Diabetes
Diabetes is a chronic disease caused by the body s failure to produce enough insulin or inability to properly use insulin. Insulin is a hormone that is continuously required for the cells to convert sugars, starches and other foods into energy to sustain life. Insulin acts like a key to unlock the cell so that food can enter it. Without insulin, the sugars and starches cannot get into the cell where they can be used, so they build up in the bloodstream. This build-up, commonly known as high blood sugar, will cause death if untreated.

Types of Diabetes
There are two main types, or classifications, of diabetes:

• Type I diabetes is an auto-immune disease in which the body destroys the insulin-producing cells of the pancreas. Type I diabetes is also called "immune-mediated" or "insulin-dependent" diabetes. Peak incidence of Type I diabetes occurs during puberty (around ten to twelve years for girls and twelve to fourteen years for boys). Signs and symptoms of Type I diabetes include:
  • may mimic the flu (in children)
  • frequent urination (elevated sugar level in the blood causes the body to produce and excrete more fluid to maintain its normal balance)
  • unusual thirst (resulting from frequent urination and high blood concentrate)
  • extreme hunger (food taken into the body cannot get into the cells where it is used)
  • unusual weight loss (since the food taken into the body is not used by the body)
  • extreme fatigue (body cannot use food to produce energy)
• Type 2 diabetes is a metabolic disorder in which the body cannot make enough or properly use insulin. Type 2 diabetes is also called "non-insulin dependent" diabetes. This form of diabetes is the most common, accounting for 90 to 95 percent of diabetes. Type 2 diabetes generally develops in individuals over age 45. Signs and symptoms of Type 2 diabetes include:
  • any of the Type 1 symptoms
  • frequent infections (compromised immune system)
  • blurred vision (nerve and blood vessel damage in the eyes)
  • cuts/bruises that are slow to heal (poor circulation from nerve and vessel damage)
  • tingling, numbness in the hands or feet (nerve and vessel damage)

Causes of Diabetes
The cause for diabetes is not clear, but seems to include both genetic and environmental factors, since diabetes can be inherited and is also associated with obesity and sedentary lifestyle. There is at present no cure for diabetes, so some form of insulin must be taken into the body on a daily basis. Diabetes is the sixth leading cause of death in the United States. If not managed properly or if severe, diabetes can also produce other complications such as blindness; kidney disease; nerve disease, resulting in amputation of limbs; heart disease; and stroke.

Managing Diabetes
Management of Type I diabetes involves injection of a form of insulin at least once daily. There are various types of insulin-some insulin reacts immediately upon injection and some types have a prolonged action time. Insulin must be injected by needle-it cannot be taken by mouth because the gastric juices would destroy it. Diet and exercise are important in managing this type of diabetes in terms of reducing or regulating the body s insulin requirement.

Management of Type 2 diabetes can often be accomplished by control of diet and exercise alone.

Problems managing diabetes can occur from two basic sources. If more insulin is taken in than food, or if more food is used through excess exercise, then a hypoglycemic reaction may occur. In hypoglycemia, the blood sugar level drops, creating an emergency to which the body responds by releasing adrenaline in an attempt to cause the body to produce more glucose. The adrenaline release causes shakiness, rapid heart rate, paleness, confusion, inappropriate emotional responses such as anger, laughing, crying, or wanting to go off alone. Symptoms may include headache, sudden hunger.

People with diabetes and those around them must be aware that these signs and symptoms are related to low blood sugar levels and that a simple sugar (cola, candy) is rapidly needed to boost the blood sugar level, followed by a snack or meal or medical attention, if required.

The second problem in managing diabetes is getting enough insulin to handle the food that is eaten, so the blood sugar level will not be too high. If the blood sugar level is too high over a period of time, complications such as nerve and blood vessel damage can occur, leading to eventual blindness or amputation. If the blood sugar level climbs suddenly to an abnormally high level, the result can be coma and death as the sugar level builds in the blood and cannot be used by the cell.

The key to managing diabetes is to maintain a correct and constant balance between diet, exercise and insulin levels. In addition to regulating the type and amount of food, exercise and insulin received daily, blood sugar and urine samples are taken daily to determine the level of balance and whether adjustments in diet, exercise or insulin type and amount are needed.

Diabetes and Adolescence

• Erratic physical growth may make insulin requirements difficult to determine.
• Concern about being "different" may make dealing with diabetes more challenging.
• Influence of peers may influence diet and activity patterns-either positively or adversely.
• Rebellious nature may result in non-compliance with diabetes management routine.
• Management of diabetes may enhance self-esteem.

Asthma
Asthma, a respiratory disease characterized by inflammation of the airways, is the most common chronic illness in children. A person with asthma is overly sensitive to certain environment stimuli, which can "trigger" an "attack" or episode of asthma at any time. Asthma attacks may be triggered by the body s release of histamine and other chemicals in response to allergen(s). Attacks can also be triggered by infections and by psychological or physiological stress.

Asthma Triggers
Things that trigger an asthma attack vary from person to person. Some common triggers include:

• allergens such as pollen, mold, certain foods or drugs
• viral infections
• tobacco smoke, paint odors, hair sprays, perfumes
• weather changes, cold air, cold water
• exercise that causes breathlessness
• emotional factors
• physiological factors such as gastro-esophageal reflux
• endocrine factors such as the menstrual cycle, hyperthyroidism
• allergic rhinitis, sinusitis and upper respiratory tract inflammation
• non-allergic hypersensitivity to drugs such as aspirin or to yellow food dye

Asthma Symptoms
Regardless of the trigger, the result is narrowing of the bronchi, swelling of the tissues, and secretion of mucous. In an asthma attack, the airways of the lung become inflamed and narrow and more mucus is produced, plugging the narrowed airways. This results in shortness of breath, coughing, wheezing, chest tightness, increased heart rate and sweating. These symptoms usually appear slowly, but become progressively worse if untreated. Air that should be expired can become trapped in the alveoli, creating hypoxia and acidosis. In such severe cases, asthma can be life threatening.

