ru care on pt wd iddm_icah

8/7/2019 RU care on pt wd IDDM_icah

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Silliman UniversityCOLLEGE OF NURSING

Dumaguete City

TOPIC: Nursing Care Management of Hospitalized Pediatric Patients with Diabetes Mellitus Type 1 or Insulin-Dependent

Diabetes Mellitus

Placement: NCM 105; Second Semester Level IV

No. of Hours: 1 hourUnit Description: This unit deals with the pathophysiology of insulin-dependent diabetes mellitus, incorporating the etiol

clinical manifestations, diagnostic test, and medical management for pediatric patients with IDDM.

application of the nursing process is given emphasis.

Central Objective:After 1 hour, the learners shall develop adequate knowledge, skills, and positive attitude ind the car

pediatric patients with insulin-dependent diabetes mellitus

SPECIFIC OBJECTIVE CONTENT TA T-L STRATEGY EVALUA

N

At the end of the ward

class, the learners shall

be able to:

Understand the disease

highlighted in the case

study.

I. Prayer

Most gracious and loving Father, we glorify your name in all theearth. Forgive us Lord for the unrighteous actions that we havedone against you and our neighbors as well. Thank you God, forthis new day that you have given us, especially for thiswonderful opportunity of being able to share your knowledge tothe rest of our fellow students. Bless us all dear God as weproceed with our ward class, and enlighten our hearts andminds that we may be able to grasp all the information tobecome more efficient and effective in caring for those in needof our love and compassionate care. This we pray in Your name.Amen.

II. A Case Study on a Child with Insulin-Dependent Diabetes

Mellitus

2 mins.

2 mins. Socialized

Discussion with

powerpoint

presentation

Active c

participat


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State the etiology of

insulin-dependent

diabetes mellitus.

Identify the clinical

manifestations

Rico is a 10 year old boy who has been recently diagnosed

with insulin-dependent diabetes mellitus. Upon assessment, the

nurse was able to trace the heredofamilial disease of the child.

According to his mothers verbalization, Ricos father has a type 1

diabetes mellitus also. His mother also reported one incidence

that Rico during their trip to California to Kansas drank the

contents of a gallon jug of water between each gas station stop.

As Ricos abdominal discomfort and nausea increases, he refused

fluid and food given to him which adds to the increasing cause of

dehydration and malnutrition. Rico according to his mother usually

experience bed-wetting, has short attention span most of the

time, and is usually irritable. Further assessment by the nurse

revealed that Rico had dry skin, and blurry vision as evidenced by

difficulty reading the letters on the Snellens chart situated 20 feet

away. Laboratory exam results showed that Rico had and elevated

fasting blood glucose of 130 mg/dl and a random blood glucose

value of 200 mg/dl. Urinalysis results also showed presence of

sugar in the urine.

III. Etiology

It is thought that IDDM is caused by genetic component,

environmental influences, and an autoimmune response. IDDM

has strong familial tendencies but does not show any specific

pattern of inheritance. The child inherits a susceptibility to the

disease rather than the disease itself.

Environmental factors such as viruses or chemicals in the dietare believed to play an important role in damaging the beta cells

in the islets of Langerhans. These are the cells responsible for

insulin production. The incidence of onset of IDDM is increased

during winter when viral diseases are more prevalent. Often the

3 mins.

3 mins.

Informal lecture

with visual aids/

video

presentation

Informal lecture

with visual aids

Active c

participat

Identificat

of the cau

of IDDM.

Active cparticipat


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associated with the

disease.

Understand and trace the

pathophysiology of IDDM.

child has a history of a viral infection 1-2 months before the onset

of the symptoms.

IV. Clinical Manifestation

The cardinal signs of IDDM are polyuria, polydipsia, and

polyphagia (excessive appetite) with significant weight loss.

Frequently identified symptoms include irritability, unexplained

fatigue or lethargy, headaches, stomachaches, and occasional

enuresis may also occur in a previously toilet-trained child.

