Escolar Documentos
Profissional Documentos
Cultura Documentos
KNH 411
November 17th, 2015
Type 1 Diabetic Case Study
6. Describe the metabolic events that led to Susans symptoms (polyuria, polydipsia,
polyphagia, weight loss, and fatigue) and integrate these with the pathophysiology of
the disease.
According to Nelms, insulin deficits in the body cause
numerous and potentially fatal consequences. When the glucose cannot
enter the cells (due to the lack of being broken down by the hormone
insulin), two things happen: hyperglycemia and the cells begin to starve.
This signals gluconeogenesis in the liver as well as stimulation of the
process glycogenolysis. The kidneys then begin to filter out as much of the
excess glucose they can which causes glycosuria and frequent urination
(polyuria). The loss of fluid then stimulates the thirst mechanism and
causes the person to become very thirsty (polydipsia). The cells are
starving due to the lack of glucose for energy and in turn, the body
responds and promotes hunger (polyphagia) (p. 481).
As the body continues on this path of degeneration if insulin
deficiency persists, the body breaks down fat stored in adipose tissue for
additional energy (this explains the weight-loss). The resulting fatty acids
are then transformed into keto acids in the liver. As the increased amount
of keto acids are produced, pH falls in the body from 7.3-6.8, which is
much more acidic than usual and ketones are secreted in the urine. The
amount of ketones that are released through the urine (measured using a
ketone stick that the patient urinates on) can be used to determine what
state of Diabetic Ketoacidosis (DKA) the patient is in (p. 481).
This entire process leads to fatigue in the patient due to the
bodys immense amount of work as it is trying to compensate for the lack
of insulin.
Nutrition Assessment
10. Determine Susans stature for age and weight for age percentiles.
Height in cm= 157.48; Age= 15
According to the CDC growth charts, she is in
the 25th percentile for stature for age.
Weight in kg= 45.45; Age= 15.
According to the CDC growth charts, she is in
the 25th percentile for weight for age.
13. What would the clinician monitor in order to determine whether or not the
prescribed energy level is adequate?
The clinician would monitor to ensure that Susan is not
losing or gaining any weight. As long as Susan follows the correct insulin
regimen that her endocrinologist prescribes, she will be able to live a
healthy life.
14. Using a computer dietary analysis program or food composition table, calculate
the kcalories, protein, fat (saturated, polyunsaturated, and monounsaturated), CHO,
fiber, and cholesterol content of Susans typical diet
According to SuperTracker, Susans target EER range was
1,600-1,700 kcal/day. This is nearly half of what Brown stated girls aged
14-18 years needed daily.
Nutrients
Target
Total Calories
1600 Calories
3391 Calories
Over
Protein (g)***
46 g
105 g
OK
Protein (% Calories)***
10 - 30%
Calories
12% Calories
OK
Carbohydrate (g)***
130 g
483 g
OK
Carbohydrate (%
Calories)***
45 - 65%
Calories
57% Calories
OK
Dietary Fiber
26 g
23 g
Under
Total Sugars
No Daily
263 g
Target or Limit
No Daily
Target or
Limit
Added Sugars
No Daily
160 g
Target or Limit
No Daily
Target or
Limit
Total Fat
25 - 35%
Calories
OK
Saturated Fat
Over
Polyunsaturated Fat
No Daily
7% Calories
Target or Limit
No Daily
Target or
Limit
Monounsaturated Fat
No Daily
10% Calories
Target or Limit
No Daily
Target or
Limit
11 g
25 g
OK
Linoleic Acid (%
Calories)***
5 - 10%
Calories
7% Calories
OK
-Linolenic Acid (%
Calories)***
0.6 - 1.2%
Calories
0.7% Calories
OK
1.1 g
2.5 g
OK
Omega 3 - EPA
No Daily
1 mg
Target or Limit
No Daily
Target or
Limit
Omega 3 - DHA
No Daily
0 mg
Target or Limit
No Daily
Target or
Limit
Cholesterol
< 300 mg
OK
32% Calories
207 mg
15. What dietary assessment tools can Susan use to coordinate her eating patterns
with her insulin and physical activity?
Susan can keep a food and insulin log of everything all the
meals and snacks that she consumes throughout the day. She will have to
become quite proficient at counting carbohydrates so that she can
correlate how many units of inulin she needs to count for the carbs.
