Question:Reflect: Diabetes in Children

Case Study

Tony Chadwick is a 16-year-old African American male admitted to ICU from the urgent care with newly diagnosed type 1 DM with DKA. His mother took him to the local urgent care with a 2-day history of vomiting and abdominal pain. Tony also complained of thirst, blurry vision, and fatigue. His mother smelled a fruity odor on his breath this morning. The nurse at the urgent care clinic found that Tony had a blood glucose level of 520 mg/dL and urine positive for ketones. Tony was immediately transferred to the local hospital, where he was admitted to ICU. He is in the 11th grade and was doing well in school until about 2 weeks ago, when he started to become easily fatigued and irritable. His mother thought that he was just staying up too late and not getting enough sleep. Tony has been well except for an upper respiratory viral infection about 2 months ago that kept him home from school for 3 days.

On arrival in the ICU, Tony is drowsy but wakes to verbal stimuli. He complains of nausea and is vomiting green-colored bile in small amounts. He complains of abdominal pain and a need to urinate.

His mother accompanies him and expresses fear that he will not survive this acute episode. She was told at the urgent care clinic that Tony has diabetes but she does not believe it. She says no one in her family or her husband's has diabetes.

Lab Results:

• AIC 12%
• Anion gap 20
• ABGs pH 7.22
• pCO2 21
• Bicarb 18
• Electrolytes are pending.
• Chest x-ray is negative.

Physical Assessment:

• Vital signs: T 99.5°F orally; P 120 bpm, thready; R 28/min, deep and labored; BP 90/60 mmHg
• Neuro: As above
• Resp: Lungs clear to auscultation
• CVS: All pulses palpable with radial pulses thready. HS are S1, S2.
• Skin: Cool and clammy but skin turgor poor
• GI: Diminished bowel sounds in all quadrants
• GU: Has not voided
• An IV is started and 0.9% NaCl is infusing. An insulin drip is started per protocol. Tony is connected to a cardiac monitor and exhibits sinus tachycardia. A Foley catheter is inserted and connected to an hourly drainage chamber (for hourly urine output measurement).

Question 1

Tony is a 16-year-old male who is involved in sports. What are some of the fears and anxieties that he may have as he resumes his normal life? How can the nurse help Tony deal with these issues?

Question 2

At the urgent care clinic, Tony's mother said this couldn't be diabetes because no one in the family has ever had it. What could the nurse tell Tony's mother to help her understand the disease and its etiology?

Question 3

Discuss the electrolyte imbalance and blood gas results that occurred on the first day of Tony's admission. How do his vital signs reflect the pathophysiology of DKA?

Answer 3

On the first day of Tony's admission his laboratory values were:

• AIC 12%
• Anion gap 20
• ABGs pH 7.22
• pCO2 21
• Bicarbonate 18

The hemoglobin A1C result is a reflection of blood glucose levels over the previous months. Red blood cells change every 120 days, so Tony has had elevated blood glucose levels for quite some time. The anion gap is a relationship between sodium, chloride, and bicarbonate, specifically sodium level - (chloride level - bicarbonate level). Because Tony's electrolyte values are pending, the anion gap of 20 would indicate that the chloride level and bicarbonate levels are low. A normal anion gap is between 12 + or - 4. The pH is 7.22, which is consistent with acidosis. The partial carbon dioxide level of 21 is the body's attempt to correct the acidosis. The bicarbonate level of 18 is also the body's attempt to correct the acidosis.

Tony's vital signs were: T 99.5°F orally; P 120 bpm, thready; R 28/min, deep and labored; BP 90/60 mmHg.

An elevated temperature could be from a fluid volume deficit or an infection. The rapid and thready heart rate is because of dehydration. The respiratory rate of 28 with deep labored respirations is the body's attempt to remove the excess carbon dioxide in the blood to help correct the acidosis. The blood pressure of 90/60 mmHg is because of dehydration.

Question 4

Tony is concerned about being embarrassed when he has to check his blood sugar and take his insulin at school. What interventions could the nurse suggest to help him with privacy?

Question 5

Tony admits to drinking alcohol occasionally. What should the nurse teach Tony about alcohol use and diabetes?

Question 6

List and explain at least four nursing diagnoses for Tony.