David Hu

Minor Case Study: Mr. A

Background: Diabetic ketoacidosis occurs when the blood contains critical levels of
ketone bodies (acetoacetate and beta-hydroxybutyrate) from an insulin shortage.
Decreased insulin production leads to a subsequent rise in glucagon levels and
glucose release by the liver, which is normally regulated by negative feedback via
insulin. Excess glucose is eliminated in the urine, which also expels electrolytes and
fluids. Diabetic ketoacidosis may lead to hyperventilation as a blood pH
compensatory mechanism.
Nutrition Assessment: Medical Diagnosis Uncontrolled T2DM, DKA
Age: 56

Labs:

Gender: M

Glucose 373 on 10/14 AM, down to

121 on 10/17

Weight:153.3lbs / 69.7kg
Height: 61 / 185.4cm

HbA1c: 10.6

BMI: 20.2
PMH: GERD, bipolar disorder (manic
depression), abdominal pain, HTN,
peripheral neuropathy secondary to
DM
Symptoms: Nausea and vomiting,
emesis for past 2 days, abdominal
pain. Self-reported weight loss of
11lbs over past several weeks.
Diet History: Pt reports poor
adherence to diabetic diet due to
bipolar disorder and lack of
motivation

Medications: Heparin
(glycosaminoglycan anticoagulant),
Novolog (insulin), Levemir (insulin),
Protonix (H-pump inhibitor), Pravachol
(statin), Oretic (hydrochlorothiazide),
Neurontin (anticonvulsant, also used
to treat neuropathic pain), Celexa
(serotonin reuptake inhibitor),
lactated Ringer's solution
(fluid/electrolyte replenishment), Kphos neutral (phosphorus)

Hospital Diet: Consistent Carb-4 + 2

hs snack
(1650kcal meals + 240kcal snacks)

Nutrition Diagnosis
1. Impaired nutrient utilization (NC 2.1) related to T2 diabetes mellitus as
evidenced by DKA and A1c of 10.6.
2. Limited adherence to nutrition-related recommendations (NB 1.6)

related to bipolar disorder as evidenced by diet history and patient

statements.

Nutrition Intervention Nutrition prescription, Interventions with

goals
Nutrition Prescription

Intervention with goals

1. Concarb-4 + 2hs snack diet

1. Continue with current hospital

diet to promote blood sugar
control

2. Diet education

2. Monitor patient weight,

appetite, and meal intake
3. Provide diabetes nutritional
education
Nutrition Monitoring and Evaluation
Indicator

Criteria

1. Weight

1. Stable

2. Blood glucose levels

2. WNL

3. A1c

3. <7%

Nutritional Requirements
Source

Kcal
requirements

Protein
requirements

Fluid
requirements

Facility standards

2055 (MSJx1.3)

84g (1.2g/kg to
maintain lean body
mass)

2439ml (35ml/kg)

EAL

N/A

N/A

N/A

Online nutrition
care manual

2055

70g (1.0g/kg)

2055-2439ml

Mr. A

Mr. A arrived on 10/14/15 and was discharged on 10/17/15. He responded well to

diabetes nutrition education and displayed a solid grasp of dietary
recommendations and medication use. He complained that he often loses
motivation to follow the diabetic diet and carb count due to his bipolar disorder
despite his knowledge of the disease.