Case 16 Pediatric Type 1 Diabetes Mellitus Objectives After completing this case, the student will be able to: 1. Describe the pathophysiology of type 1 dia- betes mellitus. 2. Develop a nutrition care plan—with appro- priate measurable goals, interventions, and strategies for monitoring and evaluation— that addresses the nutrition diagnoses for this case. 3. Integrate an insulin regimen with nutrition therapy and provide appropriate recommen- dations for carbohydrate-to-insulin ratios and correction dosages. 4, Interpret laboratory parameters to assess fluid, electrolyte, and acid-base balance. 5. Prioritize teaching and educational require- ments for a newly diagnosed type 1 diabetic. Rachel Roberts is a 12-year-old 7th grader previ- ‘ously in good health who is admitted through the ED with a new diagnosis of acute hypergly- cemia—R/O diabetes mellitus. 7 ae a a ae nr ge a a tage aS nae178 Unit Six Nutrition Therapy for Endocrine Diserdera Roberts, Rachel, Female, 12 yo. ‘Allergies: NKA Code: FULL leolation: None Pt. Location: RM 744 Physician: M. Cho ‘Admit Date: 5/4 Patient Summary: Rachel Roberts is a 12-yearold female admitted with acute-onset hyperglycemia. History: Onset of disease: Patient presented to ED after fainting at soccer practice. During ED assessment, patient was noted to have serum glucose of 724 mg/d. ‘Medical history: None—recently had strep throat ‘Surgical history: None Medications at home: None Tobacco use: Nonsmoker ‘Alcohol use: None Farnily history: Father—HTN; Mother—hyperthyroidism; Sister—celiac disease Demographics: Marital status: Single 7th-grade female Years education: 7 years Language: English only Occupation: Student ‘Hours of work: N/A Household members: Mother, sister age 8 and brother age 4—parents divorced. Father lives in city and shares custody. Ethnicity: Caucasian Religious afiliation: Catholic Admitting History/Physical: Chief complaint: "| have just gotten over strep throat a few days ago. | felt like | was well enough to go to soccer practice today but after playing about 15 minutes, | just felt horrible. | sat down and they tell me | fainted, . .. | have been really thirsty—thirstier than I have ever been in my whole life and then | have had to use the bathroom a lot. .. . even have to get up at night to go to the bathroom.” General appearance: Slim, healthy-appearing, 12-year-old fernale Vital Signs: Temp: 98.6 Pulse: 101 Resp rate: 22 BP: 122/77 Height: 5° Weight: 82 Ibs Heart: Regular rate and rhythm HEENT. Head: WNL Eyes: PERRLA Ears: Clear Nose: Clear ‘Throat: Dry mucous membranes without exudates or lesions Genitalia: Deferred Neurologic: Alert but slightly confused. Glasgow Coma Scale: 15. Cipreht nge ing tip ne Nye a yt ce tec an a cor crete crm sapit ai bac cc ces et rca‘Case 16 Pediatric Type! Diabetes Mellitus 179 Roberts, Rachel, Female, 12 vo. ‘Allergies: NKA Code: FULL Isolation: None Pt. Location: RM 744 Physician: M. Cho ‘Admit Date: 5/4 Extremities: Noncontributory Skin: Warm and dry Chestfungs: Respirations are rapid—clear to auscultation and percussion Peripheral vascular: Pulse 41 bilaterally, warm, no edema Abdomen: Active bowel sounds xd; tender, nondistended Orders: 1. Regular insulin 1 univ NS 40 mEq KClfiter @ 135 mL/hr. Begin infusion at 0.1 unit/kg/t® 3.7 ‘units/nr and increase to 5 units/hr. Flush new IV tubing with 60 mL of insulin