NCLEX-RN: Pediatric Nursing

Pediatric Nursing: ENDOCRINE SYSTEM

Focus topic: Pediatric Nursing

The endocrine system consists of a series of glands that function individually or conjointly to integrate and control innumerable metabolic activities of the body. These glands automatically regulate various body processes by releasing chemical signals called hormones, which produce specialized effects on their specific target tissues.

Pediatric Nursing: System Assessment

Focus topic: Pediatric Nursing

A. History: family history, significant perinatal history and events. Assess for history of endocrine disorders, Marfan syndrome, and size of adult relatives.
B. Assess growth patterns; evaluate patterns plotted on growth charts.

  •  Excessive growth; sudden spurts or consistently > 95th percentile.
    a. Pituitary or hypothalamic disorders.
    b. Excess adrenal, ovarian, or testicular hormone.
  •  Retarded growth; consistent pattern < 5th percentile or sudden drop-off.
    a. Endocrine and metabolic disorders; difficult to distinguish from dwarfism.
    b. Hypothyroidism or hypopituitarism possible.

C. Obesity.

  •  Sudden onset suggests hypothalamic lesion (rare); assess dietary practices.
  •  Cushing’s syndrome (with characteristic buffalo hump); evaluate medications used (chronic steroid use).

D. Abnormal skin pigmentation.
E. Abnormal hirsutism.

  • Normal variations in body occur on non-endocrine basis.
  •  May be first sign of neoplastic disease.
  • Indicates change in adrenal status.

F. Evaluate appetite changes.

  •  Polyphagia is a common sign of uncontrolled diabetes.
  •  Indicates thyrotoxicosis.
  • Nausea and weight loss may indicate Addisonian crisis or diabetic acidosis.

G. Presence of polyuria and polydipsia.

  • Symptoms usually of nonendocrine etiology.
  •  If sudden onset, suggest diabetes mellitus or insipidus.
  •  May be present with hyperparathyroidism or hyperaldosteronism.

H. Noticeable mental changes.

  • Though often subtle, may be indicative of underlying endocrine disorder.
    a. Nervousness and excitability may indicate hyperthyroidism.
    b. Mental confusion may indicate hypopituitarism, Addison’s disease, or myxedema.
  •  Mental deterioration is observed in untreated hypoparathyroidism and hypothyroidism.
  •  Mental retardation is present in some endocrine gland disorders.

System Implementation
A. Give medications on schedule to maintain accurate blood level.
B. Instruct the child and parent on signs and symptoms and side effects of medications.
C. Instruct the child and parent on methods to decrease infection.
D. Provide appropriate nutrition and education.

Pediatric Nursing

 

Pediatric Nursing: Thyroid Gland Disorders

Focus topic: Pediatric Nursing

Pediatric Nursing: Hypothyroidism

Focus topic: Pediatric Nursing

Definition: Hypothyroidism is a condition caused by low production of thyroid hormones. It can be congenital or acquired, acute or chronic. Screening is routinely done on neonates. Beyond the first 2 years of life, primary hypothyroidism can be caused by many defects, and the effects are generally less severe than the congenital form.

Assessment
A. Assess for severe retardation of physical development, resulting in decelerated growth, sexual development retardation.
B. Evaluate severe mental retardation, apathy in older children.
C. Assess for dry skin; coarse, dry, sparse brittle hair; puffiness around eyes (myxedematous skin changes).
D. Evaluate constipation.
E. Assess teething pattern (usually slow).
F. Assess for poor appetite.
G. Examine tongue (usually large).
H. Check for pot belly with umbilical hernia.
I. Assess for sensitivity to cold.
J. Evaluate laboratory values to confirm diagnosis.

  • T4 levels decreased, elevated TSH.
  •  Elevated serum cholesterol.

Implementation
A. Monitor administration of drugs; must be started immediately in infants to avoid mental deficiencies.

  •  Synthroid (levothyroxine).
  • Dosage is based on age, weight, and response to treatment.

B. Involve older children in treatment plan.
C. Support and education of family and child; make appropriate referrals.

Pediatric Nursing: Hyperthyroidism (Graves’ Disease)

Focus topic: Pediatric Nursing

Definition: The over secretion of thyroid hormone, occurring more commonly in adolescents. The etiology is unknown, but the disease is more common in girls and has familial tendencies.

Assessment
A. Obtain family history.
B. Assist with diagnostic evaluation.

  • Increased levels of T3 and T4.
  • Decreased levels of TSH.

