Download Alterations in Endocrine Function: Diabetes

Diabetes Mellitus
Kristine Ruggiero, CPNP, MSN, RN
Chapter 32
Pages 1263-1275
What is Diabetes?
•
Body does not make or properly use
insulin:
–
–
–
•
no insulin production
insufficient insulin production
resistance to insulin’s effects
No insulin to move glucose into cells:
–
–
–
high blood glucose means:
fuel loss. cells starve
short and long-term complications
Diabetes Mellitus
• Statistics:
• Diabetes is one of the most common
chronic diseases in school-aged children.
• In the United States, about 176,500
people under 20 years of age have
diabetes.
• About 1 in every 400 to 600 children has
type 1 diabetes. Each year, more than
13,000 children are diagnosed with type 1
diabetes.
Diabetes Mellitus
• Cause is uncertain, likely
environmental and genetic causes
– Genetic factors
– Autoimmune factors (Type 1)
– Viral infection
Pathophysiology of Disease
• Characterized by disturbance in
carbohydrate, protein and fat
metabolism:
– Insulin:
• Allows glucose transport into the cells for
use as energy or storage as glycogen
• Stimulates protein synthesis and free fatty
acid storage in adipose tissues
• Deficiency compromises the body tissues’
access to essential nutrients for fuel and
storage
DM
• Two primary forms:
• Type 1:
– characterized by absolute insulin insufficiency
• Type 2:
– characterized by insulin resistance with varying
degrees of insulin secretory defects
• Other forms:
–
–
–
–
Gestational
“Hybrid or Mixed”
Maturity-onset Diabetes of the Young (MODY)
Secondary Diabetes (from CF, steroids)
Type 1 Diabetes
• An autoimmune disease in which the
immune system destroys the insulinproducing beta cells of the pancreas
that regulate blood glucose.
• Acute onset
– About 75 percent of all newly diagnosed
cases of type 1 diabetes occur in
individuals younger than 18 years of
age.
Complications of DM
• Hypoglycemia (insulin
reaction)
• Ketoacidosis
• Hyperosmolar,
hyperglycemic
syndrome
• Cardiovascular disease
• Peripheral vascular
disease
• Retionopathy,
blindness
• Nephropathy, renal
failure
• Diabetic dermopathy
• Peripheral neuropathy
• Amputation
• Impaired resistance to
infection
• Cognitive depression
• Poor wound healing
Complications of DM
• Refer to Table 32-4 in text:
• Acute Complications:
– DKA
– Hypoglycemia
• Chronic Complications:
–
–
–
–
Retinopathy
Nephropathy
Neuropathy
Peripheral vascular disease
• Complications r/t G&D:
– Delay in growth
– Delay in puberty
– Menstrual disturbances
Clinical Manifestations
•
•
•
•
•
Polyuria
Polydipsia
Polyphagia
Nocturia
Weight loss and
hunger
• Weakness and fatigue
• Dehydration
– Poor skin turgor
– Dry mucous
membranes
• Vision changes
– Retinopathy or cataract
formation
– Can lead to blindness
• Frequent skin and
UTI’s
• Acanthosis nigricans
– (a velvety
hyperpigmented
thickening of the skin
around the nape of the
neck—mostly Type 2)
• Numbness or pain in
hands/ feet
Acanthosis nigricans. Courtesy of Audrey Austin, M.
D., Children’s National Medical Center, Washington, D.C.
