Diabetes Mellitus Type 1 (Juvenile Diabetes) Nursing Care Plan & Management

Notes

Description

Most pediatric patients with diabetes have type 1 diabetes mellitus (T1DM) and a lifetime dependence on exogenous insulin.

  • Diabetes mellitus (DM) is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin, an anabolic hormone.
  • Type 1 diabetes or (also known as insulin-dependent diabetes mellitus (IDDM) and juvenile diabetes melliuts) is a chronic illness characterized by the body’s inability to produce insulin due to the autoimmune destruction of the beta cells in the pancreas.
  • Insulin is produced by the beta cells of the islets of Langerhans located in the pancreas, and the absence, destruction, or other loss of these cells results in type 1 diabetes (insulin-dependent diabetes mellitus [IDDM]).
  • Diabetes mellitus is often considered an adult disease, but at least 5% of cases begin in childhood, usually at about 6 years of age or around the time of puberty.

Pathophysiology

A possible mechanism for the development of type 1 diabetes is as follows:

  • Insulin is essential to process carbohydrates, fat, and protein; it reduces blood glucose levels by allowing glucose to enter muscle cells and by stimulating the conversion of glucose to glycogen (glycogenesis) as a carbohydrate store; it also inhibits the release of stored glucose from liver glycogen (glycogenolysis) and slows the breakdown of fat to triglycerides, free fatty acids, and ketones; it stimulates fat storage; additionally, insulin inhibits the breakdown of protein and fat for glucose production (gluconeogenesis) in the liver and kidneys.
  • Hyperglycemia (ie, random blood glucose concentration of more than 200 mg/dL or 11 mmol/L) results when insulin deficiency leads to uninhibited gluconeogenesis and prevents the use and storage of circulating glucose.
  • The kidneys cannot reabsorb the excess glucose load, causing glycosuria, osmotic diuresis, thirst, and dehydration; increased fat and protein breakdown leads to ketone production and weight loss.
  • The brain depends on glucose as a fuel; as glucose levels drop below 65 mg/dL (3.2 mmol/L) counterregulatory hormones (eg, glucagon, cortisol, epinephrine) are released, and symptoms of hypoglycemia develop.
  • The glucose level at which symptoms develop varies greatly from individual to individual (and from time to time in the same individual), depending in part on the duration of diabetes, the frequency of hypoglycemic episodes, the rate of fall of glycemia, and overall control.

Statistics and Incidences

The occurrence of diabetes mellitus type 1 in the United States and worldwide are as follows:

  • The overall annual incidence of diabetes mellitus is about 24.3 cases per 100,000 person-years.
  • Although most new diabetes cases are type 1 (approximately 15,000 annually), increasing numbers of older children are being diagnosed with type 2 diabetes mellitus, especially among minority groups (3700 annually).
  • A study by Mayer-Davis et al indicated that between 2002 and 2012, the incidence of type 1 and type 2 diabetes mellitus saw a significant rise among youths in the United States; according to the report, after the figures were adjusted for age, sex, and race or ethnic group, the incidence of type 1 (in patients aged 0-19 years) and type 2 diabetes mellitus (in patients aged 10-19 years) during this period underwent a relative annual increase of 1.8% and 4.8%, respectively.
  • Type 1 diabetes mellitus has wide geographic variation in incidence and prevalence.
  • Annual incidence varies from 0.61 cases per 100,000 population in China to 41.4 cases per 100,000 population in Finland.
  • Whites have the highest reported incidence, whereas Chinese individuals have the lowest.
  • Type 1 diabetes mellitus is 1.5 times more likely to develop in American whites than in American blacks or Hispanics.
  • Males are at greater risk in regions of high incidence, particularly older males, whose incidence rates often show seasonal variation; females appear to be at a greater risk in low-incidence regions.
  • Onset in the first year of life, although unusual, can occur, so type 1 diabetes mellitus must be considered in any infant or toddler because these children have the greatest risk for mortality if the diagnosis is delayed.