Symptoms of an asthma attack include:

• anxiety
• chest "feels tight"
• difficulty breathing (leaning forward to try to breathe better)
• shortness of breath
• coughing (vomiting may accompany severe coughing)
• expiratory wheezing
• use of accessory muscles/retractions/nasal flaring
• cyanosis.

Symptoms may resolve on their own or may require medical intervention. They may last for days, clear, then repeat. Signs preceding respiratory failure include: wheezing may actually decrease or stop, child refuses to lie down and is extremely fatigued.

Causes of Asthma
The cause of asthma is not known, although there is often a family history, indicating a genetic basis. There is no cure for asthma; it must be managed on an on-going basis.

Managing Asthma
For those who have asthma triggered by nasal allergies, immuno-therapy, or allergy shots, may be effective in protecting people from the allergic response. For others, knowing what triggers the asthma response and avoiding that substance is crucial. If the substance cannot be avoided, medication may be required, either periodically or daily.

The medications work by keeping the airways dilated or relaxed, allowing easier breathing. One form of medication that dilates the bronchi is delivered through an inhaler-a small plastic device that delivers the medicine in the form of a mist directly into the airway-for rapid action. Other types of medications may be prescribed based on the individual s need and response. Another device that people with asthma may use is a peak flow meter. This device serves to measure the amount of air a person can breath out and helps determine whether or not special medicine should be taken.

Allergies
Allergic reactions are an intense or "hyper" reaction of the body s normal response to any foreign cell. An allergic reaction is one so intense that some normal body tissues are also destroyed. Signs and symptoms of allergic reactions include:

• hives
• welts
• rashes
• asthma
• anaphylaxis

Symptoms of food allergy may occur within minutes to hours after eating. They include:

• severe vomiting
• diarrhea
• cramps
• hives
• swelling
• itching or tightness around the throat
• difficulty breathing

The encounter between the body s antibodies and the foreign allergens causes the body s cells to release histamine and other chemicals designed to incapacitate the invading allergen. It is the histamine and chemicals that produce an allergic response that can range from hay fever, hives, angioedema, asthma, and local and even systemic anaphylaxis. Anaphylaxis, a sudden severe life-threatening allergic response, is fatal if not treated within minutes.

Allergy Classifications
There are four major classifications of allergies, depending on the type of bodily response generated, either cellular or humoral (antibodies). Type I responses produce the symptoms most commonly associated with allergies: sneezing, watery eyes, nasal congestion, hives and anaphylaxis. Hay fever, conjunctivitis, dermatitis, insect stings and food allergies are examples of Type I responses.

Allergy Triggers
An allergy may develop to any substance at any time or any age. Because a substance has not triggered an allergic response in the past does not mean it will not do so in the future. Some allergies, once developed, may diminish or disappear over time. What triggers an allergic response in one person may not trigger a response in another.

Common triggers, or allergens, for allergies include the following substances:

• Inhalants
  • pollen, mold
  • house dust
  • animal fur, feathers
  • fabric dyes
  • chemicals
  • Injectants
  • vaccines
  • drugs
  • insect stings
• Ingestants
  • food: cow s milk, eggs, wheat, chocolate, cola, fish, pork, chicken, corn, legumes, citrus fruits, nuts
  • drugs: aspirin, antibiotics, barbiturates
  • food additives
• Contactants
  • plants
  • topical drugs
  • resins
  • metals
  • cosmetics
  • dyes
  • chemical
• Environmental Factors
  • air pollution
  • sunshine
• Temperature Changes

Managing Allergies
There are three main goals for managing allergies:

1. identification and avoidance of the specific substance causing the allergic response (identifying the allergen)
2. relief of symptoms
3. control of the severity of future attacks

Identifying the Allergen
Skin testing may be required in some situations to identify the specific allergen(s). The surface of the skin is scraped or pricked, and a variety of common or suspected allergens are applied to the surface. Allergens can also be injected beneath the surface of the skin. The skin is observed for any changes that indicate an allergic response from each particular allergen that has been applied.

For example: If bee stings have produced an allergic response, then avoid bee stings by not going barefoot outdoors and by avoiding areas common to bees such as orchards, flower gardens, garbage cans, etc. If cheese has been determined to cause an allergic response, then avoid eating any form of cheese, ask about ingredients and preparation of foods when eating away from home, read food labels when shopping for food. If household dust has been determined to cause an allergic response, then frequently damp dust floors and furniture, remove carpets and rugs, etc.

Relief of Symptoms

• Antihistamines may be taken to block the effect of histamine.
• Bronchodilators may be used to open up the airways so breathing is easier.
• Immuno-therapy (allergy shots) may be required to gradually desensitize the person to the allergen by giving small doses of the allergen several times weekly and building the dose gradually until the person can tolerate exposure. Two months to more than a year may be required to build tolerance, then maintenance level doses are given regularly, usually once or twice a month.
• Other comfort measures may be provided, depending on the source and site of allergic response, such as applying wet compresses to skin rash, using a humidifier to moisturize the air and use of prescribed ointments for skin rashes.
• Carry an Epi-pen for self-administration of epinephrine if this measure is recommended by a physician

Controlling the Severity of Future Attacks

• Avoid cigarette smoke.
• Avoid fur-bearing pets.
• Control for house dust and dust mites.

Reference: Betz, C. L., Hunsberger, M., Wright, S., Family Centered Nursing Care of Children, Second Edition, W.B. Saunders Company, 1994.