Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
I. Understanding the Disease and Pathophysiology
1.
What are the standard diagnostic criteria (not risk factors) for T2DM? Cite the ADA Standards of Medical
Care – 2016. Which are found in Mitch’s medical record? (5)
The standard diagnostic criteria involves 4 tests; fasting plasma glucose, 2-h plasma glucose after a 75-g oral
glucose tolerance test, and A1C criteria. Fasting plasma glucose must be ​>​ 126 mg/dL (7.0 mmol/L); defined as no
caloric intake for at least 8 hours. The 2-h PG must be ​>​ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance
test (OGTT), performed under the description of the World Health Organization (WHO), using a glucose load
containing the equivalent of 75 g anhydrous glucose dissolved in water. The A1C test identifies through a cut point
>​ 6.5% (48 mmol/mol), performed in a laboratory, using a method that is NGSP certified & standardized to the
DCCT assay. A random plasma glucose ​>​ 200 mg/dL (11.1 mmol/L) is performed in patients with classic symptoms
of hyperglycemia & in a hyperglycemic crisis. Based on Mitch’s medical record, the following are found: random
plasma glucose of 1524 mg/dL, 15.2% of Hemoglobin A1C, and 475 mg/dL of fasting plasma glucose (FPG) (ADA
2014). Based on Mitch’s medical record, the following are found: random plasma glucose of 1524 mg/dL, 15.2% of
Hemoglobin A1C, and 475 mg/dL of fasting plasma glucose (FPG).
2.
Mitch was previously diagnosed with T2DM. His admits that he often does not take his medications.
For each of his diabetes pills, metformin and glyburide, state the class of medication and mechanism of
action; list potential drug side effects (i.e nausea, etc) and drug-nutrient interactions (i.e. foods or nutrients
to be added or avoided) for each drug. (6)
● Metformin (Glucophage):
-Class of Medication: Biguanide
-Mechanism of Action: Decrease hepatic glucose productive & normalize insulin levels (Krause 690, 223).
-Potential Drug Side Effects: Gastrointestinal side effects (e.g. Diarrhea, nausea, etc.) (Krause 689).
-Drug-nutrient Interactions: Causes reduced absorption of vitamin B12 and folic acid, avoid alcohol to prevent risk
of lactic acidosis, and maintain prescribed diet to limit gastrointestinal effects (Krause 738, 1102).
● Glyburide:
-Class of Medication: Second generation Sulfonylurea(s) (​ Franz, 2012, p.690).
-Mechanism of Action: Stimulate insulin secretion of beta cells​ (Franz, 2012, p.690). ​.
-Potential drug side effects: Hypoglycemia ​ (Franz, 2012, pp.689-691).
-Drug-nutrient Interactions: Avoid alcohol to prevent gluconeogenesis inhibition ​(Pronskey & Crowe, 2012, p.218).
.
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
3.
Mitch also takes other medications, Dyazide and Lipitor. List their mechanisms, potential side effects and
drug-nutrient interactions.
He is beginning insulin. For his prescribed insulins, state type; time of onset, peak, duration; potential
side-effect. (5)
● Dyazide: Hydrochlorothiazide & Triamterene
-Mechanism of Action: HCTZ & TM increases sodium excretion, TMM prevents loss of potassium, hydrogen, and
chloride ions from HCTZ. HCTZ increase excretion of water through inhibition of sodium & chloride ion
reabsorption, reduces elimination of calcium & uric acid. TMM inhibits sodium reabsorption in return for potassium
& hydrogen.
-Potential Side Effects: hyperkalemia (moderate - severe), hypokalemia, hyperglycemia, hyponatremia,
hypercalcemia, diabetes mellitus, constipation, jaundice (moderate), nausea, anorexia, diarrhea, polyuria (mild),
uticaria, photosensitivity, anaphylaxis, acidosis, pancreatitis, elevated BUN & serum creatinine, megaloblastic
anemia, impotence, hemolytic anemia.
-Drug-nutrient Interactions: Caffeine may cause potential orthostatic hypotension, Vitamin D and calcium doses
may be necessary and/or aggravate hypercalcemia, potassium supplements may cause hyperkalemia, avoid alcohol
to prevent hypotensive effect (i.e. increase in blood pressure) (Net Doctor 2015).
