This document provides information on type 1 diabetes mellitus (juvenile diabetes). It discusses that type 1 diabetes results from the body's failure to produce insulin due to the destruction of beta cells. It is treated through insulin therapy, nutritional modification, glucose monitoring, and physical activity. The nurse's role includes educating patients and families on diabetes management and monitoring for complications like hypoglycemia and hyperglycemia.

1. JUVENILE DIABETES
MELLITUS
V I J I V S
L E C T U R E R
K I M S C O L L E G E O F N U R S I N G

2. ANATOMY & PHYSIOLOGY OF PANCREAS

4. INTRODUCTION
• Diabetes mellitus is a group of metabolic disease
characterized by chronic hyperglycaemia resulting from
defects in insulin secretion, insulin action or both.
• The abnormalities in carbohydrate, fat and protein
metabolism that are found in diabetes are due to deficient
action of insulin on target tissue.

5. CLASSIFICATION
Type I diabetes mellitus or insulin dependent DM:
• Due to β-cell destruction, usually leading to absolute insulin
deficiency.
• It can be immune mediated or idiopathic.
Type 2 diabetes mellitus or non-insulin dependent DM:
• It may range from predominantly insulin resistance with
relative insulin deficiency to a predominantly secretory
defect with or without insulin resistance.

6. Other specific types of DM:
• Genetic defects of β-cell function or insulin action, disease of
the exocrine pancreas, drug induced or chemical induced or
endocrinopathies.
Gestational diabetes:
• Occurs during pregnancy.

7. TYPE I DIABETES
MELLITUS
OR
JUVENILE DIBETES
MELLITUS

8. DEFINITION
• It is a condition which results when pancreas is unable to
produce and secret insulin and depends on exogenous insulin
to prevent ketosis and preserve life.
ETIOLOGY
• Genetic factors- polymorphisms in HLA complex account for
most genetic risk factor.
• Environmental factors- virus, bovine milk protein and nitrosuria
compound.

9. • Autoimmune factors- Hashimoto thyroiditis, Addison’s disease,
Pernicious anemias.
PATHOPHYSIOLOGY
Insulin is responsible for uptake, use and
storage of glucose, amino acids and fat.
In deficiency of insulin production decreased
glucose uptake and storage as glycogen and
excessive breakdown of fat and glucose from
glycogen

10. Starvation of cells and accumulation of
glucose and fat in the blood, in the form of
free fatty acids and ketone bodies.
Concentration of glucose in the blood
Fluid shift from intracellular to extracellular
spaces and kidney.
When blood glucose approaches renal
threshold kidney fails to reabsorb all
glucose
Through osmotic diuresis glucose is
spilled into urine along with excessive
urination to dilute concentrated glucose
Polyurea dehydration & thirst
Cellular starvation hunger & excessive
eating
Free fatty acids are
converted by liver to
ketone bodies
Diabetic
Ketoacidosis

11. CLINICAL MANIFESTATIONS
• 3 ‘P’s- Polyurea, Polydipsia, Polyphagia
• Weight loss, fatigue, and blurred vision.
• Signs of diabetic ketoacidosis: nausea, vomiting, abdominal pain, acetone
odour of breath, dehydration, lethargy, Kussmaul respiration and coma
DIAGNOSIS
As per National Diabetes Data Group and WHO, the diagnosis criteria is:
Symptoms of diabetes plus random plasma glucose concentration =11.1
mmol/L(200mg/dL)

12. • Fasting plasma glucose= 7.0mmol/L(126mg/L)
• 2 hour post load glucose=11.1 mmol/L(200mg/L) during an OGTT
MANAGEMENT
The goal of treatment are:
To control hyperglycaemia
To facilitate adequate growth
To maintain age appropriate lifestyle
To prevent acute complications

13. Treatment for Juvenile Diabetes
Management
Insulin
therapy
Physical
activity
Glucose
monitorin
g
Nutritional
modificatio
n

14. INSULIN THERAPY
• The choice of insulin types and schedule of injections is determined by
child’s age, body weight and pubertal status.
• 2 types of insulin therapy
Conventional therapy- most commonly used
1-2 daily insulin injections
Total daily dose is divided into 2/3 pre breakfast and ½ pre-dinner
Intensive therapy- 3 times daily by multiple insulin injections(MDI) or pen,
or an external pump.

15. Total daily dose is divided as follows.
Basal dose- 25-30% of the total dose in toddlers and 40-
50% in older children, given at bedtime. This suppresses the
glucose production between meals and overnight.
Bolus doses- remaining dose is divided into 3 pre-meal
doses. The meal time (prandial) doses limit post prandial
hyperglycaemia.

