Diabetes Mellitus & Complications Seen in an Intellectual Disabled Patient
Hyperosmolar Hyperglycemic State Hyperosmolar Hyperglycemic State (HHS) is a potently deadly acute metabolic complication of Diabetes Mellitus.
HHS and DKA are both hyperglycemic crises seen in patients with diabetes, however they differ in the severity of dehydration, ketosis and metabolic acidosis It is often seen in Type 2 Diabetes Mellitus (T2DM), however it can be seen in Type 1 Diabetes Mellitus (T1DM) patients in conjunction with Diabetic Ketoacidosis (DKA). Progression of Hyperglycemic Crises Decreased insulin emission Increased gluconeogenesis and enhanced glycogenolysis & reduced glucose uptake by the peripheral tissues
An alternate physiological mechanism must occur in order for the cells to receive an energy source Progression of Hyperglycemic Crises
Lipolysis, or breaking down of adipose tissue occurs Ketone bodies are produced from the fatty acids to be used for energy Patients that present with HHS, do not usually have ketone production due to insulin is still being produced which prevents lipolysis from happening
Progression of Hyperosmolarity Hyperosmolarity Dehydration (decreased fluid intake) Loss of water and electrolytes Glycosuria (osmotic diuresis) Hyperglycemia Glucose Utilization Gluconeogenesis Glycogenolysis Symptoms and Preliminary Labs Polyuria Polydipsia Weight loss Blurred vision Vomiting Weakness Abdominal pain Change in Mental Status Plasma glucose BUN/Creatinine Electrolytes (with calculated anion gap) Serum ketone Serum -Hydroxybutyrate (if available) Calcium Phosphorus Arterial blood gases CBC Count Urinalysis Effect serum osmolality* must be calculated if not ordered via lab
Treatment Rehydrate- 0.9% NaCl @ 1-1.5 L in first hour, if there is no risk of a cardiac event; 0.45% NaCl @ 200-500mL/hr
Restore and Preserve Normal Glucose- Continuous IV insulin- 0.1 units/kg per hour when blood glucose levels reach 300mg/dL, the insulin infusion rate may decrease to 0.01-0.05 units/kg per hour. Once plasma glucose levels reach 200mg/dL Dextrose 5% can be added to replacement fluid Treatment Correct electrolyte deficits- When Potassium levels fall below 5.0 to 5.2 mEq/L, the upper end of normal, to prevent hypokalemia, Potassium is given intravenous at a concentration of 20 to 30 mEq/L. With hypokalemia, insulin treatment should be delayed until the serum potassium level is great than 3.3 mEq/L to avoid life-threatening conditions, Avoid Complications- Hypokalemia & Hypoglycemia with excessive insulin therapy. Monitor patients blood glucose every 1-2 hours to identify hypoglycemia & monitor potassium levels Medical Nutrition Therapy & HHS Once the hyperglycemic crisis has been resolved, the patient will need insulin therapy Patients who, were previously on insulin therapy, can resume their normal regimen For patients with newly diagnosed diabetes, the basal- bolus regimen should be started at 0.5 to 0.8 units/kg per day MNT Therapies- How to avoid future incidents, blood glucose monitoring, provide diabetes teaching to prevent recurrence with carbohydrate controlled diet, calorie controlled if patient is overweight Patient Background Information P.A., 56 year old male, of Haitian descent Lives with his sister, who is his healthcare proxy & caregiver Has been intellectually disabled and non verbal since birth Able to ambulate on his own, does need supervision at all times to assist with his activities of daily living Has not received a blood work up in a number of years, secondary to becoming agitated, upset when health care professionals attempt to draw blood No known previous hospitalizations, patient does have a history of lipid abnormalities, renal failure, seizures and hypertension Diagnosis of HHS One week prior to admission patients sister reported patient having flu like symptoms of nausea & vomiting One day prior to admission, sister noticed P.A. was weak/tired & not acting like his usual self On 10/28/13, P.A. was admitted to Franklin Hospitals Emergency room in a lethargic state with a glucose level of 1808mg/dL & was retested to show 1806 mg/dL, P.A. given insulin & began insulin infusion in the ER before being admitted to the CCU with alternated mental status, sepsis and hyperglycemia Diagnosis Criteria Effective Serum Osmolality=2[measured Na+(mEq/L)]+[glucose (mg/dL/18] P.A. Eff. Serum Osmolality = 2 [ 134 mmol/L) + [1806 mg/dL/ 18] = 368.3 mOsm/kg *Conversion factor of mEq/L to mmol/L of Na+ is 1 CriteriaforHHSDx ValuesforHHSDx ValuesseeninP.A. PlasmaGlucose >600mg/dL 1806mg/dL ArterialpH >7.30 7.28 SerumHC03(mEq/L) >18 14 UrineKetone Small negative SerumKetone Small N/A EffectSerumOsmolality >320mOsm/kg 368.3mOsm/kg AnionGap Variable WNL MentalStatus Stupor/coma Lethargic/Stupor New on Set Diabetes P.As HgbA1c= 9.3 % and C-peptide= 0.3 HgbA1c reflects at least 3 months of uncontrolled blood glucose, and C-peptide reflects a decrease insulin output by the pancreas P.A. diagnosed with new on set diabetes, likely requiring insulin therapy to help treat his diabetes