Clinical Manifestations

The most easily recognized symptoms of type 1 diabetes mellitus (T1DM) are secondary to hyperglycemia, glycosuria, and DKA.

  • Hyperglycemia. Hyperglycemia alone may not cause obvious symptoms, although some children report general malaise, headache, and weakness; children may also appear irritable and become ill-tempered.
  • Glycosuria. This condition leads to increased urinary frequency and volume (eg, polyuria), which is particularly troublesome at night (eg, nocturia) and often leads to enuresis in a previously continent child.
  • Polydipsia. Increased thirst, which may be insatiable, is secondary to the osmotic diuresis causing dehydration.
  • Polyuria. There is a dramatic increase in urinary output, probably with enuresis.
  • Polyphagia. There is an increase in hunger and food consumption.
  • Weight loss. Insulin deficiency leads to uninhibited gluconeogenesis, causing breakdown of protein and fat; weight loss may be dramatic, although the child’s appetite usually remains good; failure to thrive and wasting may be the first symptoms noted in an infant or toddler and may precede frank hyperglycemia.
  • Nonspecific malaise. Although this condition may be present before symptoms of hyperglycemia or as a separate symptom of hyperglycemia, it is often only retrospectively recognized.
  • Diabetic ketoacidosis (DKA). DKA is characterized by drowsiness, dry skin, flushed cheeks, and cherry-red lips, acetone breath with a fruity smell, and Kussmaul breathing.

Assessment and Diagnostic Findings

Early detection and control are critical in postponing or minimizing later complications of diabetes.

  • Fingerstick glucose test. Children with a family history of diabetes should be monitored for glucose using a fingerstick glucose test.
  • Urine dipstick test. For ketones in the urine, the child should be tested using urine dipstick test.
  • Fasting blood sugar (FBS). If the blood glucose level is elevated or ketonuria is present, a fasting blood sugar is performed; an FBS result of 200 mg/dl or higher almost certainly is diagnostic for diabetes when other signs are present.
  • Lipid profile. Lipid profiles are usually abnormal at diagnosis because of increased circulating triglycerides caused by gluconeogenesis.
  • Glycated hemoglobin. Glycosylated hemoglobin derivatives (HbA1a, HbA1b, HbA1c) are the result of a nonenzymatic reaction between glucose and hemoglobin; a strong correlation exists between average blood glucose concentrations over an 8- to 10-week period and the proportion of glycated hemoglobin.
  • Microalbuminuria. Microalbuminuria is the first evidence of nephropathy; the exact definition varies slightly between nations, but an increased AER is commonly defined as a ratio of first morning-void urinary albumin levels to creatinine levels that exceed 10 mg/mmol, or as a timed, overnight AER of more than 20 mcg/min but less than 200 mcg/min.

Medical Management

Management of type 1 diabetes in children includes insulin therapy and a meal and exercise plan.

  • Insulin therapy. Insulin therapy is an essential part of the treatment of diabetes in children; the dosage of insulin is adjusted according to blood glucose levels so that the levels are maintained near normal; many children are prescribed with an insulin regimen given at two times during the day: one before breakfast and the second before the evening meal.
  • Diet. Current dietary management of diabetes emphasizes a healthy, balanced diet that is high in carbohydrates and fiber and low in fat.
  • Activity. Type 1 diabetes mellitus requires no restrictions on activity; exercise has real benefits for a child with diabetes; current guidelines are increasingly sophisticated and allow children to compete at the highest levels in sports.
  • Continuous glucose monitoring. The American Diabetes Association’s Standards of Medical Care in Diabetes-2018 recommend consideration of continuous glucose monitoring for children and adolescents with type 1 diabetes, whether they are using injections or continuous subcutaneous insulin infusion, to aid in glycemic control.
Pharmacologic Management

Insulin is always required to treat type 1 diabetes mellitus; these agents are used for the treatment of type 1 diabetes mellitus, as well as for type 2 diabetes mellitus that is unresponsive to treatment with diet and/or oral hypoglycemics.