16. Types of insulin
Short acting – Human Regular, Lispro, Aspart
Intermediate acting- NPH, NPL, Lente, Ultra Lente
long acting insulin- Glargine, Detemir
Locations
Subcutaneous tissue of upper arm
Anterior and lateral aspects of the thigh, buttocks, abdomen

17. Newer techniques of Insulin Administration

19. HOW TO ADMINISTER INSULIN INJECTION

20. Points to be remember while insulin administer
• Rotating with one area recommended. Eg rotation injections
systematically within the abdomen rather than rotating to a different
area with each injections.
• Can give all shots in the same parts for a week. Eg arm area for a week
and then leg sites for a week .
• An amount of air equal to the dose of insulin required is drawn and
injected into the vial to avoid creating a vacuum.

21. Nutritional Modification
• Simple sugars should be avoided.
• Low glycaemic index and fibres are recommended.
• Saturated and trans fat should be limited.
• Timing of meals are adjusted with insulin intake.
Physical activity
• Exercise enhances the action of insulin in reducing the blood glucose
level
• Recommended activities- walking, jogging, swimming & organized sports
• Avoid exercise during peak time of insulin action

22. Blood glucose monitoring
Self monitoring of blood glucose is recommended before meals and
before bedtime.
Results should be recorded in a diary.
Glycosylated haemoglobin also monitored at regular intervals.
Complications of Diabetes
Acute- diabetic ketoacidosis and hypoglycaemia
Intermediate- lipoatrophy, limited joint mobility, growth failure and
delayed sexual maturation.
Chronic- retinopathy, peripheral neuropathy, nephropathy and

23. NURSING MANAGEMENT
• Nursing assessment
• Monitor blood glucose level, HbA1C level
• Assess for signs of hyperglycaemia and hypoglycaemia
ROLE OF NURSE
The primary focus of diabetes care is on education on everyday aspect of
diabetes management.
The nurse should educate the patient and family about insulin
administration, utilization of monitoring information, diet management,
exercise and sick day guideline and recognizing early signs of

24. SICK DAY GUIDELINES
 Monitor blood glucose and ketone 4 hourly
 Do not omit insulin even if oral intake is less
 If blood glucose >250mg/dL 10% of daily insulin requirement should be
given as plain insulin in addition to usual insulin
 In children with recurrent vomiting or diarrhoea the insulin dose may be
reduced by 20-30%
 Bring to hospital if there is altered sensorium, rapid breathing, decreased
urine output or persistent ketosis.
The nurse should work closely with the educator, dietician, psychologist and
social worker.

25. Nursing Diagnosis
Imbalanced blood glucose level related to lack of insulin production with
associated insulin resistance as evidenced by random blood glucose
>200g/dL.
Imbalance nutrition less than body requirement related to insulin deficit
Risk for injury related to hypoglycaemia or hyperglycemia
Deficient knowledge related to unfamiliarity of the treatment plan
Ineffective family coping related to chronic illness.

26. COMPLICATIONS
• Nonketotic hyperosmolar sate
• Cerebral oedema
• Hypoglycaemia
• Lipoatrophy
• Growth failure
• Limited joint mobility
• Delay in sexual maturation
Chronic complications
• Retinopathy
• Nephropathy
• Peripheral neuropathy

27. NURSING INTERVENTIONS
Maintaining glucose level
• Monitor blood glucose level pre meal and before bed time
• Administer insulin as prescribed
• Follow the insulin regimen as ordered
• Store insulin in a cool dry place, do not heat or freeze
• Rotate insulin site daily
Maintaining Nutrition
• Balance the meal and snacks with insulin injection
• Provide low fat, low glycemic index and high fibre food

28. • Identify favourite foods of child and incorporate in the meal
• Provide three meals and two or 3 snacks
• Monitor daily weight
Preventing Injury
• Teach family to recognize the signs and symptoms of hypoglycemia and
hyperglycemia
• Treat hypoglycemia promptly with 15g of easily digested carbohydrate
• Advice to adhere to the treatment regimen
• Teach strategies to prevent hypoglycemia such as avoiding missed or
delayed meal, excess insulin or excessive exercise

29. Health education
• Teach the child to self administer insulin as per directions
• Take return demonstration of insulin injection
• Advice regarding menu planning as per insulin need
• Reinforce the need for regular followup
Promoting family coping
• Encourage to express their concerns for their child
• Provide explanations for the treatment
• Identify community service support available for the family
• Allow the child and family to meet other children with diabetes
• Involve parents in the child care

30. THANK YOU