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ASSESSMENT OF SELF – CARE PRACTICES AMONG DIABETIC CHILDREN IN JEDDAH CITY ﺗﻘﻴﻴﻢ ﻣﻤﺎرﺳﺎت اﻟﻌﻨﺎﻳﺔ اﻟﺬاﺗﻴﺔ ﻟﻼﻃﻔﺎل اﻟﻤﺼﺎﺑﻴﻦ ﺑﺪاء اﻟﺴﻜﺮي ﻓﻲ ﻣﺪﻳﻨﺔ ﺟﺪة A Thesis Submitted in Partial Fulfillment of the Requirement for the Master’s Degree in Pediatric Nursing Maternal and Child Health Nursing Department College of Nursing King Saud University By SHAIMA SABRI SHUKRY AMER RABI’ II 1426 H JUN 2005 G ASSESSMENT OF SELF-CARE PRACTICES AMONG DIABETIC CHILDREN IN JEDDAH CITY BY SHAIMA SABRI SHUKRY AMER This Thesis has been Submitted On Rabi II H/ Jun 2005 G Thesis Supervisor Thesis Defense Committee Prof. Dr. Magda M.E. Youssef Prof. Dr. Magda M.E. Youssef Prof. Pediatric Nursing Prof. Pediatric Nursing Dr. Faten Ez Eldin Ahmed Associate Prof. Com. Nursing Dr. Mahasen I. Abd Elsattar Associate Prof. Med-Surg. Nursing Dr. Mohammed A.A. Alsaif Assistant Prof. Clinical Nutrition I TABLE OF CONTENTS Chapter I. II. Page Introduction 1 Problem Statement 5 Study Objectives 5 Definition of Terms 5 Literature Review 6 Diabetes Mellitus 6 Classification of Diabetes Mellitus 7 Etiology 8 Pathophysiology 10 Manifestations of Diabetes Mellitus 11 Diagnosis of diabetes Mellitus 12 Complications of Diabetes Mellitus 13 Management of Diabetes Mellitus 18 Orem’s Self-Care Theory 27 Nursing Role in Managing Diabetic Children 32 Nursing Role in Caring for Diabetic Children based on Orem Self-Care Theory 44 II III IV Material and methods Setting 48 Sampling 49 Study Design 50 Tools of Study 50 First Tool 50 Second Tool 51 Data Collection Method 51 Data Analysis 53 Results 56 Part I. Characteristics of Diabetic Children and their Families 58 Part II. Diabetic Children’s Knowledge about Self-Care Practices Part III. Diabetic Children’s Self-Care Practices 68 89 Part IV. Diabetic Children’s According to Orem Self-Care 106 V Discussion 115 VI Summary 132 VII Conclusion and Recommendations 138 VIII References 140 Appendixes Arabic summary III LIST OF TABLES No. Page I Bio-Social Characteristics of Diabetic Children 59 II Parents Biosocial Characteristics 61 III Diabetic Children’s Family History 63 IV Diabetic Children’s Medical History according to their Gender 64 V Diabetic Children’s Type of Treatment 66 VI Diabetic Children’s Knowledge about Diabetes Mellitus 69 VII Diabetic Children’s Knowledge about Hypoglycemia 71 VIII Diabetic Children’s Knowledge about Hyperglycemia 73 IX Diabetic Children’s Knowledge about Diabetic Diet according to their Gender X Diabetic Children’s Knowledge about Insulin Injection according to their Gender XI XIII 78 Diabetic Children’s Knowledge about Glucose Testing and Physical Exercise according to their Gender XII 77 80 Diabetic Children’s Knowledge about Safety Precautions according to their Gender 83 Diabetic Children’s Knowledge about Periodic Check-up 85 XIV Diabetic Children’s Knowledge about Hygienic Practices XV according to their Gender 87 Diabetic Children’s Adherence to Prescribed Diabetic Diet 90 XVI Diabetic Children’s Adherence to Prescribed Restricted Diet 92 XVII Diabetic Children Adherence to Prescribed Diet Assessed by 24 Hours Recall Method 94 XVIII Diabetic Children’s Self-Care Practice of Insulin Injection 96 XIX Diabetic Children’s Self-Care Practice of Blood Glucose Test 98 XX 99 Diabetic Children’s Self-Care Practice of Urine Test IV No. Page XXI Diabetic Children’s Rationale for Some Self-care Practices 101 XXII Diabetic Children’s Type of Physical Exercises 102 XXIII Diabetic Children’s Self-Care Practices of Hygienic Care 104 XXIV Diabetic children’s Practice Regarding to 3 Levels of Orem’s Self-Care 107 XXV-a Diabetic Children’s Practices in Relation to Self-Care Levels according to Gender 109 XXV-b Results of Mann-Whitney U test to determine Self-Care Practices Difference between Gender 111 XXVI-a Diabetic Children’s Practices in Relation to Self-Care Levels according to Age 113 XXVI-b Results of Mann-Whitney U test to determine Self-Care Practices Difference between Age Groups 114 V LIST OF FIGURES No. 1. Page Diabetic Children’s Distribution in the Studied Hospital Settings 60 2. Diabetic Children’s Source of Diet Instructions 75 3. Diabetic Children’s Source of Safety Care Instructions 82 4. Diabetic Children’s Frequency of Exercise per Week 103 VI This study dedicated To …. My Husband, Soul of My Parents and My Brother And My Children Dr. Faisal, Dr. Sultan, Nowaf Sarah and Nouf VII Acknowledgement First thanks is to Allah, the merciful, the compassionate for granting me the strength and courage the complete this study. It is my an honor to work under direct and close supervision of Professor Dr. Magda Youssef who enlightened and guided me throughout period of the study. I express my thanks, which is too little to say. I appreciate all the instructions, advice, support, efforts, guidance and encouragement, which always came on time throughout the study. I wish to thank Professor Dr. Faten Ez Eldin Ahmed for her valuable assistance and sincere guidance throughout the research process. I deeply appreciate the invaluable cooperation of diabetologist, diabetic nurse educators and clinical dietitians of pediatric diabetic ambulatory clinics at the hospital settings ( KFAFH, MCH, KAUH and KKNGH) for their support during collect data of my research. Special thanks to all diabetic children and their families that cooperated and participated in the study. Many thanks are due to Mr. Mahmoud Hamdan and Abbott company who supplied me equipments at the time of data collection. Finally I wish to thank my family for their everlasting, patience and their encouragement , without which this work would have never been finished. Chapter I INTRODUCTION 1 INTRODUCTION Diabetes is one of the most challenging health problems in the 21st Century (International Diabetic Federation, 2004). It is one of the most common chronic diseases of childhood after asthma and mental retardation (AL-Twaim, 2003). It is the fourth or fifth leading cause of death in most developed countries and there is substantial evidence that it is epidemic in many developing and newly industrialized nations (Diabetic Atlas Committee, 2003). The World Health Organization in Geneva (2004), reported that there are currently 194 million people with diabetes worldwide. This figure is expected to reach a total of 366 million by year 2030 (International Diabetes Federation, 2004). There is increasing evidence that it will become one of the foremost public health challenges to face Arabian Gulf region in this new millennium (Khatib, 2004). Recent studies (Onkamo, et al, 1999; Nashiet and Mahmoud, 2004; Al-Ali, 2004) show that globally the incidence of diabetes in children and adolescents is increasing. It is estimated that approximately 65000 children aged less than 15 years developed type 1 diabetes worldwide (Diabetes Atlas Committee, 2003). However, the incidence varies between 1/100.000/year to 40/100.000/year (Al-Aqeel, 2004) Furthermore, Abdullah (2004) cited that studies from Arab countries show definitive variability of incidence, with highest incidence being reported from Kuwait 2 (20.9/100.000/year) and lowest from Sultanate of Oman where it was 2.6/100.000/year (Abdullah, 2004). While in Saudi Arabia, the incidence of type 1 diabetes between the age group 0 - 14 is estimated to be 1718/100.000/year (Al-Twaim 2003; Al-Aqeel, 2004). Regarding type 2 diabetes, Le Febevre (2004) reported that since 1985 a marked increase in prevalence of type 2 diabetes has been reported world wide, including children and adolescents (Le Febevre, 2004). However, there are no documented data on epidemiology of type 2 diabetes among the children in Saudi Arabia (Sulimani, 2003). Diabetes is a heterogeneous disorder due to relative or absolute insulin deficiency, impaired effectiveness of insulin action or both. The major forms of diabetes are divided into type 1 (absolute insulin deficiency) and type 2 diabetes mellitus (insulin resistance, progressive insulin secretory defect) (Solimeni, 1992; Selekman et al, 1999; Eiscerbath, 2001). Diabetes Mellitus is incurable disease, has unique impact on affected children and their families (Kaufman, 2001). Their daily lives are governed by self care regimen that requires frequent blood glucose monitoring, multiple insulin injections or insulin pump therapy and insulin dose adjustment, the appropriate food intake and the balancing of activity level. Despite the attention paid to diabetes self-care management, children and families live with the fear of the acute complications of diabetes which are severe hypoglycemia, hyperglycemia and keto-acidosis, and the long-term 3 micro and macro circulatory complications such as blindness, kidneys failure, amputations, and cardiovascular disease that lead to morbidity and death (Diabetes Atlas Committee, 2003). Self-care is regarded as a goal- oriented activity that is learned. Orem self-care is based on the promise that all persons require self-care strategy in order to maintain health and quality of life, according to Orem self-care nursing system theory, three systems exist which are including wholly compensatory, nurse or advocate provides client total care; partially compensatory system where the nurse or advocate and patient share responsibility for the care; educative - development system where the client has primary responsibility for personal health with nurse or advocate acting as a consultant (Orem et al,2003). Managing children requires medical care and self management education to prevent and reduce the risk of complications. School age children and adolescents become more dependent and self-reliant by taking some responsibility for their self – management (Frey & Fox, 1990). Although, self-management gives the child and parents the feeling that they have control over the disease (Carry et al, 2001, Curtis and Hagerty, 2002), however, diabetes self-management is demanding and requires much effort, discipline, skill and knowledge. It has been found that adherence to selfcare regimes is difficult (Geoffrey et al. 2004). Numerous studies have demonstrated that many persons with diabetes have poor knowledge of the 4 disease and self-management skills to achieve satisfying glycemic control, and quality of life (Glascow and Osteen, 1992, Helmes and Harrington, 2004; Geoffrey et al, 2004). The pediatric nurse, as a member of the health care team, has a unique role in self-management of diabetic children. She has to educate the children to the best of their ability in understanding their condition in such a way that they know enough about their management and self-care in order to change their life-style (Marlow and Redding, 1990; Wong et al, 2003). Hence the pediatric nurse is most frequently and consistently in contact and care for children, she has to assess the knowledge and self-care practices of diabetic children. So assessment of self-care practices may increase understanding about poor adherence to their activities. In Saudi Arabia, assessment of self-care practices among the diabetic children has not been investigated, so the present study aims to assess diabetic children‘s self-care practices to help health professionals in general and diabetic nurses in particular to plan and implement effective strategies for improving management of diabetic children through providing effective self-management educational program to enable them to make choices independently and manger their diabetes successfully into adulthood without complications. 5 PROBLEM STATEMENT Diabetic Mellitus is a common incurable chronic disease. Its incidence is increasing every year among the children in Saudi Arabia (Al-Twain, 2003). It requires continuing medical care and education to prevent its acute and chronic complications by comprehensive education in self-management. Therefore, this study is for assessment of self-care practices among the diabetic children in Jeddah City. AIMS OF THE STUDY The study aims to: 1. Assess the diabetic children’s knowledge about self-care practices. 2. Determine the levels of the self-care practices of diabetic children. DEFINATION OF TERMS Self-Care Practices Self- care practices based on Orem theoretical framework will be either: 1) Wholly compensatory, i.e., the child is completely dependent on his/her mother for his/her care; 2) Partially compensatory, where the child can partly share in his/her care; or 3) Educative- development, where the child is completely independent for his/her care without help (Orem, et.al., 2003). Chapter II LITERATURE REVIEW 6 LITERATURE REVIEW Diabetes Mellitus Diabetes mellitus is defined as a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both. It is associated with long term dysfunction and damage to body organs particularly the kidneys, eyes, nerves, heart, and blood vessels. (Export Committee on the Diagnosis and Classification of Diabetes Mellitus, 2000, Behrman et al, 2003). Insulin is a major anabolic hormone which is needed to support the metabolism of carbohydrates, fats, and proteins (Kumar et al 1997, Wong, et al., 2003). Hence, the diabetes is a chronic illness several studies highlighted the require for continuing medical care and education to prevent acute complications and reduce the risk of long-term complications (Walker et al, 1995; Ibrahim & Gabbay, 2002; Keers et al, 2004). Persistent hyperglycemia is the hallmark of all forms of diabetes. Achieving near normal or normal glucose levels in patients requires comprehensive education in self-management and intensive treatment programs. Children and adolescent with diabetes should receive their treatment and care from a physician-coordinated team including nurses (American Diabetes Association, 2002; Diabetic Atlas Committee, 2003; Kwon et al, 2004). 7 Classification of Diabetes Mellitus There are different classifications for diabetes mellitus which are based on treatment requirements and or etiology and pathophysiology. American Diabetes Association (ADA) in 1997 was classified diabetes mellitus into four major types, which is based on etiology and pathophysiology namely: 1) Type 1 diabetes mellitus, 2) Type 2 diabetes mellitus, 3) Other specific types of diabetes, and 4) Gestational diabetes mellitus. 1- Type 1 diabetes, is characterized by destruction of pancreatic Beta cell, leading to absolute insulin deficiency. Its onset is typically in childhood and adolescence but can occur at any age. 2- Type 2 diabetes, includes the most prevalent form of diabetes (90%), which results from insulin resistance with an insulin secretary defect. It usually occurs in the obese and older children who have positive family history. 3- Other specific types of diabetes. This category applies to all form of hyperglycemia, due to genetic defects in Beta cell function, such as, maturity-onset diabetes in the young, or genetic defects in insulin action, or infections e.g., congenital rubella, or drugs, e.g., corticosteroids, or pancreatic exocrine insufficiency, e.g., cystic fibrosis, or endocrine disease, and genetic chromosal syndrome, e.g., Down’s syndrome. 8 4- Gestational diabetes, (GDM) is first recognized during the pregnancy (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2000; El Zouki, et al 2001). Etiology The clinical syndrome of diabetes mellitus results from a large variety of etiologic and pathogenic mechanisms. Although, the exact etiologic mechanism is yet unknown, Abdullah (2004) reported, that diabetes results from interaction of genetic and various factors leading to immune damage of pancreas in more than 90 % of cases. Type 1 diabetes is immune –mediated diabetes mellitus results from a cellular-mediated autoimmune destruction of the beta-cells of the pancreas, which characterized by the presence of islet cell or insulin antibodies that leads to beta-cell destruction. Beta-cell destruction, usually leads to absolute insulin deficiency. The individual with type 1 diabetes eventually become dependent on insulin for survival and risk for ketoacidosis (Atkinson & Maclaren, 1994; Schoott and Danemar, 1999; Sperling, 2000). Further, the discovery of DNA genetic marker Human Lymphocyte Antigens (HLA) associated with type 1 gives a clue for the global differences in the incidence of type 1 diabetes mellitus (Atkinson & Macleren, 1994; Grey and Boland, 1996; Porter et al, 1997; Onkamo, 1999; Behrman et al, 2003). 9 As regards type 2 diabetes mellitus, although the specific etiologies of this form of diabetes are not known, autoimmune destruction of beta-cells does not occur. The risk of developing this form of diabetes increases with age, obesity, lack of physical activity and strong genetic factor Hyperglycemia develops gradually due to defective insulin secretion which is insufficient to compensate for the insulin resistance (Polonsky et al, 1996; Kitagawa et al, 1997; American diabetic association, 2000-a; Rapaport, 2002; Srinivasan et al, 2003). Maggie et al, (2003) found that the main causes of type 2 diabetes in young Chinese patients were genetic factors (up to 14 %) and obesity (55 %) which plays more significant roles than autoimmunity (4%) (Maggie et al, 2003). This findings were supported by Al Shaikh (2004) who found that thirty children, age 10 -15 years were identified to have type 2 diabetes and they were all overweight, had family history of diabetes and their islet cell antibodies were negative (Al-Shaikh, 2004). Many studies (Diabetes Epidemiology Research International Study Group, 1998; Yoon, 2000; Sadauskaite et al, 2001; Neyestani et al, 2004) highlighted the combination of genetic and environmental factors are direct or indirect triggering mechanism in the etiology of diabetes mellitus. This triggering factors, such as, viral infections as chicken pox, mumps, congenital rubella; type of diet as cow milk proteins, increase meat intake; genetic factors as sex, family history, age; and season (spring and autumn) 10 were positively associated with the increase in the precedence of type 1 and type 2 diabetes mellitus in children and adolescents. (Salman et al, 1991; Shatoot et al, 1995; Sadiq, 1996; Cook and Harley, 1998; Fagot-Campagna, et al, 2001; Nashiet & Mahmood, 2004). Pathophysiology Insulin is needed for the metabolism of carbohydrates, fats, and proteins. Insulin facilitates the entry of these substances into the cell, with the exception of nerve cells and vascular tissue. In case of insulin deficiency, glucose is unable to enter the cell, and increases glucose concentration in the blood (hyperglycemia), which causes the movement of body fluid from the intracellular space to the extra cellular space; from there the body fluid is excreted by the kidneys. When the serum glucose level exceeds the renal threshold glucose (± 180 mg / dl) it "spills" into the urine causes glycouria, a long with an osmotic diversion of water which results in polyuria. The urinary fluid losses cause the excessive thirst observed in diabetes. This water washout results in a depletion of essential chemicals (Kumar et al,1997; Le Roith et al 2000). Because the body cells are unable to use glucose but still need a source of energy, they begin the breakdown of protein and fat for cell utilization. When large amounts of fat are metabolized, the acid which is 11 the end product of fat breakdown accumulate in the blood stream and spill into the urine causes ketonuria. Then, PH of the blood becomes acidic, resulting in severe acidosis. The breakdown of fat leads to increased serum cholesterol levels. Unthreaded diabetic children are acidotic, and dehydrated due to loss of large amount of water and build up ketone bodies in their blood (Brook, 1995, Klekamp and Churchwell, 1996; Lissauer & Clayden, 2001). Manifestations of Diabetes Mellitus The onset of type 1 diabetes mellitus is generally abrupt. The first symptoms are increased thirsty (polydipsia), increased urination (polyuria), increased food intake (polyphagia), weakness, fatigue, malaise, weight loss and irritability. Young children may also develop secondary nocturnal enuresis. (Faro, 1999; El Zouki et al 2001). In addition, because large amounts of protein and fat are being used for body energy instead of glucose, diabetic children will remain short in stature and under weight (Kaufman, 1997). Polyuria, polydipsia, vision changes, tingling, numbness of extremities, slow healing of cuts, skin infections or pruritis, and unexplained weakness or weight loss are the manifestation of type 2 12 diabetes (Jones, 1998; American Diabetes Association, 2000-a; Zdravkovich, 2004). Diagnosis of diabetes Mellitus The diagnosis is usually confirmed in a symptomatic child by finding a markedly raised random blood glucose level of ≥ 200 mg/dl (11.1 mmo/L by the WHO definition), glycouria and ketonuria. If there is any doubt, in the diagnosis, a fasting serum glucose level of > 126 mg/dl (7.0 mmol/2) or a raised glycosylated Hemoglobin (HbA1c) are helpful. A diagnostic glucose tolerance test is rarely required in children (Expert committee on the diagnosis and classification of diabetes mellitus, 2000). Glycosylated hemoglobin (HbA1c), test can be viewed as an indication of the blood glucose level overtime or as the degree of metabolic control in diabetes. It provides an index of the average blood glucose levels over the 120-day life span of erythrocytes that accumulate over the life time of the vessel wall which caused pathogenecity chronic complications (Kumar et al., 1997). Normally red blood cells carry only a trace of glucose, when the serum glucose is excessive, it attaches to hemoglobin molecules, causing glycosylated hemoglobin. The higher the serum glucose level, the higher the hemoglobin A1c (Dorchy, 1994). The non diabetic reference range for the HbA1c in the Diabetic Control and Complications 13 Trial (DCCT) was 4 – 6 %, where as the accepted average HbA1c is 7.2 % (Diabetic Control and Complications Trial Research Group, 1996). Complications of Diabetes Mellitus Diabetes mellitus is a serious condition associated with significant morbidity and mortality because of its both acute and long-term complications. The most frequent acute complications include hypoglycemia, hyperglycemia, and diabetic ketoacidosis. The most common long-term complications include micro-vascular as retinopathy, nephropathy, and neuropathy and macro-vascular as cardio vascular, cerebro vascular, peripheral vascular complications (Alemzadeh and Wyatt, 2003; Diabetic Atlas Committee, 2003). Recent studies (Levine et al, 2001; Al-Aqeel, 2004) revealed that the incidence rates of acute complications of the diabetes mellitus such as severe hypoglycemia and diabetic ketoacidosis (DKA) were notably higher in adolescents than in the adults. The morbidity and mortality of type 1 diabetes are closely associated with the development of acute and long term micro vascular and macro vascular complications (Diabetes Epidemiology Research International Mortality Study Group, 1991; International Diabetes Federations, 2003). As regards hypoglycemia, it occurs when blood glucose falls less than 72 mg/dl (4 mmol/L). It is the most common acute complication of the type 14 of 1 diabetes mellitus (Smith et al 1990; Allen et al, 2001). The onset of hypoglycemia is usually rapid and symptoms range from very mild to severe, enough to cause brain damage or death. (Sartor and Dahlquist 1995; Warner et al., 1998; Edge et al, 1999). The symptoms are highly individual and change with age, but most complain of hunger, sweatiness, and feeling of dizziness. Parents can often detect hypoglycemia in young children by their pallor and irritability, and unreasonable behaviors. If there is any doubt, the blood glucose level should be checked and food should be given in order to maintain blood glucose level (Faulkner, 1996; American Diabetes Association, 2000-b). Treating a “hypo” in early stage requires eating sweets or a sugary drink. Severe hypoglycemia, defined as the occurrence of seizures, coma, and/or the need for assistance to treat hypoglycemia. Sever hypoglycemia can occur usually due to intensified insulin therapy, over dose of insulin, missed meal or snack and over physical activity without extra calories (Bhatia & Wolfsdorf 1991; Daneman and Frank, 1998; Sochett & Daneman, 1999). Parents and school teachers should be provided with a glucagons injection kit for the treatment of severe hypoglycemia and taught how to administer to terminate severe hypos. If the child is unconscious, he should be brought to hospital and threaded by glucose intravenously (Glascow and Eaking, 1998; Al-Agha, 2005). 