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NSG 502 Exam 5 Study Guide With
Correct Solutions
The Endocrine system is _____ developed at birth than any other body system - ANSWER less Hormonal control is poorly regulated until ___________ months of age - ANSWER 12- manifestations of underdeveloped endocrine system in newborns/infants - ANSWER - poor hormone regulation imbalances in:
- concentration of fluids
- electrolytes
- amino acids
- glucose
- trace substances how are endocrine abnormalities detected in pediatrics? - ANSWER - Accurate anthropometric measurement and growth plots
- Often manifest as failure-to-thrive and/or developmental delay growth hormone deficiency - ANSWER Inadequate production or secretion of GH causing poor growth & short stature growth hormone deficiency incidence - ANSWER 1/3480 children in the US growth hormone deficiency etiology - ANSWER - Hypopituitarism
- Brain tumor (pituitary gland)
- Cranial irradiation growth hormone deficiency clinical manifestations - ANSWER - Height less than 5th percentile
- Growth rate less than 2 SD from mean for age
- Immature face
- Delayed puberty
- Hypoglycemia
- Diminished muscle mass
- Deficiencies in other hormones growth hormone deficiency diagnostic studies - ANSWER - Serial growth measurements using consistent equipment
- Bone age evaluation
- Complete metabolic laboratory analysis
- 2 positive GH levels that indicate deficiency growth hormone deficiency therapeutic management - ANSWER - Biosynthetic replacement GH
- SQ injection (usually specialty pen)
- Best administered at bedtime percocious puberty - ANSWER - Puberty before the age of 8 years in females & 9 years in males HOWEVER...
- Workup justified in Caucasian girls under 7 and African-American girls under 6 percocious puberty incidence/etiology - ANSWER - More frequently in females
- Most are idiopathic etiology
- CNS lesions or trauma
- Adrenal, ovarian, testicular tumors
- Congenital adrenal hyperplasia (CAH)
- Partial effects seen with some medications percocious puberty clinical manifestations - ANSWER - Demonstration of secondary sexual characteristics before the ages of 7 or 8 depending on gender (also consider race)
- Rapid bone growth
- Early growth plate fusion
- Short stature
- Psychological effects percocious puberty therapeutic management - ANSWER Administration of GnRH
- Detailed medication education
- Dose titrated to maintain TSH in normal range & T4 in the upper half of the normal range infant hypothyroidism nursing considerations - ANSWER - Close follow-up to adjust for growth
- Developmental screening
- Parental education/support Acquired Hypothyroidism (children, commonly adolescents; also adults) pathophysiology - ANSWER - Circulating autoantibodies bind at pituitary TSH receptor sites resulting in decreased thyroid hormone production
- Hashimoto's thyroiditis a common cause Acquired Hypothyroidism considerations - ANSWER - In contrast to congenital hypothyroidism, acquired hypothyroidism after 2 to 3 years of age is often reversible
- Hypothyroid more common in women than men Acquired Hypothyroidism manifestations - ANSWER - Goiter
- Dry, thick skin
- Coarse, dull hair
- Fatigue
- Cold intolerance
- Constipation
- Weight gain
- Edema of face, eyes, & hands
- Delayed or irregular menses; infertility
- Confusion, lethargy, depression (older adults) hypothyroidism diagnostic studies - ANSWER Primary hypothyroidism
- Elevated TSH & low T
Thyroiditis
- Elevated TSH & normal T4 that decreases over time
Secondary or tertiary hypothyroidism (pituitary=TSH & hypothalamus=TRH)
- TSH not elevated & low T
- TRH stimulation test required for diagnosis
hypothyroidism therapeutic management - ANSWER Thyroid hormone replacement -Levothyroxine -May require frequent lab tests and dose adjustments
Monitor growth & development
hypothyroidism nursing considerations - ANSWER - Constipation
- Activity intolerance
- Cardiac output
hyperthyroidism/graves disease incidence - ANSWER - 1/
- Females 5Xs more likely to be affected
- Pediatric peak age for acquiring: 11 to 15 years old
- Highest frequency: 20 to 40 years old
hyperthyroidism/graves disease etiology - ANSWER - Circulating antibodies thyroid-stimulating immunoglobulins (TSIs) bind to pituitary TSH receptor sites resulting in excessive T3 & T4 production
hyperthyroidism/graves disease neonate manifestations - ANSWER - Irritability
- Increased thyroid uptake of radioactive iodine
antithyroid drug therapy - ANSWER - Propylthiouracil (PTU) or Methimazole
- MOA: Blocking thyroid hormone production by the thyroid gland
- PTU administered three times daily & lowers thyroid hormones in several weeks
- beta blockers for side effects
- Success rate of 20 to 40%
antithyroid drug therapy side effects - ANSWER - Arthralgia
- skin rash
- pruritus
- gastric intolerance
- leukopenia
- hepatotoxicity
- hypothyroidism
antithyroid drug therapy nursing considerations - ANSWER Activity restriction despite high energy -Children may be limited to school work only -Large muscle group exercise
Emotional lability -Stress and interpersonal interactions
Nutrition -High metabolic needs -Small, frequent, high-calorie, high-protein meals
Side effects of antithyroid drugs -Agranulocytosis (severe leukopenia)
radioactive iodine - ANSWER - treats hyperthyroidism by destroying the thyroid gland
- Given as an oral solution
- Thyroid tissue destroyed in 6 to 8 weeks
radioactive iodine nursing considerations - ANSWER - treat Dryness and irritation mouth and throat with Salt and soda gargle
- Teach precautions to minimize radiation exposure to others
thyroidectomy - ANSWER - surgical removal of the thyroid gland to treat hyperthyroidism
- Iodine administered 10 to 14 days before surgery to decrease vascularity
- may be partial or total
thyroidectomy nursing considerations - ANSWER - Address fear of "having neck cut" and scarring
- Usually a period of relative hypothyroidism post-op
- Will have decreased caloric needs
- Balanced iodide levels
- Total thyroidectomy requires lifelong thyroid replacement
- Risk of parathyroid damage--hypocalcemia Signs/symptoms? -Post-op: positioning (avoid neck flexion), bleeding, risk of airway obstruction, monitor calcium levels
- The nurse reviews the laboratory results of a patient with primary hypothyroidism.