  • Insulin aspart. Rapid-acting insulin; insulin aspart is approved by the FDA for use in children aged >2 y with type 1 DM for SC daily injections and for SC continuous infusion by external insulin pump; however, it has not been studied in pediatric patients with type 2 DM; onset of action is 10-30 minutes, peak activity is 1-2 h, and duration of action is 3-6 h.
  • Insulin glulisine. Rapid-acting insulin; the safety and effectiveness of SC injections of insulin glulisine have been established in pediatric patients (aged 4-17 y) with type 1 DM; however, it has not been studied in pediatric patients with type 2 DM; onset of action is 20-30 minutes, peak activity is 1 h, and duration of action is 5 h.
  • Insulin lispro. Rapid-acting insulin; only lispro U-100 is approved by the FDA to improve glycemic control in children aged >3 y with type 1 DM; however, it has not been studied in children with type 2 DM; onset of action is 10-30 minutes, peak activity is 1-2 h, and duration of action is 2-4 h.
  • Regular insulin. Short-acting insulin. Novolin R has been approved by the FDA to improve glycemic control in pediatric patients aged 2-18 y with type 1 DM; however, it has not been studied in pediatric patients with type 2 DM; Humulin R is indicated to improve glycemic control in pediatric patients with diabetes mellitus requiring more than 200 units of insulin per day; however, there are no well-controlled studies of use of concentrated Humulin R U-500 in children.
  • Insulin NPH. Intermediate-acting insulin; it is indicated to improve glycemic control in pediatric patients with type 1 diabetes mellitus; onset of action is 3-4 h, peak effect is in 8-14 h, and usual duration of action is 16-24 h.
  • Insulin glargine. Long-acting insulin; the safety and effectiveness of glargine U-100 have been established in pediatric patients (6-15 y) with type 1 DM; however, it has not been studied in pediatric patients with type 2 DM.
  • Insulin detemir. Long-acting insulin. Insulin detemir is indicated for once- or twice-daily SC administration for the treatment of pediatric patients (aged 6-17 years) with type 1 DM; however, detemir has not been studied in pediatric patients with type 2 DM; onset of action is 3-4 h, peak activity is 6-8 h, and duration of action ranges from 5.7 h (low dose) to 23.2 h (high dose).
  • Insulin degludec. Ultra-long-acting insulin; insulin degludec is approved by the FDA to improve glycemic control in pediatric patients aged >1 y with type 1 or type 2 DM; it usually takes 3-4 days for insulin degludec to reach steady state, peak plasma time is 9 h and the durations of action is at least 42 h; it is highly protein bound, and following SC, the protein-binding provides a depot effect.

Nursing Management

Nursing care for a patient with diabetes mellitus type 1 includes the following:

Nursing Assessment

Nursing assessment for patients with diabetes mellitus type 1  involves:

  • History. When collecting data, ask the caregiver about the child’s symptoms leading up to the present illness; ask about the child’s appetite, weight loss or gain, evidence of polyuria or enuresis in a previously toilet-trained child, polydipsia, dehydration, irritability and fatigue; include the child in the interview and encourage him or her to contribute information.
  • Physical exam. Measure the height and weight and examine the skin for evidence of dryness or slowly healing sores; note signs of hyperglycemia, record vital signs, and collect a urine specimen; perform a blood glucose level determination using a bedside glucose monitor.
Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses for diabetes mellitus type 1 are:

  • Imbalanced nutrition: less than body requirements related to insufficient caloric intake to meet growth and development needs and the inability of the body to use nutrients.
  • Risk for impaired skin integrity related to slow healing process 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 Interventions

Nursing interventions for diabetes mellitus type 1 are:

  • Ensure adequate and appropriate nutrition. The child with diabetes needs a sound nutritional program that provides adequate nutrition for normal growth while it maintains the blood glucose at near normal levels; the food plan should be well balanced with foods that take into consideration the child’s food preferences, cultural customs, and lifestyle; if a particular meal is going to be late, the child should have a complex carbohydrate and protein snack.
  • Prevent skin breakdown. Teach the caregiver and child to inspect the skin daily and promptly treat even small breaks in the skin; encourage daily bathing; teach the child and caregiver to dry the skin well after bathing, and give careful attention to any area where skin touches skin, such as the groin, axilla, or other skin folds; emphasize good foot care.
  • Prevent skin infection. Diabetic children may be more susceptible to urinary tract and upper respiratory infections; teach the child and caregiver to be alert for signs of urinary tract infection; instruct them to report signs of urinary tract or upper respiratory tract infections to the care provider; insulin should never be skipped during illness; fluids need to be increased.
  • Regulate glucose levels. The child’s blood glucose levels must be monitored to maintain it within normal limits; determine the blood glucose level at least twice a day, before breakfast and before the evening meal; offer encouragement and support, helping the child to express fears and acknowledging that the fingerstick does hurt and it is acceptable to dislike it.
  • Provide child and family teaching in the management of hypoglycemia and hyperglycemia. If the blood glucose is higher than 240mg/dl, the urine may be tested for ketones; be aware of the most likeley times for an increase or decrease in the blood glucose level in relation to the insulin the child is receiving; and teach the child and family to recognize the signs of both hypoglycemia and hyperglycemia.
Evaluation

Goals are met as evidenced by:

The child/ caregiver:

  • Maintained adequate nutrition.
  • Promoted skin integrity.
  • Prevented infection.
  • Regulated glucose levels.
  • Learned adjust to having a chronic disease.
  • Learned about and managing hypoglycemia and hyperglycemia, insulin administration, and exercise needs for the child.
Documentation Guidelines

Documentation in a child with diabetes mellitus type 1 include:

  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual 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 desired outcome.

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Nursing Care Plan

Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to
  • Lack of information about the disease condition
Possibly evidenced by
  • New diagnosis of IDDM
  • Request for information regarding the pathology, blood and urine testing, insulin therapy, activity/exercise needs, dietary regimen, personal hygiene and health promotion.
Desired Outcomes
  • Client will verbalize understanding of IDDM.
  • Client and parents will demonstrate appropriate blood-glucose monitoring insulin administration, dietary management, and exercise plan.
  • Client and parents will identify signs and symptoms of hypoglycemia and hyperglycemia and correct response.
Nursing Interventions Rationale
Assess parents and child understanding
of disease and ability to perform
procedures and care, for educational
level and learning capacity, and for
developmental level.
Provides information essential to develop a learning program; children ages 8 to 10 may be able to take responsibility for some of the care.
Provide a quiet, comfortable
environment; allow time for teaching small amounts at a time and for reinforcement, demonstrations and return demonstration; start educating one day following diagnosis and limit sessions to 30 to 60 minutes.
Prevents distractions and facilitates learning.
Include as many family members in teaching sessions as possible. Promotes understanding and support of family and feeling of security for the child.
Teach about the cause of disease, disease
process and pathology; use pamphlets
and other aids appropriate for the age of child and level of comprehension of parents.
Provides basic information that may be used as a rationale for treatments and care and allows for different teaching strategies.
Instruct parents and child in insulin
administration including drawing up insulin into the syringe, rotating vial instead of shaking, drawing clear insulin first if mixing 2 types in the same syringe, injecting SC, storing insulin, rotating sites,
adjusting dosages, reusing a syringe, and needle, and disposing of them.
Promotes proper technique of insulin administration to avoid complications.
Instruct in use of a syringe-loaded injector. Provides an alternative method of insulin administration if the child is afraid of skin puncture.
Teach parents and child on how to operate a portable insulin pump to regulate insulin delivery. Provides continuous subcutaneous insulin infusion.
Instruct parents and child to monitor blood glucose levels 4 times a day (before meals and before bed), with a lancet and blood-testing meter or a reagent strip compared to a color chart; collection and testing of urine with ketostix or Clinitest. Monitors blood and urine for the presence of glucose and ketone.
Teach parents and child about dietary
planning with an importance on proper meal times and adequate caloric intake
according to age as ordered. Teach that food intake depends on activity, and describe methods to judge amounts of foods; provide a list of acceptable food items from “fast food” restaurants.
Provides information about an important aspect of the total care of the child with diabetes.
Teach parents and child about the role of
exercise and changes needed in food and insulin intake with increased or decreased activity.
Provides information about common activity pattern and effect on dietary intake and insulin needs.
Teach parents and child about skin
problems associated with diabetes, need for regular dental examinations, foot care, protection of and proper care of nails, prevention of infections and exposure to infections, eye examinations, immunizations.
Provides information about common complications as a result from chronic effects of the disease.
Instruct parents and child to keep a record of insulin administration, glucose monitoring, responses to diet and exercise, noncompliance in medical regimen and effects. Provides a method to improve self-careand demonstrates the need to notify physician for treatment evaluation and possible modification.
Instruct the child to wear or carry identification and information about the disease, treatment, and physician name. Provides information in case of an emergency.