It is also important for Susan to test her blood glucose levels
frequently in the first few weeks following the diagnosis. She can either
write down her BGs into a BG log, or with todays technology, she can
download her glucose meter to a computer and that will document the
numbers for her to save the time. This will enable Susan to see what times
of day she is running higher and what times of day she runs lower.
16. Dietitians must obtain and use information from all components of a nutrition
assessment to develop appropriate interventions and goals that are achievable for the
patient. This assessment is ongoing and continuously modified and updated throughout
the nutrition therapy process. For each of the following components of an initial nutrition
assessment, list at least three assessments you would perform for each component:
Component
Clinical
Nutrition
Weight history
Monitoring
Psychosocial/Economic
Clinical Domain
17. Does Susan have any laboratory results that support her diagnosis?
The overarching laboratory result that supports Susans
diagnosis is her blood glucose level of 250 mg/dL. This is more than
double the highest limit of the target range.
Her HBA1c test came back as 7.95% which indicates that
her average blood glucose over the past 3 months was around 175 mg/dL.
18. Why did Dr. Green order a lipid profile?
Dr. Green ordered a lipid profile to check and make sure that
Susans lack of diabetes control did not negatively impact her cholesterol
and triglycerides. Certain aspects of a persons lifestyle, including the diet,
level of physical activity, level of diabetes control, and smoking status, can
affect the lipid profile (ADA, 2010).
Chemistry
Normal Value
Susans Value
Reason for
abnormality
Nutritional
Implications
BUN
8-18 mg/dL
20 mg/dL
Diabetes
Mellitus:
Kidneys are
having to filter
out increased
amounts of
urea nitrogen
due to elevated
blood glucose
levels
BUN directly
correlates with
protein
consumption,
however in
diabetic
patients, it is
more likely for
them to have a
higher BUN
test due to
fluctuations in
the blood
glucose
Blood Glucose
70-110 mg/dL
250 mg/dL
Diabetes
mellitus: Beta
cells (insulin
producing
cells) in the
pancreas no
longer work
due to
autoimmune
function.
Pancreas
cannot produce
insulin to break
down sugar
and starches,
which leads to
hyperglycemia.
HBA1c
3.9-5.2%
7.95%
Diabetes
mellitus:
Insufficient
amounts of
insulin in the
body to break
down the
carbohydrates
consumed in
the body. This
is an average
of the last three
months.
The pancreas
is unable to
produce
enough insulin
to cover the
carbohydrates
consumed in
Susans diet
and so
hyperglycemia
occurs.
Osmolality
285-295
mmol/kg/H2O
304
mmol/kg/H2O
Diabetes
mellitus
When higher
amounts of
10
diagnosis
glucose are
attached to the
hemoglobin in
the blood, the
osmolality in
the body then
increases
Brand Name
Onset of
Action
Lispro
Humalog
5 15 min
30 90 min
3 5 hours
Novolog
5 15 min
30 90 min
3 5 hours
Glu
Apidra
5 15 min
30 90 min
3 5 hours
NPH
Humulin N
2 4 hours
4 10 hours
10 16 hours
Glargine
Lantus
2 4 hours
Peakless
20 24 hours
Detemir
Levemir
2 4 hours
6 14 hours
16 20 hours
Humulin
30 60 min
2 4 hours
(dual)
10 16 hours
50/50 premix
Humulin
30 60 min
2 5 hours
(dual)
10 16 hours
60/40 premix
Humulin
30 min
2 5 hours
(dual)
18 24 hours
Aspart
70/30 premix
Peak of
Action
Duration of
Action
(p. 491)
21. Once Susans blood glucose levels were under control, Dr. Green prescribed the
following insulin regimen: 24 units of glargine in PM with the other 24 units as lispro
divided between meals and snacks. How did Dr. Green arrive at this dosage?
Insulin doses are determined based on the individual's type
of diabetes, age, body size, insulin sensitivity, hepatic function, and the
ultimately the physicians clinical judgement. The 24 units of glargine
11
insulin (lantus) is the slow-acting insulin that mimics the pancreas in a way
that insulin is secreted in little amounts throughout the entirety of the day.
He chose 24 units based on Susans body size, age, and physical activity
level (p. 490).
The 24 units of lispro (humalog) is to be divided up and
injected at meals and snacks that contain carbohydrates. It is important to
divide up her allotted amount of carbohydrates throughout the day to avoid
extreme fluctuations in her blood glucose levels (p. 490).