T2D age of onset - ANSWER - More common in adults but can occur at any age.
- Incidence is increasing in children.
T2D type of onset - ANSWER Insidious, may go undiagnosed for years.
T2D primary defect - ANSWER - Insulin resistance
- decreased insulin production over time
Endogenous insulin production in patients with T2D - ANSWER - Initially increased in response to insulin resistance.
- Secretion diminishes over time
T2D nutritional status - ANSWER - Frequently obese/overweight
T2D symptoms - ANSWER - Frequently none
- Fatigue
- recurrent infections
- May also experience polyuria, polydipsia, and polyphagia
how is pre-diabetes characterized? - ANSWER - Impaired fasting glucose (IFG)
- Impaired glucose tolerance (IGT)
- typically asymptomatic
- long term damage to kidneys, heart, and vasculature is already occuring
what to monitor for with pre-diabetes - ANSWER - Polyuria
A1C ranges - ANSWER - normal below 5.7% -pre-diabetes 5.7 - 6.4%
T2D diagnosis - ANSWER 1. Hemoglobin A1c (HbA1c) ≥ 6.5% (>140 mg/dL)
- Fasting glucose level >126 mg/dL
- Random glucose measurement ≥200 mg/dL with symptoms
- Two-hour oral glucose tolerance test (OGTT) level ≥200 mg/dL when a glucose load of 75g is used
diabetes collaborative care goals - ANSWER - Active participant in the management of the diabetes regimen
- Informed decision making (empowerment approach)
- Experience few or no episodes of acute hyperglycemic or hypoglycemic emergencies
- Maintain blood glucose levels between 70-100 mg/dL
- Prevent, minimize, or delay complications
- Adjust lifestyle to accommodate diabetes regimen with minimum stress
know the different types of insulins. onset, duration, etc - ANSWER too lazy to put all this in so hopefully you remember from farm!
"basal bolus" insulin schedule - ANSWER - bolus rapid acting at meal time
- basal long acting once daily (evening/bed time)
Correction factor: - ANSWER insulin dose needed to correct current blood sugar to normal
diabetes care nursing considerations - ANSWER - Is patient or caregiver physically able to prepare and administer accurate doses of the medication?
- What emotions and attitudes are patient and caregiver displaying in regard to diagnosis of diabetes and insulin or oral agent treatment?
