Virtual Clinical Excursion Lesson 18 Caring for a School-Age Child with Diabetes Mellitus

Exercise 1

1. George Gonzalez has been admitted with a diagnosis of DKA. What does this mean? What are
the signs of DKA?
Diabetic Ketoacidosis is a life-threatening condition that develops when cells in the body are
unable to get the glucose they need for energy because there is not enough insulin. When sugar
cannot get into the cells it stays in the blood. Signs of DKA are increased urination, increased
thirst, fatigue, weight loos, blurred vision, abdominal pain, chest pain, kussmaul respirations,
nausea and vomiting, acetone breath odor and dehydration. A person with DKA will be
lethargic, can have a decreased level of consciousness, and can become comatose.
2. Based on the textbook and George Gonzalez’s chart, what makes George at particular risk for
developing diabetes?
George Gonzalez has been diagnosed with Type 1 Diebetes Mellitus and has been hospitalized
for Diabetic Ketoacidosis three times within the past three months. One of George Gonzalez’s

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Grandfathers had type 1 diabetes mellitus. He has fluctuation weight, lives a sedentary lifestyle

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with his favorite activity being watching TV.

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3. Match the following to show your understanding of the difference between type 1 and type 2

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DM.

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Type 1 DM Characteristics
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This is the most common childhood endocrine disease.

This type results from autoimmune process disorder.

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The pancreas is unable to produce insulin.

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Type 2 DM Characteristics

Obesity commonly coexists with this type.

Genetic predisposition is a factor.

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Cells are unable to use insulin.

4. What was George Gonzalez’s condition like when he was admitted? Was there a precipitating
factor?
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George Gonzalez was admitted into the emergency department for nausea and a stomach ache.
Blood sugar "HI" per glucometer with serum glucose 735. George is alert times three. According
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to mother, not injecting insulin consistently, and eating "whatever."

5. In George’s situation upon admission, what type of insulin is used and why? Identify any
nursing concerns with the administration of insulin IV.
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Regular insulin was given in the emergency department upon admission because it is short
acting. Any medication or substance that inters the veins takes effect quicker than other
methods. Once in the veins you cannot take back out so proper dosage is even more important.
Monitor blood glucose, vital signs, and level of consciousness periodically.
6. What are the signs of hyperglycemia?

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 Signs of hyperglycemia are: increased urination, increased thirst, fatigue, weight loss that is
gradual (over several weeks), blurred vision, emotional lability, headache, and hunger.
7. What are the signs of hypoglycemia?
Signs of hypoglycemia are: trembling, sweating, tachycardia, pallor, clammy skin, personality
change, irritability, drunken behavior, slurred speech, decreased level of consciousness to total
loss of consciousness, and seizure activity.
8. For which of the following nursing diagnoses is there evidence in George Gonzalez’s situation?
Fluid volume deficit related to abnormal fluid losses through diuresis and emesis.
9. What is your rationale for your answer to question 8? Provide the data that lead you to your
choice of nursing diagnosis.
The answer I choose for question 8 was consistent with the nursing diagnosis for diabetic
ketoacidosis which is the state that the patient is in upon admittance into the emergency
department.
10. What ongoing assessments need to be made? (Focus on the admission diagnosis.)
Respiratory status, level of consciousness, hydration status, electrolyte and acid-base balance,
blood glucose values, urinary ketones test.

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11. What is HbA1C? Explain its use as a diagnostic tool. How does the normal HbA1C compare
with George Gonzalez’s labs?

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HbA1c refers to glycated hemoglobin. It develops when hemoglobin joins with glucose in the
blood, becoming glycated. By measuring glycated hemoglobin, clinicians are able to get an

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overall picture of what our average blood sugar levels have been over a period of weeks/months.
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So HbA1C is a tool to see how well managed diabetes is. Normal HbA1C is below 42 mmol/mol
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or below 6%. George Gonzalez’s labs show the HbA1C is at 15.2%.

Exercise 2
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1. What did the nurse do that facilitated George Gonzalez’s honesty about his testing behavior
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and how he feels about it?

