Diabetes

Irene Owens, MSN, ARNP

Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 What Is Diabetes Mellitus?
The inability of the body to
produce or respond properly to
the hormone insulin
Results in a malfunction of
carbohydrate, protein, and fat
metabolism
A chronic disease that requires
lifelong behavioral changes

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Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 Types of Diabetes
Type 1 diabetes Type 2 diabetes
Called insulin-dependent Called non-insulin-dependent
diabetes mellitus or juvenile- diabetes mellitus or adult-onset
diabetes
onset diabetes
Associated with older age, obesity,
Usually strikes children and family history of diabetes, history of
young adults, although disease gestational diabetes, impaired
onset can occur at any age glucose metabolism, physical
May account for 5% to 10% of inactivity, and race/ethnicity
all diagnosed cases of diabetes Increasingly being diagnosed in
children and adolescents

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 Diagnosis

Fasting plasma glucose

concentration of 126 mg/dL
or greater
2-hour plasma glucose is
200 mg/dL or greater during an
oral glucose tolerance test

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Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 Type 1 vs Type 2 Diabetes Mellitus
Type 1 Type 2
Insulin deficiency Insulin resistance
Abrupt onset Insidious onset
Ketosis prone Not prone to ketosis
Generally not obese Usually obese
Insulin dependent Noninsulin dependent
Not responsive to oral agents Responsive to oral
Onset usually 18 years or hypoglycemic medications
younger Onset usually in adults but seen
in obese adolescents

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 Type 1 Diabetes
Clinical manifestations
Polyphagia, polydipsia, and polyuria (3 Ps)
Unexplained weight loss
Blurred vision
Lack of energy
Diminished reflexes
Irritability
Nausea and vomiting
Fruity odor of breath
Kussmaul respirations

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Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 Type 1 Diabetes

Incidence: 15 per 100,000 people in North America

Peak ages of onset: between 10 and 12 years of age in girls
and 12 to 14 years of age in boys
Risk increases if the child or adolescent has a first-degree
relative or identical twin with disease
Type 1 diabetes may show a familial tendency
Theories for disease development include genetic
components, environmental influences such as viruses, and
an autoimmune response that causes the destruction of
insulin-secreting cells of the pancreas in the islets of
Langerhans

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Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 Type 1 Diabetes
Pathophysiology
90% of the insulin-secreting cells (Beta) of the pancreas
are progressively destroyed
Absence of insulin available for metabolism causes fats
and proteins to be burned
Characterized by chronic hyperglycemia
Ketones are produced as a byproduct of fat metabolism
Ketones cannot be used by the cells in the absence of
insulin
Ketones accumulate in the blood, causing metabolic
acidosis and ketonuria

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 Insulin Therapy
Onset of Peak Effect after
Name of Insulin
Action Injection
Humalog/Novolog
5-15 min 30-60 min
(very short acting)

Regular/short acting 30 min 2-3 hr

NPH/intermediate acting 1-2.5 hr 6-9 hr

Lente/intermediate acting 2-4 hr 8-12 hr

Ultra Lente/long acting 4-6 hr

8-15 hr

Lantus (glargine)/long None

24 hr
acting
Combinations:
30 min 7-12 hr
70/30, 50/50, 75/25
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 Complications of Insulin Therapy
Lipoatrophy
Lipohypertrophy
Dawn phenomenon
Somogyis phenomenon

Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 Acute Complications of Diabetes
Diabetic ketoacidosis (DKA)
Hyperglycemic-hyperosmolar state (HHS)- was
called Hyperglycemic-hyperosmolar-
nonketotic syndrome (HHNS) in the past
Hypoglycemia from too much insulin or too
little glucose

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 Insulin Therapy
Divided as two thirds
before breakfast and
one third before dinner
Two thirds as intermediate,
one third as short or rapid
Twice-daily regimen
most common

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Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 Insulin Therapy
Rotation of sites
Mix insulin from clear to cloudy
Inject in subcutaneous tissue
Do not premix any insulin unless advised
Timing of injections in relation to meals
Insulin can be stored at room temperature
Only regular insulin may be administered
intravenously

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 Insulin Delivery Systems
Current systems
Syringes
Insulin pens
Insulin pumps

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 Monitoring
Glucose testing is more accurate and is the
preferred method of monitoring glucose
levels
Glycosylated hemoglobin (hemoglobin A1c)
level is usually measured every 3 months to
evaluate long-term control
The higher the hemoglobin A1c, the poorer
the control has been over the last 3 months

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 Benefits of Regular Physical Activity

Helps the body use glucose more effectively

Weight loss and maintenance
Increases HDL and lowers LDL cholesterol
Lowers blood glucose levels
Muscular strength
Cardiorespiratory (aerobic) fitness
Increases bone mass
(through weight-bearing activities)
Relieves anxiety and stress
Increases self-esteem
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 Complications of
Diabetes: Hypoglycemia
Blood sugar of usually less than 70 mg/dL
Clinical manifestations
Shakiness, dizziness
Sweating
Hunger
Headache
Irritability
Pale skin color
Sudden moodiness or behavior changes, such as crying for
no apparent reason
Blurred vision
Increased heart rate
Weakness and fatigue
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 Complications of Diabetes: Hypoglycemia
Causes
Too little food
Too much insulin
Extra or vigorous exercise
Treatment
Severe symptoms may require administration of
intramuscular glucagon
Fruit juice, carbonated soda, several hard candies
Follow with some protein and a complex
carbohydrate
Test and monitor blood sugar once symptoms
subside

