Diabetic Management Plan
Diabetes Mellitus is a disease known to humans since the ancient times.Hieroglyphics of Egypt, which dated back in 1500 BC, illustrated symptoms of diabetes.During this time, people depicted diabetes to be type 2 only and type 1 diabetes is a newly discovered disease.
However, this has been made clear by researches and studies that type 2 diabetes is different from type 1 diabetes (Hanas 2007). In the present, cases of diabetes continuously rise especially cases of type 1 diabetes.
Type 1 diabetes is an insulin dependent diabetes that is common to children and teenagers. Here, the body totally does not produce insulin rendering the glucose useless for an individual (Fox and Kilvert 2007). The glucose level on the blood rises and affects certain body functions making the individual seek medical attention. Diabetes has no cure. When one has diabetes, he or she has it for lifetime. However, certain ways in managing diabetes, whether it is type 1 or type 2, are found but with consideration to medication, activity, and diet.
Strict adherence to medication regimen is useful in preventing the development of diabetic complications. Regular exercise or physical activity as well as proper eating habits is also proven to help lower blood sugar levels making it controllable. In addition, frequent monitoring of blood glucose will allow an individual to anticipate and act in response to the previously read glucose level. The Case of Jodie Jodie is a 17-year-old girl who has just been diagnosed with type 1 diabetes following admission to the local Emergency Department in DKA.
She is currently studying year 12 at high school, plays netball every Saturday afternoon and enjoys going to parties with her friends. Jodie weighs 55kg with a BMI of 20. She lives happily at home with her parents and older brother. Jodie has been commenced on a basal bolus insulin regimen using Humalog and Levemir. Nutritional Management Managing diet is also a key factor in proper management of diabetes. It is important to emphasize to the client and the family that the client is not taking a diabetic diet but rather a balanced meal.
Emphasis must also be considered on the ethnicity of the client as well as cultural and religious background of the patient. Before taking these into considerations, it is important to know the basic caloric intake of the client. By multiplying the weight of the Jodie in pounds (121 lbs) to 10 (constant multiplier for female), you will come up with a total of 1210. This is the basic caloric need of Jodie. Multiplying the basic caloric need (1210) with 0. 40 (constant multiplier for rigorous activity) will come up with a resulting activity based caloric needs (605).
Calories for digestion can also be calculated by multiplying the sum of basic caloric intake and activity based caloric needs (1210 + 605) to 0. 10 (constant number). The result would be 181. 5. Lastly, compute for the total daily caloric intake by summing up the basic caloric intake, activity based caloric intake, and calories needed for digestion (1210 + 605 + 181. 5). The result would be 1996. 5. This is the caloric needs of Jodie every Saturday since she is engaged in netball and partying with her friends. On the other hand, the caloric intake of Jodie from Monday to Friday and Sunday would be 1863. 4.
Upon computing the daily caloric intake of Jodie, it can be concluded that energy needs varies among individuals on a daily basis, and depends greatly on the age, gender, and ethnicity (“How to Calculate Your Total Daily Calorie Needs ” 2010). Smart, Aslander-van Vliet and Waldron (2009) proposed how total caloric intake must be distributed: Carbohydrates must constitute about 50-55%; fats must be 30-35%; protein must be 10-15%; and sucrose must be 10%.
Therefore, Jodie must have a carbohydrate intake of 931. 7-1024. 87 calories (M-F, Sun) and 998. 25-1098. 08 calories(Sat); fat intake of 559. 02-654. 19 calories (M-F, Sun) and 598. 5-698. 78 calories (Sat); protein intake of 186. 34-279. 51 calories (M-F, Sun) and 199. 65-299. 48 calories (Sat); and sucrose intake of 186. 34 (M-F, Sun) and 199. 65 (Sat). When taking carbohydrate rich food, it might be necessary to include healthy sources like vegetables, fruits, legumes, whole grains, and low fat milk. Take into consideration other alternatives for the source of food by consulting the carbohydrate exchange table, cabohydrate counting and the use of glycemic load and index. In the consumption of fat, food with saturated fat must be limited to less than seven percent of total caloric intake.
