Genetic Factors: Type 1 DM is not inherited, but heredity is a prominent factor in the etiology. In more than 40 rare genetic syndromes, diabetes is a major feature (Harris, 2003). No simple mendelian pattern is found for DM. Children born to fathers with type 1 DM are about three times more likely to develop type 1 DM (approximately 7% frequency) than children born to mothers with type 1 DM (approximately 2% frequency) (see Research Focus box).

At least 60% of the genetic susceptibility to type 1 diabetes is conferred by human leukocyte antigen (HLA) on chromosome 6. Several alleles have been implicated, including DR3, DR4, and DQ8. The highest-risk alleles (DR3 and DR4) are found in 95% of patients with diabetes. Only 50% of nondiabetic persons have these alleles. Certain alleles, such as DR2, may actually protect the individual from diabetes (Barker and Eisenbarth, 2003).

Autoimmune Mechanisms: Pancreatic islet cell antibodies (ICAs) are found in about 70% to 85% of patients newly diagnosed with type 1 DM. The antibodies disappear by 1 year after diagnosis in most persons, but in some they may persist for years. The current theory is that the presence of the HLA genes causes a defect in the immune system that renders the possessor susceptible to a trigger event, which can be a dietary source, a virus, bacteria, or a chemical irritant. The predisposing factor initiates an autoimmune process that gradually destroys beta cells. Without beta cells, the body cannot produce insulin. It is unclear whether the ICAs are a result of the inflammatory process or a significant aspect of the beta cell destruction. Controversy exists regarding whether the autoimmune response is primarily mediated by the lymphocyte response or the humoral (antibody) response or is a result of the two.

There is a strong association between type 1 DM and other autoimmune endocrine disorders. An increased incidence of other autoimmune endocrine disorders, such as thyroiditis and Addison disease, has been found in families of children with DR3-associated type 1 DM.

Researchers have also found anti-ICAs in a number of unaffected first-degree relatives of children with type 1 DM (Bingley and Gale, 2006). These findings offer hope of identifying persons at risk for diabetes with the eventual possibility of screening and implementation of therapy. Research is also continuing to identify genetic risk and environmental triggers with the hope of developing prevention strategies such as immunizations.

Treatment with cyclosporine or other forms of immunosuppression has been tested as an early intervention in the newly diagnosed person with type 1 DM. The effects of lifelong immunosuppression must be carefully weighed against the lifelong effects of diabetes.

Diet: Cow’s milk has been implicated as a possible trigger of the autoimmune response that destroys pancreatic cells in genetically susceptible hosts, thus causing DM (Goldfarb, 2008). Further research is needed.

Viruses: A variety of viruses, including mumps, coxsackievirus B, and congenital rubella, have been implicated as the prime environmental factor in the etiology of DM. Islet cells appear to be particularly susceptible to either direct viral damage or chemical insult. The body reacts to this damaged or changed tissue in an autoimmune phenomenon. Thus the virus serves as a precipitating factor, or “trigger.” A viral etiology also helps explain the seasonal variation in the onset of DM. Although this seasonal variation is not evident in children under 5 years of age, the marked increase in older children during the winter months strongly suggests an infectious disease relationship in either cause or expression of diabetes in children.

Type 2 Diabetes: Type 1 DM is the predominant form of diabetes in the pediatric age-group. However, changes in food consumption and exercise patterns have increased the rate of type 2 DM in children and adolescents in the Unites States (Ramchandani, 2004; Kiess, Bottner, Raile, et al, 2003; Steinberger and Daniels, 2003; Stephenson, 2003). The disturbed carbohydrate metabolism of type 2 DM may be a result of a sluggish or insensitive secretory response in the pancreas or a defect in body tissues that requires unusual amounts of insulin, or it may be that the insulin secreted is rapidly destroyed, inhibited, or inactivated in affected persons. Children with type 2 diabetes often have other features of insulin resistance syndrome: polycystic ovary syndrome and acanthosis nigricans (AN). AN is found in as many as 90% of children with type 2 diabetes and is characterized by velvety hyperpigmented areas in skinfolds. Risk factors include non-European ancestry, family history of type 2 DM, obesity, insulin resistance, and older age (American Diabetes Association, 2007). While performing routine scoliosis screenings, school nurses often identify AN on the child’s neck. Refer such children to their primary care provider for further metabolic evaluation.

Ketoacidosis: When insulin is absent or there is altered insulin sensitivity, glucose is unavailable for cellular metabolism, and the body chooses alternate sources of energy, principally fat. Consequently fats break down into fatty acids, and glycerol in the fat cells is converted by the liver to ketone bodies (β-hydroxybutyric acid, acetoacetic acid, acetone). Any excess is eliminated in the urine (ketonuria) or the lungs (acetone breath). The ketone bodies in the blood (ketonemia) are strong acids that lower serum pH, producing ketoacidosis.

Ketones are organic acids that readily produce excessive quantities of free hydrogen ions, causing a fall in plasma pH. Then chemical buffers in the plasma, principally bicarbonate, combine with the hydrogen ions to form carbonic acid, which readily dissociates into water and carbon dioxide. The respiratory system attempts to eliminate the excess carbon dioxide by increased depth and rate—Kussmaul respirations, or the hyperventilation characteristic of metabolic acidosis. Sodium and potassium in the plasma buffer the ketones. The kidney attempts to compensate for the increased pH by increasing tubular secretion of hydrogen and ammonium ions in exchange for fixed base, thus depleting the base buffer concentration.

With cellular death, potassium is released from the cell (intracellular fluid) into the bloodstream (extracellular fluid) and excreted by the kidney, where the loss is accelerated by osmotic diuresis. The total body potassium is then decreased, even though the serum potassium level may be elevated as a result of the decreased fluid volume in which it circulates. Alteration in serum and tissue potassium can lead to cardiac arrest.

If insulin therapy in combination with correction of the fluid deficiency and electrolyte imbalance does not reverse these conditions, progressive deterioration occurs with dehydration, electrolyte imbalance, acidosis, coma, and death. Diabetic ketoacidosis (DKA) should be diagnosed promptly in a seriously ill patient and therapy instituted in an intensive care unit.

Long-Term Complications: Long-term complications of diabetes involve both the microvasculature and the macrovasculature. The principal microvascular complications are nephropathy, retinopathy, and neuropathy. Microvascular disease develops during the first 30 years of diabetes, beginning in the first 10 to 15 years after puberty, with renal involvement evidenced by proteinuria and clinically apparent retinopathy.

