Meet Kris, a 9-year-old who loves dancing. She’s a talented dancer at school and loves to drink sweet juices and carbonated beverages. Recently, she was diagnosed with Type 1 Diabetes Mellitus, a condition that runs in her family. This comprehensive nursing guide explores Kris’s condition and how nurses can effectively manage and educate patients with juvenile diabetes.
What is Juvenile Diabetes Mellitus?
Type 1 Diabetes Mellitus (also known as juvenile diabetes or insulin-dependent diabetes mellitus) is a chronic autoimmune disorder where the body’s immune system attacks and destroys the insulin-producing beta cells in the pancreas. Without insulin, the body cannot process glucose properly, leading to high blood sugar levels and serious health complications if left untreated.
Unlike Type 2 diabetes, which is often associated with lifestyle and obesity, Type 1 diabetes typically develops in children, adolescents, and young adults, though it can occur at any age. It requires lifelong insulin therapy for proper management.
Pathophysiology
Autoimmune Destruction Process
- Type 1 diabetes begins with a genetic predisposition linked to specific HLA alleles (especially DRB103-DQB10201 and DRB 10401-DQB10302H).
- Environmental triggers (possibly viral infections, toxins, or dietary factors) initiate an autoimmune response.
- The immune system mistakenly attacks and destroys the insulin-producing beta cells in the pancreas.
- Progressive beta cell destruction occurs over months or years before symptoms appear.
- Clinical symptoms typically develop when approximately 80-90% of beta cells have been destroyed.
- Complete or near-complete insulin deficiency results, requiring exogenous insulin therapy.
Schematic diagram of Type 1 Diabetes Mellitus pathogenesis
Metabolic Consequences
Without insulin, the following metabolic disruptions occur:
- Hyperglycemia: Glucose cannot enter cells, leading to high blood glucose levels.
- Glycosuria: Kidneys cannot reabsorb excess glucose, causing glucose in urine.
- Osmotic Diuresis: Excess glucose in the kidneys draws water, leading to increased urination.
- Fat and Protein Catabolism: Without glucose for energy, the body breaks down fat and protein.
- Ketone Production: Fat breakdown leads to ketone production and potential ketoacidosis.
- Weight Loss: Due to fluid loss and breakdown of fat and protein stores.
The Role of Insulin
Insulin is essential for multiple metabolic processes:
- Allows glucose to enter muscle and fat cells
- Stimulates the liver to store glucose as glycogen
- Promotes fat storage and synthesis of fatty acids
- Stimulates protein synthesis and uptake of amino acids
- Inhibits breakdown of fat in adipose tissue
- Inhibits gluconeogenesis (glucose production from non-carbohydrate sources)
- Promotes potassium uptake into cells
Normal Glucose Regulation
- Food is broken down into glucose during digestion
- Glucose enters the bloodstream
- Rising blood glucose triggers insulin release from pancreatic beta cells
- Insulin allows glucose to enter cells, lowering blood glucose
- When blood glucose falls, insulin secretion decreases
- Low blood glucose triggers release of counter-regulatory hormones (glucagon, cortisol, epinephrine)
Clinical Manifestations
Mnemonic: “HI SUGAR” – Symptoms of Type 1 Diabetes
H – Hazy vision (blurred vision)
I – Infections (frequent)
S – Slow to heal (wounds)
U – Urinating a lot (polyuria)
G – Great thirst (polydipsia)
A – Always hungry (polyphagia)
R – Rapid weight loss
Primary Symptoms
Polyuria
Increased urination, often including bed-wetting in previously continent children
Cause: Osmotic diuresis from excess glucose in the kidneys
Polydipsia
Excessive thirst that may be insatiable
Cause: Dehydration from increased urination
Polyphagia
Increased hunger and food consumption
Cause: Cells unable to use glucose for energy
Weight Loss
Unexpected weight loss despite normal or increased appetite
Cause: Breakdown of fat and protein for energy
Fatigue
Unusual tiredness, weakness, and irritability
Cause: Cells unable to use glucose for energy
Blurred Vision
Changes in vision or focusing ability
Cause: High glucose affecting lens of the eye
Signs of Diabetic Ketoacidosis (DKA)
DKA is a serious, potentially life-threatening complication that can occur at diagnosis or during illness. Signs include:
- Nausea and vomiting
- Abdominal pain
- Fruity-smelling breath (acetone)
- Dry skin and dry mouth
- Flushed face
- Rapid, deep breathing (Kussmaul respirations)
- Confusion or decreased consciousness
Nursing Alert: DKA is a medical emergency requiring immediate treatment. It can develop within 24 hours and lead to coma or death if untreated.