● Lipitor: Atorvastatin
-Mechanism of Action: controls elevated triglycerides (Pronskey & Crowe, 20102, p. 215-223), inhibits
hydroxymethlyglutaryl-coenzyme A (HMG-CoA) causing reduction of total cholesterol & LDL cholesterol
(Prescribers’ Digital Reference 2017).
-Potential Side Effects: myopathy, hepatic necrosis, hepatic failure, renal failure, cirrhosis, pancreatitis, hemolytic
anemia, peripheral neuropathy, jaundice, blurred vision, leukopenia, hyperglycemia, myalgia, pharyngitis, arthralgia,
diarrhea, infection, insomnia, dyspepsia, nausea, abdominal pain, flatulence, dizziness, urticaria, fatigue, and
flushing (Prescribers’ Digital Reference 2017).
- Drug-nutrient Interactions: Avoid excessive doses of niacin to prevent risk of myopathy, avoid alcohol to prevent
elevated hepatic transaminases, avoid grapefruit juice, and other citrus fruits, to avoid drug accumulation & toxicity
(Prescribers’ Digital Reference 2017).
● Lispro:
-Type: Humalog; Rapid-acting
-Time of onset: < 15 minutes
-Peak: 1 - 2 hours
-Duration: 3 - 4 hours (Franz, 2012, p. 692)
-Potential Side Effects: insulin shock, hypoglycemia, hyperinsulinemia, hypokalemia, dyspnea, hypotension, sinus
tachycardia, hypertension, peripheral edema, pharyngitis, cough, infection, diarrhea, abdominal pain, nausea, fever,
myalgia, diaphoresis, urticaria, insulin resistance (Prescribers’ Digital Reference 2017).
● Glargine:
-Type: Lantus; Long-acting
-Time of onset: 2 - 4 hours
-Peak: No peak
-Duration: 20 - 24 hours (Franz, 2012, p. 692)
-Potential Side Effects: insulin shock, angioedema, retinopathy, peripheral edema, hypertension, depression,
hypoglycemia, hyperinsulinemia, hypokalemia, erythema, hypotension, peripheral neuropathy, infection, arthralgia,
pharyngitis, cough, diarrhea, headache, rhinitis, weight gain, urticaria (Prescribers’ Digital Reference 2017)
4.
Mitch experienced symptoms and subsequent admission to the ER with the diagnosis of uncontrolled T2DM
with HHS.
Describe what led to his severe hyperglycemia.
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
State Mitch’s signs and symptoms of dehydration.
Define HHS, its etiology and symptoms.
State Mitch’s signs and symptoms of HHS. (8)
Mitch’s severe hyperglycemia is a result from no prior food education for diabetics, unregulated diet & glucose
consumption. Based on his diet recall, his described eating patterns consist of high fat, high carbohydrate as opposed
to low fat, low carbohydrate.
Signs & symptoms indicating dehydration include abnormally high blood glucose (ref. range 70-110), dry mucous
membranes without exudates or lesions in throat, pale skin color, and urine described as cloudy & amber. As well as
vital signs, such as low blood pressure (BP: 90/70), vomiting upon admission resulting in water loss, elevated BUN,
Creatinine, Osmolality levels, and low sodium levels (Mahan, Excott-Stump, & Raymond, p. 196).
Hyperglycemic hyperosmolar syndrome is a complication of Type 2 Diabetes and involves elevated blood glucose
levels without the presence of ketones. Kidneys usally remove excess glucose in the body through urine, however, if
insufficient fluids are consumed, with consistent glucose & carbohydrate intake, the kidneys may not perform this
function, resulting in high blood glucose levels. Blood will contain higher concentration of sodium, glucose,etc., as
water is lost (hyperosmolarity), drawing more water out from the body ("Diabetic hyperglycemic hyperosmolar
syndrome: MedlinePlus Medical Encyclopedia."). Hyperglycemia and dehydration can lead to HHS, leaving patients
with elevated blood glucose levels (between 400 - 2800 mg/dL), mild confusion or hallucinations, fatigue, weight
loss, nausea, or coma (Mahan, Excott-Stump, & Raymond, p. 701-702) Mitch demonstrates symptoms of high blood
glucose (1,524 mg/dL) and various signs of dehydration (BUN, Sodium, Creatinine, Osmolality, dry mucous in
throat, etc.).