drip solution prior to connecting to patient and starting insulin infusion, 2. Labs: BMP Stat Phos Stat Calcium Stat UA with culture if indicated Stat Clean catch Bedside glucose Stat Bedside I-Stat: EG7 Stat Islet cell autoantibodies screen Thyroid peroxidase antibodies TSH Comp metabolic panel (CMP) Thyroglobulin antibodies C-peptide Immunoglobulin A level Hemoglobin A;. IgAtTG; IgG4TG 3. NPO except for ice chips and medications. After 12 hours, clear liquids if stable. Then, advance to consistent carbohydrate diet order—70-80 g breaktast and lunch; 85-95 g dinner; 3-15 gram snacks. 5. Consult diabetes education team for self-management training for patient and parents to begin education after stabilized. Nursing Assessment ES faeries by ‘Abdominal appearance (concave, flat, rounded, obese, flat Paipation of abdomen (soft, rigid, firm, masses, tense) soft Bowel function (continent, incontinent, flatulence, no stool) continent, Bowel sounds (P=present, AB=absent, hypo, hyper) RUG, P (Continued)180 Unit Six Nutrition Therapy for Endocrine Disorders Roberts, Rachel, Female, 12 v0. Allergies: NKA Code: FULL leolation: Nore Pt. Location: RM 744 Physician: M. Cho Admit Date: 5/4 Nursing Assessment (Continued) Nursing Assesement 5/4 Lua P RLO P io P ‘Stool color light brown Stool consistency soft ‘Tubesfostomies NA Genitourinary Urinary continence yes Urine source clean specimen ‘Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, __| cloudy, amber blue, tea) Integumentary ‘Skin color pale Skin temperature (Ol=diaphoretic, W=warm, dry, Cl CD +=cold, M=moist, H=hot) Skin turgor (good, fair, poor, TENTH tenting] good ‘Skin condition (intact, EC= ecchymosis, A=abrasions, P=petechiae, intact R=rash, W=weeping, S=sloughing, D=dryness, EX~excoriated, T=tears, ‘SE=suboutaneous emphysema, 8=blisters, V=vesicles, N=necrosis) Mucous membranes (intact, EC=ecchymosis, A=abresions, P=petechiae, [intact ash, W=weeping, S=sloughing, D=dryness, EX=excoriated, T=tears, ‘SE=subcutaneous emphysema, B= blisters, V=vesicles, N=necrosis) ‘Other components of Braden score: special bed, sensory pressure, 2 moisture, activity, frction/shear (> 18-no risk, 16-16=low risk, 13-14=moderate risk, =12=high risk} =cool, CLM=clammy, [DI Nutrition: ‘Meal type: NPO then progress to clear liquids end then consistent carbohydrate-controlled diet Fluid requirement: 1840 ml. History: Parents present—patient states that she thinks she has lost weight recently: "My clothes are a litle loose but | don’t usually weigh myself” Mom states that the last weight she remembers was when they went to fast-care clinic for strep throat and that she weighed about 90 Ibs. Patient confirms that that is what she usually weighs. Appetite has been normal—f anything patient states she has been more hungry than usual—but thought it was probably due to starting soccer season and exercising more, Relates history of increased thirst and increased urination. pre Ca ig i nea dk ik et ii tpt cep et i mS Sn nase es magnons Cap mapronee ee menreioas ajo teaganCase 16 Pediatric ype 1 Diabetes Mellitus 181 Roberts, Rachel, Female, 12.0. Allergies: NKA Code: FULL Isolation: None Pt. Location: RIM 744 Physician: M. Cho ‘Admnit Date: 5/4 Usual intake (for past several months): Mom and Dad state that Rachel is kind of a picky eater. She eats only chicken and fish—eats