Type 1 Diabetes Mellitus
Rosa Reyes, RN
California State University, CA
July 30, 2012
Type 1 Diabetes Mellitus
Objective 1
Diabetes is a group of related conditions, each potentially resulting in elevated blood glucose levels. Insulin, a hormone secreted by the beta cells in the pancreas is responsible for controlling blood glucose levels. Diabetes may result from defects in insulin secretion or action or a combination of both factors (Childs, Cypress & Spollett, 2009, pg. 2). The diagnosis of diabetes is based on elevation of blood glucose levels. The most common forms of diabetes are designated as Type 1, Type 2 and Gestational. The subject of this portfolio is regarding Type 1.
The pathophysiology of Type 1 Diabetes can be divided into autoimmune-mediated diabetes and idiopathic diabetes. In autoimmune-mediated diabetes, insulin producing beta cells are destroyed by an autoimmune-mediated process (Childs, Cypress & Spollett, 2009, pg. 7). Beta cells are usually totally destroyed, however, in some patients, destruction is incomplete and this results in some residual insulin production. The rate of this destruction is varied. In children, it is often rapid and in adults, it may take several years. Antibody markers are usually seen. These include islet cell antibodies, insulin autoantibodies, and antibodies to glutamic acid decarboxylase (GAD), among others. Antibodies that are present early in the course of diabetes may subsequently become undetectable (Childs, Cypress & Spollett, 2009 pg. 7). There are well-recognized associations with several genes in the HLA (human leukocyte antigen) loci, including both predisposing and protective genes. Patients with Type 1 diabetes have increased incidences of other autoimmune diseases, including Hashimoto’s thyroiditis, Graves’ disease, pernicious anemia, vitiligo, celiac disease and Addison’s disease.
Idiopathic diabetes is a less common form of Type 1 diabetes, there is no evidence of autoimmune disease and immune markers are absent. This appears to be inherited, and the cause is unknown. Idiopathic diabetes is more common in people of African or Asian ethnic origin and is characterized by episodic ketoacidosis and varying degrees of insulin deficiency (Childs, Cypress & Spollett, 2009, pg. 7). The need for insulin replacement is intermittent – it comes and goes.
According to Childs, Cypress & Spollett, (2009), Type 1 diabetes occurs most frequently in children and young adults, but can be diagnosed at any age, even in the eighth and ninth decade. The rate of beta cell destruction varies; it is typically more rapid in younger individuals who frequently present with severe symptomatic hyperglycemia or sometimes with diabetic ketoacidosis. This suggests severe insulin deficiency. Insulin therapy is required for survival in these patients (Childs, Cypress & Spollett, 2009, pg. 8). Patients with slower beta cell destruction may retain some insulin secretion for many years. As the disease progresses, they require insulin for survival and are at risk of ketoacidosis. Patients with Type 1 diabetes are not typically obese at diagnosis.
Patients with diabetes are at risk of chronic microvascular and macro vascular complications. Cardiovascular disease (CVD) which includes stroke, peripheral vascular disease, hypertension, angina, myocardial infection (MI), heart failure, and sudden cardiac death, is the leading cause of death in patients with Type 1 or Type 2 diabetes.(Childs, Cypress & Spollett, 2009, pg. 91) Patients with diabetes are two to three times more likely to develop CVD than people without diabetes. Diabetic retinopathy is the leading cause of new blindness in Americans aged 20-74 years, and is up to 90% of diabetes - related blindness is preventable (Childs, Cypress & Spollett, 2009, pg. 113). Nurses can help in prevention by encouraging diabetes self-management knowledge and skills to promote glycemic and blood pressure control. Risk factors that contribute to the development of renal disease include duration of diabetes, however, only 30-50% of Type 1 patients develop diabetic. nephropathy. Diabetic neuropathy is a chronic disorder that affects bothe the peripheral nervous system (sensory and motor) and the autonomic nervous system. It is the most common of all long-term complications and the least understood.
References:
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 2
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 7
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 7
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 7
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 8
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 91
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 113
Objective 2
Attempts to prevent Type 1 diabetes have been largely unsuccessful. The multicenter Diabetes Prevention Trial (New England Journal of Medicine 346:1685-1691, 2002) in Type 1 diabetes sought to prevent the development of Type 1 diabetes in people at high risk by using low-dose injected insulin. These interventions proved ineffective. The Diabetes Prevention Program (New England Journal of Medicine 346: 393-403, 2002) demonstrated that Type 2 diabetes could be either prevented or delayed in a population of people identified to have increased risk of diabetes or pre-diabetes.
