1. G H
E SHEEHAN’S C Y
S O P
T D N E
A I G ADRENAL R
T A E P
I B N L
O E I A
N T T S
A E A I
L S SYNDROME L A
MODULE H
Heather Anderson, Christen Biddle,
Ashley Clontz, Amber Ennis, Kareena Lowery

2. Gestational Diabetes
•Gestational diabetes is a form of diabetes which manifests itself during pregnancy as a result of
hormonally mediated stress on carbohydrate metabolism and familial predisposition to diabetes.
•Glucose intolerance may be transitory for the duration of pregnancy , but frequently recurs later in life.
Manifestations
Clinical manifestations are not always apparent in gestational diabetes. Some manifestations may
include:
•Blurred vision
•Fatigue
•Frequent infections ( including ones of bladder, vagina, and skin)
•Increased thirst
•Increased urination
•Nausea and vomiting
•Weight loss in spite of increased appetite

3. Gestational Diabetes
Risk Factors:
- Previous birth
outcome often - History of - Member of high-
associated with abnormal glucose risk ethnic group
- Overweight
gestational tolerance ( Hispanic, African,
- Maternal age
diabetes - History of Native American,
over 25
- Gestational diabetes in first- South or East
diabetes in degree relative Asian, or Pacific
previous Island ancestry)
pregnancies

4. Gestational Diabetes
Nursing Diagnoses:
• Risk for Ineffective Health Maintenance r/t knowledge deficit
• Anxiety r/t threat to self and/or fetus.
• Risk for delayed development: fetal r/t endocrine disorder
• Risk for disproportionate growth: fetal r/t endocrine disorder
• Risk for unstable blood glucose level r/t pregnancy

5. Gestational Diabetes
Interventions:
•Educate the patient about a proper diet. She should consume enough calories and nutrients for
adequate weight gain, while limiting simple sugars found in sweets. Calories should be divided between
3 meals and 3 snacks a day.
•Teach the importance of regular exercise. It improves the metabolism of glucose, which helps to lower
blood glucose levels and helps control weight gain.
•Demonstrate how to check blood sugar levels and allow patient to perform a return demonstration.
•Teach the patient about the different types of insulin.
•Teach the patient how to self-inject insulin.
•Teach the patient the signs and symptoms of hypo- and hyperglycemia.

6. Gestational Diabetes
Outcomes:
•The patient will maintain a balanced diet.
•The patient will gain an adequate amount of weight throughout pregnancy.
•The patient will demonstrate checking blood sugar level and administering insulin, if needed.
•The patient will maintain normal blood glucose levels throughout pregnancy.
•The patient will list the signs and symptoms of hypo- and hyperglycemia.
•The patient will identify self-care actions to maintain target glucose levels.
•The patient will identify actions to take if blood glucose level is too low or too high.

7. Gestational Diabetes
Testing and Treatment:
• Generally a test for gestational diabetes is carried out between the 24th and 28th week of
pregnancy. If your doctor believes you could be at risk for gestational diabetes (see Risk Factors) he
or she could prescribe a glucose test earlier in the pregnancy.
• Often, gestational diabetes can be managed through a combination of diet and exercise. If that is
not possible, it is treated with insulin(usually 15% need Insulin), in a similar manner to diabetes
mellitus.

8. Gestational Diabetes
Diagnosis: A health care team will check the affected person's blood glucose level. Depending on the
mother's risk and her test results, she may have one or more of the following tests.
Screening Glucose Oral Glucose Fasting Blood
Challenge Test Tolerance Test Glucose Test
There are several tests intended to identify gestational Women who are considered at risk for gestational A fasting plasma glucose level >126 mg/dl (7.0 mmol/l)
diabetes in pregnant women. The first, called the diabetes are given a screening test called a 50 gram or a casual plasma glucose >200 mg/dl (11.1 mmol/l)
Screening glucose challenge test, is a preliminary glucose challenge between the 24th and 28th weeks of meets the threshold for the diagnosis of diabetes, if
screening test performed between 26-28 weeks. If a pregnancy (those with two or more risk factors may be confirmed on a subsequent day, and precludes the
woman tests positive during this screening test, the tested earlier). The glucose challenge is performed by need for any glucose challenge.
second test, called the Glucose Tolerance Test, may be giving 50 grams of a glucose drink and then drawing a
The following are the values that the American Diabetes
performed. This test will diagnose whether diabetes blood sample one hour later and measuring the level of
Association considers to be abnormal during the
exists or not by indicating whether or not the body is blood glucose present. Women with a blood sugar level
Glucose Tolerance Test:
using glucose (a type of sugar) effectively. The Glucose greater than 140 mg/dl may have gestational diabetes,
Challenge Screening is now considered to be a and require a follow up test called a 3-hour oral glucose • Fasting Blood Glucose Level≥95 mg/dl (5.33
standard test performed during the second trimester of tolerance test (OGTT). mmol/L)
• 1 Hour Blood Glucose Level≥180 mg/dl (10
pregnancy.
mmol/L)
• 2 Hour Blood Glucose Level≥155 mg/dl (8.6
mmol/L)
• 3 Hour Blood Glucose Level≥140 mg/dl (7.8
mmol/L)

