Emma Craig
Professor Matuszak
KNH 413
Case Study 2
17 February 2015
1. There are precipitating factors for diabetic ketoacidosis. List at least seven possible factors.
Seven possible factors for diabetic ketoacidosis are:
 Lack of blood glucose self monitoring
 Severe illness or infection
 Insulin omitted
 Increased insulin needs with growth spurts
 Inappropriately stored insulin
 Infection
 Alcohol Abuse
(Nelms, 486)
2. Describe the metabolic events that lead to symptoms associated with DKA.
Diabetic ketoacidosis usually develops as a result of infections or because the body does not take
adequate amounts of insulin. Without adequate insulin, there is in increased dependence on lipids
as the primary fuel source. The rate of lipolysis increases, resulting in the production of the
ketones aceto-acetic acid and hydroxy-butyric acid. These ketones lower serum pH, resulting in
the kidney excreting these ketone bodies in the urine. These events result in metabolic acidosis.
High levels of ketoacids result in an increase in the plasma anion gap. As pH lowers respiratory
ventilation changes to accommodate the body. Respirations are deep and labored. Additionally,
the renal system compensates by conserving bicarbonate, and there is an increase in positively
charged cation excretion (Nelms, 145).
3. Assess Susan’s physical examination. What is consistent with diabetic ketoacidosis? Give
the physiological rationale for each that you identify.
Susan came in with nausea, vomiting, acetone breath, fatigue, intense thirst, lethargy, deep, rapid
kassmaul’s respirations, poor turgor and was irritable. Kassmual’s respirations occur due to the
lowering of pH in the body. Respiratory ventilation changes to accommodate the need to reduce
pCO2. Dehydration could have been the cause of her nausea, vomiting, lethargy and poor turgor.
This decrease in fluid causes the blood to become concentrated, resulting in hyperglycemia.
Acetone breath occurs when ketones are released in the body and then breathed out. This
hyperglycemia could high also been the cause of her nausea, vomiting, increased thirsty and
lethargy (Nelms, 145, 486, 496).
4. Examine Susan’s biochemical indices both in the chemistry section and in her ABG report.
Which are consistent with DKA? Why?
The following values were abnormal:
Lab Value
Potassium
Chloride
PO4
CO4
Glucose
BUN
Creatinine
HbA1c
Ketones in urine
Glucose in urine
pH
CO2
HCO3
Susan’s Level
5.5
98-108
4.9
22
475
8-26
1.8
12.0
positive
positive
7.31
22
21
Normal Level
3.5-5.5
110
2.5-4.5
24-30
70-120
29
.6-1.3
4.8-7.8
High/Low
High
High
High
Low
High
High
High
High
7.35-7.45
23-30
24-29
low
low
low
All of the values listed above are consistent with DKA. Her electrolyte levels are off balance due
to her dehydration. She has hyperglycemia, increasing her glucose levels. Her hbA1c level is also
high, most likely due to her poor treatment of her diabetes. Her arterial blood glass values are
also consistent with DKA as her values are low. She also has high BUN, ketone in her urine and
glucose in her urine due to her DKA and the excessive amounts of ketones the body is producing
(Nelms, 145, 496).
5. If Susan’s symptoms were left untreated, what would happen?
If DKA is not treated properly, coma or death can occur. 2% to 5% of cases are fatal. In order to
prevent coma or death, adequate insulin, fluids and electrolytes should be provided (Nelms, 145).
6. Assuming Susan’s SMBG records are correct, what events seem to have precipitated the
development of DKA?
When Susan began her period, her values began to elevate. Additionally, she had a volleyball
tournament and it was her birthday. Her values very drastically increased the day of her birthday,
most likely due to eating sugary foods. The increase of her blood sugar values was over ten days.
7. What, if anything, could Susan have done to avoid DKA?
Although Susan self-monitors her blood glucose levels, she should have noted the high levels of
blood glucose. She could have taken more insulin. She then would have been able to let her
physician or parents know so she could make necessary changes to decrease her high levels.
8. While Susan is being stabilized, Tagamet is being given IV piggyback. What does “IV
piggyback” mean? What is Tagamet, and why has it been prescribed?
An IV piggyback is the delivery of additional fluid or medication through the primary
intravenous line from a second source of fluid with a secondary set of intravenous tubing.
Tagamet, also known as cimetidine, is used to treat conditions where the stomach produces too
much acidosis. This was prescribed to help counter the ketoacidosis.
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682256.html
http://medical-dictionary.thefreedictionary.com/intravenous+infusion
9. The Diabetes Control and Complications Trial was a landmark multicenter trial designed to
test the proposition that complications of diabetes mellitus are related to elevation of plasma
glucose. It is the longest and largest prospective study showing that lowering blood glucose
concentrations slows or prevents development of complications common to individuals with
diabetes. The trial compared “intensive” insulin therapy (“tight therapy”) with
“conventional” insulin therapy. Define “intensive” insulin therapy. Define “conventional”
insulin therapy.
Conventional insulin therapy consists of a constant does of basal insulin ombinted with
short-or-rapid acting insulin. Individuals using conventional insulin therapy must synchronize
administration of their insulin and food intake to avoid hypoglycemia.
Intensive insulin therapy requires multiple daily injections of bolus insulin before meals
in addition to basal insulin once or twice a day. Insulin can be adjusted to correspond to food
intake, therefore replication endogenous insulin secretion in a person without diabetes (Nelms,
487-488).
10. List the microvascular and neurologic complications associated with type 1 diabetes.
Retinopathy: This is a disorder of the retina, the tissue layer within the back of the eye that sense
light and transmits sensory information to the brain.
Nephropathy: This is a renal disease that results from damage to blood vessels from
hyperglycemia.
