1. endocrine disorder
|1-1) hypothalamus hormones|
|① GHIH(Growth Hormone Inhibiting Hormone)|
|② GHRH(GH Releasing Hormone)|
|③ MIH (Melanocyte Inhibiting Hormone)|
|④ TRH (Thyrotropin Releasing Hormone)|
|⑤ CRH(Corticotropin Releasing Hormone)|
|⑥ PIH (Prolactin Inhibiting Hormone)|
|⑦ GnRH (Gonadotropin Releasing Hormone)|
|1-2) Anterior lobe of pituitary gland hormones (the master gland)|
|① GH (Growth Hormone)|
|② somatotropic growth stimulating hormone|
|③ MSH (Melanocyte Stimulating Hormone)|
|④ TSH (Thyroiod Stimulating Hormone)|
|⑤ ACTH (AdrenoCorticoTropic Hormone)|
|⑥ PRL (PRoLactin)|
|⑦ FSH (Follicle Stimulating Hormone)|
|⑧ LH (Luteinizing Hormone)|
|1-3) posterior lobe of pituitary gland hormones|
|⑨ ★ ADH (AntiDiuretic Hormone), vasopressin||
(3) SIADH (Syndrome of Inappropriate ADH secretion)
• results in water intoxication and hyponatremia
(4) DI (Diabetes Insipidus)
• results in dehydration
• Administer vasopressin tannate (Pitressin) or desmopressin acetate (DDAVP, Simate, Minirin) as prescribed.
|1-4) thyroid gland|
|① ★ T3 and T4||
(6) thyroid storm
• This acute and life-threatening condition occurs in a client with uncontrollable hyperthyroidism.
(8) myxedema coma
• This rare but serious disorder results from persistently low thyroid production.
|1-5) parathyroid gland|
|③ PTH (ParaThyroid Hormone)||
|1-6) cortex of adrenal gland|
|① ★ glucocorticoids
(cortisol, cortisone, corticosterone)
(12) Addison’s disease
• Characterized by a hyposecretion of glucocorticoids and mineralocorticoids
• Addisonian crisis: A life-threatening disorder caused by acute adrenal insufficiency, can cause hypoglycemia, hyponatremia, hyperkalemia, hypocalcemia, A/N/V/D, weight loss, brown pigmentation, BP ↓, and shock.
• Avoid individuals with an infection. Avoid strenuous exercise and stressful situations. Avoid Over-The-Counter medications. Need for lifelong glucocorticoid therapy.
|② mineralocorticoids (aldosterone)|
|③ sex hormones|
|1-7) medullar of the adrenal gland (as part of the sympathetic nerve system)|
|④ epinephrine, norepinephrine||
|① glucagon (form α cell)|
|② insulin (form β cell)||
(14) ★ DM (Diabetes Mellitus)
• Chronic disorder of impaired carbohydrate, protein, and lipid metabolism caused by a deficiency of insulin. Macrovascular complications include coronary artery disease, cardiomyopathy, hypertension, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include retinopathy, nephropathy, and neuropathy.
• type 2 DM의 high risk: DM family history, over 45 years, obesity, HTN, CAD, GDM (9 lb), people of color
• 소아 type 2 DM 시 목 주위 접힌 부분에 pigmentation
2. ★ acute complication of DM
• Hypoglycemia occurs when the blood glucose level falls below 70mg/dl or when the blood glucose level drops rapidly from an elevated level.
|• Check the client’s blood glucose level. Give the client a 10 to 15 carbohydrate item. Take the client’s V/S. Retest the blood glucose level in 15 minutes. Document the client’s complaints, actions taken, and outcome.
For the client experiencing a severe hypoglycemic reaction who is semiconscious or unconscious, an injection of glucagon is administered SC or IM. In the hospital or ER, the client may be treated with an IV injection of 25 to 50 mL of 50% dextrose in water.
• Once symptoms resolve, a snack containing protein and carbohydrates, such as low-fat milk or cheese and crackers, is recommended unless the client plans to eat a regular meal within 60 minutes.
|② [Pediatric] sick day rules for DM
• 아프면 혈당이 오름
|• Test blood glucose levels at least every 4 hours. Test for urinary ketones with each voiding. Notify the HCP if moderate or large amounts of urinary ketones are present.
• Follow the child’s usual meal plan.