9. Gestational Diabetes
Medications
•Most women can treat gestational diabetes by changing the way they eat and exercising more often. If
these changes do not keep your blood sugar level within a target range, you may need to take insulin.
You may also need to take insulin if your doctor thinks that your baby is getting too large.
•Some doctors are using pills called glyburide and metformin to treat women who have gestational
diabetes.

10. Gestational Diabetes
Nutrition:
• Patients with gestational diabetes should most importantly avoid foods
that contains sugar.
• Counting carbohydrates in each meal is important and the total carbs each
meal is about 20-45.
• Food combinations is an important idea to consider. Many dieticians
believe it is important to mix fruits and milk because both are simple
carbohydrates.
• Milk, starches, and protein emphasized since the combination can serve as
short and long term energy.

11. Gestational Diabetes
Health Promotion:
Healthy dieting is the most important goal for gestational diabetes. These
goals include:
• Eating three small meals a day with two or three snacks at the same
time each day. Do not skip any meals or snacks
• If the patient has morning sickness, try to eat 1-2 servings of crackers
or pretzels before getting out of bed.
• Choose foods high in fiber such as breads, pasta, cereal, rice, and
fruits.
• Eat food low in sugar and fat
• Drink at least 8 cups of water a day.
• Eat less carbohydrates at breakfast than the rest of the day because this
is when insulin resistance is the greatest.
• Ask health care provider about taking prenatal vitamins and
supplements

12. Gestational Diabetes
Health Promotion:
Important goals for managing gestational diabetes continued:
• Eat at least three servings of food that are rich in iron. This ensures that
you are getting 30 mg of iron per day
• Choose at least one source of Vitamin C every day. This can include:
broccoli, oranges, grapefruit, strawberries, and honeydew.
• Choose at least one source of Vitamin A. This includes: carrots,
pumpkin, sweet potatoes, spinach, water squash, and cantaloupe.

13. Congenital Adrenal
Hyperplasia (CAH)

14. Congenital Adrenal Hyperplasia (CAH)
•CAH is a group of disorders in which the adrenal gland is not able to
manufacture adequate glucocorticoid and, while working to make glucocorticoid,
produces excess androgens.
•CAH is caused by a defect in the enzymatic pathway of adrenal steroid
production. Diminished glucocorticoid production prompts increased ACTH
production, further increasing adrenal androgen excess.
• The most life-threatening and most common form of CAH is the “salt-
wasting” crisis. This happens when mineralocorticoid production may
be normal or low.
• Infants with diminished mineralocorticoid production will waste salt
through kidneys. This results in hypovolemia, low serum sodium levels,
and hyperkalemia.
• CAH is a autosomal recessive condition.

15. Congenital Adrenal Hyperplasia (CAH)
Manifestations
•CAH is marked by ambiguous genitalia of a newborn female infant, postnatal
virilization in both sexes, and salt-wasting crisis (in the first few weeks of life)
with low serum sodium, high serum potassium, hypovolemia, and hypotensive
crisis.
•Simple virilizing CAH is not associated with salt-wasting crisis and manifests
with a muscular body, advanced bone age, and premature pubic hair. This
form typically manifest later in infancy or early childhood.
•Untreated or poorly treated CAH can result in an advanced bone age with
ultimate adult short stature.
•A milder form of CAH, 3-beta-hydroxysteroid dehydrogenase (3B-HSD), may
become symptomatic during childhood or adolescence, with the child
manifesting hirsutism, menstrual irregulations, or delayed menses.

16. Congenital Adrenal Hyperplasia
Nursing Diagnoses:
•Risk for disproportionate growth r/t congenital disorder
•Risk for electrolyte imbalance r/t endocrine dysfunction

17. Congenital Adrenal Hyperplasia
Interventions:
•Assess newborn girls for abnormal genital characteristics, such as fused labia, enlarged clitoris, or
abnormal location of urethral opening.
•Assess newborn boys with unexplained dehydration and low sodium levels for adrenal insufficiency.
•Assess older children who are taking glucocorticoids for excessive growth and signs of early puberty.
•Measure height regularly.
•Monitor renin levels closely.
•Monitor blood pressure closely if receiving mineralocorticoid replacement therapy.
•Instruct parents about the correct timing of medications and what to do when their child is sick.
•Teach parents how to prepare sodium supplements if they are needed.