Type 1 diabetes is characterized by autoimmune beta cell destruction, which is attributed to a genetic predisposition coupled with one or more viral agents and possibly chemical agents (Blacks, & Hawk, 2009, pg. 1369). The onset and progression of hyperglycemic symptoms are usually more rapid and acute in Type 1 diabetes compared to Type 2 and successful treatment depends on insulin replacement. Insulin is the principle treatment for hyperglycemia associated with Type 1 diabetes (Childs, Cypress, Spollett, 2009, pg. 36). Patients with diabetes must integrate several diabetes treatment components into their lifestyle, including insulin action times, food intake and physical activity. The role of other regulatory hormones, like glucagon and amylin, is also important to know.
The body normally controls blood glucose levels by a continuous secretion of a small amount of insulin, termed "basal insulin" and then superimposes a "bolus" when people eat. It is possible to closely mimic the pattern of basal and bolus insulin using exogenous insulin (Childs, Cypress, Spollett, 2009, pg. 37). For most individuals with Type 1 diabetes, a basal-bolus approach to management is the best choice. The basal insulin reduces hepatic glucose production, keeping it in equilibrium with the use of basal glucose by the brain and other tissues. After meals, bolus insulin secretion stimulates glucose use and storage while inhibiting hepatic glucose output, thus limiting the meal-related glucose excursion. Patients with Type 1 diabetes lack both basal and bolus insulin production; the basal-bolus approach allows for the most flexible lifestyle (Childs, Cypress, Spollett, 2009, pg. 37). Basic nursing skills necessary include understanding of this concept and being able to educate patients. Self-monitoring of blood glucose (SMBG) is essential to diabetes control regardless of treatment strategies. Pattern management is the method of choice for making insulin dose adjustment and is essential when using basal-bolus insulin therapy with rapid and long acting insulin(Childs, Cypress & Spollett, 2009, pg. 41). Optimal pattern management uses several days of SMBG records along with journaling of food, emotions, and physical activity. Nursing interventions includes helping patients learn problem-solving skills in relation to blood glucose levels and insulin dosing.
Education regarding hyperglycemia and hypoglycemia is key to nursing interventions. Patients need to be taught to recognize symptoms, causes and treatment. Education specifically on correcting hypoglycemia is a basic nursing skill. With basal-bolus insulin therapy, 15g/15min rule becomes important (Childs, Cypress, Spollett, 2009, pg. 42). This rule suggests that to treat hypoglycemia, the patient should take 15g of rapid acting glucose, wait 15 minutes, recheck blood glucose, and if levels are still low, retreat with additional 15g of rapid acting glucose. Previously, this was followed by a complex carbohydrate/protein snack, however this may not be necessary unless NPH insulin is being used.
Food planning and carbohydrate counting is important and allows flexibility for the patient with Type 1 diabetes. Rapid acting insulin (bolus) dose can be adjusted based on the carbohydrate consumption at any given time (Childs, Cypress, Spollett, 2009, pg. 43). The key to achieving the greater flexibility in meal timing and portions afforded by basal-bolus therapy is learning to count carbohydrate intake and match insulin doses appropriately. This can be taught with medical nutrition therapy given by an RD, nursing intervention could be to ensure referral to RD.
Exercise typically lowers blood glucose levels (Childs, Cypress, Spollett, 2009, pg. 44). The individual will need to either increase caloric intake or decrease insulin with additional physical activity. Key is to educate, individualize plan and monitor blood glucose.
The major education objective is to match the level of self-management to the ability of the individual patient (Blacks, & Hawk, 2009, pg. 1389). Basic nursing skills for nurses would include knowledge about Type 1 diabetes and being able to educate both patient and family. Type 1 diabetes typically affects children, so it is essential to be able to communicate with family and alleviate fears associated with diagnosis. Prevention of complications from poorly controlled diabetes involves being able to convey the importance of following guidelines including blood glucose control, insulin action, food intake and physical activity.
References:
Diabetes Prevention Trial – Type 1 Diabetes Study Group: Effects of insulin in relatives of patients with Type 1 diabetes Mellitus. New England Journal of Medicine 346:1685-1691, 2002
Diabetes Prevention Program Research Group: Reduction in the incidence of Type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine 346: 393-403, 2002
Blacks, J. & Hawk, J., (2009) Medical-Surgical Nursing (8th ed.) St. Louis, MO: Mosby Elsevier, pg. 1369
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 36
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 37
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 37
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 41
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 42
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 43
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 44
Blacks, J. & Hawk, J., (2009) Medical-Surgical Nursing (8th ed.) St. Louis, MO: Mosby Elsevier, pg. 1389
Objective 3
Diabetes self-management and related metabolic outcomes are associated with the development of diabetes-related complications. Thus, optimal glycemic control is the goal of diabetes care and patient education interventions. An individual’s personal response and participation in self-management are often based on a complex set of health beliefs, perceptions and practices that are culturally embedded (Childs, Cypress & Spollett, 2009, pg. 205).
