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JUVENILE DIABETES MELLITUS

Introduce the 3min I. INTRODUCTION

topic
The endocrine system is composed of glands that
produce and secrete chemical substances called hormones, Lecture Teacher
cum explain
which affect multiple organs and tissues. The word
discussion student
endocrine is derived from Greek Word ‘endo’ meaning
listen
inside and ‘crine’ meaning secretion. The endocrine glands
secrete their secretions directly into the blood stream to
regulate the body functions.
The endocrine region of pancreas is known as Islets of
Langerhans. These cells were discovered in 1869, by a
German pathological anatomist Paul Langerhans. The islets
constitute about 1 to 2% mass of the pancreas. The Islets of
Langerhans have three major types of cells:
 Alpha (α) cells: They produce Glucagon that increases
blood glucose level by stimulating liver and other cells
to release stored glucose (glycogenolysis).
  Beta (β) cells: They produce Insulin which lowers the
blood glucose level by facilitating the entry of glucose
into the cells for metabolism. It also causes the cells of
liver, muscles and fat tissues to take up extra glucose
from the blood and store it as Glycogen in liver and
muscles (glycogenesis).
 Delta (δ) cells: They produce somatostatin which
regulates the release of insulin and glucagon
The most common disorder of the pancreas is Diabetes
mellitus. In Diabetes mellitus the cells of islets of
Langerhans fail to produce insulin.
II. DEFINITION
Diabetes mellitus is defined as a genetically acquired
Define Diabetes 2min Lecture Teacher What is Diabetes
mellitus heterogeneous group of disorders that share glucose cum explain mellitus?
OHP
intolerance. discussion
students
It can also be defined as a disorder of carbohydrate listen
metabolism characterized by total of partial deficiency of
hormone insulin, resulting in metabolic adjustment or
physiological changes in almost all areas of body.
Enumerate the 3min II.INCIDENCE
incidence of
Juvenile It is a metabolic disease in which carbohydrate utilisation is Lecture Black Teacher What is the
diabetes reduced and that of lipid and protein is enhanced. cum board explains incidence rate of
discussion students Juvenile diabetes
mellitus Nutritional deficiency of insulin causes diabetes. This listen mellitus?
condition is on the increase. About 2 out of 1000 children
were suffering from diabetes mellitus .Almost all children
with diabetes are insulin dependent (type 1).Only children
with severe obesity may suffer from type 2 diabetes that
occurs due to insulin resistance.

Uncommon before the age of 1year.incidence increases

steady from early school age with a maximum at 12-13
years of age.
Enumerate the
etiology of 5min III. ETIOLOGY
Juvenile The exact cause of diabetes mellitus type I is still unknown.
diabetes However recent studies in epidemiology, virology,
mellitus Teacher What is the cause
immunology and genetics have indicated that precipitating Lecture explains for Juvenile
Black
cum
factors (genetic patterns, auto immune diseases, viral board students diabetes mellitus?
discussion
infections, etc.) alone or in combination may contribute to listen
the onset of diabetes.
In type I diabetes, genetic factors are very important. It
appears that certain ‘Histocompatibility Locus Antigen'
(HLA) patterns on sixth chromosome predispose an
individual to develop Type I Diabetes. It has been suggested
that in genetically susceptible individuals, exposed to
environmental factors (”such as viruses or chemicals), the
immune system begins T-lymphocyte mediated process that
damages and destroys the β cells of pancreas resulting in
complete deficiency of insulin. By the time symptoms are
evident, approximately 90% of β cells have been destroyed.
Explain the
patho-
7min IV. PATHOPHYSIOLOGY Lecture Chart Teacher How Juvenile
physiology of
Autoimmune destruction of β cells cum explain diabetes mellitus
Juvenile
discussion students occurs?
diabetes
Insulin production declines to less than 10-20% of normal listen
mellitus

Decrease transportation of glucose across cell membrane

(impaired peripheral glucose uptake)

