Katie Davis
KNH 413
Ms. Matuszak
Case Study 2 - DKA and Iron Supplementation
1. There are precipitating factors for diabetic ketoacidosis. List at least seven
possible factors.
Having Type 1 Diabetes, having Type 2 Diabetes during acute illness or when
they have become insulin deficient, becoming ill, having fever, nausea, vomiting,
and diarrhea, getting an infection, having emotional stress, and omission of
insulin as a part of management plan are all precipitating factors for DKA
(Nelms, p. 496).
2. Describe the metabolic events that led to the symptoms associated with DKA.
DKA occurs when inadequate amounts of insulin are available causing glucose
to be produced via gluconeogenesis and lipolysis. This is stimulated by counterregulatory hormones in an effort to help the body avoid starvation and produces
by-products such as ketones and glucose. These by-products accumulate in the
blood and cause osmotic diuresis to occur, which results in dehydration,
electrolyte imbalances, and fluid loss that causes the blood to become
concentrated and severe hyperglycemia to result (Nelms, p. 496).
3. Assess Susan’s physical examination. What is consistent with diabetic
ketoacidosis? Give the physiological rationale for each that you identify.
Her tachycardia and irritability are due to electrolyte imbalances caused by fluid
loss that are affecting nerve impulses to her heart and brain. Many of Susan’s
symptoms such as dry, flushed skin with low turgor pressure and dry mucous
membranes of the ears and nose are cause by dehydration resulting from osmotic
diuresis and fluid loss. Additionally, her fatigue and lethargy are caused by the
fact that her cells are being starved of energy due to lack on insulin to aid glucose
in entering her cells to be converted to energy for her daily life. Finally, her
deep, labored Kussmaul respirations are indicative of later states of severe DKA
and caused by her body’s involuntary attempt offset metabolic acidosis (Nelms,
p. 483).
4. Examine Susan’s biochemical indices both in the chemistry section and in her
ABG report. Which are consistent with DKA? Why?
Susan’s CO2 is low, which is consistent with DKA because CO2 is a by-product of
the body’s metabolism. In DKA her metabolism is not working properly and
producing less CO2. DKA brings about hyperglycemia, so her high blood
glucose and hemoglobin A1C are consistent with this fact. High potassium and
osmolality are consistent with the electrolyte imbalances brought about by fluid
loss from DKA. This fluid loss also accounts for increased hematocrit,
hemoglobin, and white blood cell count (Nelms, p. 483). Altered serum BUN
and serum creatinine are indicators of altered kidney function which is a
complication of long term high blood glucose.
5. If Susan’s symptoms were left untreated, what would happen?
Susan’s Kussmal’s respirations indicate that she is in the later states of severe
DKA. If her symptoms were left untreated, her case would quickly become fatal
due to complications with extremely high serum blood glucose. While most
DKA cases are resolved, some do end in death (Nelms, p. 496).
6. Assuming Susan’s SMBG records are correct, what events seem to have
precipitated the development of DKA?
The start of Susan’s menstrual period in addition to potential emotional stress
caused by her birthday and volleyball tournament seem to have triggered her
insulin to become ineffective and serum blood sugars to rise as DKA developed.
7. What, if anything, could Susan have done to avoid DKA?
Susan is already on an iron supplement and is educated on SMBG, so one thing
she could potentially have done to avoid DKA would be to take a birth control
pill to eliminate her periods.
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 an intravenous line that introduces and administers
medication or some other type of substance into the body of a patient (“What is
an IV Piggyback?”). Additionally, Tagamet has been prescribed because one of
its alternative uses is to prevent aspiration pneumonia due to deep, rapid
breathing and to settle her stomach from effects of vomiting (“Cimetidine”).
9. Define “intensive” insulin therapy. Define “conventional” insulin therapy.
Intensive, or flexible, insulin therapy requires multiple daily injections of bolus
insulin preceding meals plus basal insulin must be taken one or two times per
day (Nelms, p. 488). Conventional or standard insulin therapy requires a
constant dose of basal insulin that is combined with rapid-acting or bolus insulin
(Nelms, p. 487)
10. List the microvascular and neurologic complications with type 1 diabetes.
Type 1 diabetes can lead to microvascular complications such as nephropathy,
which is the leading cause of chronic kidney disease, and retinopathy, which is
the leading cause of blindness in adults. Neurologic complications of type 1
diabetes include impaired sensation or pain in hands and feet, carpal tunnel
syndrome, slowed digestion in the stomach, and autonomic neuropathy (Nelms,
p. 497).
11. What are the advantages of intensive insulin therapy?
There are advantages of intensive insulin therapy such as the fact that in this
type of therapy, insulin can be adjusted to correspond to actual food intake,
which replicates the endogenous insulin secretion in a normal, healthy person
without diabetes. It allows for adjustment of insulin in response to
hyperglycemia, variable carbohydrate intake, or varying physical activity. For
these reasons, this type of therapy also delays onset or progression of many
diabetes-related complications (Nelms, p. 488).
12. What are the risks of intensive insulin therapy (tight control)?
A person using intensive insulin therapy risks developing complications if this
person does not remember that out-of-target blood glucose levels can be caused
by factors other than food intake such as stress, illness, unpredictable insulin
absorption, or changes in exercise (Nelms, p. 489).
13. What are some of the key characteristics of candidates for intensive insulin
therapy?
Important characteristics of candidates for intensive insulin therapy include
mainly individuals with type 1 diabetes and those willing to take frequent doses
of insulin, check blood sugar often, and closely follow an eating and exercise
plan.
