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Questions: 1. Pathophysiology of clinical manifestations of Type 1 diabetes. 2. Nursing considerations related to the administration of NovoRapid. 3. The potential impact of type 1 diabetes on Briana and her family. 4. Adaptation of nursing care to accommodate Toms intellectual disability. Answers: Answer 1: High blood glucose level: The high blood glucose level in type 1 diabetes is a consequence of the autoimmune destruction of -cells of the islets of Langerhans in the pancreas. Actively functioning -cells are able to sense the levels of glucose in the blood and release the required amounts of in cells is concomitant with a loss of control on blood glucose levels. The patient suffers from high blood glucose levels and is likely to suffer from secondary complications(Bluestone, Herold, Eisenbarth, 2010) Due to the absence of insulin the transport of glucose to the cells of the body is affected and glucose remains unutilized leading to a high blood glucose level (Pubmed). Glucose in the urine: Presence of glucose in the urine is an indication of diabetes and is termed as glucosuria. In the normal course glucose is reabsorbed into the blood by the kidneys. Glucose is detected in urine at high blood glucose concentrations of 10 mmols/L or more. Glomerular filtration of glucose is higher than the amount the renal tubules can reabsorb. More than 25 mg/dl in samples of fresh urine indicates either high plasma glucose level or insufficient renal resorption of glucose and often both (Restrepo, Pino, Zarate, Mora-Guzmanb, 2013 ). The urine testing for presence of glucose was used for monitoring glycemic control among diabetics in older times. It continues to be regarded as a non-invasive and inexpensive method even now. Increased urination: Increased urination or polyuria is one of the major symptoms of diabetes. Excessive and copious amounts of urine are passed. Among adults, the volume of urine may be more than three litres a day as compared to the normal output of one or two litres a day. Many times the diagnosis of diabetes occurs when a patient complains of polyuria. It can lead to dehydration and if the treatment for diabetes for control of blood sugar levels is not started soon, it can lead to affected kidney function. Once the kidneys fail to reabsorb sugar, the presence of sugar draws out more water and polyuria results (diabetes.co.uk). Increased thirst: The increase in thirst and higher intake of water occurs due to dehydration caused by polyuria. It is termed polydipsia and is usually accompanied by short term or long term dryness of the mouth. Several times high blood sugar is detected when a patient complains of thirst. In untreated diabetes the intake of water may be as high as five litres a day. Plolyuria, polyphagia and polydipsia account for the three major symptoms that are seen in diabetic patients at the time of diagnosis. Copious drinking of water may not alleviate the feeling of thirst in patients (diabetes.co.uk, polydipsia.html). Increased appetite: Increased appetite or polyphagia is a symptom observed among patients who suffer from hyperglycemia. Due to insulin resistance, the glucose in the blood fails to enter the cells leading to low energy. The body reacts by signalling hunger or increase in appetite. More intake of food raises the blood sugar further and the patient feels hungry all the time. Lowering blood glucose through exercise is often effective and reduces blood sugar levels and also stimulates production of insulin. This helps to alleviate the symptom of polyphagia. Ketones in the urine and blood: Ketones are detected in the blood at high levels when a person suffers from hyperglycemia. Less insulin secretion by pancreas impairs the transport of blood glucose into cells and this causes the liver to burn fatty acids to produce energy leading to the production of ketones. This happens when insulin levels are low but glucagon and epinephrine levels are normal. Small levels of ketones in the blood are normal but higher levels are often caused due to diabetes. (diabetes.co.uk, /diabetes-and-ketones.html). Weight loss: Weight loss among diabetes patients results when the body burns fat because enough energy cannot be generated as the glucose utilization is impaired due to lack of transport to cells. Ketoacidosis is usually accompanied by weight loss as the body begins to lose fat and muscle. A drop in weight from 5 to 10 kg that has not been preceded by exercise or diet regimen often points at diabetes. Answer2: Prior to administration Validate the medication order: Prior to the administration of insulin the nurse should ensure whether the insulin dose is written legibly on the prescription and choose a prefilled flexipen that contains the correct dose. It should be ensured that the patient has not received the injection scheduled for that time of the day. Have comprehensive knowledge of the medication It is important to know whether the insulin is slow acting or fast acting. Slow acting insulin is given at the same time everyday (Glargine-in Briana's case) while fast acting insulin (NovoRapid -TDS) should only be administered when the patient's blood glucose is 180mg/dl and it should be immediately followed with a meal. Prepare the medication safely The insulin bottle should be at room temperature. It should be rolled between the hands gently so that a uniform fluid can be seen. Air should be drawn into the syringe equal to the number of units of insulin to be administered. The insulin should be drawn into the syringe to draw the correct number of units. Assess the patient Briana's blood sugar level