Complications P.A. has a history of renal failure and a prolonged hyperglycemic state may have further progressed his renal function decline Hyperglycemia leads to the formation of cytokines & growth factors which can lead to structural change in the kidneys, which ultimately can lead to functional changes as well Four days after admission (10/31/2013), P.As BUN/Creatinine= 68/7.44, based on the MDRD calculation his GFR= 9 mL/min/1.73m 2 , indicative of ESRD, P.A. was placed on hemodialysis Medication Contraindication Four days after admission, P.A. presented with acute pancreatitis, Amylase=176, Lipase=1171, while PA was NPO It is undetermined the root origin of P.As pancreatitis, a contraindication with propofol infusion while P.A was placed on a mechanical ventilator could have exacerbated his pancreatitis The reasoning behind this is that propofol is administered as a fat emulsion and it has a fat content very similar to 10% fat emulsion in a total parenteral nutrition solution Admission 10/28/13 Ht= 52, Wt= 177#, BMI= 32.4 (obese), IBW=118 10%, UBW= Unknown by sister, couldnt recall the last time P.A. has had his weight checked 10/28/13- Nothing by mouth (NPO), P.A sister stated that he didnt follow any special diets at home & had a good appetite. No problems chewing or swallowing Lantus 20u X 1 daily D5% NS 0.45% @ 150mL/hr Insulin infusion @ 7u/hr Glucose= 1806 mg/dL, F.S= 522, 558, Urine Glucose= 1000mg/dL , BUN/Crea= 71/3.15, Effective Serum osmolality= 368.3 mOsm/kg
Five days after admission- 11/1/13
P.A. placed on a mechanical ventilator due to acute respiratory failure (10/31/13) Wt= 194.8# (10/31/13), P.A has gained 17.8#, 10% weight gain since admission, noted generalized +2 edema Nasogastric tube feeding, Glucerna 1.2 @ 55mL/ hr (1584 kcal, 79 g of protein, 110% to meet DV) , Questionable with renal failure and on HD Lantus 20u X 1 daily D5% NS 0.45% @ 150mL/hr Insulin infusion @ 7u/hr IV Antibiotics to treat sepsis Propofol infusion (10/31/13) 10/31/13- BUN/Crea= 68/7.44, started dialysis treatment every other day until 11/8/13. Glucose= 279 mg/dL, F.S= 305, 222, 292- continue insulin infusion, rate decreased, Effective Serum Osmolality= 286 mOsm/kg
8 days after admission 11/5/13
Wt= 200.6, P.A. has gained 23.6#, 13% wt. gain since admission, Generalized +2 edema (11/5), Generalized +3 edema (11/4), Generalized +4 edema (11/3) noted. P.A also receiving making IVF, IV Antibiotics at this time P.A remained on NGT Glucerna 1.2 @ 55mL/hr, tolerating TF well no residuals BUN/Crea= 33/3.88, s/p 3 HD treatments. Glucose= 203mg/dL, F.S= 199, 220, 310, discontinue insulin infusion, P.A. receiving Lantus 15 u X 2 daily and Humalog corrective regimen PRN
Two weeks after admission-11/11/13 Wt= 184.7#, P.A has lost 16#,8 % wt. loss X 6 days due to edema reduction from +5 to +2 Swallow evaluation conducted, recommended ground consistency, diet advanced to consistent carbohydrate with no snack, low sodium and 60 gram protein diet (Pt. not receiving HD at this time) BUN/Crea= 63/ 6.82 (11/9- BUN/Crea= 40/4.53). F.S= 389, 275, 102, 130 , F.S. began going below 100 on 11/12/13, Lantus dose changed to Lantus 12u X 1 daily
Non-Verbal Communication and Dietary Intake 11/13/13- Nurse and Physician's Assistant reported P.A. coughing while eating, another swallow evaluation ordered. Observed P.A tolerating regular consistency food, speech language pathologist (SLP)to keep P.A. at a ground consistency, P.A. did resist SLP on attempts to feed him 11/15/13- Poor Po intake, P.A consuming about < 50% of his meals, Pt. has wrist restraints in place, CNA or family member has to feed pt. Suplena with Carb Steady TID ( 425kcal, 10.6 g protein) Non- Verbal Communication with food preferences and lack of ability to eat food on his own may have been demonstrated by P.A.
Hemodialysis Treatment dates- 10/31, 11/2, 11/4, 11/6, 11/8 3.5 hours Dialysate (mL/minute): 500 3 K + Potassium bath Dialysate Bath Calcium: 2.5 mEq/L Access- internal jugular central venous w/o heparin Maintain systolic blood pressure > (mmHg): 110 Desired weight loss/E.D.W: 3 kg 11/12/13- s/p insertion of Quinton PermaCath into right internal jugular vein, P.A. pending medical clearance for AV fistula
Evaluation of nutrient requirements Calories: 35 kcal/kg of IBW/day= 1,875 kcal Protein: 1.2 g/kg/IBW: 65 grams of Protein Fluid: 750-1000mL/day urine output Sodium: 2-3 g/day Potassium: 2-3 g/day Phosphorus= 0.8-1.2 g/day * Needs based on that patient is most likely going to requirement long term dialysis Nutrition Diagnoses Inability to manage self-care (NB 2.3) related to impaired cognitive ability secondary to intellectual disability as evidenced by patient unable to recognize or understand self-care required in new diagnoses of Diabetes Mellitus & End Stage Renal Disease.
