HOC final exam

what are the functions of the endocrine system

controls cell activity with hormones, regulates growth and body metabolism, differentiation of the reproductive and CNS systems in fetus, enables sexual reproduction, maintains optimal hormone levels, maintains internal homeostasis in a constantly changing external environment

what are the pediatric differences in the endocrine system

prior to puberty, productions of sex hormones is low… during puberty gonads secrete increased sex hormones (estrogen and testosterone), adrenarche (adrenal androgen production begins and stimulates development of acne, pubic hair, and body odor), menarche (onset of menstruation; around 12 yrs old)

name the endocrine glands

pituitary (anterior and posterior), hypothalamus, thyroid, parathyroid, adrenal, pancreas (islets of langerhan), gonads (ovaries and testes)

what hormones are produced by the anterior pituitary (master gland)

growth hormone, TSH, adrenocorticotropic hormone, FSH, luteinizing hormone, prolactin

what hormone is released by the posterior pituitary

ADH (regulates fluid balance)

what hormone is produced by the posterior pituitary

oxytocin (stimulates uterine contractions and breast milk letdown reflex)

what is the function of growth hormone

stimulates linear growth and bone mineral density, stimulates growth of all body tissues, stimulates synthesis of proteins in the liver (helps to reproduce and use glucose)

what is growth hormone deficiency caused by

decreased activity in the pituitary gland, infarction of the pituitary gland, CNS disease, tumors of the pituitary or hypothalamus, brain tumors, traumas, cranial irradiation, chemo

what is growth hormone deficiency characterized by

below third percentile at 1 year, hypoglycemic seizures, hyponatremia, neonatal jaundice, pale optic discs, micropenis, undescended testes

what are the clinical manifestations of growth hormone deficiency

appear “cherubic” (youthful facial features), higher pitched voice, delayed dentition (don’t get teeth when expected), delayed skeletal maturation, ripply abd fat, decreased muscle mass, delayed sexual maturation

how is growth hormone deficiency diagnosed

evaluate for short stature, anyone 2-3 standard deviations below mean height for age or falling off growth chart is evaluated; wrist x-ray (does chronological age match bone age), provocative growth hormone testes (meds stimulate release of GH, confirmation of GH deficiency based on two failures of this test), IGF-1 (low level of insulin like growth factor)

how is growth hormone deficiency treated

daily SQ injection of GH (given at night, several years, replacement is expensive

what are the nursing considerations of growth hormone deficiency

monitor and plot growth, provide teaching for injections, educate regarding medication side effects, treat child by chronological age and not size, promote positive self image, encourage realistic height expectations

what are the side effects of growth hormone replacement

slipped capital femoral epiphysis- hip or knee pain with a limp , call the doctor

inability of the kidneys to concentrate urine in response to not enough ADH or ADH and the kidney’s aren’t working together properly

diabetes insipidus

what is central diabetes insipidus and what are the causes

inadequate production of vasopressin; caused by brain tumors, brain trauma, CNS infection, and neurosurgery

what is nephrogenic diabetes insipidus and what are the causes

ineffective action of vasopressin on kidneys; caused by drug toxicity, adverse drug reactions, illness

what are the clinical manifestations of diabetes insipidus

polyuria, polydispia, enuresis, irritability, dehydration

what will we see in labs for kids with diabetes insipidus

dilute urine, hypernatremia

what diagnostic tests will be done with diabetes insipidus

serum electrolytes, urinalysis (specific gravity and osmolality decreased), CT scan or MI to r/o tumor, water deprivation test

what is the treatment of diabetes insipidus

goal is to reduce urine output, central DI- DDAVP (causes hyponatremia in infants), nephrogenic DI- thiazide diuretics (promote Na excretion, stimulate water reabsorption), indomethacin and amiloride (help preserve K+)

what are the nursing considerations with diabetes insipidus

assist with diagnosis, daily weights, monitor I&O, check urine specific gravity, monitor for dehydration, teach parents medication administration, child should wear ID bracelet, school age children need unlimited access to the bathroom

early appearance of secondary sexual characteristics (girls before 8, idiopathic and boys before 9, neurologic)

precocious puberty

what causes precocious puberty

the hypothalamus is activated to secrete GnRH prematurely, caused by tumor of ovary/adrenal gland, rare genetic condition McCune-Albright syndrome

what are the clinical manifestations of precocious puberty

advanced bone age, appear unusually tall, growth ceases prematurely, mood swings, emotional lability

what are the isolated signs of premature sexual development that often need no treatment

