FDNT 452: Medical Nutrition Therapy II Lab #6: DM Part A Please type the lab report and submit via Dropbox in Learning Hub Total Points: _____ / 31 Due: Thursday, February 24, 2022 Name: Nayle Aranda Case 18 – Adult type 2 DM: Transition to Insulin I. Understanding the Diagnosis & Pathophysiology 1. What are the standard diagnostic criteria for T2DM? Which are found in Mitch’s medical record? (2 pts) The standard diagnostic criteria for T2DM are: - A1C: > or = to 6.5% - FPG: > or = to 126 mg/dl - 2-h PG: > or = to 200 mg/dl Prediabetes: - A1C: 5.7%-6.4% - FPG: 100-125 mg/dl - 2-h PG: 140-199mg/dl Mitch’s medical record indicates an A1C at 11.5% which is really high than normal values, and his blood glucose was between 855 mg/dl and 475 mg/dl. 2. Mitch was previously diagnosed with T2DM. He admits that he often does not take his medications. What types of medications are metformin and glyburide? Describe their mechanisms (how they work to control blood glucose) as well as their potential side effects/drug-nutrient interactions. (2 pts) - Metformin: is a medication that suppresses hepatic glucose production and helps reduce insulin resistance. The side effects of Metformin are nausea, diarrhea, vomiting, and flatulence. The drug-nutrient interactions indicate that the side effects may reduce by intake with a meal or increasing the dosage. Preferable with meals to reduce bloating, nausea, diarrhea, B12 deficiency. It might be a relationship between eating high-fiber foods after taking this drug. - Glyburide: medication that stimulates insulin secretion from b-cells in the pancreas. The side effects of this medication are that it can cause hypoglycemia and weight gain. Also, it is not very accessible for everyone. Hypoglycemia can be avoided if taken with food. 3. What other medications does Mitch take? List their mechanisms and potential side effects/drug-nutrient interactions. (1 pt) Other medications that Mitch takes are: Dyazide and Lipitor. - Dyazide: is a diuretic that stimulates urine production and reduces sodium and potassium levels. The potential side effects are headaches, dizziness, and upset stomach or stomachaches. The drug-nutrient interaction include alcohol, which consumed with medication may cause worst side effects. - Lipitor: medication that helps the production of the cholesterol on the liver to be decreased. The side effects include nausea, fatigue, constipation, heartburn, and persimmons. The effect-nutrient interaction states that its intake can cause liver damage. 4. Describe the metabolic events that led to Mitch’s symptoms and subsequent admission to the ER with the diagnosis of uncontrolled T2DM with HHS. What is HHS? Compare and contrast HHS with diabetic ketoacidosis. (2 pt) The metabolic events that led to Mitch's symptoms and subsequent admission to the ED with a diagnosis of uncontrolled T2DM with HHS were his uncontrolled diabetes, lack of dietary adherence, vomiting, and failure to take his medications. The lack of control in CHO intake led to elevated blood glucose levels, which did not decrease because he admitted to not taking his medications. HHS is hyperosmolar hyperglycemic syndrome, characterized as a severe complication of diabetes mellitus. It occurs when a person's blood glucose levels are too high for a prolonged period of time, resulting in severe dehydration and confusion. Whereas in DKA the lack of insulin combined with increased catecholamines results in accelerated lipolysis and thus the production of excess fatty acids, leading to beta- oxidation and ketogenesis, in HHS the residual beta-cell function is adequate to prevent lipolysis but not hyperglycemia. 