Appropriate nursing care is essential to positive long-term management of type I and type II diabetes mellitus. Diabetes management should reflect the growing and changing needs of the child with Type I (or II). Monitoring for evidence of complications, problems with management, and providing education on this disease and management is one of the responsibilities of the nurse. It is imperative for other caregivers such as teachers and school nurses, as well as relatives to be aware of the child's diagnosis so that they can be trained and educated on the management strategies required for the child. This will ensure a continuum of care while the child is out of the home.
The nurse must be readily available to provide such assistance and take advantage of every opportunity to educate the patient and family in order to expand their understanding and skills for management (Potts & Mandleco, 2007).
Once the patient is medically stable, then education of the patient and their family members can commence. Education does not occur only upon diagnosis but is an ongoing process. Teaching opportunities are available at every meeting with the child and family.
It is important to educate the patient and family on survival strategies, concepts and skills on diabetes to ensure adequate management, which include:
1. Essential nature of insulin therapy
2. Identifying prescribed insulin
3. Preparing an accurate injection
4. Giving an injection with proper technique
5. Blood glucose monitoring and documentation
6. Urine testing for ketones
7. Understanding how to obtain supplies and equipment
8. Hypoglycemia and hyperglycemia, their causes, signs and symptoms, treatments
9. Understanding whom to call and when
10. Identifying the daily routine (timing of injections, when to do blood testing, when to eat)
11. Wearing medical identification
12. Meal planning
(Potts & Mendleco, 2007, p. 906)
Blood Glucose and Ketone monitoring
Proper instruction on blood glucose and urine-ketone monitoring should be addressed. Technique and rationale for both tests should be explained to the family. Writing down the results in a log after blood glucose monitoring should be reinforced since this will keep track of the progress in managing diabetes. This documentation will serve as a way to track "success of the regimen by identifying problem area and successful strategies for management" (Potts & Mandleco, 2007, p. 907).
In blood glucose monitoring, teach the patient the proper technique to lance the testing site with the small lancet such as using the side of the finger since the pads and tips of the finger contain many nerve endings and few capillaries (Potts & Mandleco, 2007).
Teach family and patient to test urine for ketones when glucose level is >240mg/dL and when the patient is ill (Klosser & Hatfield, 2010). It is important to stress to the family that illness will cause glucose levels to fluctuate therefore it will be important to keep a watchful eye on the patient during this time.
Signs and Symptoms of Hypoglycemia and Hyperglycemia
Educate on the signs and symptoms of hypoglycemia and hyperglycemia and how to treat each one respectively. Inform the caregiver that hypoglycemia is more likely to occur than hyperglycemia. However, if in doubt, treat as hypoglycemia. Instruct on the preparation and use of hypoglycemia agents such as glucagon kit and glucose tablets (Klossner & Hatfield, 2010).
Nutrition
Diet and meal plan instruction is typically given by a dietician or nutritionist. The nurse should help the family understand basic concepts about food intake increasing blood glucose levels and the need for consistent times for eating is essential (Potts & Mandleco, 2007). Options to discuss are: Exchange List, Caloric Requirements, Read Nutrition labels, Glycemic Index, Healthy Food Choices (Portion Control).
Hygiene
Good hygiene is also important in the patient with diabetes. Routine visits to the dentist are recommended, usually every 6 months. Since the patient with diabetes is at risk for poor wound healing it is important to make the dentist and staff aware since dental work and cleanings may injure the gums.
Proper foot care must be addressed since the individual with diabetes has poor circulation in their lower extremities. Remind family and patient to never be barefoot and ensure proper fitting of shoes. Careful trimming of toenails should be reminded and perhaps a referral to a podiatrist may be needed.
Individuals with diabetes are susceptible to yeast infections so proper cleansing of genitalia is taught.
Complications
Also important to educate families and patients is the complications of diabetes when not adequately controlled. Diabetes is the leading cause of blindness, kidney failure, and amputations in the United States (Potts & Mandleco, 2007).
Microvascular complications include neuropathy, nephropathy, and retinopathy and result from glycosylation, a process where proteins from the blood become deposited in the basement membrane of small vessels (glomeruli, retina) and become trapped by "sticky" glucose compounds (Hockenberry, 2005, p. 1080). Over time the buildup of these substances will cause the vessels to narrow and will cause subsequent interference with microcirculation to the affected areas (Hockenberry, 2005). In neuropathy glycosylation occurs on the sheath of nerves, thus interrupting neurotransmission of stimuli. With poor control, vascular changes can occur within 2.5-3 years after diagnosis and with good control, it may take 20 years or more (Hockenberry, 2005).
People who have been diagnosed at <30 years of age, have a reduced life expectancy of 15 years. Therefore it is more important than ever to have the patient and family understand the relationship between glucose control and development of long-term complications and that they can be avoided with an ideal therapy since near normal glucose control provides the best protection/prevention of long-term complications (Potts & Mandleco, 2007).
The nurse must be readily available to provide such assistance and take advantage of every opportunity to educate the patient and family in order to expand their understanding and skills for management (Potts & Mandleco, 2007).
Once the patient is medically stable, then education of the patient and their family members can commence. Education does not occur only upon diagnosis but is an ongoing process. Teaching opportunities are available at every meeting with the child and family.