Adolescent girls may have vaginitis caused by Candida, which

thrives in the hyperglycemic tissues. Symptoms develop

gradually and insidiously but have usually been present less than

a month. In severe cases diabetic ketoacidosis (DKA), a type of

metabolic acidosis, may develop.

V. Pathophysiology

Insulin is needed to support the metabolism of carbohydrates,

fats, and proteins, primarily by facilitating the entry of these

substances into the cell. Insulin is needed for the entry of these

substances into the cell. Insulin is needed for the entry of muscle

and fat cells, prevention of mobilization of fats from fat cells, and

storage of glucose as glycogen in the cells of the liver and

muscle. Insulin is not needed for the entry of glucose into nerve

cells or vascular tissue. The chemical composition and molecular

structure of insulin are such that it fits into receptor sites on the

cell membrane. Here it initiates a sequence of poorly defined

chemical reactions that alter the cell membrane to facilitate theentry of glucose into the cell and stimulate enzymatic systems

outside the cell that metabolize the glucose for energy

production.

12

mins.

Socialized

discussion with

visual aids

Active c

participat

Understan

g of

disease

process,

manifesta

s,

therapeut

managem


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Identify the different

diagnostic test and the

medical management for

such disease.

With a deficiency of insulin, glucose is unable to enter the

cell, and its concentration in the bloodstream increases. The

increased concentration of glucose (hyperglycemia) produces an

osmotic gradient that causes the movement of body fluid from

the intracellular space to the interstitial space, then to the

extracellular space and into the glomerular filtrate in order to

dilute the hyperosmolar filtrate. Normally the renal tubular

capacity to transport glucose is adequate to reabsorb all the

glucose in the glomerular filtrate. When the glucose

concentration in the glomerular filtrate exceeds the renal

threshold (6180 mg/dl), glucose spills into the urine (glycosuria)

along with an osmotic diversion of water (polyuria), a cardinal

sign of diabetes. This water washout results in a depletion of

other essential chemicals, especially potassium.

Protein is also wasted during insulin deficiency. Because

glucose is unable to enter the cells, protein is broken down and

converted to glucose by the liver (glucogenesis); this glucose

then contributes to the hyperglycemia. These mechanisms aresimilar to those seen in starvation when substrate glucose is

absent. The body is actually in the state of starvation during

insulin deficiency. Without the use of carbohydrates for energy,

fat and protein stores are depleted as the body attempts to meet

its energy needs. The hunger mechanism is triggered but

increase food intake (polyphagia) enhances the problem by

further elevating blood glucose.

When insulin is absent or there is an altered insulin

sensitivity, glucose is unavailable for cellular metabolism, and thebody chooses alternate sources of energy, principally fat.

Consequently, fat breaks down into fatty acids, and glycerol in

the fat cells is converted into the liver to ketone bodies. Any

excess is eliminated in the urine (ketonuria) or the lungs (acetone

8 mins.

Independent

study

Oral c

recitation


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breath). The ketone bodies in the blood (ketonemia) are strong

acids that lower serum pH producing ketoacidosis.

VI. Diagnostic Test and Medical Management

Three groups of children who should be considered

candidates for diabetes are (1) children who have glycosuria,

ployuria, and a history of weight loss or failure to gain despite a

voracious appetite; (2) those with transient or persistent

glycosuria; and (3) those who display manifestations of metabolic

acidosis, with or without stupor or coma. In every case, diabetes

must be considered if there is glycosuria, with or without

ketonuria and unexplained hyperglycemia.

An 8-hour fasting blood glucose level of 126 mg/dl or more, a

random blood glucose value of 200 mg/dl or more accompanied

by classic signs of diabetes, or an oral glucose tolerance test

(OGTT) finding of 200 mg/dl or more in the 2-hour sample is

almost certain to indicate diabetes. Postprandal blood glucosedeterminations and the traditional OGTTs have yielded low

detection rates in children and are not usually necessary for

establishing a diagnosis. Serum insulin levels may be normal or

moderately elevated at the onset of diabetes; delayed insulin

response to glucose indicates the presence of impaired glucose

tolerance.

