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Helping a teenager manage diabetes: forming a trusting relationship with a teenage Maori girl, newly diagnosed with type 1 diabetes, was an essential part of helping her manage the disease.

New Zealand has a diabetes epidemic, with 50 people diagnosed with the insulin-deficiency disorder every day. More than 200,000 New Zealanders have type 1 or type 2 diabetes. (1) Nurses working with people who have diabetes must form a sound partnership with the patient and their family. The following case study is my analysis of the care and treatment provided to a teenager who developed type 1 diabetes.

Anna* is a 16-year-old Maori girl, living in a small rural town with her parents. She was admitted to the emergency department (ED) of a rural hospital via ambulance, having had multiple seizures, and was unresponsive. Anna had a long history of epilepsy, and family and medical staff assumed she was having another epileptic seizure.

However, results from the initial assessment revealed a blood glucose level (BGL) of 34mmol/L, indicating hyperglycemia. Anna was given a single dose of insulin and sent to a larger hospital for specialised treatment. On arrival, her BGL had dropped to 7mmol/L,--within the acceptable range--and she was observed overnight as an inpatient. Anna and her parents left before management plans could be formulated--no formal plan had been discussed, let alone implemented.

The following week she was seen by her GP and a random BGL read 14.9mmol/L. Preliminary measurements and tests were done, including weight, height, waist circumference, vital signs and bloods. Blood antibody tests confirmed Anna had type 1 diabetes mellitus. Her GP advised her to reduce carbohydrate intake, and she was given a blood glucose monitor to perform regular tests. Her GP reviewed these a few days later, and prescribed a daily dose of protaphane insulin to stabilise her BGL. An urgent referral was sent to the community clinical nurse specialist diabetes (CNSD) for assessment.

I first met Anna and her father when they were visiting the CNSD. Over the following three months I accompanied the CNSD on visits to Anna at home, to help her and her family learn how to manage her diabetes and to assess her progress. This was in my role as the rural hospital's diabetes resource nurse, and also to do this case study.

Anna had a medical history of epilepsy, which was well-managed. She was at the "identity versus role confusion" life stage, where adolescents seek a sense of identity separate from their parents. (2) The diabetic regimen can hinder this drive for independence and peer acceptance, as research suggests adolescents may have better control of diabetes if they let their parents guide and support them in managing it. (3) When I first met Anna, I observed she appeared happy and to be coping well; having diabetes had drawn more attention to her and she appeared excited by this.

Protophane adjusted weekly

Her diabetes was being controlled by protaphane insulin, adjusted weekly. She was receiving 22 units in the morning and four units at night. After a couple of weeks, her BGLs started to become more stable; also she started keeping a diary and was monitoring her blood sugars regularly, often checking them at 2am. Nocturnal testing let her know if her BGLs were low and if the evening dose of insulin needed adjusting. (4)

Good glycaemic control slows the rate of microvascular and macrovascular disease and other complications of diabetes mellitus. (5) It is indicated by BGLs less than 8mmol/L two hours after meals, and less than 6mmol/L before meals. (6) Blood glucose monitoring is important, as insulin medication doses are formulated from these results. It may be necessary to find out which foods are causing the blood glucose to rise.

At one point, Anna's insulin was adjusted as her BGLs remained high in the morning. Once she reached her target BGL, the insulin dose would decrease again. Insulin levels may need to be adjusted temporarily during menstruation, as the hormonal change can increase BGLs. (4) It is important to document BGLs before and after meals, and during the night, so targets can be achieved safely. (7) Her diary showed her BGLs were improving with insulin, a more healthy diet and exercise. She was on basal insulin, which is long-acting and taken twice daily, 12 hours apart. This required her to have adequate carbohydrate intake, consisting of three meals a day, and snacks, to prevent hypoglycemic episodes. (3)

At the time she was diagnosed, Anna said she was walking up to three kilometres a day, and decided to take up running as well. Exercise is an important part of diabetes management, improving the action of insulin, and blood sugar control, and helping maintain overall well-being. (4) The CNSD and I advised her to take special precautions when exercising, such as pre-testing, eating extra carbohydrates, and carrying a cellphone and snacks. Delayed hypoglycemia can occur 12 to 16 hours after intense exercise and it takes time for patients and their families to gain experience in insulin adjustment. (8) We reminded her to test her BGLs before bed, and gave her an 0800 number to ring after hours if there were any problems, which gave the family access to help 24 hours a day.