Neuropathy: This is a disorder of the nerves, symptoms generally depend on the type of nerves
affected.
(Nelms, 472)
11. What are the advantages of intensive insulin therapy?
One major advantage of intensive insulin therapy is that in delays onset and slows the
progression of complications such as retinopathy, nephropathy and neuropathy in patients with
T1DM. Additionally, intensive insulin therapy replicates endogenous insulin secretion in a
person without diabetes. Intensive insulin therapy also allows for the adjustment of insulin dose
in response to hyperglycemia, variable carbohydrate intake, or alteration in usual physical
activity (Nelms, 488).
12. What are the risks of intensive insulin therapy (tight control)?
Individuals employing intensive therapy are required to know their basic doses for background
and bolus insulin. Patients also need to know out-of-target blood glucose-results can be brought
by certain other circumstances other than food intake. There may be hypoglycemia and weight
loss (Nelms, 488-489).
13. Dr. Green consults with you, and the two of you decide that Susan would benefit from insulin
pump therapy combined with CHO counting for intensive insulin therapy. This will give
Susan better glycemic control and more flexibility. What are some of the key characteristics
of candidates for intensive insulin therapy?
Patients who are candidates for intensive insulin therapy have type 1 diabetes. Additionally these
candidates must be willing to know their basic doses for background and bolus insulin.
Additionally, these candidates must be willing to pay close attention to their blood glucose levels
and follow their regimens closely (Nelms, 488-489).
14. Explain how an insulin pump works. Is Susan a candidate for an insulin pump?
Insulin pumps are powered by batteries. Regular or rapid-acting insulin is delivered through
flexible tubing and is attached to the individual via an infusion set. Continuous subcutaneous
insulin infusion allows creation of variable and adjustable insulin dosing to meet individual
insulin needs. Pump therapy duplicates insulin secretion more than other methods of insulin
delivery. Detailed instructions and training are necessary, and mastering this method requires
time and effort (Nelms, 489). Susan is a candidate for an insulin pump but she must be willing to
take the time and energy to learn how to use it. It would be beneficial for her based on her
previous history of not watching her blood glucose levels closely.
15. How would you describe CHO counting to Susan and her family?
In order for Susan and her family to fully understand carbohydrate counting, I would have some
educational materials. I would start off by explaining carbohydrate counting is a meal panning
approach that concentrates on the total amount of carbohydrates eaten at meals and snacks. 15g
of carbohydrates equals 1 count. I would offer her a chart that shows all the different foods with
their carbohydrate counting numbers, and possibly even show her a phone app if she has a
compatible phone. This will help Susan better monitor her blood glucose levels and insulin. I
would tell Susan and her family Susan should try and have protein and carbohydrate at every
meal (Nelms, 493).
16. How is CHO counting used with intensive insulin therapy?
Carbohydrate counting allows people on intensive insulin therapy to tailor their insulin to their
mealtime dose to cover the amount of carbohydrate eaten at that meal. The amount of rapid- or
short-acting insulin can be based on meal composition and/or its carbohydrate content (Nelms,
489).
17. Estimate Susan’s daily energy needs using the Harris-Benedict equation.
REE = 655.1 + 9.6W + 1.9S – 4.7A
REE = 655.1 + 9.6 (52.3 kg) + 1.9 (160 cm) – 4.7 (16 yrs)
REE = 1386 kcal/day
REE: 1386 x 1.56 (Very active)=2162.16kcal
Total of: 2100-2200 kcal/day
18. Using the 1-week food diary from Susan, calculate the average amount of CHO usually
consumed each meal and snack.
Approx.: 100 gm CHO breakfast
Approx: 90 gm CHO lunch
Approx: 30 gm CHO snack
Approx. 100 gm CHO dinner
Approx 20 gm CHO HS
19. After you have calculated Susan’s usual ChHO intake from her food record, develop a CHOcounting meal plan that she could use. Include menu ideas.
According to the harris-benedict equation, Susan should be eating about 2100 kcal per day. I
would recommend 55% CHO, 20% PRO and 25% FAT.
CHO: 2100x.55=1155 kcal CHO/4= 289g carbohydrates/15=20 carbohydrate counter per day
PRO: 2100 x .20=420 kcal/4=105g PRO
FAT: 2100 x .25= 525kcal/9= 58 g FAT
Time
CHO
Breakfast 4
Lunch
6
Snack
2
Dinner
6
HS
2
Menu Ideas
1 cup oatmeal
1 banana
1 egg
½ cup milk
2 slices toast
2 oz chicken
½ cup canned mandarins
2/3 cup yogurt
1 cup carrots
½ bagel
2 tbsp peanut butter
1 turkey burger
1 cup broccoli
½ sweet potato
1 small apple
2 small cookies
4 cups popcorn
20. Just before Susan is discharged, her mother asks you, “My friend who owns a health food
store told me Susan should use stevia instead of artificial sweeteners or sugar. What do you
think?” What will you tell Susan and her mother?
According to the FDA, stevia is recognized as a safe food additive and sweetener. I would
recommend Susan and her mother allow Susan to use stevia. I would recommend she watch her
use of it and not use it in excess.
http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understandingcarbohydrates/artificial-sweeteners/
References
Cimetidine: MedlinePlus Drug Information. (n.d.). Retrieved February 17, 2015, from
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682256.html
Low-Calorie Sweeteners. (n.d.). Retrieved February 17, 2015, from
http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understandingcarbohydrates/artificial-sweeteners/
(n.d.). Retrieved February 17, 2015, from http://medicaldictionary.thefreedictionary.com/intravenous infusion
Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L. (2011). Nutrition Therapy & Pathophysiology.
Edition 2. Belmont, CA.