Every week, two or more servings of fish is permissible but with exemption to the commercially produced fish fillet (American Diabetes Association 2007). Replace saturated fats with monounsaturated fatty acids and polyunsaturated fatty acids through the use of low fat dairy products, lean meats, olive and sesame seed oil, sunflower oil, corn oil, and soybean oil. Encourage intake of protein from vegetables (legumes) and animals (lean meat, fish, low dairy products) because it promotes growth and is a good source of nitrogen for the body. Take also into consideration that the salt intake of the client must be less than 6 grams per day.
Advise those individuals who prepare the food that they should avoid adding salt in cooking and in meals. In addition, excessive alcohol should be avoided because it interferes with gluconeogenesis resulting to prolonged hypoglycemia. The patient must also be advised to wear identifications about her diabetes, and consume carbohydrates before, during, and after drinking. Drinking, on the other hand, must be done in moderation and must consume drinks with reduced alcohol content. Prevent nocturnal hypoglycemia by consuming carbohydrate-rich bedtime snack.
Blood glucose monitoring must be done more often at night until lunchtime of the following day (Smart 2009). Monitoring Patients with Diabetes Knowing that diabetes can lead to some serious complications, it is better if one should know the things that he/she should monitor in order to prevent these complications. One should have vigilant monitoring of blood sugar. Scientific evidence shows that tightly controlling blood sugar levels can prevent the development and progression of small blood vessel (microvascular) disease and nerve disease (neuropathy) (Wendt 2009).
Since high blood sugar is considered as the culprit to most of the diabetic complications, monitoring blood glucose by the patient is extremely important to prevent consequences from unmonitored blood glucose. Low glucose level may lead to hypoglycemia. Mild hypoglycemia can cause a person to feel uncomfortable and can interfere with his normal functioning. However, severe hypoglycemia can cause seizure, loss of consciousness, and coma (Kelly 2006). Avoiding highs and lows in blood sugar will not only make the patient feel better, but will significantly reduce his/her risk of diabetes complications.
Cholesterol levels should also be monitored. A test done to monitor the cholesterol level of a diabetic person is called fasting lipid profile. It is a blood test that measures the total cholesterol, HDL and LDL cholesterol levels, and triglyceride levels in the bloodstream. It is also used to assess the risk for the development of coronary artery disease, one of the predisposing factors for heart attack (Kaufman 2010). Knowing that cholesterol affects the blood vessels of the retina and the heart gives the health provider a clue that any significant increase in the level would necessitate immediate monitoring and intervention.
If cholesterol is controlled, the risk of developing complications is greatly reduced. Keeping track of blood pressure is important because people who have diabetes tend to have more trouble with high blood pressure than people who do not have the disease. Having both diabetes and high blood pressure can pack a damaging one-two punch as far as increasing the risk of heart disease, stroke, and eye, kidney and nerve complications (Manzella 2006). Elevated blood pressure increases blood flow into the eye, accelerating diabetic retinopathy (Chous 2006). Knowing the early signs and symptoms are also key in preventing diabetic complications.
However, diabetic retinopathy has no early signs and symptoms. Jodie then must be aware of the yearly eye examination that must be done after the preliminary examination within 5 years after the diagnosis of diabetes (“Diabetes” 2010). Dilated eye examination must be done every year by an optometrist or ophthalmologist knowledgeable about and experienced with diabetes and diabetic eye disease (Chous 2006) in order to know the extent of eye affectation. Both the patient and the health provider should also monitor some signs and symptoms to prevent blindness. Any concern with regard to the patient’s vision must be taken seriously.
Be aware if the patient complains of suspended dark spots that interferes with his/her vision. It may indicate blood leak to the vitreous humor, which can lead to blindness. Also, take into consideration the increasing difficulty in performing things that require focus such as reading and sewing. Amputations can also be prevented if the patient has vigilant foot care. Foot care is important since the patient with diabetes has decreased sensation on the lower extremities. Preventive measures would include watching for signs and symptoms of impending ulceration.
The patient and the health provider should be aware of any swelling, thick hard skin or corns, and any blisters or breaks on the skin. Take good care of small cuts and abrasions immediately. When choosing shoes, make sure that they fit well and allow the toes to move freely. Another complication of type 1 diabetes is diabetic ketoacidosis, the reason why Jodie was rushed to the emergency department. The goal for the management of DKA is the correction of fluid and electrolyte imbalances, restoration of circulating blood volume to normal, and identification and correction of factors that contributes to the development of diabetic ketoacidosis.
