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Prior to administration
Briana was given a provisional diagnosis of type 1 diabetes. Type 1 diabetes is an autoimmune disorder, prevalent mostly at an early age, in and around puberty, although any age group can be affected. In type 1 diabetes selective destruction of the pancreatic insulin-producing β-cells occur, as the body mistakenly identifies the target cells as “non-self”. Type 1 diabetes often overlaps with other autoimmune diseases like autoimmune thyroid disease, coeliac disease, Addison’s disease and so on.
Genetic predisposition is considered to be the most potent trigger of type 1 diabetes. Several genetic regions have been identified and linked with the disease, some of which even include susceptibility to other autoimmune diseases. Person having a specific HLA (human leucocyte antigen) complex are generally more susceptible to the disease, which codes for antigen that may trigger the autoimmune response. Apart from a genetic predisposition several environmental factors may play a role in triggering the disease. Viral infections have been found to be associated with onset of the disease, among which enterovirus infections attracts most interest. Studies have shown that there is a temporal variation in the occurrence of the disease. It has a particular seasonal pattern, occurring more frequently during the cold season. However, progression of the disease requires a genetic predisposition, a precisely timed trigger and exposure to a driving antigen. Some other significant triggers associated with type 1 diabetes are childhood vaccination such as smallpox, tuberculosis and such, low levels of vitamin D and introduction of cow’s milk (Bluestone, Herold & Eisenbarth, 2010). As the patient’s mother suffers from coeliac disease, and considering the age of onset, the suspected trigger of her condition would be an underlying genetic factor.
The activated autoimmune cells against the pancreatic β-cells invade the islets and mediate their action through several cellular pathways like Fas/FasL, perforin/granzyme, reactive oxygen and nitrogen species and inflammatory cytokines. The most common antigens that are affects are glutamic acid decarboxylase, tyrosine phosphatase-like protein and insulin. Macrophages and dendritic cells are the first cells to infiltrate the islets; these recruit T-helper cells by antigen presentation which in turn secrete several inflammatory molecules such as IL-1β and INF-γ which further increases secretion of antigen presenting cells and other free radicals and cytokines that directly affect the pancreatic cells (Knip, M., & Siljander, H. (2008). Upon destruction of the β-cells, insulin production is reduced substantially and circulating glucose concentration in blood increases causing hyperglycaemia.
The abnormal presence of glucose in urine is known as Glucosuria. Due to lower levels of insulin in blood sufficient amount of glucose is not absorbed from the blood as are result of which blood glucose level increases. As a compensatory mechanism the kidneys try to remove the excess glucose, causing traces of glucose to be found in urine samples of the patient (Lytvyn et al., 2015).
The scientific term used to define the condition of increased urination is Polyuria. During the formation of urine the kidneys absorb the glucose present in blood and return it to the bloodstream through selective reabsorption. When excess glucose is found in the filtrate, as observed in diabetes, the kidney is unable to return all the glucose to the bloodstream and the osmotic pressure of the filtrate increases, causing excess water to be absorbed from blood into the filtrate and consequently producing large amounts of urine.
The condition of excessive thirst is known as polydipsia. As a result of polyuria as mentioned earlier the body suffers from increased water loss and consequently there is an increased thirst in the patient.
Polyphagia is the scientific term used to describe increased hunger and appetite in patients with diabetes. As in the absence of insulin the body is unable to use the glucose present in blood as a source of energy. As a consequence hunger and appetite increases. However, eating does not solve the problem if the diabetic condition is not managed properly.
Lack of glucose utilization causes breakdown of fats for optimum supply of energy. Ketones are produced in the Liver during fatty acid metabolism. Hence, in diabetic patients due to increased ketone production ketones are found in blood. Presence of ketone in urine is called Ketouria. Although ketones are found in blood of Briana it has not yet led to excessively high levels causing ketoacidosis.
With breakdown of fat for energy production, patients with diabetes suffer from weight loss as in case of Briana, who suffered a 5kg weight loss since her last appointment.
Medication orders are written descriptions, essential for administration of medicines to an individual in a healthcare facility. Several standard abbreviations are often used in such orders. A valid medication order must essentially contain Patient name, Medical Record Number, Date and Time when the order was written, dosage, route and frequency of administration and signature of the prescribing practitioner (Eslami, de Keizer & Abu-Hanna, 2008). For “as required’ medications the dosage frequency, maximum daily dosage and clinical criterion for administration must be provided.
