cortisol and corticosterone
- most important glucocorticoids in
humans
 ACUTE ADRENOCORTICAL INSUFFICIENCY

❖ Acute form of adrenocortical

insufficiency (adrenal crisis) may have a
number of causes during childhood.

more common etiologic factors:

● hemorrhage into the gland from trauma
- may be caused by a prolonged,
difficult labor and rapidly
Pheochromocytoma progressing infections, such as
- a rare tumor characterized by secretion meningococcemia, which result
of catecholamines in hemorrhage and necrosis
- ​most commonly arises from the (Waterhouse-Friderichsen
chromaffin cells of the adrenal medulla syndrome)

Clinical manifestations of pheochromocytoma Clinical Manifestations

are caused by an:
a. increased production of catecholamines, Early symptoms of adrenocortical insufficiency:
producing ● increased irritability
● hypertension ● headache
● tachycardia ● diffuse abdominal pain
● headache ● weakness
● nausea and vomiting
b. decreased gastrointestinal activity and ● diarrhea
resulting
● constipation Other symptoms:
● increased metabolism with anorexia ● Generalized hemorrhagic
● weight loss manifestations (present in
● hyperglycemia Waterhouse-Friderichsen syndrome)
● polyuria ● Abnormal serum electrolytes level
● polydipsia (hyponatremia & hypernatremia)
● hyperventilation
● nervousness Fever increases as the condition worsens and is
● heat intolerance accompanied by signs of CNS involvement, such
● diaphoresis as:
● nuchal rigidity
In severe cases, signs of congestive heart failure ● convulsions
are evident. ● stupor
● coma
child is in: ● vasopressors (used for immediate
- shock-like state with a weak, rapid vasoconstriction and elevation of blood
pulse; pressure)
- decreased blood pressure; ● Oral doses of cortisone, fluids, and salt
- shallow respirations; are given, similar to the regimen used
- cold, clammy skin; for chronic adrenal insufficiency (after
- cyanosis child’s condition has been stabilized)
● aldosterone is replaced by synthetic
Circulatory collapse is the terminal event. salt-retaining steroids (to maintain
sodium retention)
In the newborn, adrenal crisis is accompanied
by: Nursing Care Management
● extreme hyperpyrexia (high ● Vital signs and blood pressure are taken
temperature) every 15 minutes.
● tachypnea ● Seizure precautions are instituted.
● cyanosis ● Nurse should monitor the child’s
● seizures response to fluid and cortisol
replacement.
Diagnostic Evaluation ● Nurse should plan a gradual schedule
● There is no rapid, definitive test for for reintroducing liquids.
confirmation of acute adrenocortical ● Nurse must be sensitive to the family’s
insufficiency. psychologic needs and prepare them for
● Diagnosis is usually made based on each procedure.
clinical presentation. ● Nurse should keep the parents apprised
● Serum electrolytes can be helpful in of the child’s condition, emphasizing
narrowing the diagnosis. signs of improvement, such as a
● Improvement with cortisol therapy lowered temperature and normal blood
confirms the diagnosis. pressure.
● Preparation for discharge should begin
Therapeutic Management as soon as possible after the child’s
● Replacement of cortisol condition has stabilized.
● Replacement of body fluids to combat
dehydration and hypovolemia Rapid administration of fluids can precipitate
● Administration of glucose solutions to cardiac failure and overdosage with cortisol
correct hypoglycemia may cause hypotension and a sudden fall in
● Specific antibiotic therapy in the temperature.
presence of infection
● Normal saline containing 5% glucose Rapid ingestion of oral fluids may induce
(to replace lost fluid, electrolytes, and vomiting, which increases dehydration.
glucose)
CHRONIC ADRENOCORTICAL INSUFFICIENCY Nursing Care Management
(ADDISON DISEASE) ● parents need guidance concerning drug
therapy
Causes: ● Parents should always have a spare
● infection supply of medication.
● destructive lesion of the adrenal gland ● Parents need to be aware of side effects
● autoimmune processes of the drugs.
● may also be idiopathic
Undesirable side effects of cortisone:
- gastric irritation (minimized by
ingestion with food or the use of an
antacid)
- increased excitability and
sleeplessness
- weight gain (may require dietary
management to prevent obesity
- occasionally behavioral changes,
including depression or euphoria.

● Parents should be aware of signs of

overdose and report these to the
practitioner.
● Parents need to be aware that during
periods of emotional or physical crisis,
the child requires additional hormone
Therapeutic Management replacement.
● Replacement of glucocorticoids ● The child should wear a medical
(cortisol) and mineralocorticoids identification bracelet, to notify medical
(aldosterone). personnel during emergency care.
● During stressful situations (e.g., fever,
infection, emotional upset, or surgery), CUSHING SYNDROME
the dosage must be tripled. - a characteristic group of manifestations
- failure to meet this requirement will caused by excessive circulating free
precipitate an acute crisis cortisol.
● mineralocorticoid replacement (children - uncommon in children
with more severe states of chronic ➔ When seen, it is often caused
adrenal insufficiency) by excessive or prolonged
● monthly injections of steroid therapy that produces a
desoxycorticosterone acetate or cushingoid appearance
implantation of desoxycorticosterone
acetate pellets subcutaneously every 9
to 12 months
 - This condition is reversible after the The physiologic disturbances that may have
steroids are gradually discontinued. life-threatening consequences unless
- Abrupt withdrawal recognized early and treated successfully such
➔ will precipitate acute adrenal as:
insufficiency ● hyperglycemia
● susceptibility to infection
- Gradual withdrawal of exogenous ● hypertension
supplies ● hypokalemia
➔ necessary to allow the anterior
pituitary an opportunity to Children with short stature
secrete increasing amounts of ➔ may be responding to increased cortisol
ACTH to stimulate the adrenals levels, resulting in Cushing syndrome.
to produce cortisol.
Cortisol
Clinical Manifestations - inhibits the action of GH.
- symptoms that produce changes in
physical appearance
➔ occur early in the disorder and
➔ are of considerable concern to
school-age and older children
Diagnostic Evaluation

Serum cortisol levels

- should be measured at midnight and in
the morning
- along with:
● corticotropin hormone
● urinary free cortisol
● fasting blood glucose levels
➔ for hyperglycemia
● serum electrolyte levels
➔ for hypokalemia and
alkalosis
● 24-hour urinary levels of
elevated 17-hydroxycorticoids
and 17-ketosteroids

Imaging of the pituitary and adrenal glands

- to assess for tumors

Bone density
- studies for evidence of osteoporosis

Skull radiographs
- to determine enlargement of the sella
turcica may also aid in the diagnosis.

