Type 1 Diabetes Mellitus Nursing Care Management and Study Guide

Type 1 diabetes is autoimmune destruction of the insulin-producing beta cells, leaving the child with an absolute insulin deficiency and a lifelong dependence on exogenous insulin. Most pediatric diabetes is type 1. Your job is glucose control, recognizing hypoglycemia and DKA fast, and teaching a child and family to run insulin, diet, and activity for the rest of their lives.

What is Type 1 Diabetes Mellitus?

Diabetes mellitus (DM) is a chronic metabolic disorder from an absolute or relative deficiency of insulin, an anabolic hormone. Type 1 diabetes, also called insulin-dependent diabetes mellitus (IDDM) and juvenile diabetes mellitus, is the body's inability to produce insulin because of autoimmune destruction of the pancreatic beta cells. Insulin is produced by the beta cells of the islets of Langerhans in the pancreas; their absence, destruction, or loss results in type 1 diabetes. DM is often thought of as an adult disease, but at least 5% of cases begin in childhood, usually around 6 years of age or near puberty.

Pathophysiology

Insulin is essential for processing carbohydrate, fat, and protein. It lowers blood glucose by letting glucose enter muscle cells and by driving glucose into glycogen stores (glycogenesis); it inhibits release of stored glucose from liver glycogen (glycogenolysis), slows the breakdown of fat to triglycerides, free fatty acids, and ketones, and stimulates fat storage; it also blocks the breakdown of protein and fat for glucose production (gluconeogenesis) in the liver and kidneys.

Hyperglycemia (random blood glucose more than 200 mg/dL or 11 mmol/L) results when insulin deficiency unleashes gluconeogenesis and prevents the use and storage of circulating glucose. The kidneys cannot reabsorb the excess glucose, so glycosuria, osmotic diuresis, thirst, and dehydration follow, while increased fat and protein breakdown drives ketone production and weight loss. The brain runs on glucose, so when levels drop below 65 mg/dL (3.2 mmol/L), counterregulatory hormones (glucagon, cortisol, epinephrine) are released and hypoglycemic symptoms appear. The exact glucose level at which symptoms develop varies widely between people and over time in the same person, depending on duration of diabetes, frequency of hypoglycemic episodes, rate of fall, and overall control.

Statistics and Incidences

The overall annual incidence of DM is about 24.3 cases per 100,000 person-years. Most new diabetes cases are type 1 (about 15,000 annually), though increasing numbers of older children, especially in minority groups, are being diagnosed with type 2 (3700 annually). Between 2002 and 2012, incidence of both types rose significantly among US youths: after adjustment for age, sex, and race or ethnic group, type 1 (ages 0-19 years) and type 2 (ages 10-19 years) underwent relative annual increases of 1.8% and 4.8%, respectively.

Incidence varies widely by geography. Annual incidence runs from 0.61 cases per 100,000 in China to 41.4 cases per 100,000 in Finland. Whites have the highest reported incidence and Chinese individuals the lowest, and type 1 is 1.5 times more likely in American whites than in American blacks or Hispanics. Males are at greater risk in high-incidence regions, particularly older males whose rates often show seasonal variation, while females are at greater risk in low-incidence regions. Onset in the first year of life is unusual but possible, so consider type 1 in any infant or toddler, since these children carry the greatest mortality risk if diagnosis is delayed.

Clinical Manifestations

The most recognizable symptoms are secondary to hyperglycemia, glycosuria, and DKA. Hyperglycemia alone may cause little, though some children report malaise, headache, weakness, irritability, and ill temper. Glycosuria drives increased urinary frequency and volume (polyuria), troublesome at night (nocturia) and often causing enuresis in a previously continent child. Polydipsia is insatiable thirst secondary to osmotic diuresis and dehydration. Polyuria is the dramatic rise in urine output. Polyphagia is increased hunger and intake. Weight loss can be dramatic even with a good appetite, and failure to thrive and wasting may be the first signs in an infant or toddler, preceding frank hyperglycemia. Nonspecific malaise is often recognized only in retrospect. Diabetic ketoacidosis (DKA) shows drowsiness, dry skin, flushed cheeks, cherry-red lips, acetone breath with a fruity smell, and Kussmaul breathing.

Assessment and Diagnostic Findings

Early detection and control are key to postponing or minimizing later complications.

Monitor children with a family history using a fingerstick glucose test, and check the urine for ketones with a dipstick. If glucose is elevated or ketonuria is present, draw a fasting blood sugar (FBS); an FBS of 200 mg/dl or higher is almost certainly diagnostic when other signs are present. Lipid profiles are usually abnormal at diagnosis from increased circulating triglycerides driven by gluconeogenesis. Glycated hemoglobin derivatives (HbA1a, HbA1b, HbA1c) form from a nonenzymatic reaction between glucose and hemoglobin, and there is a strong correlation between average blood glucose over an 8- to 10-week period and the proportion of glycated hemoglobin. Microalbuminuria is the first evidence of nephropathy; an increased AER is commonly defined as a first morning-void urinary albumin-to-creatinine ratio exceeding 10 mg/mmol, or a timed overnight AER of more than 20 mcg/min but less than 200 mcg/min.

Medical Management

Management combines insulin therapy with a meal and exercise plan.