C. Weight loss with excellent appetite.
D. Nervousness; irritability, difficulty sleeping, heat intolerance, excessive sweating, tachycardia.
E. Characteristic exophthalmos.
F. Vomiting/diarrhea.
G. Occasionally palpable goiter.
H. Heat intolerance.
I. Warm, moist skin.

Implementation
✦✦ A. Oral administration of propylthiouracil (antithyroid medicine), iodine (to shrink the size of the thyroid gland), followed by either radioactive iodine or surgery to remove the gland. A beta blocker, e.g., Inderal (propranolol), is used to block the stimulating effects of the hyperactive thyroid gland (e.g., tremors).

  •  Teaching about medications and side effects.
  •  Administer iodine preoperatively as ordered.

B. Most common treatment is ingestion of Iodotope (radioactive iodine) as ablative therapy.
C. Surgery may be necessary (thyroidectomy).
D. Monitor for thyroid storm teach child and parents signs of and management.
E. Support child and family discharge teaching.

Pediatric Nursing: Pituitary Gland Disorders

Focus topic: Pediatric Nursing

Pediatric Nursing: Hypopituitarism (Growth Hormone Deficiency)

Focus topic: Pediatric Nursing

Definition: Hyposecretion of growth hormone (growth hormone deficiency GHD) by the anterior pituitary. Growth is symmetrical but decreased. Most causes are idiopathic, but may be related to previous trauma to pituitary area (infection, tumor, radiation therapy).

Assessment
A. Assess for retarded linear physical growth with normal weight; review family history.

B. Assess for delay of body-aging processes, delay in appearance of permanent teeth, delayed sexual development.
C. May have premature aging.
D. Examine pale, dry, smooth skin; thin hair.
E. Assess for poor development of secondary sex characteristics and external genitalia.
F. Assess for slow intellectual development.

Implementation
A. Assist with diagnostic studies (x-rays, blood tests, CT scan, MRI) and support child and family.
B. Monitor administration of human growth hormone (HGH) injections; if the imbalance is diagnosed and treated in early stage, 80% of children respond to growth hormone and increase their growth.
C. Monitor response to medication; plotting growth chart and evaluating development of secondary sex characteristics.
D. Support family and refer to social services if condition continues.
E. Support and teaching to client and family (most children responding to HGH will reach adult height but puberty may be delayed). Teach families to give injections, monitor for complications.

Pediatric Nursing: Pituitary Hyperfunction

Focus topic: Pediatric Nursing

Definition: Hypersecretion of growth hormone by the anterior pituitary (termed acromegaly if occurring after epiphyseal plates close), which occurs in childhood prior to closure of the epiphyses of the long bones.

Assessment
A. Evaluate growth trends patterns of height and weight overgrowth. Assess for symmetrical overgrowth of the long bones, increased development of muscles and viscera.
B. Assess for increased height in early adulthood (may reach height of 8 feet [243.8 cm] or more).
C. Evaluate deterioration of mental and physical processes, which may occur in early adulthood if condition untreated.
D. Early diagnosis and intervention is essential.

Implementation
A. Care for client as irradiation or surgical intervention of pituitary program is instituted.
B. Administer care for hypophysectomy.
C. Provide emotional support to child and family.

Pediatric Nursing: Phenylketonuria

Focus topic: Pediatric Nursing

Definition: An inborn error of metabolism, inheritance is via autosomal recessive transmission with an absence of the enzyme that converts phenylalanine to tyrosine. Byproducts accumulate and are toxic to the CNS. Phenylalanine is present in most protein-rich foods, cow’s milk, and breast milk.

Assessment
A. Neonatal screening done on all newborns before leaving hospital. If the infant is less than 48 hours old, the test may not be valid, as it is dependent on sufficient intake of phenylalanine from milk (breast or formula).

  •  Phenylalanine levels greater than 20 mg/dL confirms the diagnosis.
  •  Questionable results may be rescreened or child is given phenylalanine challenge.

B. Infant/child generally is fair skinned, with light hair and eyes (decreased melanin production from inability to generate melanin precursor, tyrosine).

Implementation
A. Treatment is dietary, restricting phenylalanine intake.

  •  Keep phenylalanine serum levels 2–6 mg/dL.
  •  Use low-phenylalanine formula (Lofenalac) formula for infants. Breastfeeding is contraindicated.
  •  Monitor serum phenylalanine; significant brain damage occurs when levels are 10–15 mg/dL.
  •  As the child grows, a phenylalanine-free protein supplement is provided in place of meat, dairy, fish, eggs, legumes, etc. (all protein foods). Staples are fruits, vegetables, and starches.