5.
HHS and DKA are metabolic complications associated with diabetes. Define DKA, its precipitating factors
and signs /symptoms. What characteristics of Mitch’s condition indicate HHS as opposed to DKA? (5)
Diabetic ketoacidosis (DKA) occurs in diabetic patients, in which insufficient insulin results in insufficient use
of glucose, causing production of ketones when fat becomes the primary source of energy as opposed to glucose.
Elevated levels of ketones may lead to ketoacidosis and can be measured through urine when blood glucose is > 250
mg/dl. Signs and symptoms include polyuria, polydipsia, hyperventilation, dehydration, ketone odor (fruity), and
fatigue (Franz, 2012.p. 703). Characteristics of Mitch’s condition, indicating HHS, include elevated serum glucose
levels (hyperglycemia), elevated serum osmolality (dehydration), low systolic blood pressure (BP: 90/70), nausea,
and feeling drowsy & confused (lethargy). Lack of fruity ketone odor (breath), dyspneic breathing, and abdominal
pain does not indicate ketoacidosis.
6.
Mitch was started on normal saline with potassium as well as an insulin drip. Why are these fluids a
component of his rehydration and correction of the HHS? (3)
Hyperglycemic Hyperosmolar Syndrome Saline stems from dehydration & hyperglycemia, in which treatment
involves correcting the water loss, and saline is administered until urine output is established (AAFP 2005). Sodium
is a component, in saline, involved with potassium to prevent hyponatremia, maintain normal water balance, osmotic
equilibrium, and acid-base balance; aid rehydration (p 182-187). Administration of intravenous insulin is given, post
urine output, until blood glucose levels decrease. However, potassium levels may drop when insulin is replaced and
force potassium into the cell, developing risk of hypokalemia. Condition may worsen if insulin is administered prior
to administering saline, causing water to move intracellularly (AAFP 2005).
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
7.
Describe the initial insulin therapy that was started for Mitch and his planned insulin regimen. When would
a patient be started on insulin, based on the recommendations of the ADA? How likely is it that Mitch will
need to continue insulin therapy? (3)
Once 1 L normal saline (NS) was replaced, regular administration of insulin began; 1 unit per kg per hour
through vein (intravenously) in normal saline with 40 mEq per liter potassium-chloride and 500 mL per hour for
three hours. Insulin levels decreased to 1 unit per mL, potassium-chloride levels fell to 10 mEq per liter, and is
applied at 135 mL per hour. Insulin infusion then begins at 3.7 units per hour to 5 units per hour. The MD states in
the patient’s Plan to change the IVF to normal saline, containing 5% dextrose, simultaneous with 20 mEq potassium
at 135 mL per hour, as well as beginning 0.5 units of Lispro (fast-acting insulin), every 2 hours, until glucose levels
fall between 150-200 mg/dL. Glargine should be administered, starting at 19 units, in addition to progressing Lispro,
using an ICR 1:15, while monitoring blood glucose levels between 80-200 mg/dL.
Based on ADA recommendations, insulin is administered if a patient’s A1C values are monitored & reached
every 3 months, experience a hyperglycemic crisis, demonstrating symptoms of hyperglycemia, and a random
plasma glucose ​>​ 200 mg/dL; patients trying to achieve a desired glucose range, without increasing risk for severe
hyperglycemia, should commence on insulin. Mitch’s medical history mentions being prescribed oral medication for
the past year (glyburide and metformin), which suggest him not achieving or maintaining glycemic goals that will
eventually require/continue insulin therapy.
II. Nutrition Assessment
8.
Assess Mitch’s desirable body weight and BMI. What would be a healthy weight range for Mitch? (3)
●
●
●
●
53 Y.O. Male, 5’9” (69 inches), 214#
ABW = 214#
Height = 69 inches
BMI = [Weight (#) / Height (in^2)] x 703
= [249# / (69^2)] x 703
= 36.7%; Class 2 Obesity with BMI range between 35.0 - 39.9%.