Compromised Family Coping

Compromised Family Coping: A usually supportive primary person (family member, significant other, or close friend) insufficient, ineffective, or compromised support, comfort, assistance or encouragement that may be needed by the individual to manage or master adaptive tasks related to his or her health challenge.

May be related to
  • Inadequate or inaccurate information
  • Prolonged disease or disability progression that depletes the physical and emotional supportive capacity of caretakers
Possibly evidenced by
  • Expression and/or confirmation of concern and inadequate knowledge about long-term care needs, problems and complications
  • Anxiety and guilt
  • Overprotection of child
Desired Outcomes
  • Family will explore feelings regarding the child’s long-term needs.
  • Family will determine appropriate support systems and coping skills.
Nursing Interventions Rationale
Assess family coping mechanisms and its
effectiveness, family dynamics and expectations related to longterm care, developmental level of family, response of siblings, knowledge, and use of support systems and resources, presence of guilt and anxiety, overprotection and
overeating behaviors.
Recognizes coping methods that work and the need to develop new coping skills and behaviors, family attitudes; child with special long-term needs may tighten or strain family relationships, and that over-protection may be deleterious to child’s growth and development.
Allow family members and child to express difficult areas, anxiety and explore solutions responsibly. Lessens anxiety and improves understanding; provides the family with an opportunity to recognize problems and generate problem-solving methods.
Assist family to establish short- and
long-term goals for the child and to
involve the child in the activities of the family; include the participation of
all family members in care routines.
Promotes engagement in and control over situations and keeps the role of family members and parents.
Encourage family members to verbalize feelings, to tell how they handle the chronic needs of the family member, and to define coping patterns that support or inhibit adjustment to the problems. Encourages expression of feelings to identify the need for information and support and to dismiss guilt and anxiety.
Provide support social worker,
counselor, clergy, or other as needed.
Provides assistance to the family dealing with the long-term care of a child with chronic illness.
Teach family about long-term care and treatments. Improves family’s understanding of treatment regimen and responsibilities of family.
Teach family that overprotective behavior may inhibit growth and development so they should treat the child as normally as possible. Facilitates understanding of the significance of making the child a part of the family and illustrates the unfavorable effects of being overprotective.
Explain the importance of attending follow-up appointments for physical examinations, laboratory tests. Promotes positive outcome when family collaborates with the physician and health team to monitor disease.

