PEDIATRIC NURSING

1. Diabetes Mellitus
Presented by
Mrs. Arifa T N, Second year M.Sc Nursing, MIMS CON

2. INTRODUCTION
 DM is a chronic disorder of metabolism characterized by hyperglycemia and
insulin resistance.
 It is the most common metabolic disease, resulting in metabolic adjustment or
physiologic change in almost all areas of the body
 Childhood diabetes, also referred to as juvenile or growth-onset diabetes, is
characterized by wide-range of metabolic abnormalities of carbohydrates,
proteins and fats in the body.

3. DEFINITION
Diabetes mellitus, the most common metabolic disease in children, is a
disorder of hyperglycemia resulting from defects in insulin secretion, insulin
action, or both, leading to abnormalities in carbohydrate, protein, and fat
metabolism (American Diabetes Association [ADA], 2014a)

4. INCIDENCE
 The most recent statistics (2010) indicate that in the United States,
approximately 215,000 children younger than 20 years old have either type 1
or type 2 diabetes (Centers for Disease Control and Prevention, 2010)
 It is estimated that childhood diabetes accounts for around 5% of total
population of diabetics. In India alone, there are likely to be about 4,00,000
infants and children with this disease.
 The odds are higher for African-American and Hispanic children—nearly 50% of
them will develop diabetes.
 DM in children can occur at any age, but 40% of children diagnosed are
between 10 to 14 years old and 60% are between 15 to 19 years old.
 Girls are 1.3 to 1.7 times more likely to develop type 2 diabetes than boys

5. Childhood Diabetes vs Adult Diabetes

6. CLASSIFICATION
 The old categories were insulin-dependent diabetes mellitus (IDDM), or type I,
and non–insulin-dependent diabetes mellitus (NIDDM), or type II.
 The new terms are type 1 and type 2, using Arabic symbols to avoid
confusion (e.g., type II could be read as type eleven)

7.  Type 1 DM
 Diabetic ketoacidosis
 Hypoglycemia
 Type 2 DM

9. Type 1 diabetes
 Characterized by destruction of the pancreatic beta cells, which produce
insulin; this usually leads to absolute insulin deficiency
 Type 1 diabetes has two forms.
 Immunemediated DM results from an autoimmune destruction of the beta cells; it
typically starts in children or young adults who are slim, but it can arise in adults
of any age.
 Idiopathic type 1 refers to rare forms of the disease that have no known cause.

10. Clinical Manifestations of Type 1
Diabetes Mellitus
 Polyphagia
 Polyuria
 Polydipsia
 Weight loss
 Enuresis or nocturia
 Irritability; “not himself” or “not
herself”
 Shortened attention span
 Lowered frustration tolerance
 Dry skin
 Blurred vision
 Poor wound healing
 Fatigue
 Flushed skin

11. Clinical Manifestations of Type 1
Diabetes Mellitus
 Headache
 Frequent infections
 Hyperglycemia
 Elevated blood glucose levels
 Glucosuria
 Diabetic ketosis
 Ketones and glucose in urine
 Dehydration in some cases
 Diabetic ketoacidosis (DKA)
 Dehydration
 Electrolyte imbalance
 Acidosis
 Deep, rapid breathing (Kussmaul
respirations)

13. Pathophysiology

14. Pathophysiology

15. Diagnosis
Based on the presence of classic symptoms and one of the following plasma
glucose levels
 HbA1c greater than or equal to 6.5%
 Fasting plasma glucose greater than or equal to 126 mg/dL (7 mmol/L), no
caloric intake for at least 8 hours
 Two-hour plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L)
during an oral glucose tolerance test
 Random plasma glucose concentration greater than or equal to 200 mg/dL
(11.1 mmol/L) in a patient with classic symptoms of hyperglycemia

