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Diagnosis and problem identification, planning and intervention, case presentation, case study: a patient with type 1 diabetes who transitions to insulin pump therapy by working with an advanced practice dietitian.

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Claudia Shwide-Slavin; Case Study: A Patient With Type 1 Diabetes Who Transitions to Insulin Pump Therapy by Working With an Advanced Practice Dietitian. Diabetes Spectr 1 January 2003; 16 (1): 37–40. https://doi.org/10.2337/diaspect.16.1.37

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Registered dietitians (RDs) who have earned the Board Certified–Advanced Diabetes Manager (BC-ADM) credential hold a master’s or doctorate degree in a clinically relevant area and have at least 500 hours of recent experience helping with the clinical management of people with diabetes. 1 They work in both inpatient and outpatient settings, including diabetes or endocrine-based specialty clinics, primary care offices, hospitals, and private practices. Advanced practice dietitians provide all components of diabetes care, including advanced assessment (medical history and physical examination), diagnosis, medical management, education, counseling, and overall case management.

The role of RDs in case and disease management was explored in a recent article 2 that included interviews with three dietitians who work as case managers or disease managers. All three reported experiencing challenges in practice and noted that the meaning of “case management” varies from one health care setting to another. This is also true for RD, BC-ADMs. Advanced practice dietitians specializing in diabetes require case management expertise that stresses communication skills, knowing the limits of your own discipline, knowing how to interact with other health care professionals, and knowing when to seek the expertise of other members of the diabetes care team.

Clinical practice includes assessment and data collection, diagnosis and problem identification, planning, and intervention. In many cases, diabetes educators who are dietitians and those who are nurses are cross-trained to perform the same roles. The first one to meet with a client handles that client’s assessment, and cases are discussed and interventions planned at weekly team meetings.

For advanced practice dietitians, the first session with a client often involves a complete physical assessment, not just a nutrition history. This includes a comprehensive medical history of all body systems. The diabetes-focused physical examination, just as performed by clinicians from other disciplines, includes height and weight measurement, body mass index (BMI) calculation, examination of injection sites, assessment of injection technique, and foot assessment.

Assessment also includes reviewing which medications the client is taking, evaluating their effectiveness and side effects, and determining the need for adjustment based on lifestyle, dietary intake, and blood glucose goals.

When carbohydrate counting is added to therapy, dietitians calculate carbohydrate-to-insulin ratios and teach clients how to use carbohydrate counting instead of a sliding-scale approach to insulin. Medications are adjusted based on clients’ lifestyles until blood glucose goals are achieved.

The therapeutic problem solving, regimen management, case management, and self-management training performed by advanced practice dietitians exceeds the traditional role of most dietetics professionals. 3  

A role delineation study for clinical nurse specialists, nurse practitioners, RDs, and registered pharmacists, 4 conducted in 2000 by the American Nurses Credentialing Center, reported equal findings among all four groups for the skills used to identify pathophysiology, analyze diagnostic tests, and list problems. Assessment for medical nutrition therapy typically includes evaluation of food intake, metabolic status, lifestyle, and readiness to change. For people with diabetes, monitoring glucose and measuring hemoglobin A 1c (A1C), lipids, blood pressure, and renal status are essential to evaluating nutrition-related outcomes.

The U.S. Air Force health care system conducted a pilot test giving RDs clinical privileges and evaluating their clinical judgment in patient nutritional care. A protocol was approved, and dietitians were allowed to order and interpret selected outpatient laboratory tests independently. The higher-level clinical judgments and laboratory privileges were linked to additional certifications. 5  

The Diabetes Prevention Program (DPP) also provided a unique opportunity for dietitians to demonstrate advance practice roles. 6 Dietitians served as lifestyle coaches, contacting participants at least once a month to address intervention goals. As case managers, they interviewed potential volunteers, assessed past experience with weight loss, and scheduled quarterly outcome assessments and weekly reviews of each participant’s progress at team meetings. Within the DPP’s central management, dietitians served as program coordinators and served on national study committees related to participant recruitment and retention, quality control, the use of protocols, and lifestyle advisory groups. 7  

Dietitians now play key roles in translating DPP findings and serving as community advocates to reduce the incidence of obesity and the health care burden of type 2 diabetes. This includes serving in a consultative role to other health care team members on issues regarding weight loss and risk factor reduction.

Advanced practice RDs offer comprehensive diabetes patient care services, including identifying patient goals and expected outcomes, selecting nonpharmacological and pharmacological treatments, and developing integrated plans of care. Problems discussed with patients range from acute and chronic diabetes complications to comorbid conditions, other conditions, preventive interventions, and self-management education. Advanced practice RDs also review patients’ health care resources and order laboratory tests if information is not available from referral sources. They provide supportive counseling and referral to specialists, as needed. And, they provide a full report of their findings and any regimen changes and recommendations they make to referring clinicians after each visit.

These activities and responsibilities go beyond the scope and standards of practice for the RDs and for RD, CDEs. 8 They will be included in the scope of practice document for RD, BC-ADMs that is now being developed by the Diabetes Care and Education Practice Group of The American Dietetic Association.

The following case study illustrates the clinical role of advanced practice dietitians in the field of diabetes.

B.C. is a 51-year-old white man who was diagnosed with type 1 diabetes 21 years ago. He believes that his diabetes has been fairly well controlled during the past 20 years and that his insulin needs have increased. He was recently remarried, and his wife is now helping him care for his diabetes.

His endocrinologist referred him to the RD for an urgent visit because 4 days ago he had a hypoglycemic event requiring treatment in the emergency room (ER). He has come to see the dietitian because his doctor and his wife insisted that he do so.

B.C. has had chronic problems with asymptomatic hypoglycemia. His last doctor’s visit was 3–4 weeks ago, when areas of hypertrophy were found. His endocrinologist asked him to change his injection sites from his thigh to his abdomen after the ER incident.

He does not think he needs any diabetes education but would like help in losing 10 lb. His body mass index is 25 kg/m 2 .

His medications include pravastatin (Pravacol), 10 mg daily; NPH insulin, 34 units in the morning and 13 units at bedtime; and regular insulin at breakfast and dinner following a sliding-scale algorithm. He also takes lispro (Humalog) insulin as needed to correct high blood glucose.

Before his ER visit, B.C. monitored his blood glucose only minimally, testing fasting and sometimes before dinner but not keeping records. Since his severe hypoglycemia 4 days ago, he has begun checking his blood glucose four times a day, before meals and bedtime.

Lab Results

B.C.’s most recent laboratory testing results were as follows:

A1C: 8.3% (normal 4.2–5.9%)

Lipid panel

    • Total cholesterol: 207 mg/dl (normal: 100–200 mg/dl)

    • HDL cholesterol: 46 mg/dl (normal: 35–65 mg/dl)

    • LDL cholesterol: 132 mg/dl (normal: <100 mg/dl)

    • Triglycerides: 144 mg/dl (normal: <150 mg/dl)

Creatinine: 0.9 mg/dl (normal: 0.5–1.4 mg/dl)

Microalbumin: 4 μg (normal: 0–29 μg)

At his initial visit with the RD for crisis management of asymptomatic hypoglycemia, she examined his injection sites and asked if he had made the changes recommended by his clinician. She reviewed his injection technique, diet history, incidence of hypoglycemia, and hypoglycemia treatment methods. She discussed with B.C. ways to reduce his risks of hypoglycemia, including food choices, insulin timing, and absorption variations at different injection sites.

The RD reinforced his clinician’s instruction to avoid old injection sites and added a new recommendation to lower insulin doses because of improved absorption at the new sites.

B.C. was now checking his blood glucose and recording results in a handheld electronic device in a form that could be downloaded, e-mailed, or faxed, but he was not recording his food choices. The dietitian asked him to keep food records and started his carbohydrate-counting education. A follow-up visit was scheduled for 1 week later.

