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Elizabeth FischerDr. Sara LongHND 47018 March 2014Case Study 141. What are the current thoughts regarding the etiology of type 1 diabetes mellitus (T1DM)? No one else in Rachel's family has diabetes—is this unusual? Are there any other findings in her family medical history that would be important to note? The etiology of T1DM is currently unknown, but thought to be a combination of genetics and environmental factors. Although a major risk factor for being diagnosed with T1DM is passed on through genes, current research shows that only 15 percent of people with T1DM have an effected first-degree relative. It is not highly unusual for Rachel to be the only person in her family that is diagnosed with T1DM. Her sister being diagnosed with celiac disease is important to note, because it is thought to be genetic and current research shows celiac disease and T1DM often occur together and share genetic causes. Her mother and sister both have an autoimmune disorder, and those could be predispositions for her T1DM because 85-89% of individuals diagnosed with T1DM have one or more autoantibodies present, and T1DM can be classified as an autoimmune disorder.2. What are the standard diagnostic criteria for T1DM? Which are found in Rachel's medical record?The standard diagnostic criteria for T1DM are a fasting blood glucose (meaning no meal has been eaten for at least eight hours) reading of over 126 mg/dl tested on two separate days. Along with the fasting blood glucose test a hemoglobin A1c measure of 6.5% or higher is indicative of T1DM.. Rachel’s A1c levels are higher than 6.5 percent, and she had two separate FBG readings from different days that were both well over 126 mg/dl. Another diagnostic tool is the oral blood glucose test. The test is indicative of T1DM, when the blood glucose levels are over 200 mg/dL after two hours of administering the test. Unexplained weight loss, polyphagia, polyuria, and polydipsia are all diagnostic criteria for T1DM as well Rachel is experiencing all to these diagonistic criteria as well.3. Using the information from Rachel's medical record, identify the factors that would allow the physician to distinguish between T1DM and T2DM.Rachel has symptoms indicate T1DM instead of T2DM. One way to tell this is because the autoimmune antibodies ICA, IIA and GADA are present in her laboratory values, this confirms that she has T1DM rather than T2DM.It indicates T1DM because they are only present in T1DM. Her C-peptide levels are also extremely low which confirms her diagnosis. This confirms her diagnosis because low to non-existent levels of C-peptide indicate low to non-existent levels of insulin. The low C-peptide only indicates T1DM because in T2DM the C-peptide levels remain normal or are high because insulin is still produced. 4. Describe the metabolic events that led to Rachel's symptoms and subsequent admission to the ER (polyuria, polydipsia, polyphagia, fatigue, and weight loss), integrating the pathophysiology of T1DM into your discussion.Rachel complained of using the restroom more than usual, a symptom known as polyuria. She complained of being extremely thirsty, a symptom known as polydipsia. She complained about being hungrier than usual, a symptom known as polyphagia. Rachel’s fatigue caused her to faint during her soccer game. Even though her appetite and eating habits have been normal if not increased, she has still lost weight. When glucose can no longer enter the cells, plasma glucose levels rise and cells will begin to starve. Excess glucose is then lost in the urine because the kidneys can only get rid of so much glucose from the blood at a specific rate. This results in polyuria or frequent urination. Because urine is lost, this leads to polydipsia, or her excessive thirst due to dehydration. Polyphagia sets in as a result of this loss of significant energy. Fatigue then sets in, because the cells no longer have energy available to them. Weight loss occurs because the body has to pull from the fat stores because the glucose cannot get into her cells, which causes them to starve; her body is running on ketones.5. Describe the metabolic events that result in the signs and symptoms associated with DKA. Was Rachel in this state when she was admitted? What precipitating factors may lead to DKA?The signs and symptoms associated with DKA include thirst, frequent urination, high blood glucose levels, high levels of ketones in the urine, fatigue, and nausea. One major metabolic event that results in these signs and symptoms is physiological stress, such as an infection. When insulin is not available, the body produces glucose via gluconeogenesis and lipolysis. Dehydration and electrolyte imbalance occur when glucose and ketones build up. The body uses ketoacidosis to rid of the extra ketones through the lungs. From this, her respiration becomes deep and rapid, and breath has a fruity scent similar to cheap liquor. 