With poor diabetic control, vascular changes can appear as early as to 3 years after diagnosis; however, with good to excellent control, changes can be postponed for 20 or more years. Intensive insulin therapy appears to delay the onset and slow the progression of clinically important retinopathy, including vision-threatening lesions, nephropathy, and neuropathy, by 35% to more than 70%, according to studies on treatment and complications of type 1 DM (American Diabetes Association, 2002).

The postpubertal duration, not the total duration, of type 1 DM is implicated as a risk factor for the development of microvascular disease. The process appears to be one of glycosylation, wherein proteins from the blood become deposited in the walls of small vessels (e.g., glomeruli), where they become trapped by “sticky” glucose compounds (glycosyl radicals). The buildup of these substances over time causes narrowing of the vessels, with subsequent interference with microcirculation to the affected areas (Rosenson and Herman, 2008). Macrovascular disease develops after 25 years of diabetes and creates the predominant problems in patients with type 2 DM.

Other complications have been observed in children with type 1 DM. Hypertension and atherosclerotic cardiovascular disease also contributes to the mortality and morbidity of type 1 DM (Karik, Fields, and Shannon, 2007). Hyperglycemia appears to influence thyroid function, and altered function is frequently observed at the time of diagnosis, as well as in poorly controlled diabetes. Limited mobility of small joints of the hand occurs in 30% of 7- to 18-year-old children with type 1 DM and appears to be related to changes in the skin and soft tissues surrounding the joint as a result of glycosylation.

Mild Diabetes: Although most cases of childhood diabetes are recognized during the rapid initial deterioration in carbohydrate metabolism, other cases with more benign disease are being identified with increasing frequency. A few are detected accidentally by urinalysis before overt symptoms occur. MODY, for instance, is a rare genetic type of diabetes resulting from mutations at one of five genes and transmission by an autosomal dominant inheritance (Fajans and Bell, 2003). Children with this type of diabetes phenotypically resemble type 2 DM but are usually not obese. MODY is characterized by beta cell dysfunction and is often treated similarly to type 2 DM.

Insulin Therapy: Insulin replacement is the cornerstone of management of type 1 DM. Insulin dosage is tailored to each child based on home blood glucose monitoring. The goal of insulin therapy is maintaining near-normal blood glucose values while avoiding too frequent episodes of hypoglycemia. Insulin is administered as two or more injections per day or as continuous subcutaneous infusion using a portable insulin pump.

Evidence-Based Practice—Medication Safety and Insulin Therapy

Healthy pancreatic cells secrete insulin at a low but steady basal rate with superimposed bursts of increased secretion that coincide with intake of nutrients. Consequently insulin levels in the blood increase and decrease coincidentally with rise and fall in blood glucose levels. In addition, insulin is secreted directly into the portal circulation; therefore the liver, which is the major site of glucose disposal, receives the largest concentration of insulin. No matter which method of insulin replacement is used, this normal pattern cannot be duplicated. Subcutaneous injection results in absorption of the drug into the general circulation, thus reducing the concentrations of insulin to which the liver is exposed.

Future Therapies: Islet cell or whole pancreas transplantation may offer hope to patients in the future. Viable insulin-producing cells have been injected into the portal vein, where they are transported via the circulation to the liver and eventually produce up to two thirds of the required insulin. The major use of transplants has been in persons who have serious complications, particularly those whose deteriorating kidneys have required renal transplantation and who are receiving immunosuppressive therapy. However, islet cell and pancreatic transplants tend not to be sustainable over time despite continuation of therapy. The use of nonhuman islet cells encapsulated in immunoprotective, semipermeable membranes may have a future in the treatment of type 1 DM (Campbell, 2004).

Other routes for insulin administration are being studied. Inhaled insulin, for instance, has been an effective and safe means to control postprandial glucose levels (Garg, Rosenstock, Silverman, et al, 2006).

Monitoring: Daily monitoring of blood glucose levels is an essential aspect of appropriate DM management.

Nutrition: Essentially the nutritional needs of children with diabetes are no different from those of healthy children. Children with diabetes need no special foods or supplements. They need sufficient calories to balance daily expenditure for energy and to satisfy the requirement for growth and development. Unlike the child without diabetes, whose insulin is secreted in response to food intake, insulin injected subcutaneously has a relatively predictable time of onset, peak effect, duration of action, and absorption rate depending on the type of insulin used. Consequently the timing of food consumption must be regulated to correspond to the time and action of the insulin prescribed.

Meals and snacks must be eaten according to peak insulin action, and the total number of calories and proportions of basic nutrients must be consistent from day to day. The constant release of insulin into the circulation makes the child prone to hypoglycemia between the three daily meals unless a snack is provided between meals and at bedtime. Calculate the distribution of calories to fit the activity pattern of each child. For example, a child who is more active in the afternoon needs a larger snack at that time. This larger snack might also be split to allow some food at school and some food after school. Food intake should be altered to balance food, insulin, and exercise. Extra food is needed for increased activity.

The food intake may be planned in a variety of ways but is based on a balanced diet that incorporates six basic food groups: milk, meat, vegetables, fat, fruit, and starch. There are several meal-planning approaches, including the exchange system and carbohydrate counting. The exchange system from the American Diabetes Association groups foods by nutrient content. Within each group, portion sizes of foods are calculated to give an equivalent amount of the nutrient. In the fruit list, for instance, one small apple has the equivalent amount of carbohydrate as a half banana. In the exchange system, food groups are important: fruits exchange with fruits, starches exchange with starches.

Carbohydrate counting has been popular since the Diabetes Control and Complications Trial. Portion sizes are still important, but all carbohydrates are considered equivalent. In this system, food groups are not as important as carbohydrate content. For example, one small apple and one slice of bread have the same carbohydrate amount (15 g) and may be used interchangeably.

Concentrated sweets are discouraged, and because of the increased risk for atherosclerosis in persons with DM, fat is reduced to 30% or less of the total caloric requirement. Dietary fiber has become increasingly important in dietary planning because of its influence on digestion, absorption, and metabolism of many nutrients. It has been found to diminish the rise in blood glucose after meals.

Correctly used, the diet allows for flexibility and the incorporation of preferred foods in most instances. For the growing child, never use food restriction for diabetic control, although caloric restrictions may be imposed for weight control if the child is overweight. In general, the child’s appetite should be the guide for the amount of calories needed, with the total caloric intake adjusted to appetite and activity. Box 38-15 outlines basic principles of diet management.