16. Diagnosis
 When an asymptomatic child’s screening test reveals an elevated glucose
level, confirmation of a second fasting plasma
 An oral glucose tolerance test is rarely required
 Other laboratory tests for known autoantibodies
 Plasma C-peptide levels are low or undetectable in type 1 diabetes, indicating
little or no insulin secretion
 A careful history is necessary to rule out a stress-related illness,
corticosteroid use, fracture, acute infection, cystic fibrosis, pancreatitis, or
liver disease

17. Treatment
 Clinical therapy for type 1 diabetes combines
 Insulin,
 Nutrition
 Management to support growth and maintain blood glucose at near-normal levels,
 An exercise regimen, and
 Psychosocial support

18. Insulin Therapy.
 Multiple approaches to insulin therapy for children and adolescents are
available, and an approach that works for the child and family should be
selected.
 Children often need several daily injections of insulin before meals and at
bedtime to maintain an optimal blood glucose level.
 A basal-bolus insulin regimen has resulted in improved glycemic control in the
pediatric population
 When multiple injections are used, basal insulin is administered once a day
using a very long-acting insulin (Glargine or Detemir)
 A bolus of rapid-acting insulin (insulin lispro, insulin glulisine, or insulin
aspart) is administered with each meal and snack based on the carbohydrate
grams consumed and the blood glucose level

19.  If basal-bolus therapy for type 1 diabetes is to be effective, the child and
family need to do each of the following:
 Monitor the blood glucose appropriately to establish insulin requirements. For
example, test glucose before and 2 hours after meals, as well as once a week at
midnight and 3 a.m.
 Count carbohydrates consumed.
 Incorporate exercise into the daily routine
 Continuous subcutaneous insulin infusion (CSII) pump therapy has been used
successfully in children of all ages and has been found to improve glycemic
control with less hypoglycemia

20.  Tight blood glucose control has long-term benefits and is becoming a standard
of care for children of all ages

21. Nutrition Therapy.
 The goal of nutrition therapy is to provide adequate calories for the child’s
normal growth and development
 Evaluation of the child’s food intake, metabolic status, and lifestyle is necessary
before establishing a nutrition plan
 Generally, 1 unit of insulin covers 15 g of carbohydrates, making insulin dosage
calculation for meal coverage relatively easy; however, a different ratio of insulin
to carbohydrates may be calculated for individual children
 A high-fiber diet is also recommended for improved control of blood glucose

22. Exercise Program
 Physical activity is associated with increased insulin sensitivity.
 Regular exercise and fitness improve glucose control, reduce cardiovascular risk
factors, contribute to weight loss, and improve overall well-being.
 Blood lipid levels area also positively affected. However, the child must have an
adequate caloric intake to prevent hypoglycemia.
 Excessive exercise associated with sports requires careful planning and
management

23. Complications of type 1 diabetes
 Due tolong term hyperglycemic effects on the blood vessels.
 Retinopathy,
 Heart disease,
 Renal failure, and peripheral vascular disease

24. Nursing management
Nursing Assessment and Diagnosis
 Physiologic Assessment
 Assess the child’s physiologic status, focusing on vital signs and level of
consciousness.
 Assess hydration by checking mucous membranes, skin turgor, and urine output.
 Blood initially is collected to monitor blood gases, glucose, and electrolytes. The
frequency of blood collection will depend on whether the child is in diabetic
ketoacidosis.
 When the child is stable, assess dietary and caloric intake and the ability of the
child or family to manage care

25.  Psychosocial Assessment
 Assess coping mechanisms, family strengths and resources, ability to manage the disease, and
educational needs of both the child and parents.
 Developmental Assessment
 Assess the child’s developmental level, particularly fine motor skills and cognitive level.
 Children can usually perform some of the tasks with supervision by 6 to 8 years of age.
 Adolescents often perceive type 1 diabetes as a disability and may deny having the disease so
they can be like their peers when eating and exercising.
 Talk with the adolescent and assess problem-solving skills associated with daily condition
management, and the ability to manage special circumstances such as illness or changes in
exercise.
 Self-management is the eventual goal, and the child’s responsibilities are gradually
increased.