6. Rachel will be started on a combination of Apidra prior to meals and snacks with glargine given in the a.m. and p.m. Describe the onset, peak, and duration for each of these types of insulin. Her discharge dosages are as follows: 7u glargine with Apidra prior to each meal or snack-1:15 insulin:carbohydrate ratio. Rachel’s parents want to know why she cannot take oral medications for her diabetes like some of their friends do. What would you tell them? Glargine, is a type of insulin that lowers levels of blood glucose and is longer lasting than non-man-made insulin. The onset of this medication takes 1 hour and it is peakless. The duration this medicine has effect of 20 to 26 hours. The onset of Apidra, which is also a man-made form of insulin, takes 15 minutes and it peaks in 30 to 90 minutes. The duration of Apidra’s effect is three to five hours. I would explain Rachel's parents that their friend have T2DM instead of T1DM and that T2DM can be treated with oral medication. Rachel cannot take oral medication because she has T1DM which cannot be treated with oral medication. Insulin injections are the best option for Rachel's because the medication goes straight into the bloodstream.7. Rachel’s physician explains to Rachel and her parents the Rachel’s insulin dose may change due to something called a honeymoon phase. Explain what this is and how it might affect her insulin requirements.The honeymoon phase is a period of time after an individual is diagnosed with T1DM and insulin treatment is initiated. During this period, all of the insulin-producing beta cells located in the pancreas have not yet been destroyed, so they produce insulin in varying amounts as a reaction to the newly injected insulin, but this phase will only be temporary. During the honeymoon period, Rachel will need to receive higher amounts of insulin as her insulin-producing cells are being destroyed, and taking insulin daily at every meal gives the surviving beta cells a chance to rest and produce a small amount of insulin. It is important for Rachel to take regular insulin injections during the honeymoon phase because without these injections, she has a higher risk of developing diabetic ketoacidosis.8. How does physical activity affect blood glucose levels? Rachel is a soccer player and usually plays daily. What recommendations will you make to Rachel to assist with managing her glucose during exercise and athletic events?During physical activity more glucose is needed to provide energy to the muscles. This means Rachel's blood glucose may drop during or after physical activity, so it is important that she monitors her blood glucose before, during, and after exercise. If her blood glucose goes down before exercising, I would recommend that she has a pre-exercise snack so she will be raising her blood glucose. When Rachel's blood glucose is high before starting exercise, I would recommend that she does not participate in the physical activity because the physical activity could further take her blood glucose out of the normal range. If exercise lasts for 30 minutes to an hour of moderate activity, she needs 15 grams of carbohydrate. For every hour of strenuous activity, 30 grams of CHO is needed. If Rachel has trouble controlling her blood glucose during times of strenuous physical activity sometimes physicians will lower the insulin dose for before these activities.9. Rachel’s blood glucose records indicate that her levels have been consistently high when she wakes in the morning before breakfast. Describe the dawn phenomenon. Is Rachel experiencing this? How might it be prevented? The dawn phenomenon is an early morning increase in blood glucose from the hours of 2 am and 8 am. Rachel is not experiencing the dawn phenomenon because the dawn phenomenon occurs at certain hours, whereas Rachel is not experiencing high blood glucose levels exclusively during those set hours. What Rachel is experiencing is called the rebound phenomenon and it occurs due to an excess amount of insulin during the night. Lowering the amount of insulin administered before bed can prevent this phenomenon from occurring. Another option for Rachel would be to consume a bedtime snack with fewer carbohydrates. Rachel’s body is trying to treat hyperglycemia by increasing hormone levels, which cause lipogenesis, which further increases blood glucose levels which causes the rebound phenomenon to occur. To prevent this, Rachel needs to monitor her blood glucose levels before bed and possibly wake throughout the night to further monitor blood glucose levels and possible take measures to lower them.10. The MD ordered a consistent carbohydrate-controlled diet when Rachel begins to eat. Explain the rationale for monitoring carbohydrates in diabetes nutrition therapy.When carbohydrates are consumed, they are broken down into simple sugars, causing blood glucose to rise rapidly. Since Rachel has T1DM she needs to monitor the amount of carbohydrate intake taken during a meal or snack so she can match the amount of CHO taken in with the proper insulin dose. The monitoring of CHO taken in and taking the proper insulin does along with it will allow Rachel’s blood glucose levels to remain in desirable levels and prevent damage to her body. The American Diabetes Association stated that keeping track of the amount of carbohydrate intake and setting a limit for the amount of carbohydrates eaten will help manage blood glucose level within desirable range. 