At the second visit, B.C.’s mid-afternoon blood glucose was <70 mg/dl. He did not respond to treatment with 15 g carbohydrate from 4 oz. of regular soda. His blood glucose continued to drop, measuring 47 mg/dl 15 minutes later. He drank another 8 oz. of soda, and his blood glucose increased to 63 mg/dl 1 hour later. He then drank another 8 oz. of soda and ate a sandwich before leaving the dietitian’s office. He called in 1 hour later to report that his blood glucose was finally up to 96 mg/dl.

B.C.’s records showed a pattern of mid-afternoon hypoglycemia. He was willing to add a shot of lispro at lunch to his regimen, so the RD recommended reducing his morning NPH to prevent lows later in the day.

The RD also calculated insulin and carbohydrate ratios for blood glucose correction and meal-related insulin coverage using the “1500 rule” and the “500 rule.”

The 1500 rule is a commonly accepted formula for estimating the drop in a person’s blood glucose per unit of fast-acting insulin. This value is referred to as an “insulin sensitivity factor” (ISF) or “correction factor.” To use the 1500 rule, first determine the total daily dose (TDD) of all rapid- and long-acting insulin. Then divide 1500 by the TDD to find the ISF (the number of mg/dl that 1 unit of rapid-acting insulin will lower the blood glucose level). B.C.’s average TDD was 41 units. Therefore, his estimated ISF was 37 mg/dl per 1 unit of insulin. The RD rounded this up to 40 mg/dl to be prudent, given his history of hypoglycemia.

The 500 rule is a formula for calculating the insulin-to-carbohydrate ratio. To use the 500 rule, divide 500 by the TDD. For B.C., the insulin-to-carbohydrate ratio was calculated at 1:12 (1 unit of insulin to cover every 12 g of carbohydrate), but again this was rounded up to 1:14 for safety. Later, his carbohydrate ratio was adjusted down to 1:10 based on blood glucose monitoring results before and 2 hours after meals.

The RD taught B.C. how to use the insulin-to-carbohydrate ratio instead of his sliding scale to adjust his insulin and asked him to try to follow the new recommendations. With his endocrinologist’s approval, she reduced his NPH doses to 34 units and added a shot of lispro at lunchtime, the dose to be based on the amount of carbohydrate in the meal and his before-meal blood glucose level.

The RD asked B.C. to return in 1 week for evaluation and review of his new regimen. However, 3 days later, he returned after having had another severe episode of hypoglycemia.

In the course of these early visits, a good rapport developed between B.C. and the dietitian. B.C. learned that his judgment on how hypo- and hyperglycemia felt was often inaccurate and led him to make insulin adjustments that contributed to his hypoglycemia problems. By improving B.C.’s understanding of insulin doses and blood glucose responses, the RD hoped to help him become more skilled at making insulin dose adjustments. For the time being, however, he was still at risk for asymptomatic hypoglycemia. He had recently filled a prescription for glucagon, but the RD needed to review and encourage its proper use. She also provided literature to support his wife in case she needed to administer glucagon for him.

At this third visit, the RD reduced B.C.’s morning NPH dose to 22 units because of his rapid drop in blood glucose between noon and 1:00 p.m. This reduction finally eliminated his mid-afternoon lows.

B.C. had started using carbohydrate counting to make his decisions about lunchtime insulin doses. He liked carbohydrate counting because it gave him a more viable reason for testing his blood glucose frequently. Over the years, B.C.’s glycemia had become increasingly difficult to control. He had stopped checking his blood glucose because he felt unable to improve the situation once he had the information. In the early 1990s, his endocrinologist had started him self-adjusting insulin doses using the exchange system, but he found that he was always “chasing his blood sugars.” Carbohydrate counting changed everything. He now knew what to do to improve his blood glucose levels, and that made him feel more in charge of his diabetes.

Still, although carbohydrate counting led to more frequent testing and better blood glucose control than his old sliding scale, it was not perfect. At home, he had mastered this technique, but he ate many of his meals in restaurants, where carbohydrate counting was more challenging.

B.C. found it difficult to carry different types of insulin. This and his lifestyle suggested the need to change his multiple daily injections from regular to lispro insulin. He continued checking his blood glucose before and 2 hours after meals. His insulin-to-carbohydrate ratio of 1:10 g and his ISF of 1:40 mg/dl allowed him to stay within his goal of no more than a 30-mg/dl increase in blood glucose 2 hours after meals. He continued to be asymptomatic of hypoglycemia, but lows occurred less frequently. The new goal of therapy was to recover his hypoglycemia symptoms at a more normal level of about 70 mg/dl. He was scheduled for another visit 2 weeks later.

Between visits to the RD, BC-ADM, his clinician identified problems with the timing of his long-acting insulin peak, resulting in early nocturnal lows. Based on the clinician’s clinical experience of lente demonstrating a slightly smoother peak, she changed B.C.’s long-acting insulin unit-for-unit from NPH to lente.

At B.C.’s next visit, he and the RD reviewed his insulin doses of 22 units of lente in the morning and 11 units of lente at night. His TDD including premeal lispro now averaged 49 units. His average blood glucose levels were 130 mg/dl fasting, 100 mg/dl mid-afternoon, 127 mg/dl before dinner, and 200 mg/dl at bedtime.

The bedtime levels were higher because of late meals, the fat content of restaurant meals, his meat food choices, and his inexperience at counting carbohydrates for prepared foods. The dietitian suggested mixing regular and lispro insulin to try and get the average bedtime blood glucose level to 140 mg/dl. Mixing his calculated dose to be one-third regular and two-third lispro would provide coverage lasting a little longer than that of just lispro to cover higher-fat foods that took longer to digest. At the same time, the dietitian encouraged B.C. to choose lower-fat foods to help reduce his LDL cholesterol and assist with weight loss. B.C. now had an incentive to keep accurate food records to help evaluate his accuracy at calculating insulin doses.

B.C. and the RD also reviewed his decisions for treating lows. At his first meeting, B.C. ate anything and everything when he experienced hypoglycemia, which often resulted in blood glucose levels >400 mg/dl. Now, he was appropriately using 15–30 g of quick-acting glucose—usually 4–8 oz. of orange juice. He based this amount on his blood glucose level, expecting about a 40-mg/dl rise over 30 minutes from 10 g of carbohydrate. He checked his glucose level before treating when possible and always checked 15–30 minutes after treating to evaluate the results. Once his glucose reached 80 mg/dl or above, he either ate a meal or ate 15 g of carbohydrate per hour to prevent a recurrence of hypoglycemia until his next meal.

In completing her assessment during the next few meetings with B.C., the RD identified a problem with erectile dysfunction. She notifed his clinician and referred him to a urologist. Eventually, the urologist diagnosed reduced blood flow and started B.C. on sildenafil (Viagra).

B.C. wanted to resume exercise to help his weight loss efforts. Because exercise improves insulin sensitivity and can acutely lower blood glucose, the dietitian taught B.C. how to reduce his insulin doses by 25–50% for planned physical activity to further reduce his risks of hypoglycemia. He learned to carry his blood glucose meter, fluids, and carbohydrate foods during and after exercise. His pre-exercise blood glucose goal was set at 150 mg/dl. The dietitian instructed B.C. to test his blood glucose again after exercise and to eat carbohydrate foods if it was <100 mg/dl.

She also gave instructions for unplanned exercise. He would require additional carbohydrate depending on his blood glucose level before exercise, his previous experience with similar exercise, and the timing of the exercise. Education follow-ups were scheduled with the dietitian for 1 month later and every 3 months thereafter.