Exercise: Exercise is encouraged and never restricted unless indicated by other health conditions. Exercise lowers blood glucose levels, depending on the intensity and duration of the activity. Consequently exercise should be included as part of diabetes management, and the type and amount of exercise should be planned around the child’s interests and capabilities. However, in most instances children’s activities are unplanned, and the resulting decrease in blood glucose can be compensated for by providing extra snacks before (and, if the exercise is prolonged, during) the activity. In addition to a feeling of well-being, regular exercise aids in utilization of food and often results in a reduction of insulin requirements.

Physical training tends to increase tissue sensitivity to insulin, even in the resting state. Consequently it is especially important to understand the relationship between the activity and the diabetic regimen. Vigorous muscular contraction increases regional blood flow and accelerates the absorption and circulation of insulin that is injected into the area, which can contribute to development of hypoglycemia. If exercise involving leg muscles is planned, it is recommended that nonexercised sites (arm or abdomen) be used for insulin injection. This practice may replace the need for further increased carbohydrate intake or a reduced insulin dose (or both) to avoid exercise-induced hypoglycemia.

Children with poorly controlled diabetes are particularly at risk for hyperglycemia with exercise, or exercise may actually stimulate ketoacid production. Therefore discourage the child who has marked hyperglycemia (blood glucose level >240 mg/dl) and ketonuria from strenuous physical activity until the diabetes is controlled by appropriate adjustments of insulin and diet.

Athletes and youngsters who regularly participate in organized sports should adjust their insulin dosage in anticipation of sustained physical activity during the part of the day devoted to strenuous exercise. Team sports may encourage overexertion and subsequent hypoglycemia. Insulin dosages are decreased for participation in organized sports or prolonged activities, such as swimming for several hours. It is important that the patient consult with the practitioner for advice on insulin dose adjustment.

Hypoglycemia: Occasional episodes of hypoglycemia are an integral part of insulin therapy, and an objective of diabetes management is to achieve the best possible glycemic control while minimizing the frequency and severity of hypoglycemia. Even with good control, a child may frequently experience mild symptoms of hypoglycemia. If the signs and symptoms are recognized early and promptly relieved by appropriate therapy, the child’s activity should be interrupted for no more than a few minutes

The most common causes of hypoglycemia are bursts of physical activity without additional food, or delayed, omitted, or incompletely consumed meals. Reglycosylation of muscles may occur over the ensuing 24 hours. Particular vigilance related to hypoglycemia may be necessary during the night after vigorous exertion. Occasionally, hypoglycemic reactions occur unexpectedly and without apparent cause. They may be the result of an inadvertent or deliberate error in insulin administration.

Gastroenteritis, in which there is gastric stasis, may impede the absorption of food, even though the child is eating reasonably well. It can also occur when the blood glucose level is so low that it causes stasis. Then the child may eat a meal or snack and still have an insulin reaction. Continued feeding does not seem to alter the blood glucose level because the simple glucose or sugar remains in the stomach.

The signs and symptoms of hypoglycemia are caused by both increased adrenergic activity and impaired brain function. The increased adrenergic nervous system activity plus increased secretion of catecholamines produces nervousness, pallor, tremulousness, palpitations, sweating, and hunger. Weakness, dizziness, headache, drowsiness, irritability, loss of coordination, seizures, and coma are more severe responses and reflect CNS glucose deprivation and the body’s attempts to elevate the serum glucose levels.

It is often difficult to distinguish between hyperglycemia and a hypoglycemic reaction (Table 38-6). Because the symptoms are similar and usually begin with changes in behavior, the simplest way to differentiate the two is to test the blood glucose level. The blood glucose level is low in hypoglycemia, whereas in hyperglycemia the glucose level is significantly elevated. Urinary ketones may be present after hypoglycemia as a result of starvation ketone production. In doubtful situations it is safer to give the child some simple carbohydrate. This will help alleviate the symptoms in the case of hypoglycemia but will do little harm if the child is hyperglycemic.

Children are usually able to detect the onset of hypoglycemia, but some are too young to implement treatment. Parents should become adept at recognizing the onset of symptoms—for example, a change in a child’s behavior, such as tearfulness or euphoria. In the majority of cases, 10 to 15 g of simple carbohydrate, such as 1 tbsp of table sugar, will elevate the blood glucose level and alleviate the symptoms. The simpler the carbohydrate, the more rapidly it will be absorbed (8 oz of milk equals 15 g of carbohydrate). The rapid-releasing sugar is followed by a complex carbohydrate such as a slice of bread or a cracker and by a protein such as peanut butter or milk.

For a mild reaction, milk or fruit juice is good to use in children. Milk supplies them with lactose or milk sugar, as well as a more prolonged action from the protein and fat (helps decrease absorption). Other glucose sources include Insta-Glucose (cherry-flavored glucose), carbonated drinks (not sugarless), sherbet, gelatin, or cake icing. All children with diabetes should carry with them glucose tabs, Insta-Glucose, sugar cubes, or sugar-containing candy such as LifeSavers or Charms. A difficulty with candies or icing is that the child may learn to fake a reaction to get the sweets; therefore commercial treatment products such as Insta-Glucose or glucose tabs may be preferred.

When in doubt, it is best to assume hypoglycemia and treat, but overtreatment could result in hyperglycemia. The treatment may be repeated in 10 to 15 minutes if the initial response is not satisfactory. Rest and the addition of food should be part of the plan.

An insulin reaction is often the most feared aspect of diabetes because severe brain symptoms may develop. In a severe reaction the various areas of the brain respond in sequence: the forebrain with increased drowsiness and perspiration, the hypothalamus and thalamus with tachycardia and loss of consciousness, the midbrain with seizure activity that may be started from stimulation initially from the hypothalamus, and finally the hindbrain with responses of deeper coma and decreasing reflexes. The treatment of choice for severe hypoglycemia is 50% glucose administered intravenously.

Glucagon is sometimes prescribed for home treatment of hypoglycemia. It is available as an emergency kit that must be mixed at the time of use and is administered intramuscularly or subcutaneously. Glucagon functions by releasing stored glycogen from the liver and requires about 15 to 20 minutes to elevate the blood glucose level.

Once the child is responsive, the lost glycogen stores are replaced by small amounts of sugar-containing fluid administered frequently until the child feels comfortable about trying solid foods.