11. Outline the basic principles for Rachel’s nutrition therapy to assist in control of her T1DM. There are several basic principles for Rachel's nutrition therapy that will assist in control of her T1DM. One basic principle is to maintain optimal blood glucose levels within normal limits because glucose is the body’s number one energy source and the preferred source of energy by the brain. Extremely high glucose levels should be avoided because excess glucose levels are toxic to the body and can damage tissues such as the kidney, the heart, and the retina of the eye. The body releases these toxics through urination and breathing out ketones. This can dehydrate the body slightly because it uses fluid to expel the glucose. Another principle to follow is to prevent and treat complications by modifying her nutrient intake and lifestyle when it is needed. When her blood glucose is not controlled 60-70 % of Rachel’s diet should be CHO and MUFA, 12-20% of her total kcal should be protein, <7% of her total kcal should be saturated fat, and her daily cholesterol should be less than 200 mg/day. It is Important that Rachel take her insulin that is prescribed by her doctor because if insulin is not taken, her blood glucose will decrease and she may suffer hypoglycemia. Some symptoms of hypoglycemia include headache, hunger, shaking, sweating, palpitations, and weakness. Another important principle is to maintain regular physical activity and making healthy food choices as this will help keep her blood glucose within a normal range. However, Rachel must be careful of how her body feels before, during, and after exercise and monitor her blood glucose during this time. It is important to keep blood pressure within normal limits to prevent vascular disease.12. Assess Rachel’s ht/age; wt/age; ht/wt; and BMI. What is her desirable weight? Based on CDC growth charts, Rachel's is only in the 25th percentile for weight-for-age, but she is in the 50th percentile for stature-for-age. Rachel's BMI is 16.0 which places her slightly below the 25th percentile on the CDC chart for height-for-weight. Rachel is not necessarily underweight but it would be desirable for her to regain weight to her usual body weight. If Rachel were to regain her usual body weight of 89 lbs according to the CDC growth charts she would be at her desired BMI of 18.1. A BMI of 18.1 would put her in the 50th percentile for weight-for-age..13. Identify any abnormal laboratory values measured upon her admission. Explain how they may be related to her newly diagnosed T1DM. Rachel had several lab values that were abnormal leading to her diagnosis of T1DM. Her C-peptide levels were very low during admittance, reading 0.10 ng/mL. These values are extremely low compared to the reference range of 0.51-2.72 ng/mL. Within the body C-peptide levels usually equal the amount of insulin in the body so the extremely low C-peptide levels support her newly diagnosed T1DM. ICA, GADA, and IAA antibodies were all present in her lab results. The presence of ICA and GADA indicates the destruction of beta cells. She also tested positive for glucose and ketones. Testing positive for ketones could be related to her T1Dm diagnosis because ketones build up in the body when the body is not able to use glucose as fuel. Rachel's sodium levels upon first admittance were extremely low, reading 126 mEq/L due to an electrolyte imbalance resulting from hyperglycemia, but slowly rose to 131 mEq/L. This was still considered low on the reference range of 136 to 145 mEq/L. Her glucose levels were extremely high, reading 683 mg/dL, and then lowering to 250 mg/dL, which is still very high on the reference range of 70-110 mg/dL. Rachel had extremely high levels of HbA1c reading 14.6% on a range of 3.9 to 5.2%.The high HbA1c indicates that her blood glucose has been high for at least 120 days which shows that her insulin has not been bringing her blood glucose levels down to a normal range for an extended period of time.14. Determine Rachel’s energy and protein requirements. Be sure to explain what standards you used to make this estimation. Using the EER from DRI for the age group of females 9 through 18 years of age Rachel's energy requirements are roughly 2000 kcal/day. To find her protein needs I calculated 0.95 grams of protein per kilogram of body weight, which equals 35 grams of protein per day.15. Prioritize two nutrition problems and complete the PES statement for each.Food-nutrient related knowledge deficit related to limited exposure to diabetes education as evidenced by patient’s new diagnosis of type 1 diabetes