15 Hyperglycemia is an increase in blood glucose level above the normal range (>250 mg/dl) due to insulin deficiency, too much food, not enough exercises, stress and illness. Hyperglycemia usually develop slowly as the blood sugar accumulates, leading to thirsty, polydipsia, polyuria, polyphagia, weakness, fatigue and irritability. If the case not treated ketoacidosis may occur. If the child exhibits these symptoms parents should increase the dose of insulin or introduce regular insulin and encourage the child to drink water, stay warm, and refrain from exercises (Vanelli et al, 1999; Felner and White, 2001). Diabetic Ketoacidosis is characterized by hyperglycemia and severe dehydration due to loss of water. Diabetic ketacidosis result from the breakdown of fats result in increased levels of free fatty acids in the blood, which converted by the liver to keton bodies and increased plasma ketone in the blood (ketonemia), which leads to lower serum PH. (Alemzadeh and Wyatt, 2003). Diabetic ketoacidosis is life threatening complications, and needs immediate treatment. Acetone smell breath, nausea & vomiting, very dry mouth, hyperventilation and kussmaul respiration are characteristics of metabolic acidosis. If the condition is not threaded by insulin therapy and fluid and electrolyte replacement, progressive deterioration occurs, due to severe dehydration, electrolyte imbalance, and acidosis, leading to coma and death (Kaufman and Halvorson, 1999-a; Glaser et al, 2001; Tranhtenbarg, 2005). In Addition, McNally et al, (1995) found that 16 ketoactidosis is caused most diabetes related death in children (McNally et al, 1995).. Hyperosmolar hyperglycemic nonketotic coma is the acute complication of type 2 diabetes. It occurs, due to severe dehydration resulting from hyperglycemic diuresis in children, who do not drink enough water to compensate for urinary losses. The hyperosmolar state must be corrected slowly. Normal saline solution is an appropriate choice for initial fluid deficit replacement. The insulin drip at 0.05 U/kg/h is prudent to enhance glucose uptake, water follows passively into the cell to maintain osmolality, and therefore fluid requirement must be reassessed frequently during therapy (Skyler, 1998; Rudolp et al, 2002). Long-term complications of diabetes can be divided into macro vascular complications which affect the large blood vessels, such as, those supplying blood to heart and brain, and micro vascular complications which affect small blood vessels, such as those, supplying blood to eyes and kidneys. The commonest fatal complication is coronary artery disease leading to a heart attack (Parikh et al, 2000). Stroke is also a common cause of disability and death in people with diabetes. The micro vascular complications are retinopathy which affecting the back of eye leading to loss of vision, nephropathy leads to kidney damage and neuropathy causes nerve damage (Hall, et al, 1998, Hamilton, et al, 2004). Moreover Mijalli (2002) stated that future diabetic complications may commerce in 17 childhood. The cumulative risk of developing diabetic nephropathy in type 1 diabetes mellitus is 30-40% peaking of approximately 18 years of type 1 diabetes mellitus. In addition Al-Rubiaan (2004), mentioned, that the diabetes mellitus was the leading cause of End Stage of Renal Disease (ESRD) in Saudi patients on dialysis due to diabetic nephropathy (AlRubiaan, 2004). The combination of neuropathy and peripheral vascular disease may cause ulcers of the legs and feet and also gangrene, which may lead to amputation. (Diabetic Atlas Committee, 2003; Duby et al, 2004). Although macro vascular complications are among the leading causes of death in adults with diabetes, several studies reported that, youth with type 1 and type 2 diabetes will also develop diabetes – related micro and macro vascular complications, as with adults. With poor control, vascular changes appear as early as 2½ to 3 years after diagnosis, with good control have been postponed for 20 or more years. (Bruckner 1999; American Diabetes Association, 2000-c). In addition Peppa-Patrikou et al., (1998) reported that, the children and adolescents with diabetes had much higher albumin excretion, suggesting that they may have had more advanced vascular disease, possibly because of poorer metabolic control (PeppaPatrikou et al, 1998). 18 Management of Diabetes Mellitus The management of the child with diabetes mellitus consist of a multidisciplinary approach involving the family, the child (when appropriate), and professionals, including a pediatric endocrinologist, pediatric nurse, diabetes nurse educator and dietitian as well as an mental health professionals (Karawag, 2003; Wong et al, 2003). The definitive treatment is replacement of insulin which depends on nutritional intake, activity, emotions, age and health condition of the children (Zimmerman, 2003). Management of diabetes also includes medical and nutritional guidance, continuing diabetic education, family guidance, and emotional support (Maffeo, 1997; Zeung et al, 1997; Dumas and Marboeuf, 2004). Insulin Therapy Insulin is a hormone produced by the Beta-cells of the pancreas. The primary function of insulin is to regulate blood glucose levels by controlling the rate at which blood glucose is taken up by the body cells (Kaufman and Halvorson, 1999-b). Most children are now treated only with recombinant human insulin. Human insulin is available in rapid, short, intermediate and long acting preparation, and all are packaged in the strength of 100 units/ml. Until recently, regular insulin had been the fastest- acting insulin preparation 19 (Beck et al, 2004). However, peak effect of regular insulin occurs 2 to 4 hours after an injection, whereas the postprandial carbohydrate absorption often occurs 1 hour after a meal , this causes increase the blood glucose level after 1 to 2 hours after meal. Thereafter, to compensate for this action patients are instructed to take their regular insulin injection 15 to 30 minutes before a meal and avoid foods that are absorbed rapidly (Puttagunta and Toth, 1998). Totally insulin needs vary with age and pubertal status; many children need approximately 1U/kg/day, and adolescents may need more than1.5U/kg/day.The simplest insulin regimen, often prescribed after diagnosis, is a split-mixed regimen, in which a combination of short- and intermediate-acting insulin is administered subcutaneously before breakfast and dinner. (Becker, 1998; Lissauer & Clayden, 2001). Some children require more frequent administration of insulin i.e., multiple dose, to control diabetes and for adolescent to support their growth. The adjustment of insulin is determined by measurement of the blood glucose level, timing and nature of food intake, exercises and insulin pharmacokinetics (Bryden et al, 1999). The recent long-acting analog-glargine is peakless insulin that provides 24-hours basal glycemic control and giving only once daily. In addition, when glargine is combined with a bolus of regular insulin, a more physiologic pattern of insulin effect is produced. Thus, postprandial 20 glucose elevation is better controlled, and hypoglycemia between meals and nighttime is reduced (Rosenstock 2002, Al- Twaim, 2004; Al- Agha, 2005). Insulin pump therapy is provided by the external device about size of beeper. Insulin, which is usually the short acting is delivered through the continues subcutaneous insulin infusion (CSII), via-battery power. Pumps provide a closes approximation of normal plasma insulin profiles and increased flexibility regarding timing of meals and snacks. Bolus doses of insulin are delivered through the pump to cover ingested carbohydrate and to correct high blood sugar levels according to formulas derived for each patient. Insulin pump therapy in adolescent is associated with improved metabolic control and reduced risk of hypoglycemia, without affecting psychosocial outcomes (Rosella and Perez, 2003). Although insulin pump is reserved for adults and adolescent, now it being used more for younger children (Kaufman et al 1999; AL-Agha, 2005). Intranasal and inhaled insulin administration is still experimenting with researchers (Skyler, 2001). In addition islet cell or whole pancreas transplantation may offer hope the patients in the future (Robertson, et al., 2000). 21 Oral Hypoglycemic Agents The Oral hypoglycemic agents are used to control diabetes in type 2 diabetes patients who produce some endogenous insulin and when diet control and daily exercise have been unsuccessful. If glucose level is frequently more than 200 mg/dl life-style modification The oral and hypoglycemic and HbA1c is greater than 8%, pharmacologic agents are intervention are begin. sulfonylurea, metformin (glucophage), thiazolidinediones, and α glycosidase inhibitors (Rudolph et al, 2002 ). Sulfonylurea, primarily stimulate the beta cells of the pancreas to produce more insulin (Jones, 1998; United Kingdom Prospective Diabetes Study Group, 1998). In relation to metformin, it is the first line drug for management of type 2 diabetes. The mechanism of action has not been fully delineated, but also primary function is to lower hepatic glucose production, HbA1c, hyperlipidemia, and induces modest weigh loss. It also lowers insulin resistance in muscle and fat (Garber et al, 1997). More over, Knowler et al, (2002) reported that change in lifestyle or using metformin (oral glycemic) is reduction in the incidence of type 2 diabetes (Knowler et al, 2002). Thiazolidinediones are decreasing peripheral insulin resistance within muscle and fat. It was effective in glucose control but it causes liver toxicity. In addition α glycosidase inhibitors are limit carbohydrate 22 absorption and minimize postprandial hyperglycemia. Therefore children and adolescent are limited use of these agents due to their complications (Bourgeouis, 2002; Rudolph et al, 2003). Glucose Monitoring To evaluate any regimen, the concentration of glucose in the blood must be measured before each meal, bed time, whenever a child has symptoms, and occasionally at 2 to 3 a.m. Self- blood glucose monitoring (SBGM) has improved diabetes management. By testing their own blood, children and parents are able to change their insulin regimes to maintain the glucose level in normal range 80 to 120 mg/dl.( 4-6 mmol/L) as children usually dislike having finger pricks, this limits the frequency of their use (McNabb et al, 1994). On the Other hand continuous glucose monitoring system (CGMS) is minimally invasive and entails the placement of a small, subcutaneous catheter that can be easily worn by children. Its provides continuous profile of tissue blood glucose levels, reduce nocturnal hypoglycemia and allows patient and health care team to adjust insulin regimen and nutrition plan to improve glycemic control (Kaufman et al, 2001; Saad et al, 2004). Urine glucose monitoring has no place in current diabetes management, however it is used for investigate presence of ketonbodies if 23 blood glucose level more than 250 mg /dl or 14mmol/L (Alemzadeh & Wyatt, 2003). Nutritional Therapy Nutritional therapy is cornerstones of the diabetic management. The goals of diet management in children include 1) promotion of normal growth and development, 2) keeping blood glucose level as close to normal as possible in an attempt to prevent both hypoglycemia and hyperglycemia and long-term complications, and 3) maintenance of the overall health of the patient (American Diabetes Association, 2000-d; Rudolph et al, 2002). Adherence to diabetic diet usually has been described in terms of total intake and distribution of carbohydrate. Although adherence to diabetic diet one of the essential aspects of diabetes management, also its one of which patient find compliance most difficult especially for children and adolescents (Bamnaga, 1996; Glascow and Anderson 1999; Brown, 1999). The food intake should be planned in a different way which is based on a balanced diet that included six basic food groups such as milk, meat, vegetables, fat, fruit and starch. There are several meal- planning approaches, including the exchange system which is advised by American Diabetes Association, and carbohydrate counting which became popular with the diabetes Control and Complications Trial (Wong et al, 2003). 24 The exchange system is group of foods by nutrient contents. Each group, portion sizes of foods should be calculated to give equivalent amount of the nutrient, Food groups are important therefore fruits exchanged with fruits, starch exchanged with starch, while on the carbohydrate counting food groups are not important as carbohydrate content, such as, one apple and one slice of bread have the same carbohydrate amount which is 15 gram (1 unit) and used interchangeably (National Health and Medical Research Council, 1992; Jones et al 2000). Actual caloric needs are calculated by age and weight, but careful monitoring of weight gain and linear growth is needed to modify the meal plan. Carbohydrates should constitute 55 to 60 % of the total daily calories, 30 % or less of total calories should come from fat, less than 10 % from saturated fat. Protein should constitute 15 to 20 % daily caloric intake. Patients traditionally were taught to use a complex system for meal planning to monitor protein, fat, and carbohydrate intake. However, carbohydrate is the primary nutrient which affecting postprandial glycemic response, therefore attention is now focused primarily on carbohydrate intake. One system called “carbohydrate counting” focuses on carbohydrate intake which is a simpler and less structured approach to meal planning (Hoffman, 2001, Hissa et al, 2004). Families must familiarize themselves with the foods that contain carbohydrate and the amount present in a given portion. Food models, food 25 list, and packaged food with detailed food labels all serve to assist the family in this process. Many food choices can be considered in convenient 15- gm units, called exchanges (Pyolara, 2004). Children do not need to eat a specific food at a given meal but can interchange foods, the families are initially offer a fixed meal plan base on usual eating patterns. The plan indicates a prescribed amount of carbohydrate for each meal, and for snacks between meals and bed time to cover sufficient calories to balance daily expenditure for energy to satisfy the requirement for growth and development (Gilbertson et al, 2001). Dietary fiber is encouraged in meal plan to decrease blood glucose level after meal by effects of fiber on digestion and absorption of nutrients. Insulin doses may have to be decreased if children do not want a snack at a particular time of day. Finally children and adolescent should be understand that if he/she reports breaks in dietary rules, he/she will not be punished, but unreported breaks may causes sudden sickness for him/her (American Diabetes Association and American Dietitian Association, 1994; Sue et al, 2001; Pundziute et al, 2004). Exercise Exercise should be encouraged and included as a part of diabetes management it should be planned according to children interest and 26 capabilities. Regular exercises aids in the body use of food and often decrease insulin requirements (Bernardini et al, 2004). In addition children and their families should be informed exercise may lead to hypoglycemia during or following activity. Severe hypoglycemia can usually be prevented if children eat snacks before or during exercises; if less insulin is taken, and if someone recognizes the hypoglycemic symptoms and provide treatment. For children whose exercise is not planned, carrying additional food is a good preventive step; it can be used if and when the need arises (Wysocki, 1997). 27 Orem Self – Care Theory Orem’s theory of nursing, based on the key concept of self-care, carries a particular way of viewing the reality of nursing treatments. Every individual has the capacity of self-care; however when a health problem arises it is possible that this capacity is insufficient to confront the situation, making it then necessary to receive help from other persons who compensate for this deficit (Taylor et al, 2000). Nursing according to Orem is defined as: Nursing has its special concern the individual’s need for self-care action and the provision and management of it on a continuous basis in order to sustain life and health, recover from disease or injury, and cope with their effects (Orem, 1980). Orem (2003) defined nursing as an art through which the nurse gives specialized assistance to persons with disabilities, such a character that more than ordinary assistance is necessary to meet daily needs for self care and to intelligently participate in the medical care they are receiving from the physician. The art of nursing is practiced by doing for the disable person by helping him to do for himself and/or helping him to learn how to do for himself. Nursing is also practiced by helping a capable person from the patient’s family to learn how to do for the patient. Nursing the patient is thus a practical and a didactic art (Orem et al, 2003). Moreover, Taylor et al , (2000) cited, that Orem stated that the nurse applies her art to patients with disabilities that have resulted in physical, 28 intellectual, or psychological dependency upon another for daily self-care, including intelligent patient participation in medical care (Taylor et al, 2000). Self-care is defined by Orem as: The practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well being. Normally adults voluntarily care for themselves. Infants, children, the aged, the ill, and the disabled required complete care or assistance with self-care activities (Orem, 1980). Orem’s described (2003) general theory of nursing, the conceptual structure is a unity of three theories: 1) the theory of self-care, a form of human activity essential for continued human functioning and human wellbeing in life, 2) the theory of self-care deficit, as predictive of requirements for nursing, and 3) the theory of the nursing systems as the end product of nursing (Orem et al, 2003). According to Orem, there are six different concepts are symbolized by the following of terms: self-care: human action, deliberately performed by persons for the sake of self in order to regulate one’s human functioning. Self-care agency: the human capability to give self-care. The third concepts is self-care demands; the summation of the self-care actions that will regulate the human functioning of a person, which if not performed, will result in illness, injury, deterioration of the state of well-being or death. Nursing agency concept: the human capacity to design, and manage nursing systems with and for others in need; self-care deficit: which is a 29 deficit relation of self-care agency to self care demand and the last concept is conditioning factors which related to human environmental entities. (Orem et al, 2003). According to Orem self-care theory, the nurse who is a nursing agency is the prime regulatory mechanism for the nursing system. Theory of Orem self-care is an effective tool allowing nurses to systematically asses, plan, implement, and evaluate the care needs of children with long term chronic health problem (Backscheider, 1974; Haas, 1990; Foote et al, 1993). Orem (1990) describes central relation within the self-care theory is that