At his next annual eye exam, B.C. discovered that he had background retinopathy. He also reported feeling that his daily injection regimen had become too complicated. Still feeling limited in his ability to control his diabetes and looking for an alternative to insulin injections, he wanted to discuss continuous subcutaneous insulin infusion therapy (insulin pump therapy).

He, his endocrinologist, and his dietitian discussed the pros and cons of pump therapy and how it might affect his current situation. They reviewed available insulin pumps and sets and agreed on which ones would best meet his needs. The equipment was ordered, and a training session was scheduled with the dietitian (a certified pump trainer) in 1 month.

B.C. started using an insulin pump 2 years after his first visit with the dietitian. His insulin-to-carbohydrate ratio was adjusted for his new therapy regimen, and a new ISF was calculated to help him reduce high blood glucose levels. His endocrinologist set basal insulin rates at 0.3 units/hour to start at midnight and 0.5 units/hour to start at 3:00 a.m. This more natural delivery of insulin based on B.C.’s body rhythms and lifestyle further improved his diabetes control.

One week after starting pump therapy, B.C. called the dietitian to report large urine ketones and a blood glucose level of 317 mg/dl. His endocrinologist had changed his basal rates, but he wanted to meet with the dietitian to review his sites, set insertion, troubleshooting skills, and related issues. Working together, they eventually discovered that problems with his pump sites required using a bent-needle set to resolve absorption issues.

B.C’s relationship with his endocrinologist and dietitian was seamless. He met with the dietitian when his clinician was unavailable or when he needed more time to work through problems.

B.C. has met with the RD 15 times over 3 years. Eventually, he recovered symptoms of hypoglycemia when his blood glucose levels were 70 mg/dl. After 6 months of education meetings, his lab values had reached target ranges. Most recently, his LDL cholesterol was <100 mg/dl, his A1C results were <7%, his hypoglycemia symptoms were maintained at a blood glucose level of 70 mg/dl, and his blood glucose had been stabilized using the square-wave and dual-wave features on his insulin pump.

B.C. learned how to achieve recommended goals and to self-manage his diabetes with the help of his care team: endocrinologist, cardiologist, ophthalmologist, podiatrist, urologist, and advanced practice dietitian.

Advanced practice dietitians in diabetes work in many settings and see clients referred from many different types of medical professionals. They may see clients either before or after their appointments with other members of the health care team, depending on appointment availability and their need for nutrition therapy and diabetes education. Referring clinicians rely on their evaluations and findings. When necessary, clinician approval can be obtained for immediate interventions, enhancing the timeliness of care.

Why would an RD want to obtain the skills and certification necessary to earn the BC-ADM credential? The answer, as illustrated in the case study above, lies in their routine use of two sets of skills and performance of two roles: patient education and clinical management.

Dietitians who specialize in diabetes often find that their role expands beyond provider of nutrition counseling. As part of a multidisciplinary team, they become increasingly involved with patient care. As they move patients toward self-management of their disease, they necessarily participate actively in assessment and diagnosis of patients; planning, implementation, and coordination of their diabetes care regimens; and monitoring and evaluation of their treatment options and strategies. They find that their daily professional activities go beyond diabetes education, crossing over into identifying problems, providing or coordinating clinical care, adjusting therapy, and referring to other medical professionals. They often work independently, providing consultation both to people with diabetes and to other diabetes care team members.

The BC-ADM credential acknowledges this professional autonomy while promoting team collaboration and thus improving the quality of care for people with diabetes. The new certification formally recognizes advanced practice dietitians as they move beyond their traditional roles and into clinical problem solving and case management.

Claudia Shwide-Slavin, MS, RD, BC-ADM, CDE, is a private practice dietitian in New York, N.Y.

Note of disclosure: Ms. Shwide-Slavin has received honoraria for speaking engagements from Medtronic Minimed, which manufactures insulin pumps, and Eli Lilly and Co., which manufactures insulin products for the treatment of diabetes.

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Nursing Case Study for Type 1 Diabetes

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Michael is a 14-year-old male brought into a small ER by his mother. They were driving a long distance after he competed in a wrestling tournament. He had not felt well on the bus ride with the team so his mother decided he should ride with her. His mother denies a history of chronic illness but did say he had “like a cold but with a stomachache” about 3 months ago.

She also says that he has been very thirsty, and they had to stop several times for him to urinate. She is also worried because he almost missed his wrestling “weight class” parameters because he was significantly lighter this past weekend than he has been in the past. And that is even with him eating more than usual.

What symptoms are most worrisome to the triage nurse?

• He has 2 of the 3 “p’s” – polydipsia (thirst), polyuria (frequent urination), polyphagia (hunger) which are trademarks of diabetes mellitus (DM) and/or diabetic ketoacidosis (DKA). They happen in response to the body lacking insulin and its response is to try to achieve homeostasis with these mechanisms. His weight loss could be indicative of DM as well. 
• They describe a recent viral-like illness which may precipitate a diagnosis of DM (it is thought the body has an inappropriate immune response to the illness leading to DM)

In triage, the nurse obtains a point-of-care blood glucose (BG) level and the machine gives no value. Instead, an error message indicating “hi” displays on the machine.

Why did the nurse do this test? What should they do next?

• Clues point to possible DM or DKA. Getting a BG immediately can help guide care. Always follow the facility protocol/procedure on “hi” or “lo” (often spelled this way on glucometers) readings. The protocol might dictate (standing order) stat venous draw and send it to the lab. It may be advised to try again on a different machine with a new sample. Whatever the guidance, a BG level is imperative for this patient.

Michael is AAO x 4. He complains of a “stomachache” and reports he has nausea and experienced vomiting shortly before arrival. His skin is warm and dry, but his face is flushed. When asked about pain, he says he has a headache, and his vision is blurry. The nurse notices a fruity odor on his breath when obtaining vital signs. 

BP 90/54 mmHg SpO 2 98% on Room Air

HR 122 bpm and regular

RR 26 bpm at rest

The patient and his mother are placed into an exam room immediately and the triage nurse verbally reports this to the accepting nurse.

How does the nurse interpret these symptoms?

• Michael’s symptoms are consistent with hyperglycemia (link here to cheatsheet?) DKA

What orders does the accepting nurse anticipate?

• Labs, ABGs, urinalysis, IV access (bilateral upper extremities, largest possible in case patient deteriorates). One lab, in particular, can give the provider an idea of the last 2-3 month BG average, the hemoglobin A1C.

The provider orders stat labs, urinalysis and ABGs then examines the patient. 

Why stat orders?

• This patient’s condition could deteriorate rapidly, and treatment should begin ASAP. Labs are needed to guide the plan of care. The nurse should watch for changes in the level of consciousness, respiratory changes, his response to potential fluid & electrolyte imbalances. Place on continuous cardiac monitoring as well.

Lab results are as follows:

WBC 15000 cells/mcL

Glucose 420 mg/dl

BUN 21 mg/dl

Creatinine 0.77 mg/dl

Anion gap 12

Glucose positive

Ketones positive

What do these results mean?

• CBC WBC 15000 cells/mcL – an immune response, possibly to viral illness or another issue HgbA1C 9% – indicates the average BG over the past 2-3 months has been about 212mg/dLBMP Glucose 420 mg/dl – hyperglycemia K 5.8 – electrolyte imbalance, can cause cardiac changes and need to monitor closely if IV insulin is started (will need frequent checks of this and BG) BUN 21 mg/dL – fluid imbalance Creatinine 0.77 mg/dL – normal but necessary to check for kidney function Anion gap 12 – indicative of DKAABG – metabolic acidosis Ph 7.25 HCO3 15 PaCo2 35 PaO2 88Urine – indicative of DKA Glucose positive Ketones positive

What medication orders should the nurse anticipate?