The algorithm that Dr. Green most likely used to determine
her insulin needs is 0.55 X weight (kg). This comes to a total of 24.9 units.
He could have also taken her weight in pounds and divided it by 4 (comes
to 25) to determine her total insulin needs (p. 491).
Behavioral-Environmental Domain
22. Identify at least three specific potential nutrition problems within this domain that
will need to be addressed for Susan and her family.
Susan and her family need to be 100% understanding on the
importance of monitoring blood glucose levels throughout the day. If
Susan neglects to test her blood sugar for an extended period of time, this
can easily lead to a rise in her blood glucose level to an unhealthy level
(>250 mg/dL), which could result in ketone bodies being spilled in the
urine.
It is imperative for Susan and her family to understand how
to read a nutrition label and to be able to evaluate how many
carbohydrates are in each serving of a food product. This will allow Susan
to accurately count her carbs so that she is able to give the correct dosage
of insulin to combat the carbohydrates.
Education on the consequences of not taking insulin for a
meal containing carbohydrates is critical for Susan to understand.
Ensuring that Susan is well aware of the potential consequences will
ensure a successful diabetic regimen.
Explaining to Susan that she can still eat the foods she
wants, just as long as her blood glucose is stabilized, is key. I will explain
to her that if she wants to eat a brownie after dinner for example, she can
have the brownie as long as her BG is within or close enough to the target
range. She will also need to take insulin for the brownie if she chooses to
consume it as well.
Addressing Susan and her family on the importance of
keeping a BG log and food log will also ensure a successful diabetic
12
regimen. This will allow them to see the different fluctuations in Susans
blood glucose levels- allowing them to make changes to her insulin
regimen (if the doctor approves) if needed.
23. 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 Susan is okay to eat
real sugar, just as long as she takes insulin for the carbohydrates she is
consuming. Sugar-free beverages and artificial sweeteners are okay in
moderation, but they should be avoided in large quantities. If Susans
blood sugar is above normal before she decides to indulge in a snack, it
makes sense for her to choose an option with less carbohydrates to avoid
the maintaining of the high blood glucose level. I would tell them that
artificial sugars are okay to eat in moderation, but theyre still largely
undermined in research today so I personally advise against them. It is
imperative that Susan and her mother understand the fact that just
because something says it is, sugar-free does not mean that Susan can
eat it without taking insulin. There are most likely carbohydrates in the
food, despite the fact that it is sugar-free. Carbohydrates are what Susan
needs to take insulin for.
Nutrition Diagnosis
24. Select two high-priority nutrition problems and complete the PES statement for
each.
Food and nutrition related knowledge deficit (NB- 1.1)
related to patients usual dietary intake as evidenced by patients
consumption of 11% total calories of saturated fat.
Excessive energy intake (NB-1.3) related to patients usual
dietary intake as evidenced by SuperTracker analysis of 3,391 kcalories
consumed on average.
(IDNT, 2011)
Nutrition Intervention
25. For each PES statement that you have written, establish and ideal goal (based
on the signs and symptoms) and an appropriate intervention (based on the etiology).
Food and nutrition related knowledge deficit (NB- 1.1)
related to patients usual dietary intake as evidenced by patients
consumption of 11% total calories of saturated fat.
13
26. Does the current diet order meet Susans overall nutritional needs? If yes,
explain why it is appropriate. If no, what would you recommend? Justify your answer.
The current diet order states Susan should consume 2,400
kcals (300 g CHO, 55-65 g pro, and 80 g lipids).
This is a good starting grounds for Susan to consume daily
to meet her overall nutritional needs. As a diabetic, it is critical to have
balance at all meals or snacks to avoid blood sugar spikes. For example,
a snack with just a bag of pretzels and an apple only provides
carbohydrates. Adding a tablespoon of peanut butter or one cup of milk to
this snack would ensure that Susans blood glucose levels out nicely
rather than spiking to 300 mg/dL and then coming down quickly once the
insulin was fully absorbed.