According to research by Caban and Walker (2006), the following topics were determined to be cultural issues for Hispanics with diabetes: understanding the experience of diabetes, susto (scare or fright) as a perceived cause of diabetes, perspectives about God and living with diabetes, use of folk healers in diabetes care and the use of alternative treatments.
Understanding the experience of diabetes-Hispanics connected their development of diabetes to lifestyle factors, death of a family member, trauma to the body and also as a punishment or retribution for previous self-indulgence. The concept of susto (scare or fright) is common belief. Susto, by its traditional definition is a folk illness caused by a scare or emotionally traumatic event that results in “soul loss” and induces a state of anxiety, insomnia, appetite loss and social withdrawal. The patients interviewed did not view susto as an illness but as a condition that preceded the diagnosis (Caban & Walker, 2006, pg. 590) Susto would be a cultural issue for family and can impact care because the belief to “cure” susto is to pray and “sweep” with herbs and other substances. Perspectives about god and living with diabetes include beliefs that the diagnosis of diabetes is part of God’s will. Some people perceive God as a source of support, others perceived God as controlling their diabetes and others perceived their diagnosis as a punishment from God. These beliefs are important to assess and consider in educating family members. Use of folk healers in diabetes care, researchers state that home remedies were most frequently used as complementary treatment of diabetes and that curanderos were generally not consulted for diabetes-related care. However, little research is available that evaluated the use of folk healers (Caban & Walker, 2006, pg. 590 ). Alternative treatments include the use of herbs to treat disease. Hispanics who participated also indicate that they used alternative treatment for diabetes, especially if they were recommended by people the trusted.
A cultural assessment addresses and identifies patient’s beliefs and practices in the family and individual. Culturally competent education and care requires skills of cross cultural communication, interpretation and intervention. Special consideration for patients with Type 1 diabetes, specifically to children. Depending on the age of the child, the assessment may also need to be done on the parents. Some parents or caregivers may feel responsible for the child’s diagnosis and may be dealing with guilt. Nursing staff also needs to be compassionate and empathetic.
References:
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 205
Caban, A. & Walker, E. (2006) A systematic review of research on culturally relevant issues for Hispanics with diabetes. The Diabetes Educator, Volume 32, Number 4, July /August 2006, 590. Doi:10.1177/0145721706290435
Caban, A. & Walker, E. (2006) A systematic review of research on culturally relevant issues for Hispanics with diabetes. The Diabetes Educator, Volume 32, Number 4, July /August 2006, 590. Doi:10.1177/0145721706290435
Objective 4
Discharge planning for the newly diagnosed Type 1 patient anticipates what the patient will need to continue diabetes management at home and must be initiated early in admission. Levels of diabetes education include survival, home management and improvement of lifestyle. Survival skills are essential for Type 1 patient, including insulin administration, hyperglycemia and hypoglycemia signs, symptoms and treatment, glucagon use, ketone testing, importance of monitoring blood glucose, meal planning and activity (Blacks, & Hawk, 2009, pg. 1386).
Teach proper insulin administration, have patient and or caregiver give return demonstration of insulin injections to ensure proper technique (Blacks, & Hawk, 2009, pg. 1386). If patient is a child, then much of the teaching will be done with parent or caregiver. Assess injection sites to determine need for changing site and explain need for alternating site. In addition to syringes with needles, insulin pens and other delivery devices are available today (Childs, Cypress, Spollett,2009, pg. 46). Insulin storage and administration are basic nursing skills that must be taught to patients with Type 1 diabetes. Self-injection education includes site selection, proper use of delivery method, rates of absorption, rotating site, insulin timing and action, and disposal of sharps.
