17-1

Kimberly Scannevin Case Questions for Medical Nutrition Therapy: A Case Study Approach 4th ed.
Title: Case 17 Adult Ty e ! "iabetes #ellitus: Transition to $nsulin $nstructions: Answer the questions below. You may print your answers or e-mail them to your instructor. Questions:
1. %hat are the standard dia&nostic criteria for T!"#' %hich are found in #itch(s medical record' The standard diagnostic criteria for T2D are! A1" # $.%&' or fasting plasma glucose # 12$ mg(d)' or 2-hour plasma glucose # 2** mg(d) during an oral glucose tolerance test' or a random plasma glucose of # 2** mg(d) +in patients with classic symptoms of hyperglycemia or hyperglycemic crisis + ahan' ,scott--tump . /aymond' 2*12' p. $021. itch2s medical record had an A1" # $.% & +his was 1%.2 &1' his fasting plasma glucose was # 12$ mg(d) +his was 1%23 mg(d)1' so he definitely had the first two standard diagnostic criteria positi4e for T2D . !. #itch )as reviously dia&nosed )ith T!"#. *e admits that he often does not ta+e his medications. %hat ty es of medications are metformin and &lyburide' "escribe their mechanisms as )ell as their otential side effects,dru&nutrient interactions. etformin is a glucose-lowering medication in the biguanide class5 it decreases hepatic glucose production. 6t may cause weight loss in the beginning of therapy. 7astrointestinal side effects may occur5 this medication should be ta8en with food. Another side effect is lactic acidosis. The smallest does should be gi4en twice a day for a wee8' and then be gradually increased + ahan et al.' 2*12' p. $09-$9*1. 7lyburide is a glucose-lowering medication in the sulfonylureas class5 it stimulates insulin secretion from the :cells. Disad4antages of the medication are weight gain' and ha4e potential to cause hypoglycemia + ahan et al.' 2*12' pg. $09-$9*1. -. %hat other medications does #itch ta+e' .ist their mechanisms and otential side effects,dru&nutrient interactions. Dya;ide' once daily +2% mg hydrochlorothia;ide and <7.% mg triamterene1 and )ipitor' 2* mg daily. Dya;ide is an antihypertensi4e' and is a combination of two diuretics. 6t increases the amount of urine made' and the body will rid itself of any e=cess water. ,dema is reduced as well. Dya;ide may raise potassium le4els' so they must be closely monitored. -ide effects include di;;iness' headache' blurred 4ision' loss of appetite' diarrhea' and constipation. 6n rare cases there may be muscle wea8ness' slow heartbeat +>gbru' >.' n.d.1. )ipitor is an antihyperlipidemic medicine5 it reduces )D) le4els and triglycerides in the blood' while increasing ?D) le4els. >ne should be cautious with grapefruit and citrus while on the medication5 they may interact with )ipitor. Alcohol should also be a4oided. @atients should follow a low cholesterol diet while on the medication. -ide effects include nausea' abdominal pain' constipation' diarrhea' flatulence +@rons8y and "rowe' 2*12' 1$31. 4. "escribe the metabolic events that led to #itch(s sym toms and subse/uent admission to the 01 )ith the dia&nosis of uncontrolled T!"# )ith **S. itch was in a state of hyperglycemia +high blood glucose1 and dehydration +reduced fluid inta8e1 when his cowor8er found him. ?is serum glucose le4els when admitted were 1%23 mg(d)5 people with ??- ha4e le4els ranging from 3**-20** mg(d). itch was dehydrated and was in a drowsy and confused state' which is normal with ??- +mental alterations occur1 + ahan et al.' 2*12' p. $991. itch let his diet +carbohydrate inta8e and inconsistency1 and lifestyle +no e=ercise' not ta8ing meds1 become out of control and detrimental to his health. ?is 8idneys could no longer get rid of the e=tra glucose that had built up' and he had ob4iously not been drin8ing enough fluids +the 8idneys are a way of 4oiding e=tra glucose 4ia the urine1. This led to a build up of glucose in the blood +www.diabetes.org1. ?yperosmolarity occurs when there is a loss of more water than sodium5 the blood has a high concentration. Aater is drawn out of the body2s organs' leading to dehydration
B 2*13 "engage )earning. All /ights /eser4ed. ay not be copied' scanned' or duplicated' in whole or in part' e=cept for use as permitted in a license distributed with a certain product or ser4ice or otherwise on a password-protected website for classroom use.