Illness Management: Illness alters diabetes management, and maintaining control is usually related to the seriousness of the illness. In the well-controlled child an illness runs its course as it does in the unaffected child.

The goals during an illness are to restore euglycemia, treat urinary ketones, and maintain hydration. Monitor blood glucose levels and urinary ketones every 3 hours. Some hyperglycemia and ketonuria are expected in most illnesses, even with diminished food intake, and are an indication for increased insulin. Insulin should never be omitted during an illness, although dosage requirements may increase, decrease, or remain unchanged, depending on the severity of the illness and the child’s appetite. Often the child needs supplemental insulin between usual dose times. If the child vomits more than once, if blood glucose levels remain above 240 mg/dl, or if urinary ketones remain high, notify the health care practitioner. Simple carbohydrates may be substituted for carbohydrate-containing exchanges in the meal plan. Although insulin and diet are important tools in sick-day care, fluids are the most important intervention. Fluids must be encouraged to prevent dehydration and to flush out ketones.

Surgery: The physiologic and emotional stresses related to surgery require careful adjustment of insulin. Because the child receives IV glucose during surgery and the stress of the surgery itself also raises the blood glucose level, the risk of an insulin reaction is slight. Short-acting insulins should be continued until the child is able to tolerate oral feedings and return to the routine pattern of insulin administration.

Prevention: Major advances have been made in the ability to detect susceptibility to type 1 DM, and animal studies indicate that the disease can be prevented by various immunologic interventions (Skyler and Marks, 2003). Early immunosuppression may preserve long-term endogenous insulin secretion in individuals with type 1 DM.

Cyclosporine, mycophenolic acid, and nicotinamide have shown promise in delaying beta cell destruction or lowering the incidence of type 1 DM in relatives of children with the disease. Much progress has been made in the identification of islet cell antigens targeted by the immune response. Many potential treatments to prevent type 1 DM have appeared, and human trials have begun.

Fluid and Electrolyte Therapy: All patients with DKA suffer from dehydration (10% of total body weight in severe ketoacidosis) because of the osmotic diuresis, accompanied by depletion of electrolytes, sodium, potassium, chloride, phosphate, and magnesium. Serum pH and bicarbonate reflect the degree of acidosis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones.

The initial hydrating solution is 0.9% saline solution. Traditionally deficits have been replaced at a rate of 50% over the first 8 to 12 hours and the remaining 50% over the next 16 to 24 hours. Current trends suggest more cautious fluid management to reduce the risk of cerebral edema. Consequently, the recommendations now are to replace the deficit evenly over 36 to 48 hours (Cooke and Plotnick, 2004).

Serum potassium levels may be normal on admission, but after fluid and insulin administration the rapid return of potassium to the cells can seriously deplete serum levels, with the attendant risk of cardiac arrhythmias. As soon as the child has established renal function (is voiding at least 25 ml/hr) and insulin has been given, vigorous potassium replacement is implemented. The cardiac monitor is used as a guide to therapy, and the nurse should observe the configuration of T waves every 30 to 60 minutes to determine changes that might indicate alterations in potassium concentration (widening of the Q-T interval and the appearance of a U wave following a flattened T wave indicate hypokalemia; an elevated and spreading T wave and shortening of the Q-T interval indicate hyperkalemia).

Insulin should not be given until after obtaining urine ketones and a blood glucose level. Continuous IV regular insulin is given at a dosage of 0.1 units/kg/hr. Insulin therapy should be started after the initial rehydration bolus, since serum glucose levels fall rapidly after volume expansion. Blood glucose levels should decrease by 50 to 100 mg/dl/hr. When blood glucose levels fall to 250 to 300 mg/dl, dextrose is added to the IV solution. The goal is to maintain blood glucose levels between 120 and 240 mg/dl by adding 5% to 10% dextrose. Sodium bicarbonate is used conservatively; it is used for pH less than 7.0, severe hyperkalemia, or cardiac instability. Because sodium bicarbonate has been associated with increased risk for cerebral edema, children receiving this substance must be carefully monitored for changes in level of consciousness (Brown, 2004). If bicarbonate treatment is necessary, 1 to 2 mEq/kg should be added to the IV fluids to run over 1 to 2 hours (Cooke and Plotnick, 2004).

When the critical period is over, the task of regulating insulin dosage in relation to diet and activity is started. Children should be actively involved in their own care and are given responsibility according to their ability and the guidance of the nurse.

Hospital Management: The child with DKA requires intensive nursing care. Observe vital signs and record them frequently. Hypotension caused by the contracted blood volume of the dehydrated state may cause decreased peripheral blood flow, which can be particularly hazardous to the heart, lungs, and kidneys. An elevated temperature may indicate infection and should be reported so that treatment can be implemented immediately.

Maintain careful and accurate records, including vital signs (pulse, respiration, temperature, and blood pressure), weight, IV fluids, electrolytes, insulin, blood glucose level, and intake and output. Use a urine collection device or retention catheter to obtain the urine measurements, which include volume, specific gravity, and glucose and ketone values. The volume relative to the glucose content is important because 5% glucose in a 300-ml sample is a significantly greater amount than a similar reading from a 75-ml sample. A diabetic flow sheet maintained at the bedside provides an ongoing record of the vital signs, urine and blood tests, amount of insulin given, and intake and output. Assess the level of consciousness and record it at frequent intervals. The comatose child generally regains consciousness fairly soon after initiation of therapy but is managed like any unconscious child during that time.

When the critical period is over, the task of regulating insulin dosage to diet and activity begins. The same meticulous records of intake and output, urine glucose and acetone levels, and insulin administration are maintained. Capable children should be actively involved in their own care and are given responsibility for keeping the intake and output record, testing the blood and urine, and, when appropriate, administering their own insulin—all under the nurse’s supervision and guidance (see Nursing Care Plan).

Concepts of Child and Family Education: Children and their families vary in educational background and the capacity to learn and understand the various aspects of the therapeutic program. Some families respond best to simple explanations and directions, whereas others expect thorough, in-depth information about the physiologic processes and responses associated with the disease and its therapy. All the principles of teaching and learning are applied in the educational process; therefore, before beginning, the nurse must determine the optimum time, place, method, and content to be taught. Self-management, the ultimate goal for children with diabetes, is more likely to occur when children understand the disease and the care it requires. Properly educated and motivated, most families should be able to follow a program of regulated control satisfactorily.