Dexamethasone (cortisone) suppression test

- another procedure used to establish a
more definitive diagnosis

❖ Administration of an exogenous supply

of cortisone
➢ normally suppresses ACTH
production.

Cortisol levels in individuals with Cushing

syndrome
➔ remain elevated
➔ This test is helpful in differentiating
between children who are obese and
 those who appear to have cushingoid maintain more normal
features. hypothalamic–pituitary–adrenal control
mechanisms.
Therapeutic Management ● Although a bilateral adrenalectomy
permanently solves one condition,
Surgical intervention involves ➔ it reciprocally produces another
- bilateral adrenalectomy syndrome.
- postoperative replacement of the ● Before surgery, parents need to be
cortical hormones adequately informed of the operative
➔ the therapy for this is the same benefits and disadvantages.
as that outlined for chronic ● Postoperative teaching regarding drug
adrenocortical insufficiency replacement is the same as discussed in
the previous section.
If a pituitary tumor is found, ● Anorexia and nausea and vomiting
➔ surgical extirpation or irradiation may ➔ common and may be improved
be chosen with the use of nasogastric
decompression.
Treatment of panhypopituitarism with ● Muscle and joint pain may be severe,
replacement of GH, TH, ADH, gonadotropins, ➔ requiring use of analgesics
and steroids ● Parents should be aware of the
➔ may be necessary for an indefinite physiologic reasons behind these
period symptoms in order to be supportive of
the child.
Nursing Care Management
● depends on the cause CONGENITAL ADRENAL HYPERPLASIA (CAH)
● When cushingoid features are caused - a family of disorders caused by
by steroid therapy, decreased enzyme activity required for
➔ the effects may be lessened cortisol production in the adrenal
with administration of the drug cortex.
early in the morning and on an - Adrenal gland
alternate-day basis. ➔ produces excessive amounts of
● Giving the drug early in the day cortisol precursors and
maintains the normal diurnal pattern of androgens to compensate.
cortisol secretion. - There are seven types of biochemical
➔ If given during the evening, it is defects with the most common defect
more likely to produce being 21-hydroxylase deficiency
symptoms because endogenous ➔ which constitutes more than
cortisol levels are already low, 90% of all cases of CAH
and the additional supply exerts - This deficiency is an autosomal
more pronounced effects. recessive disorder
● An alternate-day schedule allows the ➔ that results in improper steroid
anterior pituitary an opportunity to hormone synthesis
Clinical Manifestations increase in musculature with
● Excessive androgens changes toward an adult male
➔ cause masculinization of the physique.
urogenital system at ● In contrast to precocious puberty,
approximately the tenth week ➔ breasts do not develop in girls,
of fetal development. and they remain amenorrheic
● The most pronounced abnormalities and infertile.
occur in girls ● In boys,
➔ who are born with varying ➔ the testes remain small, and
degrees of ambiguous genitalia spermatogenesis does not
● Masculinization of external genitalia occur.
➔ causes the clitoris to enlarge so ● In both sexes,
that it appears as a small ➔ linear growth is accelerated,
phallus. and epiphyseal closure is
● Fusion of the labia premature, resulting in short
➔ produces a saclike structure stature by the end of puberty.
resembling the scrotum
without testes. Diagnostic Evaluation
● The label ambiguous genitalia ● Clinical diagnosis is initially based on
➔ should be applied to any infant congenital abnormalities that lead to
with hypospadias or micropenis difficulty in assigning sex to the
and no palpable gonads newborn and on signs and symptoms of
● Increased pigmentation of skin creases adrenal insufficiency
and genitalia ● Newborn screening
➔ caused by increased ACTH may ● Definitive diagnosis is confirmed by
be a subtle sign of adrenal evidence of increased 17-ketosteroid
insufficiency levels in most types of CAH
● blood electrolytes demonstrate loss of
● A saltwasting crisis frequently occurs, sodium and chloride and elevation of
➔ usually within the first few potassium
weeks of life. ● bone age is advanced and linear growth
● Infants fail to gain weight, and is increased
hyponatremia and hyperkalemia may be ● DNA analysis for positive sex
significant. determination and to rule out any other
● Cardiac arrest can occur. genetic abnormality
● Untreated CAH ● ultrasonography
➔ results in early sexual
maturation, with enlargement Therapeutic Management
of the external sexual organs; ● administration of glucocorticoids to
development of axillary, pubic, suppress the abnormally high secretions
and facial hair; deepening of of ACTH and adrenal androgens
the voice; acne; and a marked
 ● increase the dosage during episodes of condition and time to grieve for the loss
infection, fever, surgery, or other of perfection in their newborn child.
stresses ● As soon as the sex is determined,
● Acute emergencies require immediate ➔ parents should be informed of
IV or intramuscular administration. the findings and
➔ encouraged to choose an
Emergency situations: appropriate name, and
● bacterial and viral infections ➔ the child should be identified as
● vomiting a male or female with no
● surgery reference to ambiguous sex.
● fractures ● rearing a genetically female child as a
● major injuries girl is preferred
● sometimes insect stings ➔ because of the success of
surgical intervention and
● aldosterone replacement (for children ➔ the satisfactory results with
with the salt-losing type of CAH) hormones in reversing virilism
● Frequent laboratory tests (to assess the and
effects on electrolytes, hormonal ➔ providing a prospect of normal
profiles, and renin level) puberty and the ability to
conceive
Factors that influence gender assignment: ● rearing the child as a boy
genetic diagnosis ➔ child is sterile and may never be
genital appearance able to function satisfactorily in
surgical options heterosexual relationships.
fertility ● If the parents persist in their decision to
assign a male sex to a genetically
family and cultural preferences
female child,
➔ a psychologic consultation
● Hormone replacement may be required
should be requested
to permit linear growth and to initiate
➔ to explore their motivations and
male pubertal changes.
ensure their understanding of
● Surgery is usually indicated to remove
the future consequences for the
the female organs and reconstruct the
child.
phallus for satisfactory sexual relations
● cortisol and aldosterone replacement
➔ is the same as that discussed for
Nursing Care Management
chronic adrenocortical
● Of major importance is recognition of
insufficiency.
ambiguous genitalia and diagnostic
● Parents need to be aware of signs of
confirmation in newborns.
dehydration and the urgency of
● Parents need assistance in
immediate medical intervention
understanding and accepting the
➔ to stabilize the child’s condition