More restful sleep

At times, Anna worried about her BGLs, which stopped her sleeping well. Ongoing testing of BGLs at night is important during the adjustment phase, to prevent nocturnal hypoglycemia. Within a couple of weeks of starting diabetes management, she reported feeling better--she was not thirsty, and toilet visits had declined (thirst and frequent urination are symptoms of both types of diabetes), enabling a more restful night's sleep. She said since being on insulin her appetite had increased, which often caused hunger pangs in the middle of night, so she started eating a snack before bed.

The HbA1c test is used to check diabetes control over the previous three months--it measures the amount of glucose which attaches to the haemoglobin to form HbA1c. (4) Anna's HbA1c was 9.4 per cent when we first met, which is high, and may lead to complications of the eyes, kidneys, nerves and blood vessels if the level is not decreased. Consistently high levels of glucose can damage the small blood vessels. (4) Excess glucose attaches to blood vessels and nerves, altering normal structure and function, causing chemical disturbances. (10)

The target range of Hba1c for adults with type 1 diabetes is seven per cent or lower. (6) Studies show, for adolescents, the seven per cent target is neither feasible nor realistic. For teenagers, it is more practical to put it at 7.5 per cent, to take their varied eating patterns into account. Maintaining the seven per cent target can tip the young person into hypoglycemia with an accompanying sense of failure, at being unable to develop good metabolic control. (Since this case study was done, practice has changed--HbA1c readings are now reported in mmol/mol.) Other aspects of care and management are as important as maintaining good glycemic control. (7)

Foot care is an important part of managing diabetes. If diabetics do not protect their feet from injuries, significant complications may result in later life. (8) Infections thrive in a high-sugar environment and take longer to heal. This has an effect on foot injuries, plantar warts, calluses, corns and in-grown toenails. Well-fitting shoes should be worn when exercising, and feet should be covered at all times. (11) Pressure may develop into blisters, and we told Anna she would need better shoes to continue with her running, and that a podiatrist might be able to help with this. Good nail cutting is also important--Anna had been cutting her toenails incorrectly. We explained she should cut her toenails straight across, avoiding cutting down into the corners, to avoid jagged edges that could catch and lead to infection. (12) She needed to check her feet daily and dry well between her toes.

Adolescents with type 1 diabetes undergo intense lifestyle changes. Frequent glucose monitoring, dietary changes and maintaining glycemic control are challenging. (13) Studies indicate they have a higher incidence of depression, and are at risk for other psychiatric conditions such as eating (bulimia and anorexia) and anxiety disorders. (3,14) If they are diagnosed early, these disorders can be treated with interventions such as serotonin-specific re-uptake medications, cognitive behaviour therapy, interpersonal therapy and diabetes education. (13) Anna's support team will closely monitor her for these disorders and will intervene if she requires mental health treatment. Anna says she exercises to maintain her weight, does not want to get fat, and is eating a healthy diet.

Newly diagnosed adolescents and their families can face a range of feelings similar to the stages of grief. (15) Shock, denial, anger, depression, fear, guilt and acceptance are all common reactions. It is helpful to talk to friends, family and specialists. (14) Anna appears keen to manage diabetes with support from her parents and has not expressed any fear. She has support and understanding from a friend her own age. This is an essential part of a coping plan for the adolescent and gives her the strength to be different. (14)

The foundation of diabetes management is education in self-care, diabetes control and a balanced lifestyle. (4) I worked with the CNSD, Anna and her father, and we focused education sessions on diet, insulin administration, foot care, exercise, physiological status and support.

The CNSD and I developed a management plan, in partnership with Anna and her dad, explaining why it was important to keep within the plan and the need to make the goals achievable. We discussed insulin storage, administration and disposal. We watched her administer insulin, and checked to see she was rotating injection sites, to prevent lipohypertrophy--the soft, fatty, lumpy swellings that build up from frequent insulin injections in the same site. (16) They can be unsightly but, more importantly, they result in insulin being absorbed erratically. This can cause changes in the action and timing of insulin, resulting in hyper-or hypoglycemia. (16) We observed Anna's BGL technique and reminded her to wash her finger with warm water before pricking, to clean, and help blood flow to the finger tips. (12) She and her family were shown how to care for the blood glucose machine, and we reminded Anna to document BGLs in her diary.