Novorapid is a drug used for treatment of diabetes mellitus in adults, adolescents and children above the age of 1 year. It is an insulin analogue and has a faster mode of action and higher peak concentration when compared to regular human insulin. The action commences within 10-20 minutes and maximum effect is exerted between 1-3 hours after administration. The apparent half-life of Novorapid is less, facilitating faster elimination. Hypoglycemia is the most common side effect (Nordisk, 2016). Other side effects include redness, itching and swelling at the site of injection, vision problems, swelling around ankles and joints; allergic reaction and unconsciousness are the most adverse side effects. The maximum dosage in children is 10 units. The route of administration is in the subcutaneous layer.
The five rights of medication are the right patient, right time and frequency of administration, right dose, and right route and most importantly the right drug. As Briana is only 7 years old a short needle is required to inject the drug. The shortest needle of 4mm length would be appropriate for Briana.
Before administration of the drug the vital signs must be examined along with the patient’s prior history to allergy and possible drug interactions. The normal random blood glucose level is 11.1 mmol/L (American Diabetes Association. 2014). The last recorded blood glucose level of Briana was 26.0 mmol/L and hence the drug can be safely administered. The appetite of the patient must be assessed so that she can consume the next meal. Lastly, the potential subcutaneous areas for injection must be assessed.
During administration the area must be chosen precisely. Abdomen, thighs, buttocks and arms are the common areas for administration in children. Injecting into the same area at same time of the day must be ensured as absorption depends on the same. The needle must be injected into the subcutaneous layer and not further. It must be injected at 90 degree angle and kept in for 10 seconds.
After administration any symptoms of allergy, irritability, dizziness, behavioural changes and changes in level of consciousness is to be monitored. Other adverse side effects of the drug like hypoglycaemia must be documented for aiding later administrations.
Most importantly the patient must take food shortly after administration of the drug so that the blood glucose level does not fall to abnormal levels. Any signs of allergic reactions must be reported to the concerned practitioner and anti-allergic drugs must be administered without delay. Any abnormal vital signs must also be taken care of.
The blood glucose level of the patient must be monitored on a regular basis. The pulse and blood pressure must be monitored for any sign of hypoglycaemia. Potassium levels must be monitored to detect hypokalaemia.
Diagnosis of diabetes in children can impact the patient and their family both emotionally and physically. The child faces a wide range of emotional challenges and requires support from the parents and the family. The diagnosis often affects the whole family and parents find it hard to come to terms with the situation. Parents’ feeling of resentment or anger must not be misinterpreted by the child as being directed to them rather than the situation. Often the food habit of the entire family is affected which must be taken care of by other family members.
To care for diabetes Briana and her parents must ensure is having a balanced diet based on her unique requirements and maintain a healthy lifestyle. It might happen so that the food habit of Briana needs some drastic change but to main an optimum blood glucose level healthy eating is indispensible. She must be made aware of the consequences of unhealthy food on her condition so that she herself does not indulge in unhealthy food.
Mild intellectual disability is characterised by slower than normal comprehending abilities and other developmental skills. The IQ of mild intellectual disability falls in 50-70 range. The person does not have any difficulty maintaining a social life and there are not physical symptoms of the condition. However, abstract thinking and figurative language is not well comprehended by people who suffer from mild intellectual disability.
As in Tom’s condition, to make his understand his daughter’s condition improvised communication must be adopted. With help from his family it can be figured how to make things easily comprehendible for Tom. Simple direct sentences must be used while communication. Non-verbal communication is essentially effective in mild intellectual disability. Pictures and gestures can be used to explain the disorder in simpler manner.
American Diabetes Association. (2014). Diagnosis and classification of diabetes mellitus. Diabetes care, 37(Supplement 1), S81-S90.
Bluestone, J. A., Herold, K., & Eisenbarth, G. (2010). Genetics, pathogenesis and clinical interventions in type 1 diabetes. Nature, 464(7293), 1293.
Eslami, S., de Keizer, N. F., & Abu-Hanna, A. (2008). The impact of computerized physician medication order entry in hospitalized patients—a systematic review. International journal of medical informatics, 77(6), 365-376.
Knip, M., & Siljander, H. (2008). Autoimmune mechanisms in type 1 diabetes. Autoimmunity reviews, 7(7), 550-557.
Lytvyn, Y., Škrti?, M., Yang, G. K., Yip, P. M., Perkins, B. A., & Cherney, D. Z. (2015). Glycosuria-mediated urinary uric acid excretion in patients with uncomplicated type 1 diabetes mellitus. American Journal of Physiology-Renal Physiology, 308(2), F77-F83.
Nordisk, N. (2016). NovoRapid®(insulin aspart): Summary of Product Characteristics [article online].
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