DKA is a state of insulin insufficiency and may include the

presence of hyperglycemia (blood glucose level 330 mg/dl),

ketonemia (strongly positive), acidosis (pH


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Incorporate the nursing

process in the care of

pediatric patients with

IDDM.

Briefly explain the

different assessment

measures.

Therapy of IDDM combines insulin, dietary management, an

exercise regimen, and physiologic support. The goal of initial

insulin therapy is to lower blood glucose levels to normal. Long-

term insulin therapy is calculated to maintain a blood glucose

level as close to the normal range as possible and to minimize

episodes hyperglycemia and hypoglycemia.

Several forms of insulin are available. The most common

insulin regimen consists of daily administration of a combination

of a short-acting (regular) insulin and an intermediate-acting

(NPH or Lente) or long-acting insulin (Ultralente) before breakfast

and before the evening meal. However, other routines requiring

more injections are preferred by some physicians; for example,

short-acting and intermediate-acting insulin before breakfast,

short-acting insulin at supper, and intermediate-acting insulin at

bedtime. Rapid-acting insulin has recently become available and

may be used by older children and adolescents to achieve tight

glucose control. Insulin is usually provided in prepackaged doses

of 100 units/mL. Diluted insulin prepared by a pharmacist may beused for infants and toddlers who require a small insulin dosage.

Some highly motivated adolescents may choose to use an insulin

pump for diabetic management. A pen-shaped device that

contains an insulin-filled cartridge may also be used by

adolescents.

Daily blood glucose levels are tested and recorded before

meals and at bedtime. Laboratory evaluation of glycosylated

hemoglobin should be performed every 3 months. It provides and

objective measurement of glycemic control because it representsthe amount of glucose irreversibly attached to the hemoglobin

molecule over an extended period (the life span of the red blood

cell, approximately 120 days). The HbA1c level ion a person

without IDDM is 4-7%, and this level is higher than those with

20

mins.

Independentstudy/

Informal lecture

with visual aids

Active c

participat

Oralrecitation


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Identify possible nursing

diagnosis.

IDDM. The higher the level, the poorer has been the blood

glucose control over the past 3 months.

Physical activity is associated with increased insulin

sensitivity. Regular exercise and fitness improve metabolic

control with a lower insulin dose. Blood lipid levels are also

positively affected. However, the child must have an adequate

caloric intake to prevent hypoglycemia.

Long-term complications of IDDM (retinopathy, heart disease,

renal failure, and peripheral vascular disease) result from

hyperglycemic effects of the blood vessels. Despite careful

management, many diabetic children develop renal failure and

loss of vision in adulthood. Careful management is important,

however, to delay or lessen the severity of these complications.

VII.Application of the Nursing Process

7.1. Assessment

7.1.1. Physiologic Assessment

Children are generally admitted to the hospital at the time of

diagnosis. Assess the childs physiologic status, focusing on vital

signs and level of consciousness. Assess hydration by checking

mucous membranes, skin turgor, and urine output. Blood is

initially collected hourly to monitor blood gases, glucose, and

electrolytes. Once the child is stable, assess dietary and caloric

intake and the ability of the child or family to manage care.

7.1.2. Psychosocial Assessment

Parents may feel guilty at the time of diagnosis if they waited


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State the expected

outcomes in the care of

pediatric patients with

IDDM.

Identify nursing

interventions appropriate

for pediatric patients with

IDDM.

to seek care until the child began to experience symptoms of

DKA. Assess coping mechanisms, ability to manage the disease,

and educational needs of both the child and parents.