breast development, vaginal bleeding without other sexual characteristics (early menarche increases risk for breast cancer), some pubic hair

what are the diagnostic tests used for precocious puberty

lab tests of LH, FSH, sex hormones, and gonadotropins, GnRH stim test confirms diagnosis, radiologic images of brain, bone age test

what is the treatment for precocious puberty

goal is to determine cause, decrease growth rate, stabilize secondary sexual characteristics, and promote natural growth. If the cause is a tumor; surgery, radiation, chemo. GnRH analog IM injections or SQ implant replaced yearly, treatment continues until a more normal age for puberty is reached

what are the nursing management points of precocious puberty

knowing and doing tanner staging (sexual maturity ratings of breasts and genitals), plot and monitor height, provide emotional support and teach consent, promote growth and development

what ethnic group has the highest incidence of new onset type 1 diabetes in the US

caucasian or non-hispanic

what is the peak incidence of type 1 diabetes

7-15

what are the clinical manifestations of type 1 diabetes

unexplained fatigue, enuresis, significant weight loss, polyuria, polydipsia, polyphagia

disorder of carbohydrate, protein, and fat metabolism

diabetes

DM 1 is caused by…

autoimmune destruction of insulin producing pancreatic beta cells in individuals who are genetically predisposed

what is the pathophysiology of diabetes

insulin allows glucose transport into cells for energy or storage as glycogen, as insulin secretion decreases, blood glucose increases, cell glucose decreases. deficiency of insulin or insulin resistance compromise body’s access to essential nutrients for fuel. when the cells don’t have glucose for metabolism, they look to free fatty acids as an alternative energy source. this leads to ketones which messes with the acid/base balance of the body

what diagnostic tests are used with diabetes type 1

Hgb A1C greater than or equal to 6.5%, or fasting plasma glucose tests above 126, two hour plasma glucose greater than or equal to 200, random plasma glucose concentration greater than or equal to 200 in other with classic symptoms of hyperglycemia

what is the treatment for type 1 DM

daily insulin therapy which will be given SQ initially but with good compliance, she may be able to switch over to an insulin pump, carb counting, BS testing, exercise, psychosocial support

explain basal-bolus therapy that is recommended by the American diabetic association

basal insulin is administered once per day using a very long-acting insulin, bolus of rapid acting insulin administered which each meal or snack based on carb count and blood glucose level

in type 1 DM management what is the goal A1C

less than 7%

what are the complications of type 1 DM

retinopathy, heart disease, renal failure, and peripheral vascular disease

what are the nursing considerations of type 1 DM

teach about medication administration, blood glucose testing, the carb counting diet, and regular exercise, recognition and treatment of DKA

when does DKA occur

incorrect or missed insulin doses or incorrect administration of insulin, an illness, trauma, or surgery

body is burning fats and proteins for energy instead of sugars

DKA

what are the symptoms of DKA

2 poly’s present, weight loss, abd or chest pain, N/V, tachycardia, s&s of dehydration, flushed ears and cheeks, kussmaul respirations, fruity breath, altered LOC, hypotension, hyperglycemia, glycosuria, ketonuria

what are the treatments of DKA

hospitalization, isotonic IV fluids with K+ replacement, short acting insulin over pump- 0.1 unit/kg/hour continuous (any faster you risk cerebral edema and mannitol treats symptoms of this), prep IV tubing

what are the nursing considerations of DKA

administer bolus IV fluids (reverses fluid deficit), monitor insulin drip, test blood glucose levels, monitor urine for glucose and ketones, monitor I&O and symptoms of hypoglycemia

what blood sugar level is hypoglycemia

< 70

what are the symptoms of hypoglycemia

nervousness, rapid onset, hunger, sweating, pallor, tremors, seizure, numb lips or mouth

what are the symptoms of hyperglycemia

lethargy, gradual, hunger, dry skin, flushed skin, sleepiness, shock

what are the risk factors for type 2 DM

obesity, sedentary lifestyle, socioeconomics, ethnicity, and family history

what are the symptoms of type 2 DM

vague, develop gradually; obesity especially around the waist, dehydration, possible ketoacidosis, androgen mediated problems (acne, hirsutism, menstrual disturbances, polycystic ovary disease), hypertension, vaginal yeast, thrush, blurred vision, achanthosis nigricans (also a risk factor, hyperpigmentation and velvet lick thickening of skin of the neck/armpit/groin/areas of skin folds)

