Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: – – – – 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 – – – – – – 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.