Juvenile Diabetes Mellitus | CHAPTER 13 | Pediatric Nursing

Juvenile Diabetes Mellitus – Health of the children has been considered as the vital importance to all societies because children are the basic resource for the future of humankind. Nursing care of children is concerned for both the health of the children and for the illnesses that affect their growth and development. The increasing complexity of medical and nursing science has created a need for special area of child care, i.e. pediatric nursing.

Pediatric nursing is the specialized area of nursing practice concerning the care of children during wellness and illness. It includes preventive, promotive, curative and rehabilitative care of children. It emphasizes on all round development of body, mind and spirit of the growing individual. Thus, pediatric nursing involves in giving assistance, care and support to the growing and developing children to achieve their individual potential for functioning with fullest capacity.

Juvenile Diabetes Mellitus

Definition of Diabetes Mellitus:

Diabetes mellitus is a disorder of glucose intolerance due to deficiency in insulin production and its action leading to hyperglycemia and abnormalities in carbohydrate, protein and fat metabolism.

(Ref: Paediatric Nursing, Parul Datta/34/402)

Clinical Features of Diabetes Mellitus:

Classical triad features:

• Polyuria
• Polyphagia
• Polydipsia

Other features are:

• Nocturia
• Enuresis (who was earlier dry)
• Weight loss General weakness Tiredness, and bodily pains.
• Fainting attack due to hypoglycemia
• Pain abdomen Nausea & vomiting.
• Irritability
• Vulvovaginitis in girls
• Skin infection, dry skin
• Poor wound healing.

(Ref: Paediatric Nursing, Parul Datta/34/403)

Classification of Diabetes Mellitus:

A. Type I or insulin dependent diabetes mellitus (IDDM):

a) Immune mediated

b) Idiopathic

B. Type II or non-insulin dependent diabetes mellitus (NIDDM):

a) Insulin resistance.

b) Pancreatic beta -cell failure.

C. Other specific types:

a) Genetic defects of beta cell function.

b) Genetic defect of insulin action.

c) Pancreatic disease:

• Pancreatitis.
• Pancreatectomy.
• Neoplastic disease
• Cystic fibrosis
• Haemochromatosis
• Fibrocalculous pancreatopathy.

d) Excess endogenous production of hormonal antagonists to insulin:

• GH hormone-Acromegaly
• Glucocorticoid-Cushing’s syndrome.
• Glucagon-Glucagonoma
• Catecholamines-Phaeochromocytoma.
• Thyroid hormone -Thyrotoxicosis.

e) Drug induced: Corticosteroid, thiazide diuretics, phenytoin

f) Viral infections: Congenital rubella, mumps, Coxackie virus B.

g) Uncommon forms of immune-mediated diabetes.

h) Associated with genetic syndromes:

• Down’s syndrome.
• Klinefelter’s syndrome
• Turner’s syndrome
• DIDMOAD/Wolfram’s syndrome:
• (Diabetes insipidus, DM, optic atrophy, nerve deafiaess, Friedreich ataxia, myotonic dystrophy)

D. Gestational diabetes mellitus.

(Ref-Davidson-807/22)

Features of type-1 DM:

• It results from autoimmune destruction of beta cells.
• It is characterized by gross deficiency of insulin (insulinopenia) and dependence on exogenous insulin for prevention of ketoacidosis.
• It occurs mainly in childhood, juvenile-onset diabetes though there is no age bar.
• Majority of type I cases are idiopathic.

(Ref: Paediatric Nursing, Parul Datta/3rd/402)

Features of type – 2 DM:

• It is rare in children and not associated with autoimmune process or disease.
• It is usually not insulin dependent and not complicated by ketoacidosis.
• Previously it was known as adult-onset diabetes or maturity onset diabetes or stable diabetes.

(Ref: Paediatric Nursing, Parul Datta/3rd/402)

Nursing Management of DM:

Nursing Assessment:

• History of onset of signs and symptoms and associated problems like weight loss, pain abdomen, dehydration, etc. along with detailed history of illness.
• Physical examination to detect physical signs, slow healing sore, fruity smell to breath (acetone breath due to ketosis).
• Assessment of cardiac function-tachycardia, hypotension, arrhythmias, dehydration.
• Assessment of renal function-urine output, glycosuria, ketonuria, intake-output balance chart.
• Assessment of Gl function-dietary intake, diarrhea, constipation, hunger, thirst, flatullence.
• Assessment of neurologic status-numbness, pain, change in gait, tingling sensation of the extremities. Assessment of growth and development, presence of complications, review of self- monitoring record, etc.