Assessment and Diagnosis
| Diagnostic Test | Results Indicating Type 1 Diabetes | Nursing Considerations |
|---|---|---|
| Fasting Blood Glucose | ≥126 mg/dL (7.0 mmol/L) after 8-hour fast | Ensure patient has fasted; document time of last food/drink |
| Random Blood Glucose | ≥200 mg/dL (11.1 mmol/L) with symptoms | Can be performed at any time; document time of last meal |
| Oral Glucose Tolerance Test | ≥200 mg/dL (11.1 mmol/L) 2 hours after glucose load | Rarely used for Type 1 diagnosis in children |
| Glycated Hemoglobin (HbA1c) | ≥6.5% (48 mmol/mol) | Reflects average blood glucose over previous 2-3 months |
| Urine Ketones | Moderate to large amounts | Indicates fat breakdown; used to detect/monitor DKA |
| Autoantibody Testing | Presence of islet cell antibodies, GAD65, IA-2, or insulin autoantibodies | Helps distinguish Type 1 from other forms of diabetes |
| C-peptide | Low or undetectable levels | Indicates decreased insulin production |
Nursing Assessment
Health History
- Recent changes in appetite, weight, urination patterns
- Family history of diabetes or autoimmune disorders
- Recent illnesses, particularly viral infections
- Changes in behavior, energy levels, school performance
- History of bedwetting in previously toilet-trained child
- Current medications and allergies
- Developmental history and usual activity level
Physical Assessment
- Height, weight, and BMI (check for unexpected weight loss)
- Vital signs (including respiratory pattern and rate)
- Skin assessment (moisture, turgor, integrity)
- Oral mucous membranes (dryness, signs of dehydration)
- Neurological assessment (level of consciousness, orientation)
- Assessment for signs of DKA
- Point-of-care blood glucose measurement
- Urine sample for ketone testing
Medical Management
Insulin Therapy
Primary treatment for Type 1 diabetes; requires lifelong administration via injections or insulin pump
Diet Management
Balanced diet high in fiber and complex carbohydrates, with consistent meal timing and carbohydrate counting
Physical Activity
Regular exercise is encouraged with appropriate adjustments to insulin and diet to prevent hypoglycemia
Insulin Types and Actions
Rapid-Acting
Examples: Insulin aspart (NovoLog), lispro (Humalog), glulisine (Apidra)
Onset: 10-30 minutes
Peak: 1-2 hours
Duration: 3-5 hours
Use: Mealtime insulin
Short-Acting
Examples: Regular insulin (Humulin R, Novolin R)
Onset: 30-60 minutes
Peak: 2-4 hours
Duration: 6-8 hours
Use: Mealtime insulin, given before meals
Intermediate-Acting
Examples: NPH insulin (Humulin N, Novolin N)
Onset: 1.5-4 hours
Peak: 4-10 hours
Duration: 12-18 hours
Use: Basal insulin
Long-Acting
Examples: Insulin glargine (Lantus), detemir (Levemir), degludec (Tresiba)
Onset: 1-2 hours
Peak: Minimal peak
Duration: 20-24+ hours
Use: Basal insulin
Insulin Regimens
Multiple Daily Injections (MDI)
- Basal-Bolus Therapy: Long-acting insulin once or twice daily for basal needs, plus rapid-acting insulin with meals
- Benefits: Flexible meal timing, more precise dosing
- Drawbacks: Multiple injections daily
Insulin Pump Therapy
- Continuous Subcutaneous Insulin Infusion (CSII): Small device delivers continuous basal insulin with boluses at mealtimes
- Benefits: Fewer injections, more precise control
- Drawbacks: Cost, need for technical skills, attachment to device
Common insulin injection sites with proper rotation patterns
Insulin Dosage Calculation
Initial Total Daily Dose (TDD) for children:
- Weight (kg) × 0.5-0.6 units = Total daily insulin dose
- 40-50% of TDD as basal (long-acting) insulin
- 50-60% of TDD as bolus (rapid-acting) insulin, divided between meals
- Insulin-to-carbohydrate ratio (ICR): Typically start with 1 unit per 10-15g carbohydrate
- Correction factor: 1800 ÷ TDD = mg/dL drop in blood glucose per 1 unit of insulin
Note: Insulin needs vary by individual and change with puberty, illness, activity levels, and other factors. Regular dose adjustments may be needed.
