Pancreas and Parathyroid Disorders

• A hereditary endocrine disorder characterized by inadequate or lack of insulin production that results in impaired glucose absorption & metabolism resulting in hyperglycemia.

• Can either be Type 1 or type 2.

diabetes mellitus

Three cardinal symptoms of diabetes

• polyuria

• polydipsia

• hyperglycemia

This forms the endocrine portion of the pancreas

islets of Langerhans

These cells secrete glucagon

alpha islet cells

These cells secrete insulin

beta islet cells

• Involves an absolute or relative deficiency of insulin.

• Formerly referred to as juvenile diabetes or insulin-dependent diabetes, occurs almost exclusively in childhood.

• Must take insulin to replace what their pancreas cannot produce

• Results from immunologic damage to insulin-producing cells in susceptible individuals

type 1 diabetes

S/S of type 1 diabetes

• Hyperglycemia - due to glucose inability to enter body cells because of a lack of insulin, causing glucose build up in the bloodstream

• Glycosuria - due to kidneys attempt to lower hyperglycemia by excreting excess glucose into the urine

• Polyuria - 1st symptom in children together w/ polydipsia; also due to glycosuria

• Polydipsia (thirst response) - results to dehydration & constipation

• Weight loss, leading to short stature & underweight - body begins to break down protein and fat since glucose can’t be taken up by the body cells. if large amounts of fat are metabolized, weight loss occurs

• Ketoacidosis, which results to acidic blood pH - due to ketone bodies, acid end product of fat breakdown, accumulating in the blood stream

• Long-term effects DM: Vascular narrowing that leads to kidney, heart, and retinal dysfunction

Laboratory studies of type 1 diabetes

• Random plasma glucose level greater than 200 mg/dL (normal range, 70 to 110 mg/dL fasting; 90 to 180 mg/dL not fasting) & significant glycosuria.

• A diagnosis of diabetes is confirmed based on finding one of the following three criteria on two separate occasions:

  • symptoms of diabetes with a random blood glucose level greater 200 mg/dL

  • fasting blood glucose level greater than 126 mg/dL

  • two-hour plasma glucose level greater than 200 mg/dL during an oral glucose tolerance test

2 diagnostic tests to confirm diabetes

• fasting blood glucose test

• random blood glucose test

Diagnostics for type 1 diabetes

• blood analysis for

  • pH

  • partial Pressure of carbon Dioxide (PCO2)

  • sodium & potassium levels

  • WBC count

  • Glycosylated Hemoglobin (HbA Evaluation)

• electrocardiogram - if potassium is low

• nose and throat cultures

Management of type 1 diabetes

• Insulin administration

• Regulation of nutrition and exercise

• Stress management

• Blood glucose monitoring

• Urine ketone monitoring

more specific:

• Nutrition - 55% carbohydrate, 15% protein, and 30% fat

• Exercise - uses carbohydrates & helps reduce hyperglycemia

• Stress Management - increase insulin if w/ stress

• Blood Glucose Monitoring - SBGM can be done by early school age children

• Urine Ketone Monitoring - done if glucose level is above 200mg/dL

• Pancreas Transplantation - for severe cases or retinopathy

Nursing considerations when administering insulin

• Regular/short acting should be drawn 1st (mixed).

• Given SC; half of dose be given IV in emergencies.

• Given @ rm temp; can be given 90degree angle if needle is less than 0.4in; admin site should be rotated.

• Can also be given thru insulin pump & inhalation.

Administration site of insulin in children

subcutaneously on:

• upper outer arms

• outer aspects of the thighs

Types of human insulin

• lispro (humalog)

• aspart

• regular (Humulin-r)

• Lantus

• Humulin-N

• Humulin-L

• Humulin-U

Onset, peak effect, and duration of effect of lispro

• onset: immediate

• peak effect: 30 mins-1 hour

• duration of effect: 3-4 hours

Onset, peak effect, and duration of effect of aspart

• onset: 15 mins

• peak effect: 30-40 mins

• duration of effect: 3-5 hours

Onset, peak effect, and duration of effect of regular Humulin-R

• onset: 0.5-1.0

• peak effect: 2-4 hours

• duration of effect: 5-7 hours

Onset, peak effect, and duration of effect of Lantus

• onset: 1 hour

• peak effect: 5 hours

• duration of effect: 24 hours

Onset, peak effect, and duration of effect of Humulin-N, L, U

humulin-N

• onset: 1-2 hours

• peak effect: 4-12 hours

• duration of effect: 24+ hours

humulin-L

• onset: 1-3 hours

• peak effect: 6-14 hours

• duration of effect: 24+ hours

humulin-U

• onset: 6 hours

• peak effect: 16-18 hours

• duration of effect: 36+ hours

This is when only a minimal amount of insulin, or none at all, is needed for glucose regulation after blood glucose has been initially regulated by insulin.