14. Explain how an insulin pump works. Is Susan a candidate for an insulin pump?
An insulin pump is a battery-powered, computerized device approximately the
size of a pager. It can be used to deliver bolus or basal insulin through a flexible
tubing that is attached to the individual’s skin by a needle inserted into the fatty
tissue and taped in place (“Insulin Pumps”). The pump allows for the creation of
variable and adjustable insulin dosing that helps patients meet their specific
insulin needs and simulates endogenous insulin secretion even more than
intensive insulin therapy. In order to use a pump, detailed instruction and
training are necessary and mastery of the pump requires much time and energy
(Nelms, p. 489). Because Susan needs flexibility in her insulin doses due to her
variable activity levels and insulin absorption during her periods and because
Susan clearly has the self-control and dedication to follow a strict plan, an insulin
pump is a good idea for her. Susan needs to be cautious and not wear the pump
when playing volleyball.
15. How would you describe CHO counting to Susan and her family?
I would describe that carbohydrate counting has been shown to improve
metabolic control in individuals. I would explain that carbohydrate sources
include starches, fruits, milk/yogurt, and sweets and that Susan can either choose
amounts of foods containing 15 grams of carbohydrate and count those or she
can total the carbohydrate from each meal based on food labels or other nutrient
analysis sources. She should focus on eating consistent amounts of carbohydrate
at her meals and snacks and consume the amount of carbohydrate established
during her consultation and may be adjusted based on blood glucose monitoring
results (Nelms, p. 493).
16. How is CHO counting used with intensive insulin therapy?
Insulin dosage can be determined based on carbohydrate intake. In
carbohydrate counting, individuals know how many grams of carbohydrate they
are consuming and can relate this to their insulin dose. As a starting point, one
unit of rapid-acting insulin can be administered for every 10 to 15 grams of
carbohydrate. This amount will then be adjusted based on SMBG and individual
lifestyle factors.
17. Estimate Susan’s daily energy needs using the Harris-Benedict equation.
Harris-Benedict, women = 655 + (9.56 x wt kg) + (1.85 x ht cm) - (4.68 x age yrs)
REE = 655 + (9.56 x 50 kg) + (1.85 x 160.02 cm) - (4.68 x 16 yrs)
REE = 1354.16 kcal x 2.0 PAL = 2708.32 kcal = 2700 kcal
18. Using the 1-week food diary from Susan, calculate the average about of CHO
usually consumed each meal and snack.
Breakfast: Monday 87g + Tuesday 87g + Wednesday 62g + Thursday 87g + Friday
87g + Saturday 102g + Sunday 87g
85.57g CHO breakfast
Lunch: Monday 60g + Tuesday 45g + Wednesday 15g + Thursday 72g + Friday
60g + Saturday 72g + Sunday 57g
54.43g CHO lunch
Snack: Monday 30g + Tuesday 50g + Wednesday 30g + Thursday 30g + Friday
27g + Saturday 27g + Sunday 15g
29.86g CHO snack
Dinner: Monday 128g + Tuesday 22g + Wednesday 45g + Thursday 63g + Friday
63g + Saturday 30g + Sunday 45g
56.57g CHO dinner
HS: Monday 15g + Tuesday 15g + Wednesday 22.5g + Thursday 15g + Friday 15g
+ Saturday 15g + Sunday 15g
16.07g CHO HS
19. After you have calculated Susan’s usual CHO intake from her food record,
develop a CHO-counting meal plan she could use. Include menu ideas.
Daily Total:
CHO: 371g (25, 15g choices)
PRO: 101g (14, 7g or 1oz choices)
FAT: 90g (18, 5g choices)
Kcalories: 2700
Time
AM
Snack
Lunch
Snack
Dinner
HS
Menu Ideas
6 CHO 15g choices
Cereal, English muffin, juice, fruit
4 oz meat/meat substitutes Sausage, bacon
5 5g fat servings
Butter
2 CHO 15g choices
Crackers and peanut butter
6 CHO 15g choices
Whole grain bread, rice, sweet potatoes
4 oz meat/meat substitutes Fish, poultry, beef
6 5g fat servings
Butter, salad dressing, mayonnaise
2 CHO 15g choices
Pita bread and hummus
7 CHO 15g choices
Dinner roll, rice, soup
5 oz meat/meat substitutes Fish, poultry, beef
75g fat servings
Butter, salad dressing, mayonnaise
2 CHO 15g choices
Fruit, frozen yogurt
20. Just before Susan is discharged, her mother asks you, “My friend who owns a
health food store told me that Susan should use stevia instead of artificial
sweeteners or sugar. What do you think?” What will you tell Susan and her
mother?
I would tell Susan and her mother that the Academy of Nutrition and Dietetics
states that consumers can safely enjoy a wide range of nutritive sweeteners
because they are regulated by the Food and Drug Administration and generally
recognized as safe. These sweeteners should be consumed with a diet guided by
the current federal nutrition recommendations or as directed by a registered
dietitian (“Use of Nutritive and Nonnutritive Sweeteners”).
References
Cimetidine. (2013). MedlinePlus. Retrieved from
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682256.html
Insulin Pumps. (2013). American Diabetes Association. Retrieved from
http://www.diabetes.org/living-with-diabetes/treatment-andcare/medication/insulin/insulin-pumps.html
Nelms, M., Sucher, K. P., Lacey, K., and Roth, S. L. (2011). Nutrition Therapy &
Pathophysiology, Second Edition. Belmont, CA: Brooks/Cole Cengage
Learning.
Use of Nutritive and Nonnutritive Sweeteners. (2012). EatRight.org. Retrieved
from http://www.eatright.org/About/Content.aspx?id=8363
What is an IV Piggyback? (2013). Innovatius. Retrieved from
http://www.innovateus.net/innopedia/what-iv-piggyback