Pediatric Primary Care (101 page)

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Authors: Beth Richardson

Tags: #Medical, #Nursing, #General

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E. Physical findings.

1. Ketonuria, ketonemia, glucosuria.

2. Vomiting.

3. Dehydration.

4. Slow, labored breathing, flushed face and cheeks.

5. Mental confusion, lethargy.

6. Fruity odor to breath.

7. High blood glucose levels.

8. Monilial vaginitis in adolescent females.

F. Diagnostic tests.

1. Fasting plasma glucose, casual plasma glucose.

2. Urine for ketones and glucose.

3. Electrolytes and pH.

4. Blood urea nitrogen.

5. CBC.

G. Differential diagnosis.

Hypoglycemia, 251.2	Salicylate intoxication, 535.4
Intracranial lesions, 784.2	Sepsis, 038.9

1. Hypoglycemia.

2. Salicylate intoxication.

3. Sepsis.

4. Intracranial lesions.

H. Treatment.

1. Multidisciplinary approach involving family with pediatric endocrinologist, PNP, diabetic nurse educator, social worker, nutritionist.

2. Educate child and family in stabilizing blood sugars, diabetes management. Due to complexity of illness, management requires incorporation into daily life.

3. Treatment replaces insulin that child is unable to produce—the cornerstone of management.

4. Insulin dosage is tailored to child's blood glucose and HbA1c levels
Table 29-1
.
Diabetic control: based on HbA1c levels, clinical symptoms. HbA1c levels provide information on glycemic control during past 60 days.

5. Insulin is categorized by peak of onset.

6. Various insulin injection devices available.

Table 29-1
HbAlc and Glycemic Targets

Source:
Kaufman, F. (2003). Type 1 diabetes mellitus.
Pediatrics in Review, 24
, 9.

I. Follow up.

1. Review medical, nutritional, insulin therapy, daily blood glucose monitoring
(Table 29-2
).

2. Follow up every 3 months to review management plans, physical/ psychosocial needs
(Table 29-3
).

J. Complications.

Eating disorders, 307.5	Neuropathy, 357.2
Ketoacidosis, 250.1	Retinopathy, 362.1
Nephropathy, 583.9	Vaginal yeast infections, 112.9

1. Ketoacidosis.

2. Vaginal yeast infections.

3. Retinopathy.

4. Nephropathy.

5. Neuropathy.

6. Lipid profile.

7. Eating disorders.

K. Education.

1. Prevention of diabetic ketoacidosis.

2. Knowledge of onsets of action, peak action, duration of action of five types of insulin
(Table 29-4
).

3. Recognition of hypoglycemia and hyperglycemia.

4. Management of hypoglycemia: evening protein or fat snack to prevent hypoglycemia.

Table 29-2
Principal Adjustments in Basic or Set Insulin Dose

Rapid-, short-, intermediate-, or long-acting insulin is adjusted after a pattern has been identifi ed over 3-7 days.
Increase or decrease by 0.5, 1.0, 1.5, or 2.0 units (10% of dose).
Time of test	Change this insulin
2 or 3 insulin injection
Before breakfast	Evening intermediate- or long-acting
Before lunch	Morning rapid- or short-acting
Before dinner	Morning intermediate- or long-acting
Before bedtime	Evening rapid- or short-acting
In the night	Evening intermediate- or long-acting
Multiple insulin injections Same as above except:
Before dinner	Lunch rapid- or short-acting
Insulin pump
Change bolus dose if blood glucose abnormal	< 2–3 hours after the meal
Change basal dose if blood glucose abnormal	> 3 hours after the meal
Recheck to be sure the changes made return blood glucose levels to the target range.

Source:
Kaufman, F. (2003). Type 1 diabetes mellitus.
Pediatrics in Review, 24
, 9.

5. Prevention of long-term complications.

6. Role of exercise in management: Exercise improves glucose utilization.

7. Insulin therapy and monitoring of glucose levels.

8. Meal planning, nutrition: Eat meals and snacks within 1 hour of usual time.

9. School issues and coping skills.

10. Monitoring weight: Maintain ideal body weight.

Table 29-3
The Outpatient Visit for Patients with Diabetes

Physical examination	Frequency recommendations
Weight, height, body mass index (BMI)	Every 3 months/assess changes in percentile
Sexual maturity rating stage	Every 3 months/note pubertal progression
Blood pressure	Every 3 months/target < 90th percentile for age
Eye	Dilated funduscopic examination every 12 months after 5 years of diabetes
Thyroid	Every 3 months/presence of goiter, signs of thyroid dysfunction
Abdomen	Every 3 months/presence of hepatomegaly, fullness, signs of malabsorption, inflammation
Foot, peripheral pulses	Every 3 months inspection/after 12 years of age, thorough
Skin, joints, injection sites	Every 3 months/injection sites, joint mobility, lesions associated with diabetes
Neurologic	Every 12 months/signs of autonomic changes, pain, neuropathy
Laboratory test	Frequency
HbA1c	Every 3 months
Microalbuminuria	Every 12 months after puberty or after 5 years of diabetes
Urinalysis, creatinine	At presentation and with signs of renal problems
Fasting lipid profile	After stabilization at diagnosis and every few years
Thyroid function tests, including antithyroid antibodies	Every 12 months
Celiac screen	At time of diagnosis; if symptoms, at puberty
Islet antibodies	At diagnosis

Source:
Kaufman, F. (2003). Type 1 diabetes mellitus.
Pediatrics in Review, 24
, 9.

Table 29-4
Onset of Action, Peak Action, and Duration of Action in Five Types of Insulin

Source:
Kaufman, F. (2003). Type 1 diabetes mellitus.
Pediatrics in Review, 24
, 9.

V. TYPE 2 DIABETES

Acanthosis nigricans, 701.2	Polydipsia, 783.5
Dyslipidemia, 272.5	Polyuria, 788.42
Dysuria, 788.1	Sleep apnea, 780.57
Family history of type 2 diabetes, V18	Type 2 diabetes, 250
Hypertension, 401.9	Vaginal infection, 616.1
Obesity, 278	Weight loss, 783.2