• IV fluids, insulin (either IV or SQ). NOTE: only REGULAR INSULIN can be given IV, and if it is, then IV dextrose and potassium chloride should be included in the insulin IV titration protocol/order). SQ insulin may be ordered using a sliding scale. O2 via NC possibly due to potential respiratory concerns (Kussmaul respirations)

The provider tells Michael and his mother that he suspects diabetic ketoacidosis which is not uncommon for new type I diabetics. He plans to transfer Michael to a nearby city via helicopter for a higher level of care.  The patient’s mother asks why he has to be transferred.

How does the nurse explain the transfer to the mother and patient?

• DKA requires monitoring in a critical care unit. Because of his age and new-onset DM, a higher level of care is recommended in order to have access to the best resources

The flight team arrives and assesses the patient. The ER completes a report using SBAR format at the bedside. The patient and his mother are given the chance to ask questions.

What are the transport team’s priorities as they move this patient?

• Airway, breathing, and circulation (ABC) status; Mental status; Volume status.

Upon arrival to the higher level of care, Michael is admitted to the ICU overnight. By the morning he is transferred to a pediatric floor for further observation. His mother remains at his bedside. They plan to return to their home after discharge. 

How should the pediatric medical unit prepare this family for discharge? What specific teaching should be provided?

• Condition-specific education is vital including DM management with medications, exercise, nutrition, psychosocial concerns, preventative care (i.e. vaccinations), parental/family involvement. A specialized diabetic educator and/or dietician would be ideal. Assessing their education preferences and literacy level is important as well. How to give insulin injections and check BG (glucometer use) are key takeaways (have patient and parent return-demonstrate). Case management may need to get involved for prescription/supplies. An endocrinologist may be consulted so education about his specialist is also important.

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Nursing case studies.

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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• v.19(Suppl 1); 2015 Apr

Type 1 diabetes mellitus-common cases

Surender kumar.

Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India

Tight glycemic control in type 1 diabetes mellitus patients is associated with the risk of hypoglycemia. Diabetic patients are forced to change their lifestyle to adjust to the disease condition and survive it. The best way to manage diabetes would be to develop a therapy, which could adjust to the patient's conditions. Here, I present few cases wherein switching to a long-acting basal insulin analog helped combat recurrent hypoglycemic episodes experienced by the patients.

I NTRODUCTION

Tight glycemic control in type 1 diabetes mellitus (T1DM) patients is not possible because of hypoglycemia. Diabetic patients are forced to change their lifestyle to adjust to the disease condition and survive it. The best way to manage diabetes would be to develop a therapy, which could adjust to the patient's conditions.[ 1 ]

A 6-year-old boy presented with classic features of diabetic ketoacidosis, that is, weight loss and extreme weakness and osmotic features. The fasting blood sugar level was 300 mg/dL, postprandial glucose level was 467 mg/dL and hemoglobin A1c (HbA1c) was 7.2%. He was administered with standard intravenous insulin and fluid, which finally brought down the fasting blood glucose level to around 120 mg/dL. He was administered basal-bolus therapy and was discharged. Patient had two episodes of severe hypoglycemia. His parents were worried due to frequent checking of blood glucose levels many times in a day. The challenge was also to avoid urination in bed at night by the child. Otherwise he would get a common cold. The patient remained unconscious in the middle of the night and was fed up with the frequent monitoring of blood sugar. The patient and the parents had severe anxiety, depression, frustration, and disgust. The parents considered diabetes as a curse on their family. He was informed about degludec/injection tresiba, which is not yet approved in children because of lack of experience. The physician explained to them that there was nothing wrong in administering it and is not contra-indicated in T1DM.[ 2 ] The parents were also explained that insulin degludec may even help the child to convert from four injections to one injection a day, and from very frequent monitoring to once in a day. After reviewing the literature about insulin degludec, the parents were finally convinced about it. The patient was then put from basal-bolus to 2 bolus plus 1 basal and finally degludec at 16 U. Over the period of time, blood sugar level came to normal at around 110 mg/dL-pre meal. The patient was trained very well that if he wanted to reduce the frequency of monitoring of blood sugar level, then he had to follow small frequent meals. This made him felt happy because once the sugar was controlled then small amount of sweets was also given. The techniques resulted in good compliance from the patient. The patient did not report any hypoglycemic event over a period of 3 months. This was a big relief for the patient and his parents. Later parents were told that the child may require basal-bolus therapy. The outcomes of this case study were that in case of T1DM the physician should not be very aggressive except during the first 2 weeks of admission. The physician should also try to convince the parents about line of treatment, and educate both the patients and the child. The dose may be gradually stabilized without being aggressive, and this also prevents frequent episodes of hypoglycemia. Hence, gradual tightening of glycemic control is very important. The doctor should analyze the psyche of the patient and his parents.

A 57-year-old female presented with a 13 year history of diabetes. Due to the failure of oral hypoglycemic agents (OHAs) in controlling her sugar levels, for the last 3 years, she was treated with biphasic insulin aspart 30/70. She was a very frequent flier, a regular swimmer and socially very active, and this led her to have irregular meals. Hence, she often go into frequent hypoglycemia and during the last 6 months the patient's average blood glucose level during fasting were 170 mg/dL and postprandial glucose levels varied from 230 to 280 mg/dL. Even after high sugar levels, she fortunately had normal kidney functions. Patient was able to afford an insulin pump, so she was put on one. With the pump, her blood glucose was in control and patient was happy. However she soon realized the limitation of carrying it everywhere she went. These were the true feelings of a patient who was very active while she was on an insulin pump. The physician, after discussing with the patient, started her on insulin degludec and lifestyle modification, especially the diet component. Patient understood these problems and followed the diet. She followed the dietary modification and over 2 months of time, fasting blood glucose was 110 mg/dL, post meals values were around 180 mg/dL. She had only one episode of minor hypoglycemia which was due to delayed meal. The doctor later reduced degludec from 44 U to 40 U and blood glucose was still improving without any episode of hypoglycemia in the last 3 months. The outcome of this case is that with this therapy and dietary modification, a desired level of blood glucose can be achieved, without hypoglycemic risk.

An 80-year-old retired army officer, staying alone, has type 2 diabetes for the last 12 years and renal function test was normal and patient was on insulin along with other OHAs. Despite this, the patient was getting attacks of hypoglycemia, which scared the patient of unconsciousness and even death. The limiting factors were that the patient was staying alone and was dependent upon an attendant to get injections. During the weekends or holidays, the attendant was not on a regular time, and this led to irregular insulin injections, causing hypoglycemic episode to patient. This patient as well was put on insulin degludec and over a period the dose of degludec was also increased. His HbA1c and fasting blood glucose level improved without any episode of hypoglycemia. The outcomes of this case are that degludec along with dietary modifications gave desired diabetes control without any hypoglycemia.

The main barrier to tight glycemic control is hypoglycemia. This can be adjusted with slight dietary modification without changing the therapy.[ 3 ]

Source of Support: Nil

Conflict of Interest: None declared.

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Type 1 Diabetes (Case Study)

Emma Burns is a bright and bubbly 11-yearold girl like any other, who enjoys sleepovers with her friends and is excited about going to high school in 2013. Delve deeper though, and you discover that Emma was diagnosed with type 1 diabetes when she was just two.

While she lives a happy and independent life today, it was not always so simple for the Newcastle youngster. Before participating in HMRI’s diabetes diet study, Emma and her mother Kim had to follow a strict series of tables and measurements to calculate her food and insulin levels.

“Before the study we used to calculate exactly everything that Emma ate,” Kim said.

“Our family had to devote a large amount of the day to Emma’s diet and it was a constant stress when we wanted to go out for a meal.”

Any childhood disease can become extremely taxing for families as they fit clinic visits, medications and intensive therapies into an already hectic lifestyle. HMRI researcher Carmel Smart, a Senior Paediatric Diabetes and Endocrine Dietician at the John Hunter Children’s Hospital, has focused her research on counteracting just this.

