Answer Guide for Medical Nutrition Therapy: A Case Study ...



Jay Porter

NUTR 426 MNT

9/22/14

Title: Case 17 – Adult Type 2 Diabetes Mellitus: Transition to Insulin

Questions:

1. What are the standard diagnostic criteria for T2DM? Which are found in Mitch’s medical record?

Standard diagnostic criteria for T2DM are a casual plasma glucose of >200 mg/dL, an A1C of 6.5 or higher, a fasting plasma glucose of >126 mg/dL, or a 2 hour postload glucose of >200 mg/dL for an OGTT. Mitch’s medical record shows a serum glucose level of 1524 mg/dL upon arrival to ER and also a family history of T2DM.

2. Mitch was previously diagnosed with T2DM. He admits that he often does not take his medications. What types of medications are metformin and glyburide? Describe their mechanisms as well as their potential side effects/drug–nutrient interactions.

Metformin is an antihyperglycemic agent used to increase the effectiveness of insulin, decrease GI glucose absorption, and decrease hepatic glucose production. Use of metformin may cause GI problems. Glyburide is a type of sulfonylureas used orally to reduce blood glucose levels via increased production of insulin by the pancreas. Glyburide may cause dyspepsia, nausea, diarrhea, and constipation.

3. What other medications does Mitch take? List their mechanisms and potential side effects/drug–nutrient interactions.

Mitch also takes Dyazide and Lipitor. Dyazide is an antihypertensive and diuretic drug that reduces the amount of salt absorbed, side effects include taste changes, N?V and diarrhea, as well as decreased renal function. Lipitor is a type of HMG CoA reductase inhibitor, also known as statin, used to prevent cardiocascular events and atherosclerosis. Lipitor can cause nausea, dyspepsia, abdominal pain, constipation, diarrhea, and flatulence.

4. Describe the metabolic events that led to Mitch’s symptoms and subsequent admission to the ER with the diagnosis of uncontrolled T2DM with HHS.

Inconsistent use of Metformin and Glyburide by Mitch has lead to the extreme hyperglycemia. This high concentration of glucose in the blood has created a state of hyperosmolality, causing the dehydration seen in Mitch.

5. HHS and DKA are the common metabolic complications associated with diabetes. Discuss each of these clinical emergencies. Describe the information in Mitch’s chart that supports the diagnosis of HHS.

Hyperosmolar hyperglycemic state (HHS) is when the blood is extremely concentrated glucose without the presence of ketones and often causes dehydration because of the concentration gradient differences between blood and cells. Diabetic ketoacidosis (DKA) is a build of up ketones in the blood or urine due to increase breakdown of fat, fat is being broken down because of a lack of insulin to remove glucose from the blood for fuel within the cells. DKA is also associated with higher levels of blood glucose but not to the extreme extent of HHS. Mitch’s extremely high blood glucose value of 1524 mg/dL and no indication of ketones in the blood or urine support the diagnosis of HHS.

6. HHS is often associated with dehydration. After reading Mitch’s chart, list the data that are consistent with dehydration. What factors in Mitch’s history may have contributed to his dehydration?

The elevated pulse, abnormal blood pressure, warm and dry skin with poor turgor, and dry mucous membranes in the throat are all signs that Mitch is dehydrated. Mitch’s acknowledgement of having a lot of vomiting would lead to a state of dehydration typically seen with HHS along with Mitch’s diet recall lacking any water intake.

7. Assess Mitch’s intake/output record for the first 24 hours of his admission. What does this tell you? Assuming that Mitch tells you that his usual weight is 228 lbs, can you estimate the volume of his dehydration?

Mitch’s intake/output for the first 24 hours of admission is +2140 in favor of the intake. This shows that he is dehydrated and is retaining some of the water being given to him. Mitch’s current weight of 97.3 kg shows that he has lost 6% of his body weight during the dehydration, about 6.2 kg. So Mitch would need about 6.2L of water upon his arrival to the ER and about 4L more after the initial 24 hour rehydration period.

8. Mitch was started on normal saline with potassium as well as an insulin drip. Why are these fluids a component of his rehydration and correction of the HHS?

Mitch was started on Lispro and potassium as a part of his rehydration to help lower his blood glucose levels along with its osmolality. Potassium is included due to the possibility of the insulin reducing the serum levels as a side effect.

9. Describe the insulin therapy that was started for Mitch. What is Lispro? What is glargine? How likely is it that Mitch will need to continue insulin therapy?

Lispro is a type of rapid acting insulin which is needed because his blood glucose is so high. Glargine is long acting insulin which will be more helpful in the long term to help control his blood glucose values. It is likely that Mitch will need to continue to use insulin due to his diagnosis as a T2DM and his uncontrolled serum glucose levels.

10. Mitch was NPO when admitted to the hospital. What does this mean? What are the signs that will alert the RD and physician that Mitch may be ready to eat?

NPO means “nothing by mouth.” Lack of vomiting for a period of time would be a sign that shows Mitch may be ready for oral intake of some clear liquids, if liquids are well tolerated then move to a consistent carbohydrate-controlled diet.

11. Outline the basic principles for Mitch’s nutrition therapy to assist in control of his DM.

The carbohydrate-controlled diet prescribed to Mitch would be a good way to help control his DM. Also, frequent monitoring of blood glucose levels in conjunction of insulin therapy to better understand his DM.

