Download Assessment of self–care practices among diabetic children in

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
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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
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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.
Chapter VIII
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140
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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.‬‬