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DM Case Study 27
1. There are precipitating factors for diabetic ketoacidosis. List at least seven possible
factors. Seven possible factors:
Infections, Acute illnesses (CVA, alcohol/drug abuse, pancreatitis, pulmonary
embolism, MI, trauma), Psychological stress, Lack of SMBG, Insulin omitted, Increased
insulin needs with growth spurts, Pump malfunction, and Drug abuse.
Reference: http://www.diabeticlifestyle.com/type-1-diabetes/ketoacidosis-diabetesComplication
2. Describe the metabolic events that led to the symptoms associated with DKA. DKA
is a severe form of hyperglycemia. It occurs when adequate insulin is not
available.
Counter-regulatory hormones are stimulated by glucose production via
gluconeogenisis and lipolysis in an effort to avoid starvation. Lipolysis generates a waste
product called ketones. Glucose and ketones then accumulate in the bloodstream. The
next step towards DKA is osmotic diuresis occurs resulting in dehydration and electrolyte
imbalances. Fluid becomes lost and the blood becomes concentrated, bringing about
hyperglycemia. (Pg 496)
3. Assess Susan’s physical examination. What is consistent with diabetic
ketoacidosis? Give the physiological rationale for each that you indentify.
Susan’s physical examination is consistent with diabetic ketoacidosis. She is tired
looking and has fatigue, sunken eyes, cry mucous membrantes in the nose, flushed skin,
dry membranes in her eats, nausea, vomiting, and tachycardia. All signs of having dry
membranes and skin are a result of her dehydrateiong, which is an indicator of DKA. The
other four are symptoms of DKA. These symptoms occur due to the metabolic events of
DKA. (Pg 496)
4. Examine Susan’s biochemical indices both in chemistry section and in her ABG
report. Which are consistent with DKA? Why?
The biochemical indices that are consistent with DKA in the chemistry section are
Susan’s high potassium, PO4, osmolality, glucose, BUN, creatine, and HbA1C levels. In
the ABG report the indices consistent with DKA include her low pH, CO2, and HCO3levels.
5. If Susan’s symptoms were left untreated, what would happen?
Ketoacidosis is one of the most serious acute complications of type I diabetes. DKA
must be treated quickly and accurately to prevent coma and death.
(http://kidshealth.org/parent/diabetes_center/diabetes_basics/hyperglycemia.html)
6. Assuming Susan’s SMBG records are correct, what events seem to have
precipitated the development of DKA?
Because of Susan’s symptoms and her tachycardia it is apparent that her heart is
having trouble staying in normal rhythm and this could lead to heart complications and
her other symptoms indicate that she could potentially go into a coma. Another event that
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seems to be linked to her development of DKA was when she had her period for four
days followed by a volleyball tournament.
7. What, if anything, could Susan have done to avoid DKA?
Susan could have increased her insulin dose or monitored her insulin level and
sugar intake. Both could have prevented her becoming insulin deficient. (Pg 495). Also
she should have refrained from consuming alcohol. If she was monitoring her blood
glucose levels during her practices at volleyball because with this high level of activity
she might need to plan a mid practice snack in order to regulate her levels.
8. While Susan is being stabilized, Tagamet is being given IV piggyback. What does
“IV piggyback” mean? What is Tagamet, and why is it prescribed?
An IV piggyback is a way to administer medication through an intravenous line that
is inserted into a patients vein. It got its name because it is given on top of the main
intravenous solution (http://www.wisegeek.com/what-is-an-iv-piggyback.htm). Tagamet,
also known as cimetidine, is a drug used to treat ulcers, GERD, and conditions where the
stomach produces too much acid. Over‐the‐counter Tagamet is used to prevent and treat
symptoms of heart burn associated with acid indigestion and sour stomach. Tagamet
decreases the amount of acid made in the
stomach.(http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000628/).
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 concentration slows or prevents
development of complications common to individuals with diabetes. The trial
compared “intensive” insulin therapy (“tight control”) with “conventional” insulin
therapy. Define “intensive” insulin therapy. Define “conventional” insulin
therapy.
Intensive insulin therapy is an aggressive treatment approach designed to control
your blood sugar levels. This therapy requires close monitoring of blood sugar levels and
frequent doses of insulin. It involved non-scheduled meal times and up to 4 injections of
insulin a day.
Conventional insulin therapy involves one to three daily injections that are the same
every day. The type of insulin given and the number of injections and dose size are
determined based on how much an individual eats, when she eats, and how much exercise
she gets on a regular basis. It involved having scheduled meals 2-3 injections of insulin
daily.
10. List the microvascular and neurologic complications associated with type 1
diabetes.
Microvascular Complications:
Neurologic complications
Diabetic retinopathy
Peripheral neuropathy
Aldose reductase
Diabetic neuropathy
Oxidative stress
Chronic sensorimotor distal symmetric
polyneuropathy
Various growth factors
numbness
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Diabetic nephropathy
Protienuria
burning
tingling
“electrical” pain
Sensory loss
(http://clinical.diabetesjournals.org/content/26/2/77.full)
11. What are the advantages of intensive insulin therapy?
The advantages are:
 Prevent or slow the progression of long-term diabetes complications
 Reduce the risk of eye damage by more than 75 percent
 Reduce the risk of nerve damage by 60 percent
 Prevent or slow the progression of kidney disease by 50 percent
 Boost energy and help feel better overall
12. What are the risks of intensive insulin therapy (tight control)?
Intensive insulin therapy may lead to low blood sugar because when there are tight
blood sugar levels, any small change in the daily routine may cause low blood sugar.
