There are an estimated 1.2 million people, living with diabetes and 85 per cent of them have type two, while the other 13 per cent have type 1 (Australian Government Department of Health, 2016). Genetics play a big part in the development of type 1 diabetes, which is an autoimmune condition where the body’s immune system attacks the insulin-producing cells of the pancreas. Destruction of the beta cells leads to a reduction in insulin production. Glucose taken from food cannot be stored in the liver and therefore remains in the bloodstream. People with T1D cannot produce insulin and require lifelong injections of insulin for survival (Corbin et al., 2018).
This case study involves a 12-year-old girl called Sarah. Sarah presented to the hospital with abdominal pain, hyperglycaemia and mild ketoacidosis. The medical team stabilised Sarah according to the type 1 diabetes (T1D) treatment and management plan. The purpose of this case study is to assess Sarah and the family’s needs holistically, develop a care plan and prioritise the care that is required. It will provide evidence-based interventions using a child and family centred approach and will centre around providing education to the family on the management of diabetes. This includes insulin management and administration, dietary regime, exercise needs for the child and helping the family adjust to the new diagnosis. Finally, through collaboration with other health professionals and with the family, come up with a strategy to prevent short- and long-term complications of T1D.
The first area that needs assessing is Sarah and her family’s understanding of diabetes. What is their education level and at what stage is Sarah’s development? What is their ability to perform procedures of care? Determining these things will help the nurse to develop a learning program that is appropriate for her individual needs. For instance, during pre-teenage years children have the ability for complex thought, studies indicate that a child after the ages of ten, may be able to take an active role in their own care. The nurse should include Sarah in the discussions around her diagnosis (Barrouillet, 2015).
Additionally, assessing the education level of the parents, allows the nurse to use appropriate language and information that fits the needs of the parents. Any learning disadvantages should be discussed before starting, for example, hearing, sight, or learning impairments. Furthermore, assessing the parents mental and physical abilities to perform procedures like blood tests, insulin injections and following a diet regime is essential for Sarah’s care management. All these need to be taken into consideration when developing her care plan (J. L. Chiang, M. S. Kirkman, L. M. B. Laffel, & A. L. Peters, 2014).
Secondly, assessment of the families coping mechanisms and their effectiveness. The nurse needs to gauge the family dynamics and the expectations related to the long-term care of Sarah. Some family dynamics include, is the client coming from a single parent home, and what role does the father have in Sarah’s life. The nurse should establish the families support systems and resources, for example, enquire as to who is looking after affairs at home while they are in the hospital. Whether they have any family nearby, they can rely on for support or do they need a social worker, psychologist or chaplain (Hilliard, Powell, & Anderson, 2016). It also helps the nurse to examine general and specific family attitudes, for example, the response of any siblings or how the diagnosis will impact on their family.
The final areas that need to be assessed are risk factors that may contribute to unstable glucose levels. These may include the family’s perception and habits of eating and exercise. Also, Sarah’s fear and anxiety of needles could affect how well she adheres to the diabetic management plan. Plus, their general financial situation needs to be evaluated and taken into consideration. Likewise, Sarah’s age, as it is a period of many physical, emotional, mental and social changes. Sarah may also succumb to peer pressure to use alcohol, drugs and tobacco products (Luthar & Ciciolla, 2016). Another risk to examine, is Sarah’s location, as the patient lives in a rural area, services may be not as available, and her distance may affect treatment.
The immediate concern that has been identified is Sarah’s fear of needles, her distress may be linked to the cannula in her arm. Fear of needles is quite common in children, but it may affect how well she adheres to the diabetes management plan. For example, injection of insulin and BSL testing. (Cemeroglu et al., 2015) Found that individuals who have an intense fear of needles tend to have a higher haemoglobin A1c and are less likely to keep up with glucose monitoring.
Being a newly diagnosed patient and living regionally, there may be a risk of compromised family coping. This may be due to insufficient, ineffective or compromised support structures, that are needed to manage her care. Behaviours seen in teenagers with compromised coping mechanisms include but are not limited to, drug use, over consumptions of alcohol, smoking and high-risk sexual behaviours in later years (Moulton, Pickup, & Ismail, 2015). That is why it is imperative for teenagers to have a supportive network of friends, family and services available to them. It is also important that the care plan helps facilitate the patient to eventually gain independence with caring for their chronic illness (Van Vleet, Helgeson, Seltman, Korytkowski, & Hausmann, 2018).
Sarah is at risk of experiencing diabetic emergencies while at school, all students with type 1 diabetes will have low blood sugar at school at least once or twice a week. Signs of mild hypoglycaemia include hunger, confusion, shakiness and fatigue to name a few. It is essential to catch hypoglycaemia early and treat it appropriately and immediately. If not treated, very low blood sugar is an emergency. Another diabetic emergency is hyperglycaemia; studies indicate that all students will have high blood sugar from time to time. However hyperglycaemia with ketones needs action, symptoms include, rapid shallow breathing, vomiting or fruity smelling breath (“Diabetes Care in the School and Day Care Setting,” 2014).