between self-care agency as power and capability to engage in selfcare and self-care demand to meet requisites for regulating human functioning. Moreover, regarding self-care, human functioning and development, Orem (1995) stated, that if human life is to continue and develop there must be continuing inputs of materials and maintenance of conditions that support life, physical and psychological functioning and developmental processes (Orem, 1995). Lauder cited (2001), that requirements for inputs of specific materials or specific conditions are named self-care requisites, as those factors which are necessary for health and wellbeing. These factors range from basic factor such as oxygen and food, to more complex factors such as social factors. Self-care requisites can be either universal as the maintenance of a sufficient intake of air and the maintenance of a sufficient intake of water, 30 developmental which is related to developmental processes such as aging, and health deviation self-care requisites that include seeking medical attention and following a prescribed treatment regime (Lauder, 2001). Orem (1995) describes, the system of nursing in terms of nurse role and patient role in knowing and meeting patients’ therapeutic self-care demands i.e., self-care action to be performed for some period in order to meet self-care requisites, and in terms of their roles in regulating the development and exercise of patients’ powers of self –care agency. The production of nursing is a process based upon the developed powers of nurses as nursing agency to produce nursing for others, the willingness of nurses and nurses’ patients to interact and cooperate with each other, and to work with one another over time to know, and meet stable or changing components of patients’ therapeutic self care demands and to regulate the development of patients’ power of self-care. Nursing systems are what nurses make when they practice nursing (Orem, 1995; Walker and Godfrey, 1999). In addition, all action systems are produced by nurses to determine for individuals what self-care is being produced; what self care is required; and what patient are doing, not doing, or are not able to do with respect to knowing and meeting their requisites for functional regulation through the effective performance of care measures (Taylor and Godfrey, 1999). Nurses also produce nursing care and help patients understand 1) the care 31 that they use and 2) how this care can be provided under existent conditions and circumstances. Finally, nurses produce nursing care when they assist the patients’ day-to-day care demands and to regulate the exercise or development of patient capabilities to meet their own care demand (Gasemgitvatana, 2003). Finally, Orem (2003), Self – care theory indicated that nurses produce system of care for person as a client /patient with self-care deficit who requires nursing assistance. There are three levels of nursing system; wholly and partially compensatory systems and educative & development system. The wholly compensatory nursing system is applied when patient is not interacting with self care demand. Therefore the nurse helps by acting and providing the total care for the patient. While, in the partially compensatory nursing system, the nurse and patient share responsibility for care, either the nurse or the patient may have the major role in meeting the needs. The final element of Orem self-care nursing system revolves around educative and development system, where the client has primary responsibility for self-care, with nurse acting as a consultant (Orem et al, 2003). This requires the individual to learn new or relearn old techniques in order to reaffirm his self-care ability (Singhala, 1999). 32 Nursing Role in Managing Diabetic Children Nurses have important roles in diabetic management. They have to provide care in the hospital or clinic during the diagnostic phase or in the ambulatory clinic for follow-up care or at the home if the patient unable to come hospital. Pediatric nurse is competent in nursing care during all stages of illness or wellness and functions in many settings where the patients may be found (Wong et al, 2003). Nurses, who involved in the care of the children, must practice preventive health care as well as supportive & counseling and family advocacy. The best approach to prevention is education and anticipatory guidance (Tantayotai, 2003). The pediatric nurse and diabetic nurse educator both of them need to take advantage of the health care environment and move professionally to help solve problems of access, assure quality, and cost for those group of children and adolescent with diabetes mellitus. The nurses make sure that the diabetic children are doing the self-care practices to the most appropriate methods so they can be able to much better life and able to manage their problems with more successful way (Delamater et al, 1990; Diabetes Atlas Committee, 2003; Binetti and Nicolo, 2004). Managing diabetic children and adolescents is a complex and time consuming, and requires the combined efforts of several disciplines (Bonnet, et al, 1998; Daneman & Frank, 1998; Danne et al. 2001), as its 33 management is different for children than for adults. Some of these differences are;1) the need to educate parents to supervise their children's diabetes treatment,2) the necessary use of smaller doses of insulin, 3) adherence check to blood glucose level, 4) the unpredictable habits of school age children especially in terms of activity and caloric intake, that can result in varying insulin requirements from day-to-day, and 5) the importance of recognizing older children's increasing maturity and encouraging them to manage the condition themselves and at the same time, 5) discouraging parents from being overprotective Therapy encompasses initiation and adjustment of insulin, extensive teaching of the child and caretakers, and reestablishing the routine life (American Diabetic Association, 2002; Wysocki et al, 2003; Brink et al, 2002) Once the child with diabetes is diagnosed and insulin therapy is initiated, the major nurse responsibility is to educate the family and reinforce of information, and that diabetes is a permanent condition, and that insulin controls diabetes but does not cure it (American Diabetes Association, 2002-e; Selekman and Magorski, 2000). For parents, dealing with a young child with this chronic disease presents many challenges, as they must learn to diet regimen, meal planning and blood glucose monitoring with their child, promote normal developmental changes, and handle finicky eating patterns, small insulin doses, and the recognition of symptoms of hypoglycemia and 34 hyperglycemia (Grey et al, 2000). Therefore the nurse should be educated patient and family about nature of diabetes, meal planning, insulin, insulin injection glucose monitoring, Urine testing, record keeping and prevention and treatment acute complications (Brunner and Suddarth, 2003; Becker, 2004; Venters et al, 2004). Education is the cornerstone of diabetes management and the major responsibility in diabetic nursing care (Hanucharurnkal et al, 1997). The nurse is responsible for educating of the children and their families. Nurse should use a variety of techniques and strategies to provide adequate education regarding self-care management. The parents must supervise, and manage the children's therapeutic program, but the children should assume responsibility for self-management as soon as they are capable (Wysocki, 1997; Wong et al, 2003). Strategies for self-care nursing management Self-care gives the children and their families the feeling that they have control over the disease. Psychologically this helps the family members feel that they are useful and participating members of the team (Guthman et al, 1998). Strategies for nursing role related to self-care management which leads to metabolic control are clustered under the following nursing goals, teaching safe administration of insulin, teaching self-blood glucose monitoring, dietary self-management, hygiene, 35 exercises, maintaining metabolic control during illness, and decreasing the risk of complications (Wong et al, 2003). Role of the nurse in insulin injection All children require insulin for their growth, whether they are diabetic or not. However, diabetic children need insulin administration, which administered by subcutaneous way. Although teaching safe insulin administration is one of the important roles of the nurse, educating the patient and family to administer the insulin injection at the stressful time of diagnosis is difficult and a possible source of frustration (Katiyar, 2003). The nurse should allow time for the children and their families for education and encourage them to be involved in the self-management in order to be able to have proper management at home. Caregivers and the children should be taught how to give the injection from the onset of therapy. (Toobert and Glaskow, 1994; Geoffrey et al, 2004). Moreover, the role of the nurse is to support, supervise and demonstrate to the children and their families how to inject insulin, in order to decrease their anxiety. The nurse can demonstrate the injection technique by giving injection to a doll. Also she should assist the parents in giving the first injection to their children. Once parents or children have begun to give injection on their own they will still require frequent reassessment of their 36 technique and ongoing support and encouragement from the nurse (Bernadini et al, 2004). Before teaching the parents or children for insulin injection, they should be taught about the types of insulin, dose, type of syringe use, the injection sites, actual injection technique and side effects of insulin. Moreover, the nurse must taught the children and parents that they need increase dose of insulin during the illness, and every 3 to 4 months to meet their growth need (Benchell et al, 1995).The most common sites for injection of insulin include the outer medial aspect of the upper arms, the abdomen, the medial lateral aspect of the thighs, and the buttocks. The nurse must teach the children how to choose the injection site, and rotate the site in order to reduce pain and lipohypertrophy which leads to delay absorption of insulin. In addition, it is important to inform the children that absorption rate varies in different parts of the body (Lenmark, et al, 1999). Therefore education of self-care practices related to injection sites and technique should be reviewed with children and their families at regular intervals. (Skinner and Hampson, 2001; Schreurs et al, 2003). The nurse needs to help patient and family consider the cost, easy reading, handling and accuracy of measurement when choosing a syringe for daily use. Insulin syringes must be corresponding with the concentrations of insulin. Therefore for U-100 insulin, 100 U/ ml syringes must be used. Insulin bottle should be stored in cool place, and that insulin 37 is stable in its composition for up to 1 year, if opened it is safe up to 1.5 months if stored in the refrigerator. Patients should be encouraged to have an extra bottle of their prescribed insulin on hand at all time (Wong et al, 2003; Al-Agha, 2005). Other devices are available for insulin injection, such as, syringe loaded insulin and pen which eliminates conventional vials and syringes that may offer advantages to some children (Lteif and Schwenk, 1999). Role of the nurse in glucose testing Nurses should be prepared to teach and supervise blood glucose monitoring (SBGM). Self-blood glucose monitoring provides a more accurate assessment of blood glucose levels and its can be performed anywhere. The nurse responsible from teaching children and their families how to use glucometer and lancet device to obtain blood sample from either fingertips or alternate sites (McConnel et al, 2001) Moreover she should be inform them that home blood glucose monitoring is essential for optimal control of diabetes (Cox, et al, 1994; Faulkner, 1996). Many types of blood-testing meters are available, such as testing glucose or ketone in blood, the other advantages need very small drop of blood for measuring blood glucose level. The family should be shown features of several meters, including advantages and disadvantages, and allowed to choose equipments the best meets their needs. The nurse must 38 be examined the site of the finger puncture for signs of redness which explain evidence of poor technique, poor hygiene or poor skin health related to poor control (Wong et al, 2003; Uchigata et al, 2004). Testing for urinary ketones is recommended during times of illness or when blood glucose values elevated, therefore nurse should be teach the children technique of testing urine for ketone (Wysocki et al, 2003). Role of the nurse in diet regimen Normal nutrition is a major aspect of family education program. The successful diet is one that is nutritious, acceptable, and adhered to by the child and family, and that maintains the balance with insulin and activity to produce near normal plasma glucose levels. Dietary teaching and support must be ongoing for the diabetic child and family (Blouza et al, 2000). The nurse can play key roles in the initial assessment of the child’s and family’s nutritional practices, evaluating dietary management and working in collaboration with dietitians to continuously reinforce dietary program (Caravalho, 2000; Wong et al, 2003; Evert, 2005). The family is taught how the meal plan relates to the requirements of growth and development, the disease process, and the insulin treatment. Meals and snacks are modified for the children and the present food menu, cultural patterns and preferences as much as possible, and exchange lists are available that include foods that should be compatible with children and 39 their families lifestyle. Learning about specific food groups helps in making choices. Weights and measurement of food by eye-training devices help for defining serving size should be practicing several months to estimate of food portion (Bryden et al, 1999; Sue et al, 2001). Educating children or adolescent to choice health food is an ongoing task. Discussions and role playing with children and adolescent which helping with choosing food in the cafeteria or parties or with friends, or on a food break after school. It is important that the children should be learned exchange equivalents and nutritional/ carbohydrate value of popular fast food , to help for food selection, therefore the list of the fast food should be obtained. Moreover children can take sugar substitutes with moderation, such as soft drink, “sugar free” chewing gum and candies, but if there is any question about amounts, the physician, dietitian, or nurse can provide guidelines based on body weight (Clements, 1995; American Diabetic Association, 2000-d; Chiasson, 2000). On the other hand the nurse and dietitian also teach the child carbohydrate counting for food planning which provides children and their families with guidelines that facilitate glycemic control while still allowing the choice of many common foods that children and adolescent enjoy (Hoffman, 2001; Willi et al, 2004). 40 Role of the nurse in maintaining metabolic control during the illness Physical and emotional stressors or missed insulin doses can lead to hyperglycemia, measurement for glucose and ketones, and controlled by adjustments in diet and insulin dosage as needed. Parents should understand how to adjust food, activity, and insulin at time of illness or when the child is treated by steroids (Grupposo, 2003). The nurse must be alert that the adolescent girls often become hyperglycemic time of their menses and should be increased dose of insulin if necessary. Parents should understand child must always take at least the usual dose of insulin during the illness to prevent complications of diabetes (Wong et al, 2003). Role of the nurse in safety-precautions Although diabetes can now be controlled and diabetic children can live a relatively normal life, they are still at risk of complications. Decreasing the risk of acute and long-term complications either related to day to day fluctuations in blood sugar, namely hypoglycemia or hyperglycemia be result of poor metabolic control (Wong et al, 2003). The primary role of the nurse is to help the patient identify the symptoms of the various complications and facilitate understanding treatment. Nurses need to ensure that young patients and their parents, teachers, and other care givers know, causes of hypo and hyperglycemia, 41 how to prevent, how to recognize and treat them (Carry et al, 2001). Therefore role of the nurse important for teach the children and adolescent for prevention, health maintenance and health promotion skills for safety – precautions, importance of administrating insulin and its relation with meal and exercises to prevent of hypo or hyperglycemia, regular testing and recording blood and urine for glucose and ketones to glycemic control and its relation with adjustment of insulin and flexibility for meal planning. Nurses also teach children and their families’ importance of carry Identification card, and sweets with them all times to prevent complication, importance of glucagons injection to treatment of severe hypoglycemia (Wong et al, 2003). The nurse should be evaluate knowledge of children understanding diabetic diet, and how to modify during the exercises or illness and ability to modify regimen to maintain good metabolic control, by understanding importance of eating 3 main meals and snacks regularly, especially eating snacks before and during exercises to prevent of hypoglycemia (Lettina, 2001; American Diabetes Association, 2000-d; Lacey et al, 2002). Further, hygiene, i.e., personal hygiene, dental care and foot care should be discussed by the children and their families that a health promotion which develop positive self-stem and prevent infection and injury (Pediatric Nursing Staff, 2004). Finally, nurse must be explain importance of periodic check for good glycemic to reduce risk of long-term 42 complications. Periodic-checkup included; assess for growth and pubertal development, blood pressure for evidence of hypertension, detection of microalbuminuria for early signs of nephropathy, eye examination for retinopathy, dental examination for prevent of tooth decay, other associated illness, such as, thyroid disease (Diabetic Control and Complications Trial Research Group, 1994; Lissauer & Clayden, 2001; Bassili et al, 2001). Role of the Nurse in Exercises The nurse should be taught the parents exercise is an important part of the child’s daily life and should be encouraged the children. Benefits of sport participation discussed with parents and children which effect to selfesteem and sense of well being, increased fitness with associated cardiovascular benefits, and decreased concentration of lipids in the serum. Specific exercise guidelines must be developed for each child and for each activity (Rickabaugh and Saltarelli, 1999). Nurses can also inform to children and their parents that performing blood glucose level before and after the event, is important to either food and insulin dose adjustment.. Snack must be eaten before and during the exercises according to need of the children prevent of hypoglycemia (Coates and Broose, 1996). However, opposite problem, hyperglycemia may occur during exercises, if the blood glucose level is more than 250-300mg/dl (13- 16 mmol/L) if ketones are also present , exercise will not have blood glucose lowering effect, in fact 43 increase blood glucose level and ketone production which leads to diabetic ketoacidosis, in this condition the nurse teach the children take rest, increase drink water and administer short acting insulin or increase dose to prevent of diabetic ketoacidosis (El Zouki et al., 2001; Wong et al, 2003). Role of the nurse in hygiene and foot care The nurse should be emphasized all aspect of personal hygiene for the children with diabetes. Importance of wash hand and skin care must be emphasized to children and their families, to prevent of infections, recurrent candidal infections may indicate poor diabetic control (Wong et al, 2003). Importance of regular, mouth care, dental care and brush of teeth must be explained to the children to prevent of bad odor, tooth decay and gum injury (American Diabetes Association, 2000-e). The child should be informed and cautioned against wearing shoes without socks, wearing sandals or walking barefoot. Correct nail cutting, and foot care tailored to the individual children can begin health practices and habits that last a lifetime (Edrees, 2004). Nurse should be encouraged the children from an early age to take good care if skin injury happen such as cut and scratches by washing with plain soap and water, unless otherwise indicated (Diabetes Control and Complications Trial Research Group, 1993; Wong et al, 2001) 44 Nurses Role in Caring for Diabetic Children based on Orem Self-Care Theory Nursing care is directed toward helping the diabetic children meet their continuous requirements for self-care during the twenty-four hours of the day in light of their disabilities, specific dependencies, medical care, and needs arising from their personalities, habits, and status in their life (Gaffney and Moore, 1998). According to Orem self-care nursing system theory, the nurse in managing the diabetic children either provider the total care for children, i.e., wholly compensatory or helping children to care for themselves, i.e., partially compensatory or instructing children and/or another (advocate) to acquire the knowledge and the skills necessary to give the required care. The specific Orem self-care level of application of the nursing care to children is determined by the character, degree, and extends of children’s dependencies (Foster et al, 1989). The unconscious children from hypoglycemia or