5. HHS is often associated with dehydration. After reading Mitch’s chart, list the data that is consistent with dehydration (biochemical, etc). What factors in Mitch’s history may have contributed to his dehydration? (2 pts) Mr. Mitch's labs show that his creatinine, blood sugar, and BUN levels are high which may indicate signs of dehydration. His physical examination showed poor turgor, hot and dry skin, elevated pulse, abnormal blood pressure, dry mucous membranes, and dry throat. In his nutritional history, Mr. Mitch also reported vomiting putting him at risk for dehydration in addition to his HHS status, and lastly poor water intake as he indicated he only took small sips of the liquid. 6. Describe the insulin therapy that was started for Mitch. What is Lispro? What is glargine? How likely is it that Mitch will need to continue insulin therapy? (2 pts) Lispro is a rapid-acting insulin that controls blood sugar at mealtimes, and glargine is a longacting type of insulin. To control DM in the case of high glucose levels, the prescription of both is necessary, as Lispro is an immediate aid and the other is long-acting. Mr. Mitch was prescribed Lispro every 2 hours until his glucose levels are within normal parameters, and he was also prescribed Glargine in the evening at 9 pm. Mr. Mitch will most likely have to continue insulin therapy based on his uncontrolled T2DM and high glucose levels. II. Understanding the Nutrition Therapy 7. Outline the basic principles for Mitch’s nutrition therapy to assist in control of his DM. (3 pts) - Mr. Mitch’s carbohydrate intake: consistent carbs during the day - Mange his glucose levels with diet education and carb counting - Education in portion control and grams of carbs - Monitor blood glucose, fasting, units of insulin, carb snacks, and postprandial levels III. Nutrition Assessment 8. Assess Mitch’s weight and BMI (use UBW since he was dehydrated) what would be a healthy weight range for Mitch? (To calculate healthy weight range use a BMI of 25-27) (1 pt) BMI: 97.27kg / 1.75m2 = 31.76kg / m2 Obese IBW: 106 + 54lbs= 160lbs %IBW: 214lbs / 160lbs = 133% IBW Adjusted body weight: (214lbs - 160lbs) x 0.25 + 160lbs = 173.5 lbs Healthy weight range bases on BMI 25-27 = 168lbs – 182lbs Formula used to calculate for obesity: [(CBW-IBW) x 0.25] + IBW 9. Identify and discuss any abnormal laboratory values measured upon his admission. How did they change after hydration and initial treatment of his HHS? (3 pts) Be sure that you determine the nutrition requirements on the ADIME: energy, protein, and fluid needs. Abnormal laboratory values measured upon his admission are: High: - BUN: 31mEq/L 20mEq/L normal - Creatinine serum: 1.9mg/dl 1.3mg/dl normal - Glucose: 855mg/dl 465mg/dl high - Osmolality: 322.6mmol/kg/H2O - Cholesterol: 205mg/dl - VLDL: 37mg/dl - Triglycerides: 185mg/dl - HbA1C: 11.5% - WBC: 13.5 - Hematocrit: 57% - Urinary protein: 10 - Urinary glucose: +3 - Urinary Ketones: +1 Low: - Sodium: 132mEq/L 135mEq/L low - Est GFR, non-Afr Amer: 39ml 62 normal - Phosphate inorganic: 1.8mg/dl 2.1mg/dl low - Anion gap: 6.0mmol/l 11 normal After Mr. Mitch received the hydration and initial treatment of his HHS, some elevated levels decreased such as BUN and creatinine levels, and others remained high such as phosphate, and osmolality. Low values such as sodium and anion gap increased towards the normal values previous signs of possible kidney failure. IV. Nutrition Diagnosis 10. Prioritize two nutrition problems and complete the PES statement for each. Only use one on the ADIME note for evaluation using the NCP Rubric. (1 pt) - Inadequate oral intake related to lack of nutrition knowledge regarding his T2DM disease as evidenced by patient’s self-reported and his high glucose of 855 mg/dl high 11.5 A1C %. - Inadequate fluid intake related to excessive vomiting and insufficient water intake as evidenced by HHS, high BUN and creatinine levels, poor turgor, dry skin, elevated heart rate and mucous membranes and throat. V. Nutrition Intervention 11. Determine Mitch’s