Correction of circulating blood volume starts with the infusion of 1000 ml of 0. 9 percent sodium chloride for the first hour followed by the infusion of 2000 ml to 8000 ml for the next 24 hours. Assess client’s skin turgor, weight and hematocrit because these will serve as markers for the efficacy of intravenous therapy. Potassium must also be monitored because this electrolyte leaves the cells in ketoacidosis. When dealing with this, several points must be considered during the assessment and intervention phase. Frequently assess the patient’s urine output.
Take note of the amount of urine when administering potassium to the client. If the urine is less than 30 ml per hour, halt the administration of the potassium and notify the physician immediately. Continuously monitor the client for signs of hyperkalemia (oliguria, weakness, bradycardia, cardiac arrest) and hypokalemia (weakness, paralytic ileus, cardiac arrest). Hyperkalemia may ensue for the first 4 hours of treatment while hypokalemia may develop after 4 hours up to 24 hours. Monitor the client’s ECG and take note of T wave.
Its flattening or inversion may signify hypokalemia while peaking of T wave may indicate hyperkalemia (Brunner, O’Connell Smeltzer and Suddarth, 2008). Medications for Diabetes According to Hanas (2007), the American Diabetes Association instituted the individualization of blood glucose goals, with goals higher to those individuals with frequent hypoglycemic attacks. Suggestions were also made on the level of blood glucose for each age group. Jodie, a 17 year old teenager, belongs to the adolescent group (13-19). It was stated that before meals, an ideal blood glucose level is 5-7 mmol/L or 90-130 mg/dl.
At bedtime or overnight, she must have a blood glucose level of 5-8 mmol/L or 90-150 mg/dl. To accomplish this goal, Jodie is prescribed with Humalog and Levemir in order to facilitate the entry of glucose in the cells thereby preventing the increase of glucose level in the blood. Humalog is a fast- or rapid acting insulin analog that takes effect on the body after injecting it. Since it is an analog, it considered as a variation of human insulin and tends to mimic its action from the time it is secreted by the pancreas.
When taking this drug, inform the client to use disposable, sterile needles or pen. Rotate the injection sites to prevent complications like lipodystrophy. Take this drug at the same time every day. Allot a 15 minute allowance before taking a meal prior to its administration. To prevent hyperglycemia, take this drug with long acting insulin such as the Levemir (Griffith and Moore 2006). Instruct the patient to seek medical attention immediately if she experiences symptoms such as rash, hive, intense itching, and difficulty in breathing after taking a dose.
This suggests an anaphylaxis reaction and is life-threatening. Although infrequent, instruct the patient to take quick-acting sugar such as honey or fruit juice whenever she experiences excessive hunger, cold sweats, cold skin, shakiness, chills, or vision changes. This signifies that she is experiencing low blood sugar or hypoglycemia. On the other hand, Levemir is long-acting, man-made insulin that may last for 24 hours after administration. Instruct patient to use only Levemir when the vial appears to be colorless and clear. Presence of air bubbles is considered normal.
However, do not administer the drug if it looks colored, cloudy or thickened. Inject drug into subcutaneous part of the body such as the stomach, thighs, and upper arms. Just like in Humalog, rotate the injection sites to prevent lipodystrophy. The patient may also experience hypoglycemia and its treatment is the same as those of Humalog (Novo Nordisk, Inc. 2009). When taking this drug, instruct her to avoid intake of alcohol as this may increase the effect of insulin resulting to blood glucose problems (Griffith 2006). One should also take note on the time Levemir will take effect.
Levemir injected at bedtime or 10 pm (for multiple injection therapy) will have its effect during the night and breakfast. It can also be used as a two dose treatment: one in the morning and one in the dinner. Insulin injected in the morning will take effect on the lunch and afternoon while insulin injected during dinner will take effect on evening and night. Bedtime snack is necessary then to avoid night time hypoglycemia (Hanas 2007). It is also necessary to take insulin before meals. When taking Humalog as pre-breakfast insulin, it is better if Jodie should monitor her blood glucose.