salad, broccoli, carrots, tomatoes, and asparagus as her only vegetables. Breakfast—cereal and milk or Pop-Tart® with milk; packs lunch for school—peanut butter and jelly or turkey and cheese sandwich, chips, carrots, and usually drinks water. Has a cereal ‘of granola bar before soccer practice—drinks water throughout practice. Dinner is usually prepared by Mom when she is at her house—always some salad, meat, and pasta, potato, ot rice. Dad states that when the kids are with him he doesn’t cock very often and they usually order in pizze or Chinese food. Snacks include cereal, ice cream, yogurt, some fruits (apples, bananas), popcorn, chips, or cookies. MD Progress Note: 5/5 0820 Subjective: Rachel Roberts's previous 24 hours reviewed Vitals:Temp: 99.5, Pulse: 82, Resp rete: 25, BP: 101/78 Urine Output: 2660 mL. (71.8 mLikg) Physical Exem General: Alert and oriented to person, place, and time HEENT. WNL Neck: WNL Heart: WNL Lungs: Cleat to auscultation Abdomen: Active bowel sounds Assessment/Plan: Results: B ICA, GADA, IAA consistent with type 1 DM. Negative 116. Dx: New Diagnosis Type 1 Diabetes Mellitus Pian: Change IVF to Ds.45NS with 40MEq K @ 135 mi/hr. Begin Apidra 0.5 u every 2 hours until glucose is 150-200 mg/dL. Tonight begin glargine 6 u at 9 pm. Progress Apidra using ICR 1:15. Con- tinue bedside glucose checks hourly. Notify MD if blood glucose >200 or <80. .-M Cho, MD cared mpm rng shane yet a nk ager ee St yn tam ee aS Satay Seen a an a oe enya Egg Laeger oe a ne tape He i42 Unit Six Natrition Therapy for Endocrine Diserders Roberts, Rachel, Female, 12 y.. Allergioe: NEA Code: FULL teolation: None Pt. Location: RM 744 Physician: M. Cho Admit Date: 5/4 Intake/Output Date 5/4 0701-5/5 0700 Time 0701-1500 1501-2300 2301-0700 Daily total PO. NPO. NPO 320 320 iv. 1,080, 1,080 1,080 3,240 (mb/kg/nr) (3.6) (3.6) (3.6) (3.6) IN IV. piggyback TPN Total intake 1.080 7,080 1400! 3.560] (mLskg) 29.0) (23.0) 376) “5.8 Urine 600 480 1,580 2,660 {mUkg/hn (2.01) (1.61) (8.30) (2.97) Emesis output ouT Other Stool Total output 800 480) Teo, 2.660 dmUskg) (16.1) (12,9) (42.4) 714) Net /O +480 +600 —180 +900 Net since admission (5/4) +480 +1,080 +900 +900 pe 9 nn 8 Me a tt pnp cn ao et SST Sa ea aac apts nga aan ond aeroCase 16 Pediatric Type 1 Diabetes Mellieas 183 Roberts, Rachel, Female, 12 y.0. ‘Allergies: NKA Isolation: None Pr. Locetion: RM) 744 ‘Admit Data: 5/4 Laboratory Results nae TP Ref. Ranger] <5 6/4 1780 5/6 0600 | Chemistry Sodium, 1014 yo (mEq/L) 136-145 126 Ih 7311 Potassium, 10-14 yo (mEgh) _|3.5-5.0 43 40 Chloride, 10-14 yomEgt) [98-108 99) 98 Carbon dioxide, 10-14 yo 22-30 a7 28 {CO,, mEa/t) Bicarbonate, 10-14 yo (mEq/l)_|22-26 23 24 BUN, 10-14 yo ima/dL) 5-18 15 12 Creatinine serum, 10-14yo. | =12 09 08 (mg/dL BUN/Crea ratio 5 ]10.0-20.0 16.6 15 Uric acid, 10-14 yo (melt) [25-55 29 28 Est GFR, non-Afr Amer >60 98 113 ‘tal fnin/1.73:m?) Glucose, 10-14 yoim@/dt) 70-99) 683 It 250_If Phosphate, inorganic, 10-14 yo | 2.2-4.6 19 1h 21 Ny mg/dL) ‘Magnesium, 10-14 yo (mg/dl) | 1.6-2.6 Ww 2.0 Calcium, 10-14 yo (mg/dl) 86-105 10 98 ‘Anion gap (mmoVL} 10-20 40 TL 3.0 1 ‘Osmolality, 10-14 yo 275-295 295.3 It 280 {mmol/kg/H,0) Bilirubin total, 10-14 yo (mg/dL) [51.2 08 Bilirubin, direct, 10-14 yo <03 0.009 {me/dt) Protein, total, 10-14 yo. {g/l}. | 6-78 61 ‘Albumin, 10-14 yo (g/dL 35-55 37, Prealbumnin, 10-14 yo (mg/dL) — | 