Less glucose Increase blood body switches

available and glucose level over to using fat
used for energy & protein for energy
production production
when blood glucose
Hunger center is above 150-180mg/dl
stimulated Weight loss

polyphagia Renal threshold of glucose

Glucose excreted in urine(glycosuria)

Osmotic shift occurs and additional water is excreted in

urine
 Increased fluid loss

Stimulation of thirst center

Polydipsia
Enlist the 5min
V. CLINICAL MANIFESTATION
clinical
A. Major symptoms Lecture Teacher List down the
manifestation of
i. Increased Hunger (Polyphagia) cum explains clinical
Juvenile chart
ii. Increased thirst (Polydipsia) discussion students manifestation of a
diabetes
iii. Increased urination (Polyuria) listen child with
mellitus
iv. Weight loss Juvenile diabetes
v. Fatigue mellitus?
B. Minor symptoms
i. Lethargy
ii. Weakness
iii. Irritability
iv. Abdominal
v. Dry skin
vi. Delayed wound healing
vii. frequent infections
viii. Decreased attention span
Explain the 4min VI. DIAGNOSTIC EVALUATION
diagnostic a) History: Diabetes should be suspected when families
What are the
evaluation have a history of diabetes or there is a diabetic sibling diagnostic
Juvenile Lecture Power Teacher
measures for
diabetes Clinical features like polyphagia, polydipsia and polyuria. cum point explain
Juvenile diabetes
mellitus discussion student
mellitus?
b) Urine examination: for sugar and acetone. Urine sugar listen
may be detected by Benedict test
c) Fasting Blood sugar: above 126mg/dl is diagnostic,
between 100-126 mg/dl is highly probable
d) Random blood sugar: above 200mg/dl on two separate
occasions in a clinically suspected situation strongly
support the diagnosis.
e) Glucose tolerance test, though infrequently required,
should be performed in doubtful cases, with a glucose
dose of 1.75g/kg ideal BW(maximum 75 g)

Explain the 10min VII. MANGEMENT

Goal How can manage a
management of 1. To keep blood sugar levels as close to normal Teacher
Lecture child with
a child with Black explain
2. To prevent hypoglycemia cum Juvenile diabetes
Juvenile student
The management of child with Type I Diabetes needs a discussion board mellitus?
diabetes listen
mellitus multidisciplinary team approach involving the family, child
and team of professionals including a paediatric
endocrinologist, diabetes nurse educator, nutritionist and
physiologist etc. Also communication with other individuals
in child’s life is essential like teachers, school health nurse,
school guidance counselor etc. The management includes
1. Insulin Therapy
The definitive treatment is replacement of insulin.
Insulin needs are affected by the nutritional intake, activity,
emotions and other life events such as illness and puberty.
Insulin is available in highly purified pork preparation and
human insulin form manufactured by biosynthesis. Most
clinicians prefer human insulin which is available in rapid
acting, short, intermediate and long acting preparations.
Daily insulin is administered subcutaneously or by portable
pumps. Diabetes can be controlled satisfactorily in most
children by twice daily insulin regimen, consisting of a
combination of rapid or short acting and intermediate acting
insulin, given before breakfast and before dinner.
 Type of Onset Peak Effect
insulin
Rapid acting 5-15min 30-90min 5 hrs

