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Why: To identify and treat life-threatening issues immediately.

What it includes:

Airway – Is she vomiting? Risk of aspiration?

Breathing – Kussmaul respiration (deep, rapid breathing from metabolic acidosis)

Circulation – Tachycardia, low BP, capillary refill; signs of dehydration

Disability – AVPU/GCS, signs of altered mental state due to hyperglycaemia/acidosis

Exposure – Look for dehydration (dry skin), possible infection signs

Reference: Resuscitation Council UK (2023) – Quality Standards for Acute Care

NEWS2 (with caution in under-18s)

Though primarily for adults, NEWS2 can offer structure in older adolescents like Emily:

Elevated respiratory rate

Tachycardia

Hypotension or altered consciousness

Hyperglycaemia (>27 mmol/L) not scored in NEWS2, but is clinically critical here

Reference: Royal College of Physicians (2017) – NEWS2

Use in conjunction with paediatric early warning score (PEWS) if your Trust uses that for patients <18.

DKA-Specific Assessment

DKA is defined by:

Blood glucose >11 mmol/L

Ketonaemia >3.0 mmol/L or urine ketones ++

Bicarbonate <15 mmol/L and/or pH <7.3

Immediate investigations:

Blood gas (VBG or ABG) – to assess acidosis (HCO₃⁻ and pH)

Capillary ketones – ideally >3.0 mmol/L in DKA

U&Es – risk of potassium shifts, dehydration

Urinalysis – confirms ketonuria, rules out infection

Infection screen – full blood count, CRP, possible source

Reference:

NICE NG18 – Type 1 Diabetes in Children and Young People

BSPED Guidelines (British Society for Paediatric Endocrinology and Diabetes)

Mental State and Capacity (16 years old)

At 16, Emily is presumed to have capacity under the Mental Capacity Act 2005, but:

Monitor for confusion or altered GCS (DKA-related)

Assess emotional wellbeing, as stress and caregiving role may affect management

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National Institute for Health and Care Excellence (2020b). National Early Warning Score Systems That Alert to Deteriorating Adult Patients in Hospital | Advice | NICE. [online] www.nice.org.uk. Available at: https://www.nice.org.uk/advice/mib205/chapter/The-technology.

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National Institute for Health and Care Excellence (2020b). National Early Warning Score Systems That Alert to Deteriorating Adult Patients in Hospital | Advice | NICE. [online] www.nice.org.uk. Available at: https://www.nice.org.uk/advice/mib205/chapter/The-technology.

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Nursing and Midwifery Council (2018a). Future Nurse: Standards of Proficiency for Registered Nurses. [online] Nursing and Midwifery Council. Nursing and Midwifery Council. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/education-standards/future-nurse-proficiencies.pdf.

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Nursing and Midwifery Council (2018a). Future Nurse: Standards of Proficiency for Registered Nurses. [online] Nursing and Midwifery Council. Nursing and Midwifery Council. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/education-standards/future-nurse-proficiencies.pdf.

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Inconsistent with attending Diabetes appointments due to caring for other siblings

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Inconsistent with attending Diabetes appointments due to caring for other siblings

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Referral to endocrinology and diabetes specialist nurses.

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Patient Demographics: Emily is 16 years old, she is in year 11 at school and lives at

home with one parent and 5 younger siblings, who she often cares for. Emily was

diagnosed with type 1 diabetes at the age of 10. She has been managing her condition

with a basal-bolus insulin regimen and regular blood glucose monitoring. Emily is

active in sports and participates in her school's football team when family life allows

her. She has been attending regular follow-ups with her diabetes team, although her

attendance has been inconsistent due to her caregiving responsibilities.

Setting: Emergency department

Background: Emily presented to the A&E department with symptoms of severe

abdominal pain, nausea, and vomiting. Over the past few days, Emily experienced

increasing abdominal discomfort, which she initially attributed to a stomach bug.

However, her symptoms worsened, and she began to feel extremely fatigued and

dehydrated. Her parent noted that she had been more irritable and less active than

usual. Emily is on the following medication:

• Insulin Levemir 10 units twice daily

• Insulin Novorapid : Dose adjusted based on carbohydrate intake using an

insulin-to-carbohydrate ratio (ICR).

Starting ICR: 1 unit of insulin for every 10 grams of carbohydrates consumed.

Emily’s current blood glucose is 27mmols/L and her urine has tested positive for

ketones.

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Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be triggered by infections. DKA occurs when the body doesn't have enough insulin, causing the body to break down fat for energy, producing harmful ketones. Infections, especially common ones like urinary tract infections and pneumonia, can lead to DKA, particularly in individuals with type 1 diabetes or those using insulin. 

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Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be triggered by infections. DKA occurs when the body doesn't have enough insulin, causing the body to break down fat for energy, producing harmful ketones. Infections, especially common ones like urinary tract infections and pneumonia, can lead to DKA, particularly in individuals with type 1 diabetes or those using insulin. 

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British Society for Paediatric Endocrinology and Diabetes (BSPED) 

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British Society for Paediatric Endocrinology and Diabetes (BSPED) 

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Updated in 2018 from the NICE Guidance NG18 and UK Resuscitation Council recommendations in May 2021.