Blood Glucose Monitoring
- Self-monitoring of blood glucose (SMBG): Multiple fingerstick tests daily (before meals, at bedtime, and as needed)
- Continuous Glucose Monitoring (CGM): Sensors measure interstitial glucose levels, providing real-time readings and trends
- Target blood glucose ranges for children:
- Before meals: 90-130 mg/dL (5.0-7.2 mmol/L)
- Bedtime/overnight: 90-150 mg/dL (5.0-8.3 mmol/L)
- HbA1c target: <7.0%
Nursing Management
Mnemonic: “DIABETES” – Nursing Management Priorities
D – Diet planning and education
I – Insulin administration teaching
A – Activity and exercise planning
B – Blood glucose monitoring
E – Education for self-management
T – Treatment of acute complications
E – Emotional support
S – Skin and foot care
Nursing Care Priorities
Nursing Care
Nursing Diagnoses
| Nursing Diagnosis | Nursing Interventions | Expected Outcomes |
|---|---|---|
| Risk for Unstable Blood Glucose related to insulin deficiency and variable insulin requirements |
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| Imbalanced Nutrition: Less Than Body Requirements related to inability to utilize glucose |
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| Deficient Knowledge related to new diagnosis and complex management regimen |
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| Risk for Infection related to hyperglycemia and compromised immune function |
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| Interrupted Family Processes related to child’s chronic illness |
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Managing Hypoglycemia
Definition: Blood glucose <70 mg/dL (3.9 mmol/L)
Signs and Symptoms:
- Shakiness, trembling
- Sweating, clammy skin
- Hunger
- Pale skin
- Headache, dizziness
- Irritability, mood changes
- Confusion, difficulty concentrating
- Blurred vision
- Seizures (severe)
- Loss of consciousness (severe)
Treatment – Rule of 15:
- Give 15 grams of fast-acting carbohydrate
- 4 oz (1/2 cup) juice or regular soda
- 3-4 glucose tablets
- 1 tube of glucose gel
- 1 tablespoon honey or sugar
- Wait 15 minutes
- Recheck blood glucose
- If still <70 mg/dL, repeat steps 1-3
- Once blood glucose is above 70 mg/dL, provide a snack if the next meal is more than 1 hour away
Severe Hypoglycemia: If unconscious or unable to swallow safely, give glucagon injection per prescription and call emergency services.
Managing Hyperglycemia
Definition: Blood glucose >180 mg/dL (10 mmol/L) consistently
Signs and Symptoms:
- Increased thirst
- Frequent urination
- Fatigue
- Blurred vision
- Headache
- Dry skin
- Fruity breath (with ketones)
- Nausea/vomiting (with ketones)
- Abdominal pain (with ketones)
Management:
- Check blood glucose and ketones
- Administer correction insulin as prescribed
- Encourage water intake to prevent dehydration
- Monitor for ketones every 2-4 hours if glucose >240 mg/dL
- Contact healthcare provider if:
- Blood glucose remains elevated after correction dose
- Moderate to large ketones present
- Nausea, vomiting, or abdominal pain
- Difficulty breathing
Warning: If moderate to large ketones, vomiting, difficulty breathing, or altered mental status are present, seek immediate medical attention for possible DKA.