Short acting 20-60min 2-3hours 5-8 hours

Intermediate 2-4 hours 4-10 hours 10-18 hours

acting
Long acting
3-5 hours 10-16 hours 18-24hrs
Premixed
70/30

NURSING MANGEMENT
Describe the 12min Insulin administration
nurses Insulin administration should be taught to the child as well Lecture Black Teacher What are the
responsibility
as his parents. Nurses should provide information about site cum board explain nurse’s
selection and rotation. The sites for insulin injection are discussion student responsibity?
listen
abdomen, arms, legs and buttocks. There may be evidence
of lipoatrophy (atrophy of subcutaneous fat) or
lipohypertrophy (hypertrophy of subcutaneous fat) at
 injection sites so rotation of site is necessary to prevent
these complications. Also the nurses should teach the
technique of blood glucose monitoring using glucometer to
the caregivers of the child.
 The Nurse should know and inform the child’s
caregivers about the side effects and complications of
insulin therapy.
a. Local reactions: Insulin injection may lead to pruritis and
flare reaction at the site. This is due to hypersensitivity.
Also fat atrophy or lipodystrophy may occur at the
injection site.
b. Generalized reaction: Insulin administration followed
by unusual exercise, vomiting and failure to eat the
expected amount of food may lead to hypoglycemia
manifested by shakiness, dizziness, pallor, headache,
disturbed vision, hunger, fatigue, tachycardia,
disorientation, confusion, seizures and coma.
 Mild hypoglycemia can be managed effectively by giving
the child orange juice, sugar cubes or other food items
containing simple sugars. If shock is severe, emergency care
 in hospital is required.
 Glucose monitoring
 Blood glucose monitoring forms the basis of insulin
therapy. It should be done regularly to estimate the dose of
insulin required, to control the blood glucose level. The
nurse should be knowledgeable about the devices
(glucometers) available to check blood sugar. The same
should be taught to parents also, so that they can monitor the
child’s blood glucose regularly.
 Urine monitoring for sugar and ketones
 Urine monitoring for glucose is used mainly to complement
blood glucose testing. Parents should monitor both blood
and urine glucose and ketones and then use this information
with their physician to adjust the insulin dose,
 so as to avoid ketoacidosis.
 Diet, Meal planning and nutrition
 A meal plan is developed, that will help the child to attain
and maintain ideal weight, maintain proper nutrition, attain
normal growth and development and achieve “diabetes
control” so as to prevent or delay acute or chronic
 complications of diabetes. Generally the nutritionists
prescribe three meals a day and 3 snacks for diabetic
children.
The family is explained that diet should contain 55%
carbohydrate, 30% fat and 15% protein. About 70% of
carbohydrate content should be derived from complex
carbohydrates like starch. The American Diabetes
Association (ADA) exchange system is nutritionally
adequate not only for the child but also for his family. Food
items are classified into one of the six categories of the
exchange list according to their composition;
 Group 1- Milk exchange
 Group 2 - Vegetable exchange
 Group 3- Fruit exchange
 Group 4- Bread exchange
 Group 5- Meat exchange
 Group 6- Fat exchange
 Food items grouped together in a list; in the amounts
recommended, contain approximately the same
carbohydrate, protein and fat. Each food within the
 exchange list may be substituted for any other food min
the same list, in specified quantity, according to the likes
and dislikes of the child, for example, 1/2 small banana
may be exchanged for 1 cup strawberry or a small apple.
About 40 gm fiber should also be added to the diabetic
diet, as it reduces the post meal hyperglycemia.
 Involve the child and his parents in meal planning and
allow the child to eat with other children.
Exercise
No difference is seen in the need for play and exercise
between normal children and diabetic children. No activity
needs to be omitted from the life of a child who is diabetic,
as long as it is free from the potentials of injury. Parents
need to be instructed about the prevention and management
of hypoglycaemia in the following manner:
 If exercise (gym or play) is planned before a meal,
provide the child with a snack.
 If the exercise will be strenuous, instruct the child to eat
protein or carbohydrate rich snack like milk or
sandwich.
 If the exercise is extended over a period of hours,
provide the child with a snack in between and
emphasize the importance of eating something at least
every hour.
Family Education
Educate the child family about:
i. Involving school personnel in management plan for
insulin administration, exercise and meal times.
ii. Monitoring child blood glucose level, maintain
insulin coverage and notify health care providers
when child is ill.
iii. Evaluating the child for dehydration, hyperglycemia
and ketonuria.
iv. lnfluence of exercise, emotional stress and other
illness on both insulin and dietary needs.
v. Recognizing symptoms of insulin shock and diabetic
acidosis and related emergency management.
vi. Prevention of infection:
a) Attend to regular body hygiene with special
attention to foot care.
 b) Report any breaks in skin and treat them promptly.
c) Properly fitted shoes should be used.
d) Dress the child appropriately for the weather.
e) child should receive regular dental checkups,every
six months
f) Child should be vaccinated as per the schedule

