Nursing care of Juvenile Insulin Dependent Diabetes

Practice Case Study: Rachael Peterson

Rachael Peterson, a 14‐year‐old girl with childhood diabetes, visited the outpatient clinic of a major city hospital every three months. On this particular visit, the new clinic nurse, Meredith Walker RN, noticed that the injection sites on Rachael's thighs were hardened and red.

Meredith asked Rachael to demonstrate how she administered her daily insulin. It became obvious that Rachael was not following aseptic technique in the preparation of the injection. Neither was she rotating injection sites. Rachael had been a diagnosed with Insulin Dependent Diabetes three years ago, and these observations had not been documented on previous visits. Meredith became concerned about the change in the way Rachael administered insulin.

Rachael also mentioned an increase in frequent 'snacking binges' and the difficulty being diabetic in social situations when other teenage friends could eat whatever they wanted. Meredith was concerned about the long‐term effects of high glucose levels on Rachael's health following her urine test showing 3+ glucose.

Meredith decided to be firm with Rachael. She pointed out the high risks of not following her diet, of carelessness about insulin administration, and the possibility of infection. Meredith also told Rachael that she might need to be admitted to hospital for insulin therapy and stabilisation of her diet if Rachael continued to practise the same habits.

Rachael was upset by Meredith's strong warning and the threat of future hospitalisation. She also objected to Meredith's repeated suggestion about how she should administer her daily insulin by rotating injection sites. Rachael had never liked injecting herself in her abdomen or arms, so she had decided to make most injections in her thighs. She told Meredith that this was her choice, and that she had the right to decide what to do with her own body. Rachael left the clinic distraught, upset and angry.

Following Rachael's visit, Meredith discussed the situation with a colleague who was a Registered Nurse with 20 years' experience working with adolescents who had diabetes. She explained that Rachael's attitude was common among adolescent people with diabetes. She mentioned it was an expression of their anger and frustration at being 'different' and not able to do all the things that their friends could in the same way.

The nurse, however, argued against Meredith's proposal of hospitalisation for Rachael and instead, stated that in her experience, the way to achieve the best outcome for Rachael was to wait until Rachael put herself into a diabetic crisis, as this would necessitate Rachael being hospitalised. That way, the nurse argued, Rachael would quickly learn to assume more responsibility for her self‐care.

Meredith was uncertain how to proceed at this point. She was empathic to Rachael's desire to make her own choices. Yet she was very clear, as a nurse, about the importance of a safe and effective regimen, and self‐care for people with diabetes. She was also aware that any plan to admit Rachael to hospital would involve Rachael's parents. While she acknowledged the experience of her colleague, she wondered about the wisdom of the 'diabetic crisis' solution.

Case Study Questions

1. Briefly note the 'problem' that exists for Meredith.

2. Make a list of the things you think are the most ethically/legally significant factors in the scenario. In other words, consider what Meredith would have to take into account if her thinking and decisions are to be ethically or legally appropriate in this situation.

3. List two options available to Meredith, which are, in your opinion the most obvious courses of action, given what she takes the problem to be.

4. Develop an argument/rationale for the stance taken by Meredith.

As a health professional, Meredith finds it difficult to accept Rachael's decision to be so negligent when it comes to managing her diabetes and caring for her body. She feels responsible and is compelled to do what is best for Rachael and her health. On the other hand, Meredith would like to respect Rachael's wishes, but she is not comfortable with the notion of letting Rachael determine her own health care.

Meredith's problem is knowing how to act in Rachael's best interest while respecting Rachael's decisions when it comes to her own health care before her situation results in a diabetic crisis. Rachael's health and wellbeing could be compromised if she continues to neglect her diet and the correct insulin administration. Health impacts could include increasing glucose levels and the corresponding effect that has on her organs; and damage to the skin and infection on the injection sites on her thighs. Legally, Meredith is obligated to provide the best care and treatment possible for Rachael even if it is against her wishes as she is a minor.