hyperglycemia are totally depended and must be cared for. Children with uncontrolled glucose level, need to participate in the self-care with advocate in their adherence to diet, exercises and regular taking of medication, i.e., partially compensatory nursing care ,due to their lack of the knowledge and skills to do their own care independently. While children who are independent in 45 their self care, may require nurses (or advocates) to guide and teach them how to improve and develop their self-care (Eichelberger et al, 1980; Taylor et al, 2000). During the acute illness, children will be unable to participate in their own care, because they are overwhelmed with stress and their energy are depleted, a situation in which fear and anxiety prevail. Diabetic children often temporarily loose their sense of power and can not take decision regarding their health condition. On the other hand, ambulatory chronically ill patients must be fully participants, even managers of their own care. Their goals are not to cure the disease but to be able to 1) maintain an ability to perform life roles, 2) Control symptoms and disability, 3) prevent acute and long term complications, and 4) engage in activities which provide sense of fulfillment (Keers et al, 2004). Further, Orem self- care theory is vital in the treatment of diabetes mellitus, in correcting insulin therapy, in redacting hospitalization and modifying therapy according to individual needs. Undoubtedly it is the responsibility of the dialectologist, diabetic nurse educator and dietitian to instruct the children and help them in this new situation. Children must learn to live and develop normally, participating to the full in school, and all social situations, by fully understanding how to manage the illness autonomously and how to prevent acute and long term complications. Thus, the diabetic nurse educators must set objectives, making the diabetic 46 children be aware of their condition, giving them the knowledge of what to do and how to do it. In this way, quality of life can be improved for children affected by this chronic illness and they can understand how to face the future with realistic optimism (Fitzgerald, 1980; Lombardo et al, 2003). In the concept of nursing which provides the framework for this clinical operation, nursing is viewed as an action system which refers to action taken by nurses to help individuals who seek and can benefit from nursing because of predicted health related self-care. Nursing system has different purposes arising from variations in the status of the patient selfcare system and self care agency status (Backscheider, 1974). The Wholly compensatory nursing system are needed, when the children totally incapacitated, mentally and physically in case of hypoglycemic coma, coma due to diabetic ketoacidosis or the children are in a state of physical in capacitating but they are aware of what is happening in the environment, such as sick days, and children psychomotor activities are not directed toward meeting requirements for life, safety, or effective human functioning. In this situation, the nurse must ensure that all needs are met, including oxygenation, nutrients intake, elimination, body hygiene, range of motion exercises and the sensory stimulation (Orem, 1980; Haas, 1990). Although there are a number of mental capabilities required by the procedures in diabetic regimen, however the children are even able to give 47 insulin injection, they refused to take insulin regularly due to pain, thus partially compensatory nursing system is required, where the mothers should support their children in taking the injection or if there is visual problem, such as, children can not see property the dose of insulin, therefore, the nurse should be give the responsibility for one of the family member to participate in the child self-care. While in the educative and development nursing system, the child can be able to learn, and perform the required self-care, such as insulin injection, selection of proper food, selfblood glucose monitoring and personal hygiene (Biehler, 1995; Faulkner, 1996). The role of the nurse is supporting, guiding and teaching the diabetic children and their families to develop technical skills for medication administration and foot care. The nurse would also guide them in the dietary regime and would encourage them to provide an environment where the adolescents can meet their physical and physiological developmental tasks (Foster and Jansens, 1989; Foote et al, 1993; Jacobson et al, 1997; Guthman et al, 1998, Dumas and Marboeuf et al, 2004). Chapter III MATERIALS AND METHODOLOGY 48 MATERIALS AND METHODOLOGY Setting The study was conducted at four hospitals in Jeddah City, which serve a large number of diabetic children. They are: 1) Pediatric Diabetic Ambulatory Clinic of Maternity and Children Hospital (MCH). Its capacity is 486 beds and serves 431 diabetic children between the age group 5 to 14 years (Annual Statistics of Maternity Children Hospital, 1425H). In the hospital, the diabetic clinic is held three days/ week, which, provides tertiary care. 2) Pediatric Diabetic Ambulatory Clinic of King Khalid National Guard Hospital. The capacity of the hospital is 350 beds and provides tertiary care. It serves 380 diabetic children between the age group from birth to 17 years (Annual Statistics of King Khalid National Guard Hospital, 1425H). In this hospital, the diabetic clinic is held for two days/week. 3) Pediatric Diabetic Ambulatory Clinic of King Abdul-Aziz University Hospital. Its capacity is 450 beds and serves 50 -60 diabetic children between the age group from birth to 17 years / month (Annual Statistics of King Abdulaziz University Hospital, 1424H). Two clinics are held weekly, which, provides tertiary care. 4) Diabetic Ambulatory Center of King Fahed Military Hospital which has 445 capacity of beds and serves 30 – 40 diabetic children at the 49 age group from birth to 16 years / month (Annual Statistics of King Fahed Military Hospital, 1425H). Two pediatric diabetic clinics are held only one day per week, which provides tertiary care. The diabetic children usually are treated by the pediatric endocrinologist and diabetologist, diabetic nurse educator and clinical dietitian in outpatient specialist ambulatory clinic of the hospitals. Sampling Purposive samples of 200 diabetic children who fulfilled the following criteria compromised the sample of this study: 1. Age between 10 to 15 years ;Late school age (10 -12 years), early adolescence (13-15). 2. Both Genders. 3. Diagnosed as diabetes mellitus at least for 6 months. 4. Free from other chronic diseases or mental retardation. 5. Saudi nationality. Child’s advocate may be included depending on child’s ability to practice self-care independently or with his/her advocate assistance.. 50 Study Design A cross-sectional descriptive study design was used to assess diabetic children’ self care practices. Tools of the study Two tools were used to collect the data for this study. First Tool: A Structured Interview Questionnaire (Appendix “A”) A structured interview questionnaire was developed by the researcher to assess diabetic children’s knowledge about self-care practices. It included the following parts: Part I. Biosocial data, such as, age, gender, level of education, birth order, family numbers, and child’s medical history, such as, onset of diabetes and type of diabetic treatment. Part II. Child’s knowledge about diabetes mellitus, which included definition, causes, manifestations, treatment and self-care practices (diet, treatment, exercises, hygiene and safety precautions. Part III. Child’s adherence to diet regimen. A 24 hours recall method where the child (or advocate) records the type and amount of food the child consumed, the day before the interview. Part IV. Child’s exercise, which includes its importance, type and frequency of each activity per week. 51 Part V. Child’s safety precautions, which included the importance of safety precautions to prevent complications.. Second Tool: An Observational Checklist (Appendix “B”) An observational checklist was developed by the researcher to assess self-care practices of diabetic children with rationale for each procedure. This checklist was established after thorough review of nursing literature and previous researches (Skale, 1992; Brunner & Suddarth, 2001; Lettina, 2001). This tool included: Part I. Procedure of insulin injection administration. Part II. Procedure of blood glucose test. (Glucometer/strip) Part III. Procedure of urine glucose test using strip. Part IV. Hygienic care, such as skin care, mouth care, foot care. The observational checklist was designed according to Orem self- care framework (Orem et. al., 2003), to assess the self-care practices done by the diabetic child independently (educative-development) or with his/her advocate assistance (partially compensatory) or done by the advocate (wholly compensatory). Data Collection Method 1. Administrative approval for conducting the study was obtained from the directors of the four hospitals in Jeddah. 52 2. The structure interview questionnaire and check list were developed after thorough review of literature and tested for their content validity by five experts in the field of diabetes management. Correlation of validity was tested by Cronbach’s Alpha, which was 0.9231. 3. A Pilot study for the tools was carried out on 10 children in order to identify the clarity and applicability of the tools. The necessary modification was done. These 10 children were excluded from the sample. 4. Children’s records were reviewed on the day of their appointments, and the one who fulfilled the criteria was included in study. 5. Each child was individually interviewed after explaining the purpose of the study and obtaining his/her and his/her family approval for participation in the study. The child was assessed for his/her adherent to diabetic diet regimen. Also, each child or advocate was asked to report the type and amount of eaten food by the child during the previous day of the interview using the 24 hours recall method. Child’s exercises and safety precautions were also assessed. 6. After the interview, each child was observed in the clinicfor self-care practices, which included his practice of insulin injection on simulator, blood test by glucometer and urine test by strip. The observation included also child’s advocate if she participated with her 53 children in these procedures. In addition, each child was asked to report rationale (reason) behind his/her practice of each procedure. 7. The child was observed by the researcher for his/her hygienic care, which included personal hygiene (skin cleanliness) mouth and foot care. Each diabetic child took around 45 minutes to complete interview and observational checklist. Data was collected during the period of the 1st of September to 20th of December in the year of 2004G. Data Analysis Analysis of the study findings were done using various analysis methods. Data were coded and transferred into specially designed formats for data entry then data were analyzed and computed. The following statistical analysis were performed:a. Descriptive analysis which included frequency, percentage, means and standard deviation. b. In the analysis of dietary intake a 24 hours diet recall was used to estimate the daily nutrients intake. The researcher analysed the nutrients intake by using the exchange list (Pediatric Nutrition Practice Group, American Diabetes Association, 1994; Nevin-Folino, 2003). Types and amount of food for each meal and snack were calculated by totaling the number of exchanges (types and amount of 54 food) from each list and multiplying this number by the grams of carbohydrate, protein, and fat contributed by the total exchange taking in consideration that each gram carbohydrate, protein, and fat gives 4 calories (carbohydrate &protein), and 9 calories respectively. Thus, the grams of carbohydrate, protein and fat are totaled from each column; then multiplied by 4 (4 kcal/g of carbohydrate and protein) and the grams of fat are multiplied by 9 (9kcal/g of fat). Total calories and percentage of calories from each meal and snack were determined. - Estimated caloric requirement were calculated using the following formula; Boys: 1000 + 200 kcal x age Girls: 1000 + 100 kcal x age (Pediatric Nutrition Practice (See Appendix C) Group, American Diabetes Association,1994). c. For self-care practices, analysis according to Orem Self-Care levels, in each procedure, if a step of the procedure or the whole procedure is done by the diabetic child independently it is categorized as the educative & development level. If the step or the whole procedure was done by the diabetic child with his/her advocate’s assistance, it is categorized as the partially compensatory level. If the step or the 55 whole procedure was done by the advocate, it is categorized as the wholly compensatory level. d. Significant test: ‘z’ test and chi –square were used to test for significance difference between children’s knowledge & practices in relation to their gender. The level of significance selected for this study was 0.01 and 0.05. Mann-Whitney U-test was used to test whether there were significant difference in self-care dependency between gender and age group. Chapter IV RESULTS 56 RESULTS This chapter is dealing with the analytical aspect of data. The findings of this study are presented in three major parts:Part I: Characteristics of diabetic children and their families, which included: a) Bio-social data of diabetic children and their parents. b) Medical history of diabetic children Part II: Diabetic children knowledge about self-care practices, which included: a) Knowledge about diabetes mellitus and its acute complications b) Knowledge about self-care practices Part III: Diabetic children self-care practices, which included: a) Diet b) Treatment (Insulin Injection) c) Glucose test d) Exercises e) Hygiene. Part IV: Diabetic children’s practices according to Orem self-care levels. a) Diabetic children’s practices regarding to 3 level of Orem selfcare 57 b) Diabetic children’s practices in relation to self-care levels according to their gender and age. 58 Part I. Characteristics of Diabetic Children and their Families A. Bio-social characteristics of Diabetic Children's Table I shows bio-social characteristics of diabetic children, namely age, gender, birth order and level of education. About two third of the children (63%) were in the age group between 10 – 12 years (i.e. late school age stage), while the rest of the sample was between the age group 13-15 years old (i.e. early adolescence stage), with a mean age of 12 ± 1.43 years. In relation to gender, 52.5% were females, while 47.5% were male. As regards their birth order, the highest percentage was for the 3rd or 4th child (42.5%), while the lowest percentage (20.5 %) was for 5th child and more. Slightly more than half of children (56%) were in primary schools. Only 2 children were illiterate (1%). Diabetic Children’s distribution in the studied hospital settings is present in Figure 1. The parents' biosocial characteristics are presented in Table II. Slightly less than half of fathers (46%) completed intermediate and secondary education compared to one fourth of mothers (25.5%). While, slightly less than one quarter of mothers (24%) were illiterate, compared to 9% of fathers. On the other hand, 28.5% of fathers and 21.5% of mothers had university or postgraduate education. 59 Table I. Bio-Social Characteristics of Diabetic Children No. Characteristics % n=200 Age: - 10-12 year 126 63 - 13-15 year 74 37 Mean 12 S.D. ±1.43 Gender: - Male 95 47.5 - Female 105 52.5 - 1st or 2nd child 74 37 - 3rd or 4th child 85 42.5 - 5th child & more 41 20.5 - Illiterate 2 1 - Primary 112 56 - Intermediate 84 42 - High School 2 1 Birth Order: Education: 60 61 Table II. Parents Biosocial Characteristics Characteristics Father No. % n=200 Mother No. % n=200 Education: - Illiterate 18 9 48 24 - Read & Write 4 2 11 5.5 - Primary 29 14.5 47 23.5 - Intermediate & Secondary 92 46 51 25.5 - University & Postgraduate 57 28.5 43 21.5 9 4.5 4 2 - Skilled Worker 115 57.5 44 22 - Unskilled Worker 49 24.5 - - - Unemployed 6 3 - - - House maker - - 152 76 - Retired 18 9 - - - Dead 3 1.5 - - Occupation: - Professional As parents’ occupation, skilled workers, such as, teacher and administer, were the major jobs for fathers of the diabetic children, as it presented 57.5% compared to 22% for mothers. On the contrary, the majority of mothers were house-maker (76%), and 9% of fathers were retired. Only 4.5% of fathers and 2% of mothers were professional 62 workers, such as top manager, officers compared to 24.5% who were unskilled workers, such as driver, or security men. Family history of diabetic children is illustrated in Table III. It is revealed from the table that 57.5% of studied children were belonging to family of 7 and more members. Only 2.5% of families were only 3 members. The perception of the majority of families had enough income (82%). In relation to family history of diabetes mellitus, it was found that 70.5% of the sample had diabetic relatives. About 27.7% of the fathers and/or mothers of the diabetic children and 51.8% of their 2nd and 3rd degree relatives had diabetes. Diabetic siblings constituted 10.6%. See Table III. B. Medical History of Diabetic Children The type and onset of diabetes mellitus and the level of glycemic control of the diabetic children are illustrated in Table IV. It was found that 99% of the children had type 1 diabetes mellitus (100% males and 98.1% females). Only 1% of the children had type 2, who were mainly females. Less than half of the diabetic children (47.5% for both gender; 49.5% for males and 45.7% for females) had the onset of diabetes by time, since 5 years to less than 10 years, compared to 23% from one year to less than 5 years (22.1% and 23.8% for males and females respectively). 63 Table III. Diabetic Children's Family History No. Characteristics % n=200 Family Size: - 1-3 5 2.5 - 4-6 80 40 - 7 and more 115 57.5 - Enough 164 82 - Not Enough 36 18 - Yes 141 70.5 - No 59 29.5 Family Income: Family Diabetic History: Family Members diabetic history: have n=141 - Father and/or Mother 39 27.7 - Sibling 15 10.6 - Father & Sibling 14 9.9 - 2nd and 3rd Relatives 73 51.8 64 Table IV. Diabetic Children's Medical History according to their Gender Male No. % n=95 Female No. % N=105 - Type 1 95 100 103 98.1 198 - Type 2 - - 2 1.9 2 1 - < 1 Year 7 7.4 22 21 29 14.5 - 1- 21 22.1 25 23.8 46 23 - 5- 47 49.5 48 45.7 95 47.5 - 10 and more 20 21.1 10 9.5 30 15 16 16.8 28 26.7 44 22 38 40.0 40 38.1 78 39 41 43.2 37 35.2 78 39 - Blood by glucometer 95 100 105 100 200 100 - Urine by strip 40 42.1 46 48.4 86 43 Medical History Total No. % n=200 Types of Diabetes: 99 Onset of Diabetes by year: Level of Glycemic Control: Good: - (6-7.5%)* Fair: - (8-10.5%) Poor: - >10.5% and more Practice Glucose testing: * 7.5% Level according to hospitals policies As regard children’s level of glycemic control, the results show that only 22% of the children (16.8% males and 26.7% females) had good level of glycemic control (blood glucose concentration is good for long term, 65 i.e., 2 to 3 months). While, the rest of the children were either fair or poor (39% for each), (blood glucose concentration is higher for long term, i.e., 2 to 3 months) All the children were testing their blood glucose level by glucometer (100%), while only 43% of the children were testing urine for glucose by strip (42.1% males and 48.4 % females). Table V. shows the treatment of the diabetic children. It is revealed from the table that 94.5% of the diabetic children were treated with insulin and diet (96.8% and 92.4% for males and females respectively). Only 3.5% were treated by insulin, oral tablet and diet (2.1% males compared to 4.8% females) and 2% were using continuous insulin pump (1.1% for males and 2.8% for females). A mixture of short and intermediate action insulin was the main prescribed insulin treatment for the diabetic children in this study (85.5%), it was prescribed for 91.6% of male diabetic children and 80% of females. Rapid or short acting insulin and long acting insulin were the least prescribed type as they constituted 3.5% and 2.5% respectively as illustrated in Table V. In relation to the frequency of injection per day, it was revealed from Table V. that more than two third of the children (70%) were injecting insulin twice a day (75.8% males and 64.8% females). Slightly less than one fourth of the children (22.5%) were injecting insulin three times a day (21.1% males and 23.8% females). The rest of the sample was injecting 66 insulin either once a day or four times a day or Per Request Need (PRN) or every 3 days (2.5% each). Table V. Diabetic Children's Type of Treatment Male No. % n=95 Female No. % N=105 - Insulin and diet 92 96.8 97 92.4 189 94.5 - Continuous subcutaneous insulin infusion (CSII) 1 1.1 3 2.8 4 2 - Insulin, OHA* and diet 2 2.1 5 4.8 7 3.5 - Rapid or Short action 1 1.1 6 5.7 7 3.5 - Short and Intermediate action 87 91.6 84 80 - Long action (glargine) 1 1.1 4 3.8 5 2.5 - Short and Long action (glargine) 6 6.3 11 10.5 17 8.5 - Once a Day 1 1 4 3.8 5 2.5 - Twice a Day 72 75.8 68 64.8 140 - Three Times a Day 20 21.1 25 23.8 45 22.5 - Four Times a Day 1 1 4 3.8 5 2.5 - PRN or every 3 days 1 1 4 3.8 5 2.5 Treatment Total No. % n=200 Types of Treatment: Types of Insulin: 171 85.5 Frequency of Injection/day: Frequency of OHA* / day: n=2 N=5 70 N=7 - Once 2 100 3 60 5 71.4 - Three Times a Day - - 2 40 2 28.6 *Oral Hypoglycemic Agent 67 As regard the frequency of oral hypoglycemic agents (OHA) per day, out of the 3.5% who were receiving OHA, only 71.4% of them were taking once a day (100% males and 60% females). See Table V. 68 Part II. Diabetic Children’s Knowledge about Self-Care Practices A. Diabetic Children’s Knowledge about Diabetes Mellitus and its Acute Complications Diabetic children's knowledge about diabetes mellitus is illustrated in Table VI. It is clear from the table that the knowledge of the diabetic children about the range of normal glucose level was poor, where only 21.5% of the children mentioned the right normal glucose level. When children were asked to define diabetes mellitus, 83% of children gave the right definition, i.e., increase in the blood glucose level (84.2% males and 81.9% females). Deficiency of insulin was reported by almost half of the children as the cause of diabetes mellitus (45.5%). Eating too much sweet and food as well as hereditary was mentioned by 18.5% of the children. However, slightly more than one fourth of diabetic children did not know the cause of diabetes (28%). See table VI. The majority of the diabetic children were able to state the three main signs of diabetes mellitus; 83.5% for polyuria, 82% for polydispsia and 77.5% for thirsty. On the other hand, 16.5% of the children did not know the manifestations of diabetes (14.7% males and 18.1% females). 