7.1.3. Developmental Assessment

Assess the childs developmental level, particularly fine motor

skills and cognitive level. The child will need to learn how to

obtain and read a blood glucose sample and how to draw up and

administer insulin. Children are usually able to perform some of

these tasks with supervision by 6-8 years of age. Self-

management is the eventual goal, and the childs responsibilities

are gradually increased. They usually perceive IDDM as a

disability and often deny having the disease so they can be like

their peers when eating and exercising. Talk with the child to

evaluate motivation to manage diet, exercise regimen, blood

glucose testing, and insulin therapy. Although the adolescent is

cognitively able to manage self-care, the desire to be like peers

often interferes with compliance.

7.2. Diagnosis

Ineffective breathing pattern r/t effort to compensate for

metabolic acidosis

Risk for fluid volume deficit r/t hyperglycemia

Risk for altered nutrition: Less than body requirements r/t

glycosuria

Risk for injury r/t periods of hypoglycemia and ketoacidosis

Ineffective management of therapeutic regimen r/t denial of

chronic condition

Knowledge deficit r/t lack of exposure to diabetic

management in the newly diagnosed child

Powerlessness r/t presence of a chronic illness requiring a


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rigorous dietary, exercise, and medication regimen

7.3. Planning

Expected patient outcomes includes the following:

Appropriate meal and snack planning.

Develop and appropriate insulin regimen and physical

activity program.

Child and family will be educated about the disease,

assessment techniques, and therapy.

Child will experience minimum complications of diabetes.

Child will develop a positive self-image.

Child and family will receive adequate support.

7.4. Implementation

Nursing care focuses on teaching the child and parents aboutthe disease and its management, managing dietary intake,

providing emotional support, and planning strategies for daily

management in the community.

7.4.1. Providing Education

The nurse is an important member of the management team

(physician, nurse, nutritionist, and social worker) and is usually

responsible for educating the child and family. Teaching often is

performed in the home setting, since children may be

hospitalized only briefly following diagnosis.

The timing and amount of information provided are especially

important in the first days following diagnosis. Both the child and

parents are often in the state of shock and disbelief; information


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presented during this period may need to be repeated. This time

should be used to assess learning needs and to answer the

familys questions. Initial teaching focuses on the skills necessary

for home management (insulin administration, blood glucose

testing, urine testing, record keeping, dietary management, and

the recognition and treatment of both hypoglycemia and

hyperglycemia).

Explain the goals of insulin therapy. Teach the child and

parents how to administer insulin and test blood glucose.

Rotating the injection sites is important to decrease the chances

of lipodystrophy (development of fibrotic tissue that interferes

with absorption of insulin). An understanding of the different

types of insulin is essential.

Once the child and parents demonstrate understanding of this

information, guidelines for managing episodes of hyperglycemia

during acute illness and using a sliding scale are taught. A sliding

scale indicates specific insulin dosages appropriate for aparticular blood glucose level. The family also needs to learn sick

day care guidelines to prevent diabetic ketoacidosis.

Caution parents to check the blood glucose level of a toddler

who is extremely sleepy or irritable, as these can be signs of

either hypoglycemia or hyperglycemia.

7.4.2. Managing Dietary Intake

The preferred diet for children with IDDM is a low-saturated

fat, low-sodium diet that avoids concentrated sugars. The childneeds adequate calories to reach or maintain a desirable body

weight. Usually at the time of diagnosis the child needs to regain

lost weight, so extra calories may be recommended.


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Dietary intake should include three meals per day, eaten at

consistent intervals, plus a midafternoon carbohydrate snack and

a bedtime snack high in protein. A consistent intake of

carbohydrates at each meal and snack is needed.

Many adolescents find that carbohydrate counting for dietary

management gives them more flexibility in disease management.

They learn the number of units of insulin needed to.

7.4.3. Providing Emotional Support

The diagnosis of IDDM often comes as a shock to the family. If

there is a familial history, parents may feel guilty about having

caused the disease. The diagnosis of a chronic disease that

requires daily management can be difficult to accept. Give

parents information about diabetes education programs, put

them in touch with other parents of diabetic children, and help

them to learn the role they can play in managing the disease.

Support for the child depends on age and developmental age.

Encourage the child to express feelings about the disease and its

management. The adolescent may benefit from contact with

other adolescents who have IDDM.

