Type 1 Diabetes Mellitus

Collaborative care
1. Primary goals of care (must be individually tailored
  1. Reach ideal blood sugar levels and maintain it
  2. educate both client and parent regarding the necessary skills and knowledge to manage the disease
  3. decrease symptoms and promote well-being
  4. prevent acute and non-acute complications
  5. delay onset and progression of long-term complications
  6. optimize quality of life for client and family
2. Nursing Care
  1. b) Insulin Therapy
    1. # of injections, timing, and dose of insulin per day
      1. dependent on age, lifestyle, meal plan, general health and motivation
      2. depends on family socioeconomic factors, and family, physician preferences
      3. dependent on duration of diabetes
        1) Honeymoon period - two years after initial dianosis
        low insulin required (< 0.5 units/kg/day)
        2) After the two years, intensive diabetes management
    2. Types
      1. i) and ii) used in conjunction with each other
        i) basal-bolus regimens
        Study: long and rapid-acting insulin-determir and glargine
        improves fast-acting blood glucose levels and fewer episodes of nocturnal hypoglycemia
        ii) continuous subcutaneous insulin fusion (insulin pump therapy)
        reduction in glycated hemoglobin (A1C) with reduced hypoglycemia for 12-24 mos.
  2. a) Glucose Monitoring
    1. 1) self-monitoring of glucose
      1. useful in evaluating individual response to therapy, to see if glycemic targets are being achieved
        computerized blood glucose meters most accurate and precise but proper patient education is mandatory
      2. prior to meals and snacks, at bedtime, and before exercise
    2. 2) Glycosylated Hemoglobin (HbA1c) Testing
      1. long-term assessment of glucose control
        evaluate whether planned insulin regimens is effective
        patient with stable glycemic levels: perform 2x/year
        patient with unstable glycemic levels or have recently changed their therapy: perform every 2-3 months
3. Nutrition
  1. Follow 4 Canadian food groups
  2. Individualized to one`s nutritional needs, eating habits and lifestyle
    1. planned and evaluated at least annually
  3. Teach using plate method
4. Lifestyle
  1. Smoking cessation
    1. increase risk for macrovascular and microvascular diabetes complications
      1. Teach about smoking prevention
  2. Safe sex
    1. avoid unplanned pregnancy
      1. increased risk of STDs, and other maternal and fetal complications
        education about sexual health and contraception
5. Psychological Issues
  1. Early identification, early intenvention to avoid impact over course of development
    1. increased risk for depression, anxiety, eating disorders
      1. associated with poor glycemic control
      2. affected by family distress- maternal anxiety and depression
  2. be aware of insulin omissions in young adult females to maintain body image
Nursing Management
1. 1) Assessment
  1. Non-Acute/Post stabilization of acute complications
    1. obtain complete health hx, and conduct physical assessment
      1. Look for: S&S of DKA, hemorrhages and exudates in the retina, presences of scars and wounds especially around feet, peripheral sensory loss, peripheral edema, presence of ankle and knee reflexes using a tendon hammer, carotid bruits for artherosclerosis
      2. Assess for history of mental health services, presence of family and social support for diabetes self-care tasks, alcohol and substance abuse history
    2. measure fasting blood glucose, urine ketone levels, hemoglobin A1c,
    3. psychological/social health
      1. Ability to perform self-care and to learn self-care skills
        visual, motor, and neuronal deficits, and literacy skills
      2. presence of family support and financial resources
  2. Acute
    1. DKA
      1. S&S: ketonuria, Kussmaul respirations, OHypo, lethargy, fruity breath odour nausea, vomiting, abdominal pain
        arterial blood pH < 7.3, serum bicarbonate level < 15 mEq/L, moderate to high levels of ketone in urine
    2. acute hypoglycemia
      1. S&S: weakness, fatigue, hunger, shakiness, nervousness, sweating, light-headedness, sleepiness, confusion, difficulty speaking, anxiety
        serum glucose level: <50 mg/dL in men, <45 mg/dL in women, <40 mg/dL in children
2. 2) Planning
  1. i) maintain optimal blood glucose level, fluid, and electrolyte balance
    1. ii) promote quality of life
      1. improve ability to perform self-care
      2. manage anxiety, depression
      3. improve nutritional intake and meet healthy weight goals
3. 3) Implementation
  1. Acute intervention
    1. maintain fluid and electrolyte balance
