Patient's question:
More than a year old, polydipsia and polyuria; anorexia. Current condition: poor immunity, prone to illness. Past diagnosis and treatment history and effectiveness: undergone CT; urinary system examination also showed no abnormalities.Doctor's answer:
Hello, it is recommended to check your blood sugar to see if you have diabetes. Childhood diabetesDiabetes mellitus is a chronic systemic endocrine and metabolic disease caused by an absolute or relative lack of insulin, leading to disorders in sugar, fat, protein, water, and electrolyte metabolism. Diabetes can be divided into primary and secondary types, with the primary type being the majority. Primary diabetes is further classified into two types: insulin-dependent diabetes (IDDM, also known as Type 1) and non-insulin-dependent diabetes (NIDDM, also known as Type 2). Most cases of childhood diabetes are Type 1. The condition is often more severe in children than in adults and is prone to cause diabetic ketoacidosis.
### [Etiology and Pathogenesis]
Insulin promotes glucose utilization and the synthesis of proteins and fats. When insulin secretion is insufficient, glucose utilization decreases, leading to energy deficiency, fatigue, and weakness. Tissues cannot utilize glucose, resulting in energy deficiency and a feeling of hunger, which may cause increased appetite. Inability to utilize glucose reduces hepatic glycogen synthesis and increases gluconeogenesis, raising blood glucose levels above the renal threshold, causing osmotic diuresis (polyuria), electrolyte imbalance, and chronic dehydration, leading to thirst and increased fluid intake. Reduced protein synthesis delays growth and development and weakens the immune system, making infections more likely. Fat breakdown leads to weight loss. Due to impaired fat metabolism, intermediate products cannot enter the citric acid cycle, causing ketone bodies such as acetoacetate, β-hydroxybutyrate, and pyruvate to accumulate in the blood, forming diabetic ketoacidosis.
The onset of Type 1 diabetes is associated with genetic factors, viral infections, autoimmune reactions, and other factors. It is believed that individuals with tissue antigen genes on chromosome 6 have an increased risk of autoimmune reactions when triggered by viral infections or other factors, leading to direct or indirect damage to pancreatic β-cells, resulting in impaired insulin secretion and the onset of the disease.
### [Clinical Manifestations]
Childhood diabetes typically has a rapid onset, with common symptoms including polyuria, polydipsia, weight loss, weakness, and fatigue. Polyphagia may be less pronounced, and enuresis can be an early symptom in infants. Approximately 40% of children first present with diabetic ketoacidosis, often triggered by acute infections, overeating, delayed diagnosis, or sudden interruption of insulin therapy. Symptoms include vomiting, abdominal pain, hepatomegaly, severe dehydration, shock, coma, or even death due to acidosis.
A few children may have a slower onset, with symptoms such as mental sluggishness, weakness, and weight loss. If left untreated for a prolonged period, growth and development may be affected.
Laboratory tests typically show positive urine glucose, elevated fasting blood glucose, abnormal glucose tolerance tests, and increased blood lipids. During diabetic ketoacidosis, urine ketones are positive, blood ketones are elevated, blood gas analysis results are abnormal, carbon dioxide binding capacity and pH levels are reduced, serum sodium and chloride levels are lower than normal, and potassium levels are often normal before treatment. Blood tests may show elevated white blood cell counts and neutrophils.
### [Treatment Principles]
1. Dietary control
2. Prevention and treatment of hypoglycemia and diabetic ketoacidosis
3. Insulin replacement therapy. Currently, with proper education, management, and treatment, children with diabetes can have prolonged lifespans and normal growth and development.
### [Nursing Assessment]
1. Medical History: Inquire about any history of acute infections before onset, focusing on symptoms such as polyuria, polydipsia, polyphagia, weight loss, frequent skin sores or enuresis, and a family history of diabetes.
2. Physical and Mental Status: Check for signs of dehydration, shock, or coma in the child. Assess the child’s and parents’ understanding and attitudes toward diabetes.
3. Diagnostic Tests: Monitor blood glucose, urine glucose, and urine ketone levels promptly.
### [Common Nursing Diagnoses]
1. Imbalanced Nutrition: Less Than Body Requirements – Related to insulin deficiency and metabolic disorders.
2. Urinary Elimination Disturbance – Related to osmotic diuresis.
3. Risk for Infection – Related to weakened immunity.
4. Ineffective Therapeutic Regimen Management – Related to knowledge deficits and poor self-control in the child.
5. Potential Complications
(1) Diabetic Ketoacidosis – Related to acute infections or overeating leading to the accumulation of acidic metabolites.
(2) Hypoglycemia or Hypoglycemic Coma – Related to excessive insulin.
### [Expected Goals]
1. The child and family can explain the purpose and specific methods of dietary control and adhere to the diet.
2. The child’s urination returns to normal, dehydration and acidosis are corrected promptly.
3. No new infections occur during hospitalization.
4. The child and family can explain the precautions for insulin use, perform self-monitoring of blood and urine glucose, and demonstrate willingness to follow the treatment plan.
