DIABETES

Julia E. Blanchette

Overview

Diabetes mellitus (DM) is a chronic metabolic disorder in which the body does not metabolize carbohydrates, fats, and proteins because of progressive loss or function of pancreatic beta cells resulting in hyperglycemia (American Diabetes Association [ADA], 2017). The majority of pediatric patients with diabetes have type 1 diabetes (T1D) although some have type 2 diabetes (T2D) or other forms (ADA, 2017). Despite medical advances, a majority of children with T1D do not obtain optimal glycemic control resulting in higher mortality rates, shortened average life spans, and risk of long-term complications (ADA, 2017; Juvenile Diabetes Research Foundation [JDRF], 2016). Nurses focus on the prevention of decline in health status and future complications. Care delivery is focused on family-centered self-management care to maintain optimal and safe glycemic control for children with DM (ADA, 2017).

Background

There are more than 200,000 Americans younger than 20 years living with T1D (JDRF, 2016). Since the past decade, there has been a 21% increase in the prevalence of childhood T1D (Centers for Disease Control and Prevention [CDC], 2014; JDRF, 2016). The annual increase in the prevalence of childhood T2D is expected to quadruple in the coming 40 years (CDC, 2014). Both types of DM are polygenic and have many disease progression factors (ADA, 2017). Common environmental factors associated with the development of T1D and T2D include dietary factors, endocrine disruption, environmental toxins, gut microbiome composition, and infection (ADA, 2017). Children who are at risk for T1D are those who have a family member with T1D or autoimmune diseases such as celiac disease or Hashimoto’s thyroiditis (ADA, 2017). A majority are Whites who have inherited complex risk factors from both parents, although there may be no previous family history of DM (ADA, 2017). Children at risk for T2D include those who have a body mass index (BMI) greater than the 85% for sex and age, weight greater than the 120% for ideal height, a family history of T2D in first- and second-degree relatives, and are Native American, African American, Hispanic, or Asian/South Pacific Islander ethnicity (ADA, 2017).

The onset of T1D occurs suddenly and most frequently in children younger than 4 years of age and during adolescence (ADA, 2017). It is a multifactorial disease caused by autoimmune destruction of insulin-producing pancreatic beta cells in those who are predisposed (ADA, 2016). Hyperglycemia or increased blood glucose occurs because of a decreased secretion of insulin (ADA, 2017). Fat is then used as an energy source when glucose is unavailable to the cells for metabolism-causing diabetes ketoacidosis (DKA), an acute life-threatening form of metabolic 59acidosis, which presents in at least one third of T1D onset (ADA, 2017). The onset of T2D is less common than T1D in childhood and occurs because of insulin resistance and the relative decrease in insulin secretion, resulting in elevated glucose levels (ADA, 2017). Insulin resistance is when the body is less able to use insulin resulting in reduced absorption of glucose into the cells for fuel (ADA, 2017). Insulin resistance causes excess production of glucose from the liver and dysfunction or total loss of function of the pancreatic beta cells (ADA, 2017).

Diabetes management for optimal glycemic control includes insulin administration, blood glucose monitoring, carbohydrate counting, treatment of hyperglycemia, treatment of hypoglycemia, exercise, nutrition therapy, family counseling, stress management, and self-monitoring of trends in insulin requirement and glucose levels (ADA, 2017). In the hospital, diabetes management includes a monitored initiation of insulin therapy via hospital protocol, fluid replacement, and family-centered diabetes education (ADA, 2017). Basal and bolus insulin administration occur through an intravenous (IV), insulin pumps, insulin syringe, or insulin pen. Basal insulin is a continuous insulin in small doses over a 24-hour period (ADA, 2017). Basal administration occurs via infusion of rapid-acting or one daily dose of long-acting insulin analogs (ADA, 2017). Bolus insulin is for hyperglycemia and carbohydrate corrections and is determined based on the patient’s weight and blood sugar targets; a sliding scale regimen is strongly discouraged for inpatient settings (ADA, 2017). However, those with T2D may not be insulin dependent and may have tailored pharmacological treatment such as Metformin and increased physical activity (ADA, 2017).

Despite knowledge of risk factors, medical advances, and technology advances in diabetes care, children with DM still have higher mortality rates owing to complications than the rest of the population, especially during pubertal years because of the increased insulin sensitivity (ADA, 2017). Of the children living with DM, less than one third obtain the recommended glycemic control targets placing them at high risk for DKA and complications (JDRF, 2015).

Clinical Aspects

ASSESSMENT

The child’s history, key physical assessment findings, and laboratory data are vital components of nursing care for children with DM. Children with both types of DM often present with polydipsia, polyphagia, blurred vision, and polyuria (ADA, 2017). Many children present with weight loss and flu-like symptoms, which have been present for several weeks (ADA, 2017). Diagnosis of DM in children occurs when symptoms manifest, and A1C is greater than or equal to 6.5%, a casual plasma glucose level is greater than or equal to 200 mg/dl, or a fasting plasma glucose level is greater than or equal to 126 mg/dl (ADA, 2017). Although DM diagnosis occurs under the same glycemic criteria, classification of the type of diabetes is important in determining therapy. Children with T2D may have conditions or signs associated with insulin resistance such as acanthosis 60nigricans (dark velvety patches) on the skin folds, hypertension, dyslipidemia, polycystic ovarian syndrome, history of small for gestational age at birth, or maternal history of gestational diabetes mellitus (ADA, 2017). Children at risk should be screened every 3 years after the age of 10 years or at the onset of puberty if it occurs earlier (ADA, 2017). Those with T2D do not typically present with DKA (ADA, 2017).