18. Congenital Adrenal Hyperplasia
Outcomes:
·•The
patient
will
maintain
normal
serum
sodium
levels.
·•The
patient
will
maintain
an
average
height
for
age
and
sex.
·•The
parents
will
be
able
to
explain
how
and
when
to
give
medications.

19. Congenital Adrenal Hyperplasia
Prenatal
Testing
• Doctors have the tools to screen and diagnose congenital adrenal hyperplasia in fetuses. These tools
are used most often when siblings have the disease or family members are known to carry the gene
defect.
If you're pregnant and have the condition or a family history of the condition, your doctor may recommend
one of the following tests:
• Amniocentesis. This procedure uses a needle to withdraw a sample of cells from the amniotic fluid in
the womb and determine in the laboratory whether the condition is present.
• Chorionic villus sampling. This test involves withdrawing cells from the placenta for analysis in the
laboratory.
If the condition is diagnosed before birth, treatment can be started in the womb. Prenatal diagnosis and
therapy may be able to reduce the risk of complications.
Testing to determine a child's sex
After birth, your child may have ambiguous external genitalia, so you may not sure of your child's sex. In
that case, genetic blood tests can analyze chromosomes — in a test called karyotyping — to determine the
sex of your child.
In addition, a pelvic ultrasound can be used to produce images of female reproductive structures — the
cervix, uterus and fallopian tubes — to confirm whether your child is a girl.

20. Congenital Adrenal Hyperplasia
Diagnosis
• Physical exam. Your child's doctor will examine your child and evaluate symptoms. If, based
on these findings, the doctor suspects congenital adrenal hyperplasia, the next step is to
confirm the diagnosis with blood and urine tests.
• Blood and urine tests. Tests used to diagnose congenital adrenal hyperplasia measure levels
of hormones manufactured by the adrenal glands — cortisol, aldosterone and androgens. A
diagnosis can be made when there are abnormal levels of these hormones.
In many states, doctors are required to conduct hormonal tests for congenital adrenal hyperplasia in
newborns during the first few days of life. Blood is drawn with a heel prick of the newborn and
analyzed.

21. Congenital Adrenal Hyperplasia
Medications:
•In most cases, your child's doctor will prescribe replacement hormone medication to boost the levels
of deficient hormones in your child and restore them to normal levels. For example, your child may take
an oral drug — such as hydrocortisone or dexamethasone to replace cortisol and fludrocortisone to
replace aldosterone — on a daily basis. At times, children with congenital adrenal hyperplasia need
multiple drugs, with even higher doses prescribed during periods of illness or severe stress, including
surgery

22. Congenital Adrenal Hyperplasia
Nutrition:
Patients with congenital adrenal hyperplasia should remain on an
unrestricted diet.
Patients should be able to have access to as salt because salt wasting is
common in congenital adrenal hyperplasia
Monitoring caloric intake is important and should be restricted if excess
weight gain occurs.
Weight gain can occur because glucocorticoids stimulate appetite.
Foods with high salt content should be emphasized, these foods include:
Ketchup, Salad Dressings, Baking soda and Baking powders, Broths, soups,
and Gravies, Soy sauce, Salami, Bacon, and cured meats

23. Congenital Adrenal Hyperplasia
Health
Promotion:
Parents with a family history of congenital adrenal hyperplasia or has a
newborn diagnosed with the disease should consider genetic counseling.
New born screening is very important, the screening is performed using a
routine heel stick, obtaining blood from the infant.
Check-ups for the disease should be emphasized to educate and monitor
the disease in the patient. Patients should be equip to recognized new
symptoms and changes.
Patients should also understand the importance of adhering to medication
and treatment of the disease

24. SHEEHAN’S SYNDROME

25. Sheehan’s Syndrome
•Sheehan’s is a deficiency of various hormones the pituitary gland controls ; thyroid, adrenal, breast milk
production, and menstrual function.
•Postpartum hemorrhage is the most common cause of pituitary infarction, which results in decreased
hormone secretion.
•The pituitary gland normally enlarges during pregnancy, and when hypotension results from hemorrhage,
ischemia and necrosis of the gland occur. Usually this condition develops immediately after delivery, although
some cases have occurred several years later.