### [Nursing Measures]
1. Dietary Control: Dietary control is a crucial aspect of nursing. Explain its importance and specific methods in simple terms to the child and family to ensure compliance. Measure the child’s weight weekly. Once the condition stabilizes, regularly monitor weight and height according to the child’s age, as growth rate can indicate whether metabolic disorders are under control. Follow medical advice for a low-sugar diet or provide meals as recommended by a nutritionist. Nutritional needs are similar to those of healthy children of the same age, gender, weight, and activity level. Daily calorie needs = 1000 + (age × 80–100). Calorie distribution: 50% carbohydrates, 20% protein, and 30% fat. Divide the daily calories into three meals (1/5, 2/5, 2/5), leaving a small portion for snacks between meals. Provide additional snacks (20g carbohydrates) or reduce insulin dosage if the child is highly active. Foods should be rich in protein and fiber, while limiting pure sugars and saturated fats. Meals should be served at fixed times and in fixed quantities, and the child should be encouraged to finish all provided food to avoid additional snacks. Record eating habits in detail. The goal of dietary control is to maintain normal weight, reduce blood glucose fluctuations, and keep blood lipids within normal limits.
2. Management of Urinary Elimination Disturbances: Polyuria and polydipsia are caused by osmotic diuresis. Record fluid intake and output accurately. Provide urinals and assist with urination for polyuric children. Wake up enuretic children at regular intervals at night. Urine glucose can cause itching in the perineal area, requiring daily cleaning twice a day. Change diapers promptly for infants. Provide sufficient fluids for polydipsic children to prevent dehydration.
3. Prevention of Infection: Due to weakened immunity, children with diabetes are prone to infections, especially skin infections. Bathe and wash the child’s hair frequently to keep the skin clean. Trim nails regularly to prevent skin scratches, punctures, or other injuries. Treat conditions like folliculitis or skin injuries promptly. Maintain proper perineal hygiene to prevent urinary tract infections. If an infection occurs, antibiotics should be administered to prevent it from worsening or triggering diabetic ketoacidosis.
4. Psychological Support and Correct Drug Administration: Diabetes requires lifelong medication, behavioral interventions, and dietary management, which can cause significant psychological stress for the child and family. Adherence to and correct execution of the treatment plan are key to success. Nurses should patiently explain diabetes-related knowledge, encourage confidence, and emphasize the importance of treatment.
- Explain the importance of strict dietary control.
- Explain the benefits of daily physical activity in lowering blood glucose levels, increasing insulin secretion, and reducing blood lipids.
- Encourage and guide the child and family to independently monitor blood and urine glucose. Teach them to use paper strips to measure peripheral blood glucose and Benedict’s reagent or test strips for urine glucose monitoring.
- Teach the correct method for drawing up and injecting insulin. Use 1ml syringes to ensure accurate dosing. Insulin preparations include regular insulin (RI), intermediate-acting protamine zinc insulin (NPH), and long-acting insulin zinc (PZI). For new cases, the dosage is 0.5–1.0 U/kg per day (mix NPH and RI in a 2:1 or 3:1 ratio, or mix RI and PZI in a 3:1 or 4:1 ratio). Administer 2/3 of the daily dose in the morning and 1/3 in the evening 15–30 minutes before meals. Check urine glucose before each meal and adjust the dose every 2–3 days until urine glucose tests show no more than ++.
- Explain the precautions for using insulin. Due to the unique clinical course of childhood diabetes, which includes acute metabolic disorders, temporary remission, intensification, and permanent diabetes, insulin dosage should be adjusted according to the disease stage.
- Avoid injecting insulin intradermally to prevent tissue necrosis. Injection sites can include the anterior thigh, abdomen, outer upper arm, or buttocks. Change the injection site at least every 1–2 cm to prevent local subcutaneous fat atrophy and hardening. Eat promptly after injection to prevent hypoglycemia. Learn to observe hypoglycemic symptoms.
- Guide regular follow-up to adjust insulin dosage.
- Educate the child to carry glucose tablets and a card with their name, address, diagnosis, dietary treatment plan, insulin dosage, hospital name, and treating physician in case of complications.
5. Nursing Care for Children with Diabetic Ketoacidosis: Diabetic ketoacidosis is a leading cause of death in acute cases. Immediate intervention is required for hyperglycemia, dehydration, electrolyte imbalance, acidosis, and infection.
- Establish two intravenous lines immediately. One is for rapid fluid administration to correct dehydration and acidosis (commonly 20ml/kg of normal saline, infused within 30 minutes to 1 hour, followed by continued fluid administration based on dehydration severity). The other line is for administering a small dose of insulin to lower blood glucose, preferably using a micro-infusion pump to ensure uniform delivery.
- During fluid administration, as acidosis is corrected and insulin and glucose are infused, potassium moves from the extracellular to intracellular space, which can lead to fatal hypokalemia. Therefore, potassium should be immediately after fluid replacement and urination.
- For severely acidotic children (pH