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2. What is the nurse trying to accomplish when she asks George Gonzalez to do his own finger
stick? How does his developmental stage affect his compliance with treatment?
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George Gonzalez is a school age child so it is developmentally appropriate for him to stick his
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own finger. This gets George involved in his monitoring and care of his diabetes which can
encourage compliance with his treatment.
3. What are some reasons why George Gonzalez may be noncompliance with blood glucose
testing?
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George Gonzalez’s parents are recently separated (four months ago) which may have been the
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trigger for his noncompliance. Also, being a school age child, there is the challenge of
incorporating diabetes care within a busy school day, the stigma of being different, fear of being
bullied, and not realizing how serious of a situation it is when he is noncompliant.
4. What does the nurse do that is positive as she observes George Gonzalez give his injection?
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5. Explain the content and methods you would use in teaching the skill of self-administration of
insulin.
The nurse should talk about the appropriate needle/syringe type, the different injection sites,
rotating the injection site, proper cleaning, sanitary practices, and disposal of needle. When
using a 3/8 inch needle a 90 degree angle is the appropriate angle for administration. When

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 using a ½ inch needle it is important to use a 45 degree angle to inject with to avoid injecting
into the muscle or vascular space. Practice injecting angles on an object specifically for injection
practicing.
6. What are possible barriers to learning the skill of injection technique?
Possible barriers to learning the skill of injection technique are language barriers, age, cognitive
development, and fear.
7. List areas of content associated with discussing site rotation.

Either side of the stomach, upper thigh, side thigh, hip, and back of arms are the different site
locations.

8. The abdomen is the site from which insulin is most rapidly absorbed.

9. Match the type of insulin with its corresponding characteristics.

Regular

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Onset of 30-60 minutes

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Peak at 2-3 hours

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Duration of 5-8 hours

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NPH rs e
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Onset of 2-4 hours

Peak at 4-10 hours

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Duration of 10-16 hours

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10. At what point during the day is George Gonzalez most at risk for hypoglycemic reaction?
After school at a sports practice.
11. Using George Gonzalez’s morning insulin order, describe the steps for drawing up two forms of
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insulin in one syringe.

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Roll the insulin bottles gently between your hands. Roll the long-acting insuiin until all the wite
powder has dissolved. Do NOT shake the bottles. Wipe the rubber lid of both insulin bottles
with an alcohol wipe. Let alcohol dry. Remove the plastic cap that covers the needle on your
insulin syringe. Pull the plunger back on your insulin syringe and draw air into the syringe equal
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to the number of units to be given. Short-acting (clear) insulin is drawn up first followed by long-
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acting (cloudy) insulin.

12. Why is the short-acting insulin always drawn up first?
Short-acting insulin is always drawn up first to prevent it from becoming contaminated by the
other type of insulin.
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Exercise 3

1. List the learning needs of a patient newly diagnosed with diabetes.

Some learning needs of a patient newly diagnosed with diabetes are: general information about type
1 diabetes mellitus, how to administer and store insulin, how to monitor blood glucose levels and

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 use the equipment properly, signs and management of hypoglycemia, strategies for when the child is
ill, nutrition and exercise principles, potential long-term complications, and available resources for
community services and emotional support.

2. Which of the above learning needs apply directly to George Gonzalez and his family?
Learning needs that apply directly to George Gonzalez would be how to monitor blood glucose
levels and use equipment properly, potential long-term complications, and available community
services and emotional support.
3. What anticipatory guidance can you offer George Gonzalez’s mother with regard to how
insulin needs change as he moves toward adolescence?
As George Gonzalez moves towards adolescence and puberty there will be larger requirements
of insulin dosages.
4. Discuss the relationship among insulin, food, and exercise. Explain it in terms that would be
understandable for George Gonzalez and his family.
Insulin dosage is balance with food intake and it is necessary to have a consistent intake,
particularly of carbohydrate food products. Exercise is an important aspect of diabetes

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management. Exercise enhances the action of insulin in lowering blood glucose levels. Extra

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carbohydrate snacks are needed to correlate to duration of exercise to help prevent

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hypoglycemia.

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5. Did you consider the “honeymoon phase” as part of your discussion? Why is this significant to

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parent teaching? What should you say about it?
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No I didn’t include the honeymoon phase in my discussion above. The honeymoon phase is
significant to parent teaching to avoid the misconception that the diabetes is “going away” and
to provide instruction on recognition and treatment of hypoglycemia. The honeymoon phase is
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characterized by hypoglycemia and a decreasing need for insulin.

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6. What are the sequelae of untreated or poorly managed diabetes? Explain why they occur.
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Serious complications are associated with long-term type 1 diabetes including retinopathy,
nephropathy, neuropathy, and cardiovascular disease. Studies have demonstrated that strict
metabolic control of diabetes may decrease the severity of complications and/or delay onset.
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7. Evaluate George Gonzalez’s understanding of his condition and management of hypoglycemia.

8. George Gonzalez’s mother seems to have a _________ understanding.
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9. Given the responses of George Gonzalez and his mother, is there need for teaching in this
area? If so, what teaching techniques would be most effective?
Yes, there is a need for teaching in this area. The most effective teaching technique would be
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teach back.
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