what are the diagnostic tests for type 2 DM

obesity, acanthuses nigricans, glucose levels above 200 without fasting, high blood pressure, possible dyslipidemia

what are the treatments for type 2 DM

normalize blood glucose and HbA1C, decreasing weight, increasing exercise, normalize lipid profile and BP, metformin

glandular breast tissue in males, estrogen > testosterone; associated with Klinefelter syndrome, tumors, testicular trauma, viral orchiditis, growth hormone, essential oils

gynecomastia

lack of menstruation- permanent or temporary, primary or secondary, seen in athletes and girls with eating disorders

amenorrhea

menstrual pain or cramping, leading cause of school absence in adolescent females; associated with pelvic abnormalities, endometriosis, uterine fibroids, PID, IUDs, ovarian cysts

dysmenorrhea

autosomal recessive disease that is a deficiency of liver enzyme that breaks down phenylalanine into tyrosine and leads to irreversible brain damage and severe intellectual disability

phenylketonuria (PKU)

what are the clinical manifestations of PKU

must or mousey odor to body and urine, vomiting, irritability, hyperactivity, eczema, seizures, lighter complexion than non affected siblings, hypertonic or hyper reflexive deep tendon reflexes, microcephaly, prominent maxilla with widely spaced teeth, delayed growth

what are the diagnostic tests of PKU

all infants are screened via blood test in newborn period after 24 hours, child needs to have been on breast milk or formula for at least 24 hours before the test

what are the treatments for PKU

keep plasma phenylalanine levels between 1-6, use special formula or breastfeed, diet low in phenylalanine for entire life, avoid high protein foods and aspartame, use elemental medical foods

what do you inspect for in a GU exam in females 

redness, lesions, inflammation, abnormal discharge 

what do you inspect for in a GU exam in males

redness, lesions, abnormal discharge, foreskin in uncircumcised making sure there is a wide enough opening for good urine stream, position of the urethral meatus, shape of the penis, scrotal size, palpate the scrotum to determine if the testes are there

what causes a UTI

bacterial, viral, or fungal infection, contamination from stool or hands, urinary stasis (kids should void 5-6 times per day), structural abnormalities, constipation (pressure on the urinary system leading to urinary stasis), chemical irritants (bubble baths), sex or sexual abuse

UTI in the lower urinary tract which includes the urethra or bladder

cystitis

UTI in the upper urinary tract which involves the ureters, renal pelvis, and penal parenchyma 

pyelonephritis 

any fever of unknown origin in a child less than 2 years should be tested for a…

UTI

what are the signs and symptoms of a UTI

fever, irritability, frequent toileting, complaints of pain when voiding

what diagnostic test is used to confirm a diagnose of a UTI

urine culture and sensitivity (using clean catch midstream or sterile cath specimen)

what is recommended after the first UTI to rule out structural abnormalities 

renal ultrasound 

what are the treatments for a UTI

antibiotics will be started as soon as urine is collected (7-14 day course), admitted to hospital if can’t tolerate oral antibiotics or if there is a need for rehydration

congenital abnormalities that involve abnormal location of the urethra meatus 

hypospadias and epispadias

episdadias and …. which is where the posterior bladder wall extrudes through the lower abdominal wall, are the same condition with epispadias being the milder form

bladder exstrophy 

while doing an assessment on a baby boy, the nurse noticed the baby’s urethral meatus was located on the ventral side of his penis. she knows this to be what congenital anomaly? 

hypospadias 

what do the defects in hypospadias result from

failure of the urethral folds to fuse completely over the urethral groove (runs in families)

hypospadias can occur in conjunction with what conditions

congenital chorded (fibroids line of tissue that causes a ventral curvature of the penis shaft), inguinal hernias, cryptorchidism (undescended testes), partial absence of foreskin 

what is the treatment for hypospadias

surgical repair (correct placement of the urethral meatus at the end of the penis, release of chordee to strengthen penis, satisfactory cosmetic appearance) 

what does surgical repair of hypospadias involve

create a new urethral meatus and leave a stent or catheter in place for urinary drainage until surgical site is healed, empty bag q8 hours, sponge baths only 

besides pain medications, what are used post op from hypospadias correction

anticholinergics such as oxybutynin for bladder spasms, antibiotics until stent or cath is removed 

what diapering technique is used post op from hypospadias correction

double diapering, inside diaper collects stool, outside diaper collects urine that drains from the stent 