● DBW using Hamwi: Males: 106# for 5’ + 6# for each inch >60”
● DBW = 106# + (6# x 9”) = 160#
● DBW range = 160 +/- 10% = 144 - 176#
● %DBW = (ABW / DBW) x 100
● %DBW = (214# / 160#) x 100 = 133.75%; > 120% IBW - possible nutrition risk.
A healthy weight range for Mitch would fall between 144 to 176 lbs., based on desirable weight range.
(Hammond & Litchford, 2012, p. 166) (Lysen & Israel, 2012, p. 470)
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
9.
For each lab value, state its abnormal value upon admission and what the value means / indicates.
How did glucose, sodium, phosphate and osmolality change - state the changed value and why it changed.
(16)
Initial lab values:
● Glucose: 1524 mg/dL (High)
o Reference Range: 70-110 mg/dL
o
●
●
Creatinine: 9 mg/dL (High)
o
Reference Range: 0.6-1.2 mg/dL
o
Indication: poor kidney function as a result from dehydration.
Sodium: 132 mEq/L (Below)
o Reference Range: 136-145 mEq/L
o
●
Indication: dehydration, electrolyte concentrations in urine, displayed in urine color (dark).
BUN: 31 mg/dL (High)
o Reference Range: 8-18 mg/dL
o
●
Indication: water loss, dehydration, diabetic coma, elevated serum albumin, coenzyme q10,
glutathione, and carotenoids.
Specific gravity: 1.045 (High)
o Reference Range: 1.003-1.030
o
●
Indication: within normal range.
Osmolality: 360 mmol/kg/H20 (high)
o Reference Range: 285-295 mmol/kg/H20
o
●
Indication: measures glycemic targets, unregulated blood glucose, HHS.
C-peptide: WNL 1.10 ng/dL
o Reference Range: 0.51-2.72 ng/dL
o
●
Indication: CVD risk.
HbA​1c​: 15.2% (High)
o Reference Range: 3.9-5.2%
o
●
Indication: inadequate fluid intake, poor renal function, and dehydration.
Cholesterol: 205 mg/dL (High)
o Reference Range: 120-199 mg/dL
o
●
Indication: electrolyte excretion, response to acid-base balance, osmotic equilibrium, and water
balance. Patient demonstrates dehydration (Charney, 2012, pp 182-187).
Phosphate: 1.8 (Below)
o Reference Range: 2.3-4.7
o
●
Indication: severe hyperglycemia in T2DM; elevated blood glucose levels and dehydration.
Indication: damage towards kidney(s) and function as a result from dehydration and protein
catabolism.
Glucose in urine: +! (High)
o Reference Range: Negative
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
o
●
Indication: elevated blood glucose levels, hyperglycemia, unregulated diabetes mellitus, excessive
glucose filtration in the kidneys.
Protein in urine: +! (High)
o Reference Range: Negative
o
Indication: proteinuria, serum albumin present, impaired kidney function due to dehydration.
Changed values:
● Glucose: 475 mg/dL (High)
o Initial Value: 1524 mg/dL
o
●
Osmolality: 304 mmol/kg/H20 (High)
o Initial Value: 360 mmol/kg/H20
o
●
Indication: insulin therapy applied intravenously, hydration status being restored.
Sodium: 134 mEq/L (Below)
o Initial Value: 132 mEq/L
o
●
Indication: Patient is taking Lispro; fast-acting insulin. Hydration status being restored.
Indication: serum saline is applied intravenously, sodium being a component, hydration is being
maintained/monitored.
Phosphate: 2.1 mg/dL (Below)
o Initial Value: 1.8 mg/dL
o
Indication: rehydration applied intravenously, proper kidney function.
10. Determine Mitch’s energy requirements for weight maintenance using Mifflin St. Jeor equation; state why
this equation is an appropriate choice; use AF and SF as appropriate.
Determine Mitch’s protein requirements justifying the use of DBW vs. ABWand g protein / kg.