12. Assess Mitch’s weight and BMI. What would be a healthy weight range for Mitch?

Mitch’s current weight is 214 pounds and has a BMI of 31.7 kg/m2. Mitch’s IBW is 160 pounds. A BMI of 18.5-24.9 is considered within normal range, which is equivalent to Mitch weighing between 125 and 168 pounds.

13. Identify and discuss any abnormal laboratory values measured upon his admission. How did they change after hydration and initial treatment of his HHS?

Mitch’s altered lab values before hydration were sodium (low), BUN (high), creatinine serum (high), glucose (high), phosphate (low), osmolality (high), cholesterol (high), triglycerides (high), HbA1C (high), WBC (high), and Hct (high). After hydration and initial treatment of HHS, all of the altered levels had shifted toward within normal limits but were all still outside of the normal range.

14. Determine Mitch’s energy and protein requirements for weight maintenance. What energy and protein intakes would you recommend to assist with weight loss?

Energy and protein requirements for weight maintenance are 2350 (1806 x 1.3 for light activity) kcal/day and 78-97 grams/day. To achieve weight loss I would recommend the consumption of 1850 kcals/day along with increased amounts of exercise.

15. Prioritize two nutrition problems and complete the PES statement for each.

Inadequate fluid intake (NI 3.1) RT excessive vomiting for 12-24 hours AEB HHS, dry mucous membranes in throat, drowsy, poor skin turgor, fast pulse and respiratory rate, cloudy urine, pale skin, elevated BUN, and low sodium.

Food and nutrition related knowledge deficit (NB 1.1) RT lack of prior nutrition related education about T2DM AEB patient statement of never seen anyone for diabetes teaching beyond what his physician has told him and HHS related to T2DM.

16. Determine Mitch’s initial CHO prescription using his diet history as well as your assessment of his energy requirements.

If adhering to the recommended 1850 kcal/day, carbohydrates should make up 45-65% of total kcals/day, which is 208-300 grams/day.

17. Identify two initial nutrition goals to assist with weight loss.

Two nutritional goals would be to adhere to the recommended kcals/day of 1850 and counting and monitoring the carbohydrate content of meals and snacks.

18. Mitch also has hypertension and high cholesterol levels. Describe how your nutrition interventions for diabetes can include nutrition therapy for his other conditions.

With improvement in Mitch’s overall diet, he will be consuming less carbohydrates and unhealthy fats that he eats on a regular basis by replacing them with healthy fats along with a decreased amount of sodium. This change to diet can help Mitch improve his control of diabetes along with his hypertension and hyperlipidemia. Diet in combination with exercise can also help with weight loss and controlling of his diabetes.

19. Write an ADIME note for your initial nutrition assessment.

Student Name ______Jay Porter______________

Case ___Mitchell Fagan________

Nutrition Assessment

|Food & Nutrition History |Anthropometrics |Biochemical/Tests/Procedures |

|Doesn’t follow any strict diet except for |5’9” |Temp: 100.5 |

|not adding salt, tries to avoid |CBW: 214# |Pulse: 105 |

|high-cholesterol foods and stays away from |UBW: 228# |Resp rate: 26 |

|high-sugar desserts. |%UBW: 93.9% |BP: 90/70 |

| |BMI: 31.7 |Serum glucose: 1524 mg/dL |

| |IBW: 160# | |

| |%IBW: 133.8% | |

| |Healthy weight range: 125-168# | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

|Nutrition Focused Physical Find. |Client History |Comparative Standards |

|Drowsy and confused |T2DM x 1 year (Glyburdie, Metformin) |Kcal: 1850 kcal/day ((MSJx1.3)-500) |

|Vomiting 12-24hrs. |Doesn’t take T2DM meds regularly. |Pro: 78-97 g/d (0.8-1 g/kg) |

|Skin: warm and dry; poor turgor |HTN, hyperlipidemia, gout |Fluid: 2000-2500 L/d (after rehydration) |

| |Dyazide, Lipitor |Carb: 208-300 g/d (45-65%) |

| |Tobacco use: 1 ppd x 20 yrs - now quit |Lipid: 41-72 g/d (20-35%) |

| |Alcohol use: 3-4 drinks per week |Fiber: 30 g/d |

| |Fx: father-HTN, mother-T2DM | |

| |Single - lives alone | |

| | | |

Nutrition Diagnosis

| |

|Nutritional Problem: Inadequate fluid intake (NI 3.1) |

| |

|Related to (etiology): excessive vomiting |

|As evidenced by (signs & symptoms): HHS, dry mucous membranes in throat, drowsy, poor skin turgor, fast pulse and respiratory rate, cloudy urine, pale|

|skin, elevated BUN, and low sodium |

Nutrition Intervention(s)

|Nutrition Rx: 1850 kcal/day |

| |

|General/healthful diet (ND 1.2) |

|Goal: consume a diet lower in simple carbohydrates and higher in fruits and vegetables |

| |

|Nutrition relationship to health/disease (E 1.4) |

|Goal: education about nutrition’s relationship with T2DM, HTN, hyperlipidemia, and gout |

| |

|Prescription medications (ND 6.1) |

|Goal: insulin therapy |

Monitor/Evaluate

Energy Intake (FH 1.1)

Food intake (FH 1.2.2)

Alcohol intake frequency (FH 1.4.1.2)

Carbohydrate intake (FH 1.5.3.1)

Prescription medication use (FH 3.1.1)

Physical activity frequency (FH 7.3.3)

Weight (AD 1.1.2)

Electrolyte and renal profile (BD 1.2)

Glucose/endocrine profile (BD 1.5)

Lipid Profile (BD 1.7)

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