 ● Parents should have injectable paralysis, and tetany and may
hydrocortisone available and know how be responsible for polyuria and
to prepare and administer the consequent polydipsia.
intramuscular injection ● clinical diagnosis is suspected when
● Parents, and later the child, need to there are findings of:
understand that the medical regimen ○ hypertension
must be a lifelong commitment; ○ hypokalemia
➔ therefore provide them with ○ polyuria
the education and counseling ➔ that fail to respond to
that is most likely to ensure ADH administration.
informed and willing ● Renin and angiotensin titers
compliance. ➔ are abnormally low
● parents need a great deal of help in ● Urinary levels of
understanding the reason for the 17-hydroxycorticosteroids and
incorrect sex identification and the 17-ketosteroids
options for sex reassignment or ➔ are normal in primary
medical-surgical intervention. hyperaldosteronism
● Parents should be referred for genetic ◆ caused by an
counseling aldosterone-secreting
➔ before they conceive another tumor but are usually
child because CAH is an abnormal in
autosomal recessive disorder. adrenogenital
● Prenatal diagnosis and treatment are syndrome.
available.
Therapeutic Management
HYPERALDOSTERONISM ● Temporary treatment of the disorder
● Excessive secretion of aldosterone involves:
➔ may be caused by an adrenal ○ replacement of potassium and
tumor or, ○ administration of
➔ in some types of adrenogenital spironolactone (Aldactone)
syndromes, result from - a diuretic that blocks
enzymatic deficiency. the effects of
● signs and symptoms aldosterone,
➔ caused by increased sodium - thereby promoting
levels, water retention, and excretion of sodium and
potassium loss water, while preserving
● Hypervolemia potassium
➔ causes hypertension and ● Definitive treatment is similar to that
resultant headaches for chronic adrenocortical insufficiency
● Hypokalemia
➔ results in muscular weakness,
paresthesia, episodes of
Nursing Care Management Clinical Manifestations
● An important nursing consideration is - caused by an increased production of:
recognition of the syndrome, ● catecholamines
➔ particularly in children with ● producing hypertension
high blood pressure. ● tachycardia
● Other clues include: ● headache
○ bed-wetting ● decreased gastrointestinal
○ excessive thirst activity with resulting
○ unexplained weakness constipation
● If diuretics are used, they should be ● increased metabolism with
administered in the morning anorexia
➔ to avoid accidents during the ● weight loss
night. ● hyperglycemia
● Children need unrestricted restroom ● polyuria
privileges at school. ● polydipsia
● Potassium supplements should be ● hyperventilation
mixed with fruit juice such as grape ● nervousness
juice ● heat intolerance
➔ to increase their acceptability, ● diaphoresis
and potassium-rich foods - In severe cases, signs of congestive
should be encouraged. heart failure are evident.
● Parents need to be aware of the signs of
hypokalemia and hyperkalemia. Diagnostic Evaluation
● After an adrenalectomy, nursing care is ● The clinical manifestations mimic those
similar to that for chronic adrenocortical of other disorders, such as
insufficiency. hyperthyroidism or DM.
● Tests specific to these conditions may
PHEOCHROMOCYTOMA be performed as part of the differential
- a rare tumor characterized by secretion diagnosis.
of catecholamines. ● In a small number of instances a
- The tumor most commonly arises from palpable tumor suggests the diagnosis.
the chromaffin cells of the adrenal ● Usually the tumor is identified by
medulla ➔ CT scan or MRI.
➔ but may occur wherever these ● Definitive tests include 24-hour
cells are found, such as along measurement of urinary levels of the
the paraganglia of the aorta or catecholamine metabolites
thoracolumbar sympathetic
chain.
Therapeutic Management ○ absence of hypertensive attacks
● Definitive treatment consists of (e.g., flushing or blanching,
➔ surgical removal of the tumor fainting, headache, palpitations,
● In children, the tumors may be bilateral tachycardia, nausea and
requiring a vomiting, profuse sweating)
➔ bilateral adrenalectomy ○ heat tolerance
➔ lifelong glucocorticoid ○ decrease in perspiration
➔ mineralocorticoid therapy ○ disappearance of hyperglycemia
● The major complications that can occur
during surgery are: Nursing Care Management
○ severe hypertension ● initial nursing objective: identification
○ tachyarrhythmias of children with this disorder
○ hypotension ● Children with hypertension and
➔ first two are caused by hypertensive attacks should be
excessive release of assessed for pheochromocytoma.
catecholamines during ● Because of behavioral changes
manipulation of the tumor (nervousness, excitability, overactivity,
➔ latter results from and even psychosis),
catecholamine withdrawal and ➔ increased cardiac and
hypovolemic shock respiratory activity may appear
● Preoperative medication to be related to an acute
- To inhibit the effects of anxiety attack.
catecholamines ● careful history of the onset of
- is begun 1 to 3 weeks before symptoms and association with
surgery to prevent these stressful events
complications. ➔ helpful in distinguishing
● The major group of drugs used is the between an organic and a
➔ α-adrenergic blocking agents psychologic cause for the
➔ with or without β-adrenergic symptoms
blocking agents ● Preoperative nursing care involves
➔ frequent monitoring of vital
● Phenoxybenzamine (Dibenzyline) signs and
- most commonly used ➔ observation for evidence of
α-adrenergic blocker hypertensive attacks and
● To control catecholamine release after congestive heart failure.
α-adrenergic blockage has been ● Therapeutic effects are evidenced by
achieved, the child is given normal vital signs and absence of
➔ β-adrenergic blocking agents glycosuria.
● Success of therapy is judged by: ● Note daily blood glucose levels, urine
○ lowering of blood pressure to acetone, and any signs of hyperglycemia
normal and report immediately.
 ● The environment is made conducive to ● insulin-dependent diabetes
rest and free of emotional stress. mellitus (IDDM), or
● Parents are encouraged to room-in with ➔ type I
their child and to participate in care. ● non–insulin-dependent
● Play activities need to be tailored to the diabetes mellitus (NIDDM), or
child’s energy level without being overly ➔ type II
strenuous or challenging ● In 1997
➔ because these can increase ➔ these terms were eliminated
metabolic rate and promote because treatment can vary
frustration and anxiety (some people with NIDDM
● After surgery, the child is observed for require insulin) and
signs of shock from removal of excess ➔ because the terms do not
catecholamines. indicate the underlying
● If a bilateral adrenalectomy was problem.
performed, the nursing interventions ● type 1 and type 2
are those discussed for chronic ➔ new terms
adrenocortical insufficiency. ➔ using Arabic symbols to avoid
confusion
DISORDERS OF PANCREATIC HORMONE
SECRETION