• Always give insulin, even if the child does not have an appetite, or contact the HCP for specific instructions.
• Encourage liquids to aid in clearing ketones.
• Encourage rest, especially if urinary ketones are present.
|③ DKA (Diabetic KetoAcidosis)
• DKA is a life-threatening complication of type 1 DM that develops when a severe insulin deficiency occurs.
|• hyperglycemia, ketosis, acidosis, dehydration
|• Treat dehydration with rapid IV infusions of 0.9 or 0.45% NS as prescribed. Treat hyperglycemia with insulin administration IV as prescribed. An IV bolus dose of insulin, usually 5 to 10 units, may be prescribed before a continuous infusion is begun. Insulin is infused continuously until SC administration resumes to prevent a rebound of the blood glucose level. Dextrose is added to IV fluids when the blood glucose level reaches 250 to 300mg/dl. Correct electrolyte imbalances. (Monitor potassium level closely because when the client receives treatment for dehydration and acidosis, the serum potassium level will decrease.
• client during illness education: Take insulin or oral antidiabetic medications as prescribed. Determine the blood glucose level and test the urine for ketones every 3 to 4 hours. If the usual meal plan cannot be followed, substitute soft foods 6 to 8 times a day. If vomiting, diarrhea, or fever occurs, consume liquids every 30 to 60 minutes to prevent dehydration and to provide calories.
|④ HHNS (Hyperglycemic Hyperosmolar Nonketotic Syndrome)
• Extreme hyperglycemia occurs without ketosis or acidosis. Enough insulin is present with HHNS to prevent the breakdown of fats for energy, thus preventing ketosis.
- client education regarding monitoring of blood glucose level: Use the proper procedure to obtain the sample for determining the blood glucose level. Perform the procedure precisely to obtain accurate results. Follow the manufacturer’s instructions for the glucometer. Wash hands before and after performing the procedure to prevent infection. Calibrate the monitor as instructed by the manufacturer. Check the expiration date on the test strips. If the blood glucose level results do not seem reasonable, reread the instructions, reassess the technique, check the expiration date of the test strips, and perform the procedure again to verify results.
- DM diet: The DM client’s diet should take into account weight, medication, activity level, and other health problems. Day-to-day consistency in timing and amount of food intake helps control the blood glucose level. As prescribed by the HCP, the client may be advised to follow the recommendations of the American Diabetic Association diet or U.S. dietary guidelines issued by the U.S. Departments of Agriculture and Health and Human Services. Carbohydrate counting may be a simpler approach for some clients; it focuses on the total grams of carbohydrates eaten per meal. The client may be more compliant with carbohydrate counting, resulting in better glycemic control; it is usually necessary for clients undergoing intense insulin therapy. Incorporate the diet into individual client needs, lifestyle, and cultural and socioeconomic patterns. carbohydrate ; protein : fat = 5 : 2 : 1. Avoid alcohol, but when drinking alcohol, take some foods with alcohol.
- DM exercise: Exercise lowers the blood glucose level, encourages weight loss, reduces cardiovascular risks, improves circulation and muscle tone, decreases total cholesterol and triglyceride levels, and decreases insulin resistance and glucose intolerance. Instruct the client in dietary adjustments when exercising; dietary adjustments are individualized. If the client requires extra food during exercise to prevent hypoglycemia, it need not be deducted from the regular meal plan. Instruct the client with DM to monitor the blood glucose level before, during, and after exercising. If the blood glucose level is higher than 250mg/dl and urinary ketones are present, the client is instructed not to exercise until the blood glucose level is closer to normal and urinary ketones are absent.
- ★ preventive foot care instructions: Provide meticulous skincare and proper foot care. Inspect feet daily and monitor feet for redness, swelling, or break in skin integrity. Notify the HCP if redness or a break in the skin occurs. Avoid thermal injuries from hot water, heating pads, and baths. Wash feet with warm (not hot) water and dry thoroughly (avoid foot soaks). Apply moisturizing lotion to the feet but not between the toes. Prevent moisture from accumulating between the toes. Cut toenails straight across and smooth nails with an emery board. Avoid self-treating corns, blisters, or ingrown toenails. Do not cross legs or wear tight garments that may constrict blood flow. Wear loose socks and well-fitting (not tight) shoes; do not go barefoot. Wear clean cotton socks to keep the feet warm and change the socks daily. Avoid wearing the same pair of shoes 2 days in a row. Avoid wearing open-toed shoes or shoes with a strap that goes between the toes. Check shoes for cracks or tears in the lining and for foreign objects before putting them on. Break-in new shoes gradually. Avoid smoking.