Sick Day Management
Even when ill, insulin should NEVER be skipped
Monitoring:
- Check blood glucose every 2-4 hours
- Check urine ketones when blood glucose is >240 mg/dL
- Monitor temperature, hydration, and symptoms
Management:
- Continue insulin administration (often requires additional doses)
- Maintain fluid intake (water, sugar-free liquids if blood glucose is high)
- If unable to eat solid food, provide carbohydrates through liquids
- For each episode of vomiting or diarrhea, replace with 8 oz of fluid containing electrolytes
When to seek medical help:
- Persistent vomiting (>2 hours)
- Moderate to large ketones
- Difficulty breathing
- Unable to keep fluids down
- Blood glucose remains >240 mg/dL despite correction doses
- Signs of dehydration (dry mouth, sunken eyes, decreased urination)
Patient and Family Education
Mnemonic: “GLUCOSE BAD” – Patient Education Framework
G – Glycemic control (HbA1c, blood glucose monitoring)
L – Lifestyle changes (diet, exercise)
U – Understanding medications (insulin types, actions)
C – Complications prevention
O – Ongoing care (regular appointments)
S – Sick day management
E – Emergency situations
B – Blood glucose monitoring
A – Adjustments for activities
D – Diet planning
Essential Education Topics
Insulin Administration
- Types of insulin and their action profiles
- Storage of insulin (refrigeration, expiration dates)
- Drawing up insulin (if using syringes)
- Injection technique and site rotation
- Use of insulin pens or pumps if applicable
- Disposal of sharps
Blood Glucose Monitoring
- How to use the glucose meter
- When to check blood glucose (before meals, bedtime, with symptoms)
- Target blood glucose ranges
- Recording and interpreting results
- CGM use if applicable (sensor insertion, reading trends)
- Troubleshooting equipment issues
Nutrition Management
- Carbohydrate counting
- Reading food labels
- Meal planning and timing
- Fast food and restaurant eating
- Special occasion foods (birthday parties, holidays)
- Insulin-to-carbohydrate ratios
Hypoglycemia Management
- Recognizing symptoms
- The “Rule of 15” for treatment
- When and how to use glucagon
- Prevention strategies
- Adjusting for exercise and activity
- Medical ID awareness
School and Social Considerations
- Developing a school diabetes care plan
- Educating teachers and school staff
- Handling physical education and sports
- Managing parties and special events
- Planning for sleepovers and trips
- Disclosure decisions (who to tell about diabetes)
Psychosocial Adaptation
- Addressing feelings about diagnosis
- Age-appropriate responsibility for care
- Preventing diabetes burnout
- Coping strategies
- Support resources (groups, camps, online communities)
- Family adjustment and sibling concerns
Teaching Insulin Administration
Injection Technique
- Wash hands thoroughly
- Gather supplies (insulin, syringe/pen, alcohol swab)
- Check insulin expiration date and appearance
- Gently roll insulin bottle to mix (if using NPH)
- Clean injection site with alcohol swab
- Pinch up skin at injection site
- Insert needle at 90° angle (or 45° if very thin)
- Release pinched skin
- Push plunger to inject insulin
- Count to 10 before removing needle
- Dispose of needle properly in sharps container
Site Rotation
Proper rotation of injection sites prevents lipohypertrophy (fatty lumps) and ensures consistent insulin absorption.
- Abdomen: One inch away from navel, fastest absorption
- Upper outer arms: Back of arm in fatty tissue
- Thighs: Front and outer sides
- Buttocks: Upper outer quadrant
Teaching Tip: Use a rotation grid or body map to help track injection sites. Inject in the same general area (e.g., abdomen) for consistent absorption, but move at least one inch from the previous injection site.
Age-Specific Education Considerations
| Age Group | Developmental Considerations | Education Approach |
|---|---|---|
| Toddlers/Preschoolers (2-5 years) |
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| School-Age (6-11 years) |
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| Adolescents (12-18 years) |
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School Considerations
A comprehensive diabetes management plan for school should include:
- Diabetes Medical Management Plan (DMMP): Detailed care instructions from healthcare provider
- Individualized Education Program (IEP) or 504 Plan: Legal accommodations for diabetes care at school
- Emergency Action Plans: For hypoglycemia and hyperglycemia
- Staff Training: Education for teachers, nurses, and other staff
- Supplies Storage: Designated location for diabetes supplies and emergency items
Nursing Tip: Assist families in developing a comprehensive school plan. Provide educational materials and offer to participate in staff training sessions if possible.