initial CHO prescription using his diet history and your assessment of his energy requirements. (Tip: use 50% of total calories from CHO) (1 pt) How many total grams of CHO? How many grams each meal? How many carbohydrate servings per meal? Energy requirements: 10 x weight (97.27 kg) + 6.25 x height (175.26cm) – 5 x age (53y) + 5 = 1808 x (AF 1.4 dehydration) = 2531 2600kcal – 500kcal weight loss = 2100kcal Total calories of CHO: 2100kcals x 50% = 1050kcals Total grams of CHO: 1050kcals / 4kcals = 260 grams Total CHO portions per day: 260g / 15g (1 exchange of carb) = 17 exchanges Total CHO servings per meal: 17 exchanges / 4 meals (breakfast, lunch, dinner, snacks) = 4.25 exchanges – 4 servings approximately Total CHO grams per meal: 63.75 grams – 60 grams approximately 12. Mitch also has hypertension and high cholesterol levels. Describe how your nutrition interventions for diabetes can include nutrition therapy for his other conditions. (1 pt) The nutrition intervention for diabetes can benefit from hypertension and hypercholesterolemia. The 2TDM nutrition therapy can also include other guidelines and recommendations to help those complications. We could include healthy fats and limited unhealthy, saturated, and trans fats, as well as, include a low sodium guideline diet. Other factors such as exercise and water intake help to control those risk factors. Complete an ADIME note. (10 pts) Nutrition Assessment DX Acute hyperglycemia, HHS GOUT____ PMH__T2DM, HTN, Hyperlipidemia, Sex M Age 53 Wt 214lbs Ht_5’9’’__Adj.BW 174lbs IBW_160lbs___ % IBW_143%_ UBW_228lbs____%UBW_94%___% Wt. Δ_____6.14%__BMI___33 Obese___ Labs Glu 475-855 205 TG 185 Alb 4.9_ Bun 20-31 Cr 1.3- 1.9 Na 132 - 135 K+ 3.9 - 4 Chol Hgb 14.5 Hct 57 A1c 11.5% Others(s) ______________________________________________ Pertinent Medications _Glyburide, Metformin, Dyazide, Lipitor NFPA: GI: N V D C Dentition 90/70 Skin Condition: dry Vital Signs T: 100.5 BP: Current Diet Order/regimen NPO, clear liquids, restricted sodium water_____ Food Intake: deficit, sips of Fat/Muscle Loss __n/a______________________________________Edema: none +1____+2_____+3_________ Micronutrient Exam: n/a Estimated nutrition Needs: 2100 kcal/day based on Mifflin St Jeor x AF 1.4 – 500kcal _416g__protein/day based on 14- 20% of kcals g/kg) 2000 – 2500 ml fluid/day based on hydration recommendation ml/kg or 1 ml/kcal (applies only in TF) _____________________________________________________________________________________ ___________ Nutrition Diagnostic Statement :( P related to E as evidenced by S) _____________________________________________________________________________________ Inadequate oral intake related to lack of nutrition knowledge regarding his T2DM disease as evidenced by patient’s self-reported and his high glucose of 855 mg/dl high 11.5 A1C %. Nutrition Intervention/Goals Goal/s: Educate the patient on the carbohydrate diet and control. Recommendations/Plan: _x_Nutrition prescription: _adjustment to meal plan and carbs portion control _x_Snacks/supplements: educate best snacks options to his diet_______________ _x_Provide education: __CHO portion control, fluid intake control, control glucose with diet _ ___Other_______________________________________________________________________________ ______________________________________________________________________________________ ___Notify ___Physician____Nursing by ___note/ phone/ discuss in person Monitoring/Evaluation _x__Intake: adjustment process to diet, not exceed more than 50% of carbs prescripted _x_ Labs/tests: monitor high current lab values and A1C _x_ Wt change: monitor weigh to healthy BMI and prevent dehydration___ _____Other_____________________________________________________________________________ Signature__Nayle Aranda______Date:____2/24/2022_______________Time__1:00pm____________