The time elapsed before the administration of pre-breakfast insulin depends on the level of blood glucose she has in the morning. Blood Glucose Levels Rapid Acting Insulin (Humalog) Ordinary or Short Acting Insulin mmol/L mg/dl < 3 < 55 After the meal Just before 3 – 5 55 – 90 Just before 15 minutes before 5 – 10 90 – 180 Just before 30 minutes before 10 – 14 180 – 250 10 minutes before 45 minutes before ? 14 ? 250 20 minutes before 60 minutes before Source: Hanas, R. (2007).
Type 1 Diabetes in Children, Adolescents, and Young Adults: How to become an expert on your own diabetes (3rd ed. . United Kingdom: Class Publishing Ltd. Checking blood glucose before lunch is also necessary. When using rapid acting insulin, a blood glucose reading taken two hours after breakfast is enough. Blood Glucose Measure < 4 mmol/L < 70 mg/dl Decrease the insulin dose at breakfast by one to two units > 8 mmol/L > 145 mg/dl Increase the insulin dose at breakfast by one to two units Patient experiences cold sweat, hunger, shakiness (signs of hypoglycemia) between breakfast and lunch. Decrease the insulin dose at breakfast by one to two units Source: Hanas, R. (2007).
Type 1 Diabetes in Children, Adolescents, and Young Adults: How to become an expert on your own diabetes (3rd ed. ). United Kingdom: Class Publishing Ltd The Concept of Psychology in Diabetes Adolescence is the time during which an individual attempts to establish their identity and begin involving themselves into sexual relationships. As an adolescent grew, the client will begin to take responsibilities with his or her action. Add up to these responsibilities are those involving their management of diabetes. The challenge here does not only involve the adolescent but also the health care provider and the family itself.
Adolescent are in the position wherein they are faced with developmental tasks needed to accomplish in addition to the need of managing their lives with diabetes. Health care providers and family must also consider their actions to make sure that treatment and regimens do not interfere with age-related activities of the adolescent thereby allowing growth and development (Snoek and Skinner 2005). Several complications in diabetes are also found to be associated with poor parental interaction of the adolescent’s diabetes management. DKA is one of these complications.
Snoek and Skinner (2005) revealed that individuals belonging to a family that lacks support and warmth are typical to hose patients who have DKA. Moreover, diabetic individuals who have unresolved family problems and lack of parental participation in the treatment have a tendency to belong in this population with DKA. It was also linked that the possibility of child abuse (physical, sexual or social) may be triggering factor an adolescent ran away from home skipping his/her dose of insulin. Another possibility is that an adolescent is undergoing the phase of rebellion or rejection.
Lifestyle management for teenagers with diabetes may result to resentful feelings as well as the stage of rejection. Consequently, the adolescent omits his/her insulin dose but this is considered to be part of how an adolescent adopts to his/her life of a diabetic person (Snoek 2005). To provide solutions with this problem, a scheduled telephone call every two to three weeks may be used to provide assistance and support to the patient through the use of problem solving techniques. Motivational interviewing (MI), which is a collaborative approach between patient and the health care provider, can also be utilized.
It is a directive approach that aims to resolve patient’s anxiety and ambivalence regarding diabetic management by supporting the adolescent and respecting their decisions regarding diabetes management (Miller and Rollnick 2005). With this, an individual will report less worry and anxiety, and satisfaction with the present life and a more positive outlook (Snoek 2005). Patient Education Approach Educational tools are used to disseminate information and knowledge in order to maximize the management of blood glucose and prevent complications from it.
Since no study shows which type of teaching methods is appropriate for education, its approach must be varied but is well adapted to the age of the child and the needs of the family. It must not be too rigid that it invokes confusion and failure resulting to distress and harm on the part of the adolescent and family (Funnel and Anderson 2004). Health education tools may include the use of food pyramid and plate models that will advocate the basics of nutrition and healthy eating habits.
Extensive patient education may also be necessary for adolescents and the families to help them estimates the amount of carbohydrates in foods, its exchange or portions. Education can also include guides on how to read food labels and how to recognize the nutritional content of food. Several methods are also instituted to facilitate adolescent’s learning in measuring carbohydrates. Exchange or portion system, carbohydrate counting, and glycemic index and glycemic load are some of these methods (Smart 2009).