What daily energy intake would you recommend for an appropriate rate of weight loss? Justify your
recommendation. (3)
EER:
Mifflin-St. Jeor Eq. Male: kcal/day = 10 (wt) + 6.25 (ht) - 5 (age) +5
Wt. = 214# / 2.2 kg = 97.27 kg
Ht. = 69 inches = 175.26 cm
Age = 53 YO
Kcal/day = 10 (97.27) kg) + 6.25 (175.26 cm) - 5(53 YO) + 5
*Physical Activity Level (PAL) 1-1.39 Sedentary lifestyle, EER Range = 1808.08 kcal/day x 1.39 = 2513.23
kcal/day.*
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
Mitch’s energy requirements for weight maintenance is 1808.08 - 2513.23 kcal/day. The Mifflin-St. Jeor equation is
an appropriate choice due to its purpose of determining EER for both normal weight and obese people. PAL is a
coefficient applied to the equation to determine, as accurate as possible, energy requirements (Ireton-Jones, 2012, p.
24-26).
The DRI protein requirements for diabetic patients, is equivalent for non-diabetic patients; 0.8 g/kg/day or 15-20%
reduced from total kcal. Excessive protein consumption should be avoided to prevent nephropathy & weight gain
(Franz, 2012, p. 684-688). It is ideal to use DBW, as opposed to ABW, based on his physiology because if he
consumes protein in accordance to his ABW, he will consume more than necessary.
Mitch’s protein requirements:
Protein ≥ 0.8 g/kg/d
= (0.8 g x 97.27 kg/day) = 77.82 g/day
ADA recommendations state DRI requirements for macronutrients is no different from the requirements of
non-diabetic patients; carbohydrate: 45-65%, protein: 10-35%, fat: 20-35%. Based on the patient’s EER range, I
would recommend following the end range of 2,300 kcal/day, as well as incorporating physical activity, to
implement burning 500 kcal/day (500 kcal/day x 7 days = 3,500 kcal/week), while still being within EER range
(Franz, 2012, p. 684-686).
III. Understanding the Nutrition Therapy
11. Mitch was NPO when admitted to the hospital. Why? What does this mean? When will Mitch be ready to eat?
What foods would be recommended immediately following NPO, before initiating a diet for diabetes? (4)
Mitch was NPO, meaning non per os or no oral intake, when admitted to the hospital due to undergoing emesis,
prior 12-24 hours with having, stated, “sips of water” before his hyperglycemic crisis. When lab values reach within
reference range, and hydration status has improved, he may return to a normal diet. Once glucose is stabilized, liquid
diet will be administered, advancing to consistent carbohydrate diet, following normal diet for T2DM management
with dietitian’s consult. Take into consideration foods that may cause GI distress and high glycemic index, as they
may elevate blood glucose levels.
12. Mitch was prescribed an initial ICR 1:15. Explain what this means.
Outline the general principles for nutrition therapy, to assist in control of DM, for: meals and snacks,
carbohydrate, sugar substitutes, fats and weight reduction. Cite the ADA’s Clinical Practice
Recommendations for Medical Nutrition Therapy – 2016. (5)
An ICR 1:15 indicates an insulin to carbohydrate ratio, in which intake is monitored within one meal for 1 unit
of insulin to 15 grams of carbohydrates. Administration is dependent on patient’s weight, caloric intake, and
physiology.
Based on ADA’s recommendations for medical nutrition therapy, a Mediterranean-style, MUFA-rich eating
pattern assists in glycemic control. Snack foods containing long-chain n-3 fatty acids and linolenic acid is
recommended, as well as replacing substituting low-glycemic load foods for higher glycemic load foods may
modestly improve glycemic control. Consuming whole grains is recommended and sugar-sweetened beverages,
sweeteners (e.g. high fructose corn syrup, sucrose, etc.), and isocaloric amounts of CHO are cautioned to avoid
displacing nutrient-dense foods. Reducing energy intake while maintaining a healthful eating pattern is
recommended to promote weight loss (ADA 2014).
IV. Nutrition Diagnosis
13. Write 2 priority nutrition diagnoses, each in PES format. Cite eNCPT. (6)
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
1.
