1 Type 1 Diabetes Mellitus
Diabetes Mellitus (DM) is a common endocrine, metabolic disorder of the childhood and adolescence. The expert committee of WHO and American Diabetes Association (ADA) classified DM as two types, Type 1 (T1DM) and Type 2. (Dutta, 2007) T1 DM results from an autoimmune process which damages the pancreatic ? cells. It leads to an absolute insulin deficiency. It occurs mainly in childhood. (Juvenile onset Diabetes/ Insulin Dependence Diabetes Mellitus/IDDM) Majority of T1 DM cases are idiopathic. Type 2 Diabetes (Non-Insulin Dependent Diabetes/ NIDDM) is in rare in childhood. It is not associated with the autoimmune process.
Etiology of T1DM may be as genetic component or environmental influence autoimmune reactions. Environmental factors are infectious disease like mumps and environmental toxins. There is an influence of the autoimmune ? cells of pancreas due to autoimmune reaction. Because of the inflammatory process, autoimmune ? cells produce abnormal Human Langerhan Antigen. This process stimulates an ongoing immune response and destroys autoimmune ? cells which secrete insulin. Insulin helps transport glucose into cells. Over 90% of the Islets in Langerhan are destroyed in this condition. The remaining cells are unable to produce sufficient insulin to maintain a normal blood glucose level (80-100 mg/dl. This results in high blood glucose level and low glucose level in the cells ( Lissauer & Clayden, 2003).
A child who presents features glucose urea, ketone urea, raised random blood glucose level > 11.1mmol/l can be diagnosed as diabetes. Fasting blood sugar or glycosylated hemoglobin can be done to confirm the condition. Diagnostic glucose tolerates test not commonly used in children. (Dutta, 2007; Lissauer & Clayden, 2003).
Management will depend on clinical presentation of patients. Patients who presented in advanced diabetes ketoasidosis need urgent treatment. Patients who do not have critical conditions can be managed at home, but intensive education programmes are essential. Education in the most important in areas of disease condition is vital. such as: insulin administration, diet planning, balance of food intake, insulin and exercise, prevent complications, blood glucose monitoring, glucose testing, treatment of hypoglycemia, make awareness of available resources, and strengthen the psychological adaptation.
The long term goals of the management of diabetes are normal growth and development, maintain normal home and school life, diabetes control with knowledge and techniques, self-care with appropriate level of parental involvement, avoidance of hypoglycemia and prevention measures of long term complications.
2.1.3 Insulin administration
An animal-derived or synthetic form of insulin used to treat diabetes. Insulin is made by recombinant DNA technology or chemical modification of pork and cows as chemically identical to human insulin. Short acting, medium acting and long acting insulin are different formulations. Insulin has three characteristics. They are onset, peak time and duration. Onset is the length of time spends to reach the blood stream and begin to start action. Peak time is the time of maximum strength of insulin action. Duration means how long action remaining in the blood stream.
Insulin administration sites are the upper arm, the anterior lateral aspect of the thigh, the buttocks and the abdomen. Subcutaneous injection route is used. Different sizes of syringes, pen like devices, insulin pump, and insulin containing cartridges are usable devices. Frequency of insulin administration differs according to insulin type and condition of the patient. Insulin is usually recommended to administer before meal.
Intensive management with frequent insulin administration results hypoglycemia. A regular review of long term complication is needed. Increase blood pressure, renal diseases, nephropathy, retinopathy are the associated are chronic complications which are needed to follow up. Effective diabetes control in childhood and adolescents reduces the risk of long term complications (DCCT / EDIC, 2005).
2.1.5 Nursing care
Nursing care focuses on making the child and parents adaptation to disease by continuing management activities effectively. Managing dietary intake, insulin, exercise, and providing emotional support and planning strategies for daily management and supporting shared responsibilities on self-care the vital nursing responsible interventions. It is vital to consider cultural factors in the care of people with diabetes. Diabetes self-care activities which are mainly focused in nursing care of diabetes should be practice in daily and lifelong. Culture influences towards the care of patients with diabetes (Tripp-Reimer et al, 2001). Culturally appropriate, community- based diabetes care leads to significant improvement in clinical diabetes care (Philis-Tsimikas et al, 2004)
World Health Organization (WHO) identified adolescence as the period in human growth and development that occurs after childhood and before adulthood, from age 10- 19. It is a critical transition period in the life span. This is the period of transition from childhood to adult. The characteristics of this period may vary across time and this period often not well understood by both adolescents and parents. Many adolescents are at risk of having depressive features due to problems and conflicts arise within families (Family Policy for Sri Lanka, 2010). Important key development experience such as movements towards independence and development of identity occur in this transition period. Adolescence is a time of transition, exploration and experimentation. Specific physical, psychological and social role changes occur during this period due to puberty and brain development. It makes strong impact of adults’ health. Empowering adolescents with knowledge and skills is important strategy to reduce risk behavior and strengthen their future life. (School and adolescents health unit, 2013)
WHO categorizes young people between 10-19 years of age as adolescents; the group of 10-14 years olds belongs to the early adolescents; the age group 15-17 years belongs to the mid adolescents; 18-19 years of age belongs to late adolescents and the all in the age 10-24 years old are in the group of young people. The adolescents accounted for 19.7% or 3.7 million of Sri Lankan in 2002. The number is expected to decrease to 3.1 million by 2021. (de Silva et al, 2002). The estimated number of adolescents in Sri Lanka is 3.8 million adolescents comprising one fifth of the population. Nearly 70% of our adolescents attend school (School and Adolescent Health Unit, 2013)
2.2.1 Physical development
The significant changes of growth development can be seen in the adolescence period. Their growth spurt begins between the ages of 9 and 15 years. Reproductive changes are the most prominent in the physical development. Acceleration in growth rate, the development of pubic hair, structural and functional changes of reproductive organs, appearance of ancillary hair and sweat gland development are several changes can be seen due to hormonal involvement of this period. Girls usually begin the growth spurt around 10. The rapid growth development is shown in 10-12 years, but decelerates after 12 years. Boys begin to rapid increase of growth at about 12.5 years old. Peak of their development reaches after the age of 14 and it declines with the age of 16. (Emerson, 2004)
2.2.2 Cognitive development
Swiss psychologist Jean Piaget proposed four stages of cognitive development: (a) sensorimotor; (b) preoperational; (c) concrete operational; (d) formal operation. Sensorimotor period and preoperational period occur the first two years of the life and 2-7 years respectively. The Concrete operations occur between the ages of 7 and 12. Children in this period can begin to think logically and hypothetically. (Emerson, 2004)
Erik Erickson suggests eight stages of human development: (a) trust vs. mistrust; (b) autonomy vs. shame and doubt; (c) initiative vs. guilt; (d) industry vs. inferiority; (e) identity vs. identity diffusion; (f) intimacy vs. isolation; (g) generosity vs. self-absorption and (h) integrity vs. despair. The children between 6 to 11 years begin to develop a sense of importance and self-worth. Peer group interactions mostly affect for the development. Ericson recognized this psychological development as “industry vs. inferiority”. Lack of adequate and effective interaction of peer groups results states of “inferior”.
From 11 years onwards described by Erickson’s development stages as “identity vs. identity diffusion”. In this period adolescents begin to develop a sense of them. They could identify different “selves” as their experience. Contribution of physical, intellectual, social development and the development of sexual impulses are mainly important for formation of an “Identity” in the adolescent period. (Emerson, 2004)