Carmel’s research demonstrated that carbohydrate counting down to the last gram did not improve the accuracy of insulin treatment in children with type 1 diabetes.

Instead, Carmel proved that estimating carbohydrate portions worked just as effectively.

The outcomes of this study mean life-changing results for children like Emma. “No studies have looked at this very practical issue that has the potential to make a difference in the daily lives of children with diabetes,” Carmel said.

“I’ve made it my goal to give families the right information and the flexibility to help them manage diabetes more effectively.”

As research progresses, the role of food is being successfully changed from a major hurdle to something that diabetic children can enjoy.

“This method of carbohydrate counting has allowed us to relax and Emma now has the freedom to go out with her friends without having to worry about food or her diabetes,” Kim said.

Adds Emma: “I feel like everybody else now … I feel normal and I have a normal life, I just need to do a few extra things than my friends.”

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Depression and Type 1 diabetes: case studies

January 26, 2020 by Diabetes Care

Here are two case studies to further understand how depression and type 1 diabetes can be intertwined and can affect teens.

In my last blog, I quoted from the Diabetes Care Journal- June 2006/vol. 29 pg 1389 that the level of depressive symptoms in children and adolescents with type 1 diabetes is nearly double that of the highest estimate of depression in youth in general.

Due to the rise of depression and suicides in the teen and young adult population, I thought I would describe two case studies that may illustrate what young people experience and feel, and their frustrations in life as they manage their lives and their type 1 diabetes.

The first case is about a girl who was diagnosed with type 1 diabetes at an early age. Her parents assisted her with her management until, at age 9, she told them that she could do it on her own. She did this until she was 14 or 15 years of age. At this time she was given a new insulin regimen, which confused her and ended up causing her to have extreme hypoglycemia (low blood sugar levels) and hyperglycemia (high blood sugar levels). She could not figure this out. She could not understand why she could not work out the carb ratio and insulin intake. She was an A student, so why could she not figure out this new regimen? She found the situation very frustrating.

With these extreme hypo and hyper glucose levels, the teen had difficulty concentrating in school and became angry about her diabetes. She could not figure her diabetes management out. She asked for the old regimen to be implemented, but this was not supported by her diabetes endocrinologist. She became angry, frustrated, and anxious. She could not sleep and became depressed. She started to sleep longer during the day, not wanting to eat and she did not want to take her insulin. She started to ask herself questions: Why me? Why do I have to have diabetes? Why can’t I be like everyone else…normal? She ended up in hospital with Diabetic ketoacidosis ( DKA).

While in hospital, the teen worked with the hospital healthcare team and figured out how to manage her diabetes. At home she continued this management and started to see a counsellor on living with diabetes and how to manage life struggles. She is doing very well today.

My last case is about a young man, age 16. He was diagnosed at 7 years of age with type 1 diabetes. His management during elementary and junior high school was very well monitored, which he was very pleased about. He praised himself on his strict management and therefore good glucose level readings. When he reached 16 years of age, he could not regulate his glucose levels very well. His levels would fluctuate, which frightened him. He had heard stories about people he knew with type 1 diabetes experiencing DKA (diabetic ketoacidosis) – see Ketones…what are they and what do they mean? , lows, and not having control over their lives. He became very anxious. He did not sleep at night, worrying about not waking up in the morning. He constantly tested his glucose levels and made readjustments. He became so tired, that he just wanted to sleep, but could not. He relayed this information to his endocrinology team and started to see the social worker. With this assistance, support and counselling, he has learned to be mindful of his body’s reactions to lows and highs, and has put his fears into perspective and is able to cope with them way better. He is happier and enjoying life more.

These cases illustrate the frustrations that can arise as individuals manage their diabetes. These are only two case examples; there are definitely other cases that may be worse.  As I stated in my last blog, if someone you know is experiencing problems with their diabetes management and is exhibiting depressive signs, please consult the endo team, family doctor or go to your nearest hospital emergency department for help.

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• Diabetes Care for Children & Young People

Vol:10 | No:03

Case study: A five-year-old boy with Down’s syndrome recently diagnosed with type 1 diabetes

• 18 Aug 2021

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He was started on insulin therapy with multiple daily injections and received a Dexcom G6™ (Dexcom Inc, San Diego, CA, USA) for real-time continuous glucose monitoring (rtCGM). The insulin regimen chosen was 1.5 units of long-acting insulin analogue (Levemir) with breakfast and 2.5 units at bedtime; and meal-time fast-acting insulin aspart (Fiasp). His parents were given carbohydrate counting education and he was started on insulin aspart injection with ratios of 1:15 for breakfast, 1:16 for lunch and 1:21 for dinner. A month after starting insulin therapy, his HbA 1c was 75 mmol/mol (11.7%).

There is a higher incidence of T1D in individuals with DS compared with the general population (Bergholdt et al, 2006, Rohrer et al, 2010). Furthermore, Bergholdt et al (2006) considered the prevalence of T1D in all children born in Denmark from 1981–2000 and found the prevalence of children with DS and T1D was 4.2 times higher than the prevalence of T1D in the background population. DS is also associated with a higher risk of developing other autoimmune conditions, such as coeliac disease and hypothyroidism (Lämmer et al, 2008; Aitken et al, 2013). In one study, the incidence of individuals with diabetes and DS who were diagnosed with thyroid disease and coeliac disease was 74% and 14%, respectively (Aitken et al, 2013). The child presented in this case study did not have a co-existing autoimmune condition at diagnosis, but there is an increased risk that he will develop  one in the future.

Additional challenges

A diagnosis of T1D has a huge impact on the lives of both the child and their parents. It involves a lifetime of daily injections, monitoring glucose levels and accounting for every meal and snack eaten. For all families of a recently diagnosed child this is a challenging time (Lindström et al, 2011), but for the family of a child with DS, there are additional challenges for both them and the diabetes care teams (Pikora et al, 2014). The aim of diabetes care is to provide education and support for the child and family, and ultimately to empower the developing adolescent to become independent in their daily diabetes management. DS adds additional challenges to this process (McVilly et al, 2014; Pikora et al, 2014).

The characteristics associated with DS need to be considered by the diabetes team when implementing insulin therapy. Cognitive development varies between individuals with DS, particularly with regards to language, processing language and verbal working memory (Silverman, 2007; Couzens et al, 2012). Additionally, Couzens et al (2012) suggested that long-term medical conditions affecting daily lives were associated with a negative impact on cognitive ability and development of the child with DS. The child in this case report is still very young and it is unclear how his cognitive development will progress. He currently attends a mainstream primary school and both parents have university level education; these two factors have been shown to be supportive of cognitive growth (Couzens et al, 2012).

Learning disability (LD) associated with DS may also affect the communication of common T1D symptoms such as thirst, headaches, blurred vision and mood change. These may not be well communicated, making it more difficult to monitor and manage the condition (Taggart et al, 2013). LD does not preclude common emotions, such as feeling different and self-conscious when monitoring glucose levels in front of others (Dysch et al, 2012; McVilly et al, 2014). This could be the reason why LD has also been associated with sub-optimal glycaemic control (Taggart et al, 2013). This may not always be the case, however. In contrast, Rohrer et al (2010) found individuals with DS and T1D achieved better HbA 1c and used less insulin than people with T1D without DS, despite their intellectual impairment. The authors speculated that this may be due to their simpler lifestyle and acceptance of routine. We should be mindful of these possibilities as the child develops.

Continuous glucose monitoring

The diabetes team opted to use continuous glucose monitoring (CGM) to overcome some of the issues of more challenging glycaemic control associated with LD. CGM is beneficial for children and young people (CYP) who have an impaired awareness of hypoglycaemia, or are unable to articulate symptoms of hypoglycaemia or hyperglycaemia, as was the situation with the  child in this case study (Danne et al, 2018). The internationally agreed target range for glucose levels is 3.9–10 mmol/L (Battelino et al, 2019) and CGM has been shown to improve “time in range”, regardless of the type of insulin therapy used.