Complications of Type 1 Diabetes
Acute Complications
Diabetic Ketoacidosis (DKA)
A life-threatening emergency caused by insulin deficiency, leading to ketone production and metabolic acidosis.
- Signs/Symptoms: Nausea, vomiting, abdominal pain, fruity breath, Kussmaul respirations, dehydration, altered mental status
- Nursing Management: IV fluids, insulin therapy, electrolyte replacement, frequent monitoring
- Prevention: Never skip insulin, check ketones during illness or with high blood glucose
Severe Hypoglycemia
Blood glucose low enough to cause unconsciousness, seizures, or inability to self-treat.
- Signs/Symptoms: Confusion, seizures, loss of consciousness
- Nursing Management: Glucagon administration, positioning for safety, glucose monitoring
- Prevention: Regular glucose monitoring, proper insulin dosing, carrying fast-acting carbohydrates
Long-term Complications
Long-term complications are related to prolonged hyperglycemia and can affect multiple body systems. Good glycemic control can significantly reduce the risk of these complications.
Microvascular Complications
- Diabetic Retinopathy: Leading cause of blindness, damage to blood vessels in retina
- Diabetic Nephropathy: Kidney damage that can lead to chronic kidney disease
- Diabetic Neuropathy: Nerve damage causing pain, tingling, or numbness, especially in extremities
Macrovascular Complications
- Cardiovascular Disease: Increased risk of heart attack and stroke
- Peripheral Vascular Disease: Poor circulation, especially to lower extremities
Diabetic Retinopathy
(Hover/tap for prevention)
Prevention
- Annual eye examinations
- Tight glycemic control
- Control blood pressure
- Early intervention for vision changes
Diabetic Nephropathy
(Hover/tap for prevention)
Prevention
- Annual urine microalbumin tests
- Optimal blood glucose control
- Blood pressure management
- Renal-protective medications if indicated
Diabetic Neuropathy
(Hover/tap for prevention)
Prevention
- Glycemic control
- Regular foot examinations
- Proper footwear
- Address symptoms promptly
- Avoid prolonged standing
Cardiovascular Disease
(Hover/tap for prevention)
Prevention
- Regular physical activity
- Heart-healthy diet
- Glycemic control
- Lipid management
- Blood pressure control
- Avoid smoking
Nursing Interventions for Complication Prevention
Eye Care
- Educate on importance of annual eye exams
- Teach to report vision changes promptly
- Emphasize glycemic control to prevent damage
- Assist with referrals to ophthalmology
Foot Care
- Daily foot inspection for injuries or changes
- Proper foot hygiene and moisturizing
- Appropriate footwear selection
- Never walk barefoot
- Regular nail care (straight across)
- Prompt treatment of any foot problems
Cardiovascular Care
- Regular physical activity as tolerated
- Heart-healthy diet low in saturated fats
- Blood pressure monitoring
- Lipid profile monitoring
- Smoking prevention/cessation counseling
- Stress management techniques
Recent Advances in Type 1 Diabetes Management
Technology Advancements
- Continuous Glucose Monitoring (CGM): Real-time glucose readings without fingersticks, with trend arrows and customizable alerts
- Hybrid Closed-Loop Systems: “Artificial pancreas” systems that automatically adjust insulin delivery based on CGM readings
- Smart Insulin Pens: Track insulin doses, suggest corrections, and connect to smartphone apps
- Telemedicine: Remote diabetes care and education, especially valuable for rural populations
- Mobile Apps: Tools for tracking glucose, insulin, diet, and activity with data sharing capabilities
Treatment Innovations
- Islet Cell Transplantation: Transplantation of insulin-producing cells to restore insulin production
- Faster-Acting Insulins: Ultra-rapid insulins that more closely mimic natural insulin response
- Adjunctive Therapies: GLP-1 receptor agonists and SGLT inhibitors to improve glucose control
- Teplizumab (Tzield): First drug approved to delay onset of Type 1 diabetes in at-risk individuals
- Stem Cell Therapy: Promising research in generating insulin-producing cells from stem cells
Future Directions
Immunotherapy Research
- Targeting the autoimmune process to preserve beta cell function
- Combination therapies addressing multiple immune pathways
- Potential for disease modification in early stages
Encapsulation Technology
- Protecting transplanted islet cells from immune attack
- Eliminating need for immunosuppression
- Development of bioengineered insulins with glucose-responsive features
Nursing Implications: Stay current with technological and treatment advances to provide up-to-date education. Assess patients’ ability to use new technologies and provide appropriate training and support.