69 Table VI. Diabetic Children’s Knowledge about Diabetes Mellitus Male Female Total No. % No. % No. % ChiSig. n=95 n=105 n=200 Square (P value) Normal blood glucose level: - From 80 to 120mlg/dl 21 22.1 22 21 43 21.5 - Wrong answer 61 64.2 77 73.3 138 69 - Don't know 13 13.7 6 Definition: - Define it 80 84.2 86 81.9 166 83 - Don't Know 15 15.8 19 18.1 34 17 Causes:* - Deficiency of insulin 46 48.4 45 42.9 91 45.5 3.967 0.138 0.118 0.665 - Heredity 15 15.8 22 21 37 18.5 4.416 0.353 - Stress 1 - Don't know 21 22.1 35 33.3 56 28 Manifestations:* - Polyuria 81 85.3 86 81.9 167 83.5 - Polydipsia 78 82.1 86 81.9 164 82 - Thirsty 70 73.7 85 81 155 77.5 - Weakness 10 10.5 1 1 11 5.5 - Shaking 10 10.5 1 1 11 5.5 18.978 - Abdominal pain 7 7.4 14 13.3 21 10.5 - Headache & Loss of Weight 2 2.1 - - 2 1 - Blurred Vision 1 1.1 - - 1 0.5 - Don't know 14 14.7 19 18.1 33 16.5 Treatment:* - Insulin 93 97.9 105 100 198 99 - Diet 10 10.5 18 17.1 28 14 - Exercises 12 12.6 2 1.9 13 6.5 9.882 - Oral tables 2 2.1 3 2.9 5 2.5 - Don't know 2 * More than one answer was given. 2.1 - - 2 1 5.7 19 9.5 - Eat too much sweet and food 20 21.1 17 16.2 37 18.5 1.1 2 1.9 3 1.5 0.004 0.020 70 Insulin was the main treatment for diabetes reported by the diabetic children as it constituted 99% (97.9% males and 100% females), followed by diet (14% for both gender; 10.5% for males and 17.1% for females). Oral hypoglycemic agents were mentioned only by 2.5% of children (2.1% males and 2.9% females). Regarding the diabetic children’s knowledge about diabetes mellitus according to their gender, no significant differences were found between both gender except for manifestations (P < 0.004) and treatments (P < 0.020). Diabetic children’s knowledge about hypoglycemia as an acute complication of diabetes mellitus is presented in Table VII. The study revealed that only slightly more than one fourth of the children (27%) knew the range of low blood glucose level. On the other hand, the rest of children either gave wrong answers (43.5% for both gender; 46.3% males and 43.5% females) or did not know (29.5% for both gender; 31.6% for males and 27.6% for females). In relation to causes of hypoglycemia, children reported that not eating meals or snack as a cause by 62% of the children, followed by exercising without eating meals (23%), not eating after taking insulin injection (20%). See Table VII. 71 Table VII. Diabetic Children’s Knowledge about Hypoglycemia Knowledge Male Female Total No. % No. % No. % ChiSig. n=95 n=105 n=200 Square (P value) Low blood glucose level: - < 80 mg/dl 21 22.1 33 31.4 54 27 - Wrong answer 44 46.3 43 40.9 87 43.5 2.201 - Don't know 30 31.6 29 27.6 59 29.5 0.333 Causes:* - Not eating meals or snacks 57 60 67 63.8 124 62 - Not eating meals and exercising 25 26.3 21 20 46 23 - Taking dose and not eating 20 21.1 20 19 40 20 - Over dose of insulin 11 11.6 9 8.6 20 10 - Don't know 7 8.6 16 7.4 9 1.459 0.834 0.195 8 Manifestations:* - Dizziness 90 94.7 99 94.3 189 94.5 - Shaking 87 91.6 86 81.9 173 86.5 - Sweating 70 73.7 73 69.5 143 71.5 - Vomiting 29 30.5 28 26.7 57 28.5 - Hunger 25 26.3 29 27.6 54 27 - Palpitation 25 26.3 29 27.6 54 27 13.544 - Headache 17 17.9 13 12.4 30 15 - Weakness 17 17.9 13 12.4 30 15 - Blurred Vision 3 3.2 13 12.4 16 8 - Coma 3 3.2 13 12.4 16 8 - Don't know 5 5.3 6 5.7 11 5.5 Treatment:* - Take sweets 75 78.9 80 76.2 155 77.5 - Drink Juice 75 78.9 80 76.2 155 77.5 - Drink juice and eat sandwich 18 18.9 22 21 40 20 - Don't know 2 * More than one answer was given. 2.1 3 2.9 5 2.5 0.289 0.962 72 Dizziness, shaking and sweating were the major manifestations of hypoglycemia reported by the children as they constituted 94.5%, 86.5% and 71.5% respectively. Vomiting, hunger and palpitation were mentioned by almost one fourth of the children as they ranged from 28.5% to 27%. Only 5.5% of the diabetic children did not know the manifestations (5.3%, 5.7%, for males and females respectively), as shown in Table VII. Taking sweets and drinking juice to increase low blood glucose were the main treatment of hypoglycemia mentioned by the children (77.5% for each). While, 20% of children stated that drinking juice and eating sandwich are treatments of hypoglycemia. No statistical significant differences were found between males and females’ knowledge about hypoglycemia as shown in Table. VII. Table VIII. shows the diabetic children's knowledge about hyperglycemia. It was clear from the table that only 25.5% of the children knew the range of high blood glucose level which is more than 250 mg/dl (16.8% males compared to 33.3% females). The rest of the sample either gave wrong values (63.5% for both gender; 72.6% for males compared to 55.2% for females) or didn't know the value (11%). Eating too much sweets and carbohydrates was the major cause of hyperglycemia reported by children, as it presented 93% compared to 13.5% for low dose insulin and 9% for not exercising. Not taking insulin injection and overeating and taking low dose of insulin were reported by 73 13.5% of children. Only 5% of diabetic children did not know the causes of hyperglycemia (4.2% and 5.7% for males and females respectively). Table VIII. Diabetic Children’s Knowledge about Hyperglycemia Knowledge Male Female Total No. % No. % No. % ChiSig. n=95 n=105 n=200 Square (P value) High blood glucose level: - > 250 mg/dl 16 16.8 35 33.3 51 25.5 - Wrong answer 69 72.6 58 55.2 127 63.5 7.732 - Don't know 10 10.5 12 11.4 22 11 0.021 Causes:* - Eating too much sweets and carbohydrates 91 95.8 95 90.5 186 93 - Not taking insulin injection 10 10.5 17 16.2 27 13.5 - Over eating and taking low dose insulin 10 10.5 17 16.2 27 13.5 - Not doing exercise 11 11.6 7 6.7 18 9 - Stress 1 1.1 3 2.9 4 2 - Don't know 4 4.2 6 5.7 10 5 4.835 0.436 14.310 0.046 0.514 0.972 Manifestations:* - Polyuria 64 67.4 84 80 148 74 - Polydipsia 64 67.4 84 80 148 74 - Thirsty 31 32.6 25 23.8 56 28 - Weakness 12 12.6 33 31.4 45 22.5 - Headache 13 13.7 19 18.1 32 16 - Nervous 13 13.7 19 18.1 32 16 - Abdominal pain 8 - Don't know 31 32.6 21 20 52 26 8.4 7 6.7 15 7.5 Treatment:* - Increase dose of insulin 80 84.2 87 82.9 167 83.5 - Drinks a lot of water 80 84.2 87 82.9 167 83.5 - Take short acting insulin 48 50.5 58 55.2 106 53 - Exercise 17 17.9 22 21 39 19.5 - Don't know 2 2.1 * More than one answer was given. 3 2.9 5 2.5 74 As regard the manifestations of hyperglycemia, polyuria and polydipsia were the main manifestations reported by the children as they constituted 74% for each (67.4% males compared to 80% females). While, 26% of the children did not know the manifestations. The rest of the reported hyperglycemic manifestations ranged from 28% for thirsty (12.6% males compared to 31.4% females), to 7.5% for abdominal pain (8.4% 6.7%, males and females respectively). The majority of the diabetic children (83.5%) knew treatment of hyperglycemia, which was either by increasing dose of short-acting insulin or drinking a lot of water to decrease blood glucose level (84.2%, 82.9% for males and females respectively for each). Almost one fifth of diabetic children mentioned exercises to decrease their blood glucose 19.5%). There were statistical significant differences found between the males and females’ knowledge about high blood glucose level (P < 0.021) and hyperglycemic manifestations (P < 0.046). B. Diabetic Children’s Knowledge about Self-Care Practices 1. Diabetic Children’s Knowledge about Diabetic Diet Figure 2. illustrates diabetic children’s source of diet instructions were given mainly by verbal instructions with either dietitian or health care providers. 75 76 Table IX. illustrates diabetic children’s knowledge about the diabetic diet. It is shown; that when diabetic children were asked about importance of main meal, 91% reported it is important (92.6% males, 89.5% females). Half of the children (50.5%) mentioned that the main meal is important to maintain glucose level (52.3% and 48.9% for males and females respectively). The difference was not statistically significant. Slightly more than half of the children reported that eating snacks is important in their diet. Prevent hypoglycemia was the main cause reported by children about importance of snacks as it constituted 75.7%. While, 33% of children stated that it is important to restrict from eating carbohydrates and sweets. Prevention of hyperglycemia was the main reason given by 80.3% of children for the importance of restricting carbohydrates and sweets (79.3% and 81.1% for males and females respectively). Diabetic children’s knowledge about importance of insulin injection is presented in Table X. Almost all children (97.5% for both gender; 96.8% for males and 98.1% for females) see that insulin injection is important for their treatment. All children (100%) reported that the control of blood glucose and/or prevention of complications are the main reasons for insulin injection. 77 Table IX. Diabetic Children's Knowledge about Diabetic Diet according to their Gender Knowledge Importance of main meal Male Female Total No. % No. % No. % ChiSig. n=95 n=105 n=200 Square (P value) 88 92.6 94 89.5 182 91 Reason: n=88 n=94 n=182 - Maintain glucose level 46 52.3 46 48.9 92 50.5 - Prevent Complication 11 12.5 23 24.5 34 18.7 4.685 - Hunger 31 35.2 25 26.6 56 30.8 Importance of snacks 53 55.8 62 115 57.5 Reason: n=53 n=62 n=115 - Control blood glucose level 5 4 6.5 9 - Prevent hypoglycemia 38 71.7 49 79 87 75.7 0.855 - Hunger Importance of restricting carbohydrates and sweets 10 18.9 9 14.5 29 30.5 37 35.2 Reason: 9.4 59 n=29 20.7 n=37 7 0.096 7.8 0.652 19 16.5 66 33 n = 66 - Control blood glucose level 6 18.9 13 19.7 - Prevent hyperglycemia 23 79.3 30 81.1 53 80.3 0.032 0.858 78 79 Two third of the diabetic children (66.5%) mentioned that it is important to take insulin 15 -30 minutes before meals (63.2% for males and 69.5% for females). When asked about the reason, 51.1% of the children stated the reason is to start action of insulin (48.3%, males and 53.4% females), and 48.9% to prevent the increase of glucose level in blood after meals (51.7% and 46.6% for males and females respectively). It is observed from Table X that all of the children (100%) were mentioned the importance of rotating the site of injection. Prevent swelling was the main reason for children’s rotation of injection site as it was reported by 81.5%. Prevention of pain and change skin color was reported by 13% of children, and increase absorption and prevents skin damage by 5.5%. Fifty percent of the diabetic children mentioned the importance of dose adjustment of insulin (48.4% males and 51.4% females) and only one reason was given by children which was to control blood glucose (100% for both gender). No statistical significant differences were found between male and female children regarding their knowledge about insulin injection as shown in Table X. Table XI. represents the diabetic children’s knowledge about glucose test and exercises. It was observed that blood glucose test was important for 57 % of children (52.6 % for males and 60.9 % for females). Control 80 81 blood glucose and prevent complications were the rationale given by children for checking blood glucose level. On the other hand, 43 % of the diabetic children mentioned the urine test is important. Almost half of the children (54.7) reported that urine test is important to check for ketone and sugar and 45.3% for the presence of sugar. No statistical significant differences were found between male and female children regarding their knowledge about glucose testing as shown in Table XI. Seventy three percent of the diabetic children reported the importance of exercises (82.1% for male children were compared to 64.8% for females) and 71.2% of them mentioned that exercise is important to control blood glucose level (69.2% for males and 73.5% for females). The difference was statistically significant between the males and females (P < 0.004). See Table XI. It was observed from Figure 3. Safety precautions instructions were mainly given by diabetologist for all the hospitals except in King Khalid National Guard Hospital which given by diabetic nurse educator (See Figure 3). Diabetic children’s knowledge about importance of safety precautions is presented in Table XII. It is revealed from the table that 89% of children considered the regularity in taking treatment is important (86.3% for males and 91.4% for females). Control blood glucose and prevention of complications were the main reasons for the diabetic children for taking 82 83 84 medication regularly (100% for both gender). On the contrary, only 43% of the children stated that glucagon injection is important. The majority of them reported that glucagon injection was important in order to treat hypoglycemic shock (74.4%,) and 25.6% to treat hypoglycemia. See Table XII. When the children were asked about the importance of carrying identification card (ID), only 18.5% reported that it is important to carry the ID (12.6% males, 16.2% females). Prevention of complications was the reason given by all the children for carrying the ID (100%). Regarding the importance of carrying sweet as a safety precaution, 55.5% of the diabetic children stated its importance (50.5% for males and 60% for females). Prevent hypoglycemia was the main reason stated by the diabetic children for the importance of carrying sweet or sugar (100%). Eating snacks before exercising as a safety precaution was mentioned by 61% of the diabetic children (63.2% males and 59% females) and the rationale given was to prevent hyperglycemia (100% for both genders). No statistical significant difference was found between males and female children’s knowledge about safety precautions (See Table XII). Diabetic Children’s knowledge about regular periodical medical check-up is illustrated in Table XIII. It was clear that regular diabetologist visit was important for the majority of the diabetic children (89%). When 85 86 they were asked for the reason for its importance, 76.4% stated it was to control blood glucose level, and 23.6% for prescription of medication. In relation to the importance of ophthalmologist visit as a safety precaution, 61% of the children stated it is important and 80.3% of them for eye examination and 19.7% to prevent complications. Only 33% of the children considered dentist visit is important and the reason given was for treatment and follow-up (100% for each). Seventy five percent of the children mentioned the importance of diabetic educator visits. The majority of diabetic children (88.7%) mentioned that the reason for this visit is to control blood glucose level and only 11.3% to receive the instruction of self-care. As regards dietitian visit, 65.5% of the children reported its importance. Instruction about diabetic diet was the important reason for dietitian visit for the majority of diabetic children (93.1%). On the other hand, only 6.9% of the children reported weight control as the reason for visiting the dietitian. The differences between male and female children’s knowledge about periodic check-up were not statistically significant as shown in Table XIII. Diabetic children’s knowledge about hygienic practices is shown in Table XIV. It was clear that personal hygiene was important for most of the diabetic children (95%). Slightly more than half of the children (51.6%) considered it important to prevent disease and 48.4% to prevent bad odors. 87 88 Almost all the diabetic children (96.5%) reported the importance of foot care. Prevention of infection was reported by 77.7% of children as a rationale for wearing shoes, while to prevent gangrene was mentioned by 22.3% of children. See Table XIV. Importance of wearing proper shoes was stated by half of the children (51.5%). While, the importance of cutting nails straight was reported by 34.5% of children. However, the reason beyond their importance was prevention of injury (100% for both each). There is no statistical significant difference was found between male and female children’s knowledge regarding their hygienic practices as illustrated in Table XIV. 89 Part III. Diabetic Children’s Self –Care Practices: A. Self-Care Practices of Diabetic Diet Diabetic children’s adherence to diabetic diet is shown in Table XV. It was found that nearly two third of the diabetic children (64%) adhered to diabetic diet (64.2% - 63.8% for males and females respectively). When the diabetic children were asked if they eat the 3 main meals, the majority of them (91.5%) reported that they always eat the three main meals (92.6% males and 90.5% females). On the contrary, the percentage of children who always eat 3 snacks was only 35.5% (33.7% for males and 37.1% for females) and half of the children (49.5%) sometimes eat the snacks (52.6% males and 46.7% females respectively). As regard the adherence to food exchange, it was found that one third of the diabetic children either always or sometimes adhered to food exchange (37.5% and 36% respectively). Female children who always adhere to food exchange were more than male children (46.7% compared to 27.4% respectively). On the contrary, male children who sometimes adhere to food exchange (45.3%) were more than the females (27.6%). For meal estimation, 41% of children reported that they always estimate the meal quantity and 38% estimated it sometimes. Only 5% of the diabetic children never estimate the meal quantity. 90 91 Females who always estimate meals properly were more than males (30.5% for males and 50.5% for females) and males who sometimes estimate their meals were more than females (44.2% and 32.4% for males and females respectively). The majority of diabetic children (90.5%) in both gender stated that they never calculate the calories of their food (92.6% - 88.6% for males and females respectively). Only 2% of children always calculate the required calories and 6.5% of the children calculate it sometimes (5.3% males and 7.6% females). There were statistically significant differences found between the male and female children’s adherence to prescribed diet in relation to food exchange (P < 0.025) and proper meal estimation (P < 0.040). See Table XV. It was observed from Table XVI, that only 10% of children always restrict taking carbohydrates compared to 55.5% who sometimes restrict eating it (54.7%, 56.2% for males and females respectively). On the other hand, 11.5% stated that they never restrict taking carbohydrates. In relation to sweets restriction, slightly less than half of the children (43.5%) mentioned they sometimes restrict taking sweets while 9.5% reported that they never restrict eating sweet (12, 6% males and 6.7% females). Only 21.5% of children always restrict taking sweets (16.8% males and 25.7%females). See Table XVI. 92 93 No statistical significant differences were found between male and female children’s adherence to prescribed restricted diet as shown in Table XVI. Diabetic children‘s daily dietary intake is shown in Table XVII. It was clear that slightly more than half of the children (56.5%) were taking carbohydrate more than their daily requirements (61.1% males, 52.4% females). Only 42.5% of diabetic children received the daily requirement of carbohydrate (37.9% males and 46.7% females). On the other hand, only 57% of the children were taking the daily requirement of protein (55.8% and 58.1% for males and females respectively). While, 40.5% of the children were taking protein less than their daily requirements. In relation to fat intake, more than half of the diabetic children (57.5%) were taking the daily fat requirement (61.1% males and 54.3% females). Twenty eight percentages of the diabetic children were taking fat more than the daily requirement and 14.5% received less than the daily requirement ass illustrated in Table XVII. It is revealed from the same table that half of the diabetic children (50.5%) were taking calories more than daily requirements (54.7% for males and 46.7% for females). While the percentage of the children who received the daily caloric requirement was 34% (31.6% males sand 36.2% females). 