When to teach a family and child is best judged by their psychologic state and emotional readiness. When a child is newly diagnosed, the psychologic adjustment to the disease can block the learning process completely. For example, in a follow-up visit family members may state that they are hearing a certain bit of information for the first time even though the material had been covered several times in the course of teaching.

Certainly the first 3 or 4 days after diagnosis are not an optimum time for complex learning. In fact, the later the more complex material is presented, the better. For example, one successful program teaches only essential, or survival, information first and intense information a month later. Another program advocates teaching 1 week after diagnosis followed by a review of survival techniques 2 weeks after discharge. Probably the worst time for teaching is the day or so after diagnosis, when the education must be compressed into a few hours or days so that the child can be discharged early.

Regardless of the teaching plan, the nurse must accurately assess individual ability to learn. This includes assessment of the individuals’ educational background and emotional stability and the use of appropriate measurement tools, such as a pretest or an objective assessment of the learners’ educational level. The stepped approach to patient education employs the method of simple to complex. The stepped approach involves (1) using good interpersonal skills, (2) teaching about the illness and regimen, and (3) overcoming obstacles to behavior change.

The setting for the educational process can facilitate learning. If the child must be hospitalized, bedside education may be necessary in some cases, but the coming and going of a number of people is distracting. At times in the educational process individual instruction is needed, but contact with other children or parents can assist in adjustment to the reality of the disease and the implications of having a chronic condition.

A child learns best when sessions are short, no more than 15 to 20 minutes. The parents do best with periods of 45 to 60 minutes, or longer if they are inquisitive. Education should involve all the senses. Although visual aids are valuable tools, participation is the most effective method for learning. For example, to teach blood glucose testing, the nurse explains the technique, demonstrates the procedure, and allows the learner to perform the procedure; this is followed by a review of the material using visual aids, with learning validated by some testing method that includes feedback. A variety of teaching methods and teaching aids can be used. Some visual aids may be beautifully illustrated but miss a major point; therefore materials should be previewed for accuracy and appropriateness. Varying the presentation with a variety of audiovisual materials, including films, slide-tape programs, and books, stimulates the senses and helps the individual learn.

Several organizations are prepared to assist with education and dissemination of knowledge about diabetes. The American Diabetes Association,* Canadian Diabetes Association,† Juvenile Diabetes Research Foundation International,‡ and American Association of Diabetes Educators§ are valuable resources for a wide variety of educational materials. The National Institute of Diabetes and Digestive and Kidney Diseases¶ publishes a number of comprehensive annotated bibliographies, including “Educational Materials for and About Young People with Diabetes,” a compilation of resource materials for children, siblings, parents, teachers, and health professionals; and “Sports and Exercise for People with Diabetes.”

The content of the educational course must include all aspects of the disease as they relate to the individual child. Many aspects of the disease may not be covered in an initial educational course but can be postponed until subsequent office or clinic visits or can be done through referral sources such as the American Diabetes Association. The minimum information needed should help the family manage from one day to the next; expanded information helps the individual with long-term adjustment to the disease. The more the family understands about the disease in relation to body needs, the better they are able to maintain a high degree of control. Important content needed for minimum management is discussed briefly in the following sections.

Identification: One of the first things the nurse should call to the parents’ attention is the need for the child to wear some means of medical identification. Usually recommended is the Medic-Alert identification, a stainless steel, silver, or gold-plated identification bracelet that is visible and immediately recognizable. It contains a collect telephone number that medical personnel can call around the clock for medical records and personal information.

Nature of Diabetes: The better the parents understand the pathophysiology of diabetes and the function and action of insulin and glucagon in relation to caloric intake and exercise, the better they will understand the disease and its effects on the child. Parents need answers to a number of questions (voiced or unvoiced) to increase their confidence in coping with the disease. For example, they may want to know about the various procedures performed on their child and treatment rationale, such as what is being put in the IV bottle and the expected effect.

Meal Planning: Normal nutrition is a major aspect of the family education program. The nutritionist usually conducts diet instruction, with reinforcement and guidance from the nurse. The emphasis is on adequate intake for age, consistent menus, complex carbohydrates, and consistent eating times. The family learns how the meal plan relates to the requirements of growth and development, the disease process, and the insulin regimen. Meals and snacks are modified based on the child’s preferences and current menu, preserving cultural patterns and preferences as much as possible. Extensive exchange lists are available that include foods compatible with most lifestyles.

Learning about foods within specific food groups helps in making choices. Weights and measures of foods are used as eye-training devices for defining serving sizes and should be practiced for about 3 months, with gradual progression to estimation of food portions. Even when the child and family become competent in estimating portion sizes, reassessment should take place weekly or monthly and when there is any change of brands.

Family members should also be guided in reading labels for the nutritional value of foods and food content. They need to become familiar with the carbohydrate content of food groups. Substitution with foods of equal carbohydrate content is the skill needed for successful carbohydrate counting. Substitution might be necessary if a food is not available in sufficient quantity or for the teenager who wishes to eat fast food with peers. The use of a multiple daily injection program lends flexibility to the timing of meals.

Educating children or teenagers to make healthy food choices is an ongoing task. Teach younger children to choose from a special treat box stocked with sugar-free items when others bring high-sugar treats to the classroom. Discussions with school-age children might include situations encountered at school or parties, such as choosing food in the cafeteria or bringing substitute treats to parties. Role-playing and discussion help teenagers deal with food choices when on dates, with friends, or on a food break after school.

Lists of popular fast-food items and items served at the major fast-food chains can be obtained from the restaurants to help guide food selections. It is important that the child know the nutritional value of these items (the major chains are remarkably uniform), but the child should be cautioned to avoid high-fat, high-sugar, and high-carbohydrate items. For example, the child could choose a plain hamburger instead of a double cheeseburger.

Children should use sugar substitutes with moderation in items such as soft drinks. Artificial sweeteners have been shown to be safe, but if there is any question about amounts, the physician, dietitian, or nurse specialist can provide guidelines based on body weight. Sugar-free chewing gum and candies made with sorbitol may be used in moderation by children with DM. Although sorbitol is less cariogenic than other varieties of sugar substitutes, it is an alcohol sugar that is metabolized to fructose and then to glucose. Furthermore, large amounts can cause osmotic diarrhea. Most dietetic foods contain sorbitol. They are more expensive than regular foods. Also, although a product may be sugar free, it is not necessarily carbohydrate free.

