Type 1 Diabetes Mellitus

Type 1 Diabetes Mellitus

1. Assessment

   • Signs
     • excessive thirst
       • An excess amount of sugar in the blood forces the kidneys to excrete in urine, which pulls out the water in the body with it. This causes excessive thirst and frequent urination
     • frequent urination
     • sudden weight loss
       • Fat and ketones are broken down to provide energy for cells and compensate for lack of glucose in cells. This causes a rapid drop in weight
   • Symptoms
     • fatigue
       • Glucose is needed because it provides energy to the cells of target tissues. Since there is no insulin, glucose is staying in the blood and out of the tissues. The tissues have no energy, making the person feel fatigued and dizzy
     • dizziness
     • blurred vision
   • Questions to consider
     • Is there a family history of Type 1 Diabetes?
     • How has this been affecting your daily life?

2. Diagnosis

   • What is Type 1 Diabetes?
     • "Insulin dependent diabetes"
     • Hyperglycemia (high blood sugar) due to little/no insulin in the body
       • Destruction of beta cells in the pancreas can no longer produce insulin
         • Body needs insulin to break down glucose and take it into cells to use as energy
           • No insulin = no sugar being taken into cells = no glucose being used as energy
             • HIGH AMOUNT OF SUGAR IN BLOOD
   • What causes Type 1 Diabetes?
     • Idiopathic or immunological processes
       • LADA (Late Autoimmune Diabetes in Adults)
       • Pathologic Hyperglycemia
       • Maturity Onset Diabetes of the Young (MODY2 & MODY3 due to HNF-1 alpha gene)
   • What are ways to test if you have Type 1 Diabetes?
     • Blood Test for blood sugar levels
       • Glycated Hemoglobin Tests
       • Fasting blood sugar test
       • Random blood sugar test

3. Planning

   • Identify the goals of the patient
     • Task Mastery
     • Physical Motivation
     • Social Motivation
   • Determine cognitive ability of the patient/parent/guardian and other factors that affect care
     • Age
       • If the child is too young, explain to family when their child is to take meds, signs of hypo/hyperglycemia, what to do when each happens, when to call a healthcare provider, when/how to check blood sugar, modifying diet and exercise routine, collaborating with the child’s school, etc.
     • Education level
       • Give parent tips on educating/involving their child in their own health care plan
         • The use of storytelling (and mutual storytelling to check their understanding of the subject), the use of play to create a constant exposure to their new environment/lifestyle change, involving siblings/other family members, explaining using pictures and flow charts
     • Lifestyle
       • Develop a care plan with the patient/family that works around their current lifestyle (school, soccer practice, etc.)
     • Social supports
   • What are potential barriers affecting their care?
     • Lack of social support
       • Refer the patient and/or their family to local support groups, resources they may need etc.
     • Geographical Location
     • Lack of education/understanding
       • Make sure to explain concepts at the level of education that they are familiar/comfortable with. Clarify difficult concepts, and go through procedures etc explaining why things are done. Then review with the patient and/or their family to check their level of understanding

4. Implementation

   • Go through medication administration with parent/patient/guardian
     • How to administer pens/syringe/etc.
       • Rotate injection site of same body part for each administration
         • Possible sites: Abdomen, anterior thigh, upper arm, scapular area of upper back, ventrodorsal gluteal area
           • AREAS TO AVOID: areas with bony prominence, large blood vessels, is inflamed or tender, is on a paralyzed/inactive limb, is excoriated/edematous/scar tissue
           • Cleanse site with alcohol, pinch 2.5cm of the skin, insert needle at 45 or 90 degree angle, release skin and Inject without aspirating. Withdraw needle and place antiseptic swab and apply pressure over the injection site. Follow needle stick precautions and discard needle and sharps in designated receptacle. Assess patient and provide ongoing evaluation of effect of medication (i.e. glycemic control).
     • How many times a day medications should administered
     • Different kinds of insulin therapy
       • Long acting, short acting, mixed, etc.
   • Teach patient and their families the signs and symptoms of both hyper and hypoglycemia
     • Collaborate and create a care plan what to do when this happens
       • "I'm sweaty, cold, and clammy, give me some candy!"
         • When showing signs of hypoglycemia, give simple carbs like sugar
     • Hypoglycemia: Nervousness, irritability, Confusion, Tachycardia, Hunger, Nausea, Fatigue, Seizures, Loss of Consciousness
     • Hyperglycemia: Loss of Appetite, Vomiting, Thirst, Polyuria, Weakness, Tachypnea, Exsiccosis, Metabolic Acidosis
     • 4-8 mmol/L are normal, but under 4 is low and over 10 is high for a child with Type 1 Diabetes
       • Wash hands with soap and warm water. Puncture the side of the finger pad rather than near the center. The puncture should be only deep enough to obtain a sufficiently large drop of blood. Unnecessarily deep punctures may cause pain and bruising.Lancets should be disposed of in designated “sharps” containers obtained from drug stores.

5. Evaluation

   • Psychosocial Response
     • Have the patient's goals been met?
       • Is the patient feeling better?
     • Has the patient displayed effective coping strategies?
       • Is the patient making good lifestyle choices (healthy diet, exercise, etc.)?
       • Has the patient been supported by family, friends etc.?
       • Is this treatment plan feasible for the patient
         • If not, reevaluate and collaborate with the patient/family and brainstorm a more viable and effective treatment plan
   • Physical Response
     • Have the signs and symptoms that were experienced earlier diminished?
     • Are there any signs/symptoms of further complications?
       • Diabetic Ketoacidosis (DKA)
         • When fat is broken down for energy because there is not enough insulin to break down sugar. This causes the release of ketones, which changes blood pH (more acidic). This is released in urine, and electrolytes that the body needs follow it out of the body. This can cause hypovolemia, shock, kidney failure, coma and death
       • Blood Vessel Damage
         • Diabetic Foot Syndrome
           • Ulcers due to inappropriate footwear or Ischemic Foot Disease which leads to necrosis due to lack of perfusion resulting from peripheral occlusion.
         • Macroangiopathic Damage
           • Peripheral Arterial Occlusion Disease, Arteriosclerosis of Coronary arteries, Heart Attack, Arteriosclerosis of cerebral arteries, Cerebral infarction
         • Microangiopathic Damage
           • Diabetic Glomerulosclerosis, Renal Hypertrophy, Diabetic Retinopathy
       • Hyperglycemic Hyperosmotic Nonketotic Syndrome (HHNS)
         • A life-threatening syndrome that can occur in the patient with diabetes who is able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion. Laboratory values in HHNS include blood glucose greater than 34 mmol/L and an increase in serum osmolality. Ketone bodies are absent or minimal in both blood and urine.
       • Diabulimia
         • An eating disorder that involves overdosing on insulin in order to break down fat and lose weight
     • Glycated Hemoglobin Tests
       • Measurement of degree of glucose control during previous 3 months (lifespan of hemoglobin molecule); shows management of blood sugar level
         • Less than 7% good for patients with diabetes
     • Is there damage to surrounding tissue of insulin injection site?

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