3. complications of insulin therapy
|① local allergic reactions||– redness, swelling, tenderness, induration, a wheal at the site of injection
– occur 1 to 2 hrs after administration
|– Instruct the client to cleanse the skin with alcohol before injection.|
|② insulin lipodystrophy
– lipoatrophy : loss of SC fat
– lipohypertrophy : development of fibrous fatty masses
|– The use of human insulin helps prevent insulin lipoatrophy.
– Instruct the client to avoid injecting insulin into affected sites.
– Instruct the client about the importance of rotating insulin injection sites.
|③ insulin resistance
– The client receiving insulin develops immune antibodies that bind the insulin, thereby decreasing the insulin available for use in the body. Insulin resistance is also the term used for lack of tissue sensitivity to the insulin from the body, which results in hyperglycemia.
|– Treatment consists of administering a purer insulin preparation.|
|④ Dawn phenomenon
– Dawn phenomenon results from reduced tissue sensitivity to insulin, and usually develops between 5 and 8 AM. Pre-breakfast hyperglycemia occurs.
|– Treatment includes administering an evening dose or increasing the amount of a current dose of intermediate-acting insulin at about 10PM.|
|⑤ Somogyi phenomenon
– Normal or elevated blood glucose levels are present at bedtime. Hypoglycemia occurs at about 2 to 3 AM, which causes an increase in the production of counter regulatory hormones. By about 7 AM, in response to the counter regulatory hormones, the blood glucose rebounds significantly to the hyperglycemic ranges.
|– Treatment includes decreasing the evening (pre-dinner or bedtime) dose of intermediate-acting insulin or increasing the bedtime snack.|
4. [Pediatric] phenylketonuria
|– Phenylketonuria is a genetic disorder that results in CNS damage from toxic levels of phenylalanine in the blood.||– characterized by blood phenylalanine levels greater than 20 mg/dl||– screening of newborn infants for phenylketonuria
– If phenylketonuria is diagnosed, restrict phenylalanine intake. High-protein foods (meats and dairy products) and aspartame are avoided because they contain large amounts of phenylalanine. Educate the parents about the use of special preparation formulas and about the foods that contain phenylalanine.
5. [Pediatric] fever
|– Normal temperature for a child : 36.4 to 37℃ (97.5 to 98.6℉)
38℃ (100.4℉) is considered to be fever.
|– Monitor V/S.
– Remove excess clothing and blankets, reduce the room temperature, and increase the air circulation. Use other cooling measures such as the application of a cool compress to the forehead if appropriate.
– Administer a sponge bath with tepid water for 20 to 30 minutes and gently squeeze water from a facecloth over the back and chest and recheck the temperature 30 minutes after the bath. Do not use alcohol because it can cause peripheral vasoconstriction.
– Administer antipyretics such as ibuprofen (Motrin) as prescribed. Aspirin should not be administered, unless specifically prescribed, because of the risk of Reye’s syndrome.
– Retake the temperature 30 to 60 minutes after the antipyretic is administered.
– Provide adequate fluid intake as tolerated and as prescribed.
– Monitor for signs and symptoms that indicate dehydration and electrolyte imbalances.
6. [Pediatric] dehydration
|– Dehydration is a common fluid and electrolyte imbalance in infants and children. Infants and children are more vulnerable to fluid volume deficit because more of their body water is in the extracellular fluid compartment.||– Monitor V/S.
– Monitor I/O.
– Monitor LOC.
|– mild to moderate :
slightly increased HR, slightly increased RR
|– Provide oral rehydration therapy with Pedialyte or a similar rehydration solution as prescribed. Avoid carbonated beverages because they are gas-producing and fluids that contain high amounts of sugar, such as apple juice.|
|– severe : 10% weight loss,
BP : orthostatic to shock,
sunken eyes, sunken fontanel,
oliguria or anuria
|– Maintain NPO status to place the bowel at rest.
– Provide fluid and electrolyte replacement by the IV route as prescribed.