17-2 +CDiabetic hyperglycemic hyperosmolar'D 2*121. The compilation of these metabolic e4ents led to admission. 2. itch2s ,/

**S and "KA are the common metabolic com lications associated )ith diabetes. "iscuss each of these clinical emer&encies. "escribe the information in #itch(s chart that su orts the dia&nosis of **S. ,=empt question. **S is often associated )ith dehydration. After readin& #itch(s chart4 list the data that are consistent )ith dehydration. %hat factors in #itch(s history may have contributed to his dehydration' ,=empt question. Assess #itch(s inta+e,out ut record for the first !4 hours of his admission. %hat does this tell you' Assumin& that #itch tells you that his usual )ei&ht is !!5 lbs4 can you estimate the volume of his dehydrationE itch was rehydrating as seen from his inta8e(output record o4er his first 23 hours of admission. ?is net number for inta8e(output was slowly decreasing' which means his body was rehydrating. The 4olume of his dehydration was! 220 lbs. F 213 lbs G 13 lbs. 13 lbs.(220 lbs. = 1** G $.1 & dehydrated

3.

7.

5.

#itch )as started on normal saline )ith otassium as )ell as an insulin dri . %hy are these fluids a com onent of his rehydration and correction of the **S' -aline' potassium' and insulin are a component of rehydration and correction of ??-' as the saline solution wor8s to replace lost fluid and correct hyponatremia. Aater alone would dilute the blood and stimulate urine output + ahan et al.' 2*12' p. %191. itch2s sodium lab results were at 1<2 and 1<3 m,q()' which is low compared to the reference range of 1<$-13% m,q(). @otassium is an important component of rehydration as it the main intracellular electrolyte and helps maintain body fluids along with sodium. @otassium is important in generating ner4e' heart and muscle electrical impulses + ahan et al.' 2*12' p. %191. The insulin drip was to correct the blood glucose le4els that were abnormally high' thus wor8ing towards correcting ??-. The rehydration with saline and potassium would help correct the ??- as well' decreasing the hyperosmolarity of the blood. 9. Describe the insulin therapy that was started for that itch will need to continue insulin therapyE itch. Ahat is )isproE Ahat is glargineE ?ow li8ely is it

itch was started on )ispro *.% u e4ery 2 hours until his glucose went down to 1%*-2** mg(d). )ispro is rapid acting insulin +?umalog1' which is used as a bolus insulin. 6t is an insulin analog that binds to insulin receptors' functioning similar to human insulin. 6t has a 1%-minute onset of action' $*-9* minute pea8 acti4ity' and a < to % hour duration + ahan et al.' 2*12' p. $911. 7largine has been planned for him to begin in the e4ening' at 19 u at 9 pm. 7largine is an insulin analog which is long acting5 it has slow inHection site dissolution' and has a relati4ely constant deli4ery. 6t is usually gi4en at bedtime' but can be gi4en before any meal' but its timing must be consistent + ahan et al.' 2*12' p. $911. -ince itch2s Type 2 is uncontrolled' if he continues down the same path of non-compliance with his diet' he will in all probability ha4e to stay on his insulin therapy5 he seems to also be on the 4erge of 8idney problems +due to his lab 4alues1' so re-e4aluation would ha4e to occur in a couple of wee8s(months. 1*. itch was I@> when admitted to the hospital. Ahat does this meanE Ahat are the signs that will alert the /D and physician that itch may be ready to eatE I@> +nil per os1 means Jnothing by mouth2. This translates to no food or be4erages by mouth. itch may be ready to eat when he is stable' not 4omiting +has no nausea1 and has an appetite again(feels up to eating. 11. >utline the basic principles for itch2s nutrition therapy to assist in control of his D . itch needs to adopt(recei4e more education on how to impro4e his nutrition to help control his diabetes. 6nter4entions would include! weight loss through reduced energy inta8e +reducing calories by %** calories per day15 carbohydrate counting' control' and impro4ed food choices5 and increased physical acti4ity. etabolic

B 2*13 "engage )earning. All /ights /eser4ed. ay not be copied' scanned' or duplicated' in whole or in part' e=cept for use as permitted in a license distributed with a certain product or ser4ice or otherwise on a password-protected website for classroom use.