Inadequate Oral Intake (NI-2.1) as related to food and nutrition related knowledge deficit concerning
appropriate oral food/beverage intake as evidenced by dry skin, mucous membranes, nausea, and vomiting.
2.
Altered Nutrition-Related Laboratory Values (NC-2.2) related to HHS as evidenced by ↑ BUN, ↑ Plasma
glucose and/or HgbA1c levels, and Inadequate blood glucose control.
V. Nutrition Intervention
14. Determine Mitch’s initial CHO prescription using his diet history as well as your assessment of his energy
requirements for weight loss: State daily kcal intake, percent kcal from CHO, g CHO, number of CHO
choices per day; Suggest the number of CHO choices you would recommend for 3 meals and 2 snacks based
on his diet history and medication. Cite Choose Your Foods: Exchange Lists for Meal Planning/Food
Choices. (5)
Mitch’s CHO Prescription:
● Daily kcal intake range: 1,808 - 2,513 kcal/day (EER - Mifflin-St. Jeor Eqt.)
● % kcal from CHO: 1,808 kcal/day - 2,513 kcal/day) x 55% = 995 - 1,382 kcal/day
● g CHO: (995 kcal/day - 1,382 kcal/day) / 4 kcal/g = 249 - 346 g CHO
● Number of CHO choices per day:
(249 - 346 g CHO) / 15 g/choice = 17 - 23 choices/day
CHO Choices: 3 meals, 2 snacks | 17 choices /day:
● Breakfast: 4 CHO choices
● Snack: 2 CHO choices
● Lunch: 5 CHO choices
● Snack: 2 CHO choices
●
Dinner: 3 CHO choices
15. Identify two initial nutrition goals to assist with weight-loss. (4)
1. Patient will incorporate PAL, beginning at 20 minutes per day for 3 days, for 2 weeks.
2.
Patient will substitute simple starches with complex starches for one week.
16. Mitch also has hypertension and high cholesterol levels. State the recommendations for the lipid profile,
LDL, HDL, Cholesterol and Triglycerides for people with diabetes
Describe nutrition recommendations for fiber, types of fat and sodium for Mitch and why. (4)
Diabetic Lipid Profile Recommendations:
● LDL: < 130 mg/dL
● HDL: >40 mg/dL
● Cholesterol: < 200 mg/dL
● Triglycerides: < 150 mg/dL
Nutrient recommendations for fiber intake for people with diabetes is similar for the general public; 25-30 g
of fiber per day, with 7-13 g from soluble fiber sources for cardioprotective nutrition therapy (Franz, 2012, p. 686).
It is an essential component of management and self management education (ADA 2014).
Evidence, based on recommendations, suggest consumption of n-3 polyunsaturated fatty acids and 2-3
servings of fish per week (Franz, 2012, p. 687). PUFA and MUFA are recommended as substitutes for saturated and
trans fat. Patients with type 2 diabetes have an increased risk of lipid abnormalities that contribute towards CVD
risk, thus recommendations are based on improving lipid profile in patients (ADA 2014).
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
Intake of foods with added sodium should be avoided or substituted, while the recommendation for the general
population states reducing sodium < 2,300 mg/day. Further reduction in sodium should be individualized for patients
with diabetes; < 1,500 mg/day.
VI. Nutrition Monitoring and Evaluation
17. Write an ADIME/SOAP note for your initial nutrition assessment. Remember to always sign and date your
note (5). Create a meal plan based on his glucose, weight loss and lipid goals and his food preferences using
exchanges (5). Use forms provided below: (10)
A – Assessment
S - Subjective
Chief Complaint: “I had a lot of vomiting that I thought at first was food poisoning but I just kept getting worse.” Patient is inconsistent with
diabetic medication, states “I hate how they make me feel but I almost always take my other medications for blood pressure and cholesterol.”
UBW: N/A
Nutritional supplement: None
Weight change: gain / loss: N/A
Vitamins / herbs: None
Appetite: normal; 12-14 hours prior to admission- no caloric intake as a
result from symptoms.
Food preparation: often eats out; sometimes eats homemade meals.
