لخّصلي

This case study details the diagnosis and management of 10-year-old Emma Mason's newly diagnosed type 1 diabetes mellitus (T1DM). Admitted with acute hyperglycemia (724 mg/dL) after fainting at softball practice, Emma exhibited classic symptoms: polyuria, polydipsia, and recent weight loss (from 82 lbs to 69 lbs). Laboratory results confirmed T1DM, showing elevated HbA1c (14.6%), positive GAD65 and IA-2 antibodies, and low C-peptide. Treatment involved intravenous insulin, electrolyte correction, and dietary management. The case study analyzes Emma's medical history, physical examination, laboratory data, and insulin regimen. It also explores the pathophysiology of T1DM, the metabolic events leading to her symptoms, and the management of DKA (although Emma was not in DKA on admission). The case concludes with questions focusing on nutrition therapy, including calculating energy and protein requirements, developing a nutrition care plan with appropriate carbohydrate counting, adjusting insulin doses based on blood glucose levels (using ICR and the 1800 rule), and evaluating Emma’s progress at a follow-up visit, considering her exercise regimen and potential for hypoglycemia. Her family history is notable for hypertension, hyperthyroidism, and celiac disease in relatives.

159
Case 14
Pediatric Type 1 Diabetes Mellitus
Emma Mason is a 10-year-old 5th grader previously in good health who is admitted through the ED
with a new diagnosis of acute hyperglycemia—R/O diabetes mellitus.
Objectives
After completing this case, the student will be
able to:

1. Describe the pathophysiology of type 1
   
   diabetes mellitus.


2. Interpret laboratory parameters to assess
   fluid, electrolyte, and acid-base balance.


3. Integrate an insulin regimen with nutrition
   therapy and provide appropriate recommen-
   dations for carbohydrate-to-insulin ratios
   and correction dosages.


4. Prioritize teaching and educational require-
   ments for a child and family with newly
   diagnosed type 1 diabetes.


5. Develop a nutrition care plan—with appro-
   priate measurable goals, interventions, and
   strategies for monitoring and evaluation—
   that addresses the nutrition diagnoses for
   this case.
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   160 Unit Six Nutrition Therapy for Endocrine Disorders
   Patient Summary: Emma Mason is a 10-year-old female admitted with acute-
   onset hyperglycemia.
   History:
   Onset of disease: Patient presented to ED after fainting at softball practice.
   
   During ED assessment, patient was noted to have serum glucose of 724 mg/dL.
   Medical history: None—recently had strep throat
   Surgical history: None
   Medications at home: None
   Tobacco use: Nonsmoker
   Alcohol use: None
   Family history: Father—HTN; mother—hyperthyroidism; sister—celiac disease
   Demographics:
   Marital status: N/A (5th-grade female)
   Years education: 5 years
   Language: English only
   Occupation: Student
   Hours of work: N/A
   Household members: Mother, father, sister age 8, and brother age 4
   Ethnicity: Caucasian
   Religious affiliation: Lutheran
   Admitting History/Physical:
   Chief complaint: “I had strep throat a few days ago. I felt like I was well enough to go to softball
   practice today but after playing about 15 minutes, I just felt horrible. I sat down and they tell me I
   fainted. . . . I have been really thirsty—thirstier than I have ever been in my whole life and then I
   have had to use the bathroom a lot. . . . I even have to get up at night to go to the bathroom.”
   General appearance: Slim, distressed, 10-year-old female
   Vital Signs: Temp: 98.6°F Pulse: 101 Resp rate: 22
   BP: 122/77 Height: 53" Weight: 69 lbs
   (weight at appointment
   
   7 days previous: 71 lbs;
   weight 3 months previous: 82 lbs)
   Heart: Regular rate and rhythm
   HEENT: Head: WNL
   Eyes: PERRLA
   Ears: clear
   Nose: clear
   Throat: dry mucous membranes without exudates or lesions
   iS
   to
   ck
   .c
   om
   /lo
   co
   75
   Mason, Emma, Female, 10 y.o.
   Allergies: NKA Code: FULL Isolation: None
   Pt. Location: RM 744 Physician: M. Cho Admit Date: 5/3
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   Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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   Case 14 Pediatric Type 1 Diabetes Mellitus 161
   Genitalia: Deferred
   Neurologic: Alert but slightly confused. Glasgow Coma Scale: 15.
   Extremities: Noncontributory
   Skin: Cool, clammy
   Chest/lungs: Respirations are rapid—clear to auscultation and percussion
   Peripheral vascular: Pulse 41 bilaterally, no edema
   Abdomen: Active bowel sounds ×4; tender, nondistended
   Orders:


6. Regular insulin 1 unit/mL NS 40 mEq KCl/liter @ 108 mL/hr. Begin infusion at 0.1 unit/kg/hr =
   3.7 units/hr. Begin dextrose when glucose is 100 mg/
   dL per hour.


7. Labs: BMP Stat
   Phos Stat
   Calcium Stat
   UA with culture if indicated Stat Clean catch
   Bedside glucose Stat
   Bedside I-Stat: EG7 Stat
   GAD 65
   IA-2
   Thyroid peroxidase antibodies
   TSH
   Comp metabolic panel (CMP)
   Thyroglobulin antibodies
   C-peptide
   Hemoglobin A1c
   TTG-IgA


8. NPO except for ice chips and medications. After 12 hours, clear liquids if stable. Then, advance to
   consistent carbohydrate diet order.