26. Sheehan’s Syndrome
Manifestations:
•Slowed mental function, weight gain, & difficulty staying warm
•Difficulty breastfeeding or inability to beast feed
•No menstrual period (amenorrhea) or infrequent menstruation (oligomenorrhea)
•Loss of pubic or underarm hair
•Low blood pressure
•Fatigue
•Weight loss
Some may not realize they have Sheehan’s syndrome until they need treatment for thyroid or
adrenal insufficiency.

27. Sheehan’s Syndrome
Nursing
Diagnoses:
·•Risk
for
bleeding
r/t
postpartum
complications
·•Deficient
fluid
volume
r/t
active
fluid
loss
·•Risk
for
shock
r/t
hypovolemia

28. Sheehan’s Syndrome
Interventions
·•Prevent
postpartum
hemorrhage.
·•Assess
for
signs
of
bleeding,
such
as
excessive
bruising
and
petechiae.
·•Administer
blood
transfusions
as
needed.
·•Provide
oxygen
as
ordered.
·•Administer
IV
fluids
as
prescribed.

29. Sheehan’s Syndrome
Outcomes
• The patient will remain oriented to person, place, and
time.
• The patient will maintain oxygen saturation above 95%.
• The patient will have adequate levels of hemoglobin and
hematocrit.
• The patient will have no bruising or petechiae.
• The patient will maintain a systolic blood pressure above
90 mm Hg.

30. Sheehan’s Syndrome
Diagnosis:
Upon a general investigation symptoms may include: an inability to breast-feed
(breast milk never "comes in"), Fatigue, Loss of pubic and axillary hair,
amenorrhea, or lack of menstrual bleeding and low blood pressure
If your history and signs and symptoms suggest pituitary insufficiency, you'll
have blood tests to check your pituitary hormone levels. You may need
specialized stimulation testing of the pituitary hormones, which typically is
done after consulting an endocrinologist.
You may also need imaging tests, such as magnetic resonance imaging or
computerized tomography, to check the size of your pituitary and to look for
other possible reasons for your symptoms, such as a pituitary tumor.

31. Sheehan’s Syndrome
Medications:
Treatment for Sheehan's syndrome is lifelong hormone replacement therapy. Your
doctor may recommend one or more of the following medications:
Corticosteroids.
•
Levothyroxine
Estrogen
Growth hormone
Your endocrinologist is likely to test your blood regularly to make sure that you're getting adequate
— but not excessive — amounts of any hormones that you take. Generally, hormone levels are
checked every few weeks or months at the beginning of treatment and then once a year thereafter

32. Sheehan’s Syndrome
Nutrition:
Because Sheehan’s is a postpartum syndrome, there are no
specific changes needed in the diet or nutrition.
Health
Promotion:
• The severe bleeding from childbirth that can cause Sheehans Syndrome can often be
avoided by health management and prenatal care during the pregnancy.
• To make sure one is managing their health during pregnancy, the following can be
included:
• Ask about pre-appointment restrictions, in case tests need to be performed
• Even if they seem unrelated, write down any symptom changes.
• Make a list of important medical information, such as medications and past surgical
procedures.
• Take a family member or friend to each appointment to soak up more information.

33. NCLEX
Questions:
1.) A nurse implements a teaching plan for a
pregnant client who is newly diagnosed with
gestational diabetes. Which statement made by
the client indicates a need for further teaching?
A.) “I should stay on the diabetic diet.”
B.) “I should perform glucose monitoring at
home.”
C.) “I should avoid exercise because of the
negative effects on insulin production.”
D.) “I should be aware of any infections and report
signs of infection immediately to my doctor.”

34. ANSWER: C
Exercise is safe and lowers blood
glucose levels.

35. 2.) An infant is born with ambiguous genitalia.
Tests are being done to assist in gender
assignment. The parents tell the nurse that
family and friends are asking what caused the
baby to be this way. What should the nurse’s
intervention include?
A.) Explain the disorder so that parents can explain
it to others.
B.) Help parents understand that no one knows
how this occurs.
C.) Suggest that parents avoid family and friends
until the gender is assigned.
D.) Encourage parents not to worry while the tests
are being done.

36. ANSWER: A
This is the most therapeutic approach
while the parents await the gender
assignment.

37. 3.) The best evaluation for the client outcome
of accurate insulin administration is that she
will:
A.) Repeat the taught steps of the technique.
B.) Accurately withdraw, mix, and inject insulin.
C.) Have normal fasting and postprandial glucose
levels.
D.) State that she understands the teaching given.

38. ANSWER: B
A return demonstration is the best way to evaluate
that teaching has been effective.

39. Resources:
Ignatavicius Workman. (2010). Medical-Surgical
Nursing. Saunders Elselvier
www.medscape.com