what are the home going instructions after hypospadias correction

stent care, signs of infection, when to call doctor (fever, swelling, redness, pain, strong smelling urine, change in urine stream, urine is leaking from areas other than penis), urine will be blood tinged for several days, limit child’s activity for 2 weeks 

explain vesicoureteral reflux 

urine backs up from bladder into ureters because the opening of the ureter sits too low in the bladder, urine back up causes infection in the kidney which can lead to scarring, HTN, and renal failure. staged between 1-5 (1 being least severe, and 5 being most)

how is vesicoureteral reflux diagnosed

frequent UTIs, renal ultrasound, voiding cystourethrogram (this is the definitive diagnoses tool)

what is the surgical treatment for vesicoureteral reflux if it is severe enough

ureteral reimplantation; ureter is reimplanted at higher place in bladder 

what are the nursing interventions after surgical correct of vesicoureteral reflux 

IV fluids, Foley catheter (monitor for blood clots, assess urine characteristics and urine flow), assess output, administer pain meds and antispasmodics for bladder spasms, antibiotics; can be discharged when they can spontaneously void after having the foley removed 

what are the home going instructions after surgical correction of vesicoureteral reflux 

antispasmodics are constipating so reinforce increase of fiber, when to call doctor (temp over 38.5, abd/back pain, swelling, redness of the incision), short shower or tub bath, avoid active play for 3 weeks following surgery 

repeated involuntary voiding after child is expected to have bladder control (age 5-6 years old)

enuresis

what are the different types of enuresis

nocturnal, diurnal, or both

primary (maturational delay, small bladder)

secondary (dry for 6-12 months and then starts wetting the bed; stress, infections, sleep disorders)

what conditions need to be ruled out with enuresis

small bladder, too deep of sleep to wake up to a full bladder, neurologic defects, structural defects, renal insufficiency, UTI, diabetes 

what are the treatments for enuresis

fluid restriction (late in the day and before bed, no caffeine), bladder training (drink a lot and hold for as long as they can, practice stopping midstream, void wait a few minutes and then void again), enuresis alarms, medications for primary nocturnal enuresis (desmopressin, oxybutynin, impiraprine)

alteration in kidney function secondary to increased glomerular membrane permeability to plasma protein characterized by edema, proteinuria, hypoalbuminemia, hypoproteinemia, hyperlipidemia, and altered immunity

nephrotic syndrome 

the most common form of nephrotic syndrome and has no identifiable cause (primary)

minimal change nephrotic syndrome (MCNS)

what will you see in nephrotic syndrome

gradual weight gain, peri-orbital edema in AM- moves to ABD, possible vomiting, abd pain, malnourishment

how does nephrotic syndrome affect the. body systems

renal- decreased UO, dark frothy urine'

cardio- HTN from hypovolemia

vascular- thrombosis

GI- anorexia, vomiting, abd pain

skin- pallor, brittle hair, edema, shiny skin with prominent veins

pulmonary- respiratory distress from pulmonary effusion 

how is nephrotic syndrome diagnosed

history, physical, urinalysis (3-4+ protein), albumin, sodium, BUN, cholesterol, electrolytes 

what are the treatments for nephrotic syndrome 

prednisone to decrease proteinuria (4-6 weeks then wean 8 weeks to 5 months), if don’t respond well IV methylprenisolone, those with massive edema get IV albumin and furosemide, antibiotics, antihypertensives, pain medication

what are the home going instructions for nephrotic syndrome

fluid restrictions until edema resolves, paints monitor urine daily for protein, maintain a diary to record results, monitor child’s weight every week 

inflammation of the glomeruli of the kidneys, responsible for to groupA beta hemolytic strep infection (skin or pharynx)

acute post infectious glomerulonephritis (APIGN)

acute post infectious glomerulonephritis (APIGN) shows up how many days after strep infection

10-21

what is the pathophysiology of acute post infectious glomerulonephritis (APIGN)

immune complex reaction; antigens from strep and killer antibodies clump together and become trapped in glomeruli, glomeruli become inflamed and obstructed, obstructed capillaries decreases GFR, vascular permeability increases (allows RBC, protein, and red cell casts to be excreted causing Na and water to be retained), kidneys become incapable of filtering and eliminating wastes 

what are the clinical manifestations of acute post infectious glomerulonephritis (APIGN)

some asymptomatic, abrupt onset, flank or mid abd pain, irritability, malaise, fever, microscopic or gross hematuria, proteinuria, mild peri orbital edema early on, dependent edema, pulmonary congestion or ascites, acute HTN (HA, N/V, lethargy, seizures)