Risk for Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

May be related to
  • [not applicable]
Possibly evidenced by
  • Hyperglycemia— headache, confusion, blurred vision, irritability, fatigue, dry mouth, abdominal pain, weight loss, polyuria, polydipsia, polyphagia
  • Hypoglycemia— sweating, shakiness, nervousness, lightheadedness, weakness, hunger, nausea, palpitations, moodiness, pale skin, loss of consciousness
Desired Outcomes
  • Client’s blood glucose levels will maintain between 60 mg/dL and 120 mg/dL.
  • Client’s urine will be free from ketones and glucose.
Nursing Interventions Rationale
Assess for signs and symptoms of
hyperglycemia; Monitor serum glucose level, urine for glucose and ketones, pH and electrolyte levels.
Provides information about the effect of increased blood glucose levels caused by an illness, inappropriate diet, stress or failure to administer insulin; glucose is unable to enter the cells, and protein is broken down and converted to glucose by the liver, causing the hyperglycemia; fat and protein stores are depleted to provide energy for the body when carbohydrates are not able to be used for energy.
Assess for signs and symptoms of
hypoglycemia, serum glucose level.
Provides information about the occurrence of hypoglycemia caused by an increased
activity without additional food intake
or failure or incomplete ingestion of
meals, improper insulin administration, illness.
Administer insulin subcutaneously as prescribed, increase dosage depending on the glucose levels; rotate injection sites,  minimize food intake during an infection or illness and modify the dosage of insulin during an illness. Provides insulin replacement to maintain normal blood glucose levels without causing hypoglycemia; two or more injections may be given daily subcutaneous (SC) using a portable syringe pump or by intermittent bolus injections with a syringe and needle.
Encourage a diet with calories that balance
with the energy requirements and paired with the type and action of insulin, and snacks between meals and at bedtime as appropriate.
Provides nutritional needs of the child for proper growth and development using the exchange system or by carbohydrate
counting— monitoring carbohydrate intake only, maintaining consistent level at meals and snacks, and adjusting insulin as needed (requires close supervision
of a physician).
Promote exercise program compatible with insulin regimen; instruct to increase
carbohydrate intake prior a strenuous
activities.
Guides in the utilization of dietary intake, regular activity may decrease the amount of insulin required; an insulin reduction and increased carbohydrate intake prior to a strenuous exercise may avoid hypoglycemia.
Encourage rest periods and provide a quick source of a simple carbohydrate such as fruit juice, milk products followed by a
complex carbohydrate such as bread in
amounts of 15 gm; repeat intake in 10
minutes for an expected response of a
reduced pulse rate; administer 50 percent glucose per IV or glucagon IM if
hypoglycemia is severe.
Relieves the symptoms of hypoglycemia as soon as observed; glucagon releases the glycogen stored in the liver to assist in restoring glucose levels; Administration of IV glucose is done when the condition is severe and child is unable to take glucose source orally. Glucagon, a hormone, releases stored glycogen from the liver and increases blood glucose within 5 to 15 minutes.
Educate parents and child about signs and symptoms, reasons why they happen, and measures to take. Provides information about abnormal blood glucose levels causing complications of hyperglycemia, hypoglycemia, and the consequences.
Educate parents and child to regulate
insulin, control dietary intake, and
exercise to accommodate needs of an individual child.
Supports the child’s growth and development needs while avoiding complications.
Educate parents and child to modify administration of insulin depending on
the blood glucose testing and glycosuria, during an illness or after changes in food
intake or activities.
Prevents and treats hyperglycemia;  Prevents serious complication of ketoacidosis.
Instruct parents and child to take a
quick-acting carbohydrate followed by a longer-acting carbohydrate and to have Lifesavers, sugar cubes, Instaglucose on hand at all times; instruct parents that, in the case of severe hypoglycemia, if the child is unconscious or unable to take oral
fluids, to rub honey or syrup on the child’s buccal surface until alert enough to take fluids/foods by mouth.
Prevents and/or treats hypoglycemia.
Instruct parents and child to notify
irregular blood and urine test results,  difficulty in managing blood glucose levels, presence of an infection or illness.
Avoids more severe complications and long-term effects of the disease; poor control leads to serious and severe consequences in a few hours.