Taking the following precautions:

i. The child should carry an identification card which
states that the Child is a diabetic and includes the
child's name, address, telephone number and the
treating physician’s name and telephone number.
ii. The child should always carry some sugar source
(like sugar cubes or glucose powder) that can be
consumed in case, hypoglycemia occurs.
NURSING DIAGNOSIS
1. Impaired blood glucose level, hyperglycemia related
Enumerate the to imbalance between insulin supply and its demands
complication of as manifested by changing the blood glucose level.
juvenile
diabetes 2. Impaired nutritional status less than body requirements
mellitus related to metabolic catabolism and lack of insulin as
manifested by weight loss
3. Compromised family coping related to inadequate or
inaccurate information as manifested by anxiety
4. Knowledge deficit related to disease condition as
manifested by verbalization of parents
5. Risk for unstable blood glucose level related to
deficient knowledge of diabetes management
6. Risk for injury related to hypoglycemia

VIII. COMPLICATIONS
All forms of diabetes increase the risk of long term
complications. These complications usually occur 10 20
years after the diagnosis. The major long-term
complications related to damaged blood vessels are:
i. Ischemic Heart Disease
ii. Stroke
iii. Peripheral vascular disease
iv. Diabetes also causes ‘microvascular’ complications
(damage to small blood vessels) that result in:
a) Diabetic retinopathy
b) Reduced vision and potentially blindness
 c) Diabetic nephropathy and chronic renal disease
resulting in proteinuria
d) Diabetic neuropathy causing numbness, tingling and
pain in the feet
e) Skin damage
f) Diabetic foot, which may require amputation
IX. SUMMARY

So far we discussed about Juvenile diabetes mellitus,in that

first we saw about definition then incidence, etiology,
pathophysiology, clinical manifestation ,diagnostic
evaluation, management, nursing management and
complication

X. CONCLUSION
Juvenile diabetes is emerging health problem in modern
era. Like old population the incidence of juvenile diabetes
is increasing day by day. It is time for the health planner to
prevent and control the disease; otherwise it will be major
problem after a decade.
XI. STUDENT ASSIGMENT
Write the nursing care plan for a child with juvenile
 diabetes mellitus
XII. BIBLIOGRAPHY
 Suraj Gupte.The short text book of pediatrics.12thed.
Health sciences publisher;2016.

 Dorothy R.Marlow,Barbara A.Redding.Text book of

pediatric nursing.6th ed.Saunders publication; 2007.
 Assumma Beevi T.M.Textbook of pediatric
nursing.Elsesvier publication; 2009.
 Parul Datta. pediatric nursing.2nd ed.Jaypee brothers
medical publishers; 2009
 Rimple Sharma. Essentials of Pediatric Nursing 2nd ed
.Jaypee brothers medical publishers; 2009
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INTRODUCTION

Introduce the An arterial line (also art-line or a-line) is a

topic thin catheter inserted into an artery. It is most commonly
used in intensive care medicine and anesthesia to
monitor blood pressure directly and in real-time (rather than
by intermittent and indirect measurement) and to obtain Lecture Power Teacher
samples for arterial blood gas analysis. Arterial lines are cum point explain
generally not used to administer medication, since many discussion audience
injectable drugs may lead to serious tissue damage and even listen
require amputation of the limb if administered into
an artery rather than a vein.An arterial line is usually inserted
into the radial artery in the wrist, but can also be inserted into
the brachial artery at the elbow, into the femoral artery in the
groin, into the dorsalis pedis artery in the foot, or into
the ulnar artery in the wrist. A golden rule is that there has to
be collateral circulation to the area affected by the chosen
artery, so that peripheral circulation is maintained by another
artery even if circulation is disturbed in the cannulated artery.
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DEFINITION