B. Family and child need comprehensive multidisciplinary teaching program about diet and nutrition.

Pediatric Nursing: Diabetes Mellitus

Focus topic: Pediatric Nursing

Definition: A total or partial deficiency of insulin. The most common childhood endocrine disorder, incidence peaks in adolescence. (See Diabetes Mellitus in Chapter 8, Endocrine System section.)

Characteristics
A. Until the 1990s, more than 95% of children with diabetes had type 1, usually from genetic predispositions and environmental triggers.

  •  The number of children, especially adolescents, with type 2 diabetes has increased dramatically.
  •  Between 10 and 50% of newly diagnosed children with diabetes have type 2.

B. Rates are highest in Native Americans, blacks, and Hispanics.
C. Family history and obesity are major contributors.

Classification
A. Type 1. An absolute deficiency of insulin and clients are insulin dependent. Often diagnosed in early childhood or adolescence. Requires replacement of insulin.
B. Type 2. The body fails to use insulin properly and may also have deficient insulin levels. Type 2 diabetes has increased dramatically in children.

Assessment
A. Type 1. Obvious symptoms develop quickly in type 1, usually over 2–3 weeks or less.

  •  High blood glucose levels cause the child to urinate excessively, causing an increase in thirst and desire to  consume fluids.
  •  Some become dehydrated, resulting in weakness, lethargy, and tachycardia.
  • Diabetic ketoacidosis occurs at onset of the disease and is diagnosed in about one-third of children with type 1 diabetes.
    a. Ketoacidosis causes nausea, vomiting, fatigue, and abdominal pain.
    b. Acetone-smelling (fruity) breath, Kussmaul respirations, headaches, and changes in LOC may be present; in extreme cases, condition progresses to coma or death.
    c. The blood glucose level with this presentation is > 300 mg/dL with ketones in the serum and in urine.

B. Type 2. Symptoms are milder in children with type 2 diabetes than those with type 1 and develop more slowly—over weeks or even a few months.

  •  Parents may notice a mild or moderate increase in child’s thirst and urination or only vague symptoms, such as fatigue.
  •  Usually children with type 2 diabetes do not develop ketoacidosis or severe dehydration.

C. As with adults; random blood glucose levels > 200 mg/dL or fasting glucose level > 125 mg/dL.
D. Clinical signs: polyphagia, polyuria, polydipsia, weight loss, enuresis, decreased attention span, glycosuria and ketonuria.

Implementation
A. When type 1 diabetes is initially diagnosed, children are usually hospitalized, and those with diabetic ketoacidosis are usually managed in a pediatric intensive care unit (PICU) and given fluids (to treat dehydration) and insulin (often intravenously) for a brief time.

  • Those without ketoacidosis typically receive two or more daily injections of insulin or continuously by a small infusion pump.
  • Frequent blood glucose monitoring is necessary.

B. Children with type 2 diabetes do not usually need to receive treatment in the hospital.

  • They do require treatment with drugs to lower blood sugar levels (antihyperglycemic drugs, usually Glucophage), which are taken by mouth.
  • Drugs used for adults with type 2 diabetes are also used in children; some of the side effects (diarrhea) cause more problems in children.
  • Occasionally some children with type 2 diabetes need insulin.
  • Children who lose weight, improve their diet, and exercise regularly can be tapered off drugs.

C. Nutritional management and education are important for all children with diabetes.

  • Parents and older children are taught how to gauge carbohydrate content of food and adjust what children eat to maintain a consistent daily intake of carbohydrates.
  • Children of all ages may find it difficult to consistently follow a properly balanced meal plan (consumed at regular intervals) and avoid high-sugar snacks.

D. Infants and preschool-aged children are difficult to manage because of the need to support growth and avoid hypoglycemia.

E. Adolescents may have particular problems controlling glucose levels.

  •  Hormonal changes during puberty affect how the body responds to insulin, and higher doses are usually required.
  •  Adolescent lifestyle: peer pressure, increased activities, erratic schedules, body image, or eating disorders may interfere with prescribed treatment regimen, especially meal plan compliance.
  •  Alcohol, cigarettes, and illicit drug use  experimentation with these substances may cause adolescents to neglect their treatment regimen.
  • Conflicts with parents and other authority figures impact compliance and interfere with management.
  •  Adolescents need adults to recognize issues and give them the opportunity to discuss problems with a healthcare practitioner and participate in a group setting with other adolescent diabetics.
    a. The focus should remain on keeping their blood sugar levels under control.
    b. Adolescents also need to check their blood sugar levels frequently.

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