Insulin therapy is essential, with the dose adjusted to blood glucose to keep levels near normal; many children are on a regimen given two times daily, before breakfast and before the evening meal. Diet emphasizes a healthy, balanced plan high in carbohydrate and fiber and low in fat. Type 1 requires no activity restrictions, and exercise has real benefits, with current guidelines sophisticated enough to let children compete at the highest levels. The American Diabetes Association's Standards of Medical Care in Diabetes-2018 recommend considering continuous glucose monitoring for children and adolescents with type 1, whether on injections or continuous subcutaneous insulin infusion, to aid glycemic control.

Pharmacologic Management

Insulin is always required for type 1 diabetes, and is also used for type 2 unresponsive to diet and/or oral hypoglycemics.

• Insulin aspart (rapid-acting). FDA-approved for children aged >2 y with type 1 DM for SC daily injections and SC continuous infusion by external pump; not studied in pediatric type 2 DM. Onset 10-30 minutes, peak 1-2 h, duration 3-6 h.
• Insulin glulisine (rapid-acting). Established for SC injection in pediatric patients aged 4-17 y with type 1 DM; not studied in pediatric type 2 DM. Onset 20-30 minutes, peak 1 h, duration 5 h.
• Insulin lispro (rapid-acting). Only lispro U-100 is FDA-approved to improve glycemic control in children aged >3 y with type 1 DM; not studied in children with type 2 DM. Onset 10-30 minutes, peak 1-2 h, duration 2-4 h.
• Regular insulin (short-acting). Novolin R is FDA-approved for pediatric patients aged 2-18 y with type 1 DM; not studied in pediatric type 2 DM. Humulin R is indicated for pediatric patients with DM requiring more than 200 units of insulin per day, though there are no well-controlled studies of concentrated Humulin R U-500 in children.
• Insulin NPH (intermediate-acting). Indicated to improve glycemic control in pediatric patients with type 1 DM. Onset 3-4 h, peak 8-14 h, usual duration 16-24 h.
• Insulin glargine (long-acting). Glargine U-100 is established in pediatric patients aged 6-15 y with type 1 DM; not studied in pediatric type 2 DM.
• Insulin detemir (long-acting). Indicated for once- or twice-daily SC use in pediatric patients aged 6-17 years with type 1 DM; not studied in pediatric type 2 DM. Onset 3-4 h, peak 6-8 h, duration ranges from 5.7 h (low dose) to 23.2 h (high dose).
• Insulin degludec (ultra-long-acting). FDA-approved for pediatric patients aged >1 y with type 1 or type 2 DM. Reaches steady state in about 3-4 days, peak plasma time 9 h, duration at least 42 h. It is highly protein bound, and after SC injection the protein binding gives a depot effect.

Nursing Management

Nursing Assessment

Take a history from the caregiver covering symptoms leading up to the present illness: appetite, weight loss or gain, polyuria or new enuresis in a previously toilet-trained child, polydipsia, dehydration, irritability, and fatigue. Include the child and encourage them to contribute. On physical exam, measure height and weight, inspect the skin for dryness or slow-healing sores, note signs of hyperglycemia, record vital signs, collect a urine specimen, and run a bedside blood glucose.

Nursing Diagnoses

• Imbalanced nutrition, less than body requirements, related to insufficient caloric intake for growth and the body's inability to use nutrients.
• Risk for impaired skin integrity related to slow healing and decreased circulation.
• Risk for infection related to elevated glucose levels.
• Deficient knowledge related to complications of hypoglycemia and hyperglycemia.
• Deficient knowledge related to appropriate exercise and activity.

Nursing Care Planning and Goals

• Maintain adequate nutrition.
• Promote skin integrity.
• Prevent infection.
• Regulate glucose levels.
• Adjust to living with a chronic disease.
• Learn to manage hypoglycemia and hyperglycemia, insulin administration, and the child's exercise needs.

Nursing Interventions

Ensure adequate, appropriate nutrition. The child needs a sound program that supports normal growth while keeping blood glucose near normal. Build a balanced plan around the child's food preferences, cultural customs, and lifestyle, and if a meal will be late, give a complex carbohydrate and protein snack.

Prevent skin breakdown. Teach the caregiver and child to inspect the skin daily and treat even small breaks promptly. Encourage daily bathing, drying well afterward with attention to skin-on-skin areas like the groin, axilla, and other folds, and emphasize good foot care.

Prevent infection. Diabetic children are more susceptible to urinary tract and upper respiratory infections, so teach the family to watch for and report signs of either. Insulin is never skipped during illness, and fluids must be increased.

Regulate glucose. Monitor blood glucose to keep it within normal limits, checking at least twice a day, before breakfast and before the evening meal. Offer support, let the child voice fears, and acknowledge that the fingerstick hurts and it is fine to dislike it.

Teach hypoglycemia and hyperglycemia management. If blood glucose is higher than 240 mg/dl, test the urine for ketones. Know the most likely times for a rise or fall relative to the child's insulin, and teach the family to recognize the signs of both hypoglycemia and hyperglycemia.

Evaluation

Goals are met when the child and caregiver maintain adequate nutrition, promote skin integrity, prevent infection, regulate glucose levels, adjust to the chronic disease, and learn to manage hypoglycemia and hyperglycemia, insulin administration, and exercise needs.

Documentation Guidelines

• Individual findings: contributing factors, interactions, the nature of social exchanges, and specifics of behavior.
• Intake and output.
• Cultural and religious beliefs and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.