Traveling: Traveling requires advance planning, especially when a trip involves crossing time zones. A number of tips are included in pamphlets available free of charge. Suggestions for traveling encompass what will be needed from the practitioner before leaving, what and how much to take along, needs in transit, what to consider at the destination, and planning for when the child returns home. Planning is needed no matter what type of travel is considered—automobile, plane, bus, or train.

Insulin: Families need to understand the treatment method and the insulin prescribed, including the effective duration, onset, and peak action. They also need to know the characteristics of the various types of insulins, the proper mixing and dilution of insulins, and how to substitute another type when their usual brand is not available (insulin is a nonprescription drug). Insulin need not be refrigerated but should be maintained at a temperature between 15° and 29.5° C (59° and 85° F). Freezing renders insulin inactive.

Insulin bottles that have been “opened” (i.e., the stopper has been punctured) should be stored at room temperature or refrigerated for up to 28 to 30 days. After 1 month these vials should be discarded. Unopened vials should be refrigerated and are good until the expiration date on the label. Diabetic supplies should not be left in a hot environment.

Injection Procedure: Learning to give insulin injections is a source of anxiety for both parents and children. It is helpful for the learner to know that this important aspect of care will become as routine as brushing the teeth. First, the basic injection technique is taught, using an orange or similar item and sterile normal saline for practice. To gain children’s confidence, the nurse can demonstrate the technique by giving a skillful injection to the parent and then having the parent return the demonstration by giving the nurse an injection. With practice and confidence, the parents soon are able to give the insulin injection to their children, and their children trust them. Another effective strategy is to instruct the children and then have them teach the technique to the parents while the nurse observes. Both parents should participate, and as little time as possible should elapse between instruction and the actual injection, especially with parents and teenage learners.

Animation—Insulin Injection

Insulin can be injected into any area in which there is adipose (fat) tissue over muscle; the drug is injected at a 90-degree angle. Newly diagnosed children may have lost adipose tissue, and care should be exerted not to inject intramuscularly. The pinch technique is the most effective method for tenting the skin to allow easy entrance of the needle to subcutaneous tissues in children. The site selected sometimes depends on whether children or parents administer the insulin. The arms, thighs, hips, and abdomen are usual injection sites for insulin. The children can reach the thighs, abdomen, and part of the hip and arm easily but may require help to inject other sites. For example, a parent can pinch a loose fold of skin of the arm while the child injects the insulin.

The parents and child are helped to work out a rotation pattern to various areas of the body to enhance absorption, since insulin absorption is slowed by fat pads that develop in overused injection areas. The most efficient rotation plan involves giving about four to six injections in one area (each injection about 2.5 cm [1 inch] apart, or the diameter of the insulin vial from the previous injection) and then moving to another area.

Remember that the absorption rate varies in different parts of the body (Table 38-7). Methodically using one anatomic area and then moving to another (as described in the previous paragraph) minimize variations in absorption rates. However, vigorous exercise, which enhances absorption from exercised muscles, also alters absorption. Therefore it is recommended that a site be chosen other than the exercising extremity (e.g., avoiding legs and arms when playing in a tennis tournament).

Injection sites for an entire month can be determined in advance on a simple chart. For example, the “paper doll” (body outline) described on p. 138 can be constructed and insulin sites marked by the child. After injection, the child places the date on the appropriate site. To keep in practice, it is a good idea for the parent to give two or three injections a week in areas that are difficult for the child to reach.

The same basic methodology is used when teaching children to give their own insulin injections (Fig. 38-8). They should practice first on an orange or a doll, building courage gradually. The first attempt is usually awkward because children tend to slowly push the needle through the skin rather than using a quick approach. It is best not to pressure them into assuming this responsibility until they are ready. When children participate in a group learning situation or have an opportunity to observe their peers giving their own injections, they may become more motivated. Warn parents that at some time children will give themselves an uncomfortable injection at home and that they will need parental support and encouragement. Otherwise children may not wish to give themselves injections for some time.

Other devices are available for insulin injection and may offer advantages to some children. Children who do not wish to give themselves injections can learn to use a syringe-loaded injector (Inject-Ease). With the device, puncture is always automatic. Adolescents respond well to a self-contained and compact device resembling a fountain pen (NovoPen), which eliminates conventional vials and syringes. Preloaded pens may also improve adherence to intensive insulin regimens, improve lifestyle flexibility, and decrease pain (Rex, Jensen, and Lawton, 2006).

Teaching includes the proper way to equalize pressure in the bottle by injecting an amount of air equal to the amount of solution withdrawn and how to remove air bubbles from the syringe. When insulin doses are small, an air bubble in the syringe can displace a significant amount of medication. Since the introduction of the 0.5-ml and 0.3-ml syringes, the risk of incorrect dosage has diminished. Advise patients who have small doses of mixed insulins to use one of these syringes. Insulin syringes should be compared for accuracy, comfort, and strength. The family and child should be able to choose both “their” insulin and “their” syringe from a variety of samples. The needle length and gauge are also factors to consider from the point of view of comfort (e.g., use the shortest and smallest-gauge needle available). Some brands of syringes may be more comfortable than others. When currently available syringes are used, insulin injections of less than 2 units of U100 may have an unacceptably large error. Diluted insulin is sometimes used if the prescribed dose is less than 2 units. Special diluent is available from the insulin manufacturers (Eli Lilly, 2007).

When the child’s dosage requires the injection of both short- and intermediate-acting insulin at the same time, most families prefer to mix the two and use a single injection. Insulin can be premixed and stored in the refrigerator for later use. Commercially prepared insulin mixtures are also available (e.g., 70/30 and 50/50). To obtain maximum benefit from mixing insulins, the recommended practice is to (1) inject the measured amount of air (equivalent to the dosage) into the long-acting insulin; (2) inject the measured amount of air into the rapid-acting (clear) insulin and, without removing the needle; (3) withdraw the clear insulin; and (4) insert the needle (already containing the clear insulin) into the long-acting (cloudy) insulin and then withdraw the desired amount.

Nurses should also teach proper disposal of equipment after use in the home. Although not standard practice in the hospital, the use of a needle clipper is recommended to safely remove and house the used needle. The syringe plunger can be broken before disposal. An excellent means for syringe disposal is in an opaque, puncture-resistant container, such as an empty coffee can, bleach bottle, or milk carton. The container is labeled “biohazardous waste” and is discarded with similar material only, not with household refuse and consistent with local regulations.

