Ch. 31 Flashcards
which type of diabetes is more common
type I is more common than type II in children
covid and diabetes
since covid, the amount of children with diabetes has increased
- having covid increased the risk of diabetes
symptomatology of diabetes
regressing in developmental milestones
- secondary enuresis
mixing insulins
don’t do with children
- do multiple daily injections rather than mixing
___ and ___ alter insulin requirements
illness and exercise
calorie vs food restriction if child is overweight
limit calories not food if child is overweight
hypo v hyperglycemic episodes
hard to differentiate
- ok to assume hypo if personality changes and they don’t have a glucometer
- if they have a glucometer, test before assuming
blood glucose lab values: toddlers/preschoolers (<6 years)
before meals: 100-180 mg/dL
bedtime: 100-200 mg/dL
A1C: </= 7.5%
blood glucose lab values: school age (6-12 years)
before meals: 90-130 mg/dL
bedtime: 90-150 mg/dL
A1C: < 7%
blood glucose lab values: adolescents and young adults (>12 years)
before meals: 90-130 mg/dL
bedtime: 90-150 mg/dL
A1C: < 7%
toddlers and preschoolers < 6 years: blood glucose implications
high risk and vulnerability to hypoglycemia
school age 6-12 years: blood glucose implications
risks of hypoglycemia and relatively low risk of complications before puberty
adolescents and young adults > 12 years: blood glucose implications
risk of hypoglycemia
developmental and psychological issues
rapid acting insulin
names: lispro, aspart, glulisine
onset: < 15 min
peak: 30-90 min
duration: 3-4 hr (up to 5)
short-acting insulin
names: regular
onset: 30 min
peak: 2-4 hr
duration: 4-8 hr
intermediate insulin
names: NPH
onset: 2-6 hr
peak: 4-14 hr
duration: 14-20 hr
long-acting insulin
names: glargine, detemir
onset: 6-14 hr
peak: none or small peak after 10-16 hr
duration: 20-24 hr
insulin injection sites: fastest absorption site
abdomen
insulin injection sites: a little slower (2nd fastest)
the back of the arms
insulin injection sites: even slower (2nd slowest)
the legs
insulin injection sites: slowest absorption site
the buttocks
injection sites of insulin should
rotate/change every week or two to get the most out of your insulin
what happens if you choose the same injection site each time you inject?
hard lumps (fat tissue swells) can develop under the skin; insulin is absorbed slowly
- this is called lipohypertrophy
lipohypertrophy can be prevented by
rotating injection sites
- horizontal pattern
- curve pattern
- crisscross pattern
- zig zag pattern
injection sites for infants
no abdomen!
injection sites for children
abdomen ONLY if child has at least 1/2” of pinchable skin
otherwise no abdomen
injection sites for adolescents
abdomen (1/2” of pinchable skin)
why can’t we inject insulin into a site that will be exercised?
exercise can increase blood flow; makes insulin absorbed at a faster rate
*may have to give a snack with extra carbohydrates for every 45-60min of exercise
type II DM: acanthosis nigricans
thicker hyperpigmented skin especially seen in the back of the neck, axilla, and groin
resolves overtime when blood sugars are under better control
DM: nursing care goals
- restore euglycemia
- reduce urinary ketones
- maintain hydration
DM: illness management
- Monitor BS q 3 hrs.
- Monitor urinary ketones q 3 hrs.
- Continue the usual insulin regimen.
- Supplemental insulin based on BS.
- Encourage fluids (force if needed)
- Call provider if multiple emesis episodes, BS >240 continuously or urine ketones remain high (>3+)
DKA: nursing care goals
- rapid assessment
- adequate insulin coverage
- reverse dehydration
- electrolyte replacement (esp. K+) to correct hydration and acidosis
DKA: management
- Cardiopulmonary monitoring
- Admission weight
- Serial vitals and labs at bedside
- CBC with diff, BMP, ABG
- Strict I/O (Foley)
- IVF (1.5-2 days) with K+
- Regular insulin IV (0.1 units/kg/hr.)