The Dexcom G6 was chosen because it offers rtCGM and has been shown to increase time in range from 47.4% to 57.0% in children, when combined with a structured education programme (Pemberton et al, 2020). NICE (2015) recommends rtCGM with a hypoglycaemia alarm system for children with an inability to recognise and communicate the symptoms of hypoglycaemia. Puhr et al (2019) found the switch to Dexcom G6 with hypoglycaemia alarms reduced the time in hypoglycaemia by 40% for those with a hypoglycaemia threshold setting of 3.9 mmol/L, and by 33.3% for those with a threshold setting of 4.4 mmol/L. Pemberton et al (2020) report that the Dexcom G6 is currently the only device available in the UK which meets the Food and Drug Administration requirements for use in the ages 2–70 years, has four hypoglycaemia prevention alarms and does not require frequent finger-prick calibrations.

In the current case it was thought that, based on his age and current cognitive development, this child might not recognise and be able to communicate symptoms associated with low blood glucose levels (Taggart et al, 2013). The Dexcom G6 offers a solution to this and enables his parents to monitor real-time data, as well as reducing the frequency of finger-prick blood glucose tests. As with all children with T1D, DS does not reduce the perceived impact on daily life, and children with DS may still have a needle phobia (Pikora et al, 2014). His parents have found the ability to monitor his glucose levels throughout the day when he is at school reassuring. In addition, rtCGM allows overnight monitoring for nocturnal hypoglycaemia.

Fast-acting insulin

This child has a regular meal pattern and routine regarding his meal choices. Following discussions with his parents regarding meal patterns, a view was taken that although he tended to eat from a limited range of meals, the actual portion size of his meal varied and was often difficult to predict until during, or even after, the meal. The team decided that the most appropriate bolus insulin would be Fiasp, which has been shown to start acting 5 minutes earlier than insulin aspart (Heise et al, 2017; Russell-Jones et al, 2017; Shiramoto et al, 2018). The speed of onset offered the parents more flexibility at mealtimes to accommodate the fluctuating appetite of a five-year-old.

Diabetes education

The aim of education for CYP with T1D is to empower children and adolescents to manage their own diabetes according to their chosen management plan (Phelan et al, 2018). The same is true of education for children with special educational needs and LD (Dysch et al, 2012; McVilly et al, 2014). DS is associated with delays in overall cognitive development and language development (Finestack and Abbeduto, 2010; Quinn et al, 2020). As a team, we will need to adapt our style of education to reflect this child’s cognitive learning. This will involve working with the family to ensure that all diabetes-related education is unambiguous and to establish their  preferred style of communication.

Augmentative and alternative communication

As a team, we will need to consider different teaching strategies to help engage the child to participate in his own care as he gets older. One such strategy is augmentative and alternative communication (AAC). AAC is often used to support CYP with cognitive disabilities, including children with DS. Symbols are used to teach instructions and to communicate needs (Binger and Light, 2007; Finke et al, 2017; Quinn et al, 2020).

Multi-symbol messages and using symbols in different combinations can convey simple requests and tasks, such as “more milk” or “drink milk” (Binger and Light, 2007). AAC modelling (AAC-MOD) involves a combination of symbols while simultaneously modelling the spoken messages and is used to aid the child’s understanding of those messages (Quinn et al, 2020). AAC-MOD provides a method of communication to aid participation in daily routines.

Similarly, objects could be used as an alternative to symbols. Diabetes-related objects of reference could include an empty insulin pen with a symbol prior to receiving an injection, so the child understands what is about to happen. Symbols could then be used to create a schedule to help this child understand what he needs to do throughout  the day to manage his diabetes. These could be combined with a task schedule board. When a task is completed, it is removed from the schedule board. This can help remind a person which tasks have been completed and which are still to be done. At the time of writing, AAC-MOD had not yet been implemented in practice.

Children spend a significant proportion of their day at school, and maintaining glucose levels as near normal as possible is important in order to optimise their learning ability (Bratina et al, 2018). Schools in England should support children with medical conditions, so that they have full access to education (Department of Education, 2015). In pupils with medical conditions who have special education needs, this provision should be delivered in a coordinated way (Department of Education, Department of Health, 2015). Education, Health and Care Plans (EHCPs) are used to identify additional needs and are designed to increase collaboration between education, health and care teams (Boesley and Crane, 2018).

This child already had a comprehensive EHCP due to his pre-existing healthcare needs and has one-to-one support from a teaching assistant (TA) throughout the school day. This has enabled the school to accommodate his additional care needs as a result of diabetes. For example, his parents requested his insulin injections to be given in his classroom rather than in the school office, as had been the case with previous pupils with T1D. His mother describes him as stubborn and knew he could potentially refuse to go to the office. To minimise the negative associations with his diabetes, it was agreed his injections could be administered in the lobby area of his classroom. Due to the fact that this child had one-to-one support already in place through his existing EHCP, the school felt able to accommodate this and the additional medical care required as a result of his new diagnosis of T1D.

This child’s response to insulin injections varies and he will sometimes say “no, don’t hurt me” to his TA. To address concerns that his classmates might be distressed by this, parental permission was obtained for the Year 1 children to watch the BBC Get Well Soon episode “Learning more about diabetes”. This enabled the children to ask questions and was well received by the parents. His mother reports that he is comfortable engaging in his care in the classroom and his classmates appear happy to chat openly about it.

This child’s current primary school is working with his parents and healthcare team to tailor his support to meet his specific needs, and it has the resources to do so. As he progresses through secondary education, the healthcare team need to be cognizant that this may not always be the case. They  will need to continue to work collaboratively with future schools to ensure this tailored support can continue where practicable.

Future challenges

As a team we will need to develop our service and practice over the coming years to ensure this child has the support he needs to manage his diabetes. In the meantime, there is a paucity of studies about DS and the management of T1D, and McVilly et al (2014) suggest further research is needed to determine the type of support techniques and organisational support that are required to maximise active involvement by individuals with LD in the self-management of their diabetes. Whichever strategies are chosen, it will require ongoing collaboration, clear communication and coordinated planning between us, the healthcare team, his family, school staff and, at a later stage, the individual himself, to ensure he gains the support he needs and is empowered to manage his diabetes care as independently as possible.

Acknowledgement

The author would like to acknowledge Birmingham City University’s Children & Young Persons Diabetes Care Module.