DIABETES MELLITUS (DM)

- a chronic disorder of metabolism
- characterized by hyperglycemia and
insulin resistance.
- most common metabolic disease,
resulting in metabolic adjustment or
physiologic change in almost all areas of
the body.
- The odds are higher for African
American and Hispanic children
- can occur at any age
➔ 40% of children diagnosed are
between 10 and 14 years old
➔ 60% are between 15 and 19
years old
- Girls are 1.3 to 1.7 times more likely to
develop type 2 diabetes than boys
- DM had been classified according to the
type of treatment needed.
- old categories were
 ● In children younger than 10 years old
➔ most diabetes cases are type 1 - People with type 2 can range from
and occur frequently in predominantly insulin resistant with
non-Hispanic whites. relative insulin deficiency to
● In the age-group 10 to 19 years old, predominantly deficient in insulin
➔ type 1 diabetes secretion with some insulin resistance.
- more prominent in - It typically occurs in those who are
non-Hispanic whites ● older than 45 years of age
followed by African ● are overweight and sedentary
Americans and then ● have a family history of
Hispanics diabetes
● lowest prevalence is among American - symptomatology of diabetes is more
Indians readily recognizable in children than in
adults
Type 1 diabetes - Diabetes is a great imitator;
- characterized by destruction of the - influenza, gastroenteritis, and
pancreatic β cells, which produce appendicitis
insulin ➔ are the conditions most often
- this usually leads to absolute insulin diagnosed when it turns out
deficiency. that the disease is really
- has two forms diabetes
1. Immune-mediated DM
- results from an
autoimmune
destruction of the β
cells
- typically starts in
children or young adults
who are slim, but it can
arise in adults of any
age.
2. Idiopathic type 1
- refers to rare forms of
the disease that have
no known cause

Type 2 diabetes
- insulin resistance
➔ in which the body fails to use
insulin properly combined with
relative (rather than absolute)
insulin deficiency.
Pathophysiology body fluid from the intracellular
space to the interstitial space
Insulin and then to the extracellular
- is needed to support the space and into the glomerular
metabolism of carbohydrates, filtrate to “dilute” the
fats, and proteins, hyperosmolar filtrate.
➔ primarily by facilitating - Normally, the renal tubular
the entry of these capacity to transport glucose is
substances into the adequate to reabsorb all the
cells glucose in the glomerular
- needed for the entry of glucose filtrate.
into the muscle and fat cells, - When the glucose
prevention of mobilization of concentration in the glomerular
fats from fat cells, and storage filtrate exceeds the renal
of glucose as glycogen in the threshold (180 mg/dl), glucose
cells of liver and muscle spills into the urine (glycosuria)
- not needed for the entry of along with an osmotic diversion
glucose into nerve cells or of water (polyuria), a cardinal
vascular tissue sign of diabetes.
- chemical composition and - The urinary fluid losses cause
molecular structure of insulin the excessive thirst (polydipsia)
are such that it fits into receptor observed in diabetes.
sites on the cell membrane. - This water “washout” results in
➔ it initiates a sequence a depletion of other essential
of poorly defined chemicals, especially potassium.
chemical reactions that - Protein is also wasted during
alter the cell membrane insulin deficiency.
to facilitate the entry of - Because glucose is unable to
glucose into the cell enter the cells, protein is
and stimulate broken down and converted to
enzymatic systems glucose by the liver
outside the cell that (glucogenesis); this glucose
metabolize the glucose then contributes to the
for energy production hyperglycemia.
- With a deficiency of insulin, - These mechanisms are similar
glucose is unable to enter the to those seen in starvation
cells, and its concentration in when substrate (glucose) is
the bloodstream increases. absent.
- The increased concentration of - The body is actually in a state of
glucose (hyperglycemia) starvation during insulin
produces an osmotic gradient deficiency.
that causes the movement of
 - Without the use of ● Any excess is eliminated in the urine
carbohydrates for energy, fat (ketonuria) or the lungs (acetone
and protein stores are depleted breath). The ketone bodies in the blood
as the body attempts to meet (ketonemia) are strong acids that lower
its energy needs. serum pH, producing ketoacidosis.
- The hunger mechanism is
triggered, but increased food Ketones
intake (polyphagia) enhances - are organic acids that readily produce
the problem by further excessive quantities of free hydrogen
elevating blood glucose. ions, causing a fall in plasma pH.