26. Nursing diagnosis
 Imbalanced nutrition less than body requirement
 Ineffective Breathing Pattern
 Ineffective Coping
 Readiness for enhanced family process
 Risk for Deficient Fluid Volume
 Risk for complications

27. Provide Education
 Initial teaching focuses on
 the survival skills necessary for home management, including insulin
administration, blood glucose testing, meal planning, and the recognition and
treatment of both hypoglycemia and hyperglycemia.

28. Emotional support
 Provide the family with information about diabetes education programs,
 Refer them to support groups with other parents of children with diabetes,
and assist them in learning the role of disease management.
 Support for the child depends on age and developmental stage.
 Encourage the child to express feelings about the disease and its
management.
 The adolescent may benefit from contact with other adolescents who have
diabetes.

29. Home Care Teaching
 Diabetic regimen (insulin administration, food plan, blood glucose monitoring,
and exercise) into the family’s present lifestyle..
 Provide written materials and refer parents to books and other materials they
can use in teaching the child about diabetes.

30. Community care
 Maintain a record of the child’s growth measurements and vital signs. Review
the child’s typical dietary intake and exercise regimens
 Continually work with the child to encourage responsibility for self-care and
with parents to promote the child’s self-care
 Explain to parents that the child should wear some type of medical alert
identification
 Help them have an individualized school health plan developed
 To ensure that school administrators and teachers can identify the signs of
hypoglycemia or hyperglycemia and provide emergency

31. Diabetic ketoacidosis (DKA
 Diabetic ketoacidosis (DKA) is a common and potentially lifethreatening
condition that occurs primarily in children with type 1 diabetes.
 Potential causes of DKA include incorrect or missed insulin doses, incorrect
administration of insulin, or an illness, trauma, or surgery.
 DKA may be present in children with new-onset diabetes.

32. Pathology
 Insulin deficiency is accompanied by a compensatory increase in hormones
(epinephrine, norepinephrine, cortisol, growth hormone, and glucagon) that
are released when inadequate glucose is delivered to the cells.
 The muscle cells break down protein into amino acids that are then converted
to glucose by the liver, leading to hyperglycemia.
 The adipose tissue releases fatty acids that are transformed by the liver into
ketone bodies.
 Their accumulation leads to ketoacidosis.
 The hyperglycemia causes an osmotic diuresis resulting in dehydration,
acidosis, and hyperosmolality.
 The rising ketones lead to metabolic acidosis.
 DKA is associated with severe metabolic, electrolyte, and fluid imbalances

33. Clinical features
 Characteristic signs of DKA include polyuria, polydipsia, weight loss,
abdominal pain, nausea and vomiting, tachycardia, signs of dehydration,
flushed ears and cheeks, Kussmaul respirations, acetone breath (fruity smell),
altered level of consciousness, and hypotension. Hyperglycemia, glycosuria,
and ketonuria are also present.
 In response to metabolic acidosis, children complain of abdominal or chest
pain, nausea, and vomiting.
 The disorder may progress to electrolyte disturbances, arrhythmias, altered
consciousness, pupillary changes, irregular respirations, inappropriate slowing
of the heart rate, and widening pulse pressure

34. Diagnosis
 Diabetic ketoacidosis is present with the following findings:
 blood glucose level greater than 250 mg/dL, serum ketones, acidosis (pH less than
7.3 and bicarbonate less than 15 mEq/L), and ketonuria.
 Alteration in electrolytes occur.
 The blood urea nitrogen (BUN) and creatinine are elevated

35. Management
 The child with ketoacidosis is hospitalized.
 Medical management includes isotonic intravenous fluids and electrolytes for
dehydration and acidosis.
 Intravenous insulin (0.1 unit kg perhour) is administered by continuous
infusion pump to decrease the serum glucose level at a rate not to exceed
100 mg/ dL/hr.