“honeymoon” period

This is a sign fat tissue is being used for energy or that the child is becoming acidotic

acetone revealed by a test strip

• Formerly known as non–insulin dependent diabetes.

• Characterized by diminished insulin secretion & not caused by autoimmune factors.

• Usually daily insulin not needed, because it can be managed with diet alone or with diet and an oral hypoglycemic agent.

• Once thought to occur only in older adults, but is now seen in over- weight adolescents, termed maturity-onset diabetes of youth.

• Development of PCOS is strongly associated with this disorder

type 2 diabetes

S/S of type 2 diabetes

symptoms often become apparent for the first time at puberty because increasing sex hormones increasing insulin resistance, creating a need for more insulin production

• Sugar in urine but few ketones - due to hyperglycemia and kidneys can no longer reabsorb glucose, spiling or excreting in the urine

• Lessened amounts of thirst & increased urination - fluid follows glucose in the urine through osmosis, leading to polyuria. in some people with long-term type 2 diabetes, the thirst mechanism may be reduced, causing less thirst despite increased urination.

• Dark shiny patches on the skin (acanthosis nigricans) - high levels in the bloodstream can stimulate the growth of skin cells and melanocytes

  • most often found between the fingers and between the toes, on the back of the neck (“dirty neck”), and in axillary ceases

• PCOS - insulin can stimulate the ovaries to produce more androgens, disrupt the normal development of follicles in the ovaries, and decrease the production of SHBG by the liver that binds to testosterone

Management of type 2 diabetes

• nutrition and exercise

• oral anti-glycemic agent: biguanide (metformin) - decreases the amount of glucose produced by the liver and increases insulin sensitivity in both the liver and muscle cells

• sulfonylurea (glyburide) - if metformin is not effective

• A lowered blood calcium level

• May be caused by changes in either calcium or phosphorus metabolism

• Occurs because phosphorus and calcium levels are always inverse proportion in the bloodstream

hypocalcemia

When does hypocalcemia usually happen?

• occur in infants who experienced birth anoxia as phosphorus is released with anoxia

• immature infants - parathyroid glands are immature

• infants of people with diabetes - it tends to accompany the hypoglycemia that occurs in these infants shortly after birth

S/S of hypocalcemia

• chief sign: latent tetany or neuromuscular irritability - occurs if blood calcium level falls below 7/5 mg per dL

• jitteriness when handled or if the infant has been crying for an extended period

if blood calcium levels falls well below 7 mg per dL:

• manifest tetany - muscular twitching

• carpopedal spasm - abduction of the hand and flexion of the wrist with the thumb positioned across the palm

• pedal spasm (foot spasm) - foot is extended, toes flex, sole of the foot cups

without therapy:

• generalized seizures or spasm of the larynx, with the infant emitting a high-pitched, crowing sound on inspiration

These are 3 tests for detecting of hypocalcemia

• Chvostek

• trousseau

• peroneal

This sign of hypocalcemia is when the skin anterior to external ear (just over sixth cranial nerve) is tapped, facial muscles surrounding the eye, nose, and mouth contract unilaterally

chvostek

This sign of hypocalcemia is when upper arm is constricted by tourniquet for 2-3 minutes and area becomes blanched, carpal spasm is elicited (hand abducts, wrist flexes, thumb is positioned across cupped palms)

trousseau

This sign of hypocalcemia is when fibular side of leg over peroneal nerve is tapped, foot abducts and dorsiflexes.

peroneal

Management of hypocalcemia

aimed at increasing the calcium level in the blood above the point of latent tetany

• 10% calcium chloride PO - if infant can suck

• 10% solution calcium gluconate IV - if the tetany has so progressed that the child does not have enough muscular coordination to take oral fluid safely

• Anticonvulsant therapy - for generalized seizures

• Emergency equipment for intubation - relieve laryngospasm

• Oral calcium therapy - after immediate therapy to increase low blood calcium levels; until their calcium level stabilizes at greater than 7.5 mg per dL

• Vit D (calcitriol) - vitamin D is necessary for the absorption of calcium from the GI tract