Monitoring: Nurses should also be prepared to teach and supervise blood glucose monitoring. SMBG is associated with few complications, and although it does not necessarily lead to improved metabolic control, it provides a more accurate assessment of blood glucose levels than can be obtained with the historical urine testing. Blood glucose monitoring has the added advantage that it can be performed anywhere (see Atraumatic Care box).

Blood for testing can be obtained by two different methods: manually or with a mechanical bloodletting device. A mechanical device is recommended for children, although the child and family should learn to use both methods in the event of mechanical failure. Several lancet devices are available from which to choose, and each provides a means for obtaining a large drop of blood for testing (Fig. 38-9).

The blood sample may be obtained from fingertips or alternate sites such as the forearm. Alternate site testing requires a meter that can test a small volume of blood. Not all meters are capable of this.

The practitioner should examine signs of redness and soreness at the site of finger puncture. It may be evidence of poor technique, poor hygiene, or poor skin healing relative to poor control. Many types of blood-testing meters are available for home use. Newer technology has brought about improvements in meter size and ease of use. The family should be shown features of several meters, including advantages and disadvantages, and allowed to choose equipment that best meets their needs.

The least expensive testing method uses a reagent strip to which blood is applied (Fig. 38-10). After blotting, the color change is compared to a color scale for an estimation of the blood glucose level. The strips can be cut in half (although not all professionals recommend this) to obtain two readings per strip. This method is not accepted practice but may be necessary for some families or situations.

Shopping: Diabetic maintenance is an expensive necessity. Families should investigate all sources of obtaining supplies for managing the disease. Prices are often lower when supplies are purchased in volume; however, it is not advisable to buy bulk items that are unfamiliar, since the new items may not be satisfactory for the individual child or may become outdated before they are used. Costs vary considerably among pharmacies and other suppliers, including the numerous discount mail-order establishments. When buying by mail, it is important to find a supplier that responds to the family’s satisfaction and to allow ample time for delivery to avoid running out of supplies. Parents are also cautioned not to substitute insulins or the type of insulin syringe (e.g., a 1-ml syringe for the low-dose type) simply to save money. Parent groups and the local American Diabetes Association can offer some suggestions for investigation. Most states have legislation mandating that insurance companies cover the cost of diabetes supplies and education.

Hyperglycemia: Severe hyperglycemia is most often caused by illness, growth, emotional upset, or missed insulin doses. Emotional stress from school finals or examinations or physical response to immunizations are examples of causes of hyperglycemia. With careful glucose monitoring, any elevation can be managed by adjustment of insulin or food intake. Parents should understand how to adjust food, activity, and insulin at the time of illness or when the child is treated for an illness with a medication known to raise the blood glucose level (e.g., steroids). The hyperglycemia is managed by increasing insulin soon after the increased glucose level is noted.

Hypoglycemia: Hypoglycemia is caused by imbalances of food intake, insulin, and activity. Ideally hypoglycemia should be prevented, and parents need to be prepared to prevent, recognize, and treat the problem. They should be familiar with the signs of hypoglycemia and instructed in treatment, including care of the child with seizures. (See Chapter 37.) Early signs are adrenergic, including sweating and trembling, which help raise the blood glucose level, much like the reaction when an individual is startled or anxious. The second set of symptoms that follow an untreated adrenergic reaction are neuroglycopenic (also called brain hypoglycemia). These symptoms typically include difficulty with balance, memory, attention, or concentration; dizziness or lightheadedness; and slurred speech. Severe and prolonged hypoglycemia leads to seizures, coma, and possible death (Cryer, 2003). In particular, infants are at an increased risk because of the developing brains’ vulnerability to the potential neurotoxic insult of hypoglycemia (Cooke and Plotnick, 2004). Hypoglycemia can be managed effectively (see Emergency Treatment box).

It is advisable for parents to plan for anticipated excitement or exercise. In addition, gastroenteritis may decrease insulin needs slightly as a result of poor appetite, vomiting, or diarrhea. If the blood glucose level is low but urinary ketones are present, the family should be aware of the increased need for simple carbohydrates and liquids.

Hygiene: All aspects of personal hygiene should be emphasized for the child with diabetes. Caution the child against wearing shoes without socks, wearing sandals, or walking barefoot. Correct nail and extremity care tailored to the individual child (with the guidance of a podiatrist) can begin health practices that last a lifetime. Eyes should be checked once a year unless the child wears glasses, and then as directed by the ophthalmologist. Regular dental care is emphasized, and cuts and scratches should be treated with plain soap and water unless otherwise indicated. Diaper rash in infants and candidal infections in teens may indicate poor diabetes control.

Exercise: Exercise is an important component of the treatment plan. If the child is more active at one time of the day than at another time, food or insulin can be altered to meet that activity pattern. Food should be increased in the summer, when children tend to be more active. Decreased activity on return to school may require a decrease in food intake or increase in insulin dosage. The child who is active in team sports needs a snack about a half hour before the anticipated activity. Races or other competition may call for a slightly higher food intake than practice times.

Food intake usually needs to be repeated for prolonged activity periods, often as frequently as every 45 minutes to 1 hour. Families should be informed that if increased food is not tolerated, decreased insulin is the next course of action. If the timing of the exercise is changed so that the supper meal is delayed, the insulin in the second or third dose of the day may be moved back to precede the mealtime. Sugar may sometimes be needed during exercise periods for quick response. Elevated blood glucose levels after extreme activity may represent the body’s adrenergic response to exercise. If the blood glucose level is elevated (>240 mg/dl) before planned exercise, urine ketones should be checked and the activity may need to be postponed until the blood glucose is controlled.

Without adequate insulin levels the cells are unable to receive glucose, the preferred fuel, despite the high level of blood glucose. The low insulin level allows glucagon to act, uninhibited, to increase hepatic glucose production, further raising the blood glucose level with no means to use sugar at the muscle site. Breakdown of fat (lipolysis) is the alternative, and the end product of lipolysis is ketone body production (Cooke and Plotnick, 2008).

Record Keeping: Home records are an invaluable aid to diabetes self-management. The nurse and family devise a method to chart insulin administered, blood glucose values, urine ketone results, and other factors and events that affect diabetes control. The child and family should observe for patterns of blood glucose responses to events such as exercise. If lapses in management occur (such as eating a candy bar), the child should be encouraged to note this and not be criticized for the transgression.