Case Study: Managing Kris’s Diabetes
Let’s return to 9-year-old Kris, who was recently diagnosed with Type 1 diabetes. As her nurse, you are responsible for developing an appropriate care plan and providing education to Kris and her family.
Nursing Assessment
- Kris is an active 9-year-old who loves dancing
- Family history of diabetes
- Current weight: 28 kg (slight weight loss noted)
- Presenting symptoms: polyuria, polydipsia, fatigue
- Blood glucose at diagnosis: 342 mg/dL
- HbA1c: 10.2%
- No signs of DKA at present
- Family appears anxious but engaged in learning
Nursing Care Plan
| Nursing Diagnosis | Interventions | Evaluation |
|---|---|---|
| Risk for Unstable Blood Glucose related to new-onset diabetes and adjustment to insulin therapy |
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Kris and parents demonstrate accurate blood glucose monitoring and understand target ranges. They can recognize and appropriately treat hypo/hyperglycemia. |
| Deficient Knowledge related to new diagnosis of Type 1 diabetes |
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Kris and parents demonstrate understanding of diabetes management and can correctly perform all required skills. |
| Risk for Imbalanced Nutrition related to changes in diet and insulin regimen |
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Kris and parents identify carbohydrate content of common foods and understand insulin-to-carbohydrate ratios. |
| Risk for Ineffective Coping related to chronic illness diagnosis |
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Kris and family identify positive coping strategies and utilize appropriate support resources. |
Special Considerations for Kris’s Dancing
Since Kris loves dancing, special attention should be given to managing diabetes during physical activity:
- Pre-exercise planning:
- Check blood glucose before dancing (target: 120-180 mg/dL)
- Have fast-acting carbohydrates available (juice, glucose tabs)
- Consider reducing pre-activity insulin dose by 25-50%
- During activity:
- For dancing lasting >30 minutes, check glucose midway
- Consume 15g carbohydrate for every 30-60 minutes of activity
- Watch for signs of hypoglycemia
- Post-exercise considerations:
- Check blood glucose after dancing
- Be aware of delayed hypoglycemia (up to 24 hours post-exercise)
- Adjust evening insulin if needed
School Plan for Kris
Develop a comprehensive school plan including:
- Diabetes Medical Management Plan from healthcare provider
- 504 Plan for accommodations (blood glucose checking, insulin administration, bathroom access)
- Emergency plans for hypoglycemia and hyperglycemia
- Designated staff trained in diabetes care
- Plan for school parties, field trips, and special events
- Considerations for dance class and physical education
Nursing Role: Coordinate with school nurse, provide education to school personnel, and help develop appropriate plans to ensure Kris can participate fully in school activities while managing diabetes safely.
References
1. American Diabetes Association. (2022). Standards of Medical Care in Diabetes. Diabetes Care, 45(Supplement 1).
2. Centers for Disease Control and Prevention. (2024). Type 1 Diabetes. https://www.cdc.gov/diabetes/about/about-type-1-diabetes.html
3. National Health Service. (2025). Complications of Type 1 Diabetes. https://www.nhs.uk/conditions/type-1-diabetes/complications/
4. International Society for Pediatric and Adolescent Diabetes. (2022). ISPAD Clinical Practice Consensus Guidelines.
5. NursesLabs. (2024). Type 1 Diabetes Mellitus Nursing Care Management and Study Guide. https://nurseslabs.com/diabetes-mellitus-type-1-juvenile-diabetes/
6. StatPearls. (2023). Type 1 Diabetes (Nursing). https://www.ncbi.nlm.nih.gov/books/NBK568751/