7.4.4. Discharge Planning and Home Care

Home care needs should be identified and addresses before

discharge. This is often difficult because of the short

hospitalization of children with newly diagnosed diabetes. Homehealth or visiting nurses should be notified to visit the family

within 24 hours of discharge. The goal of the teaching plan is to

enable the child and family to assume the necessary

responsibility for home care and to manage hyperglycemic


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Identify outcomes

following a successful

management of IDDM in

children.

episodes.

Make every effort to incorporate the diabetic regimen (insulin

administration, diet, blood glucose monitoring, and exercise) into

the familys present lifestyle. The fewer changes the family has to

make, the greater the chance of compliance.

Provide written materials and refer parents to books and

other materials they can use in teaching the child about diabetes.

7.4.5. Care in the Community

During follow-up visits, ask the child or parents about signs

indicating problems in diabetic control. Record growth

measurements and vital signs in the childs chart. Assess the

childs sexual development using Tanner staging guidelines.

Puberty may be delayed if diabetic control is inadequate. Review

the childs typical dietary intake and exercise regimens.

Continually work with the child to help him or her assume

responsibility for self-care and for parents to promote the childs

self-care. The childs developmental stage and cognitive level

influence his or her readiness to take on responsibility for self-

care. Summer camps and other programs for diabetic children

are often helpful in providing education and support.

The preschool childs need for autonomy and control can be

met by allowing the child to choose snacks or to pick which finger

to stick for glucose testing and by helping parents to gathernecessary supplies. School-age children can learn to test blood

glucose, administer insulin, and keep records. They should be

taught how to select food appropriate for dietary management

and how to plan for an exercise program. They need to learn to 5 mins.


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Evaluate the ward class

objectively.

recognize the signs of hypoglycemia and hyperglycemia, and

understand the importance of carrying a rapidly absorbed sugar

product.

Adolescents should take on a total responsibility for self-care,

however, they benefit from the ongoing supervision by the family.

Although they understand explanations about the potential

complication of diabetes, they are present-time oriented and may

rebel against the daily regimentation of insulin injections anddietary management. Successful self-care depends in part on the

adolescents adjustment to the chronic nature of the disease and

feelings of being different form peers.

Children with Type 1 diabetes often learn manipulative

behaviors, using their disease to obtain something they want.

Teach parents to be alert to signs of manipulation, such as

helpless, demanding, whining behaviors, and any evidence of

poor coping. Food may become a battleground for toddlers who

are picky eaters, but must have adequate intake for the insulindose. Referral for counseling may be appropriate for some

families.

The child with IDDM may develop circulatory and neurologic

changes over time. Emphasize the importance of good foot care

from an early age, for example wearing clean white socks;

changing socks and shoes when they are damp; washing, drying,

and powdering feet; And keeping toenails short.

Explain to the parents that the child should wear some type ofmedical alert identification. Assist them in having an individual

school health plan developed to ensure that school administrators

and teachers can identify the signs of hypoglycemia or

hyperglycemia and provide emergency management.

5 mins.

.

Modified

question and

answer game

Game:Charades

1. The group willbe divided into

two.2. Each groupwill choose twoof its members

to do thecharades.

3. Both of thegroups will be

given the sameparticular

situation to actout.

4. The rest ofthe group mates

will have toguess what their

teammates infront are acting

out.

5. The groupwhich has themost number ofcorrect guesses

wins.

Answers

questions

75% leve

competen


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7.5. Evaluation

The effectiveness of nursing interventions for the family and

child with IDDM is determined by continual assessment and

evaluation of care based on the following guidelines:

Interview the family to determine their understanding of

the ease; have child and family demonstrate and discuss

the needed assessment and therapeutic techniques.

Interview family regarding their understanding of control;

analyze and evaluate management records.

Discuss the childs disease with him or her.

Interview family and child regarding their feedings and

concerns about the disease.