Nursing Diagnosis

Important nursing diagnoses should include the followings;

• Altered nutritional intake due to insulin deficiency and alteration of metabolism.
• Knowledge deficit related to insulin therapy.
• Knowledge deficit related to blood glucose monitoring.
• Risk of injury related to hypoglycemia.
• Fluid-volume deficit related to DKA.
• Fear and anxiety related to long-term illness.
• Risk for infection related to hyperglycemic state.

Nursing Interventions;

• Providing nutritional requirement as planned to prevent complications and to promote growth.
• Increasing knowledge and skill about insulin therapy.
• Using rotation of sites methods for injections at upper arms and thighs.
• Outer areas of abdomen and hips may also be used. Insulin syringe with measuring scale, (same as unit strength of insulin) is required for administration of insulin.
• Aseptic technique to be followed during SC injections.
• Urine testing to be done before insulin injection and meal to be kept ready.
• Record to be maintained for urine test findings and insulin dose.
• Observing for any complications and encouraging to express feeling.
• Providing instructions about self-monitoring of blood glucose level
• Identifying and controlling hypoglycemia-informing about symptoms of hypoglycemia it’s cause and prevention.
• Restoring fluid balance by IV fluid therapy in DKA.
• Reducing fear and anxiety by emotional support and health teaching on home care, follow-up, ophthalmic checkup, blood testing, exercise, play, avoidance of stress and trauma, continuation of school activities, identity card as diabetic, signs of hypo- or hyperglycemia, etc.
• Preventing infections by aseptic measures of injection, routine immunization, general cleanliness, hygienic measures especially care of skin, feet, legs, hands and prevention of cuts and injuries.

(Ref: Paediatric Nursing, Parul Datta/3rd/405)

Complications of DM

Management of DM in Adult:

Principle management of diabetes is “3D”

1. Discipline

2. Diet

3. Drugs

A. Discipline:

a) Patient motivation and education are central, idea about how to avoid complication ( eg. Hypoglycemia, long term complication of hyperglycemia)

b) Lifestyle changes: Diet, exercise, (insulin resistance)

c) Regular follow up

d) Tight BP control

B. Diet:

a) Restricted diet: Sweet, sugar, saturated fat

b) Measured diet: Carbohydrate 60%, Protein 20%, fat 20%

• Daily energy intake (calories):
• An obese middle aged or elderly person – 1000to 1600 kcal daily
• A young active person 1800 to 3000 Kcal daily (if overweight <1800 Kcal daily)
• Carbohydrate:
• Daily intake from 100g to maximum 300g
• If 300g, 3 main meals = 180 mg, 3 snacks = 90 g and 0.5 liters of milk = 30gm
• Consumption of both soluble fibre supplements and fibre rich foods (eg. barley, beans, peas)
• Protein – Moderate protein
• Fat-Total intake of fat should be reduced
• Alcohol – low intake but abstinence if obesity or hypertension
• Salt-Reduced intake (<6g daily)
• Diabetic foods and sweeteners

c) Unmeasured diet: Green vegetables, tomato or lemon, cucumber

d) Types of diabetic diets:

• Low energy, weight reducing diet: A diet of 1000 Kcal/day (1500Kcal in active person)
• Weight maintenance diet
• Nibbling

Say weight 60 kg, so energy 1200 Kcal, Now it is given on the course of the day

Example:

1. 3 main meals:

• Morning: 2 slice bread + 1 egg + vegetables + dal
• Midday: 1.5 plate rice + vegetables + fish + meat + dal
• Night: 3 slice bread + vegetable + dal nogen sigion

2. In each of snacks (eg. at 11 am, 5 pm and 11 pm): 2 piece protein biscuit or 1 small banana + 1 biscuit

3. Milk without cheese, 0.5 litters in the course of the day

C. Drugs:

a) Oral hypoglycemic drugs:

• Sulphonylureas eg. chlorpropamide (indication: non obese patients with NIDDM who fails to respond dietary measure alone)
• Biguanides eg. metformin (indication: obese patients with NIDDM or in combination with sulfonylures)

b) Insulin:

• Unmodified (eg. actrapid): Short acting
• Modified (eg. monotard, isophane): Intermediate and long acting

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