● Then chemical buffers in the plasma,

principally bicarbonate, combine with
the hydrogen ions to form carbonic acid
➔ which readily dissociates into
water and carbon dioxide.
● The respiratory system attempts to
eliminate the excess carbon dioxide by
increased depth and rate—Kussmaul
respirations, or the hyperventilation
characteristic of metabolic acidosis.
● The ketones are buffered by sodium
and potassium in the plasma.
● The kidneys
Ketoacidosis ➔ attempt to compensate for the
● When insulin is absent or insulin increased pH by increasing
sensitivity is altered, tubular secretion of hydrogen
➔ glucose is unavailable for and ammonium ions in
cellular metabolism, and the exchange for fixed base, thus
body chooses alternate sources depleting the base buffer
of energy, principally fat. concentration.
● Consequently, ● With cellular death,
➔ fats break down into fatty acids, ➔ potassium is released from the
and glycerol in the fat cells cells (intracellular fluid) into the
bloodstream (extracellular fluid)
fats -> fatty acids + glycerol and excreted by the kidneys,
where the loss is accelerated by
➔ is converted by the liver to osmotic diuresis.
ketone bodies ● The total body potassium
◆ (e.g., β-hydroxybutyric - is then decreased even though
acid, acetoacetic acid, the serum potassium level may
acetone) be elevated as a result of the
 decreased fluid volume in which ● The process appears to be one of
it circulates. glycosylation,
● Alteration in serum and tissue ➔ wherein proteins from the
potassium can lead to cardiac arrest. blood become deposited in the
● If these conditions are not reversed by walls of small vessels (e.g.,
insulin therapy in combination with glomeruli), where they become
correction of the fluid deficiency and trapped by “sticky” glucose
electrolyte imbalance compounds (glycosyl radicals).
➔ progressive deterioration ● The buildup of these substances over
occurs, with time causes narrowing of the vessels,
● dehydration with subsequent interference with
● electrolyte imbalance microcirculation to the affected areas
● acidosis ● Intensive insulin therapy
● coma ➔ appears to delay the onset and
● death slow the progression of
retinopathy, nephropathy, and
Diabetic ketoacidosis (DKA) neuropathy.
- should be diagnosed promptly in a ● Children who have type 2 DM
seriously ill patient and therapy ➔ have a higher risk of long-term
instituted in an intensive care unit. cardiovascular disease,
including
◆ hypertension
Long-Term Complications ◆ stroke
- involve both the microvasculature and ◆ myocardial infarction
the macrovasculature. ➔ than individuals who develop
type 2 DM in adulthood
The principal microvascular complications are ● Other complications have been
● nephropathy observed in children with type 1 DM.
● retinopathy ● Hyperglycemia
● neuropathy - appears to influence thyroid
function, and altered function is
Microvascular disease frequently observed at the time
● develops during the first 30 years of of diagnosis and in poorly
diabetes, controlled diabetes.
● beginning in the first 10 to 15 years ● Limited mobility of small joints of the
after puberty, with renal involvement hand occurs in 30% of 7- to 18-year-old
evidenced by proteinuria and clinically children with type 1 DM and
apparent retinopathy. ➔ appears to be related to
● develops after 25 years of diabetes and changes in the skin and soft
creates the predominant problems in tissues surrounding the joint as
patients with type 2 DM. a result of glycosylation.
Diagnostic Evaluation (4) hemoglobin A1C of 6.5% or more

Three groups of children who are candidates for ● Postprandial blood glucose
diabetes are determinations and the traditional
(1) children who have glycosuria, polyuria, OGTTs
and a history of weight loss or failure ➔ have yielded low detection
to gain despite a voracious appetite; rates in children and are not
(2) those with transient or persistent usually necessary for
glycosuria; and establishing a diagnosis.
(3) those who display manifestations of ● Serum insulin levels
metabolic acidosis, with or without ➔ may be normal or moderately
stupor or coma elevated at the onset of
diabetes; delayed insulin
● diabetes must be considered if there is response to glucose indicates
glycosuria, with or without ketonuria, impaired glucose tolerance.
and unexplained hyperglycemia. ● Ketoacidosis
● Glycosuria by itself is not diagnostic of ➔ must be differentiated from
diabetes. other causes of acidosis or
● Other sugars, such as galactose, coma, including
➔ can produce a positive result ◆ hypoglycemia
with certain test strips, and a ◆ uremia
mild degree of glycosuria can be ◆ gastroenteritis with
caused by other conditions, metabolic acidosis
such as: ◆ salicylate intoxication
◆ infection encephalitis
◆ trauma ◆ other intracranial
◆ emotional or lesions.
◆ physical stress DKA
◆ hyperalimentation - is a state of relative insulin insufficiency
◆ some renal or and may include the presence of
endocrine diseases ● hyperglycemia
➔ (blood glucose level
DM is diagnosed based on any of the following ≥200 mg/dl),
four abnormal glucose metabolites: ● acidosis
(1) 8-hour fasting blood glucose level of ➔ (pH <7.30 and
126 mg/dl or more, bicarbonate <15
(2) a random blood glucose value of 200 mmol/L),
mg/dl or more accompanied by classic ● glycosuria
signs of diabetes, ● ketonuria
(3) an oral glucose tolerance test (OGTT)
finding of 200 mg/dl or more in the
2-hour sample, or
glucose oxidase tapes (Keto-Diastix) ● Consequently, insulin levels in the blood
- Tests used to determine glycosuria and increase and decrease coincidentally,
ketonuria with the rise and fall in blood glucose
levels.
Therapeutic Management ● Insulin
➔ secreted directly into the portal
child is unable to produce circulation;
➔ definitive treatment: replacement of ➔ herefore the liver, which is the
insulin major site of glucose disposal,
receives the largest
❖ Medical and nutritional guidance are concentration of insulin.