Factors affecting food intake: severe hyperglycemia, emesis
Chewing / swallowing problem / sore mouth
Nausea / ​vomiting​ / diarrhea / constipation
Food intolerance / allergies: N/A
Social / cultural / religious / financial: single, retired military, lives
alone, 8-5 daily work hours, 3-4 drinks per week.
Other: 1 ppd x 20 years tobacco use – now quit. Currently works as
consultant to military equipment company.
Diet prior to admit: avoids added salt/sodium, high cholesterol, high
sugary foods. Diversified food preferences.
O – Objective
Current Diet Order:
NPO except for ice chips and medications. After 12 hours, clear liquids if stable. Then, advance to consistent-carbohydrate diet. Consult dietitian
for advancement, total carbohydrate Rx, and distribution.
Medical Diagnosis: unregulated T2DM w/ HHS
Nutrition Focused Physical Signs & Symptoms:
Temp:100.5 F,
BP: 90/70
Throat: Dry mucous membranes;
Neurologic: Alert but previously drowsy with
mild confusion;
Skin: Warm and dry;
Skin temp: DI
Chest/lungs: Respirations are rapid
Pertinent Medical History: Type 2 DM x 1 year- prescribed
glyburide and metformin but admits that he has not taken the
medications regularly; HTN; hyperlipidemia; gout
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
Gender: Male
•​
Female •​
Age:
53 YO
% UBW: N/A
Ht: 5’9”
Wt:
% wt ​Δ​: N/A
Admit ​•
Current ​•
DBW: 160#, 144-176#
BMI: 32
% DBW: 133.74%
Other:
Nutritionally Relevant Laboratory Data:
Initial lab values:
-Glucose: ↑ 1524 mg/dL
-Creatinine: ↑ 1.9 mg/dL
-Sodium: ↓ 132 mEq/L
-Phosphate: ↓ 1.8 mg/dL
-Cholesterol: ↑ 205 mg/dL
-HbA1c: ↑ 15.2%
-C-peptide: WNL 1.10 ng/mL
-Osmolality: ↑ 360 mmol/kg/H2O
-Specific gravity: ↑ 1.045
-BUN: ↑ 31 mg/dL
-Glucose in urine: ↑ +
-Protein in urine: ↑+
Changed values:
-Glucose: ↑ 475 mg/dL
-Osmolality: ↑ 304 mmol/kg/H2O
-Sodium: ↓ 134 mEq/L
-Phosphate: ↓ 2.1 mg/dL
Drug Nutrient Interaction:
Avoid alcohol
Estimated Energy Need:
Estimated Protein Need:
Estimated Fluid Need:
1,808.08 – 2,513.23​ kcal / day
Based on: Mifflin-St. Jeor
77.82​ g/day
Based on: ​>​ 0.8 g/kg/day for wt. loss
management
2,000-2,500​ ml / day
Based on: 20-26 mL/kg/day
Nutrition Diagnosis (D)
A - Assessment (A)
State no more than 2 priority Nutrition Diagnosis statements in PES Format. Use Nutrition Diagnosis Terminology sheet
ND Term (Problem) related to (Etiology) as evidenced by (Signs and Symptoms) :
1.
Inadequate Oral Intake (NI-2.1) as related to food and nutrition related knowledge deficit concerning appropriate oral food/beverage
intake as evidenced by dry skin, mucous membranes, nausea, and vomiting.
2.
Altered Nutrition-Related Laboratory Values (NC-2.2) related to HHS as evidenced by ↑ BUN, ↑ Plasma glucose and/or HgbA1c levels,
and Inadequate blood glucose control.
Nutrition Intervention (I)
P - Plan
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
List Nutrition Interventions. Use Nutrition Intervention Terminology sheet. (The intervention(s) must address the problems (diagnoses)​.
●
●
●
●
●
●
General/healthful diet ND-1.1​ ​
Consistent carbohydrate diet ND-1.2.4.1
Purpose of the nutrition education E-1.1
Survival information E-1.3
Self-monitoring C-2.3
Cognitive restructuring C-2.8
Goal(s):
1.
2.
Patient will reach ~75% of the total kcal requirements per day for one week.
Patient will consume 2,000 mL per day, for one week, to restore electrolyte balance & water loss.