94 Table XVII. Diabetic Children Adherence to Prescribed Diet Assessed by 24 Hours Recall Method Practices Male No. % n=95 Female No. % n=105 Total No. % n=200 ChiPSquare Value Adherence to daily needs for carbohydrates: - Less than daily requirements 1 1 1 0.9 2 1 - Daily requirement 36 37.9 49 46.7 85 42.5 - More than daily requirements 58 61.1 55 52.4 113 56.5 1.572 0.456 0.373 0.830 1.016 0.602 1.340 0.512 Adherence to daily intake protein: - Less than daily requirements 39 41.1 42 40 81 40.5 - Daily requirement 53 55.8 61 58.1 114 57 - More than daily requirements 3 3.2 2 1.9 5 2.5 - Less than daily requirements 12 12.6 17 16.2 29 14.5 - Daily requirement 58 61.1 57 54.3 115 57.5 - More than daily requirements 25 26.3 31 29.5 56 28 Adherence to daily intake of fat: Adherence to daily intake of calories: - Less than daily requirements 13 13.7 18 17.1 31 15.5 - Daily requirement 30 31.6 38 36.2 68 34 - More than daily requirements 52 54.7 49 46.7 101 50.5 No statistical significant differences were found between male and female children for their daily dietary intake of carbohydrates, proteins, fat and calories as shown in Table XVII. 95 B. Self –Care practices of Insulin Injection Table XVIII. represents the diabetic children’s self -care practice of insulin injection. Although the majority of the procedure steps were done (100%), it was observed that only 41% of the sample washed their hands at the beginning of the procedures. In relation to preparation of equipments, data shows that 69% of children and 23.5% of advocates independently prepared the equipment; while only 7.5% the children prepared the equipment with their advocates (partially compensatory). Insulin vial was rolled by 74% of children and / or advocates and the top of the vial was wiped by 81.5%. While recording of insulin injection in dairy book was carried out by 57.5% of the sample. In relation to Orem Self- care levels, it is revealed from Table XVIII. that more than half of the children carried out the steps of the procedure independently, i.e., educative and development level, where the percentages ranged between 57.5% for injecting the insulin to 72% for washing hands. It was observed also that 42.5% of advocates, who were mainly the mothers, injected the insulin (simulator), i.e., wholly compensatory self-care level. 96 97 C. Self – Care Practices of Glucose Test Diabetic children’s self-care practice of blood glucose test is shown in Table XIX. It was clear that, only 34% of the sample either the children (educative &development) or their advocates (wholly compensatory) washed their hands. On the other hand, it was observed that the children practiced most of the steps independently (educative &development). However, 17.5% of the advocate punctured the children’s fingers and 15.2% discarded the needles and 23.2% recorded the result. Applying a drop of blood, obtaining and interpreting the result were done by the children with their advocate’s assistance, i.e., partially compensatory selfcare level (4.5%; 5.5% and 4.6% respectively). It is revealed from Table XX that only 43% of the children knew how to test urine for glucose, while the rest of children did not know how to test the urine. For those who know the test, only 25.6% of the children and their advocates washed their hands at the beginning of urine test. On the contrary, almost all the children and advocates (97.7%) washed their hands at the end of the procedure. It is also observed from Table XX. that all the steps of the procedures were carried out by almost two third of children independently, i.e., educative & development self -care level as percentages ranged between 91.8 % for preparing equipment to 64.7 % for recording the result. Advocates carried out the procedure (i.e., wholly compensatory) for almost 98 99 100 one third of their children as the percentage ranged from 35.3% for recording the result to 7% for preparation of equipment. Table XXI. illustrates the rationale for some self-care practices. It is shown that washing hand was reported important by all the diabetic children (100%) for cleanliness and protection from micro-organism. The majority of children in both genders mentioned that they have to discard needle properly in order to prevent injury (71.6% males, 85.7% females). When the diabetic children were asked about the reason of documenting the results of blood glucose test, the majority of the children (77.5%) reported that it is important for follow-up and glucose level control (74.7% males, 80% females), 14% for dose adjustment (15.8% males and 12.4% females). Only 8.5% of the children did not know the reason for doing it (9.5% - 7.6%, males and females respectively). D. Self-Care Practices of Physical Exercises: Diabetic children’s types of physical exercises are presented in Table XXII. It is revealed from the table that 73% of children were exercising (82.1% males compared to 64.8% females). Walking was the major type of the physical exercise practiced by diabetic children (68.5%) followed by football (41.8%). Females were practiced walking more than males (95.6% females compared to 44.9% males). While, football was practiced by males more than females (61.5% for males and 19.1% females). 101 102 Table XXII. Diabetic Children’s Type of Physical Exercises Practices Male Female No. % No. % n=95 n=105 Total No. % n=200 Z P-Value 2.76 0.003 Exercise - Yes 78 Types 82.1 68 n=78 64.8 146 n=68 73 n=146 - Walking 35 44.9 65 95.6 100 68.5 8.24 0.000 - Bicycling 12 15.4 11 16.2 23 15.8 0.13 0.896 - Swimming 8 10.3 16 23.5 24 16.4 2.15 0.032 - Running 16 20.5 19 27.9 35 23.9 1.05 0.296 - Football 48 61.5 13 19.1 61 41.8 5.82 0.000 - Others 5 6.4 9 13.2 17 11.6 1.38 0.169 It is observed from Figure 4 that 69% of the children of both genders were walking 2 to 3 days per week. While, 2 to 3 days swimming per week was the least diabetic children exercise (4% for both genders). On the other hand, more than half of the diabetic children (57%) were playing football for 2 to 3 days per week. E. Self- Care Practices of Hygienic Care Table XXIII. shows the diabetic children self-care practices of hygienic care. It was observed that almost all the children’s skin, eyes and mouth were clean (96%, 98% and 98.5% for skin, eyes and mouth respectively). Only 53.5% of the children’s teeth were clean. The majority of children’s feet and nails were clean (90% and 88% respectively). 103 104 Table XXIII. Diabetic Children's Self-care Practices of Hygienic Care Personal Hygiene Male No. % n= 95 Female No. % n= 105 Total No. % n= 200 Z P-Value Cleanness of: -Skin 89 93.7 103 98.1 192 96 1.56 0.119 - Eyes 92 96.8 104 98 1.09 0.277 - Mouth 94 98.9 103 98.1 197 98.5 0.50 0.615 - Teeth 47 49.5 60 57.1 107 53.5 1.09 0.276 82 86.3 98 93.3 180 90 1.64 0.101 75 78.9 101 96.2 176 88 3.76 0.000 Face: Foot: - Nails 99 196 Nail Cut: - Straight way 51 53.7 72 68.6 123 61.5 2.18 0.029 - Short nail 84 88.4 96 91.4 180 90 0.70 0.481 - Cotton 36 37.9 56 53.3 92 46 2.22 0.027 - Clean 36 37.9 56 53.3 92 46 2.22 0.027 - Proper size 36 37.9 56 53.3 92 46 2.22 0.027 - Proper and comfortable 36 37.9 56 53.3 92 46 2.22 0.027 - Slipper or sandal 59 62.1 49 46.7 108 54 2.22 0.027 - Proper heel 95 93 4.02 0.000 Socks: Shoes: 100 91 86.7 186 105 Although 90% of children had short nails (88.4% males and 91.4% females), 61.5% only cut their nails in straight way (53.7% males and 68.6% females). As regards socks and shoes, it was observed that less than half of the diabetic children (46%) were wearing proper and comfortable shoes with clean and proper size of socks (46% for both genders; 37.9% males compared to 53.3% females). Fifty four percent of children were wearing either slipper or sandal (62.1% for males and 46.7% females). The differences between male and female children’s hygienic care were statistically significant except for cleanliness of skin and face as shown in Table XXIII. 106 Part IV. Diabetic Children’s Practices According to Orem Self – Care Level A) Diabetic children’s practice according to 3 levels of Orem Self – Care: Diabetic children’s self –care practices in relation to the three level of Orem self-care is presented in Table XXIV. It was observed that blood glucose test was the highest self care practiced by the diabetic children independently (79.5%), i.e., educative & development, compared to only 2% of the children who were totally dependent on their advocates, i.e., wholly compensatory. Slightly more than half of the diabetic children (55%) practiced insulin injection independently (educative &development), and 25.5% were totally depended on their advocates (wholly compensatory). While only 19.5% of the children participated with their advocate in insulin injection (partially compensatory level of self-care) Sixty six point three percent of diabetic children test urine independently. Only 7% of children test it with assistance (partially compensatory self – care). On the other hand, more than one fourth of the urine test was done by advocate, i.e., wholly compensatory (26.7%). 107 108 It is revealed from the same table that almost half of the children shared with advocate the food selected and meal estimation, i.e., partially compensatory (53.5% and 54% respectively). All children were independent in their dental care (100%) and 95.5% of them were independent in the foot care and 90% in the personal hygiene, i.e., educative & development self-care level. On the other hand, 63.5% of children select their shoes and socks independently, while 35% of them share the selection with their advocates. The differences in dependency care were statistically significant at (P < 0.001) as shown in Table XXIV. B) Diabetic Children’s Practice in Relation to 3 Levels of Orem SelfCare according to their Gender and Age Table XXV-a. illustrates the distribution of diabetic children’s practices in relation to Orem 3 level of self-care according to children’s gender. It was found that females were more independent in insulin injection than males, i.e., educative & development (58.1% for females and 51.6% for males). While, 28.4% of male children and 22.9% of females have the insulin injection by their advocates, i.e., wholly compensatory. Educative & development level was more for the female children than males in blood glucose test, i.e., who were independently practiced blood glucose test (81.9% females and 76.8% males). None of male children were 109 110 totally depended on their advocates in testing their blood glucose level compared to 3.8% of the female children (Wholly compensatory). On the other hand, partially compensatory self-care, i.e., children participated with their advocate for blood glucose testing was high in the male than female children as they constituted 23.2% for males and 14.3% for females. For urine test, the highest percentage for both male and female groups was the educative & development self-care, where diabetic children were totally depended on themselves (55% for males and 76.1% females). While, 40% of males depend on their advocates for testing their urine, i.e., wholly compensatory compared to 15.2% of the females. As regards diet, it was shown from Table XXV-a. that more than half of the children of both gender participated with their advocates in their food selection and estimation, i.e., partially compensatory self – care (53.7% and 53.3% for males and females for food selection, and 54.7% for males and 52.4% females for food estimation respectively). Only one male child (1%) who dependents on his advocate for food selection and 2 children (2.1%) for meal estimation and 5 females were dependent on their advocates for food estimation (4.8%). For hygiene, it is clear from the table that almost all children of both gender were responsible for their personal hygiene, i.e., educative & development as the percentages ranged from 100% for dental for both 111 gender to 89.5% for males children and 90.5% for females regarding their personal hygiene. On the other hand, 57.9% of males and 68.6% of females select their shoes and socks independently; i.e., educative & development, and 40% of males and 31.4% of females shared their advocates in the selection of their shoes and socks as illustrated in Table XXV-a. Table XXV-b illustrates the statistical significant differences between males and females. The differences are not statistically significant in the level of self-care dependency variables between the male and female children except in care dependency of practicing urine test, where the result shows that the male children are more dependent than female children to their advocate at 5% significant (wholly compensatory) Table XXV-b. Results of Mann-Whitney U test to determine Self-care Practices Difference between Gender Care Dependency Variable - Insulin injection - Blood glucose test - Urine test - Food selection - Meal estimation - Personal hygiene / clean body - Dental care - Foot care - Shoes & socks selection MannMean Rank Wilcoxon Male Female Whitney W U n=95 n=105 103.48 97.80 4704.5 10269.5 0.769 AsympSig. (2tallied 0.442 103.62 97.68 4691 10256 1.035 0.301 48.62 101.53 100.08 38.38 99.57 100.88 704.5 4889.5 4947.5 1650.5 10454.5 9507.5 2.288 0.277 0.112 0.022 0.782 0.911 101.03 100.02 4937.5 10502.5 0.235 0.814 100.50 98.11 100.50 102.67 4987.5 4670 10552.5 9320 0.000 1.55 1.000 0.121 106.24 95.30 4442 10007 1.594 0.111 Z 112 Distribution of diabetic children in relation to self –care level according to age is illustrated in Tables XXVI-a and XXVI-b. It is revealed from the Tables that in all these practices, the older age group of diabetic children (13 – 15 years) were more self-dependent than the younger age group (10 – 12 years), i.e., educative & development. On the other hand, the younger age group children were more depended (partially or wholly) on their advocates to help them perform these tasks compared to the elder children. Statistical significant differences were found in most of the studied items related to care dependency variables between age groups at 1% and 5 % level of significant. 113 114 Table XXVI-b. Results of Mann-Whitney U test to determine Self-care Practices Difference between Age Groups Care Dependency Variable - Insulin injection - Blood glucose test - Urine test - Food selection - Meal estimation - Personal hygiene / clean body - Dental care - Foot care - Shoes & socks selection Mean Rank Age Age 10-13 13-15 n=126 n=74 108.23 87.34 MannWilcoxon Whitney W U Z AsympSig. (2tallied 3688.0 6463.0 2.739 0.006 106.87 89.65 3859.0 6634.0 2.899 0.004 45.55 113.26 114.52 41.03 78.77 76.63 820.0 3054.0 2895.5 1600.0 5829.0 5670.5 1.008 4.700 5.108 0.313 0.000 0.000 103.99 94.55 4222.0 6997.0 2.143 0.032 100.50 101.56 100.50 98.70 4662.0 4529.0 7437.0 7304.0 0.000 0.937 1.000 0.349 111.48 81.80 3278.0 6053.0 4.183 0.000 Chapter V DISCUSSION 115 DISCUSSION Diabetes is a chronic metabolic illness that requires continuing medical and cost-effective nursing care as well as self-management education to prevent acute complications and reduce the risk of long-term complications (Taib, 1998; Zimmermen, 2003; Diabetes Atlas Committee, 2003). It was clear from the findings of this study that type 1 diabetes mellitus is the main type of diabetes among the studied children who are under 15 years of age. This finding is supported by Swift et al (1993) and Karvenon et al (2000) who reported that although type 1 diabetes mellitus occur at any age yet is has a peak incidence between the ages 10-15 year. Although several studies reported that there an increase in the incidence of type 2 diabetes mellitus in children aged less than 15 years in United States, Europe, Japan and Arabian Gulf Countries, as its prevalence ranged from 9 -13.9 /1000/ years. (American Diabetic Association, 2000-a; International Diabetes Federation, 2003; Diabetes Atlas Committee, 2003; AL-Shaikh, 2004), yet it is not congruent with the result of the present study, where only 2 cases (1 %) had type 2 diabetes mellitus. Although the majority of diabetic children of the present study did not know the normal blood glucose level, yet they were able to give the right 116 definition of Diabetes Mellitus. This may be attributed to the nature and the name of the disease which indicates the increase in blood glucose level. Rudolph et al (2002) stated that the main manifestations of Diabetes Mellitus and hyperglycemia are polyuria, polydispsia, thirsty, weight loss and polyphagia, while shaking, dizziness and sweating are manifestations of hypoglycemia (Rudolph et al, 2002). The result of this study revealed that diabetic children knew these manifestations of diabetes mellitus, hypo and hyperglycemia. This may be related to the fact that these manifestations can easily be detected by children themselves, as they feel them whenever fluctuation of their blood glucose level occurs. This finding is supported by Nathan et al (1996) who found that change in health status of diabetic children are most often related to fluctuation in blood glucose levels. When blood glucose drops, brain glucose supply is reduced, the children begin to feel shaky, sweaty and heart thumping, while when the blood glucose is elevated, the children feel thirst, polydispsia and polyuria (Nathan et al, 1996). Insulin administrations, increase dose of the insulin or increase water intake are mentioned as the main treatment of diabetes mellitus and hyperglycemia by the majority of the studied children. On the contrary, Yee and Edward (2003) mentioned that appropriate management requires more than the adjustment in insulin dose, where practical, medical and psychosocial factors also need to be considered in treatment. Insulin 117 therapy was mentioned more than controlling diet as the treatment of diabetes mellitus by the majority of the children. This can be explained in the light of the fact that most of these children have type 1diabetes where its main treatment is exogenous insulin (Yee and Edward, 2003). The treatment of hypo and hyperglycemia are considered emergency condition for prevention of further complications (Pediatric Nursing staff, 2004). Treatment of hypoglycemia by taking sweet and drinking juice were reported by three-fourth of diabetic children. This finding can be attributed to the fact that diabetic children between the age group 10-15 years are in the formal- operational cognitive development where they can understand what is happing to their bodies and when they feel any abnormal symptoms they may be able to function independently (Berk, 2003). In addition, they like to eat sweets and drink juice in this age (Teung. 1998) Because hypoglycemia is an acute condition that need emergency treatment as stated by Edge et al, (1999), diabetologist and diabetic nurse educators might explained to children its manifestations and treatment during their visits (Edge et al, 1999). Also, more than two third of children’s family members are diabetic (See Table III), so the children may be exposed to the experience of hypoglycemia and its management. Although the children in this study were knowledgeable about definition, main manifestations and treatment of diabetes mellitus, hypo and hyperglycemia, yet, the majority of them did not know the normal, low 118 and high blood glucose level and half of them did not know the causes of diabetes mellitus and hyperglycemia. This may be a result of children’s improper education by their diabetologist, nurse educators or dietitian who may concentrate their education on the care management rather than the nature of the disease or gave the information to caregivers not to children. In addition, they may not have the enough time to educate and reassess children’s knowledge. American Diabetes Association (2000-d) reported that the standard daily food intake is divided into 3 main meals with snacks between meals and before going to bed to prevent hypoglycemia (American Diabetes Association, 2000-d, Franz et al, 2004). The majority of the diabetic children in the present study for both sexes knew the importance of the main meals and always eating 3 main meals to maintain their blood glucose. This finding can be explained in the light of the fact that the diabetic children need energy for their growth and development and physical activities in this age. Also taking insulin injection as treatment forces them to eat the main meals. Feeling of hunger is another factor contributed to children’s adherence to the main meals. Although more than half of the children reported the importance of snacks to prevent hypoglycemia, only one fourth of children were always eating snacks. This may be due to children' loss of appetite, escape of 119 snacks, not practicing exercise or they are totally depended on their advocates for meal planning and serving. It was clear from the findings of this study that nearly two third of the children adhered to diabetic diet regimen. Diabetes Atlas Committee (2003) and Yousr (2004) stated that there is some evidence that selfmanagement activities, such as diet, has been reported to be poor (Diabetes Atlas Committee, 2003; Yousr, 2004). Several studies have shown that exchange diet is difficult to understand and implement without knowing the carbohydrate content of food (Anderson, 1997; Waldron et al, 2002), and that many children with diabetes do not improve glycemic control and their parents can not understand and follow food exchange and calculate calories (Anderson, 1990; Miller, 1998). The present study revealed that about one fourth of children either rarely or never adhere to food exchange and estimation of food. Only one third of the children always had implemented them. On the other hand, almost all the children did not calculate their calories intake (see Table XV). These findings may be returned to the role of the diabetic nurse educators and dietitians in the ambulatory clinic who may not promote the children’s self-care educations by not considering the children readiness for dietary self-care management. This finding is supported by Venters et al (2004) who stated that nurses and dietitians gave different information to their diabetic patients (Venters et al, 2004). 