Aitken R, Mehers K, Williams A et al (2013) Early-onset coexisting autoimmunity and decreased HLA-mediated susceptibility are the characteristics of diabetes in Down Syndrome. Diabetes Care 36 : 1181–85 Battelino T, Danne T, Bergenstal R et al (2019) Clinical targets for continuous glucose monitoring data interpretation: Recommendations from the International Consensus on Time in Range. Diabetes Care 42 : 1593–1603 Bergholdt R, Eising S, Nerup J, Pociot F (2006) Increased prevalence of Down’s syndrome in individuals with type 1 diabetes in Denmark: A nationwide population-based study. Diabetologia 49 : 1179–1182 Binger C, Light J (2007) The effect of aided AAC modeling on the expression of multi-symbol messages by preschoolers who use AAC. Augment Altern Commun 23 : 30–43 Boesley L, Crane L (2018) Forget the Health and Care and just call them Education Plans’: SENCOs’ perspectives on Education, Health and Care plans. J Res Spec Educ Needs 18 : 36–47 Bratina N, Forsander G, Annan F et al (2018) ISPAD Clinical Practice Consensus Guidelines 2018: Management and support of children and adolescents with type 1 diabetes in school. Pediatr Diabetes 19 : 287–301 Couzens D, Haynes M and Cuskelly M (2012) Individual and environmental characteristics associated with cognitive development in Down Syndrome: A longitudinal study. J Appl Res Intellect Disabil 25 : 396–413 Danne T, Phillip M, Buckingham B et al (2018) ISPAD Clinical Practice Consensus Guidelines 2018: Insulin treatment in children and adolescents with diabetes. Pediatr Diabetes 19 : 115–35 Department of Education (2015) Supporting pupils at school with medical conditions: Statutory guidance for governing bodies of maintained schools and proprietors of academies in England . Available at: https://bit.ly/3uegTdc(acessed 04.05.21) Department of Education, Department of Health (2015) Special educational needs and disability code of practice 0 to 25 years: Statutory guidance for organisations which work with and support children and young people who have special educational needs or disabilities. Available at: https://bit.ly/3gZ7zWK (accessed 04.05.21) Dysch C, Chung M, Fox J (2012) How do people with intellectual disabilities and diabetes experience and perceive their illness? J Appl Res Intellect Disabil 25 : 39–49 Finke EH, Davis JM, Benedict M et al (2017) Effects of a least-to-most prompting procedure on multisymbol message production in children with autism spectrum disorder who use augmentative and alternative communication. Am J Speech Lang Pathol 26 : 81–98 Finestack LH, Abbeduto L (2010) Expressive language profiles of verbally expressive adolescents and young adults with Down syndrome or fragile X syndrome. J Speech Lang Hear Res 53 : 1334–8 Heise T, Pieber TR,  Danne T et al (2017) A pooled analysis of clinical pharmacology trials investigating the pharmacokinetic and pharmacodynamic characteristics of fast-acting insulin aspart in adults with type 1 diabetes. Clin Pharmacokinet 56 : 551–9 Lämmer C, Weimann E (2008) Early onset of type I diabetes mellitus, Hashimoto’s thyroiditis and celiac disease in a 7-yr-old boy with Down’s syndrome. Pediatr Diabetes 9 : 423–5 Lindström C, Aman J, Norberg AL (2011) Parental burnout in relation to sociodemographic, psychosocial and personality factors as well as disease duration and glycaemic control in children with type 1 diabetes mellitus. Acta Paediatr 100 : 1011–7 McVilly K, McGillivray J, Curtis A et al (2014) Diabetes in people with an intellectual disability: A systematic review of prevalence, incidence and impact. Diabet Med 31 : 897–904 NICE (2015) Diabetes (type 1 and type 2) in children and young people: Diagnosis and management . NICE, London [NG18]. Available from: https://www.nice.org.uk/NG18 (accessed 04.05.21) Pemberton J, Kershaw M, Dias R et al (2020) DYNAMIC: Dynamic glucose management strategies delivered through a structured education program improves time in range in a socioeconomically deprived cohort of children and young people with type 1 diabetes with a history of hypoglycemia. Pediatr Diabetes 22 : 249–60 Phelan H, Lange K, Cengiz E et al (2018) ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes education in children and adolescents. Pediatr Diabetes 19 : 75–83 Pikora T, Bourke J, Bathgate K et al (2014) Health conditions and their impact among adolescents and young adults with Down Syndrome PloS One 9 : e96868 Puhr S, Derdzinski M, Welsh JB et al (2019) Real-world hypoglycemia avoidance with a continuous glucose monitoring system’s predictive low glucose alert. Diabetes Technol Ther 21 : 155–8 Quinn ED, Kaiser AP, Ledford JR (2020) Teaching preschoolers with Down Syndrome using Augmentative and Alternative Communication Modeling during small group dialog reading. Am J Speech Lang Pathol 29 : 80–100 Rohrer T, Hennes P, Thon A et al (2010) Down’s syndrome in diabetic patients aged <20 years: An analysis of metabolic status, glycaemic control and autoimmunity in comparison with type 1 diabetes. Diabetologia 53 : 1070–5 Russell-Jones D, Bode B, DeBlock C et al (2017) Fast-acting insulin aspart improves glycemic control in basal-bolus treatment for type 1 diabetes: Results of a 26-week multicenter, active-controlled, treat-to-target, randomized, parallel-group trial. Diabetes Care 40 : 943–50 Shiramoto M, Nishida T, Hansen AK, Haahr H (2018) Fast-acting insulin aspart in Japanese patients with type 1 diabetes: Faster onset, higher early exposure and greater early glucose-lowering effect relative to insulin aspart. J Diabetes Investig 9 : 303–10 Silverman W (2007) Down syndrome: cognitive phenotype. Ment Retard Dev Disabil Res Rev 13 : 228–36 Taggart L, Coates V, Truesdale-Kennedy M (2013) Management and quality indicators of diabetes mellitus in people with intellectual disabilities. J Intellect Disabil Res 57 : 1152–63

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16 Nov 2022

NICE guidance urges local trusts to improve processes and advocate for CGM use in children and young people.

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Case Study of Type 1 Diabetes

Diabetes mellitus (DM) is a multisystem disease with both biochemical and anatomical/structural consequences. (Wolfsdorf et al: 2009) It is a chronic disease of carbohydrate, fat, and protein metabolism caused by the lack of insulin, which results from the marked and progressive inability of the pancreas to secrete insulin because of autoimmune destruction of the beta cells. Type 1 DM can occur at any age.It occurs most commonly in juveniles but can also occur in adults, especially in those in their late 30s and early 40s.

Unlike people with Type 2 DM, those with Type 1 DM are generally not obese and may present initially with diabetic ketoacidosis (DKA). The distinguishing characteristic of a patient with Type 1 DM is that if his or her insulin is withdrawn, ketosis and eventually ketoacidosis develop. Therefore, patients are dependent on exogenous insulin. Vanelli et al: 2007) Treatment of Type 1 DM in a young child requires a multidisciplinary approach inclusive of doctors, nurses, dieticians, parent/s and others who may have care for the child for periods longer than a few hours; so care and responsibility for Type 1 DM in a child, may also include teachers and extended family etc. (NICE 2004) In patients with new-onset Type 1 diabetes, lifelong insulin therapy must be started.As a chronic disease, Type 1 DM requires long-term medical attention, both to limit the development of its devastating complications and to manage them when they do occur, it is therefore essential that those caring for a child with Type 1 DM have a good working knowledge of the disease, and a practical understanding of how to manage and respond to this disease, if the child is too young to be able to manage this disease for themselves.

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(Craig et al: 2007) This case study examines the roles and responsibilities of those adults, who might have some element of accountability for managing and caring for a young child with Type 1 DMCase Study of V V, a 6 year old female, was taken to the doctor’s clinic with an approximate 10 lb. weight loss over the last few weeks; symptom’s included nausea, increased thirst and urination. When asked by the doctor, V denied having any abdominal pain. V’s father has had Type 1 DM for 14 years and one of V’s cousin’s was diagnosed with Type 1 DM at age 18 months. As a result of an existing family condition, the doctor tested V for Type 1 DM.

Medical tests confirmed that V was suffering from Type 1 DM.Because Type 1 DM is a catabolic disorder in which circulating insulin is very low or absent, plasma glucagon is elevated, and the pancreatic beta cells fail to respond to all insulin-secretory stimuli. Tests also disclosed that V’s pancreas evidenced lymphocytic infiltration and destruction of insulin-secreting cells of the islets of Langerhans, causing insulin deficiency. As a result of the confirmation of Type 1 DM, the doctor administered exogenous insulin to reverse V’s catabolic condition, prevent ketosis, decrease hyperglucagonemia, and normalise V’s lipid and protein metabolism.Prognosis for V. Whilst the family have an above average comprehension of the difficulties that V will experience for the rest of her life, despite their own experiences and knowledge, the doctor still had a duty of care to outline to V’s parents how he intended to advise and support V.