Her literacy level required simple language and her father told us she was a visual learner. I gave her some colourful pamphlets in easy language and we went through them, which allowed me to assess her level of understanding. It is important at the start not to give too much information because it can be overwhelming and easily forgotten. (17)

I made her a fridge magnet which showed some popular foods she ate regularly. It showed the carbohydrate values and she used it conscientiously when planning her food consumption. We discussed healthy eating and the need to reduce carbohydrate levels and salt intake. Anna ate large quantities of bread, potatoes, sweets and cola, which are popular foods with adolescents. We talked about switching to zero-calorie cola and the need to reduce the junky, or empty, carbohydrates. Carbohydrates are important but need to be eaten at regular times and in regular quantity. (8) This helps maintain BGLs, even if the individual is on long-acting insulin. (18)

Although she found it difficult, Anna started choosing her foods more carefully, based on carbohydrate balance and portion size. Adolescents are often desperate to be part of the group which often focuses on fast food, fad diets and erratic eating behaviour. Studies have revealed that eating disorders in teenagers with diabetes are higher than those without. (9)

We discussed an exercise plan and I suggested running with a buddy. Although Anna needed no encouragement to exercise, I believed a green prescription, with a support person to monitor and encourage exercise, would help her. If she were given some different options, she might enjoy changes to her exercise regime. It is important to empower patients to make their own choices. (19)

Even with the best of intentions, mistakes can occur. Anna mistakenly took her morning dose of Protaphane at night and her worried family took her into the local hospital's ED. The family was taught what to do if this happened again. It is a common mistake, (8) usually rectified by eating carbohydrates similar to the whole daily intake.

We talked about what she, or a family member, should do if she experienced hypoglycemia--interventions include taking Hypofit, drinking a can of regular coke, or eating jelly beans. We stressed that BGLs must be rechecked regularly. She and her father learnt to recognise the symptoms of hypoglycemia, and how to avoid it by eating carbohydrates regularly at regular meal times, having snacks and testing BGLs, before and after exercising. They have a Glucagon hypokit which they learnt how to use.

Test for ketones

If Anna's BGL was more than 15mmol/L, she was told to test for ketones. These are acids produced when the body burns fat for energy when there is not enough insulin, and BGLs remain elevated. At high levels, they can damage the body and lead to ketoacidosis. This can be life-threatening, leading to dehydration and coma. (8) If her urine was positive for ketones, she needed to contact her GP or after-hours emergency service. She was aware of the symptoms of hyperglycemia--polydipsia, polyuria, polyphagia, abdominal pain, blurred vision, lethargy and nausea/vomiting. (12)

Initially Anna and her father had limited knowledge about diabetes. As the weeks passed, they gained insight into its signs and symptoms, and learnt how to manage and prevent complications. Her mother was working, so her father took the role of helping her manage her diabetes.

Her BGLs were elevated when we first met, at 11.6mmol/L, and tended to get higher before the evening meal. She learnt to limit fizzy drinks, test her BGLs diligently, document what she ate, and keep a logbook of BGLs. She was very motivated to exercise and started jogging. She started exercising in shoes that fitted correctly, and with some basic knowledge of foot care, was cutting her toenails correctly.

The family was happy for me to visit and would tell me about any problems and ask questions. Without prompting, Anna talked about what she was doing and how she was feeling. The family knew to contact the CNSD if they had any concerns and had a list of phone numbers to ring in an emergency.

Referrals were sent to a dietitian, adolescent diabetes clinical specialist, podiatrist, and retinal screening programme, for optimal management of her diabetes. The home schooling educator was also asked to support Anna in managing her diabetes.

The purpose of my first meeting Anna and her father was for us to get to know one another. I wanted to establish a therapeutic relationship with them so they could trust me. I used active listening skills and respect for their culture--eg taking shoes off at the door and asking permission to touch her--to help form this bond. This trusting therapeutic relationship is essential for people to keep coming to health sessions. (20) I was able to help Anna make changes to her diet, and the fridge chart helped this. The opportunity to visit the family at home gave me insight into how difficult it can be to manage diabetes and how it can affect daily life. It made me realise how supportive diabetes nurses can be and how challenging and rewarding the role is.