The insertion of an indwelling catheter in order to monitor a

particular hemodynamic parameter in the circulation in real
time

INDICATION

Explain the 1. Continuous, beat-to-beat blood pressure Power Teacher What are the
indication for measurement. point explains indication for
arterial Thermodynamically unstable pts. /ICU patient, requiring Lecture students arterial
inotropic support cum
catheterisation listen catheterisation?
Patients undergoing major surgery discussion
2. Frequent arterial blood gas analysis –
Patient with respiratory failure on ventilator -severe
acid/base disturbance.
Enumerate the Teacher What are the
CONTRAINDICATION
contraindiaction Power explain contra indication
Absolute contraindications Lecture point students for arterial
cum listen catheterisation ?
• Absence of collateral circulation (eg. abnormal modified
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Allen's test) discussion

• Local infection

• Distorted anatomy (eg, previous surgical interventions,

congenital malformations)

• Active Raynaud’s Disease

• Thromboangitis obliterans (Buerger disease)

• Burns

• Aneurysm

• Stent or synthetic vascular graft

• Arteriovenous malformation or AV fistula

Relative contraindications

• Severe peripheral vascular disease

Teacher
• Severe coagulopathy (INR > 3.0, APTT > 100sec ) explains
Lecture Power
students
• Severe thrombocytopenia (platelet count 50 x 109/L, ) cum point
listen
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• Recent use of thrombolytic agents discussion

ARTICLES Power
point
Enlist the 1.Arterial Cannula Lecture
articles for cum
 Made from polytetrafluoroethylene (Teflon) to Teacher Which are the
arterial discussion
minimize the risk of clot formation. explains articles needed ?
catheterisation
 22G cannula for pediatrics student
 24G cannula for neonates. listen
 Larger Gauge cannula increases the risk of thrombosis
 The cannula is connected to an arterial giving set.

2. Arterial set.

specialised plastic tubing, short and stiff to reduce

resonance, connected to a 500 ml bag

3.Saline bag

-500 ml 0.9, saline pressurized to 300 mmHg using a pressure

bag, i.e. a pressure higher than arterial systolic pressure to
prevent back flow to the cannula to the given set the arterial
set and saline bag with 2500 units heparin in corporate a
continuous slow flushing system of 3-4 ml per hour to keep
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the line free from clots.

. -The Arterial set and arterial line should be free from air Lecture
bubbles. cum
Teacher
discussion
- The line is attached to a transducer. explains
student
-Do not allow the saline bag to empty
listen
 To maintain patency of arterial cannula.
 To prevent air embolism
 To maintain accuracy of blood pressure reading
 To maintain accuracy of fluid balance chart
 To prevent backflow of blood

4. Transducer, amplifier and electrical recording ?

equipment.

The transducer is zeroed and placed level with the heart.

5.Tape and/or steri-strips

6.An arm board or towel roll

7.Opsite or Tegaderm cover dressing Local anaesthetic (1%

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or 2% lidocaine ,lidocaine cream)

8.Suture material for femoral arterial line placement (2.0 silk)

Scissors

9. Monitor cable for transducing arterial waveform.

10.Benzoin solution

PROCEDURE
Explain the Lecture Teacher How to do the
procedure 1. Ensure that all preprocedure steps are taken cum explain arterial
Power
discussion students catheterisation?
2. Assure that pressure tubing with transducer is connected to point
listen
bedside monitor.

3. Perform the Allen's test to assure adequate collateral blood

flow if using the radial artery.