17-< control needs to be attained5 blood glucose control must be attained. itch would be taught the basic principles of carbohydrate counting and foods which are in the carbohydrate category' portion si;es' and ser4ings of carbohydrates per meal. onitoring blood glucose le4els and adHusting carbohydrate inta8e is also important + ahan et al.' 2*12' p. $9$1. 12. Assess itch2s weight and K 6. Ahat would be a healthy weight range for itchE itch2s K 6

itch2s weight is 213 lbs. Lor his height he should be around 1$* lbs. +using ideal body weight1. is! 213 lbs.(2.2 G 97.< 8g obese. %29D G $9D $9D = *.*2%3 G 1.7% m

97.< 8g(+1.7%12 G <1.0 for K 6' which is

1<. 6dentify and discuss any abnormal laboratory 4alues measured upon his admission. ?ow did they change after hydration and initial treatment of his ??-E itch2s abnormal laboratory 4alues upon admission! -odium F low' 1<2 m,q()5 after hydration and treatment still low' but impro4ed to 1<3 m,q(). This 4alue would be low upon admission as he had been 4omiting' not eating' and was dehydrated. KMI F high' <1 mg(d)5 after hydration and treatment5 still high' but impro4ed to 2* mg(d). This would be high upon admission as protein catabolism was high due to his to=ic blood sugar' protein was being degraded for energy. "reatinine serum F high' 1.9 mg(d)' after hydration and treatment still slightly high' impro4ed to 1.< mg(d). ?igh as 8idney functioning is off. Diabetes can cause 8idney disease. 7lucose F high' 1%23 mg(d)' after hydration and treatment much lower +impro4ed1' but still abnormally high5 37% mg(d). ?igh upon admission as his he has insulin resistance and :-cell failure5 he had not been ta8ing his medication(following any sort of diabetes diet(e=ercising. @hosphate' inorganic F low' 1.0 mg(d)' after hydration and treatment impro4ed' but still low5 2.1 mg(d). )ow phosphate goes along with renal failure' which again has to do with the 8idneys. >smolality F high' <$* mmol(8g(?2>' after hydration and treatment impro4ed' but still slightly high5 <.3 mmol(8g(?2>. >smolality was high at admittance as he was dehydrated. These 4alues were abnormal as well but not re-tested after hydration and treatment. "holesterol F high' 2*% mg(d)' Triglycerides F high' 10% mg(d) ?bA1" F high' 1%.2& AK" F high' 1<.% +=1*< mm<1 ?ematocrit F high' %7& -pecific 7ra4ity F high' 1.*3% p? F low' %.* @rotein F high' 1* mg(d) 7lucose in the urine F positi4e Netones in the urine F positi4e @rot ch8 in urine - positi4e 13. Determine itch2s energy and protein requirements for weight maintenance. Ahat energy and protein inta8es would you recommend to assist with weight lossE Aeight aintenance T,,! 1*0$-1*.1 = Age +yr1 O @A = +1<.7 = Aeight +8g1 O 31$ = ?eight +m11

B 2*13 "engage )earning. All /ights /eser4ed. ay not be copied' scanned' or duplicated' in whole or in part' e=cept for use as permitted in a license distributed with a certain product or ser4ice or otherwise on a password-protected website for classroom use.