36. Complications in DKA
 Faster reduction of hyperglycemia and serum osmolality increases the risk for
cerebral edema. When glucose is lowered too rapidly, water is freed and
attracted to the glucose, which has accumulated in large quantities in the
brain.
 Cerebral edema is the most common complication of DKA and the most
common cause of death in children with diabetes .
 As insulin and fluids are administered, potassium shifts to the cells, resulting
in hypokalemia.
 Potassium replacement is needed as hypokalemia can lead to cardiac
arrhythmia.

37. Nursing management
 Continuously monitor the child’s vital signs, respiratory status,perfusion, and
mental status
 Assess for changes in neurologic status, respiratory pattern, blood pressure,
and heart rate
 Monitor for cardiac arrhythmias associated with hypokalemia.
 Assess for signs of dehydration, including dry skin and mucous membranes and
depressed fontanelles in infants.
 Monitor blood glucose levels hourly or as indicated
 Frequently monitor the electrolytes and acid–base status, as well as urine
glucose and ketone
 Assess for signs of hypoglycemia that may occur during insulin infusion

38.  Intravenous fluids are given in boluses of 10 to 20 mL/kg rapidly over 5
minutes if the child is in hypovolemic shock.
 Adequate fluids are given to reverse the fluid deficit.
 The insulin infusion must be carefully titrated to control the gradual
reduction in hyperglycemia.
 The child is tapered off intravenous insulin and transitioned to subcutaneous
insulin when clinically stable.
 Oral feedings are reintroduced when the child is alert and the glucose level is
stabilized.

39.  The prevention of future episodes of DKA is important.
 The parents and child need to learn strategies to keep hyperglycemic
episodes from progressing to DKA.
 Parents should have specific instructions on how often to check the blood
glucose and when to check the urine for ketones when the child is sick.
 If the child has an elevated blood glucose and moderate or large amounts of
ketones, treatment with extra insulin and fluids can be initiated.
 Increased attention to blood glucose and urine ketone monitoring is especially
important when the child has significant stressors such as an illness.
 It is important for the child and family to understand that insulin is required
even when the child is not eating to counter the hormones secreted in
response to the stressor

40. Hypoglycemia
 Hypoglycemia can develop within minutes in children with type 1 diabetes
mellitus.
 Blood glucose levels suddenly drop or fall below 70 mg/dL.
 Children are at risk of hypoglycemia because of their rapid growth rates and
unpredictable eating habits and physical activity.

41. Causes
 Deceased caloric intake
 Increased exercise
 Overdose of insulin
 Gastroenteritis
 Common problem in neonates
 Infants and children
 Insulin excess
 B cell tumors
 Drug induced
 Beckwith syndrome
 Liver disease and hormonal
deficiency
 Fasting
 Other
 Galactosemia
 Fructose intolerance
 Maternal diabetes

43. Signs and symptoms
 Swelling
 Pallor
 CNS signs: irritability, headache, seizures and coma

44. Multidisciplinary management
 Administration of IV dextrose 2-4 mL/kg of 10 % to prevent permanent
damage to brain
 Care must be taken to avoid excess volume. Corticosteroids may also be given
if there is possibility of hypopituitarism

45. Nursing diagnosis
 Activity intolerance
 Alternation in comfort
 Potential for injury
 Sensory-perceptual alternation

46. Interventions
 Goal : the child's blood sugar will remain with normal limits
 For mild attacks, give food that increases the glucose level (eg: sugar, honey,
orange juice, milk)
 For moderate attacks give concentrated sugar solution
 Educate parents and other close to detect early symptoms
 Easily available sugar preparation

47. Type 2 diabetes
 Type 2 diabetes usually arises because of insulin resistance in which the
body fails to use insulin properly combined with relative (rather than
absolute) insulin deficiency.
 People with type 2 can range from predominantly insulin resistant with
relative insulin deficiency to predominantly deficient in insulin secretion with
some insulin resistance
 Type 2 diabetes is a disease associated with insulin resistance (an alteration
of the insulin receptor that signals the presence of insulin in the interior of
cells).