4. Wash hands and don gloves

5. For the radial artery, the arm is restrained, palm up, with
an arm board to hold the wrist dorsiflexed
Lecture
5. Apply anesthetic agent (local lidocaine 1-2% or lidocaine
cum Teacher
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cream). discussion explain

students
6. Locate pulsating artery via palpation.
listen
7. Cleanse area selected for arterial line placement.

8. Prepare patient for puncture.

9. Stabilize artery by pulling skin taut.

10. Puncture skin at 45-60 degree angle for radial artery; 90 Power
degrees for femoral artery. point
Lecture
11. Advance catheter when flash of blood is observed in cum
catheter. discussion

12. Connect to pressure I.V. tubing and check for arterial

waveform on bedside monitor.

13. Cleanse area of any blood and allow site to dry.

14. Apply Benzoin to cleansed area and allow to dry and

become "tacky.'

15. Secure arterial line with tape and cover with a Tegaderm
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dressing.

16. Secure iv tubing to prevent it from being caught and

pulling on arterial secured with a suture.

17. Properly dispose of the I.V. sharps and other used

materials.

Removal of arterial catheter

Explain the Lecture How to remove
Disconnect the cable from the monitor which will
removal of cum the arterial
automatically turn off the alarms. Teacher
arterial catheter discussion catheter?
explains
Take out the sutures in the usual way with a fresh sterile kit. Power
student
Have a gauze piece ready, pull the catheter, and manually point
listen
compress the site for at least 3 to 5 minutes.

Make sure the patient's hand is still perfused. Check for

hematoma or bleeding, put a compression dressing on the site
(not too tight!), which you can then take off after about an
hour.

Recheck the site hourly for a few hours afterwards — a

hematoma could still form, and since there isn't a whole lot of
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room in a wrist, you'd definitely want to know!

MECHANISM OF ACTION

A transducer is a device that reads the fluctuations in pressure

— it doesn't matter if it's arterial, or central venous, or PA
The column of saline in the arterial set transmits the pressure
changes to the diaphragm in the transducer

 The transducer reads the changing pressure, and changes

it into an electrical signal that goes up and down as the
pressure does which is displayed as an arterial waveform
 The transducer connects to the bedside monitor with a
cable, and the wave shows up on the screen, going from
left to rig
Enlist the COMPLICATION Lecture Teacher What are the
complication cum explain complications of
 Haemorrhage may occur if there are leaks in the system. discussion student arterial
Connections must be tightly secured and the giving set listen catheterisation?
and line closely observed..
 Emboli. Air or thrombo emboli may occur.

Care should be taken to aspirate air bubbles

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 Accidental drug injection may cause severe, irreversible

damage to the hand.

-No drugs should be injected via an arterial line

- The line should be labelled (in red) to reduce the likelihood

of this occurring

 Arterial vasospasm
 Partial occlusion due to large cannula width, multiple
attempts at insertion and long duration of use
 Permanent total occlusion
 Sepsis or bacteraemia secondary to infected radial
arterial lines is very rare (0.13°M;

-local infection is more common.

-if the area looks inflamed the line site should be changed.
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NURSES RESPONSIBILITY Teacher

explain
1. The nurse should understand waveforms on the monitor Lecture student
What are the
2. Know how to zero (calibrate) the arterial line cum nurses
Power listen
3. Check for blood pressure accuracy discussion responsibity ?
4. Neurovascular assessment of 5 P’s point
Enumerate the
 Pain
nurses
 Pulses
responsibility  Pallor
 Paresthesia
 Paralysis
5. Know how to draw blood from arterial line
6. Watch for complication
7. Provide psychological support to patient and families
8. Record all the findings

s
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Lecture
cum
discussion
,

Explain the .
present state of
immunization in
India Flash
card
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Describe the
nurses
What are the
responsibility
nurses
while giving
responsibility ?
immunization

Flash
card
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Point out the

present state of
immunization of
children in India?
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What are the

nurses
responsibility
while giving
immunization?
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