17-3 T,, G 1*0$ F 1*.1 = %< O 1 = +1<.7 = 97.< 8g O 31$ = 1.7% m1 G T,, G 1*0$ - %<%.< O 2*$1.*1 T,, G 2$11.71 for weight maintenance @rotein for weight maintenance G *.0 g = 97.< 8g G 77.03 grams of protein for weight maintenance. To assist with weight loss! %2-$* grams of protein per day. ,nergy inta8e for weight loss5 6 would recommend a %**-calorie deficit per day5 so begin weight loss at around 21** calories per day. 1%. @rioriti;e two nutrition problems and complete the @,- statement for each. 1. 6nconsistent carbohydrate inta8e I6-%.0.3 +1*$7<1 +@1 related to physiological causes requiring careful timing and consistency in the amount of carbohydrate' e.g.' diabetes' +,1 as e4idenced by hyperglycemia documented by blood glucose le4els of 1%23 mg(d) and ?bA1" le4els of 1%.2&. 2. Iot ready for diet(lifestyle change IK-1.< +1*77%1 +@1 related to unwilling or disinterested in learning(applying information +,1 as e4idenced by self-report of not following a strict diet' self report of not ta8ing medication' and his food recall. 1$. Determine itch2s initial "?> prescription using his diet history as well as your assessment of his energy requirements. itch2s "?> prescription! 21** calories per day(2 G 1*%* calories of carbohydrates. This is equi4alent to 2$2.% grams of carbohydrates spread out e4enly between three meals and two snac8s. 17. 6dentify two initial nutrition goals to assist with weight loss. 1. Decrease daily total calorie inta8e by %** calories a day to safely and slowly get bac8 down to optimal weight. 2. Kegin a physical acti4ity log and start mo4ing the body for at least thirty minutes a day. -ince he was sedentary pre4iously' a wal8ing routine or comparable acti4ity should be started. 10. itch also has hypertension and high cholesterol le4els. Describe how your nutrition inter4entions for diabetes can include nutrition therapy for his other conditions. Diet' weight reduction and e=ercise benefit not Hust diabetes' but hypertension and cholesterol 4alues as well. -erum lipids le4els may decrease as well as body inflammation + ahan et al.' 2*12' p. 7%2-7%<1. Ky reducing calories and ma8ing better food choices' itch2s cholesterol le4els should impro4e' as if his K 6 decreases from weigh loss efforts' e=tra adipose tissue le4els should decrease. ,4en a small weight loss +from efforts of calorie reduction or e=ercise1 can impro4e high blood pressure and cholesterol le4els + ahan et al.' 2*12' p. 7%21. 19. Arite an AD6 , note for your initial nutrition assessment. itch is an obese male' age %<' who needs diabetes counseling and education. Through e=ercise' consistent carbohydrates spread e4enly through meals and careful carbohydrate monitoring' itch may see impro4ement. itch should follow up in two wee8s to see how his lifestyle change is progressing' and ensure compliance with the program. 7lucose and ?KA1" lab 4alues should be rechec8ed in one month and three months to trac8 progress.

B 2*13 "engage )earning. All /ights /eser4ed. ay not be copied' scanned' or duplicated' in whole or in part' e=cept for use as permitted in a license distributed with a certain product or ser4ice or otherwise on a password-protected website for classroom use.

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/eferences American Diabetes Association. +2*1<1. Hyperosmolar hyperglycemic nonketotic syndrome. /etrie4ed from http!((www.diabetes.org(li4ing-with-diabetes(complications(hyperosmolar-hyperglycemic.html ahan' ).N.' ,scott--tump' -. . /aymond' P.). +2*121. Krauses food and the nutrition care process. -t. )ouis' >! ,lse4ier -aunders. edline@lus. +2*121. Diabetic hyperglycemic hyperosmolar syndrome. /etrie4ed from http!((www.nlm.nih.go4(medlineplus(ency(article(***<*3.htm >gbru' >. +n.d.1. Triamterene and hydrochlorothiazide, Maxzide, Dyazide. /etrie4ed from http!((www.medicinenet.com(triamtereneQandQhydrochlorothia;ide(article.htm @rons8y' R. . . "rowe' -. P. +2*121. ood medication interactionsTM! The foremost drug"nutrient interactions resource +17th ed.1. Kirchrun4ille' @A! Lood- edication 6nteractions.

B 2*13 "engage )earning. All /ights /eser4ed. ay not be copied' scanned' or duplicated' in whole or in part' e=cept for use as permitted in a license distributed with a certain product or ser4ice or otherwise on a password-protected website for classroom use.