120 In regards importance of carbohydrates and sweets restriction, it was found that only one third of children knew the importance of their restriction and more than half of the children sometime restricted eating carbohydrates, while less than half of them restricted eating sweets. Although diet restriction have shown a control of glucose level, Standiford et al. (1997), found that food restriction including inability to eat what children want to eat and have to restrict sugar intake were the chief problems of diabetic children and adolescents (Standiford et al., 1997). On the contrary, Bryden et al, (1999) indicated that parents of children and adolescents need to learn insulin adjustment rather than to restrict food to control blood glucose level (Bryden et al, 1999). American Diabetes Association (2000-d) reported that the meal plan is not a restriction of calories; it is intended to ensure a reasonably consistent food intake and nutritionally balanced diet (American Diabetes Association, 2000-d). Moreover, many authors (Jones et al, 2000; Hoffman 2001; McConne et al, 2001) mentioned that adequate calories play a role in preventing and treating acute and long- term complications of diabetes. However, the result of this study found that studied children were taking carbohydrate, fat and calories more than their daily requirements which is reflected in their poor or fair glycemic control level. This can be explained in the light of Gilbert et al (2001) and Hissa et al (2004) who indicated that calculation of calories intake is difficult and associated with some physiological and 121 psychological problems and disordered eating behavior (Gilbert et al, 2001; Hissa et al, 2004). Further, the present study is supported by the results of Bamnaga study (1996) which showed that the teenage had difficulty to adhere to diet regimen because the children may not want to look different from their peer group and they enjoy eating in restaurants (Bamnaga, 1996). Moreover, this is in agreement with other researcher who found that children and adolescents’ adherence to diabetic self-care regimen and their response vary with age and worsens with transition into adolescence (Hampson et al 1990; Faulkner, 2003). This study examined the knowledge of children about the importance of insulin injection. It was found that almost all the children reported that insulin injection and rotating injection site are important. This might be due to the fact that type 1 diabetes treatment is insulin injection, which mainly prescribed by their diabetologist. Taking injection frequently might be the cause of children’s rotation of the site of injection to avoid pain and swelling. On the other hand, half of the children did not know dose adjustment of insulin and only one third of the diabetic children did not know the importance of taking insulin 15 – 30 minutes before meals. This may be due to lack of knowledge or demonstration of injection or may be the children are more dependent on their mothers for dose adjustment. In addition, dose adjustment needs calculation where children may not be able to carry. This result is consistent with Kaufmen (2001) and Binetti and 122 Nicola (2004) who stated that appropriate adjustment of insulin regiments is important to achieve good glycemic control and give the individual increasing flexibility in choosing when and what to eat (Kaufmen, 2001; Binetti and Nicola, 2004). In addition Al-Agha (2005) stated that shortacting insulin is best administered at least 15 – 30 minutes in order to allow sufficient time for absorption and prevent post prandial high blood glucose level (Al-Agha, 2005). Regarding the importance of glucose test, the present study revealed that although all children have to test their blood glucose, only half of them know its importance. This may be due to their lack of self management education. These findings are congruent with Diabetic Atlas Committee (2003) reported that the main reasons for not practicing self-monitoring blood glucose were high cost of testing, lack of diabetes education or patients interest and testing supplies. High cost of supplies was the major reason given by all responding participants. On the other hand, half of the children know the importance of blood glucose test, the minority of them see urine test is important, who are known to carry out this procedure (Diabetes Atlas Committee, 2003). This finding can be explained in the light of the fact that urine test is extremely unpleasant procedure, or it may not be requested by diabetologist or children did not know the procedure or they did not know the procedure or they did not have urine strip. This finding is in agreement with the findings of Bamnaga (1996) and Schreurs 123 et al (2003) who found that urine test and its home monitoring for adolescent is extremely unpleasant and is a major problem for young diabetes (Bamnaga, 1996; Schreurs et al, 2003). The benefits of physical exercises included lowering blood glucose level and increase tissue sensitivity to insulin even in resting stage (American Diabetes Association, 2003; Kollipara and Warren – Boulton, 2004). Physical activity and exercise are critical components of diabetes management. Everyone can benefit from regular physical exercise, but it is even more important for school-age children and adolescent to maintain cardiovascular fitness and control weight, Taib (2004) suggested that with the epidemic incidence of childhood obesity and diabetes in youth; physical education should be part of the school day for all children. School-age children and adolescent with diabetes should participate fully in physical exercises and team sports. To maintain blood glucose level during exercise, they will make adjustments in their insulin and food intake (Taib, 2004). In examining the knowledge of the children in this study for importance of physical exercise, more than one third only of the children reported its importance, and practice physical exercises. The male diabetic children were practicing exercise more than females The finding is explained in the light of the fact that adherence to physical exercise is difficult because of the culture of the Saudi where there are some restrictions especially on females in relation to exercises. Female diabetic 124 children had difficulty in practicing exercises, because no physical exercises allowed at school, and sport clubs are expensive. Transportation and economic problem are barriers that affect the diabetic children practice of physical exercises. In addition, Fesbes (1999) and Bawazer (2004) reported that change in life style, such as, sitting for long time in front of game play and eating fast food help in decreasing children’s exercises (Fesbes, 1999; Bawazer, 2004). In relation to types of physical exercises it was found that the majority of the female children were walking compared to less than half the males. This finding is supported by Wen et al (2004) who found that diabetic person are less likely to engage in activities other than walking and, that the majority of the female children prefer walking as a physical activity (Wen, 2004). On the contrary, Bamnaga (1996) found that the female diabetic patients are less practicing walking due to some barriers (Bamnaga, 1996). In addition, in the present study football was practiced by the male children more than female children. In examining the result of children’s knowledge about safety precautions of diabetic children, the majority of the studied children, especially the female, mentioned the importance of taking medication regularly to prevent complications. While only less than one fourth of children knew the importance of glucagon injection. This can be explained in the light of children’s lack of enough information about using glucagon 125 injection to prevent and treat hypoglycemic shock. However, many authors highlighted the prescription of glucagon for home treatment of hypoglycemia due to its function.(Beregsiaszi et al, 1997; Poster et al, 1997). Moreover, it was found that almost all the children did not know the importance of carrying identification card to prevent complications. This can be explained in the light of the fact that hospital do not provide this identification card to diabetic children or children did not have enough information about the importance of carrying the identification card to prevent complications. Further, only slightly more than half of the children in the present study knew the importance of carrying sweets to prevent hypoglycemic attack. This result is consistent with Clements (1995) and Chobot et al (2000), where their diabetic children carry nothing or ‘non soluble sugar’ with them. (Clements, 1995; Chobot et al, 2000). American Diabetes Association (2000-e); and the Diabetes Prevention Program (2002), highlighted the importance of periodic check-up and follow-up care for prevention and early detection of complications (American Diabetes Association , 2000-e; the Diabetes Prevention Program, 2002). Matsuoka (2001), White et al (2001) and Curtis and Hagerty (2002) emphasized the need for detailed physical examination to pediatric diabetic children by pediatric diabetic care teams (Matsuoka, 126 2001; White et al, 2001; Curtis and Hagerty 2002). The present study revealed that periodic check-up for diabetologist and diabetic nurse educators were important for the majority of the diabetic children. While, slightly less than two third of the children reported the importance of ophthalmologist and dietitian visits. This may be due to the fact that diabetologists and diabetic nurse educator are the core of these children’s management. The Diabetic children under study knew that the reason behind controlling blood glucose level and diet instruction was the dietitian and diabetic nurse guidance (Table XIII). Arrieta et al (2003) emphasized that periodic check-up to dentist and good dental care are vital parts of the selfcare practice. Children who practiced dental care on early age usually maintain the habit throughout life (Arrieta et al, 2003). In the present study, dentist visit was the least important visit mentioned by the children, which may be a result of lack of children’s referral to dentist by their diabetologists, family negligence of their children hygienic care or/and children’s lack of information about the relationship between the gingivitis and tooth decay (Akyuz and Oktay, 1996). In addition to the fact that dental care of decayed teeth is painful so children might try to avoid these visits. Children lack of importance of dentist visit reflected in their teeth cleanliness where only half of them had clean teeth as shown in Table XXIII. 127 Luggetti et al (1999) stated that good physical hygiene is necessary for comfort and well being. School-age children and adolescents gain the “sense of achievement and intelligent” and their psychomotor skills allow them to become more involved in promoting their own hygienic self-care and keep their body clean (Luggetti et al, 1999). This is congruent with the findings of the present study where almost all the children knew the importance of hygienic care, which is reflected in their hygienic practices of cleanness of skin, eye, mouth, foot and nail. This may be due to the reinforcement of their mothers or that children at this age enjoy taking responsibility for themselves and they are in the stage of competition with their peers (Berk, 2003). Although two third of children had cut nails straight, only one third of them knew its importance, this may be a result of children and their mother’s lack of knowledge and may be due to inadequate instruction given by diabetic nurse educators. Although half of the children in this study mentioned the importance of wearing proper shoes, it was observed that more than half of them were wearing slipper or sandal. This can be attributed to Saudi culture of wearing slippers and sandals instead of shoes as a result of Saudi hot weather. As regard self-care practices of insulin injection, blood and urine glucose test, it is observed in the present study that all the steps of the each procedure were done except washing hand at the beginning of the 128 procedure and recording the results. Although hand washing is important and most basic technique for prevention of cross-infection and children mentioned the importance of washing hand, they did not applied it in their practice (Center for Disease Control and Prevention, 1997). This may be explained in the light of family customs where they encourage their children to wash their hands only before and after eating and toileting. This is supported by the findings of urine analysis where children and advocates washed their hands at the end of the procedure as urine analysis is extremely unpleasant procedure as reported Bamnaga, 1996 and Dalewitz et al, 1996. Helme and Harrington (2004) reported the importance of record keeping of glucose levels, urine analysis so that the physicians can review these results and make the necessary changes to patient’s self-care regimen (Helme and Harrington, 2004). The reasons of not recording the results may be due to children or their advocates’ lack of interest of recording or they lack knowledge about their importance or lack of motivation and reinforcement by the diabetic nurse educator or due to unavailability of diary book either from the hospital or patients themselves. According to Orem 3 levels of self-care, the majority of the children carried the steps of the procedure of insulin injection and glucose tests (blood & urine) independently, i.e., educative and developmental self-care level, except preparation of injection site, injecting insulin, puncture finger 129 for blood glucose and recording the results which were mainly done by their advocates, i.e., wholly compensatory. The children independent practices may be attributed to the method used for their education which might involve nurse and the client setting objectives and learning process together. This approach provides the children the opportunity to manage self-care, and accepts responsibilities and perform the task well (Baines, 1993; Anderson et al, 1997). On the other hand, the reasons for advocates preparation of injection, injecting insulin and puncture finger might be due to children’s fear of pain of injection and puncture, their bad experience with injection/needle. In addition, advocates’ overprotection of their children and for the accuracy of insulin dose. Generally, children’s self-care practices according to the 3 levels of Orem self-care theory, it was found that the whole procedures of blood glucose test and hygienic care were mainly done by the majority of the diabetic children independently, i.e., educative and development level. This finding figuring-out the fact that these children are at the age of either late school-age or early adolescent, therefore they are usually capable of taking the full responsibility for their hygienic care under slight parental supervision. Also, the children might use glycometer easily as it is resemble the play games that they like at this age. In addition, with everyday advances in technology glycometer becomes easy in its usage. Lombardo et al (2003) and Cruppuso (2003) stated that modern technology 130 has brought many novelties in the diabetic field, such as more accurate and smaller glucose meters or finger prick devices which requires minimal amount of blood (Lombardo et al, 2003; Cruppuso, 2003). The whole process of the insulin injection and urine test were done either by educated and development practice or partially compensatory practice and one fourth of the children were wholly compensatory self-care practice in carrying these procedures. Wholly compensatory self-care practice may be a result of children’s fear and annoyance with insulin injection as reported by Standiford et al (1997) and Mollema et al (1999). In addition, they stated that preadolescents (late-school age) and adolescent usually depend on their families for support and care (Walker et al, 1995; Dalewitz et al, 1996). Half of the diabetic children in this study were found to participate with their advocates in their dietary self-care practices and selection of shoes and socks i.e. partially compensatory self-care. This is supported by Jacobson (1997) and Standiford et al (1997) who found adolescents in their studies were in better metabolic control when they perceived their families as being supportive (Jacobson, 1997; Standiford et al, 1997). Also, according to Walker et al (1995) believes that their diabetic patients did not have the requisite knowledge concerning nutrition for self-management (Walker et al, 1995), therefore, these children seek their advocate's advice. In addition, parents may be attempting to foster the children’s 131 independence but at the same time are having much difficulty “letting go” of the diabetic management task they have been accustomed to do as stated by Foster et al, (1989) and McConnel,( 2001). In this study females were slightly more educative and development than males in practicing insulin injection, blood, urine glucose tests, diet, hygienic care, although the differences were not statistically significant. (See Table XXV-a.). This may be attributed to the fact that females reach puberty earlier than males therefore, they have the responsibility for their self-care. This is supported by the Wong et al (2003). In addition, Standiford et al (1997) found in their study that parents reported giving more responsibility to girls than boys (Standiford et al, 1997). In this study the older children were found more educative and development in their self-care practices than younger ones. This is consistent with the finding of Standiford et al (1997). On the other hand, older age group are in the formal-operational thinking and respond to the self management instructions more than the younger age group who are in pre-operational level according to Piaget cognitive development theory (Teung, 1999; Berk, 2003). Chapter VI SUMMARY 132 SUMMARY Diabetes Mellitus is one of the most common incurable and chronic metabolic diseases of childhood. Because it is a chronic illness, it requires continuing medical care and education to prevent acute complications and to reduce the risk of long-term complications; diabetic children require comprehensive education in self- management. This study aimed to find out the diabetic children’s knowledge about self-care practices and determine the levels of their self-care practices according to Orem Self – Care theory. The study was carried out at four pediatric ambulatory clinics. These settings are King Fahd Army Hospital, Maternity Children Hospital, King Abdulaziz University Hospital and King Khaled National Guard Hospital in Jeddah. Two hundred Saudi diabetic children of both genders, aging 10 – 15 years, diagnosed at least for 6 months and are free from other chronic diseases and mental retardation comprised the sample. Two tools were used for data collection. The first tool was a structured interview questionnaire that was develops to collect personal data, data related to medical history, diabetic children’s knowledge about diabetes mellitus and its complications and their adherence to diet regimen, exercise and safety- precautions. The second tool was an observational checklist that 133 was developed to assess the children’s self – care practices of insulin injection, glucose tests, and hygienic care. The observational checklist was developed according to Orem self – care framework to assess the self –care practices done by the diabetic children independently (educative and development) or with their advocate assistances (partially compensatory) or done by advocate (wholly compensatory). Each child was individually interviewed to assess his/her knowledge and adherence to diet regimen, which included the 24 hours recall method, exercises and safety precautions. Then, he/she was observed for his/her self-care practices using the observation checklist. The result of the study revealed that: • Almost all the diabetic children (99%) had type 1 diabetes mellitus, and 70.5% had diabetic relatives. • About two thirds of the sample (63%) was in age group between 10-12 years and 52.5% were females. • The majority (96.5%) of children were treated with insulin and diet, 3.5% by Oral hypoglycemic agents (OHA) and diet and 2% by continuous insulin infusion. • Only 21.5% of children knew the normal blood glucose level, 27% knew the low glucose level and 25.5% knew the high blood glucose level. 134 • Eighty three percent (83%) of children gave the right definition of diabetes mellitus. • Less than half of children (45.5%) reported that insulin deficiency is the main cause of diabetes, and 18.5% mentioned eating too much sweet and hereditary. • Polyuria, polydipsia, and thirsty were the main manifestations of diabetes mellitus reported by children as they constituted 83.5%, 82% and 77.5% respectively. • The majority (91%) of the children reported the importance of the eating the main meals, 57.5% reported the importance of eating snacks and 33% to abstain carbohydrate and sweets. • Almost all children (97.5%) see that insulin injection is important for their treatment. • Blood glucose test was important for only 57% of children and urine glucose test for only 43% of them. • Physical exercise was important for 73% of diabetic children • For safety precautions, carrying identification card carrying identification card was important for only 18.5% of children, carrying sweets were important for 55.5% of them, eating snacks before exercising by 61% of children and glucogen injection for 43%. 135 • Diabetic children reported the importance of regular check-up for diabetologist (89%), ophthalmologist (61%), dentist (33%), diabetic nurse educators (75%) and dietitian (65.5%). • Personal hygiene was important for 95% the children and foot care for 96.5%, wearing proper shoes for 51.5% and straight nail cut for 34.5%. • Two third of the diabetic children (64%) adhered to diabetic diet regimen. • Only 10% of children always restrict taking carbohydrates. • More than half (56.5%) of the children were taking carbohydrates and 50.5% calories more than their daily requirements. • Less than half of the children and their advocates washed their hand at the beginning of each procedure. While almost all children and advocates washed their hands after urine test. • Half of the children carried out the steps of insulin injection independently. • All the steps of blood glucose test were done by children independently, however 17% of advocates punctured their children fingers and 23.2% recorded the results (wholly compensatory). • All the steps of the urine test were carried by almost two third of the children, i.e., educative and development. 