Her target protein goal is 40g (rounded up) and her diet
order states she should be consuming 55-65g protein. This will inevitably
benefit her for the reasons stated in the previous bullet. Protein helps to
stabilize blood glucose levels (ADA, 2010).
contraception. Susan and her parents verbalize understanding of the instructions and
have no further questions at this time. They are instructed to return in 2 weeks for
appointments with the outpatient dietitian and CDE. When you come into work Monday
morning, you see that Susan was admitted through the ER Saturday night with a BG of
50 mg/dL. You see her when you make rounds and review her chart. During an
interview, Susan tells you she was invited to a party Saturday night after her discharge
on Friday. She tested her blood glucose before going to the party and it measured 95
mg/dL. She took two units of insulin and knew she needed to have a snack that
contained approximately 15 grams of CHO, so she drank a beer when she arrived at the
party. She remembers getting lightheaded and then woke up in the ER. What happened
to Susan physiologically?
There are a couple things that went awry that Saturday night
with Susans diabetes management. First things first, she tested early in
the night and her BG was 95 mg/dL. This is without a doubt in the normal
range and so she did not need to take any insulin. Assuming she took
insulin to cover a snack that she inevitably forgot to eat, her blood sugar
dropped. On top of already having a low BG due to too much insulin, she
decided to drink a beer. Alcohol (beer in particular) has a unique effect on
diabetes. Alcohol has the effect of raising a persons blood sugar and then
bringing it down on its own (ADA, 2010). This is why T1 diabetics are
informed not to take any insulin for alcohol. Now, this gets tricky in terms
of mixed drinks because more often than not, mixed drinks come with a
significant amount of carbohydrates. Unless the diabetic watched the
bartender measure out the juices and/or mixers in the mixed drink, they
should just avoid mixed drinks at all costs. It then gets tricky if the diabetic
has to guess the amount of carbohydrates in the mixed drink.
Susan knows that she is only 15 years old and she will most
likely face the consequences of underage drinking with her mother and
father. As the dietitian, I will encourage her to stay away from alcohol for a
while. At least until she gets older and has a deeper understanding of how
her diabetes and insulin regimen work- especially when paired with
alcohol. Teenagers will be teenagers, so it is imperative that Susan be
educated on the effects of alcohol and T1 diabetes; for if not, she might
possibly end up back in the hospital again in the future.
28. What kind of educational information will you give her before this discharge?
Keep in mind that she is underage for legal consumption of alcohol.
First things first, I will start by telling Susan that there is no
such thing as a perfect diabetic. T1 diabetes affects every single aspect of
a persons life and it is easy to make mistakes. There will be good days
with T1 and there will be bad days; thats okay because this disease in
15
particular is extremely difficult to manage. I will also inform her that it can
be done! There are so many resources online that would be helpful for
Susan to use as support in managing her type 1 diabetes. The American
Diabetes Association in particular has many useful tools and resources
that aid in support and help with managing this difficult disease.
As stated previously in the answer to question 27, teenagers
will be teenagers. I, as the dietitian, will take a realistic point of view
regarding the education that I will provide for Susan. First and foremost,
she will be encouraged to refrain from drinking until she is at the legal age
of 21. Prior to this discharge, I will inform her on the details of the many
ways that alcohol affects a diabetics body. It is important and critical for
her to be aware of how insulin affects her for if she ever decides to go
against the law again and drink before she is 21 years of age. See
question 27 for the details of the effect of alcohol on diabetes
management.
Before this discharge, we would also review everything that
she was educated on previously before the first discharge. Clearly, she is
not quite understanding how insulin will affect her body if she does not eat
a corresponding amount of carbohydrates to meet her needs. We will
simply review the education materials used in the first education session
so she leaves this discharge 100% aware of what can and cannot be done
with her diabetes management.
16
RESOURCES
American Diabetes Association. (2010, January 10). Diagnosis and Classification of
Diabetes Mellitus. Retrieved November 11, 2015, from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797383/
Brown, J. (2011). Nutrition through the life cycle (4th ed.). Belmont, CA: Wadsworth,
CENGAGE Learning.
Causes of Diabetes. (2014, June 1). Retrieved November 11, 2015, from
http://www.niddk.nih.gov/health-information/health-topics/Diabetes/causesdiabetes/Pages/index.aspx
Centers for Disease Control and Prevention. (2001, August 24). Retrieved November
12, 2015, from http://www.cdc.gov/growthcharts/html_charts/wtage.htm#females
Diabetes Complications. (2014, June 23). Retrieved November 10, 2015, from
http://www.cdc.gov/diabetes/statistics/complications_national.htm
Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA:
Wadsworth, Cengage Learning.
Nelms, M., & Roth, S. (2004). Medical nutrition therapy: A case study approach (2nd
ed.). Belmont, CA: Wadsworth/Thomson Learning.
17