Complications: The nurse should present the implications of the disease in a tactful, clear, and nonthreatening manner. Knowledge of the complications of diabetes and their relationship to control provides a basis for knowledgeable decision making. Eye and kidney diseases are the greatest threats, with neurologic complications close behind. Clear explanations of these problems clarify false information often given by well-meaning friends. The information should include discussion of research so that the family is left with the positive impression that others are concerned about finding answers and preventing complications. It also gives them hope that somehow, some way, a prevention or cure will be possible.

Self-Management: Self-management is the key to close control. Being able to make changes when they are needed rather than waiting until the next contact with health care professionals is important for self-management and gives the individual and family the feeling they have control over the disease. Psychologically this helps family members feel they are useful and participating members of the team. Allowing the child to learn to look at records objectively promotes independence in self-management support. As children grow and assume more responsibility for self-management, they develop confidence in their ability to manage their disease and confidence in themselves as persons. They learn to respond to the disease and to make more accurate interpretations and changes in treatment when they become adults.

Self-management techniques to be mastered are the testing and adjustment of insulin and diet with alterations in day-to-day activities and anticipation of unusual occurrences. However, the nurse should provide guidelines regarding when to consult with the health care professionals. For instance, the degree of metabolic control before an illness is a determining factor in seeking medical help during the illness. In an individual with poor control, it takes only a few hours before the trouble is severe, whereas if control is good before the illness, several days may elapse before help is needed. Also caution patients and families to seek assistance if glucose levels are elevated and urine is not clear of ketones after 24 hours of self-management.

Child and Family Support: Just as the physiologic responses affect the child, the parents and other family members of the child with newly diagnosed DM experience various emotional responses to the crisis. Care in the acute setting is short but may create fears and frustrations. The prospect of a chronic illness in their child engenders all the feelings and concerns that are faced by parents of children with other chronic illnesses. (See Chapter 22.) The threat of complications and death is always present, as well as the continuing drain on emotional and financial resources.

Certain fears may develop as a result of past experiences with the disease. A severe insulin reaction with seizures can contribute to fear of repetition. Once parents observe a seizure or the adolescent has one in a public place, the desire to maintain better control is reinforced. They must understand how to prevent problems and how to handle problems calmly and coolly if they occur, and they must understand the complexities of the body, the disease, and its complications. Young children usually adjust well to problems related to the disease. With toddlers and preschoolers, insulin injections and glucose testing may be difficult at first. However, they usually accept the procedures when the parents use a matter-of-fact approach without calling attention to a “hurt” and treat the procedure like any other routine part of the child’s life. After the injection, time with some special and positive attention, such as reading, talking, or another pleasant activity, is one way to convert children who initially refuse injections to those who accept them.

In the years before adolescence children probably accept their condition most easily. They are able to understand the basic concepts related to their disease and its treatment. They are able to test blood glucose and urine; recognize food groups; give injections; keep records; and distinguish between fear, excitement, and hypoglycemia. They understand how to recognize, prevent, and treat hypoglycemia. However, they still need considerable parental involvement.

Adolescents appear to have the most difficulty adjusting. Adolescence is a time of stress in trying to be perfect and like one’s peers, and no matter what others say, having diabetes is being different. Some adolescents are more upset about not being able to have a candy bar than about injections, diet, and other aspects of management. If children can accept the difference as a part of life—in other words, that each person is different in some way—then with adequate parental support they should be able to adjust well.

Problems of adjustment to diabetes are especially difficult for the young person whose disease is diagnosed in adolescence. Denial is sometimes expressed by omitting insulin, not performing tests, and eating incorrectly, although denial of the disease usually diminishes during this period as the adolescent with DM begins to feel competent and worthy. Diabetes makes the teenager different when conformity and sameness are desired; having the disease emphasizes vulnerability and imperfection when the search for identity is the foremost developmental task of adolescence. It is often difficult for the adolescent to know what to tell friends.

Camping and other special groups are useful. At diabetes camp, children learn that they are not alone. As a result, they become more independent and resourceful in other settings. Useful information about such camps and organizations can be obtained from the American Diabetes Association. A list of accredited camps specifically for children and teenagers with diabetes is also available from the American Camp Association.*

Puberty is associated with decreased sensitivity to insulin that normally would be compensated for by an increased insulin secretion. Health care professionals should anticipate that pubertal patients will have more difficulty maintaining glycemic control. Insulin doses commonly need to be increased, often dramatically (Tfayli and Arslanian, 2007). Patients should learn to give themselves additional doses of rapid-acting insulin (5% to 10% of their daily dose) when their blood glucose levels are increased. The use of supplemental rapid-acting insulin is preferred to withholding food in the adolescent.

Eating disorders, such as bulimia or anorexia nervosa, in the teenager with type 1 DM (see Chapter 21) pose a serious health hazard (Ackard, Vik, Neumark-Sztainer, et al, 2008). The nurse should be alert to a history of preoccupation with weight, food faddism, excessive caloric restriction, or unexplained hypoglycemia. Moreover, insulin manipulation or omission has been identified as a weight loss tool used by some female adolescents (Tierney, Deaton, Webb, et al, 2008).

Inaccurate doses of insulin may occur inadvertently or, if they occur frequently, may be an attention-seeking device; in a number of cases they may demonstrate adolescent depression and, more seriously, a subconscious but socially accepted method of suicide. Excessive intake of food leads to obesity and may also be symptomatic of depression. Psychiatric counseling may be needed if suicidal tendencies are amplified by the diabetes.

Rehospitalizations are most often related to poor control of the disease, although they may be indirectly related to poor coping and are a method of avoiding the pressures caused by family and peers. The hospital may represent an environment that is peaceful and free of stress. The goal for this problem is to determine the cause of the hospitalization. It may be related to poor control, poor self-management, or the need for better supportive management at home. Evaluation should be based on the physiologic and psychologic adjustment of the child and family.

1. Yes. Rebecca has had five hospital admissions for DKA in the past year. Numerous factors must be involved with her unstable disease.

2. a. The normal tasks of adolescence can play a significant role in blood glucose instability.

3. The first priority would be to focus directly on the issues of hyperglycemia. Determination of Rebecca’s practice of monitoring and management of her diabetes at home is essential. Areas of diabetes management that should be emphasized include careful dietary management, an appropriate exercise program, conscientious self-testing of blood glucose, appropriate administration of daily insulin, and adherence to sliding-scaling insulin therapy. Discussion of the emotional stressors she identifies at this time is appropriate.

4. Yes, Rebecca’s history of DKA over the past year supports her inability to monitor and manage her diabetes.