Explain and review steps to prevent hyperglycemia/hypoglycemia, including recognizing symptoms and treatment( Blacks & Hawk, 2009, pg. 1386). Patient (and caregiver) will need to know symptoms of hypoglycemia (cold sweats, weakness trembling, nervousness, irritability, pallor, increase in heart rate, confusion, fatigue and/or abnormal behavior) vs. hyperglycemia (increase in urination, increase in appetite, weakness, fatigue, blurred vision, headache, nausea and vomiting). Best thing to teach them is to check blood glucose if unsure. Treatment is completely different, hypoglycemia requires sugar to increase blood glucose and hyperglycemia requires insulin to reduce blood glucose. The rule of 15g/15min (mentioned in Objective 2) should be explained in detail. Ensure patient has prescription for Glucagon Kit and proper use. Glucagon Kit is important specifically to Type 1 patient due to their risk of hypoglycemia due to insulin use.
Explain and demonstrate Self Monitoring Blood Glucose (SMBG) (Blacks & Hawk, 2009, pg. 1386). Patients and their caregiver must learn to check blood glucose, have patient (parent/caregiver) give return demonstration to ensure proper technique. Nurses need to explain need to check blood glucose and what to do with the results. Review glucose records with patient (parent/caregiver) and explain how to identify trends to improve glucose control. Explain and review ketone testing. If blood glucose over 250mg/dl, patient should be advised to call physician for guidance (Blacks & Hawk, 2009, pg. 1386). Physician may suggest adjustment to insulin dose to prevent development of diabetic ketoacidosis (DKA). Explain DKA, ensure patient and caregiver aware of symptoms and that this is a serious condition that may need immediate medical attention.
Explain need for individualized meal plan. Reviewing a patient's food history in correlation with the blood glucose values is critical to the success of any glucose management strategy, but it becomes essential in basal-bolus therapy (Childs, Cypress, Spollett, 2009, pg. 44). Patient should have referral to Registered Dietician for meal planning. It is very important to ensure proper nutrition, and at the same time be aware of how food affects blood glucose. Patient should have a plan for sick days, also be aware that when he/she is sick, the blood glucose may be elevated, even if patient is not eating like normal. Patient should be informed to continue to check blood glucose and take medication. Patient should also have a list of foods on hand for sick days and who to call during illness.
Patient and family should be referred to an Endocrinologist, Certified Diabetes Educator and a Registered Dietician. Ideally, the patient should be taught about the disease and encouraged to achieve self-management with guidance from the healthcare provider. The more control the patient with diabetes can feel, the more likely the patient is to accept and adhere to the management program. The basis for self-management is a sound education program related to diabetes (Blacks & Hawk, 2009, pg. 1389). Community resources include support groups, group classes for education, and possibly exercise opportunities. If patient is a child, there are Diabetes Camps for the child; some also include support for the parents and family. Referring parent/caregiver to school nurses. Give patient and family helpful resource information like referring them to the American Diabetes Association website.
Nurses should offer additional emotional and practical support to patients and if patient is a child, to parents also.
Assessing the discharge needs after exacerbation include determining diabetes knowledge and past management of the disease including coping skills. It is essential to identify sub optimal controlled diabetes and acute hyperglycemia at the time of hospital admission and to implement therapy to control blood glucose. The nurse must keep in mind opportunities to improve diabetes management, particularly if suboptimal glycemic control is the underlying cause for hospitalization (Childs, Cypress & Spollett, 2009, pg. 343). Chronic hyperglycemia is associated with several diabetic complications – mainly damage to the eyes, kidneys and nerves, as well as other organs. Patients with diabetes are also at much higher risk for cardiovascular disease, such as heart attack and stroke.
References:
Blacks, J. & Hawk, J., (2009) Medical-Surgical Nursing (8th ed.) St. Louis, MO: Mosby Elsevier, pg. 1386
Blacks, J. & Hawk, J., (2009) Medical-Surgical Nursing (8th ed.) St. Louis, MO: Mosby Elsevier, pg. 1386
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 46
Blacks, J. & Hawk, J., (2009) Medical-Surgical Nursing (8th ed.) St. Louis, MO: Mosby Elsevier, pg. 1386
Blacks, J. & Hawk, J., (2009) Medical-Surgical Nursing (8th ed.) St. Louis, MO: Mosby Elsevier, pg. 1386
Blacks, J. & Hawk, J., (2009) Medical-Surgical Nursing (8th ed.) St. Louis, MO: Mosby Elsevier, pg. 1386
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 44
Blacks, J. & Hawk, J., (2009) Medical-Surgical Nursing (8th ed.) St. Louis, MO: Mosby Elsevier, pg. 1389
Childs, B., Cypress, M., Spollett, G., (2009) Complete nurse’s guide to diabetes care. (2nd ed.) Alexandria, Virginia, American Diabetes Association, pg. 343