mellitus.Altered nutrition related laboratory values (blood glucose) related to insufficient insulin as evidenced by hyperglycemic (724 mg/dL) and HbA1C 14.6%.Insufficient carbohydrate intake related to limited exposure to diabetes education as evidenced by patient’s diet history and patient’s new diagnosis of type 1 diabetes mellitus.Impaired nutrition metabolism related to inadequate insulin as evidenced by blood glucose value of 724 mg/dL.Underweight related to impaired nutrient intake as evidenced by BMI less than 25th percentile.16. Determine Rachel’s initial nutrition prescription using her diet record from home as a guideline, as well as you assessment of her energy requirements. Rachel’s EER shows that she should be consuming at least 2000 kcals per day and 35 g of protein per day. I would recommend that 45-65% of her total diet be CHO. Instead of recommending a specific amount of CHO at each meal I would recommend that she learn the CHO to insulin ratio. Her learning this ratio would allow her to keep her insulin levels within normal range but also allow her to eat enough CHO at each meal to adjust for growth and development.17. What is an insulin:CHO ratio (ICR)? Rachel’s physician ordered her ICR to start at 1:15. If her usual breakfast is 2 Pop-Tarts and 8oz skim milk, how much Apidra should she take to cover the carbohydrate in this meal?An insulin:CHO ratio is a basic guideline for the amount of insulin necessary to metabolize the amount of carbohydrate consumed in a meal or a snack. For example, Rachel’s physician ordered one unit of insulin for every 15 grams of carbohydrate, which would be written as 1:15. The poptarts contain 76 g of CHO and the skim milk contains 12 g of CHO giving a total of 88 g of CHO consumed at the meal. She would need 6 units of insulin when eating this breakfast. This can be determined by dividing the 88 total grams of CHO by 15.18. Dr. Cho set Rachel’s fasting blood glucose goal at 90-180mg/dL. If her total daily insulin dose is 33 u and her fasting a.m. blood glucose is 240mg/dL, what would her correction dose be?When Rachel’s total daily insulin dose is 33 units with a fasting blood glucose of 240 mg/dL her target fasting blood glucose is 90-180 mg/dL. In order for Rachel to meet this target, she would have a correction dose of one unit of Apidra. To come up with this correction does 1800 is divided by the 33total daily units giving the answer of one unit lowering the blood glucose by 54. Then 180 is subtracted from the 240 giving a blood glucose difference of 60. The 60 is close to 54 showing that she will only need one correcton unit to lower her blood glucose into the normal range.19. Write an ADIME note for your initial nutrition assessment. Date: 19 March 2014Time: 1340 A. 12 y/o female, Ht-5’0”, Wt-82 lbs, Dx-Type 1 Diabetes Mellitus, and hyperglycemia, Diet Rx: ~2400 kcal, EER: ~35g Protein. Current diet order: NPO until progress made, then moved to carbohydrate controlled diet. Fluid requirement: 1840 mL. Father was Dx with HTN, Mother was Dx with hyperthyroidism, and sister was Dx with celiac disease.D. Food-nutrient related knowledge deficit related to limited exposure to diabetes education as evidenced by patient’s new diagnosis of type 1 diabetes mellitus.Insufficient carbohydrate intake related to limited exposure to diabetes education as evidenced by patient’s diet history and patient’s new diagnosis of type 1 diabetes mellitus.Impaired nutrition metabolism related to inadequate insulin as evidenced by blood glucose value of 724 mg/dL.I. Initiate self-management training for patient and parents on diabetes education and insulin administration, nutrition prescription, meal planning, sign/symptoms and Tx of hyperglycemia, carbohydrate intake, and physical activity.M/E. Monitor daily weight and blood glucose levels (multiple times per day), monitor and evaluate nutrition knowledge and skills.Elizabeth Fischer, the Virgin Queen20. When Rachel comes back to the clinic, she brings the following food and blood glucose record with her.a. Determine the amount of carbohydrates she is consuming at each meal. 7:30 a.m. meal: 115 g CHO 12:00 p.m. meal: 60 g CHO 2:00 p.m. meal: 23 g CHO 4:30 p.m. meal: 30 g CHO 6:30 p.m. meal: 95 g CHO 8:30 p.m. meal: 60 g CHO b. Determine whether she is taking adequate amounts of Apidra for each meal according to her record.Throughout the course of the day Rachel is consistently taking less Apidra than is recommended for each meal besides her 8:30 pm meal when she took the adequate amount. c. Calculate a correction dose for her to use. 7:30 a.m. meal: Took 5 u Apidra; should have taken 8 u Apidra 12:00 p.m. meal: Took 6 u Apidra; should have taken 4 u Apidra 2:00 p.m. meal: Did not take Apidra; should have taken 1 u Apidra 4:30 p.m. meal: Did not take Apidra; should have taken 2 u Apidra 6:30 p.m. meal: Took 5 u Apidra; should have taken 7 u Apidra 8:30 p.m. meal: Took adequate amount (4 u Apidra) ................
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