- Decrease BS by 50-100 mg/dL/hr
- Add dextrose to IVF when BS falls <300
hypoglycemia: mild reaction (how to treat)
(adrenergic symptoms)
- give child 10-15g of a simple, high-carbohydrate substance (pref. liquid- ie OJ)
- follow with starch-protein snack
hypoglycemia: moderate reaction
(neuroglycopenic symptoms)
- give child 10-15g of a simple, high-carbohydrate substance (pref. liquid- ie OJ)
- repeat in 10-15 min if symptoms persist
- follow with larger snack
- watch child closely
hypoglycemia: severe reaction (how to treat)
(unresponsive, unconscious, or seizures)
- administer glucagon as prescribed
- follow with planned meal or snack when child is able to eat, or add snack of 10% of daily calories
- consult team re: dosing change
hypoglycemia nocturnal reaction: nursing interventions
(magic number is 10*)
- give child 10-15g of a simple carbohydrate
- follow with snack of 10% of daily calories
central precocious puberty (CPP)
type of early onset puberty
- before age of 7 in females with lighter skin or white skin
- before 6 in females of darker skin
- before age 9 in males
CPP clinical features
- Begins before age 7 in white girls, before 6 in AA girls and before age 9 in boys
- Usual progression of puberty
- Advanced ht., wt., and osseous maturation
- Early closure of growth plate resulting in less than normal height for age
- Elevated GH levels (includes FSH and LH)
- Idiopathic (girls)/ pathologic: ie tumor (boys)
growth hormone deficiency (GHD)
- Stunted somatic growth
- Familial but can be linked with other causes
GHD clinical features
- Weight percentile exceeds height
- Immature facial appearance
- Frontal bossing
- Truncal obesity
- Hypoplastic genitalia
- High pitched voice
- Delayed bone maturation
- Low GH level and possibly others
- Short stature, but HT and WT are proportional
- Delayed epiphyseal closure
- Retarded bone age compared with height
- Premature aging (later in life)
- Increased insulin sensitivity
- Normal intelligence
- Emotional problems (common)
causes of precocious puberty
girls: 90-95% are idiopathic- no cause
boys: underlying pathologic cause, ie tumor
(goal of) treatment of precocious puberty
goal of treatment is to stop and possibly reverse the onset of puberty
- treatment will depend on the type and underlying cause, if known
central/idiopathic precocious puberty: s/sx
onset of puberty (usual pattern)
gonadotropin levels increase
central/idiopathic precocious puberty: treatment
- CT or MRI to r/o tumor. Will x-ray bone growth to evaluate bone maturity and premature epiphyseal plate closure. Blood work. Treatment of any underlying cause if known (ex. Tumor removal).
- Pharmacology: Lupron Depot (synthetic luteinizing hormone-releasing hormone) injections.
peripheral precocious puberty: s/sx
some puberty s/sx but not all; out of order
estrogen or testosterone levels increase (not gonadotropin)
peripheral precocious puberty: treatment
- Depends on cause of increase in estrogen or testosterone levels. (ex. Tumor removal).
- Diagnostics to evaluate cause.
- Blood work.
incomplete precocious puberty: s/sx
partial development ie unilateral breast development
incomplete precocious puberty: treatment
- Wait and see. Usually resolves on its own.
- Blood work to confirm no activation of GnRH or hormones.
advanced bone age
the child’s bone structure is that of an older age
lupron depot
an injection administered monthly or q3months or GnRH analog histrelin implant
(placed SQ in arm)
- to treat CPP
why would dose changes be necessary with lupron depot
- hormone and clinical suppression are not achieved with the starting dose
- the child’s body weight changes
if lupron depot is effective
females: breast development will stop and may regress
males: the penis and testicles may shrink back to a size that is normal for their age
is missing a dose of lupron depot a problem?
yes- can precipitate return of CPP s/sx
treatment of GHD
Biosynthetic GH subcutaneous injections daily at bedtime
- 80% success rate
- Greatest results in year 1
- Likely to attain less than normal height even with treatment
- May have additional hormone deficiencies
when to stop GHD treatment
- Velocity < 1 inch
- Bone age of 14 (females) and 16 (males)
before/during/after treatment of GHD, assess for
- Socioemotional concerns pre-treatment
- Realistic expectations
- Effective coping during/post-treatment
intramuscular injections: sites and volume amounts
- Vastus Lateralis and Ventrogluteal Sites: 0.5-2 mL volume
- Deltoid: up to 1 mL
intramuscular injections
- Traditional hormone replacement therapy
- Vaccines
- Other medications (rabies vaccine, antibiotics etc.)
subcutaneous injections: sites
Numerous sites (kids usually rotate between 4-8 sites)
- anywhere you can pinch at least an 1/2-1in of skin in the abdomen
- legs (thigh)
- upper outer triceps
subcutaneous injections
- hormone replacement (pen)
- insulin
- vaccines
if the volume of an injections exceeds the warranted amount per injection,
divide into multiple injections