Plan for Monitoring and Evaluation (M E)
List indicators for monitoring and evaluation. Use Nutrition Assessment and Monitoring & Evaluation sheets. (Upon follow-up, the plan for
monitoring would indicate if interventions are addressing the problems).
Anthropometrics:
● Body Mass Index (AD-1.1.5.1)
●
●
Weight (AD-1.1.2)
Weight Change (AD-1.1.4)
Food/Nutrition-Related History Outcomes:
● Total energy intake (FH-1.1.1.1)
●
●
●
●
●
●
Amount of food (FH-1.2.2.1)​
Types of food/meals (FH-1.2.2.2)
Meal/snack pattern (FH-1.2.2.3)
Food variety (FH-1.2.2.5)
Total carbohydrate intake (FH-1.5.5.1)
Insulin-to-carbohydrate ratio (FH-1.5.5.13)
Biochemical Data, Medical Tests, and Procedure Outcomes (BD)
● Lipid profile (BD-1.7)
● Glucose/endocrine profile (BD-1.5)
● Electrolyte and renal profile (BD-1.2)
● Urine profile (BD- 1.12)
Signature:
Date:
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
EXCHANGE LISTS FOR MEAL PLANNING
Carbohydrate
Protein
Fat
247.5 g
90 g
112.5 g
990 kcal
360 kcal
450 kcal
% Carbohydrate ~55%
% Protein ~20%
% Fat ~25%
EXCHANGES
MORNING MEAL
____ CHO group
Menu
CHOg
____ Starch
Oatmeal (1/2 cup)
____ Fruit
Blueberries (1/2 cup)
____ Milk
1 % milk (1 cup)
____
Meat group
____
Fat group
MORNING SNACK
NOON MEAL
PROg
Hard boiled eggs (1 large egg)
Peanut butter and Pretzels
Total Kcal 1,800 KCAL
FATg
kcal
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
____
CHO group
____ Starch.
Multigrain bread (1 roll)
____ Fruit
Small orange (1)
____ Milk
1% milk (1 cup)
____ Veg
Cabbage, cooked (1 cup)
____
Meat group
Beef meatballs (3 medium-szied)
____
Fat group
Olive oil (1 tspn)
AFTERNOON SNACK
EVENING MEAL.
____
Carrots w/ Ranch sauce
CHO group
____ Starch
Sweet potatoes (1/2 cup)
____ Fruit
Banana (1 medium)
____ Milk
1% milk (1 cup)
____ Veg
Garden salad (1/2 cup)
____
Meat group
Oven roasted chicken (1/4 chicken)
____
Fat group
Canola oil (1 tspn)
BEDTIME SNACK
Half cup Yogurt
Name:
Case 17 - Adult Type 2 Diabetes Mellitus: Transition to Insulin
References:
Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT):
Dietetics ​Language for Nutrition Care. http://ncpt.webauthor.com. Accessed [Month Day,
Year that you ​visited the site].
American Diabetes Association. (2016). Standards of medical care in diabetes. Diabetes care,
39(supplement 1), s26-s28.
DKA (Ketoacidosis) & Ketones. (2017). Retrieved March 19, 2017, fromhttp://www.diabetes.
org/
living-with-diabetes/complications/ketoacidosis-dka.html?referrer=https%3A%2F ​%2Fw
ww.google.com%2F 2015
Escott-Stump, S., Mahan, K. L., & Raymond, J.L. (2012). Krause’s Food and the Nutrition Care
Process (13th Ed) (pp 1102). St. Louis, MO: Elsevier.
Marshall, H. (2015, October 27). Dyazide (triamterene, hydrochlorothiazide). Retrieved March ​
19, 2017, from
http://www.netdoctor.co.uk/medicines/heart-and-blood/a6630/dyazide-​​triamterene-hydro
chlorothiazide/
PDR Search. (2017). Atorvastatin calcium - Drug Summary Retrieved March 21, 2017,
from ​http://www.pdr.net/drug-summary/Lipitor-atorvastatin-calcium-2338.3993​
Stoner, G. D. (2005, May 01). Hyperosmolar Hyperglycemic State. Retrieved March 19, 2017, ​
from http://www.aafp.org/afp/2005/0501/p1723.html