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 Complications of Diabetes: Hyperglycemia

Blood glucose greater than 180 mg/dL and

stays there for several readings
Clinical manifestations
Extreme thirst
Frequent urination
Blurred vision
Drowsiness
Nausea
Hunger
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Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 Complications of Diabetes: Hyperglycemia

Causes
Not enough insulin
Larger food intake than usual
Less exercise than usual
Illness such as cold or flu
Stresses from family, school, or personal
situations
Treatment
Push sugar-free liquids
Insulin
Activity
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 Illness Management
Continue insulin treatment
Patients with type 1 diabetes need insulin to live. Illness
often increases the amount of insulin the body needs.
Insulin should never be withheld.
Stay close to the meal plan
If a patient has an upset stomach and cannot eat, give
clear liquids that contain carbohydrates
(sports drinks, juices, gelatin, broth, frozen fruit bars).
Give plenty of liquids
Encourage the patient to drink as much water and other
noncaffeinated beverages as possible.

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 Illness Management
Choose medications wisely
Many over-the-counter medications contain
sugar and/or alcohol.
Glucose in medications can rapidly add up;
patients should look for a glucose-free version
of the medication. If unavailable,
carbohydrates must be accounted for in the
meal plan.
Alcohol-free medicines are best.
Many decongestants can raise blood glucose
levels.

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Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 Food for Sick Days

Patients may not want to eat when sick

They must eat to keep the body from burning fats for fuel and
to speed healing.
Food ideas for sick days for patients with diabetes include:

Fluids Solids
1 double-stick popsicle Crackers
1 cup electrolyte sports Vanilla wafers
drink Graham crackers
1 cup soup 1 slice dry toast
1/2 cup fruit juice (not light bread)
1/2 cup regular soft drink Mashed potatoes
(not diet) Regular gelatin dessert

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 Long-Term Complications
of Diabetes
Microvascular problems
Neuropathy
Retinopathy
Nephropathy
Macrovascular problems
Peripheral vascular disease
Atherosclerosis

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 Developmental Issues
Infants
Very rapid growth
Continuing brain development
Trusting relationships with the parents
Erratic eating habits
(food can become a power struggle)
Erratic sleep patterns
Treatment schedule is difficult to keep because
of feeding and sleeping patterns

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 Developmental Issues
Toddlers
Can participate in some self-care
Look for parental approval while they test
their limits
Show decreased appetite and picky eating
habits (easily distracted from eating)
Begin to show more regular sleep patterns
Difficult to distinguish a low blood sugar
reaction from a normal temper tantrum

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 Developmental Issues
Preschool
Peer issues begin to emerge
Can understand rules
Can perform more self-care, including blood tests
under parental supervision
Eating behavior is less erratic
Very energetic, so hypoglycemia can be a problem
Regular sleep patterns
May be more challenging to provide snacks and
meals that match what siblings and friends eat

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 Developmental Issues
School age
Fear of being different from other children
Can perform most self-care, including blood tests
and insulin injections
Eager to learn
Beginning to understand consequences of their
actions
Tests independent decision making
Most time spent away from home

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 Developmental Issues
Early adolescence
Erratic growth, which affects insulin requirements
Glucose control may be erratic in spite of everyones
best efforts
Concerned about body image
Greatly influenced by friends
May challenge authority
Development of self-esteem
Beginning to understand abstract concepts

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 Developmental Issues
Adolescence
Puberty is well underway
Concerned with physical appearance
Clearer sense of self (can set goals)
Increased autonomy
Risk-taking behaviors, including not taking insulin and
not performing blood sugar tests
Many social activities are unpredictable
Counseling regarding contraception, alcohol,
and smoking

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 Proper Foot Care
Foot injury is the most common complication
of diabetes leading to hospitalization
Prevention of high-risk conditions
Peripheral sensation management
Footwear
Foot care

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 Chronic Pain
Neuropathic pain results from damage to the
nervous system anywhere along the nerve
Pharmacologic agents
Nonpharmacologic interventions

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Ineffective Tissue Perfusion: Renal
Interventions include:
Control of blood glucose levels
Yearly evaluation of kidney function
Control of blood pressure levels
Prompt treatment of UTIs
Avoidance of nephrotoxic drugs
Diet therapy
Fluid and electrolyte management

Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
Risk for Injury Related to Disturbed
Sensory Perception: Visual
Interventions include:
Blood glucose control
Environmental management:
Incandescent lamp
Coding objects
Syringes with magnifiers
Use of adaptive devices

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 Potential for Hypoglycemia
Blood glucose level <70 mg/dL
Diet therapycarbohydrate replacement
Drug therapyglucagon, 50% dextrose,
diazoxide, octreotide
Prevention strategies for:
Insulin excess
Deficient food intake
Exercise
Alcohol

Elsevier items and derived items 2007, 2002 by Saunders, an imprint of Elsevier Inc.
 Resources for Parents and Children
American Diabetes Association www.diabetes.org/home.jsp

Children with Diabetes

www.childrenwithdiabetes.com/index_cwd.htm
KidsHealth
kidshealth.org

The Lawson Wilkins Pediatric

Endocrine Society www.lwpes.org

The Magic Foundation

www.magicfoundation.org

The US National Library of Medicine National Institutes of Health

www.nlm.nih.gov/medlineplus/encyclopedia.html

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