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Department for Education (DfE) Guidance – Supporting pupils at school with medical conditions (2015)

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Department for Education (DfE) Guidance – Supporting pupils at school with medical conditions (2015)

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Ensures schools create healthcare plans, allow flexibility for appointments, and accommodate fluctuating health needs.

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NICE (National Institute for Health and Care Excellence).

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NICE (National Institute for Health and Care Excellence).

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Diabetes (type 1 and type 2) in children and young people: diagnosis and management (NICE Guideline NG18).

Published 2015 (updated 2022).

Available at: https://www.nice.org.uk/guidance/ng18

— Guidelines on managing diabetes in young people including psychosocial and safeguarding considerations.

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We would also dip Emily's urine for pregnancy

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Wong, D.L. and Baker, C.M., 1988. Pain assessment using the Wong-Baker FACES Pain Rating Scale. Pain Management Nursing, 4(4), pp. 41–42

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Wong, D.L. and Baker, C.M., 1988. Pain assessment using the Wong-Baker FACES Pain Rating Scale. Pain Management Nursing, 4(4), pp. 41–42

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Safeguarding Considerations – Emily (16 years old, Type 1 Diabetes, DKA)

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Safeguarding Considerations – Emily (16 years old, Type 1 Diabetes, DKA)

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Young Carer Responsibilities

Emily is responsible for caring for five younger siblings, which raises red flags:

Excessive caregiving may affect her own health, development, and education.

Missed diabetes appointments suggest her caring role may be impacting her ability to self-manage.

She may lack adult supervision or appropriate support.

young carers must be assessed for support needs.

Neglect or Unmet Needs

While there’s no direct evidence of neglect, the following must be considered:

Is Emily’s home environment providing her with the support and supervision she needs to manage a complex, life-threatening condition like diabetes?

Is she consistently provided access to healthcare, food, and time for self-care?

Consider emotional neglect, where her own needs may be deprioritised due to household circumstances.

Reference: Working Together to Safeguard Children (HM Government, 2018) — defines neglect as persistent failure to meet a child’s basic needs.

Mental Health and Emotional Wellbeing

Diabetes itself increases risk for low mood, burnout, or self-neglect.

Being a young carer may contribute to emotional stress, social isolation, or anxiety.

If Emily is showing signs of withdrawal, low mood, or poor treatment adherence, a CAMHS (Child and Adolescent Mental Health Services) referral should be considered.

NICE NG135 – Children and young people’s experience of healthcare

NICE NG82 – Safeguarding in healthcare settings

Capacity and Consent

At 16, Emily is presumed to have capacity under the Mental Capacity Act (2005).

Still, if she is confused due to DKA or emotional stress, a temporary best interest approach may be needed.

Ensure decisions about her treatment involve clear explanation, reassurance, and appropriate adult support.

Education and School Attendance

As a Year 11 student, safeguarding also includes ensuring her right to education is not compromised by illness or home demands.

Referral to the school nurse or education welfare officer may help coordinate health and academic support.

Multi-Agency Referral (Early Help or Social Care)

If concerns are validated, you should:

Complete an Early Help Assessment (if concerns are emerging but below social services threshold).

Refer to Children’s Social Care under Section 17 of the Children Act 1989 if Emily is a child in need (due to health or caregiving impact).

Involve the Named Safeguarding Nurse or Designated Safeguarding Lead in your Trust.

Key Safeguarding References

Children Act 1989 & 2004 – Duties to safeguard and promote the welfare of children

Children and Families Act 2014 – Legal rights for young carers

NMC Code (2018) – Prioritise people; preserve safety

Working Together to Safeguard Children (2023) – National safeguarding framework

NICE NG82 – Safeguarding in health and social care settings

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To Rule Out Abdominal Causes Beyond DKA

Abdominal pain in DKA can sometimes be due to other acute abdominal pathologies (e.g., appendicitis, cholecystitis, pancreatitis).

If the pain is localized, severe, persistent, or there are signs of peritonitis, an abdominal ultrasound can help rule out surgical emergencies.

Ultrasound is the first-line imaging to evaluate:

Gallbladder (cholelithiasis/cholecystitis)

Appendix (appendicitis)

Pancreas (pancreatitis)

Ovaries (especially in females with PCOS, though Emily doesn’t have this)

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Keeping children safe in education (Department of education, 2023) is a statutory government guidance document published by the Department for Education in England. It outlines how schools and colleges must safeguard and promote the welfare of children.

Key elements : -

Early identification of risk

Emily’s caregiving role and inconsistent school and clinic attendance place her at higher risk of education neglect and health related harm.

Designated safeguarding lead role The DSL at Emilys school should be informed of emergency admission and her family pressures so they can support her needs and assess the risks

Multi agency working - Emilys case would benefit from a team around the child meeting involving health, education and social care and ensure her needs are being met.

Mental health support - Emily maybe experiencing anxiety, low mood because of her responsibilities and having a serious health conditions requiring referral to mental health services.

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Department for Education (DfE). (2023). Keeping Children Safe in Education: Statutory Guidance for Schools and Colleges. Available at: https://www.gov.uk/government/publications/keeping-children-safe-in-education--2 [Accessed June 2025].

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Emily would benefit from a Libre as it could help her maintain her diabetes.

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SEPSIS Screening - important if there’s any concern of infection triggering DKA.

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SEPSIS Screening - important if there’s any concern of infection triggering DKA.

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Pain Assessment