primary, but management also includes ● No matter which method of insulin
continuing diabetes education, family replacement is used, this normal
guidance, and emotional support. pattern cannot be duplicated.
● Subcutaneous injection
Insulin Therapy ➔ results in absorption of the drug
● Insulin replacement into the general circulation,
➔ is the cornerstone of thus reducing the
management of type 1 DM concentrations of insulin to
● Insulin dosage which the liver is exposed.
➔ is tailored to each child based
on home blood glucose Insulin Preparations
monitoring. ● Insulin
● Goal of insulin therapy: ➔ is available in highly purified
➔ is maintaining near-normal pork preparations and in
blood glucose values while ● human insulin biosynthesized by and
avoiding too frequent episodes extracted from bacterial or yeast
of hypoglycemia. cultures.
● Insulin ● Most clinicians suggest human insulin
➔ is administered as two or more as the treatment of choice.
injections per day or as ● Insulin
continuous subcutaneous ➔ is available in rapid-,
infusion using a portable insulin intermediate-, and long-acting
pump. preparations; all are packaged
● Healthy pancreatic cells in the strength of 100 U/ml.
➔ secrete insulin at a low but ● Some insulin is available as premixed
steady basal rate with insulins, such as 70/30 and 50/50
superimposed bursts of ratios,
increased secretion that ➔ the first number indicating the
coincide with intake of percentage of
nutrients. intermediate-acting insulin and
the second number the
 percentage of rapid-acting - takes 6 to 14 hours to start
insulin. working.
- It has no peak or a very small
Types of Insulin peak 10 to 16 hours after
injection.
There are four types of insulin, based on the - The insulin stays in the blood
following criteria: between 20 and 24 hours.
● How soon the insulin starts working
(onset) Some insulins come mixed together (e.g.,
● When the insulin works the hardest Novolin 70/30).
(peak time) ➔ For example, you can buy regular
● How long the insulin lasts in the body insulin and NPH insulins already mixed
(duration) in one bottle, which makes it easier to
inject two kinds of insulin at the same
However, each person responds to insulin in his time.
or her own way. That is why onset, peak time, ➔ However, you cannot adjust the amount
and duration are given as ranges. of one insulin without also changing
how much you get of the other insulin.
(1) Rapid-acting insulin
- (e.g., NovoLog) Dosage.
- reaches the blood within 15 ● Conventional management
minutes after injection. - a twice-daily insulin regimen of
- The insulin peaks 30 to 90 a combination of rapid-acting
minutes later and may last as and intermediate-acting insulin
long as 5 hours. drawn up into the same syringe
(2) Short-acting (regular) insulin and injected before breakfast
- (e.g., Novolin R) and before the evening meal.
- usually reaches the blood ● The amount of morning regular insulin
within 30 minutes after is determined by patterns in the late
injection. morning and lunchtime blood glucose
- The insulin peaks 2 to 4 hours values.
later and stays in the blood for ● The morning intermediate-acting
about 4 to 8 hours. dosage
(3) Intermediate-acting insulins - is determined by patterns in the
- (e.g., Novolin N) late afternoon and supper
- reach the blood 2 to 6 hours blood glucose values.
after injection. ● Fasting blood glucose patterns at
- The insulins peak 4 to 14 hours breakfast
later and stay in the blood for ➔ help determine the evening
about 14 to 20 hours. dose of intermediate insulin,
(4) Long-acting insulin ● and the blood glucose patterns at
- (e.g., Lantus) bedtime
 ➔ help determine the evening ● Some children require more frequent
dose of rapid-acting (regular) insulin administration. This includes
insulin. children with difficult-to-control
● For some children, better morning diabetes and children during the
glucose control is achieved by a later adolescent growth spurt.
(bedtime) injection of
intermediate-acting insulin. Methods of administration.
● Regular insulin ● Daily insulin
- best administered at least 30 - SQ by twice-daily injections, by
minutes before meals. multiple-dose injections, or by
- allows sufficient time for means of an insulin infusion
absorption and results in a pump
significantly greater reduction ● insulin pump
in the postprandial rise in - an electromechanical device
blood glucose designed to deliver fixed
● Intensive therapy amounts of regular or lispro
- consists of multiple injections insulin continuously (basal
throughout the day with a rate), thereby more closely
once- or twice-daily dose of imitating the release of the
long-acting (Ultralente) insulin hormone by the islet cells.
➔ to simulate the basal ● Using aseptic technique, the child or
insulin secretion and parent changes the needle and
injections of catheter every 48 to 72 hours and then
rapid-acting insulin tapes them in place.
before each meal. ● Pump therapy
● A multiple daily injection program - is expensive and requires
reduces microvascular complications of commitment from the parent
diabetes in young, healthy patients who and child.
have type 1 DM. ● It should also not be removed for more
● The precise dose of insulin needed than 1 hour at a time, which may limit
cannot be predicted. some activities.
● Usually 60% to 75% of the total daily ● Skin infections
dose is given before breakfast, and the - are common, and as with any
remainder is given before the evening other mechanical device, it is
meal. subject to malfunction.
● Furthermore, insulin requirements do ● pumps are equipped with alarms that
not remain constant but change signal problems, such as a depleted
continuously during growth and battery, an occluded needle or tubing,
development; the need varies according or a microprocessor malfunction.
to the child’s activity level and pubertal
status.
● Illness also alters insulin requirements.
Monitoring