17-39 7 ‘Ammonia, 10-14 yoNHs, ual) | 40-80 a ‘Alkaline phosphatase, 10-14 yo | <600 702 (UA) ALT, 10-14 yo (UA) 328 a AST, 10-14 yo (U/L) 19-28 21 lee 10-14 yo (U/L) 0-70 31 (Continued) aad Sov Set gre cos ony Cap aay ara Cr nbonnanTos newyork aN184 Voit Six Nutrition Therapy for Endocrine Disorders Roberts, Rachel, Female, 12 yo ‘Allergies: NKA Code: FULL. Isolation: None Pt. Location: RM 744 Physielan: M. Cho ‘Admit Date: 5/4 Laboratory Results (Continued) Za) Ref. Range, 7 5/4 1700 ‘575 0600 Lactate dehydrogenase, 208-378 208 10-14 yo (UA) Cholesterol, 10-14 yo (mg/dL) [124-201 F 128 119-202 M ‘Tiglycerides, 10-14 yo (mg/at)_| 70-103 55, Ti, 10-14 yo (ug/aL} 56-117 81 Ty, 10-14 yo (ug/l) 83-213 Ed HbAc, 10-14 yo (9%) 39-62 14.6 It C-peptide ingiml) 051-272 O10 ICA = + it GADA = +t TARA = + It TAA = +t 17g IgA antibody (U/mL) <4 2 tTg.lgG antibody (UimL) <6 1 Hematology 7 WBC, 10-14 yo 10% mm [4.0-13.5 a6 ABC, 10-14 yo (x 10%mm) —_[3.7-5.3 48 Hemoglobin, 10-14 yo 1-16 125 {Higb, g/d} Hematoorit, 10-14 yo (Het, %6) [31-43 7 Hematology, Manual Diff Neutrophil. 10-14 yo (%) 36-38 7 Lymphooyte, 10-14 yo (%)___ [25-33 28 ‘Monocyte, 10=14 yo (96) OF 4 Eosinophil, 10-14 yo (96) 06 0 Basophil, 10-14 yo (%) o2 1 Blasts, 10-14 yo (%) 3210 3 Urinalysis, Collection method = Clean catch Color = yellow ‘Appearance = clear SE Serer ans a a aie a a as Se eaCase16 Pediatric Type 1 Diabetes Mellitus 185 Roberts, Rachel, Female, 12.0. ‘Allergies: NKA (Code: FULL Isolation: None Pt. Location: RM 244 Physician: M. Cho . Admit Date: 5/4 Laboratory Results (Continued) Ret. Range ‘574 1780 ‘5/5 0600 Specific gravity, 10-14 yo. 1.001-1.035, 1.036 Hf pH, 10-14 yo = S7 49 Protein (mg/dL) Neg +4 it Glucose (mg/dL) Neg +3 It Ketones Neg 1H Biood {Neg Neg Bilirubirr 7 Neg Neg Nitrites : ‘Neg Neg Urobilinogen, 10-14 yo (EU/dL)_ | <1.0 0.01 Leukocyte esterase Neg Neg Prot chk Neg +4 It WBCs, 10-14 yo (HPF) O58 a4 RECs, 10-14 yo VHPF) 02 0 Bact, oO oO Mucus, 0 0 Crys. oO oO Casts ULPF) oO 0 Yeast 0 0 see a et4186 Unit Six Nutrition Therapy for Endocrine Diserders ‘Case Questions L._ Understanding the Diagnosis and Pathophysiology - 1. What are the current thoughts regarding the etiology of type 1 diabetes mellitus (TDM)? No one else in Rachel’ family has diabetes—is this unusual? Are there any other findings inher family medical history that would be important to note? 2. What are the standard diagnostic criteria for TIDM? Which are found in Rachel's medical record? 3. Dr. Cho requested these labs be drawn: Islet cell autoantibodies screen; TSH; thyroglobulin antibodies; C-peptide; immunoglobulin A level; hemoglobin A, and tissue transglutamin- ase antibodies. Describe how each is related to the diagnosis of type I diabetes. 4. Using the information from Rachel's medical record, identify the factors that would allow the physician to distinguish between TLDM and T2DM. 5. Describe the metabolic events that led to Rachel's symptoms and subsequent admission to the ED (polyuria, polydipsia, polyphagia, fatigue, and weight loss), integrating the patho- physiology of T1DM into your discussion. 