Physical assessment for a hospitalized child with DM should focus on detecting and preventing DKA. Children with T1D often present with DKA at diagnosis through infection, insulin pump failure, expired insulin, the omission of insulin and inadequate insulin, mental health issues, lack of family or social support; after trauma or after surgery can also cause DKA (ADA, 2017). Assessment should focus on the changes in the cardiovascular system (hypotension, arrhythmias, widening pulse rate), respiratory system (Kussmaul respirations, respiratory rate, acid–base disturbance), neurologic system (pupillary changes, altered level of consciousness), and integumentary system (dry mucous membranes, sunken eyes, decreased skin turgor; ADA, 2017). A child in DKA may also complain of abdominal pain, nausea, vomiting, and have fruity breath (ADA, 2017). Diagnosis of DKA occurs when plasma glucose is greater than 250 mg/dL, arterial pH is greater than 7.3, serum bicarbonate is greater than 15 mEq/L and moderate, or greater ketonuria is present (ADA, 2017). Management of DKA includes isotonic IV fluids, electrolyte replacement, regular IV insulin (0.1 unit/kg/hr), potassium supplementation, and phosphate supplementation (ADA, 2017). If cerebral edema occurs, it must be treated with mannitol (ADA, 2017).

Blood glucose is monitored at least every hour and is managed based on hospital protocols to prevent hyperglycemia and hypoglycemia (ADA, 2017). Young children may not be able to communicate hypoglycemia symptoms efficiently. In addition, children with complications may have hypoglycemia unawareness (ADA, 2017). Children who are not new to diabetes may have continuous blood glucose monitors to prevent hypoglycemia unawareness. The child is not required to take off a continuous monitor, although you should still monitor the child’s blood glucose via the hospital’s policy.

A plan for preventing and treating hypoglycemia (blood glucose below 70 mg/dL) is established for each patient and episodes are documented (ADA, 2017). Signs of hypoglycemia include sudden heart palpitations, fatigue, pallor, shakiness, anxiety, diaphoresis, hunger, and irritability (ADA, 2017). Hypoglycemia occurs from a sudden reduction of corticosteroids, reduced oral intake, extra insulin, and increased physical activity (ADA, 2017). It typically requires treatment of 15 g of fast-acting carbohydrates and when the blood sugar rises, a complex carbohydrate (ADA, 2017). If a patient is unresponsive with severe hypoglycemia (less than 40 mg/dL), glucagon or IV dextrose may be administered.

NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS

Nursing care of the hospitalized child with DM should focus on the prevention of DKA and severe hypoglycemia. Priority nursing-related problems include 61imbalanced nutrition less than body’s requirements, fluid volume deficit, the risk of injury (for hypoglycemia), the risk of infection, fatigue, and knowledge deficit related to new diabetes diagnosis or self-management skills.

Evidence-based practice supports interventions to improve glycemic control. According to evidence-based practice, diabetes self-management education includes medical nutrition therapy, psychosocial support at diagnosis and regularly after that in a developmentally appropriate manner. These interventions result in a less frequent decline in health status and improved glycemic control (ADA, 2017). The use of a team-based approach and shared decision making between the youth and family members results in improved diabetes self-efficacy, protocol adherence, and positive metabolic outcomes (ADA, 2017). Moreover, evidence-based practice suggests that the child should have periodic assessments to determine the need for self-care skills education. Premature transfer of diabetes care from the parent to the child can result in nonadherence and deterioration in glycemic control (ADA, 2017). Psychosocial and family issues should also be assessed to ensure that adherence to diabetes self-management is not impacted; early detection of depression, anxiety, and eating disorders can minimize adverse effects on diabetes management and improve glycemic control (ADA, 2017).

OUTCOMES

The results of evidence-based nursing care are to incorporate family-centered self-management to reach optimal glycemic control, to prevent DKA and severe hypoglycemia. Monitoring for changes in physical assessment and blood glucose changes can provide evidence for intervening with blood glucose levels. It is vital to monitor children’s blood glucose levels frequently and to pay attention to signs and symptoms of decline in health status.

Summary

Treatment plans for optimal glycemic outcomes incorporate family dynamics, mental health, developmental readiness, and physiological changes. Hospitalized children with DM can rapidly progress into DKA or severe hypoglycemia if not monitored and managed appropriately. Changes in glucose and insulin patterns can be related to physical growth, puberty, insulin pump failure, a decline in mental health, and children beginning to provide their self-care. Educating families to recognize these developmental changes and the signs and symptoms of DKA, hyperglycemia, and hypoglycemia is vital in the prevention of poor health outcomes.

American Diabetes Association. (2017). Standards of medical care in diabetes—2017: Summary of revisions. Diabetes Care, 40(Suppl. 1), S4–S5. doi:10.2337/dc17-S003

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