TABLE 31.3 Plasma Blood Glucose and

Hemoglobin A1C Goals for Type 1 Diabetes
Mellitus by Age-Group

Blood glucose. Self-monitoring of blood glucose

(SMBG) blood cell, approximately 120 days.
- has improved diabetes - The attachment is not reversible;
management - therefore this glycosylated hemoglobin
- is used successfully by children reflects the average blood glucose
from the onset of their levels over the previous 2 to 3 months.
diabetes. - The test is a satisfactory method for
- By testing their own blood, assessing control, detecting incorrect
children are able to change testing, monitoring the effectiveness of
their insulin regimen to changes in treatment, defining patients’
maintain their glucose level in goals, and detecting nonadherence.
the euglycemic (normal) range - Nondiabetic hemoglobin A1C values
of 80 to 120 mg/dl. ➔ are generally between 4% and
- Diabetes management depends 6% but can vary by laboratory.
to a great extent on SMBG. In - Diabetes control for children depends
general, children tolerate the on age, with hemoglobin A1C levels
testing well.
Urine.
Glycosylated hemoglobin. - Urine testing for glucose
- The measurement of glycosylated ➔ is no longer used for diabetes
hemoglobin (hemoglobin A1C) levels management.
➔ is a satisfactory method for - There is poor correlation between
assessing control of diabetes. simultaneous glycosuria and blood
- As red blood cells circulate in the glucose concentrations.
bloodstream, glucose molecules - However, urine testing can be carried
gradually attach to the hemoglobin A out
molecules and remain there for the ➔ to detect evidence of
lifetime of the red ketonuria.
Nutrition ● Dietary fiber
● the nutritional needs of children with ➔ has become increasingly
diabetes are no different from those of important in dietary planning
healthy children. because of its influence on
● They need sufficient calories digestion, absorption, and
➔ to balance daily expenditure for metabolism of many nutrients.
energy and ● It has been found to diminish the rise in
➔ to satisfy the requirement for blood glucose after meals.
growth and development. ● For growing children,
● Insulin injected subcutaneously has a ➔ food restriction should never
relatively be used for diabetes control,
➔ predictable time of onset ➔ although caloric restrictions
➔ peak effect may be imposed for weight
➔ duration of action control if the child is
➔ absorption rate depending on overweight.
the type of insulin used. ● Child’s appetite
● The timing of food consumption must ➔ should be the guide for the
be regulated to correspond to the amount of calories needed,
timing and action of the insulin with the total caloric intake
prescribed. adjusted to appetite and
● Meals and snacks must be eaten activity.
according to peak insulin action, and
the total number of calories and
proportions of basic nutrients
➔ must be consistent from day to
day
● The constant release of insulin into the
circulation
➔ makes the child prone to
hypoglycemia between the
three daily meals unless a snack
is provided between meals and
at bedtime.
● Food intake should be altered to Exercise
balance food, insulin, and exercise. - is encouraged and never restricted
● Extra food is needed for increased unless indicated by other health
activity. conditions.
● Concentrated sweets are discouraged, - lowers blood glucose levels, depending
and because of the increased risk of on the intensity and duration of the
atherosclerosis in persons with DM, fat activity.
is reduced to 30% or less of the total
caloric requirement.
 - exercise should be included as part of ○ Loss of coordination
diabetes management, and the type ○ Seizure
and amount of exercise should be ○ Coma
planned around the child’s interests and ● Hyperglycemia and hypoglycemic
capabilities. reaction is difficult to distinguish
- in most instances, children’s activities ○ Simplest way to differentiate is
are unplanned, and to test the blood glucose level
➔ the resulting decrease in blood ○ Ketone may be present after
glucose can be compensated hypoglycemia
for by ● Simple carbohydrate
◆ providing extra snacks ○ Alleviate the symptoms in the
before (and if the case of hypoglycemia but will
exercise is prolonged, do harm if the child is
during) the activity hyperglycemic
● Children able to detect the onset of
● In addition to a feeling of well-being, hypoglycemia - (if occur)
➔ regular exercise aids in ○ Simple carbohydrates -
utilization of food and often absorbed rapidly then complex
results in a reduction of insulin carbohydrates
requirements. ○ For mild, milk or fruit juice is
good food to use in children
Hypoglycemia ● Glucagon
● An integral part of insulin therapy ○ Prescribed for home treatment
● Objective of diabetes management: of hypoglycemia
○ To achieve the best possible ○ Must be mixed at the time of
glycemic control while use
minimizing the frequency and ○ Administered intramuscularly or
severity of hypoglycemia subcutaneously
● Signs and symptoms (caused: increase ○ Function: releasing stored
adrenergic activity and impaired brain glycogen from the liver and
function) requires 15-20 minutes to
○ Tachycardia elevate the blood glucose level
○ Tremors ● Morning hyperglycemia
○ Sweating ○ Insulin waning
○ Irritability ■ Progressive rise in
○ Aggression blood glucose levels
○ Hunger from bedtime to
● Severe responses and reflect CNS morning
glucose deprivation ■ Treatment: increase the
○ Drowsiness nocturnal insulin dose
○ Personality changes ○ True dawn
○ Mental confusion
 ■ Normal glucose level ● Management
until about 3am, when ○ Rapid assessment
the level begins to rise ○ Adequate insulin to reduce the
○ Somogyi effect elevated blood glucose level
■ Occur at any time but ○ Fluids to overcome dehydration
often entails an ○ Electrolyte replacement
elevated blood glucose ● Emergency situation
level at bedtime and a ○ Admitted to intensive care
drop at 2am, with a facility
rebound rise following ● Priority:
■ Treatment: decrease ○ To obtain venous access for
the nocturnal insulin administration of fluids,
dose electrolytes, and insulin
■ The rebound is caused ● Oxygen may be administered for
by counterregulatory cyanotic and arterial oxygen of less than
hormones 80%
(epinephrine, GH, and ● Gastric suction
corticosteroids) ○ Applied to unconscious children
Illness Management to avoid pulmonary aspiration
● Illness alters diabetes management ● Antibiotics
● Goals during an illness: ○ Febrile children after
○ Restore euglycemia, treat appropriate specimens are
urinary ketones, and maintain obtained for culture
hydration
● Monitor blood glucose level and Fluid and Electrolyte Therapy
ketones every 3 hours ● DKA experience dehydration
● Insulin should never be omitted during ○ Because of osmotic diuresis,
the illness accompanied by depletion of
● If the child vomits more than once, if electrolytes
blood glucose levels remain above 240 ● Serum pH and bicarbonate
mg/dl, or if urinary ketones remain high ○ Reflects the degree of acidosis
○ Notify health care practitioner ● Initial hydrating solution
● Fluids are the most important ○ 0.9% saline solution
intervention *Traditionally, 50% of deficit is replaced over
○ Prevent dehydration and flush the first 8 hours, and the remaining over the
out ketones next 16-24 hours
*Current trends, fluid deficit should be replaced
Therapeutic Management of Diabetic evenly over 36-48 hours - to reduce the risk of
Ketoacidosis cerebral edema
● DKA, most complete state of insulin ● After fluid and insulin administration,
deficiency the rapid return of potassium to the cell
○ Life-threatening can seriously deplete serum levels
 ○ Cardiac arrhythmias ● Hypotension caused by contracted
○ Established renal function and blood volume
and insulin is given, vigorous ○ may cause decreased peripheral
potassium replacement is blood flow
implemented ● Elevated temperature
○ Cardiac monitor serve as the ○ Indicate infection and should be
guide to therapy reported
● Continuous IV regular insulin is given at ● Diabetic flow sheet
0.1U/kg/hr ○ Maintained at bedside provides
● Insulin therapy should be started after an ongoing record of the V/S,
the initial rehydration bolus urine and blood test, amount of
○ Blood glucose should decrease insulin given, and I&)
by 50-100mg/dl/hr ● If the critical period is over, the task of
● If fall to 250-300 mg/dl regulating insulin dosage to diet and
○ Dextrose is added to the IV activity is begun.
solution
○ Goal: maintain blood glucose Child and Family Education
levels between 120-240 mg/dl ● Vary in educational background and the
by adding 5%-10% dextrose capacity to learn and understand
● Best respond to simple explanations
Nursing Care Management and directions
● Children with diabetes exhibit a degree ● Nurse must determine the optimum
of metabolic lability and have episodes time, place, method and content to be