should be checked just before injecting insulin and patient should be watched for signs of hypoglycemia. Since she is a new patient, her blood pressure should be checked. Check whether the patient is feeling nausea, whether she will be able to hold the meal that will be consumed right after the insulin is administered. During administration Administer the medication safely Correct size of the needle should be chosen. Since Briana is a child and has lost weight recently, a 4mm or 6mm needle can be used. A subcutaneous injection should be given. The nurse should inject insulin into the subcutaneous fat and not into the muscle tissue by raising the skin and using a smaller needle. An 8mm needle is usually used unless specified by the doctor in some cases. The insulin pen should then be held in place to a count of ten to allow the insulin to disperse from the site where it is being injected (NHS, 2014). After administration Document nursing care It is important to make an entry in the chart about the details of the insulin injection. Date, time, site of injection, dosage given should be recorded in a clear and legible fashion. Ensure patient safety Patient should not show signs of allergy and a meal should be consumed immediately after the injection. Monitor the patient Patient's blood glucose should be monitored every hour until two consecutive readings are observed in the normal range. If any sign of hypoglycemia (blood glucose level is at or below 70 mg/dl) is observed patient should be given glucose orally. Answer 3 Emotional The emotional impact of Briana's diagnosis on the family is likely to be considerable due to her young age. The parents will be responsible for monitoring blood glucose levels, administration of medication and watching her food intake and physical exercise(Whittemore, Jaser, Chao, Jang, Grey, 2012). These tasks can prove to be daunting for her mother because of her father's intellectual disability and another infant to care for. The father has already shown signs of being overwhelmed at the time of diagnosis, more so because of his inability to comprehend the illness. Parents can suffer from distress and anxiety because there is disruption of routines. Post traumatic distress is common among parents soon after diagnosis. Physical A change in routine disrupts the family schedule and adds to the stress of the parents. It can be physically demanding to take care of the child's needs and the parents have to care of themselves and other children in the family. A constant watch over Briana's diet, exercise, medication and monitoring blood glucose levels can increase the demands on her parents' physically. Positive lifestyle changes in some cases can improve the adherence to healthy lifestyle of the family (Helgeson, Becker, Escobar, Siminerio, 2012). Answer 4. It is important to recognize the father's intellectual disability and the impediments that he may face when taking care of a young child with type 1 diabetes. Training and educating the father may need extra inputs, particularly with regard to administering insulin, monitoring blood sugar levels, recognising hypoglycemia and the strict regimen of diet and exercise that has to be followed. Awareness about complications that could occur if the medical team's advice is not adhered to has to be added as an extra layer of caution. Educating the parent who has difficulty in understanding, with the help of educational tools, remaining in touch with a social worker, periodic visits to the family during the initial days are important steps to be taken as a nurse. Monitoring the child's behaviour, pacifying the child in times of crises, maintaining a positive atmosphere that fosters the correct diet and exercise for the whole family need to be taught to the parent (Coren, Hutchfield, Thomae, Gustafsson, 2010). References Bluestone, J., Herold, K., Eisenbarth, G. (2010). Genetics, pathogenesis and clinical interventions in type 1 diabetes. Nature. 2010 Apr 29; 464(7293): 12931300., 464(7293): 12931300. Coren, E., Hutchfield, J., Thomae, M., Gustafsson, C. (2010). Parent training support for intellectually disabled parents. Cochrane Databae of Systematic Revi, (6):CD007987. diabetes.co.uk. (n.d.). /diabetes-and-ketones.html. Retrieved from https://www.diabetes.co.uk: https://www.diabetes.co.uk/diabetes-and-ketones.html diabetes.co.uk. (n.d.). polydipsia.html. Retrieved from https://www.diabetes.co.uk: https://www.diabetes.co.uk/symptoms/polydipsia.html diabetes.co.uk. (n.d.). polyuria.html. Retrieved from https://www.diabetes.co.uk: https://www.diabetes.co.uk/symptoms/polyuria.html Grissinger, M. (2011). Avoiding Problems With Insulin Pens In the Hospital. Pharmacy and Therapeutics, 36(10), 615616. Helgeson, V., Becker, D., Escobar, O., Siminerio, L. (2012). Families With Children With Diabetes: Implications of Parent Stress for Parent and Child Health. Journal of Pediatric Psychology, 37(4): 467478. NHS. (2014, May 20). 20May14.pdf. Retrieved from https://www.nhslanarkshire.org.uk: https://www.nhslanarkshire.org.uk/Services/Diabetes/Diabetes%20Clinical%20Guidelines/Documents/Guideline%20for%20the%20Administration%20of%20Insulin%20by%20Nursing%20Staff%20final%20May14.pdf Pubmed. (n.d.). /PMHT0024702/. Retrieved from https://www.ncbi.nlm.nih.gov: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024702/ Restrepo, B., Pino, P., Zarate, I., Mora-Guzmanb, F. (2013 ). Dipstick urinalysis for diabetes screening in TB patients. International Health, 5(2): 157159. Whittemore, R., Jaser, S., Chao, A., Jang, M., Grey, M. (2012). Psychological Experience of Parents of Children With Type 1 Diabetes. Diabetes Education, 38(4): 562579.