It is important to educate the patient and family on survival strategies, concepts and skills on diabetes to ensure adequate management, which include:
1. Essential nature of insulin therapy
2. Identifying prescribed insulin
3. Preparing an accurate injection
4. Giving an injection with proper technique
5. Blood glucose monitoring and documentation
6. Urine testing for ketones
7. Understanding how to obtain supplies and equipment
8. Hypoglycemia and hyperglycemia, their causes, signs and symptoms, treatments
9. Understanding whom to call and when
10. Identifying the daily routine (timing of injections, when to do blood testing, when to eat)
11. Wearing medical identification
12. Meal planning
(Potts & Mendleco, 2007, p. 906)
Blood Glucose and Ketone monitoring
Proper instruction on blood glucose and urine-ketone monitoring should be addressed. Technique and rationale for both tests should be explained to the family. Writing down the results in a log after blood glucose monitoring should be reinforced since this will keep track of the progress in managing diabetes. This documentation will serve as a way to track "success of the regimen by identifying problem area and successful strategies for management" (Potts & Mandleco, 2007, p. 907).
In blood glucose monitoring, teach the patient the proper technique to lance the testing site with the small lancet such as using the side of the finger since the pads and tips of the finger contain many nerve endings and few capillaries (Potts & Mandleco, 2007).
Teach family and patient to test urine for ketones when glucose level is >240mg/dL and when the patient is ill (Klosser & Hatfield, 2010). It is important to stress to the family that illness will cause glucose levels to fluctuate therefore it will be important to keep a watchful eye on the patient during this time.
Signs and Symptoms of Hypoglycemia and Hyperglycemia
Educate on the signs and symptoms of hypoglycemia and hyperglycemia and how to treat each one respectively. Inform the caregiver that hypoglycemia is more likely to occur than hyperglycemia. However, if in doubt, treat as hypoglycemia. Instruct on the preparation and use of hypoglycemia agents such as glucagon kit and glucose tablets (Klossner & Hatfield, 2010).
Nutrition
Diet and meal plan instruction is typically given by a dietician or nutritionist. The nurse should help the family understand basic concepts about food intake increasing blood glucose levels and the need for consistent times for eating is essential (Potts & Mandleco, 2007). Options to discuss are: Exchange List, Caloric Requirements, Read Nutrition labels, Glycemic Index, Healthy Food Choices (Portion Control).
Hygiene
Good hygiene is also important in the patient with diabetes. Routine visits to the dentist are recommended, usually every 6 months. Since the patient with diabetes is at risk for poor wound healing it is important to make the dentist and staff aware since dental work and cleanings may injure the gums.
Proper foot care must be addressed since the individual with diabetes has poor circulation in their lower extremities. Remind family and patient to never be barefoot and ensure proper fitting of shoes. Careful trimming of toenails should be reminded and perhaps a referral to a podiatrist may be needed.
Individuals with diabetes are susceptible to yeast infections so proper cleansing of genitalia is taught.
Complications
Also important to educate families and patients is the complications of diabetes when not adequately controlled. Diabetes is the leading cause of blindness, kidney failure, and amputations in the United States (Potts & Mandleco, 2007).
Microvascular complications include neuropathy, nephropathy, and retinopathy and result from glycosylation, a process where proteins from the blood become deposited in the basement membrane of small vessels (glomeruli, retina) and become trapped by "sticky" glucose compounds (Hockenberry, 2005, p. 1080). Over time the buildup of these substances will cause the vessels to narrow and will cause subsequent interference with microcirculation to the affected areas (Hockenberry, 2005). In neuropathy glycosylation occurs on the sheath of nerves, thus interrupting neurotransmission of stimuli. With poor control, vascular changes can occur within 2.5-3 years after diagnosis and with good control, it may take 20 years or more (Hockenberry, 2005).
People who have been diagnosed at <30 years of age, have a reduced life expectancy of 15 years. Therefore it is more important than ever to have the patient and family understand the relationship between glucose control and development of long-term complications and that they can be avoided with an ideal therapy since near normal glucose control provides the best protection/prevention of long-term complications (Potts & Mandleco, 2007).
*Observe for any signs and symptoms in all members of a family with a history of diabetes. The family should be taught to observe the patient for frequent thirst, urination, and weight loss. All relatives of diabetics are considered high-risk and should be tested periodically.
Dietary Concerns: Alcohol
- Alcohol is absorbed before other nutrients
- Large amounts can be converted to fat and increase risk for DKA
- Alcohol can interfere with glucose production = hypoglycemia
- Impaired patient may not be able to recognize S & S hypoglycemia
- Teach pt to eat if consuming alcohol
Dietary Concerns: Sweeteners
- Moderation in sweeteners is encouraged
- Sweeteners have been approved by the
FDA for safe use for people with DM - Saccharin (Sweet N Low)
- Aspartame (NutraSweet)
- ----4 calories per packet, loses sweetness with heat
- Sucralose (Splenda)
- ----600 times sweeter than sugar
Illness and Stress
- Illness and stress may contribute to hyperglycemia
- Increase in stress hormones = increase in glucose levels
- Do not eliminate insulin doses when nausea & vomiting occur
- Take prescribed sick day dose and eat frequent, small portions of carbohydrates
- Drink fluid to prevent dehydration
- Monitor BS & urine ketones every 3-4 hours
- Report Blood Glucose levels of > 300 or ketones in urine to physician