of DKA that require hospitalization taught
○ interferes with education and ● Self-management
social development ○ Ultimate goal for children with
○ Display characteristic diabetes
personality structure ○ Likely to occur when children
○ Passive and nonassertive and understand the disease and the
incline to smooth over conflicts care it requires
without resolution ● When to teach a family and child is best
○ These children experience judged by their psychological state and
emotional arousal with little emotional readiness
opportunity or ability to ● Participation is a effective method for
resolve learning
○ Emotional stress cause increase
production of endogenous Medical Identification
catecholamines which lead to ● Call for parent’s attention is the need
ketonemia and ketonuria for the child to wear some means of
medical identification
Hospital Management ● Medic-alert identification
● DKA requires intensive nursing care
 ○ Stainless steel or silver-or Traveling
gold-plated identification ● Traveling requires planning, especially
bracelet when trip involves crossing time zones
○ Contains telephone number
that medical personnel can call Insulin
around the clock for medical ● Need to know the characteristics of the
records and personal various types of insulins, the proper
information mixing and dilution, and how to
substitute another type when their
Nature of Diabetes unusual brand is not available
● The better the parents understand the ● Insulin bottle that have been opened
pathophysio of diabetes and the should be stored at room temperature
function and action of insulin and or refrigerators up to 28-30 days
glucagon in relation to caloric intake ● Unopened vials should be refrigerated
and exercise and are good until expiration date on
○ the better they will understand label
the disease and effect ● Should not be left in hot environment
● Parents need answers to a number of
questions Injection Procedure
○ To increase their confidence in ● Learning to give insulin injections
coping with the disease ○ Source of anxiety for both
parents and children
Meal Planning ● To gain children’s confidence
● The family is taught how the meal plan ○ Nurse can demonstrate the
relates to the requirement of growth technique by giving skillful
and development, the disease process, injection to the parent and the
and insulin regimen having the parent return
● Learning about foods within specific demonstration by giving the
food groups helps in making choices nurse and injection
● Substitution with foods of equal ● Another effective strategy
carbohydrates content ○ Instruct the children and then
○ Is the skill needed for successful have them teach technique to
carbohydrate counting the parents while the nurse
○ Might be necessary if a food is observes
not available in sufficient ● Injected in any area where there is
quantity adipose tissue over the muscle
● Avoid high-fat and ○ Arms, thighs, hips, and
high-sugar/high-carbohydrate items abdomen
● Sugar free chewing gums and candies ● Injected at a 90-degree angle
make with sorbitol may be used in ● Pinch technique
moderation by children with DM ○ The most effective method for
tenting the skin to allow easy
 entrance of the needle to insulin and then withdraw the desired
subcutaneous tissue amount
● Work out a rotation pattern to various Continuous subcutaneous insulin infusion
area of the body to enhance absorption ● Portable insulin pump
○ Because insulin absorption is ○ Child and parent learn to
slowed by fat pads that develop operate the device
in overused injection areas ○ Parent and child learn
○ Giving about 4-6 injection in ■ Technical aspects
one area and then move to ■ Prevention and
another area treatment for
● Absorption is altered by vigorous hyperglycemia, sick day
exercise - exercised muscle management, and meal
● Basic methodology planning
○ Teaching children to give their ■ Effects of exercise,
own insulin injection stress, and diet
■ Practice on orange or ■ Decision-making
doll strategies to evaluate
● Children who do not wish to inject blood glucose level
themselves can be taught to use ● Numerous blood glucose measurement
syringe-loaded injector (at least 4/day)
○ Puncture is always automatic ○ Essential part of infusion pump
● Adolescents respond well to ● Simply wearing the pump will not
self-contained and compact device normalized blood glucose
resembling a fountain ball pen ○ It is insulin delivery device
● When requires the injection of both ● Major problems
short - and intermediate-acting insulin ○ Inflammation from irritation
○ Mixing the two medication and ○ Infection at the insertion site
use of single syringe -the site should be cleaned thoroughly before
● Insulin can be premixed and stored in the needle is inserted and then covered with a
the refrigerator transparent dressing
To obtain maximum benefit from mixing -the site is changed and rotated every 48 - 72
insulin hours or at the first sign of inflammation
1. Inject the measured amount of air into
the long-acting insulin (equivalent to Monitoring
the dosage) ● Nurse should prepare to teach and
2. Inject the measured amount of air into supervise blood glucose monitoring.
the rapid-acting insulin (clear) without ● SMBG
removing the needle ○ Provides more accurate
3. Withdraw the clear insulin assessment of blood glucose
4. Insert the needle (containing clear level than can be obtained with
insulin) into the long-acting (cloudy) the historical urine testing
 ● Blood for testing can be obtained by ○ Sweating and trembling - which
two different methods help raise the blood glucose
○ Manually level
○ Mechanical bloodletting device ● Second set of symptoms that followed
● Blood sample obtained from untreated adrenergic reaction
○ fingertips or ○ Neuroglycopenic (brain
○ alternate sites, forearm hypoglycemia)
● Practitioner examines for signs of ○ Difficulty in balance, memory,
redness and soreness at the site attention, or concentration and
○ Evidence of poor technique, slurred speech
poor hygiene, or poor skin ● Severe and prolonged hypoglycemia
healing ○ Leads to seizure and coma
● Least expensive testing method
○ Reagent strip Hygiene
○ The color change us compared ● Caution against wearing shoes without
against a color scale for n sock, wearing sandals, and walking
estimation of the blood glucose barefoot
level ● Correct nail and extremity care tailored
● Urine testing to individual
○ Is recommended during times ● Eyes should be check once a year
of illness and when blood ● Cuts and scratches should be treated
glucose values are elevated with
○ Plain soap and water
Hyperglycemia ● Diaper rash in infants and candidal
● Severe hyperglycemia caused by infection in teens
○ Illness, growth, emotional ○ Poor diabetes control
upset, or missed insulin doses
● Any elevation can be managed by Exercise
adjustment of insulin or food intake ● Food should be increased in the
● Managed also by increasing insulin soon summer, when the children tend to be
after the increased glucose level is more active
noted ● Decreased activity on return to school
● Adolescent girls often become may require decrease in food intake or
hyperglycemic around the time of their increase in insulin dosage
menses ● Children who are active in team sports
○ Need a snack about half hour
Sign of Hypoglycemia before the anticipated activity
● Caused by imbalances of food intake, ● Food intake will usually need to be
insulin, and activity repeated for prolonged activity periods,
● Early signs (adrenergic) often as every 45 min to 1 hour
 ● Elevated blood glucose levels after ○ Because they are trying to be
extreme activity may represent the perfect and similar to one’s
body’s adrenergic response to exercise peers
*Ketonuria in the presence of hyperglycemia is
an early sign of ketoacidosis and a
contraindication to exercise

Record Keeping
● Home records are invaluable aid to
diabetes self-management
● Child and family are encouraged to
observe for patterns of blood glucose
responses to events
● If lapses in management occur, the child
should be encouraged to note this and
not be criticized for the transgression

Self-management
● Key to close control
● As children grow and assume more
responsibility of self-management,
○ they develop confidence in
their ability to manage their
disease and confidence in
themselves
● Puberty is associated with decreased
sensitivity to insulin that normally
would be compensated for by an
increase insulin secretions

Child or Adolescent and Family Support

● Certain fears may develop of past
experiences with the disease
● Severe insulin reaction with seizure can
contribute to fear of repetition
● They must understand how to prevent
problems and how to handle problems
calmly if they occur
● In the years before adolescence, they
probably accept their condition
● Adolescents appear to have the most
difficult adjusting