Risk for Unstable Blood Glucose Level

Risk for Unstable Blood Glucose Level: Risk for variation of blood glucose/sugar levels from the normal range.

May be related to
  • Deficient knowledge of diabetes management
  • Developmental level
  • Inadequate blood glucose monitoring
  • Lack of adherence to diabetes management
Possibly evidenced by
  • [not applicable]
Desired Outcomes
  • Client will maintain a blood glucose reading of less than 180 mg/dL; fasting blood glucose levels of less than <140 mg/dL; hemoglobin A1C level <7%.
Nursing Interventions Rationale
Monitor for signs of hyperglycemia such as fatigue, blurred vision, dry mouth. Hyperglycemia happens due to an inadequate amount of insulin to glucose. Excess glucose in the blood creates an osmotic effect that results in polyuria, polydipsia, polyphagia.
Monitor for signs of hypoglycemia such as sweating, lightheadedness, weakness, nausea, tachycardia. Manifestations of hypoglycemia may depend on every individual but are consistent in the same individual. The signs are the result of both increased adrenergic activity and decreased glucose delivery to the brain.
Assess feet for temperature, pulses, color, and sensation. Monitors peripheral perfusion and neuropathy
Monitor blood glucose level prior meals and at bedtime. Blood glucose should be between 140 to 180 mg/dL. Non-intensive care patients should be maintained at pre-meal levels <140 mg/dL.
Review client’s HbA1c-glycosylated hemoglobin. Measures blood glucose levels over the past 2 to 3 months. A level of 6.5% to 7% is acceptable.
Assess child’s and parent’s current knowledge and understanding about the prescribed diet. Noncompliance to dietary guidelines can result in hyperglycemia. An individualized diet plan is recommended.
Assess the pattern of physical activity. Regular exercise is a core part of diabetes management and reduces the risk for cardiovascular complications.
Instruct the proper use of insulin as directed:
  • Rapid-acting insulin analogs: lisproinsulin (Humalog), insulin aspart
Have an onset of action within 15 minutes of administration. The duration of action is 2 to 3 hours for Humalog and 3 to 5 hours for aspart.
  • Short-acting insulin: regular
Has an onset of action within 30 minutes of administration; duration of action is 4 to 8 hours.
  • Intermediate-acting insulin: neutral protamine Hagedorn (NPH), insulin zinc suspension (Lente)
Onset of action for the intermediate-acting is one hour after administration; duration of action is 18 to 26 hours.
  • Intermediate and rapid: 70% NPH/30% regular.
Premixed concentration has an onset of action similar to that of rapid-acting insulin and a duration of action similar to that of intermediate-acting insulin.
  • Long-acting insulin: Ultralente, insulin glargine (Lantus)
Have an onset of one hour after administration. Duration of action is 36 hours for Ultralente is 36 hours and for glargine is at least 24 hours.
Instruct the patient on the proper preparation and administration of insulin.
  • Injection procedures.
Absorption of insulin is more consistent when insulin is always injected in the same anatomical site. Absorption if fastest in the abdomen, followed by the arms, thighs, and buttocks. It is recommended by the American Diabetes Association to administer insulin into the subcutaneous tissue of the abdomen.
  • Rotation of injection within one anatomical site.
Injection of insulin in the same site over time will result in lipoatrophy and lipohypertrophy with reduced insulin absorption.
  • Storage of insulin.
Insulin should be refrigerated at 2º to 8º C (36º to 46º F). Unopened vials may be stored until their expiration date. To prevent irritation from “cold insulin,” vials may be stored at temperatures of 15º to 30ºC (59º to 86ºF) for 1 month. Opened vials are to be discarded after that time.
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