Diet is a significant factor in Sarah’s diagnosis, unstable glucose level may be a result of poor diet management. Eating habits need to be discussed and a dietitian could be recommended for personal advice, depending on the family’s situation (Battersby, Sweeney, Toome, Fairchild, & Miller, 2017).
Long term, the patient is at risk of developing comorbidities that happen as a result of consistent poor control of blood sugar levels, for example, kidney disease and cardiovascular problems. Over time diabetes can cause diabetic nephropathy, if the kidneys stop functioning properly dialysis or kidney transplant may be needed. Another common complication seen in people with diabetes is neuropathy. It is a progressive damage of the nervous system, that can lead to loss of feeling in the limbs, reduced circulation and impaired normal wound healing in the extremities (J. L. Chiang, M. S. Kirkman, L. M. Laffel, & A. L. Peters, 2014).
The current best practice guidelines for the care of paediatric patients dealing with chronic illnesses, is a child and family centred approach. C&FCC refers to an establishment of care plans that involve the child and their family. The family will be informed of the importance of follow up visits, as this promotes positive outcome when the family is involved. The aim is for Sarah is to enhance her overall health and well-being, by helping the client manage and deal with the stressors of the diagnosis independently (Cheraghi, Shamsaei, Mortazavi, & Moghimbeigi, 2015). The short-term goal is to instruct Sarah and the family on how to monitor sugar levels and to provide her with skills to enhance confidence in the self-administration of insulin. The immediate to long-term goal clinically, is to prevent the development of chronic diseases that arise as a result of poor management of sugar levels. This will be done through careful management of diet, insulin administration, education and encouraging Sarah on the importance of physical activity (Delamater, de Wit, McDarby, Malik, & Acerini, 2014).
The goal of this education session is to give Sarah and the family comprehensive information on type 1 diabetes, and the long-term management plans. The nurse will utilise pamphlets and visual aids appropriate for the child’s and parents learning needs. The nurse will also demonstrate the appropriate use of insulin pumps, use of glucometer and how to administer insulin using pens while Sarah is waiting for an insulin pump. The goal is for the parent to verbalise understanding of the T1D plan, also the parent and child should be able to verbalise and identify the signs and symptoms of hyperglycaemia and hypoglycaemia. Lastly, the parents and patient should understand that the child will have the illness for life, and prevention of complication requires cooperation with the medical staff and allied healthcare workers.
To help ease stress, anxiety and concerns prior to taking the educational sessions, the nurse should inform Sarah and her family of the services available to them. Such as, Ronald McDonald House or the Patient Assisted Travel Scheme for accommodation and travel. For mental health and well-being there are resources like eheadspace or kids helpline. Other helpful services are, Rural Health West, Allied Health, Health Direct and of course National Diabetic Services Scheme (WACRH, 2018). NDSS is a government scheme that is aimed at supporting people with diabetes, through access to information, services and government- subsidised products including the insulin pumps. Some of the services the NDSS provides are, information about diabetes self-management, how to order diabetic products and ways to access services available in their area. Also, healthy eating and physical activity programs, peer support groups and healthcare professionals. Application for the scheme can be made while the patient is at the hospital to lessen the stress. (Diabetes Australia, 2018).
Next, the educational sessions will be taught in small durations at a time, in a quiet and comfortable environment. The nurse will allow the patient and the family members to express areas of difficulty, anxiety and explore solutions. One area of anxiety for Sarah is the fear of needles. To lessen Sarah’s stress and encourage compliance to the management plan the nurse should recommend insulin pump therapy. Insulin pumps deliver rapid or short- acting insulin 24 hours a day through a catheter that is placed under the skin. Users set the pump to give them small basal amounts of insulin constantly throughout the day. Pumps also release bolus doses of insulin at meal times and at times when blood glucose levels are too high. Other advantages of insulin pumps include; fewer large changes in blood glucose levels and they allow the patient to perform physical activity without having to eat large amounts of carbohydrates (Steineck et al., 2015).
Increased physical activity should be recommended to Sarah. (Colberg et al., 2016) Found that aerobic training increases mitochondrial density and insulin sensitivity. Moderate to higher volumes of aerobic exercises is associated with lower levels of cardiovascular diseases in type 1 diabetes.
While waiting for the pump, the nurse will demonstrate to the parent and child the correct way to administer insulin using pens, how to use a glucometer and explain the importance of regular glucose testing, especially before every meal (Chalew et al., 2018). Another device that helps with management is the continuous glucose monitoring device. The CGM allows the individual and health caregivers to track blood glucose levels throughout the day and over a period of time, CGM’s also reduces the frequency of finger prick testing (Lind et al., 2017).
Sarah and the family will verbalise their understanding of type 1 diabetes and the symptoms of hyperglycaemia and hypoglycaemia. Also, they will demonstrate how to appropriately monitor blood glucose, insulin administration, dietary management and the exercise plan. In dealing with compromised family coping, Sarah and her family will explore feelings regarding the child’s long-term needs. With the services recommended, the family can choose the resources that are appropriate, for example, a consultation with an exercise physiologist, dietician or counsellor. Recommendations will be given to see their local doctor within two weeks to review progress. The effectiveness of the care plan will be based on how many diabetic emergencies that the client experiences in a given period. This will give the healthcare team an idea of how well Sarah manages her diabetes.