Weight gain is another risk with intensive insulin therapy. When using insulin for lower
blood sugar levels, the sugar in your bloodstream enters cells in the body instead of being
excreted in urine. The body converts the sugar the cells don’t use for energy into fat,
which can lead to weight gain. It is important to closely follow exercise and meal plans in
order to regulate weight.
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 of intensive insulin therapy?
Intensive insulin therapy is recommended for most people who have type I
diabetes. Intensive insulin therapy may not be recommended for children, older adults,
individuals who struggle with frequent or severe bouts of low blood sugar, and
individuals with heart disease, blood vessel disease or sever diabetes complications.
(http://www.mayoclinic.com/health/intensive-insulintherapy/DA00088/NSECTIONGROUP=2)
14. Explain how an insulin pump works. Is Susan a candidate for an insulin pump?
An insulin pump is a about the size of a pager and is powered by batteries. There
are regular ones or rapid acting. They work by delivering insulin through a flexible tube
that is attached to an individual via an infusion set. One type of insulin pump, a
continuous subcutaneous insulin infusion allows creation of variable and adjustable doses
of insulin. This type of pump is good for specific and individualized dosing needs.
Compared to other methods of insulin delivery, an insulin pump duplicates insulin
secretion more closely to natural insulin secretion. Time, mastery, instructions, and
training are needed to understand and use an insulin pump. Based on this description and
Susan’s information, I would say that she is a good candidate for an insulin pump.With
her high level of activity it is hard for her to regulate her blood glucose levels during this
time and having aninsulin pump would automatically monitor and regulate these levels
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for her.(Pg 489)
15. How would you describe CHO counting to Susan and her family?
Carbohydrate counting is a meal planning approach that totals the amount of
carbohydrates eaten during meals and snacks. It encourages eating a wide variety of
carbohydrates. Using carbohydrate counting has been shown to improve metabolic and
glycemic control with diabetes. The amount of carbohydrates an individual can have is
established in consultation with the individual and the nutrition professional. Amounts of
carbohydrates allowed are adjusted based on blood glucose monitoring results and the
context of the individual’s lifestyle. (Pg 493)
16. How is CHO counting used with intensive insulin therapy?
CHO counting is used with intensive insulin therapy. Individuals on intensive
insulin therapy who used an insulin pump or multiple daily insulin injections first used it.
Carbohydrate counting helps people who use insulin tailor their mealtime insulin dose to
cover the amount of carbohydrates eaten at that meal. Carbohydrate counting helps
control blood glucose levels (http://www.diabetesselfmanagement.com/Articles/DiabetesDefinitions/carbohydrate_counting/).
17. Estimate Susan’s daily energy needs using the Harris-Benedict equation.
655(9.56 x wt) + (1.85 x ht) – (4.68 x age) 655 + (9.56 x 57.2) + (1.85 x 160.02) –
(4.68 x 16) 655+ (546.832) + (296.037) – (74.88) =1,422.989 kcal x 2.0 =
2,845.978 kcal
18. Using the 1-week food diary from Susan (next page), calculate the average
amount of CHO usually consumed each meal and snack.
a. 100 grams CHO breakfast
b. 60 grams CHO lunch
c. 30 grams CHO snack
d. 75 grams CHO dinner
e. 45 grams CHO HS
19. After you have calculated Susan’s usual CHO intake from her food record
(Question 18), develop a CHO‐ counting meal plan that she could use. Include
menu ideas.
Meal
Nutrients
Food Ideas
Breakfast
45-60 grams of carbohydrates or
1 cup of Cheerios with ½ cup
3-4 CHO choices
2% milk, ½ of a banana with 1
1 oz meat/meat substitutes
T peanut butter
1-2 servings of fat
Lunch
45-60 grams of carbohydrates or
Turkey sandwich: 2 slices
3-4 CHO choices
whole wheat bread, 2 oz deli
2-3 oz meat/meat substitutes
turkey, lettuce, tomato, 2 tsp
1-2 servings fat
mayonnaise, mustard, 1 medium
apple, 1 oz carrot sticks, 2 T fat
free Ranch dressing
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Snack
Dinner
HS
15-25 grams of carbohydrates or
1-2 CHO choices
Limit meat and fat
45-60 grams of carbohydrates or
3-4 CHO choices
3 oz meat/meat substitutes
1-2 servings fat
15 grams of carbohydrates or
1 CHO choice
limit meat and fat
1 oz pretzels with peanut butter
or hummus, or a yogurt
3 oz chicken breast-grilled with
bbq sauce, side salad with fat
free dressing, 1 small baked
potato with sour cream and
cheese, 1 8oz glass of 2% milk,
1 small slice of cake
3 graham crackers or 1 small
piece of fruit or ½ cup of ice
cream
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?
Stevia is gaining popularity among the diabetic community because it stimulates
the release of insulin and normalizes the response to glucose. I would advise her to take
caution when consuming Stevia because it can lower blood sugar and can interfere with
insulin and other medications. I would recommend that Susan stay away from Stevia in
order to ensure there is no interference with insulin levels and medication.
References
Intensive insulin therapy: Achieving tight blood sugar control - MayoClinic.com. Mayo
Clinic. Retrieved March 25, 2012, from http://www.mayoclinic.com/health/intensiveinsulin-therapy/DA00088
Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology. Belmont, California: Wadsworth, Cengage Learning.
What Is an IV Piggyback? wiseGEEK: clear answers for common questions. Retrieved
March 25, 2012, from http://www.wisegeek.com/what-is-an-iv-piggyback.htm
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