136 • Walking was the major type of exercise practiced by female children than males. While, football was practiced by male children more than females. • Almost all the children’s skin, eye and mouth were clean (96%, 98% and 98.5% respectively), while only 53.5% had clean teeth. • Ninety percent of children had short nails, 61.5% cut their nails straight. • Less than half (46%) of the children were wearing proper and comfortable shoes with clean, proper size socks. • More than half (55%) of children practiced insulin injection independently (educative and development). • Seventy nine point five percent (79.5%) of children practiced blood glucose test independently. • Two third of children practiced urine test by educative and development. • All children carried out their dental care (100%), 95% carried foot care and personal hygiene independently, i.e., educative and development. • Two third of children selected their shoes and socks independently. • Female children were more independent than males in insulin injection and glucose tests. • More than half of the children of both genders shared with their advocates the food selection and estimation. 137 • Almost all children of both genders were responsible for their hygiene i.e., educative and development. • The older age group of children was more self-care dependent than younger ones. Chapter VII CONCLUSION AND RECOMMENDATIONS 138 CONCLUSION AND RECOMMENDATIONS From the previous results, it can be concluded that majority of diabetic children were knowledgeable about some aspects of diabetes mellitus, its treatment and complications and self-care management. But they lack knowledge about snacks, meal estimation, calculation of calories and carrying identification card. Diabetic children did not adhere properly to diabetic diet and dental care but they exercise, have good hygienic practices. Most of the children were independent in their glucose tests and hygienic care. But they are either wholly or partially compensatory with for insulin injection, food selection and estimation. No gender differences in children’s knowledge and self-care practices. But, the younger the children the more they are dependent on their advocates for their care. Based on the previous findings and conclusion the following are recommended: 1. Nurse educators should have more active role in educating children and their families to empower their knowledge and self-management. 2. Active participating of diabetic children in self-care practices should be motivated. 3. Diabetic care self-learning package should be available for diabetic children. 139 4. Carrying identification card should be mandatory by hospitals policies. 5. Ongoing assessment for children and their parent’s knowledge and practices should be carried periodically. 6. Encourage campaign for diabetic children to improve their independently and self-care practices. 7. Mass media should have an increasing role in diabetic education. For Further Study 1- A study must be conducted to investigate the barriers for self-care practices. 2- A study need to be conducted for further investigation of children’s knowledge and practice in each aspect of the self-care practices. 3- Assess role of the diabetic nurse educator in teaching children selfcare practices. 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APPENDIXES APPENDIX "A" اﺳﺘﻤﺎرة اﺳﺘﺒﻴﺎن ﻟﻘﻴﺎس اﻟﻤﻤﺎرﺳﺎت اﻟﺬاﺗﻴﺔ اﻷﻃﻔﺎل اﻟﻤﺼﺎﺑﻴﻦ ﺑﺪاء اﻟﺴﻜﺮي )اﻟﺘﻐﺬﻳﺔ ـ اﻷﻧﺸﻄﺔ ـ اﻹﺟﺮاءات اﻟﻮﻗﺎﺋﻴﺔ (. اﻟﺘﺎرﻳﺦ: رﻗﻢ اﻟﻤﻘﺎﺑﻠﺔ اﻟﺸﺨﺼﻴﺔ : اﻟﻤﻜﺎن: اﻟﺠﺰء اﻷول : ﻣﻌﻠﻮﻣﺎت دﻳﻤﻮﻏﺮاﻓﻴﺔ ﻋﻦ ﻣﺮﺿﻲ اﻟﺴﻜﺮ. *أ -ﺑﻴﺎﻧﺎت ﻋﻦ اﻟﻄﻔﻞ ) ( Child اﺳﻢ اﻟﻄﻔﻞ....................................................................: .١اﻟﻌﻤﺮ: ﺏ ١١ -ﺴﻨﺔ ) ( ﺍ١٠ -ﺳﻨﻮات ) ( د ١٣ -ﺳﻨﺔ ) ( ﺠ ١٢ -ﺳﻨﺔ ) ( ه ١٥ -١٤ّ -ﺳﻨﺔ ) ( .٢اﻟﺠﻨﺲ: ب -أﻧﺜﻰ ) ( أ -ذآﺮ ) ( _٣ﺗﺮﺗﻴﺒﻪ ﺑﻴﻦ اﻷﺧﻮة: أ -اﻷول ) ( ب – اﻟﺜﺎﻧﻲ ) ( ﺠ –اﻟﺜﺎﻟﺚ ) ( د – اﻟﺮاﺑﻊ ) ( هـ ﺁﺧﺮ ) ( ﻳﺬآﺮ.................... -٤ﻣﺴﺘﻮى اﻟﺘﻌﻠﻴﻢ : أ -ﻻ ﻳﻘ ﺮأ وﻻ ﻳﻜﺘ ﺐ ) ( ﺠ-اﺑﺘﺪاﺋﻲ هـ ﺛﺎﻧﻮي *ب -ﺑﻴﺎﻧﺎت ﻋﻦ ﺗﻌﻠﻴﻢ اﻟﻮاﻟﺪﻳﻦ -٥ﻣﺴﺘﻮى ﺗﻌﻠﻴﻢ اﻷم: أ -ﻻ ﺗﻘﺮأ وﻻ ﺗﻜﺘﺐ ﺠ -اﺑﺘﺪاﺋﻲ ه -ﺛﺎﻧﻮي ) ( ز-دراﺳﺎت ﻋﻠﻴﺎ ) -٦ﻣﺴﺘﻮى ﺗﻌﻠﻴﻢ اﻷب: أ-ﻻ ﻳﻘﺮأ وﻻ ﻳﻜﺘﺐ ) ﺠ-اﺑﺘﺪاﺋﻲ ) ( ه -ﺛﺎﻧﻮي ) ( ز -دراﺳﺎت ﻋﻠﻴﺎ ) ) ( ) ( ب – ﻳﻘ ﺮأ و ﻳﻜﺘ ﺐ ﻓﻘ ﻂ ) ( د – ﻣﺘﻮﺳﻂ ) ( ) ( ب -ﺗﻜﺘﺐ و ﺗﻘﺮأ ) ( ) ( ) ( د -ﻣﺘﻮﺳﻂ ) ( و -ﺟﺎﻣﻌﻲ ( ( ( ب -ﻳﻜﺘﺐ وﻳﻘﺮأ ) ( ) ( د-ﻣﺘﻮﺳﻂ ) ( و -ﺟﺎﻣﻌﻲ -٧وﻇﻴﻔﺔ اﻷم: ) ( ب -ﺗﻌﻤ ا -ﺭﺒــــــــــﺔ ﻣ ﻨﺰل ﺗﺬآﺮ................................................. -٨وﻇﻴﻔﺔ اﻷب: ب -ﻳﻌﻤ أ -ﻻ ﻳﻌﻤﻞ ) ( ﻳﺬآﺮ....................................................... *ج -ﺑﻴﺎﻧﺎت ﻋﻦ اﻟﻌﺎﺋﻠﺔ : -٩ﻋﺪد أﻓﺮاد اﻟﻌﺎﺋﻠﺔ: أ( ) ٣ – ١ - ج) ١٠ – ٧ - -١٠هﻞ دﺧﻞ اﻷﺳﺮة: أ -ﻳﻜﻔﻲ ) ( ﻞ ) ﻞ ) ( ( ب( ) ٦ – ٤- ( د ١٠ -ﻓﺄآﺜﺮ) ( ب -ﻻ ﻳﻜﻔﻲ ) ( -١١هﻞ هﻨﺎك أﺣﺪ ﻓﻲ اﻟﻌﺎﺋﻠﺔ ﻣﺼﺎب ﺑﺎﻟﺴﻜﺮ؟ ب-ﻻ ) ( أ -ﻧﻌﻢ ) ( -١٢ﻓﻲ ﺣﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ :ﻣﻦ هﻮ: أ -اﻷب ) ( ب -اﻷم ) ( ﺠ -اﻷخ ) ( د -اﻷﺧﺖ ) ( ه -ﺷﺨﺺ ﺁﺧﺮ ﻣﻦ أﻓﺮاد اﻟﻌﺎﺋﻠﺔ ) اذآﺮﻩ().............................. *د -اﻟﺘﺎرﻳﺦ اﻟﻄﺒﻲ ( Medical History ) : ٣ﻧﺎﺗﺞ ﺗﺤﻠﻴﻞ ﺳﻜﺮ اﻟﺘﺮاآﻤﻲ ﻓﻲ اﻟﺪم-------------------(HbA1c.) . -١٤ﻧﻮع داء اﻟﺴﻜﺮي: ( ) ب -اﻟﻨﻮع اﻟﺜﺎﻧﻲ ( أ -اﻟﻨﻮع اﻷول ) -١٥ﻣﻨﺬ ﻣﺘﻰ اﻹﺻﺎﺑﺔ ﺑﺪاء اﻟﺴﻜﺮي ؟ ( ب-ﺳﻨﺔ ) أ -أﻗﻞ ﻣﻦ ﺳﻨﺔ ) ( د١٠ -ﺳﻨﻮات او أآﺜﺮ ) ( ) ﺠ٥ -ﺳﻨﻮات - ١٦ﻣﺎ هﻮ ﻧﻮع اﻟﻌﻼج. ) ب -ﺣﺒﻮب ﻋﻦ ﻃﺮﻳﻖ اﻟﻔﻢ ( أ -اﻷﻧﺴﻮﻟﻴﻦ ) د -ﺣﻤﻴﺔ ﻏﺬاﺋﻴﺔ ﻓﻘﻂ ﺠ -أﻧﺴﻮﻟﻴﻦ +ﺣﺒﻮب ﻋﻦ ﻃﺮﻳﻖ اﻟﻔﻢ ) ( ................................... ه -ﻃﺮق أﺧﺮى ) ( ﺗﺬآﺮ. ( ( ( ) ( -١٧إذا آﺎن اﻷﻧﺴﻮﻟﻴﻦ هﻮ اﻟﻌﻼج ،ﻣﺎ ﻧﻮع اﻻﻧﺴﻮﻟﻴﻦ؟ ب -أﻧﺴﻮﻟﻴﻦ ﻣﺘﻮﺳﻂ اﻟﻤﻔﻌﻮل) ( ( أ-اﻧﺴﻮﻟﻴﻦ ﻗﺼﻴﺮ اﻟﻤﻔﻌﻮل ) د-ﺟﺮﻋﺔ ﻣﺰدوﺟﺔ ﻣﻦ ﻧﻮﻋﻴﻦ ﻣﻦ اﻷﻧﺴﻮﻟﻴﻦ) ﺠ-أﻧﺴﻮﻟﻴﻦ ﻃﻮﻳﻞ اﻟﻤﻔﻌﻮل) ( ه -أﻧﺴﻮﻟﻴﻦ ﺟﻼرﺣﻴﻦ )( ) (Lantus ( -١٨آﻢ ﻣﺮة ﺗﺄﺧﺬ إﺑﺮة اﻷﻧﺴﻮﻟﻴﻦ ﻓﻲ اﻟﻴﻮم؟ ب -ﻣﺮﺗﻴﻦ ) ( أ-ﻣﺮة واﺣﺪة ) ( د-اﺧﺮ ) ( ﺗﺬآﺮ................ ﺠ ٣ -ﻣﺮات ) ( -١٩إذا آﺎن ﻋﻦ ﻃﺮﻳﻖ اﻟﻔﻢ )ﺣﺒﻮب (آﻢ ﺣﺒﻪ ﻓﻲ اﻟﻴﻮم؟: ( ب-ﺣﺒﺘﻴﻦ ﻓﻲ اﻟﻴﻮم ) ( ) أ -ﺣﺒﺔ ﻓﻲ اﻟﻴﻮم د -أآﺜﺮ ) ( ﻳﺬآﺮ.................. ﺠ ٣-ﺣﺒﺎت ﻓﻲ اﻟﻴﻮم ) ( -٢٠هﻞ ﺗﻘﻮم ﺑﺘﺤﺎﻟﻴﻞ ﻟﻤﻌﺮﻓﺔ ﻧﺴﺒﺔ اﻟﺴﻜﺮ ﻟﺪﻳﻚ؟ ب -ﻻ ) ( أ -ﻧﻌﻢ ) ( -٢١ﻓﻲ ﺣﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎ هﻲ اﻟﺘﺤﺎﻟﻴﻞ اﻟﻤﺴﺘﺨﺪﻣﺔ ﻟﻤﻌﺮﻓﺔ ﻧﺴﺒﺔ اﻟﺴﻜﺮ ﻟﺪﻳﻚ؟ أ -ﺗﺤﻠﻴﻞ اﻟﺪم ﺑﺎﺳﺘﺨﺪام ﺷﺮاﺋﻂ ﻣﻘﺎرﻧﺔ ﺑﺎﻟﻨﻈﺮ ﻓﻘﻂ ) ( ب-ﺗﺤﻠﻴﻞ اﻟﺪم ﺑﺎﺳﺘﺨﺪام اﻟﺠﻬﺎز) ( ( ﺠ -ﺗﺤﻠﻴﻞ اﻟﺒﻮل ﺑﺎﺳﺘﺨﺪام اﻷﺷﺮﻃﺔ ) اﻟﺠﺰء اﻟﺜﺎﻧﻲ . ﺗﻘﻴﻴﻢ ﻣﻤﺎرﺳﺎت اﻟﻌﻨﺎﻳﺔ اﻟﺬاﺗﻴﺔ ﻓﻲ ﺧﻄﺔ اﻟﻨﻈﺎم اﻟﻐﺬاﺋﻲ .١هﻞ ﺗﺘﺒﻊ ﻧﻈﺎم ﻏﺬاﺋﻲ اﻟﺴﻜﺮ )ﺣﻤﻴﺔ (: ب -ﻻ ) ( أ -ﻧﻌﻢ ) ( ﻓﻲ ﺣﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ: -٢ﻣﺎ هﻲ اﻹرﺷﺎدات اﻟﺘﻲ اﺳﺘﻌﻤﺎﻟﻬﺎ ﻓﻲ اﺧﺘﻴﺎر اﻟﺤﻤﻴﺔ ؟ ب -ﻧﻤﻮذج ﺗﺴﺠﻴﻞ اﻟﺤﻤﻴﺔ ) ( أ-ﻗﺎﺋﻤﺔ اﺳﺘﺒﺪال ) ( د-ﻧﺸﺮة ﻟﻤﺠﻤﻮﻋﺔ ﺧﻴﺎرات ﻣﻦ اﻟﺤﻤﻴﺔ ) ( ﺠ-ﻣﻨﺎﻗﺸﺎت ﻋﺎﻣﺔ ﻋﻦ اﻷآﻞ ) ( أﺷﻴﺎء أﺧﺮى ) ( ﻳﺬآﺮ................... اﻟﺠﺰء اﻟﺜﺎﻟﺚ. ﺗﻘﻴﻴﻢ ﻣﻤﺎرﺳﺎت اﻟﻌﻨﺎﻳﺔ اﻟﺬاﺗﻴﺔ ﻓﻲ ﺗﻄﺒﻴﻖ اﻟﻨﺸﺎﻃﺎت اﻟﺮﻳﺎﺿﻴﺔ . ب -ﻻ ) ( -١هﻞ ﺗﻘﻮم ﺑﻨﺸﺎﻃﺎت رﻳﺎﺿﻴﺔ؟ أ -ﻧﻌﻢ ) ( -٢ﻓﻲ ﺣﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ -:ﻣﺎ هﻲ ﻧﻮع اﻷﻧﺸﻄﺔ وﻋﺪد اﻟﻤﺮات ﻓﻲ ﻷﺳﺒﻮع؟ ﻧﻮع اﻷﻧﺸﻄﺔ -١اﻟﻤﺸﻲ -٢رآﻮب اﻟﺪراﺟﺔ /اﻟﻌﺠﻞ -٣اﻟﺴﺒﺎﺣﺔ -٤اﻟﺮﻳﺎﺿﺔ اﻟﺒﺪﻧﻴﺔ ﺑﺎﻟﻤﺪرﺳﺔ -٥اﻟﺮآﺾ -٦آﺮة ﻗﺪم -٧ﺁﺧﺮ ﻳﺬآﺮ ................................ اﻟﻤﺪة ﻋﺪد اﻟﻤﺮات ﻓﻰ اﻷﺳﺒﻮع ه- اﻟﺠﺰء اﻟﺮاﺑﻊ. أ -ﺗﻘﻴﻴﻢ ﻣﻌﻠﻮﻣﺎت اﻟﻌﻨﺎﻳﺔ اﻟﺬاﺗﻴﺔ ﻟﻼﺣﺘﻴﺎﻃﺎت اﻵﻣﻨﺔ ﻟﻤﻨﻊ ﺣﺪوث اﻟﻤﻀﺎﻋﻔﺎت .١ﺗﻘﻴﻴﻢ ﻣﻌﻠﻮﻣﺎت اﻟﻄﻔﻞ ﻋﻦ ﻣﺮض اﻟﺴﻜﺮ ﻟﻤﻨﻊ ﺣﺪث اﻟﻤﻀﺎﻋﻔﺎت: -١ﻣﺎ هﻮ اﻟﻤﻌﺪل اﻟﻄﺒﻴﻌﻲ ﻟﻤﺴﺘﻮى ﺳﻜﺮ اﻟﺪم؟ ....................................... -٢هﻞ ﺗﻌﺮف ﻣﺎ هﻮ ﻣﺮض اﻟﺴﻜﺮي ؟ أ -ﻧﻌﻢ ) ( ب -ﻻ ) ( - ٣ﻓﻲ ﺣﺎﻟﺔ اﻻﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎهﻮ؟ ............................................................................................................. ............................................................................................................. ............................................................................................................. - ٤هﻞ ﺗﻌﺮف أﺳﺒﺎب ﻣﺮض اﻟﺴﻜﺮي؟ أ -ﻧﻌﻢ ) ( ب -ﻻ ) ( -٥ﻓﻲ ﺣﺎﻟﺔ اﻻﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎ هﻲ؟ ............................................................................................................. ............................................................................................................. -٦هﻞ ﺗﻌﺮف اﻋﺮض و ﻋﻼﻣﺎت ﻣﺮض اﻟﺴﻜﺮي؟ أ -ﻧﻌﻢ ) ( ب -ﻻ ) ( -٧ﻓﻰ ﺤﺎﻟﺔ ﺍﻹﺠﺎﺒﺔ ﺒﻨﻌﻡ ،ﻤﺎ ﻫﻭ؟ ........................................................................................................ ............................................................................................................. ( -٨هﻞ ﺗﻌﺮف أﻋﺮض و ﻋﻼﻣﺎت ﻣﺮض اﻟﺴﻜﺮي؟ أ، -ﻋﻢ ) ( ب) - -٩ﻓﻲ ﺣﺎﻟﺔ اﻻﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎ هﻲ ؟ ............................................................................................................. ............................................................................................................. ............................................................................................................ -١٠ﻣﺎ هﻮﻣﻌﺪل اﻧﺨﻔﺎض ﻣﺴﺘﻮى ﺳﻜﺮ اﻟﺪم؟ ............................................................................................................ - ١١هﻞ ﺗﻌﺮف أﺳﺒﺎب اﻧﺨﻔﺎض ﻧﺴﺒﺔ اﻟﺴﻜﺮﻓﻲ اﻟﺪم؟ أ -ﻧﻌﻢ ) ( ب -ﻻ ) ( - ١٢ﻓﻲ ﺣﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎ هﻰ؟ ........................................................................................................ ............................................................................................................. -١٣هﻞ ﺗﻌﺮف أﻋﺮاض اﻧﺨﻔﺎض ﻧﺴﺒﺔ اﻟﺴﻜﺮ ﻓﻲ اﻟﺪم؟ أ -ﻧﻌﻢ ) ( ب -ﻻ ) ( -١٤ﻓﻲ ﺤﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎ هﻲ؟ ............................................................................................................. ............................................................................................................. -١٥هﻞ ﺗﻌﺮف ﻋﻼج اﻧﺨﻔﺎض ﺳﻜﺮاﻟﺪم ؟ أ -ﻧﻌﻢ ) ب -ﻻ ) ( ( ١٦ﻓﻲ ﺣﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎ هﻲ؟ ............................................................................................................. ............................................................................................................. -١٧ﻣﺎ هﻮ ﻣﻌﺪل ارﺗﻔﺎع ﻣﺴﺘﻮى ﺳﻜﺮ اﻟﺪم؟ .............................. -١٨هﻞ ﺗﻌﺮف أ ﺳﺒﺎب ارﺗﻔﺎع ﻧﺴﺒﺔ اﻟﺴﻜﺮﻓﻲ اﻟﺪم؟ أ -ﻧﻌﻢ ) ( ( ب -ﻻ ) -١٩ﻓﻲ ﺣﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎ هﻲ؟ ............................................................................................................. ............................................................................................................. ( -٢٠هﻞ ﺗﻌﺮف اﻋﺮاض ارﺗﻔﺎع ﻧﺴﺒﺔ اﻟﺴﻜﺮﻓﻲ اﻟﺪم؟ أ -ﻧﻌﻢ ) ( ب -ﻻ ) -٢١ﻓﻲ ﺣﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎ هﻲ؟ ............................................................................................................. ............................................................................................................. -٢٢هﻞ ﺗﻌﺮف ﻋﻼج ارﺗﻔﺎع ﻧﺴﺒﺔ اﻟﺴﻜﺮﻓﻲ اﻟﺪم؟ أ -ﻧﻌﻢ ) ( ب -ﻻ ) ( -٢٣ﻓﻲ ﺣﺎﻟﺔ اﻹﺟﺎﺑﺔ ﺑﻨﻌﻢ ،ﻣﺎ هﻲ ؟ ............................................................................................................. ............................................................................................................. ب -ﺗﻘﻴﻴﻢ أهﻤﻴﺔ اﻹﺣﺘﻴﺎﻃﺎت اﻵﻣﻨﻪ ﻟﻠﻌﻨﺎﻳﻪ اﻟﺬاﺗﻴﻪ-: ﺍﻟﺭﻗﻡ ﻟﻤﻨﻊ ﺤﺩﻭﺙ ﺍﻟﻤﻀﺎﻋﻔﺎﺕ ١ -ﺤﻤل ﺒﻁﺎﻗﺔ ﺍﻟﺘﻌﺭﻴﻑ ﺒﺄﻨﻲ ﻤﺭﻴﺽ ﺒﺎﻟﺴﻜﺭ ٢ -ﺯﻴﺎﺭﺓ ﻁﺒﻴﺏ ﺍﻟﻤﺭﺽ ﺍﻟﺴﻜﺭﻱ ﺒﺎﻨﺘﻅﺎﻡ ٣ -ﺯﻴﺎﺭﺓ ﺃﺨﺼﺎﺌﻴﺔ ﻤﺜﻘﻔﺔ ﺍﻟﺴﻜﺭﻱ ﺒﺎﻨﺘﻅﺎﻡ ٣ -ﺯﻴﺎﺭﺓ ﺍﺨﺼﺎﺌﻲ ﺍﻟﺘﻐﺫﻴﻪ ﺒﺎﻨﺘﻅﺎﻡ ٤ -ﺯﻴﺎﺭﺓ ﻁﺒﻴﺏ ﺍﻟﻌﻴﻭﻥ ٥ -ﺯﻴﺎﺭﺓ ﻁﺒﻴﺏ ﺍﻷﺴﻨﺎﻥ ٦ -ﺃﺨﺫ ﺍﻟﻌﻼﺝ ﺒﺎﻨﺘﻅﺎﻡ ٧ -ﺤﻤل ﻗﻁﻌﺔ ﺴﻜﺭ ﺃﻭ ﺤﻠﻭﻯ ٨ - -ﺍﺴﺘﺨﺩﺍﻡ ﺤﻘﻨﺔ ﺍﻟﺠﻠﻭﻜﺎﺠﻭﻥ ٩ -ﺃﻜل ﻭﺠﺒﺎﺕ ﺤﻔﻴﻔﺔ ﻗﺒل ﺍﻟﻨﺸﺎﻁﺎﺕ ﺍﻟﺭﻴﺎﻀﻲ - ١٠ﺃﻟﺒﺱ ﺍﻟﺤﺫﺍﺀ ﺍﻟﻤﻨﺎﺴﺏ ﻤﻊ ﺸﺭﺏ ﻤﻥ ﺍﻟﻘﻁﻥ ١١ﺃﻗﺹ ﺃﻅﺎﻓﺭ ﺒﺨﻁ ﻤﺴﺘﻘﻴﻡ - ١٢ﺘﺤﻠﻴل ﻨﺴﺒﺔ ﺍﻟﺴﻜﺭ ﻓﻲ ﺍﻟﺩﻡ - ١٣ﻤﺎ ﻫﻲ ﺃﻫﻤﻴﺔ ﺍﻷﻨﺴﻭﻟﻴﻥ ﻓﻲ ﻋﻼﺝ ﻤﺭﺽ ﺍﻟﺴﻜﺭ - ١٤ﻤﺎ ﻫﻲ ﺃﻫﻤﻴﺔ ﺃﺨﺫ ﺍﺒﺭﺓ ﺍﻻﻨﺴﻭﻟﻴﻥ ١٥ﺃﻭ ٣٠ﺩﻗﻴﻘﺔ ﻗﺒل ﺍﻷﻜل - ١٥ﻤﺎ ﻫﻲ ﺍﻫﻤﻴﺔ ﺘﻐﻴﺭ ﺃﻤﺎﻜﻥ ﺍﻋﻁﺎ ﺤﻘﻨﺔ ﺍﻻﻨﺴﻭﻟﻴﻥ ١٦ﻤﺎ ﻫﻲ ﺃﻫﻤﻴﺔ ﺘﻨﻅﻴﻡ ﺠﺭﻋﺔ ﺍﻻﻨﺴﻭﻟﻴﻥ - ١٧ﺘﺤﻠﻴل ﻨﺴﺒﺔ ﺍﻟﺴﻜﺭ /ﻜﻴﺘﻭﻥ ١٨ﺃﻫﻤﻴﺔ ﺤﻔﻅ ﻋﻠﻰ ﻨﻅﺎﻓﺔ ﺠﺴﻤﻙ ١٩ﺃﻫﻤﻴﺔ ﺤﻔﻅ ﻋﻠﻰ ﻨﻅﺎﻓﺔ ﻓﻤﻙ ٢٠ﺃﻫﻤﻴﺔ ﻨﻅﺎﻓﺔ ﺍﻟﻘﺩﻤﻴﻥ ﻨﻌﻡ ﻻ ﻓﻲ ﻋﻠﻠﻲ ﻟﻤﺎﺫﺍ؟ ﺠ -ﻤﺼﺎﺩﺭ ﻤﻌﻠﻭﻤﺎﺕ ﺍﻷﻁﻔﺎل ﻋﻥ ﺍﻹﺤﺘﻴﺎﻁﺎﺕ ﺍﻵﻤﻨﺔ: .٢أﺧﺼﺎﺋﻰ اﻟﺘﻐﺬﻳﺔ ) ( .١إﺳﺘﺸﺎرى داء اﻟﺴﻜﺮى ) ( .٤اﻟﻮاﻟﺪﻳﻦ /اﻗﺎرب ) ( .٣ﻣﻤﺮﺿﺔ اﻟﺘﺜﻘﻴﻒ اﻟﺼﺤﻰ ) ( ﻳﺬآﺮ ................................ ) ( .٤ﺁﺧﺮ د .ﺗﻘﻴﻴﻢ ﻣﻦ اﻟﺬي ﻳﻘﻮم ﺑﺎﻟﻤﻤﺎرﺳﺎت اﻟﺬاﺗﻴﺔ: اﻟﺮﻗﻢ اﻟﻤﻤﺎرﺳﺎت اﻟﺬاﺗﻴﻪ ١ إﻋﻄ اﻟﻌﻼج)اﻹﻧﺴﻮﻟﻴﻦ\اﻟﺤﺒﻮب( ﺗﺤﻠﻴﻞ اﻟﺴﻜﺮ ﻓﻲ اﻟﺪم ﺗﺤﻠﻴﻞ اﻟﺴﻜﺮ ﻓﻲ ااﻟﺒﻮل ﻓﻲ إﺧﺘﻴﺎر اﻟﻄﻌﺎم ﻓﻲ ﺗﺤﺪﻳﺪ آﻤﻴﺔ اﻟﻄﻌﺎم ﻧﻈﺎﻓﺔ اﻟﺠﺴﻢ ﻧﻈﺎﻓﺔ اﻷﺳﻨﺎن اﻟﻌﻨﺎﻳﻪ ﺑﺎﻟﻘﺪﻣﻴﻦ اﺧﺘﻴﺎر اﻟﺤﺬاء واﻟﺠﻮارب اﻟﻄﻔﻞ ٢ ٣ ٤ ٥ ٦ ٧ ٨ ٩ ﺎء اﻟﺬي ﻳﻘﻮم ﺑﺎﻟﻤﻤﺎرﺳﺎت اﻟﺬاﺗﻴﻪ اﻟﻄﻔﻞ ﺑﻤﺴﺎﻋﺪة اﻟﺸﺨﺺ اﻟﺬي ﻣﺴﺎﻋﺪة اﻵﺧﺮﻳﻦ ﻳﻌﺘﻨﻲ ﺑﻪ APPENDIX "B" INSTRUMENT-II Part One Check List for Insulin Injection Technique Name of child:………………………………. Date:…............ Setting:……………………………………………………………………. No PERFORMANCE D 1 Wash hands. 2 Prepare equipments. 3 4 Invert or roll of the vial of insulin in the hands to mix well. Wipe top of the vial 5 Prepare dose of insulin 6 7 Prepare site of insulin injection Inject insulin 8 Record in diary notebook 9 Discard used equipments D = Done ND =Not Done C = Child A = Advocate ND C A B = Both (child & advocate) B Remarks INSTRUMENT –II Part Two Check List for Blood Glucose Test Name of Child:……………………………………Date:…………………… Setting: ………………………………………………………………………. D No PERFORMANCE 1 2 3 4 5 6 7 8 9 10 ND C A B Remarks Wash hands. Prepare equipments. Set on glycometer Prepare lancet and site Puncture finger Apply drop of blood on strip Obtain reading Discard needle Record result Interpret result D = Done C = Child ND = Not Done A = Advocate B = Both (child & advocate) ﻋﻠﻠﻲ ﻟﻤﻠﺫﺍ ﺘﻐﺴل ﻴﺩﻴﻙ؟.١ ............................................................................................. ﻟﻤﺎﺫﺍ ﺘﻀﻊ ﺍﻹﺒﺭ ﻓﻰ ﻤﻜﺎﻨﻬﺎ ﺍﻟﻤﻨﺎﺴﺏ ﺒﻌﺩ ﺍﺴﺘﺨﺩﺍﻤﻬﺎ؟.٢ ......................................................................................................................... ﻟﻤﺎذا ﺗﺴﺠﻴﻞ ﻧﺘﺎﻳﺞ اﻟﺘﺤﻠﻴﻞ ﻓﻲ ﻣﺬآﺮة اﻟﺴﻜﺮي؟- .٣ ......................................................................................................................... INSTRUMENT-II Part Three Check list of Urine test for Glucose and/or Ketones. Name of Child:………………………………… Date : …………. Setting :…………………………………………………….………………… No PERFORMANCE 1 Wash hands. 2 Prepare equipments. 3 Prepare sample of urine. 4 Remove strip from bottle 5 Immerse strip into urine 6 Remove strip from urine 7 Hold strip horizontal 8 Interpret result 9 Discard equipments 10 Wash hands 11 Record result. D = Done D ND ND = Not Done A = Done by Advocate C = Done by Child B = Both (done by child and advocate) C A B Remark INSTRUMENT–II Part Four Check list for Observation of Hygienic Care Name of the child/Advocate: ……………………… Date:……………… Setting:……………………………………………………………………… No HYGIENIC CARE Skin Care:I 1.Clean II Face 1. Clean eyes 1. Clean mouth 2. 3. Clean teeth III Foot 1.Clean foot 2. Clean toes , nails 3. Cut nails properly (straight) IV Socks 1. Wear cotton socks 2. Wear clean socks 3. Wear well fitting socks/ proper size V Shoes 1. Wear proper and comfortable shoes 2. Wear sandals or slippers 3. Wear low heeled shoes Yes No APPENDIX “C” ﺗﺴﺠﻴﻞ اﻟﻮﺟﺒﺎت اﻟﻐﺬاﺋﻴﺔ ﻟﻤﺪة ٢٤ﺳﺎﻋﺔ أذآﺮ ﻣﺎذا أآﻠﺖ أﻣﺲ ﻣﻦ أ ﻃﻌﻤﻪ ﻣﻊ ذآﺮاﻟﻨﻮﻋﻴﺔ و اﻟﻜﻤﻴﺔ: اﻟﻮﺟﺒﺎت، اﻟﻨﻮﻋﻴﻪ اﻓﻄﺎر : ............................................................. ............................................................. ............................................................. وﺟﺒﺔ ﺧﻔﻴﻔﺔ: .............................................................. .............................................................. ﻏﺬاء: .............................................................. .............................................................. .............................................................. وﺟﺒﺔ ﺧﻔﻴﻔﺔ: ................................................................ ................................................................ ﻋﺸﺎء: ................................................................. ................................................................. وﺟﺒﺔ ﻗﺒﻞ اﻟﻨﻮم: ................................................................ ................................................................ اﻟﻜﻤﻴﺔ ARABIC SUMMARY ١ ﻤﻠﺨﺹ ﺍﻟﺭﺴﺎﻟﺔ ﻲ .وذﻟﻚ ﻷﻧﻪ داء اﻟﺴﻜّﺮي أﺣﺪ اﻷﻣﺮاض اﻟﻤﺰﻣﻨﺔ اﻟﺘﻲ ﺗﺼﻴﺐ اﻷﻃﻔﺎل واﻷآﺜﺮ ﺷﻴﻮﻋ ًﺎ ﺑﻌﺪ اﻟﺮﺑﻮ واﻟﺘﺄﺧ ِﺮ اﻟﻌﻘﻠ ِ ﻲ ﻣﺴﺘﻤﺮ ﻟ َﻤﻨْﻊ ﺣﺪوث ﻣﻀﺎﻋﻔﺎت ﺣﺎ ّدةِ ،وﻟﺘَﺨﻔﻴﺾ ﺧﻄ ِﺮ اﻟﻤﻀﺎﻋﻔﺎت ﻃﻮﻳﻠﺔ ﺐ ﻋﻨﺎﻳ َﺔ وﺗﻌﻠﻴ َﻢ ﻃﺒ َ ﻣﺮض ﻣُﺰﻣﻦ ﻳَﺘﻄﻠّ ُ ى إﻟﻰ ﺗﻌﻠﻴ َﻢ ﺷﺎﻣ َﻞ ﻓﻲ ﻣﻤﺎرﺳﺎت اﻟﻌﻨﺎﻳﺔ اﻟﺬاﺗﻴﺔ. اﻟﻤﺪى .وﻳﺤﺘﺎج أﻃﻔﺎ َل ﻣﺮﺿﻰ اﻟﺪاء اﻟﺴﻜﺮ َ ي ﻋﻦ اﻟﻌﻨﺎﻳ ِﺔ اﻟﺬاﺗﻴ ِﺔ وﺗُﺤﺪﻳ ُﺪ ﻣﺴﺘﻮﻳﺎت ﺴﻜّﺮ ِ ﺗﻬﺪّف هﺬﻩ اﻟﺪراﺳ ِﺔ اﻟﻰ ﻣﻌﺮﻓ ِﺔ ﻣﻌﻠﻮﻣﺎت اﻷﻃﻔﺎ ِل اﻟﻤﺮﺿﻰ ﺑﺎﻟﺪاء اﻟ ُ ﻣﻤﺎرﺳﺎﺗِﻬﻢ ﻟﻬﺬﻩ اﻟﺮﻋﺎﻳﺔ وذﻟﻚ ﻃﺒﻘ ًﺎ ﻟﻨﻈﺮﻳﺔ أورم ﻟﻠﻌﻨﺎﻳ ِﺔ اﻟﺬاﺗﻴﺔ. ﻚ ﻓﻬﺪ ﻟﻘﻮى اﻷﻣﻦ وﻣﺴﺘﺸﻔﻰ ت ﺧﺎرﺟﻴﺔ ﻻﻃﻔﺎل اﻟﺪاء اﻟﺴﻜﺮى ﺑﻤﺴﺘﺸﻔﻰ اﻟﻤﻠ َ وﻗﺪ اﺟﺮﻳﺖ اﻟﺪراﺳﺔ ﻓﻲ أرﺑﻌﺔ ﻋﻴﺎدا ِ ﻚ ﻋﺒﺪ اﻟﻌﺰﻳﺰاﻟﺠﺎﻣﻌﻰ وﻣﺴﺘﺸﻔﻰ اﻟﻤﻠﻚ ﺧﺎﻟﺪ ﺑﻤﺪﻳﻨﺔ ﺟﺪة .وإﺷﺘﻤﻠﺖ اﻟﻌﻴﻨﺔ ﻋﻠﻰ اﻷﻣﻮﻣﺔ واﻷﻃﻔﺎ ِل وﻣﺴﺘﺸﻔﻰ اﻟﻤﻠ ِ ٢٠٠ﻃﻔﻞ ﺳﻌﻮدى ﻣﺮﻳﺾ ﺑﺎﻟﺪاء اﻟﺴﻜﺮى ﻣﻦ آﻼ اﻟﺠﻨﺴﻴﻦ ﻣﻤﻦ ﺗﺘﺮاوح أﻋﻤﺎرهﻢ ﻣﺎ ﺑﻴﻦ ١٠إﻟﻰ ١٥ﺳﻨﺔ و ﺗﻢ ﻲ. ض اﻟﻤُﺰﻣﻨ ِﺔ اﻷﺧﺮى واﻟﺘﺄﺧﺮ اﻟﻌﻘﻠ ِ ﺗﺸﺨّﻴﺼﻬﻢ ﻋﻠﻰ اﻷﻗﻞ ﻣﻦ ٦ﺷﻬﻮ ِر ﻣﻀﺖ ،و ﺧﺎﻟﻴﻮن ﻣﻦ اﻷﻣﺮا ِ ت ﺠﻤْﻊ اﻟﺒﻴﺎﻧﺎ ِ ت ﻫﻤﺎ :اﻷداة اﻷوﻟﻰ اﺳﺘﻤﺎرة ﻣﻘﺎﺑﻠﺔ ﺷﺨﺼﻴﺔ اﻋﻌﺖ ﺧﺼﻴﺼ ًﺎ ﻟ َ وﻗﺪ اﺳﺘﺨﺪﻣﺖ أداﺗﻴﻦ ﻟﺠﻤﻊ اﻟﺒﻴﺎﻧﺎ ِ ت ﻋﻦ اﻟﺘﺎرﻳﺦ اﻟﻤﺮﺿﻲ اﻟﺸﺨﺼﻴﺔ ﻟﻸﻃﻔﺎل وواﻟﺪﻳﻬﻢ وﺑﻴﺎﻧﺎ ُ ي ﺣﻮل اﻟﺪاء اﻟﺴﻜّﺮي وﻣﻀﺎﻋﻔﺎﺗﻪ وإﻟﺘﺰاﻣﻬﻢ ﺑﻨﻈﺎ ِم اﻟﺘﻐﺬﻳﺔ اﻟﺴﻜّﺮىِ ،واﻟﻨﺸﺎط ﺴﻜّﺮ ِ وﻣﻌﻠﻮﻣﺎت اﻃﻔﺎ ِل اﻟﺪاء اﻟ ُ اﻟﺮﻳﺎﺿﻲ ،وإﺟﺮاءات اﻟﺴﻼﻣﺔ اﻟﻮﻗﺎﺋﻴﺔ َ. ت ﺖ ﻗﺎﺋﻤ َﺔ ﻣﻼﺣﻈﺎت اﻋﻌﺪت ﺧﺼﻴﺼ َﺎ ﻃﺒﻘ ًﺎ ﻹﻃﺎر ﻧﻈﺮﻳﺔ أورم ﻟﻠﻌﻨﺎﻳﺔ اﻟﺬاﺗﻴﺔ -ﻟﺘَﻘﻴﻴﻢ ﻣﻤﺎرﺳﺎ ِ واﻷداة اﻟﺜﺎﻧﻴﺔ آَﺎﻧ ْ ى. اﻟﻌﻨﺎﻳ ِﺔ اﻟﺬاﺗﻴﺔ ﻟﻸﻃﻔﺎ ِل اﻟﻤﺮﺿﻰ ﺑﺎﻟﺪاء اﻟﺴﻜﺮ ِ ﺗﻤﺖ ﻣﻘﺎﺑﻠﺔ اﻷﻃﻔﺎل ﺑﺸﻜﻞ ﻣﻨﻔﺮد ﻟﺘَﻘﻴﻴﻢ ﻣﺪى ﻣﻌﻠﻮﻣﺎﺗﻬﻢ واﻟﺘﺰاﻣﻬﻢ ﺑﻨﻈﺎ ِم اﻟﺘﻐﺬﻳﺔ اﻟﺴﻜّﺮىِ ،واﻟﺘﻤﺎرﻳﻦ واﺣﺘﻴﺎﻃﻴﺎت اﻟﺴﻼﻣﺔ ﺛﻢ ﺗﻢ ﻣﻼﺣﻈﺔ آﻞ ﻃﻔﻞ اﺛﻨﺎء ﺗﻄﺒﻴﻖ اﻟﻤﻤﺎرﺳﺎت اﻟﺬاﺗﻴﺔ. ﺗﺸﻴﺮ ﻧﺘﺎﺋﺞ اﻟﺪراﺳﺔ اﻟﻰ: ﺗﻘﺮﻳﺒ ًﺎ ُآﻞّ اﻟﻌﻴﻨﺔ ) (% ٩٩ﻣﺼﺎﺑﻴﻦ ﺑﺎﻟﻨﻮع اﻷول ﻣﻦ اﻟﺪاء اﻟﺴﻜﺮى % ٧٠٫٥ﻣﻨﻬﻢ ﻟﺪﻳﻬﻢ اﻗﺮﺑﺎء ﻣﺮﺿﻰﺑﺎﻟﺪاء اﻟﺴﻜﺮى. ٢ ن ﻓﻲ اﻟﻤﺠﻤﻮﻋ ِﺔ اﻟﻌُﻤﺮﻳﺔ ﺑﻴﻦ ١٠اﻟﻰ ١٢ﺳﻨﺔ و -ﻗﺮاﺑﺔ ﺛﻠﺜﻲ اﻟﻌﻴّﻨ ِﺔ ) (% ٦٣آَﺎ َ %٥٢٫٥آﺎﻧﻮا إﻧﺎث. ص واﻟﺤﻤﻴ ِﺔ. ﺞ ﺑﺎﻷﻧﺴﻮﻟﻴﻦ ،و % ٣٫٥ﻣﻦ اﻟﻌﻴﻨﺔ ﻳﻌﺎﻟﺞ ﺑﺎﻷﻗﺮا ِ % ٩٦٫٥ﻣﻦ اﻷﻃﻔﺎل ﻳﻌﺎﻟ َف ﻣﻌﺪل اﻧﺨﻔﺎﺿﻪ ﻓﻲ % ٢١٫٥ﻣﻦ اﻷﻃﻔﺎل اﺳﺘﻄﺎع ﻣﻌﺮﻓﺔ اﻟﻤﻌﺪل اﻟﻄﺒﻴﻌﻰ ﻟﻠﺴﻜﺮ ﻓﻰ اﻟﺪم % ٢٧ ،ﻋَﺮ َف ﻣﻌﺪﻟﻪ اﻟﻤﺮﺗﻔﻊ. اﻟﺪم ،و % ٢٥٫٥ﻋَﺮ َ ﺢ ﻟﺪاء اﻟﺴﻜّﺮي. ﻒ اﻟﺼﺤﻴ َ ﻰ اﻟﺘﻌﺮﻳ َ ﻦ اﻟﻌﻴﻨﺔ أﻋﻄ َ ِ % ٨٣ﻣ ْﻲ ﻟﻤﺮض اﻟﺪاء اﻟﺴﻜّﺮى و% ١٨٫٥ ﺐ اﻟﺮﺋﻴﺴ ُ ﺺ اﻷﻧﺴﻮﻟﻴﻦ هﻮ اﻟﺴﺒ ُ ن ﻧﻘ ِ % ٤٥٫٥ﻣﻦ اﻷﻃﻔﺎل ذَآﺮوا إ ّذَآ َﺮ أن اﻟﺴﺒﺐ أآﻞ اﻟﻜﺜﻴﺮ ﻣﻦ اﻟﺤﻠﻮى واﻟﻮراﺛﺔ. ﺖ اآﺜﺮ أﻋﺮاض اﻟﺪاء اﻟﺴﻜﺮى اﻟﺘﻰ ذآﺮهﺎ اﻷﻃﻔﺎل ﺣﻴﺚ آﺎﻧﺖ آﺜﺮة اﻟﺘﺒﻮل وآﺜﺮة ﺷﺮب اﻟﻤﺎء و اﻟﻌﻄﺶ ،آَﺎﻧ ْﻧﺴﺒﻬﻢ % ٨٢ ،%٨٣٫٥و % ٧٧٫٥ﻋﻠﻰ اﻟﺘﻮاﻟﻲ. ت اﻟﻄﻌﺎم اﻟﺮﺋﻴﺴﻴﺔ و % ٥٧٫٥ذآﺮوا أهﻤﻴ ِﺔ أآﻞ اﻟﻮﺟﺒﺎت % ٩١ﻣﻦ اﻷﻃﻔﺎل ذآﺮوا أهﻤﻴﺔ أآﻞ وﺟﺒﺎ ِاﻟﺨﻔﻴﻔﺔِ ،ﺑﻴﻨﻤﺎ % ٣٣ﻣﻦ اﻟﻌﻴﻨﺔ ذَآ َﺮ أهﻤﻴﺔ اﻹﻣﺘﺎع ﻋﻦ اﻟﻨﺸﻮﻳﺎت واﻟﺤﻠﻮﻳﺎت. ﻦ اﻷﻧﺴﻮﻟﻴﻦ ﻣﻬﻤ ِﺔ ﻟﻌﺎﻟﺠِﻬﻢ و % ٦٦٫٥ذآﺮوا أهﻤﻴ ِﺔ أﺧﺬ ﺣﻘﻨﺔ ن ﺣﻘ ِ ﻗﺮاﺑﺔ ﺟﻤﻴﻊ اﻷﻃﻔﺎل ) (% ٩٧٫٥ﻳَﺮو َﻦ اﻷﻃﻔﺎل وإﺧﺘﺒﺎ ِر ﺳﻜ ِﺮ اﻟﺒﻮ ِل آﺎن ﻣﻬﻢ ل % ٤٣ﻣﻨﻬﻢ. ن ﻣﻬ َﻢ لِ % ٥٧ﻣ ْ إﺧﺘﺒﺎر ﺳﻜ ِﺮ اﻟﺪ ﱢم آَﺎ َ ﺣﻤْﻞ ﺑﻄﺎﻗ ِﺔ ﺗﻌﺮﻳﻒ ﻦ اﻷﻃﻔﺎل ذآﺮوا أهﻤﻴ ِﺔ َ اﻣﺎ ﻋﻦ إﺟﺮاءات اﻷﺣﺘﻴﺎﻃﺎت اﻵﻣﻨﺔ ١٨ﻓﺎن % ١٨,٥ﻓﻘﻂ ِﻣ ْﺣﻤْﻞ ﻗﻄﻌﺔ ﺣﻠﻮى ﻣﻌﻬﻢ و % ٦١أآﻞ وﺟﺒﺎت ﺧﻔﻴﻔ ِﺔ ﻗﺒﻞ ﻣﻤﺎرﺳﺔ ﺑﻤﺮض اﻟﺪاء اﻟﺴﻜﺮى و % ٥٥٫٥أهﻤﻴﺔ َ اﻟﻨﺸﺎط اﻟﺮﻳﺎﺿﻲ و % ٤٣أهﻤﻴﺔ ﺣﻘﻦ اﻟﺠﻠﻴﻜﻮﺟﻴﻦ. ﺺ اﻟﻤﻨﺘﻈ ِﻢ ﻟﺪى ﻃﺒﻴﺐ اﻟﺪاء اﻟﺴﻜﺮى و % ٦١ﻷﺧﺼﺎﺋﻲ اﻟﻌﻴﻮن ، %٨٩ﻣﻦ اﻷﻃﻔﺎل ذآﺮوا أهﻤﻴﺔ اﻟﻔﺤ ِ % ٣٣ﻟﻄﺒﻴﺐ اﻷﺳﻨﺎن % ٧٥ ،ﻟﻤﻤﺮﺿﺔ اﻟﺘﺜﻘﻴﻒ اﻟﺼﺤﻰ ،و % ٦٥٫٥ﻷﺧﺼﺎﺋﻲ اﻟﺘﻐﺬﻳﺔ. آﺎﻧﺖ اﻟﻨﻈﺎﻓﺔ اﻟﺸﺨﺼﻴﺔ ﻣﻬﻤﺔ ل % ٩٥ﻣﻦ اﻷﻃﻔﺎل و % ٩٨٫٥ﻟﻠﻌﻨﺎﻳﺔ ﺑﺎﻷﺳﻨﺎن و % ٩٦٫٥ﻟﻠﻌﻨﺎﻳﺔﺑﺎﻟﻘﺪﻣﻴﻦ و % ٥١٫٥ﻟﻠﺒﺲ اﻷﺣﺬﻳ ِﺔ اﻟﻤﻨﺎﺳﺒﺔ ﻟﻘﺪم ﻣﺮﻳﺾ اﻟﺪاء اﻟﺴﻜﺮى و % ٣٤٫٥ﻷهﻤﻴ ِﺔ ﺗﻘﻠﻴﻢ اﻷﻇﺎﻓﺮ ﺑﺸﻜﻞ ﻣﺴﺘﻘﻴﻢ ِ. ت وﺟﺪ هﻦ ﺛُﻠﺜﻲ اﻷﻃﻔﺎل ) (% ٦٤ﻣﻠﺘﺰﻣﻮن ﺑﻨﻈﺎ ِم اﻟﺘﻐﺬﻳﺔ اﻟﺬى ﻳﺤﺘﻮى ﻋﻠﻰ ﻧﺴﺒﺔ ﻗﻠﻴﻠﺔ ﻣﻦ اﻟﻜﺮﺑﻮهﻴﺪرا ِت. % ١٠ -ﻓﻘﻂ ﻣﻦ اﻷﻃﻔﺎل داﺋﻢ اﻻﻣﺘﻨﺎع ﻋﻦ َأﺧْﺬ اﻟﻜﺮﺑﻮهﻴﺪرا ِ ٣ ﻦ اﻟﺴُﻌﺮات ﻦ اﻟﻤﺘﻄﻠﺐ اﻟﻴﻮﻣﻲ % ٥٠٫٥ ،ﻳﺘﻨﺎوﻟﻦ ﻣ َ ت أآﺜﺮ ِﻣ ْ % ٥٦٫٥ﻣﻦ اﻷﻃﻔﺎل ﻳﺘﻨﺎوﻟﻮن آﻤﻴﺔ آﺮﺑﻮهﻴﺪرا ِﻦ اﻟﻤﺘﻄﻠﺒﺎت اﻟﻴﻮﻣﻴﺔ. اﻟﺤﺮارﻳ َﺔ أآﺜﺮ ِﻣ ْ ﻒ اﻷﻃﻔﺎل وذوﻳﻬﻢ ﻗﺎﻣﻮا ﺑﻐﺴﻞ أ َﻳﺪﱢﻳﻬﻢ ﻓﻲ ﺑِﺪاﻳﺔ أى إﺟﺮا ِء .ﺑﻴﻨﻤﺎ ﻏَﺴ َﻞ ﻗﺮاﺑﺔ ﺟﻤﻴﻊ اﻷﻃﻔﺎل وذوﻳﻬﻢ ﺼ ِ ﻦ ِﻧ ْ أﻗﻞ ِﻣ ْأﻳﺪﻳﻬﻢ ﺑﻌﺪ اﺧﺘﺒﺎر اﻟﺒﻮ ِل. ﻦ اﻷﻧﺴﻮﻟﻴﻦ ﺑﺸﻜﻞ ﻣﺴﺘﻘﻞ. ت ﺣﻘ ِ ﻧ ّﻔ َﺬ ِﻧﺼْﻒ اﻷﻃﻔﺎل ﺧﻄﻮا َﻦ ذوي ﺚ ﺑﺸﻜﻞ ﻣﺴﺘﻘﻞ ،ﻣﻊ اﻟﻌﻠﻢ أن ِ % ١٧ﻣ ْ ﺖ ﻣِﻦ ﻗِﺒﻞ ﻋﻴﻨﺔ اﻟﺒﺤ ِ ﻋﻤِﻠ ْ ﺗﻘﺮﻳﺒ ًﺎ ُآﻞّ ﺧﻄﻮات اﺧﺘﺒﺎر ﺟﻠﻮآﻮ ِز اﻟﺪ ﱢم ُﺐ إﺻﺒ َﻊ أﻃﻔﺎﻟِﻬﻢ . اﻷﻃﻔﺎل ﻗﺎﻣﻮا ﺑﺜَﻘ َ ﺛﻠﺜﻲ اﻷﻃﻔﺎل ﻗﺎﻣﻮا ﺑﻜﻞ ﺧﻄﻮات اﺧﺘﺒﺎ ِر ﺳﻜ ِﺮ اﻟﺒﻮ ِل ﺑﺸﻜﻞ ﻣﺴﺘﻘﻞ ) .(% ٦٦٫٣ﻦ اﻟﺮﻳﺎﺿﻴﺔ واﻟﺬي ﺗﻤﺎرﺳﻪ اﻻﻧﺎث أآﺜﺮ ﻣﻦ اﻟﺬآﻮر ،ﺑﻴﻨﻤﺎ آﺮة اﻟﻘﺪم آﺎﻧﺖ ﻲ ﻟﻠﺘﻤﺎرﻳ ِ ع اﻟﺮﺋﻴﺴ َ آﺎن اﻟﻤﺸﻲ اﻟﻨﻮ َﺗﻤﺎرس أآﺜﺮ ﻣﻦ ﻗﺒﻞ اﻟﺬآﻮر . ﻦ و َﻓ ﱠﻢ اﻷﻃﻔﺎل ﻧﻈﻴﻒ ) % ٩٨ ،% ٩٦و % ٩٨٫٥ﻋﻠﻰ اﻟﺘﻮاﻟﻲ( ،ﺑﻴﻨﻤﺎ % ٥٣٫٥ﻓﻘﻂ آَﺎﻧﺖ آﺎن ﺟﻠﺪ وﻋﻴ َأﺳﻨﺎﻧﻬ ُﻢ ﻧﻈﻴﻔ ُﺔ. ﻦ اﻷﻃﻔﺎل آَﺎﻧﺖ أﻇﺎﻓﺮه َﻢ ﻗﺼﻴﺮةُ ،و % ٦١٫٥ﻗﺎﻣﻮا ﺑﻘﺺ أﻇﺎﻓﺮهﻢ ﺑﻄﺮﻳﻘﺔ ﻣﺴﺘﻘﻴﻤﺔ. ِ % ٩٠ﻣ ْ- ع. ب ﻧﻈﻴﻔﺔ وﻣﻨﺎﺳﺒﺔ اﻟﺤﺠ ِﻢ واﻟﻨﻮ َ % ٤٦ﻣﻦ اﻷﻃﻔﺎل آَﺎﻧﻮا َﻳﻠْﺒﺴﻮن أﺣﺬﻳ َﺔ ﻣﻨﺎﺳﺒﺔ وﻣﺮﻳﺤ َﺔ وﺑﺠﻮار ِ ﻦ اﻷﻧﺴﻮﻟﻴﻦ ﺑﺸﻜﻞ ﻣﺴﺘﻘﻞ . % ٥٥ﻣﻦ اﻷﻃﻔﺎل زاوﻟﻮا ﺣﻘ َ ﻗﺎم %٧٩٫٥ﻣﻦ اﻷﻃﻔﺎل ﺑﺎﺧﺘﺒﺎرﺳﻜﺮ اﻟﺪ ﱢم ﺑﺼﻔﺘﻪ ﻋﻨﺎﻳ ًﺔ ذاﺗﻴﺔ ﺑﺸﻜﻞ ﻣﺴﺘﻘﻞ. % ٦٦٫٣ﻣﻦ اﻷﻃﻔﺎل زاو َل اﺧﺘﺒﺎر ﺳﻜﺮ اﻟﺒﻮ ًل ﺑﺸﻜﻞ ﻣﺴﺘﻘﻞ .- % ١٠٠ﻣﻦ اﻷﻃﻔﺎل ﻗﺎﻣﻮا ﺑﺎﻟﻌﻨﺎﻳﺔ ﺑﺄﺳﻨﺎﻧﻬﻢ و % ٩٥ﺑﺎﻟﻌﻨﺎﻳ َﺔ ﺑﺎﻟﻘﺪ ِم واﻟﻨﻈﺎﻓ ِﺔ اﻟﺸﺨﺼﻴ ِﺔ ﺑﺸﻜﻞ ﻣﺴﺘﻘﻞ. % ٦٣٫٥ﻣﻦ اﻷﻃﻔﺎل ﻳَﺨﺘﺎ ُر أﺣﺬﻳﺘَﻬﻢ وﺟﻮارﺑَﻬﻢ ﺑﺸﻜﻞ ﻣﺴﺘﻘﻞ.ﻦ اﻟﺬآﻮ ِر. ﻦ اﻷﻧﺴﻮﻟﻴﻦ واﺧﺘﺒﺎرات اﻟﺴﻜ ِﺮ ِﻣ ْ آﺎن اﻹﻧﺎث اﻷﻃﻔﺎل أآﺜﺮ اﺳﺘﻘﻼﻟﻴﺔ ﻓﻲ ﺣﻘ ِﻦ آﻼ اﻟﺠﻨﺴﻴﻦ اﺷﺘﺮآﻮا ﻣﻊ ذوﻳﻬﻢ ﻓﻲ اﺧﺘﻴﺎر وﺗﻘﺪﻳ ِﺮ اﻟﻐﺬا َء. ﻦ ِﻧﺼْﻒ اﻷﻃﻔﺎل ﻣ ِ أآﺜﺮ ِﻣ ْ ﻗﺮاﺑﺔ ﺟﻤﻴﻊ اﻷﻃﻔﺎل ﻣﻦ آﻼ اﻟﺠﻨﺴﻴﻦ آَﺎﻧﻮا ﻣﺴﺆوﻟﻴﻦ ﻋﻦ ﻧﻈﺎﻓﺘِﻬﻢ . -أﺷﺎرت اﻟﺪراﺳﺔ أن اﻷﻃﻔﺎ ِل اﻷآﺒﺮ ﻋﻤﺮا آَﺎﻧﻮا أآﺜﺮ إﺗﺒﺎﻋﺎ ﻟﻠﻌﻨﺎﻳ ِﺔ اﻟﺬاﺗﻴِﺔ ﻣﻦ اﻷﻃﻔﺎل اﻷﺻﻐ ِﺮ ﺳﻨﺎ. ٤ واﺳﺘﻨﺎدا ﻋﻠﻰ اﻟﻨﺘﺎﺋﺞ اﻟﺴﺎﺑﻘﺔ ﻴﻭﺻﻲ ﺑﺎﻟﺘﺎﻟﻲ: ن ﻟﻠ ُﻤﻤَﺮﺿ ِﺔ دور أآﺒ ُﺮ ً ﻓﻲ ﺗَﻌﻠﻴﻢ اﻷﻃﻔﺎ ِل وذوﻳﻬﻢ. ن ﻳﻜﻮ َ َ .١أ ْ .٢اﻟﺘﺄآﻴﺪ ﻋﻠﻰ ﺗﻌﻠﻴﻢ وﺗﺜﻘﻴﻒ اﻷﻃﻔﺎل وذوﻳﻬﻢ ﻋﻦ اﻟﺤﻤﻴ ِﺔ اﻟﻐﺬاﺋﻴﺔ ﻟﻤﺮﺿﻰ اﻟﺪاء اﻟﺴﻜﺮى وأهﻤﻴﺘﻬﺎ وﻣﻀﺎﻋﻔﺎت إهﻤﺎﻟﻬﺎ. .٣ان ﺗﻜﻮن اﻟﻤﻌﻠﻮﻣﺎت واﻹرﺷﺎدات ﻋﻦ اﻟﻌﻨﺎﻳﺔ اﻟﺬاﺗﻴﺔ ﻣﻜﺘﻮﺑﺔ. .٤أن ﺗﺸﻤﻞ ﻗﻮاﻧﻴﻦ اﻟﻤﺴﺘﺸﻔﻴﺎت ﻋﻠﻰ ﺿﺮورة ﺣﻤﻞ ﻣﺮﻳﺾ اﻟﺪاء اﻟﺴﻜﺮى ﻟﺒﻄﺎﻗﺔ اﻟﺘﻌﺮﻳﻒ ﺑﺄﻧﻪ ﻣﺮﻳﺾ ﺑﻬﺬا اﻟﻤﺮض. .٥ﺗﻘﻴﻴﻢ وإﻋﺎدة ﺗﻘﻴﻴﻢ ﻣﺴﺘﻮى اﻟﻤﻌﻠﻮﻣﺎت واﻟﻤﻤﺎرﺳﺎت اﻟﺨﺎﺻﺔ ﺑﻤﺮﺿﻰ اﻟﺪاء اﻟﺴﻜﺮى ﻟﺪى اﻷﻃﻔﺎل اﻟﻤﺮﺿﻰ وذوﻳﻬﻢ وذﻟﻚ ﻟﻀﻤﺎن اﻟﻌﻨﺎﻳ ِﺔ اﻟﻤﻼﺋﻤ ِﺔ. .٦ﺿﺮورة إﺳﺘﺨﺪام ﻃﺮق ﺗﻌﻠﻴﻤﻴﺔ ﻣﺨﺘﻠﻔﺔ وﺟﺬاﺑﺔ ﻣﻦ ﻗﺒﻞ ُﻣﻤَﺮﺿ ِﺔ اﻟﺘﺜﻴﻒ اﻟﺼﺤﻰ ﻟﺤﺚ اﻷﻃﻔﺎل ﻋﻠﻰ ﻣﻤﺎرﺳﺔ اﻟﻌﻨﺎﻳﺔ اﻟﺬاﺗﻴﺔ. ت اﻟﻌﻨﺎﻳ ِﺔ اﻟﺬاﺗﻴ ِﺔ. .٧اﻟﻘﻴﺎم ﺑﺤﻤﻼت ﻟﺘﻌﻠﻴ ِﻢ اﻷﻃﻔﺎ ِل اﻟﻤﺮﺿﻰ ﺑﺎﻟﺴﻜﺮ ﻟﺘﺄآﻴﺪ وﺗَﺸﺠﻴﻊ ﻣﻤﺎرﺳﺎ ِ ى وأﺳﺮهﻢ. .٨ان ﻳﻜﻮن ﻟﻺﻋﻼم اﻟﺠﻤﺎهﻴﺮي دو ُر ﻓﻲ ﺗَﻌﻠﻴﻢ اﻷﻃﻔﺎ ِل اﻟﻤﺮﺿﻰ ﺑﺎﻟﺪاء اﻟﺴﻜﺮ ِ ﺗﻮﺻﻴﺎت ﻟﺪراﺳﺎت أﺧﺮى: ت اﻟﻌﻨﺎﻳ ِﺔ اﻟﺬاﺗﻴ ِﺔ ﻟﺪى اﻷﻃﻔﺎل. - ١دراﺳﺔ ﺗﺠﺮى ﻟﺘَﺤﺮّي اﻟﻤﻮاﻧ ِﻊ اﻟﻰ ﺗﻌﻴﻖ ﻣﻤﺎرﺳﺎ ِ ت – ٢دراﺳﺔ ﺗﻮﺳﻌﻴﺔ ﻋﻦ ﻣﻌﻠﻮﻣﺎت وﻣﻤﺎرﺳﺎت اﻷﻃﻔﺎل اﻟﻤﺮﺿﻰ ﺑﺎﻟﺪاء اﻟﺴﻜﺮى ﻟﻜﻞ وﺟﻪ ﻣﻦ أوﺟﻪ ﻣﻤﺎرﺳﺎ ِ اﻟﻌﻨﺎﻳ ِﺔ اﻟﺬاﺗﻴ ِﺔ.