Observing this newly diagnosed person with diabetes, and the plan she followed, brought home to me how difficult it can be to get help in rural communities. I gained an understanding of support networks, the services available, and why collaboration and communication are important to manage diabetes.

References

(1) Diabetes New Zealand. (2011) About diabetes. http://www.diabetes.org.nz/about_diabetes. Retrieved 12/3/13.

(2) Santrock, J.W. (2008) Lifespan development (11th ed). New York: McGraw-Hill.

(3) Delameter, A.M. (2009) Psychological care of children and adolescents with diabetes. Pediatric Diabetes; 10: 12, pp 175-184.

(4) Dunning, T. (2009) Care of people with diabetes: a manual of nursing practice. (3rd ed.). Oxford: Wiley-Blackwell.

(5) Mullen, B. & Watts Kelley, P.A. (2006) Diabetes nurse case management: an effective tool. Journal of the American Academy of Nurse Practitoners, 18: 1, pp 22-30.

(6) Waikato Regional Diabetes Service. (2011) Community and in-patient medical guidelines. Hamilton: Waikato District Health Board.

(7) Silverstein, J., Kilngensmith, G., Copeland, K., Plotnick, L. et al. (2005) Care of children & adolescents with type 1 diabetes. Diabetes Care; 28: 1, pp186-212.

(8) Amber, G., Barron, B., May, C., Ambler, E. & Cameron, F. (eds). (2002) Caring for diabetes in children and adolescents: a parent's manual. (New Zealand Edition). Westmead, NSW: Combined Children's Diabetes Services of New South Wales.

(9) Childs, B.P. & Kruger, D. (2005) Treatment strategies for type 1 diabetes. In B. Childs, M. Cypress & G. Spollet (eds). Complete nurse's guide to diabetes care; pp 33-48. Virginia: American Diabetes Association.

(10) Farmer, L., Pearson, S. & Strong, A. (2004) Type 2 diabetes and how to live with it. Wellington: Massey University.

(11) Levy, D. (2011) Practical diabetes care (3rd ed). London: Wiley-Backwell.

(12) McDowell, J.R.S., Matthews, D.M. & Brown, F.J. (eds) (2007) Diabetes: a handbook for the primary healthcare team. Philadephia: Elsevier.

(13) Kanner, S., Hamrin, V. & Grey, M. (2003) Depression in adolescents with diabetes. Journal of Child & Adolescent Psychiatric Nursing, 16: 1, pp 15-24.

(14) Huus, K. & Enskar, K. (2007) Adolescents' experience of living with diabetes. Paediatric Nursing; 19: 3, pp29-31.

(15) Vickers, M.H. & Parris, M.A. (2005) Towards ending the silence: working woman caring for children with chronic illness. Employee Responsibilities & Rights Journal; 17: 2, pp 91-108.

(16) Waddingham, S. (2008) How to prevent and manage lipohypertrophy at injection sites. British Journal of Primary Care Nursing; 5: 6, pp 296-298.

(17) Philips, A. (2009) Diabetes and learning disabilities. Practice Nursing; 20: 12, pp 601-604.

(18) Delahanty, L.M. & McCulloch, D.K. (2012) Nutritional considerations in type 1 diabetes mellitus. www.uptodate.com/contents/nutritionalconsiderations-in-type-1-diabetes-mellitus. Retrieved 11/11/12.

(19) Anderson, B.J. & Rubin, R.R. (2002) Practical psychology for diabetes clinicians. Virginia: American Diabetes Association.

(20) Hartrick Doane, G. & Varcoe, C. (2005) Family nursing as relational inquiry: developing health-promoting practice. Philadelphia: Lippincott Williams & Wilkins.

* Not her real name, to preserve her privacy.

* This article was reviewed by Kai Tiaki Nursing New Zealand practice article review committee member Sha Panapa, MidCentral DHB diabetes nurse practitioner Pauline Giles, and the Kai Tiaki Nursing New Zealand co-editors.

Sue Bennett, RN, is a staff nurse in an acute ward at Waikato Hospital. At the time of writing this article, she worked in a medical ward at Tokoroa Hospital.
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Title Annotation:practice
Author:Bennett, Sue
Publication:Kai Tiaki: Nursing New Zealand
Article Type:Case study
Geographic Code:8NEWZ
Date:Apr 1, 2013
Words:3104
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