This is in keeping with best clinical practice, because every case of Type 1 DM has to be managed on an individual basis, according to the National Institute for Health and Clinical Excellence. NICE 2004) NICE guidelines also recommend that children and young people with Type 1 DM should be offered an on-going integrated package of care, by a multidisciplinary paediatric diabetes care team. The reasons for this are to optimise the efficacy of care and to reduce the risk of difficulties or complications that a child might experience, as a result of this disease. NICE also recommend that the careteam should include members with appropriate training in clinical, educational, dietetic, lifestyle, mental health and foot care aspects of diabetes for children and young people.Due to distance, as well as parental knowledge, the doctor advised that he thought it would be more practical for V to receive home based treatment and management, and arranged for the specialist diabetic nurse (SDN) within the practice to schedule home visits.

Medical tests for V were also organised to be held at the clinic, initially on a monthly basis, so that a professional monitoring of V’s condition could take place, as well as providing a forum for oversight and support, in respect of any family concerns that might arise as a result ofV’s disease. Clinical/ homecare of V by specialist diabetic nurse. Outside of her responsibility for scheduling home visits, the SDN organised for the clinics dietician to accompany her on V’s home visits for a three month period, to assess V’s progress and to formulate a dietary plan that provides V and her parents with all the necessary dietary information, to sustain and manage V’s disease, whilst providing a best outcomes scenario for V.Diet is an exceptionally important factor when managing Type 1 DM because the NICE target for long-term glycaemic control is an HbA1c level of less than 7. 5% without frequent disabling hypoglycaemia, therefore, V’s care package should be designed to attempt to achieve this. V will have a greater chance of keeping within desired levels if her diet is coordinated with her insulin management; consequently it is essential that a specialist diet is created that will account for the individual needs of V, to accomplish this.

Lawrence 2005) V’s parents will also require additional understanding in respect of their daughter’s dietary considerations, as they will have to cater to their daughter’s dietary needs for the foreseeable future, and these will differ to those of her father. The SDN has also arranged for the other specialists within her clinical team to arrange to visit V’s home or to attend to V on clinical visits, resulting in compliance with the current NICE guidelines.The SDN has also contacted V’s school, and arranged to assess the schools ability to respond to the management of V’s disease. Whilst the school nurse may have some training in managing Type 1 DM, there are likely to be occasions when they are not available to provide the necessary support, therefore it is essential that the school has an alternative/s to the school nurse, who also have the necessary training to be able to deal with V’s disease.The SDN’s assessment may result in training being provided to a number of other school staff, to offset the potential for the school nurse not being available, and this is also in keeping with best care outcomes. Although type 1 diabetes is a medical condition, it has a direct impact on cognitive functions when the blood sugar levels are out of range.

This means that children at school need access to their medication, insulin, and blood glucose testing equipment, in order to control this serious medical condition.Young children need help with injections, blood tests and interpretation of the results. All children will need help to monitor hypoglycaemia and moderate or severe episodes will be likely to need treating by a third party, especially if a child is young. High blood sugar effects the concentration levels significantly and is very harmful to the health of the child. In the short term high blood sugar causes frequent urination, blurred vision and difficulty concentrating and can make children feel very unwell.

High blood sugar is extremely harmful to the cells in the body, particularly those of the eyes, kidneys, circulatory system and nerves. Not treating high blood glucose levels can eventually lead to a condition called ketoacidosis, which, if not treated can be fatal. Hypoglycaemic episodes can occur despite best care practice, and it is therefore essential that an alternative trained school staff member is available within school hours; to respond to a hypoglycaemic episode, should one occur.This training is essential, because on rare occasions, a child with hypoglycaemic coma may not recover within 10 minutes, despite appropriate therapy. It has been advised that under no circumstances should further treatment be given, especially intravenous glucose, until the blood glucose level is checked and still found to be subnormal, without specialist training, overtreatment might occur.

Overtreatment of hypoglycaemia can lead to cerebral edema and death. (Craig et al: 2009) Another concern for the SDN is likely to be the fact that Type 1 DM is not a statemented concern within schools.Because Type 1 DM is as disease, there is no provision within education, to treat a child with this disease under any educational ‘Special Needs’ criteria. Nonetheless, a child with Type 1 DM is likely to suffer from educational deprivation, as they will require attention by the school nurse, lasting approximately 20 minutes per session, twice daily, five a days a week, resulting in 3. 35 hours of lost education weekly, and this could be more, if the needs of V require more than two interventions a day within school hours.Since there is no funding in place for extra support, whether this be for children needing general supervision with snacks and blood tests, for help to administer injections or for an extra trained staff member, to ensure safety on a school trip etc.

, whilst most parents do not consider their child with diabetes, to be disabled, or to have “learning difficulties” as such, all children diagnosed with diabetes should be considered under the Code of Practice (DfES 2001) as having SENs due to their medical needs.The Code of Practice acknowledges a relationship between a child’s medical status and educational needs, at paragraph 7. 65, it says that: “Medical conditions may have a significant impact on a child’s experiences and the way they function at school. The impact may be direct in that the condition may affect cognitive or physical abilities, behaviour or emotional state. The impact may also be indirect, perhaps disrupting access to education through unwanted effects of treatments or through the psychological effects that serious or chronic illness or disability can have on a child and their family. Type 1 diabetes, and its treatment, has a substantial effect on a child’s health and education because of the wide-ranging impact on the ability to learn and upon cognitive functions.

It is vital for schools to fully understand diabetes and how best to support a child with this medical condition in order for the child to access the full curriculum. Discussion with the parents and the school is therefore advisable, so that V is not marginalised educationally as a result of her disease. Parental role and responsibilitiesProvided the correct support and information is given to the parents, V’s disease can be regulated and managed appropriately to achieve best outcomes. Nonetheless, as V gets older, it is likely that she will want to manage her own medication and she should be taught and encouraged to do so. This training falls primarily within the role and responsibility of the parents, and they are likely to be the people who will provide V with the correct training, as well as the dietary information that V will require to enable and empower her to manage her disease.

Appropriate exercise, coupled to a healthy diet can minimise the impact that V will experience as a result of her condition. It is also the responsibility of the parents to ensure that V attends the clinic at the arranged times, and that she is encouraged to participate as fully as she is able in all of the schools curricula and non-curricular activities. Other social aspects of V’s life must also be considered and addressed. For normalisation to occur, (Osburn 2006) V must be encouraged to view her disease in the most productive manner.Others must also be encouraged to view V’s disease in a way that does not lead to V’s friends and other social relationships, treating V as anything other than a normal child.

Other parents should be encouraged to invite V to their children’s birthday parties, without becoming concerned that V might become hypoglycaemic if she has a slice of birthday cake. Conclusion As evidenced in this case study, as identified by NICE, it is important to have a multidisciplinary approach to the care and management of Type 1 DM.If the appropriate care package is provided for V, her condition need not become a life burdening millstone around her neck, and V can look forward to having a quality of life that is on Parr with other people who do not have a disability or disease. Whilst the prognosis for V is dependent upon other factors outside of her control, provided her parents, as well as those professionals who are involved with the well-being of V, contribute to a best outcomes approach, then hypoglycaemic episodes in V’s life will be greatly reduced, as a consequence of their input.Word count 2166 References Craig ME, Wong CH, Alexander J, Maguire AM, Silink M.

Delayed referral of new-onset type 1 diabetes increases the risk of diabetic ketoacidosis. Med J Aust 2009;190:219. DfES 2001 Special Education Needs: Code of Practice https://www. education. gov. uk/publications/standard/publicationDetail/Page1/DfES%200581%202001 last accessed on 15/1/2012 National Institute for Health and Clinical Excellence.

(2004) http://www. nice. org. uk/nicemedia/live/10944/29402/29402. pdf last accessed on

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