The care plan for Sarah was developed using the C&FCC framework, it allowed Sarah and her parents to be actively involved with improving her health and wellbeing. This case study has highlighted some of the problems that Sarah and the family may be facing due to the new diagnosis. For example, compromised family coping and the risk of developing diabetes-related complications. The case study has also provided general and specific nursing intervention in collaboration with allied health professionals. Sarah has also been made aware of various government schemes and resources that people with diabetes can access.
Australian Government Department of Health. (2016). Diabetes Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/content/chronic-diabetes
Barrouillet, P. (2015). Theories of cognitive development: From Piaget to today. Developmental Review, 38, 1-12. doi:https://doi.org/10.1016/j.dr.2015.07.004
Battersby, R., Sweeney, A., Toome, S., Fairchild, J., & Miller, J. (2017). Audit of the dietetic care of patients with type 1 diabetes at a large Australian paediatric tertiary hospital and comparison with the International Society for Paediatric and Adolescent Diabetes nutrition guidelines. Nutrition & Dietetics, 74(4), 408-414.
Cemeroglu, A., Can, A., Davis, A., Cemeroglu, O., Kleis, L., Daniel, M., . . . Koehler, T. (2015). Fear of Needles in Children with Type 1 Diabetes Mellitus on Multiple Daily Injections and Continuous Subcutaneous Insulin Infusion. Endocrine Practice, 21(1), 46-53. doi:10.4158/ep14252.Or
Chalew, S., Gomez, R., Vargas, A., Kamps, J., Jurgen, B., Scribner, R., & Hempe, J. (2018). Hemoglobin A1c, frequency of glucose testing and social disadvantage: Metrics of racial health disparity in youth with type 1 diabetes. Journal of Diabetes and its Complications.
Cheraghi, F., Shamsaei, F., Mortazavi, S. Z., & Moghimbeigi, A. (2015). The Effect of Family-centered Care on Management of Blood Glucose Levels in Adolescents with Diabetes. International Journal of Community Based Nursing and Midwifery, 3(3), 177-186.
Chiang, J. L., Kirkman, M. S., Laffel, L. M., & Peters, A. L. (2014). Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care, 37(7), 2034-2054.
Chiang, J. L., Kirkman, M. S., Laffel, L. M. B., & Peters, A. L. (2014). Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes Association. Diabetes Care, 37(7), 2034-2054. doi:10.2337/dc14-1140
Colberg, S. R., Sigal, R. J., Yardley, J. E., Riddell, M. C., Dunstan, D. W., Dempsey, P. C., . . . Tate, D. F. (2016). Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care, 39(11), 2065-2079. doi:10.2337/dc16-1728
Corbin, K. D., Driscoll, K. A., Pratley, R. E., Smith, S. R., Maahs, D. M., Mayer-Davis, E. J., . . . Obesity, N. (2018). Obesity in Type 1 Diabetes: Pathophysiology, Clinical Impact and Mechanisms. Endocrine Reviews. doi:10.1210/er.2017-00191
Delamater, A. M., de Wit, M., McDarby, V., Malik, J., & Acerini, C. L. (2014). Psychological care of children and adolescents with type 1 diabetes. Pediatric diabetes, 15(S20), 232-244.
Diabetes Australia. (2018). online services Retrieved from https://www.ndss.com.au/
Diabetes Care in the School and Day Care Setting. (2014). Diabetes Care, 37(Supplement 1), S91-S96. doi:10.2337/dc14-S091
Hilliard, M. E., Powell, P. W., & Anderson, B. J. (2016). Evidence-based behavioral interventions to promote diabetes management in children, adolescents, and families. American Psychologist, 71(7), 590.
Lind, M., Polonsky, W., Hirsch, I. B., Heise, T., Bolinder, J., Dahlqvist, S., . . . Wedel, H. (2017). Continuous glucose monitoring vs conventional therapy for glycemic control in adults with type 1 diabetes treated with multiple daily insulin injections: the GOLD randomized clinical trial. JAMA, 317(4), 379-387.
Luthar, S. S., & Ciciolla, L. (2016). What it feels like to be a mother: Variations by children’s developmental stages. Developmental psychology, 52(1), 143.
Moulton, C. D., Pickup, J. C., & Ismail, K. (2015). The link between depression and diabetes: the search for shared mechanisms. The Lancet Diabetes & Endocrinology, 3(6), 461-471.
Steineck, I., Cederholm, J., Eliasson, B., Rawshani, A., Eeg-Olofsson, K., Svensson, A.-M., . . . Gudbjörnsdóttir, S. (2015). Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18 168 people with type 1 diabetes: observational study. BMJ : British Medical Journal, 350. doi:10.1136/bmj.h3234
Van Vleet, M., Helgeson, V. S., Seltman, H. J., Korytkowski, M. T., & Hausmann, L. R. (2018). An examination of the communal coping process in recently diagnosed diabetes. Journal of Social and Personal Relationships, 0265407518761226.
WACRH. (2018). projects Retrieved from http://www.wacrh.uwa.edu.au/research/current-projects