6. Describe the metabolic events that result in the signs and symptoms associated with DKA. ‘Was Rachel in this state when she was admitted? What precipitating factors may lead to DKA? 7. Rachel will be started on a combination of Apidra prior to meals and snacks, with glargine given in the am. and p.m. Describe the onset, peak, and duration for each of these types of insulin. Her discharge dosages are as follows: 7 u glargine with Apidra prior to each meal or snack—1:15 insulin:carbohydrate ratio. Rachef’s parents want to know why she cannot take oral medications for her diabetes like some of their friends do. What would you tell them? 8, Rachels physician explains to Rachel and her parents that Rachel’ insulin dose may change due to something called a honeymoon phase. Explain what this is and how it might affect her insulin requirements. tt Copy ary ip Nn meee pt pn telnet ype i dy a, eT ET TR Ea a gestern asap ipa+ Case 16 Pediatric Type 1 Diabetes Melitos 187 9. How does physical activity affect blood glucose levels? Rachel is a soccer player and usually plays daily. What recommendations will you make to Rachel to assist with managing her glucose during exercise and athletic events? 10. Ata follow-up visit, Rachel's blood glucose records indicate that her levels have been con- sistently high when she wakes in the morning before breakfast. Describe the dawn phe- nomenon. Is Rachel experiencing this? How might it be prevented? IL. Understanding the Nutrition Therapy 11. ‘The MD ordered a carbohydrate~ By srlld det fo when Rachel begins wo ext. Explain the rationale for monitoring carbohydrate in diabetes nutrition therapy. 12, Outline the basic principles for Rachel's nutrition therapy to assist in control of her TIDM. TIL. Nutrition Assessment 13, Assess Rachel’ ht/age; wt/age; ht/wt; and BMI. What is her desirable weight? 14, Identify any abnormal laboratory values measured upon her admission. Explain how they may be related to her newly diagnosed T1DM. 415. Determine Rachel's energy and protein requirements. Be sure to explain what standards you used to make this estimation. IV. Nutrition Diagnosis 16. Prioritize two nutrition problems and complete the PES statement for each. V. Nutrition Intervention 17, Determine Rachel’ initial nutrition prescription using her usual intake at home as a guide- line, as well as your assessment of her energy requirements. pa cern 8 Rio Ny cl a erm eo emery pene ee a eee ee eee ee en Sra scan tcmopaniee nn188 Unit Six. Netrition Therapy for Endocrine Disarders 18. What is an insulin:CHO ratio (JCR)? Rachel's physician ordered her ICR to start at 1:15. If her usual breakfast is 2 Pop-Tarts and 8 oz skim milk, how much Apidra should she take to cover the carbohydrate in this meal? 19, Dr. Cho set Rachel’ fasting blood glucose goal at 90-180 mg/dL. If her total daily insulin dose is 33 u and her fasting a.m. blood glucose is 240 mg/dL, what would her correction dose be? VL Nutrition Monitoring and Evaluation 20. Write an ADIME note for your initial nutrition assessment. 21. When Rachel comes back to the clinic, she brings the following food and blood glucose record with her. ‘a Determine the amount of carbohydrates she is consuming at each meal. b. Determine whether she is taking adequate amounts of Apidra for each meal according toher record. What of BG patient =| would Time Diet CHO | Beercise (mpldt)_| took 730 am. 2 Pop-Tarts| (Pre) 150 | Su Apidra banana 16 02 skin enilk with Ovaltine (2 tbsp) 10:30am. 12.n008 slices of pepperoni (Gre) 180 | 6u Apidra pizza 2 ehocolate chip cookies Water 2pm. ‘Granola bar PE dass— 30-minutes L