Registered Nurse Case Study: Caring for Sarah Burns with T1D

This case study focuses on the nursing care of Sarah Burns, a 5-year-old diagnosed with Type 1 Diabetes (T1D). The assignment details Sarah's medical history, social background, and emergency department review, including her symptoms of increased appetite, excessive thirst, fatigue, weight loss, and frequent urination. The solution addresses insulin administration (NovoRapid), including its onset, peak, and duration of action, emphasizing the importance of timing injections with meals to avoid hypoglycemia. It covers hypoglycemia, its causes, symptoms, and treatment. The appropriate insulin pen needle length and injection angle are discussed, considering Sarah's age and weight. The importance of blood glucose level (BGL) testing before and after insulin administration is highlighted. Potential physical and emotional challenges Sarah may face are also explored, including limitations on physical activity and psychological impacts like anxiety and fear. The case study provides a comprehensive overview of managing T1D in a young child, emphasizing the role of a registered nurse in providing holistic care. This document is a valuable resource for students on Desklib, offering insights into diabetes management and nursing practice.

Answer 1
Sarah was diagnosed with Type 1 Diabetes (T1D) in which the insulin producing cells in the
pancreas are destroyed by CD4+ and CD8+ T cells and macrophages infiltrating the islets.
The autoimmune destruction of pancreatic beta-cells, leads to a deficiency of insulin
secretion. In addition to the loss of insulin secretion, the function of pancreatic α-cells is also
abnormal and there is excessive secretion of glucagons in T1DM patients. In patients with
T1DM, glucagons secretion is not suppressed by hyperglycemia. The resultant
inappropriately elevated glucagons levels exacerbate the metabolic defects due to insulin
deficiency (Baynest, 2015). So, to reverse these metabolic derangements occurring in the
body of Sarah because of deficiency of insulin, insulin is prescribed to Sarah. In Sarah’s
body, insulin will begin acting by joining with a glycoprotein receptor on the cell surface.
The alpha subunit of the receptor which binds the hormone while the beta-subunit is a
tyrosine-specific protein kinase. When this kinase is activated, a signal is generated which
ultimately leads to action of insulin on glucose, lipid, and protein metabolism.
Answer 2
a) The onset of action of NovoRapid occurs within 10-20 minutes of subcutaneous
injection. The peak effect is exerted between 1 and 3 hours after injection. The
duration of action is 3 to 5 hours (Bullock & Manias, 2017).
b) Since NovoRapid is a fast acting insulin with a shorter duration of action, it should be
given immediately prior to a meal so that complications such as hypoglycaemia can
be avoided.
Answer 3
a) Hypoglycemia is a condition in which the blood glucose level of a human reaches below 4
mmol/L (72mg/dL).
b) Causes of hypoglycemia in people without diabetes include certain medications such as
quinine, excessive alcohol intake, critical illnesses like severe hepatitis, anorexia nervosa,
tumor of the pancreas and hormonal deficiencies. Causes of hypoglycemia in people with
diabetes overdose or diabetes medications like insulin, less intake of food or excessive
exercise.
c) Common symptoms of hypoglycemia are sweating, dizziness, fatigue, irritability, pale
skin, hunger, weakness, increased heart rate and confusion. If hypoglycemia is severe, the
symptoms may include blurred vision, loss of consciousness and convulsions.
d) Treatment of hypoglycemia includes immediate initial treatment to raise the blood sugar
level and management of the underlying condition that led to hypoglycemia to prevent its
recurrence. Hypoglycemia can be immediately treated by consuming 15-20g of fast acting
carbohydrate such as glucose tablets, sweets, sugary fizzy drinks or fruit juice.
Answer 4
a) The most suitable insulin pen needle length for Sarah is 4mm.