9. Consult diabetes education team for self-management training for patient and parents to begin
   education after stabilized.
   Nursing Assessment 5/4
   Abdominal appearance (concave, flat, rounded, obese, distended) flat
   Palpation of abdomen (soft, rigid, firm, masses, tense) soft
   Bowel function (continent, incontinent, flatulence, no stool) continent
   Bowel sounds (P=present, AB=absent, hypo, hyper)
   Mason, Emma, Female, 10 y.o.
   Allergies: NKA Code: FULL Isolation: None
   Pt. Location: RM 744 Physician: M. Cho Admit Date: 5/3
   (Continued)
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   Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
   Copyright 2022 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203
   162 Unit Six Nutrition Therapy for Endocrine Disorders
   Mason, Emma, Female, 10 y.o.
   Allergies: NKA Code: FULL Isolation: None
   Pt. Location: RM 744 Physician: M. Cho Admit Date: 5/3
   Nursing Assessment 5/4
   RUQ P
   LUQ P
   RLQ P
   LLQ P
   Stool color light brown
   Stool consistency soft
   Tubes/ostomies NA
   Genitourinary
   Urinary continence yes
   Urine source clean specimen
   Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, blue,
   tea)
   cloudy, amber
   Integumentary
   Skin color pale
   Skin temperature (DI=diaphoretic, W=warm, dry, CL=cool, CLM=clammy,
   CD+=cold, M=moist, H=hot)
   DI, CLM
   Skin turgor (good, fair, poor, TENT=tenting) fair
   Skin condition (intact, EC=ecchymosis, A=abrasions, P=petechiae,
   R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated, T=tears,
   SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis)
   intact
   Mucous membranes (intact, EC=ecchymosis, A=abrasions, P=petechiae,
   R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated, T=tears,
   SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis)
   intact
   Other components of Braden score: special bed, sensory pressure, mois-
   ture, activity, friction/shear (>18 = no risk, 15–16 = low risk, 13–14 = moder-
   ate risk, ≤12 = high risk)
   21
   Nutrition:
   Meal type: NPO then progress to clear liquids and then regular diet with carb counts. Fluid require-
   ment: 1730 mL
   History: Parents present—patient states that she thinks she has lost weight recently: “My clothes
   are a little baggy, but I don’t usually weigh myself.” Patient’s mother states that the last weight she
   remembers was when they went to urgent-care clinic for strep throat and that she weighed about
   71 lbs. Mother states that appetite has been normal—if anything patient states she has been more
   hungry than usual—but thought it was probably due to starting soccer season and exercising more.
   Relates history of increased thirst and increased urination.
   Nursing Assessment (Continued)
   Copyright 2022 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
   Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
   Copyright 2022 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203
   Case 14 Pediatric Type 1 Diabetes Mellitus 163
   Mason, Emma, Female, 10 y.o.
   Allergies: NKA Code: FULL Isolation: None
   Pt. Location: RM 744 Physician: M. Cho Admit Date: 5/3
   Usual intake (for past several months): Mom and Dad state that Emma is kind of a picky eater
   
   in that she tries to eat only “healthy” food. She eats only chicken and fish—eats salad, broccoli,
   
   carrots, tomatoes, and asparagus as her only vegetables. Breakfast—cereal and milk or whole-
   wheat bagel with milk; packs lunch for school—peanut butter and jelly or turkey and cheese sand-
   wich; carrots, apple, or grapes; and usually drinks water. Has a cereal or granola bar before softball
   
   practice—drinks water throughout practice. Dinner is usually prepared by both Mom and Dad—
   always some salad and meat with pasta, potato, or rice. They do order in or eat out 1–2 × per week.
   This is usually pizza, Mexican, or Asian foods. Snacks include cereal, ice cream, yogurt, some fruits
   (apples, bananas), popcorn, chips, or cookies.
   MD Progress Note:
   5/5 0820
   Subjective: Emma Mason’s previous 24 hours reviewed
   Vitals: Temp: 99.5°F, Pulse: 82, Resp rate: 25, BP: 101/78
   Urine Output: 2660 mL (71.8 mL/kg)
   Physical Exam
   General: Alert and oriented to person, place, and time
   HEENT: WNL
   Neck: WNL
   Heart: WNL
   Lungs: Clear to auscultation
   Abdomen: Active bowel sounds
   Assessment/Plan: Results: GAD65 AB, IA-2 AB consistent with type 1 DM. Negative TTG.
   Dx: New diagnosis type 1 diabetes mellitus
   Plan: Change IVF to D5.45NS with 40MEq K @ 108 mL/hr. Begin Lispro 0.5 u every 2 hours until
   glucose is 150–200 mg/dL. Tonight, begin glargine 6 u at 9 pm. Progress Lispro using ICR 1:30.
   Continue bedside glucose checks hourly. Notify MD if blood glucose >200 or 60 98 113
   Glucose, 10–14 y.o. (mg/dL) 70–99 683 ! 250 !
   Phosphate, inorganic, 10–14 y.o.
   (mg/dL)
   2.2–4.6 1.9 ! 2.1 !
   Magnesium, 10–14 y.o. (mg/dL) 1.6–2.6 1.7 2.0
   Calcium, 10–14 y.o. (mg/dL) 8.6–10.5 10 9.8
   Anion gap (mmol/L) 10–20 4.0 ! 9.0 !
   Osmolality, 10–14 y.o.
   
   (mmol/kg/H2O)
   275–295 295.3 ! 280
   Bilirubin total, 10–14 y.o. (mg/dL) ≤1.2 0.8
   Bilirubin, direct, 10–14 y.o. (mg/dL)