- Clarification of diabetes medications for NPO status
- Hold metformin day of and for 48 hours post surgery/ radiologic procedures requiring contrast medium
- Resume metformin after serum creatinine is within normal limits
"sick day rules" for patients with diabetes - ANSWER - Call primary care provider (PCP)
- Blood glucose every 4 hours
- Urine for ketones when blood glucose is >240 mg/dl (for Type 1)
- Take insulin/oral antidiabetic agents
- Drink 8-12 oz sugar free liquids every hour awake
- Eat regular meals (if possible)
- Call PCP for mod/large ketones, N/V, uncontrolled blood glucose (>300 for two readings), high fever
weight management is important for which type of diabetes? - ANSWER 2
considerations for carb counting in patients with diabetes - ANSWER - important for calculating insulin dose in T1D
- important for BG control in T2D
- Involve dietician and certified diabetes educator
- one serving of carbs = 15g
- 45-60 g per meal
- 130g per day
exercise therapy requirements for patients with diabetes - ANSWER 150 minutes/week
of a moderate-intensity aerobic physical activity and (for Type 2) resistance training 3 times/week in the absence of contraindications
how does exercise benefit patients with T2D? - ANSWER - ↑ insulin receptor sites (less insulin needed in the long term)
- Lowers blood glucose levels
- Contributes to weight loss
hypoglycemia prevention during exercise for patients with T2D - ANSWER - Monitor blood glucose levels before, during, and after exercise
- Small carbohydrate snacks every 30 minutes
- Exercise after meals
- especially important for patients on insulin
when/how should exercise plans be started for t2d? - ANSWER - After medical clearance
- Slowly with gradual progression
- Should be individualized
diabetes health promotion - ANSWER - Identify & screen at risk individuals
- Screen all adults over 45
- Weight management/physical activity
hospitalization/surgery considerations for diabetes - ANSWER - Risk for delayed surgical recovery
- Stress and illness impact glycemic control (per hospital protocol usually target blood glucose less than 180mg/dL)
hyperglycemia s/s - ANSWER - dry mouth
- Skin dry and loose; eyes soft and sunken
- Abdominal pain, anorexia, nausea/vomiting
- Kussmaul respirations
- Sweet, fruity breath odor (acetone)
- Blood glucose level ≥ 250 mg/dL
- Blood pH lower than 7.30 (HCO3 < 16 mEq/L)
- Moderate to high ketone levels in urine or serum
DKA interprofessional care - ANSWER - Ensure patent airway and O2 PRN
- IV access for fluids (NS) and to correct electrolyte imbalance (especially K+)
- Protect from cerebral edema; monitor for fluid overload, renal or cardiac compromise
- IV insulin drip and reduce glucose by 30- mg/dL per hour
Hyperosmolar Hyperglycemic Syndrome (HHS) - ANSWER - acute complication of T2D
- extreme hyperglycemia causes profound dehydration and electrolyte imbalances
- insulin is usually present in patients with T2D so ketoacidosis does not occur
HHS s/s - ANSWER - glucose levels > 600 mg/dL
- Somnolence
- Coma
- Seizures
- Hemiparesis
- Aphasia
HHS interprofessional care - ANSWER - Medical emergency; high mortality rate
- Ensure patent airway and O2 PRN
- IV access for fluids and to correct electrolyte imbalance (especially K+)
- More fluid replacement needed (more profoundly dehydrated)
- Correct cause
common causes of hypoglycemia - ANSWER - Insulin/oral agent was administered and food was late/missed
- Overestimation of insulin needs (carb count incorrect)
- Unplanned increase in activity
mild hypoglycemia treatment - ANSWER - BG 40-
- Treat with 10-15g of carb
- recheck BG in 15 minutes
moderate hypoglycemia treatment - ANSWER - BG < 40
- Treat with 15-30g of carb
- recheck BG in 15 minutes
moderate hypoglycemia s/s - ANSWER - Deprives brain cells of fuel & impairs CNS
- Cold, clammy skin
- pale
- rapid pulse
- rapid shallow respirations
- marked change in mood
how to give glucose to NPO/unconscious patient - ANSWER - IV D50 (20-50 mL)
- Capsaicin cream (Axsain, Zostrix)
nephropathy r/t diabetes - ANSWER - damage to small vessels in glomeruli
- Leading cause of end-stage renal disease
- Prevention - proper diabetes management
- Annual urinalysis for microalbuminiria
- Serum creatinine to estimate GFR & stage CKD
- Blood pressure management
- Prompt treatment of UTIs
- Avoidance of nephrotoxic drug
retinopathy r/t diabetes - ANSWER - Leading cause of blindness
- Prevention - proper diabetes management
- Not reversible
- Maintenance of remaining vision
infection r/t diabetes - ANSWER - Elevated glucose is a risk for infection
- Impaired mobilization of inflammatory cells and impaired phagocytosis by neutrophils and monocytes
- Loss of sensation may delay detection or provide a skin opening to become infected
- Treatment must be prompt and vigorous including glucose management (<180mg/dL)
gerontological considerations for diabetes - ANSWER - Prevalence of type 2 increases with age
- Delayed psychomotor function could interfere with treatment
- Must consider patient's own desire for treatment and coexisting medical problems
- Recognize limitations in physical activity, manual dexterity, and visual acuity
- Education based on individual's needs, using slower pace if needed
pediatric considerations for diabetes - ANSWER - Recognition of hypoglycemia
- Math skills for carb counting and insulin dosing
- Impact on parents and family
- Childcare
- Disease management at school
- Unpredictable with eating/activity (sports)
- Developmentally appropriate education
- Psychological effects of life-long management of chronic illness
considerations for pediatric A1C goals - ANSWER - generally younger children are okay with higher A1C and BG levels
- approach adult standard with age
- The nurse is assessing a patient newly diagnosed with type 1 diabetes. Which symptom reported by the patient correlates with the diagnosis?
a. Excessive thirst b. Gradual weight gain c. Overwhelming fatigue d. Recurrent blurred vision - ANSWER a
- When distinguishing between persons with type 1 diabetes from type 2 diabetes, the nurse is aware that
a. persons with type 1 diabetes require insulin therapy. b. autoantibodies to pancreatic β-cells are found in type 2 diabetes. c. persons with type 1 diabetes may be managed with metformin alone.