b) This length is appropriate because she is young and lean and to ensure that the injection is
not inserted intramuscularly instead of subcutaneously, it is the best to use 4mm needle
(Presti, et al., 2012). It is established that 4-mm needle is long enough to penetrate the skin
but sufficiently short to avoid reaching muscle (Hirsch, et al., 2010). Another technique
which can be used for Sarah considering her loss of weight raising her skin and then injecting
the insulin.
Answer 5
Sarah needs a BGL test prior to an insulin injection. Blood glucose level may vary
unpredictably even after a strict schedule, so careful monitoring is essential. BGL test is
essential particularly prior to insulin injection because NovoRapid is a fast acting insulin and
if Sarah’s glucose levels are already low then after insulin shot, it may lower drastically
which may lead to complications such as hypoglycaemia. BGL alters in response to food,
stress, activity, etc. and since Sarah is only 5 years old, she cannot account for these factors
on her own, therefore, it is essential to test her BGL prior to insulin injections.
Answer 6
a) NovoRapid insulin is given subcutaneously, that is under the skin. Sarah can be given
insulin in front of her waist (abdomen), the upper arm or the front of her thighs. And the site
of the injection must be rotated within the particular area of skin that that is used with each
injection. Rotation of site will lower the risk of development of lumps or skin pitting.
b) The appropriate injection angle for Sarah is 45 degrees.
c) 45 degrees angle is appropriate for Sarah as she has lost weight and became lean so when a
4mm needle is tilted to 45 degrees it can be ensured that the insulin is given subcutaneously
and not intramuscularly (Hofman, et al., 2010).
Answer 7
a) Sarah’s BGL need to be tested 2 hours after administration of NovoRapid
b) A BGL is required after 2 hours to monitor that insulin level is working in corresponds
with meals and next dose can be given as per the schedule.
Answer 8
Sarah may experience certain physical challenges on daily basis on living with T1D primarily
due to low blood glucose and self-care activities (Freeborn, et al., 2013). Young children
have unpredictable physical activity patterns and Sarah’s parents may restrict her physical
activities because of fear of hypoglycaemia or alternatively may not suitably modify her T1D
management in response to physical activity (Yardley, et al., 2013). Study has also revealed
that young children with T1D were less active overall, and participated in physical activity
for less time than normal young children (Sundberg, et al., 2012). So, it is likely that Sarah
will be less active.
Answer 9

Sarah may experience certain emotional impacts living with T1D including shock, denial,
anger, sadness, fear and guilt. She may be anxious about her condition. She may develop fear
of needles. She may also develop a feeling of overwhelm or frustration by the various tasks
included in her daily routine such as insulin shots, glucose monitoring, clinical visits, dietary
restrictions, etc. On having a different routine or having to do certain tasks which her peers
are not doing, she may develop of being ‘different’. A study has found that that young
children with T1D are at heightened risk for psychological disorders like anxiety or
depression (Zenlea, et al., 2013).
References
Baynest, H. W. (2015). Classification, Pathophysiology, Diagnosis and Management of
Diabetes. Journal of Diabetes and Metabolism, 6(5). doi:10.4172/2155-6156.1000541
Bullock, S., & Manias, E. (2017). Fundamentals of Pharmacology (8 ed.). Pearson.
Freeborn, Dyches, Roper, & Mandleco. (2013). Identifying challenges of living with type 1
diabetes: child and youth perspectives. J Clin Nurs, 22(13-14), 1890-98.
Hirsch, Klaff, & Bailey. (2010). Comparative glycemic control, safety and patient ratings for
a new 4 mm\32G insulin pen needle in adults with diabetes. Curr Med Res Opin, 26,
1531-41.
Hofman, Derraik, & into. (2010). Defining the ideal injection techniques when using 5-mm
needles in children and adults. Diabetes Care. Diabetes Care, 33(9), 1940-4.
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Presti, L., Ingegnosi, & Strauss. (2012). Skin and subcutaneous thickness at injecting sites in
children with diabetes: ultrasound findings and recommendations for giving injection.
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Sundberg, Forsander, Fasth, & Ekelund. (2012). Children younger than 7 years with type 1
diabetes are less physically active than healthy controls. Acta Paediatr, 101(11),
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Yardley, Mollard, Macintosh, Macmillan, Wicklow, & Berard. (2013). Vigorous intensity
exercise for glycemic control in patients with type 1 diabetes. Can J Diabetes, 37(6),
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Zenlea, Mednick, Rein, Quinn, Wolfsdorf, & Rhodes. (2013). Routine behavioral and mental
health screening in young children with type 1 diabetes mellitus. Pediatr Diabetes.
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