Impaired ability to prepare foods/meals (NB 2.4) related to impaired cognitive ability related to intellectual disability as evidenced by patients caregivers being the providers of patients foods/ meals prior to admission. Nutrition Interventions Nutrition Education: Verbal and written to patients sister on dietary recommendations for diabetic patient receiving hemodialysis Medical Food Supplement: If sister feels P.A. isnt meeting needs with food alone, discuss supplements such as Nepro with Carb Steady and RenaMent Coordination of Care: With registered dietitian at dialysis center (if possible) and with social worker in hospital. Discussion along with social worker about placement in a group home Goals and Plans Goal: Patients intake to meet estimated nutritional needs and nutrient recommendations for a diabetic receiving hemodialysis
Plan: Patients food and meals to be provided by caregivers (sister, home health aide) to meet estimated nutritional needs and nutrient requirements for a diabetic receiving hemodialysis
Monitoring and Evaluation Monitor: Check for understanding of dietary recommendations with caregivers and monitor patients PO intake. See if feasible for caregivers to document via a food log to with what foods they are providing to patient and how much is he consuming Evaluation: Patients caregivers will verbalize nutritional recommendations for diabetic patient receiving hemodialysis and patient intake will reflect dietary recommendations for a diabetic patient receiving hemodialysis.
Proposed Follow Up Plan: If caregivers kept a food journal, review food journal to see how P.A. has been eating and if his caregivers are providing the appropriate foods. Ask caregivers how they feel about the food the are providing to P.A., what about these recommendations do they find the most difficulty and why Interventions: From what the caregivers are saying, discuss ways to solve the issues with the diet. If can isnt being managed properly at home, discuss placement in a group home Goal: For P.A. to be in an environment where he will receive the proper care regarding his medical and nutritional needs. Prognosis and Discharge P.A. was discharged from Franklin Hospital on 11/18/13, to a sub-acute rehab facility for rehabilitation to help with getting him ambulatory again, and his family wishes for him to return home after. It will be very difficult for P.A.s caregivers to manage both his nutritional care and medical care as they both involve continual involvement since the patient himself cannot manage his own self-care Empowering patients to self manage their care is something that is preached often by nutrition professionals to both diabetic patients and dialysis patients, however this is unfeasible with P.A.
Objective To describe & compare the dietary intake of adults with mild to moderate mental retardation among three different community residential settings. Case Report 325 adults (178 males, 147 females) with mild to moderate mental retardation were interviewed along with their direct care provider using a Dietary Fat Screener and Fruit and Vegetable Screener to obtain a recall of typical food consumed over the past year. Results Women who lived in group homes scored significantly higher on the F & V screener than those who lived in semi-independent setting or with family members (p < .001). The men who resided in group homes also scored similarly higher, though not statistically significant. Conclusions The researchers concluded that the greater fruit and vegetable intake seen group homes may be due to staff training, higher levels of supervision of meals, planned menus, or reduced personal freedom to choose unhealthy foods. Draheim , C. C., Stanish , H. I., Williams , D. P., & McCubbin, J. A. (2007). Dietary intake of adults with mental retardation who reside in community settings. American Journal on Mental Retardation, 112(5), 392-400. Prevalence of Dietary Intake Estimates for Men and Women (%) by Residential Settings EstimateofDietaryIntake GroupHomen=169 WithFamilyn=48 Semiindepend.n=108 Men n=91 n=28 n=59 DietaryFatScreenerScores <30%ofcalories 15.4 28.6 25 3035%ofcalories 15.4 10.7 23.3 >35%ofcalories 15.3 21.4 16.7 4050%ofcalories 54.9 39.3 35 FruitandVegetableScreenerscores 5ormorefruits/veggies/day 4.4 0 1.7 3or4fruits/veggies/day 45.1 28.6 38.3 <3fruits/veggies/day 50.5 71.4 60 Women n=78 n=20 n=49 DietaryFatScreenerScores <30%ofcalories 20.5 30 28.6 3035%ofcalories 20.5 25 16.3 >35%ofcalories 15.4 10.1 12.2 4050%ofcalories 43.3 35 42.9 FruitandVegetableScreenerscores 5ormorefruits/veggies/day 6.4 0 0 3or4fruits/veggies/day 65.4 55 36.7 <3fruits/veggies/day 28.2 45 63.3 Nutrition Quality of Life P.AS nutrition quality of life may improve if he is placed in group home residence. His dietary requirements are difficult to manage, even for a patient that has total understanding of what these recommendations entail It is unlikely that P.As family will be able to provide proper medical and nutritional therapies required by P.As current condition without resistance from P.A. A group home setting will provided an environment where a more positive outcome may occur