FIGURE 32–12
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Clinical Manifestations
• Skin changes
• Diminished DTR’s
– Dry, itchy skin (esp
• Orthostatic
hands/ feet)
hypotension
– Cool temperature
• Characteristic
• Postprandial feeling
“fruity” breath odor
of nausea or
in ketoacidosis
fullness
• Possible
• Nocturnal diarrhea
hypovolemia and
• Decreased
shock in
peripheral pulses
ketoacidosis
Type 1 Specific Symptoms
• (Refer to Table on p 1267)
• Rapidly developing sxs
• Muscle wasting and loss of subcutaneous
fat
• Ketoacidosis
• Honeymoon period
– A one-time remission of the sxs, occurs shortly
after tx is started
– Last-ditch effort by pancreas to produce insulin
– When sxs reappear the child will be insulin
dependent for life
Type 2 Specific Symptoms
• Hypertension
• Vague, long-standing symptoms
that develop gradually
• Severe viral infection
• Other endocrine diseases
• Recent stress or trauma
• Use of drugs that increase blood glucose
levels
• Obesity, particularly around abdomen
• Acanthosis nigricans
Diagnosis of DM
• Based on hx and PE
– including the presence of classic
symptoms as described previously
• And serum glucose levels
Diagnostic Test Findings
• Fasting plasma glucose level greater than
or equal to 126 mg/dl on at least 2
occasions
• Random blood glucose level greater than
or equal to 200 mg/dl
• Two-hour postprandial blood glucose level
greater than or equal to 200 mg/dl
• Glycosylated hemoglobin increased
• Urinalysis possibly showing acetone or
glucose
• Ophthalmologic examination may show
diabetic retinopathy
Management of DM
• Glycemic Control to prevent
complications
• Nutritional Therapy
• Regular exercise
• Psychosocial support
Insulin Therapy
• The ADA recommends that blood
glucose levels be normalized using
basal-bolus tx for children and
adolescents
• Basal-Bolus Therapy:
– Monitoring blood glucose 4-8X’s/ day
and once a week at midnight and 3 am
– Consistent carbohydrate monitoring
– Anticipating exercise in the routine
Insulin Therapy
• Goal of insulin therapy:
– Maintain serum glucose levels from 80120 mg/dL b/f meals
– 100-140 mg/dL at bedtime (ADA, 2002)
• Insulin can be administered:
– Subcutaneous insulin infusion (SCII)
– Multiple daily injections (MDIs)
Insulin Infusion Pump
• Refer to Table 32-6: Age-based Criteria for
Selecting Insulin Pump Therapy
• Refer to Table 32-7: Advantages and
Disadvantages of an External Insulin
Infusion Pump
Insulin Therapy
• Stress, infection and illness may
increase or decrease insulin needs
• Increased insulin doses are often
required during growth and puberty
Insulin Therapy
• Glycemic Control to Prevent Complications
– Refer to Table 32-5 for Insulin Action
• Rapid Acting Insulin
– Lispro/ Humalog
• Short Acting
– Regular
• Intermediate Acting
– NPH, Lente
• Long Acting
– Ultralente, Lantos/ insulin glargine
• Combine therapy
– Intermediate acting mixed with short acting or rapid
acting
Evaluation of Insulin
Therapy
• Hemoglobin A1C: measures glycosylated
hemoglobin
– Performed every 3 months
– Objective measurement of glycemic control
– Represents amount of glucose irreversibly
attached to Hgb molecule over its lifetime
– HbA1C (w/o Diabetes)= b/l 6.2%
– HbA1C (w/ Diabetes)= 7.5-8%
Evaluation of Insulin
therapy
• HbA1C= average
blood glucose control
for the past few
months
• With diabetes= extra
glucose in
bloodstream
• This extra glucose
enters your red blood
cells and links up (or
glycates) with
molecules of
hemoglobin.
• HbA1C= Batting
Average
Management of DM
• Nutrition Therapy:
– Establish daily nutrition therapy
– Carbohydrate counting= flexibility in meal
planning
– Food pyramid to teach family adequate portion
control
• Exercise Program:
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–
–
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Physical activity= increased insulin sensitivity
Improves blood glucose control
Controls weight
Reduces cardiovascular risks
Nursing Care
• Focuses on teaching child/ family about
DM and its management
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–
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Dietary intake
Promoting G&D milestones
Emotional support
Planning strategies for daily management
Medication teaching
Refer to Box 32-7 for questions to ask when
planning diabetic education
FIGURE 32–10
Insulin injection sites. Give all morning insulin in one site (e.g., arms) and all evening
insulin in another (e.g., legs) because of different rates of absorption from these sites. Space injections about
1.25 cm (0.5 in.) apart.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nursing Care
• The child’s developmental stage and
cognitive level influence their readiness to
assume responsibility for self-care
– Preschool child: need for autonomy and control
can be met allowing child to choose the snack
or pick the finger being stuck
– School-aged: ensure they can recognize the
s/sx of hypo/ hyperglycemia (can test blood
sugar and give insulin shots)
– Adolescents: need to adjust to chronic nature
of disease; be clear about role in diabetes
management/ parental involvement
Any Questions???
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.