48. Risk factors for type 2 DM
 Significant risk factors for type 2 diabetes includes
 Obesity,
 Low levels of physical activity,
 Intake of high-energy foods,
 Low socioeconomic status, ethnicity, and
 Family history of diabetes (over 75% of children with type 2 diabetes have a first-
or second-degree relative with diabetes)
 The incidence was highest in children ages 10 to 19

49. Etiology and Pathophysiology
 Children who are obese are at risk to develop type 2 diabetes because the
excess body fat decreases the body’s ability to use insulin
 The onset of puberty and increased secretion of growth hormone are believed
to be contributing factors in the development of insulin resistance
 The pancreatic cells produce more insulin in an attempt to overcome the
insulin resistance and maintain a normal glucose tolerance. When the beta
cells are not able to produce enough insulin, blood glucose levels increase

50. Clinical Manifestations
 Signs and symptoms of type 2 diabetes vary.
 The child may not have any symptoms or may present with polydipsia,
polyuria, blurred vision, and fatigue
 Acanthosis nigricans is described as a hyperpigmentation and thickening of
the skin with velvety irregularities in the skin folds of the back of the neck,
axillae, and flexor skin surfaces.
 The child with type 2 diabetes is usually obese with a high waist
circumference.
 Approximately 5% to 25% of children with type 2 diabetes present with
ketoacidosis at the time of diagnosis

51. Diagnosis
 Blood glucose levels of 200 mg/dL or greater without fasting or a fasting
glucose of 126 mg/dL or greater, are diagnostic of diabetes
 HbA1c] predicts the average blood glucose over the past 3 months
 Islet cell autoantibodies, fasting insulin levels, and C-peptide levels are used
to help differentiate between type 1 and type 2 diabetes but are not
definitive.
 Islet cell autoantibodies are suggestive for type 1 diabetes; however,
autoantibodies specific to a certain antigen are not present in approximately
15% of children with type 1 diabetes.

52.  Additionally, some children with type 2 diabetes will have detectable
autoantibodies.
 Insulin and C-peptide levels are usually low in children with type 1 diabetes,
there is some overlap with type 2, so these values are not helpful with the
initial classification
 A fasting lipid profile is obtained since dyslipidemia (primarily elevated
triglycerides and LDL cholesterol) is usually present
 High blood pressure for age, gender, and height percentile is also seen

53. Clinical therapy
 The multiple goals
 Normalizing the blood glucose and hba1c levels,
 Decreasing weight,
 Increasing exercise,
 Normalizing lipid profile and blood pressure, and
 Preventing complications.

54. Clinical therapy
 If the child or adolescent presents with severe hyperglycemia or diabetic
ketoacidosis, insulin will be required to gain initial glycemic control.
 When metabolic control is achieved, oral medication (metformin) is initiated
as the child is weaned off of insulin.

55. Nursing management
 Nursing assessment and diagnosis
 Family history
 Monitor the child’s blood glucose levels and blood pressure.
 Assess the child’s diet and activity patterns to determine appropriate changes for
disease management.

56.  Diagnosis
 Activity intolerance
 Ineffective family health management
 Situational low self-esteem
 Planning and implementation
 Managing the child’s blood glucose levels and hypertension during the
hospitalization,
 Assessing growth and dietary intake,
 Evaluating goals for weight loss and exercise programs, and
 Reviewing the child’s knowledge about diabetes and strategies for management at
home

57.  Evaluation
 The child decreases sedentary activity time to less than 2 hours a day.
 The child’s daily intake of fruits and vegetables increases to five to eight servings
daily, and total fat intake decreases to less than 30% of total calories.
 The child’s BMI slowly and consistently decreases