      1. IV fluid and/or oral fluids as prescribed
    2. insulin therapy
      1. Initially give IV bolus
        as pt condition improves gives subcutaneous injections
  2. health promotion
    1. address any misconceptions pt or family has about diabetes
    2. provide emotional support, setting aside time to talk with pt and.or family
      1. especially in a newly diagnosed patient
        in adult-diagnosed T1DM patients, sudden and new approach to daily life is needed
        barriers: not obtaining enough info about T1DM, limited time and access to appropriate healthcare network, social stigma with living with diabetes
      2. provide opportunities to express feelings about his ilness
    3. educate family and pt about diabetes self-care, nutrition, and healthy lifestyle
      1. focus on client-centred care, and promote client freedom and choice
        provide positive reinforcement for increasing involvement in self-care activities
        establish mutual and specific short-term and long-term goals for self-management in controlling blood glucose
        adult patients and family of younger patients should have adequate information to participate in decision making
        establish personal network of supportive healthcare professionals and family members
        2 years before child turn into adult (18 yrs of age), health care provider must begin to collaboratively develop a transition plan from pediatric to adult diabetes care
4. 4) Evaluation
  1. observe the stabilization of acute situations
    1. are blood glucose, ketone levels, and vital signs stabilized?
      1. yes
        Are they meeting the blood glucose, ketone level goals as individualized by their healthcare practitioners?
        yes
        Has patient's psychological/emotional status improved in comparison to the beginning of the encounter?
        Does the patient have a better understanding on the self-care interventions as suggested?
        no
        How can I correct/re-align their level of understanding of T1DM?
        How can nurse educational methods be adjusted to be more acceptable for the patient?
        How does the nurse feel about her experience with the patient?
        What improvements can be made next time?
        Does the patient seem receptive to the lifestyle changes as proposed?
        Make referrals to nutritionists, psychologists, and other healthcare professionals as needed
      2. no
        re-assess
Etiology and Epidemiology
1. happens most often in childhood, but adults can also develop it later in life
  1. general population risk: 1/300, 6/100 chance if a first degree relative was diagnosed (sister, brother, son, daughter
    1. More than 300,000 Canadians live with T1DM.
    2. pts with first-degree diagnosed relative
      1. annual screening before 10 yrs old, and 1 additional screening during adolescence
2. Cause of T1DM is still unknown, but studies suggest could be genetic or viral
  1. increased risk by mutation of the HLA genes
    1. HLA complex helps immune system distinguish the body's own proteins from foreign, pathological proteins
      1. When HLA complex is mutated, T-cells recognize endogenous insulin as invasive, subsequently destroying them
  2. Rubella, mumps, cytomegalovirus have been suggested to destroy insulin-producing beta cells
Pathology, Clinical Manifestations, and Co-morbidities
1. Body can't produce insulin
  1. no hormone to store glucose from food intake into liver, muscle, and fat cells
    1. unregulated glucose levels in blood
      1. polydipsia, polyphagia, polyuria, extreme fatigue, blurry vision, slow healing of cuts and bruises, weight loss despite massive food intake, tingling, pain, and numbness in peripheries
        Comorbidities
        Diabetic Ketoacidosis (leading cause of mortality in children with T1DM)- body digests lipids instead of glucose, and there is a buildup of ketones in the body
        prevented through early diagnosis and initiation of insulin therapy
        Nerve, capillary damage
        neuropathy, nephropathy, eye damage, foot damage, infections
        hypertension, artherosclerosis
        increased risk for heart attacks, heart failure, myocardial infarction
        dyslipidemia
Diagnosis
1. Glycated hemoglobin A1C >= 6.5
  1. If A1C not available or pregnant
    1. Random blood sugar test or a 75 g oral glucose tolerancetest >= 11.1 mmol/L
    2. Fasting blood sugar test >= 7 mmol/L on 2 separate tests
      1. Check for symptoms of polyphagia, polydipsia, and polyuria
        Ketone test to confirm type 1, not type 2

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Type 1 Diabetes Mellitus

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	Created by Katlyn Ai about 8 years ago