Outcomes of a successful disease management includes the

following:

Diet record indicates meals and snacks have the

appropriate distribution of carbohydrates, protein, and fats,

and daily caloric intake goals are met.

The child and family make minimal changes in usual

lifestyle while managing the Type 1 diabetes.

The child demonstrate enhanced coping skills and

expresses positive attitude toward self. The child displays

warmth and affection toward family.

The child is able to perform as many diabetic care

techniques as possible for age.

VIII.Open Forum

IX. Learners Evaluation


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References:

Ball, J.et.al. (2003). Pediatric Nursing. 3rd ed. Singapore Pearson Education Incorporated. Singapore.

Black, J. & Hawks, J. (2005). Medical- surgical nursing: clinical management for positive outcomes. (7th ed.) Philadelphia: W. B. Saunders.

Hozinski, M. (1992). Nursing Care of the Critically Ill Child. 2nd ed. Mosby-Year Book Inc.

Marieb, E.N. (2007). Human anatomy and physiology. 11th ed. The Benjamin/Cummings publishing Company, Inc. Redwood City, Californ

McCance, K.et.al. Pathophysiology: The Biologic Basis for disease in Adults and Children. 7th ed. Missouri: Mosby Inc.

Potter, P. A. & Perry A. G. (2002). Fundamentals of nursing. Mosby, St. Louis, Missouri.


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Shier, D., Buttler, J., & Lewis, R. (2007). Holes human anatomy and physiology. McGraw Hill, N.Y.

Smeltzer, E.C., Bare, B. G., Hinkle, J.L., & Cleever, K. H. (2008). Brunner & Suddarths Textbook of medical-surgical nursing. 11th ed. LippincWilliam and Wilkins,

Philadelphia.

Thomas, D.et.al. (2003). Core Curriculum for pediatric Emergency Nursing . 9th ed. Jones and Barlett Publishing Inc.

Wong, D.et.al. (1999). Nursing care of Infants and Children. 7th ed. Missouri: Mosby Inc.

Internet sources:

http://www.youtube.com/watch?v=_OOWhuC_9Lw&feature=related

http://www.youtube.com/watch?v=NmDZVTeOlKI&feature=related

http://nursingcrib.com/case-study/diabetes-mellitus-case-study/

http://emedicine.medscape.com/article/117739-overview#IntroductionPathophysiology

COLLEGE OF NURSING

Silliman University

Dumaguete City, Negros Oriental

RESOURCE UNIT ON THE CARE OF HOSPITALIZED PEDIATRIC

PATIENTS WITHINSULIN-DEPENDENT DIABETES MELLITUSINSULIN-DEPENDENT DIABETES MELLITUS
http://www.youtube.com/watch?v=_OOWhuC_9Lw&feature=relatedhttp://www.youtube.com/watch?v=NmDZVTeOlKI&feature=relatedhttp://nursingcrib.com/case-study/diabetes-mellitus-case-study/http://emedicine.medscape.com/article/117739-overview#IntroductionPathophysiologyhttp://www.youtube.com/watch?v=_OOWhuC_9Lw&feature=relatedhttp://www.youtube.com/watch?v=NmDZVTeOlKI&feature=relatedhttp://nursingcrib.com/case-study/diabetes-mellitus-case-study/http://emedicine.medscape.com/article/117739-overview#IntroductionPathophysiology


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Submitted by:Rondario, Jezica Marie T.

BSN IV Section A4

Submitted to:Mrs. Ma. Magnolia Rose Partosa-Etea

Clinical InstructorDate of Submission: January 8, 2011

VISION

A leading Christian institution committed to total human development

for the well-being of society and environment.

MISSION

1. Infuse into the academic learning the Christian faith anchored onthe gospel of Jesus Christ; provide an environment where Christian

fellowship and relationship can be nurtured and promoted.2. Provide opportunities for growth and excellence in every

dimension of the University life in order to strengthen character,competence and faith.3. Instill in all members of the University community an enlightened

social consciousness and a deep sense of justice and compassion.4. Promote unity among peoples and contribute to national

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