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Jillian O’NeilKNH 41302/18/14Case Study 2 – Diabetes Mellitus with Diabetic KetoacidosisThere are precipitating factors for diabetic ketoacidosis. List at least seven possible factors. Seven possible factors that can cause Diabetic Ketoacidosis include: infections, psychological stress, lack of SMBG, insulin omitted, increased insulin needs with growth spurts, pump malfunction and drug abuse. (Nelms 503)Describe the metabolic events that led to the symptoms associated with DKA. Classic DKA symptoms include dehydration, polyuria, polydipsia, weight loss, vomiting, abdominal pain, acetone breath and Kussmaul respirations (Nelms 503). When insulin is not adequately available to the patient’s body, the counter-regulatory hormones are stimulated to avoid starvation. This action causes the glucose production through gluconeogenesis and lipolysis. The ketones generated are by-products of lipolysis. Osmotic diuresis occurs when the glucose and ketones accumulate in the bloodstream. This results in dehydration and electrolyte imbalances. In addition, while the fluid is lost, hyperglycemia may occur if the blood becomes too concentrated (Nelms 496). Assess Susan’s physical examination. What is consistent with diabetic ketoacidosis? Give the physiological rationale for each that you identify?Based upon Susan’s physical examination, multiple factors are consistent with diabetic ketoacidosis. She is experiencing extreme thirst – polydipsia a common symptom of DKA. In addition, she may be suffering from dehydration due to the symptoms of fatigue and confusion. Dehydration and electrolyte imbalances are due to the osmotic diuresis that occurs from the accumulation of glucose and ketones in the blood stream. Dehydration may also cause the symptoms of tachycardia, sunken eyes, dry ear membranes, dry mucus membranes in the nose, and dry, flushed skin with poor turgor; in addition, it can cause constipation, tender abdomen and deep respirations. Her blood glucose levels are high due to the hyperglycemia from the blood becoming too concentrated. Vomiting and weight loss are other two key symptoms for DKA because of the body’s mechanism to control blood glucose levels and from the extreme fluid loss. She has been experiencing difficulty breathing, thus the Kussmaul respirations. (Nelms 503, Case Study Packet)Examine Susan’s biochemical indices both in the chemistry section and in her ABG report. Which are consistent with DKA? Why?Susan’s elevated biochemical values of potassium, chloride, PO4, osmolality, glucose, and creatinine indicate dehydration – which is a consistent symptom of patients with DKA. Her ABG levels indicated a low value of pH, Co2 content, and HCO3. A decreased value of ABG would reflect diabetic ketoacidosis. Her values indicate DKA because they are associated with the causes, symptoms, characteristics, and laboratory finding of diabetic ketoacidosis as explained by Nelms on page 503. (Wisse, Nelms)If Susan’s symptoms were left untreated, what would happen?If Susan’s symptoms were left untreated, her condition may cause fatal complications – including extreme dehydration, coma, or swelling in the brain – leading towards death. (Raghavan)Assuming Susan’s SMBG records are correct, what events seem to have precipitated the development of DKA?Assuming she recorded correctly, multiple events may have triggered the development of DKA. If she had a meal late or forgot to consume her scheduled snack, an alteration was caused in her blood glucose levels. During her period, the changes of hormone levels (particularly estrogen and progesterone) may produce a temporary resistance to insulin. They may cause a fluctuation in blood sugars. In addition, exercise (volleyball tournament) should not occur when the blood glucose levels are already high and ketones are present in the urine because further internal complications may occur. Lastly, typical birthdays include abnormal food intakes – including sweets and desserts. Therefore, these items may increase her simple carbohydrate intake and fluctuate her blood glucose levels even more than they already were post-period. (Raghavan, Wisse, Nelms)What, if anything, could Susan have done to avoid DKA?To avoid DKA, Susan could have stayed on her scheduled DM diet – both with proper times and proper intake of foods. Adding simple carbohydrates and other foods not within the DM diet may cause increased symptoms and thus, lead to DKA. In addition, she could have avoided dehydration by staying hydrated and consuming water in the prevention of “being thirsty” and other complications. Lastly, she should have not participated in her volleyball tournament when her blood glucose levels were not at a stabilized level. While Susan is being stabilized, Tagamet is being given IV piggyback. What does “IV piggyback” mean? What is Tagamet, and why has it been prescribed?IV Piggyback refers to a medication given in addition to the standard IV saline solution. Cimetidine, known as Tagamet, is a drug that inhibits histamine by binding to histamine receptors. This action ultimately causes an inhibition of gastric acid secretion. It is often used to treat stomach and intestine ulcers as well as a preventative measure. In addition, is used to treat stomach and throat problems caused by excessive stomach acid. Susan’s ABG values returned with a low level of pH – indicating an altered stomach acid level. Therefore, it may have been prescribed to aid her body in controlling the proper amount of acid levels in the stomach. (WebMD)The Diabetes control and Complications trial was a landmark multicenter trial designed to test the proposition that complications of diabetes mellitus are related to elevation of plasma glucose. It is the longest and largest prospective study showing that lowering blood glucose concentration slows or prevents development of complications common to individuals with diabetes. The trial compared “intensive” insulin therapy (“tight control”) with “conventional” insulin therapy. Define “intensive” insulin therapy. Define “conventional” insulin therapy. Intensive insulin therapy “requires multiple daily injections (MDIs) of bolus insulin before meals in addition to basal insulin once or twice daily.” (Nelms 488)Conventional insulin therapy involves “a constant dose of basal insulin combined with short or rapid acting insulin.” (Nelms 487)List the microvascular and neurological complications associated with type 1 diabetes. Macrovacular complications include: cardiovascular disease, which can lead to the risk factor of Type 2 Diabetes. Microvascular complications include: nephropathy, which could occur from hypertension and hyperglycemia; as well as retinopathy, which could occur from an increased duration of DM, hyperglycemia and hypertension. Neurological complications include peripheral neuropathy and autonomic neuropathy – including cardiovascular, genitourinary and gastroparesis medical concerns. (Nelms 487)What are the advantages of intensive insulin therapy?Advantages of intensive insulin therapy include: the flexibility to adjust insulin based on food intake, allowing adjustment of insulin dose in response to hyperglycemia, variable carbohydrate intake or an altered physical activity level. This type of therapy is beneficial because it delays the onset and slows the progression of complications. (Nelms 488)What are the risks of intensive insulin therapy (tight control)?Risks of intensive insulin therapy include: extreme weight loss and low blood sugar levels. Having a patient on tight control will cause their diet regimen to be stricter than previously. Therefore, rapid weight loss may occur and ultimately cause fluctuation in blood sugar levels. (Nelms, WebMD)Dr. Green consults with you, and the two of you decide that Susan would benefit from insulin pump therapy combined with CHO counting for intensive insulin therapy. This will give Susan better glycemic control and more flexibility. What are some of the key characteristics of candidates for intensive insulin therapy?Candidates for intensive insulin therapy must: understand the characteristics of CHO, understand carbohydrate counting, currently does not have heart disease or any current extreme complications, and have the ability to control their blood sugar through the understanding of their diet and insulin. (Nelms 489)Explain how an insulin pump works. Is Susan a candidate for an insulin pump?Battery operated, an insulin pump delivers insulin through flexible tubing that is attached to the patient through an infusion set. CSII, continuous subcutaneous insulin infusion, allows variability and adjustments of insulin doses to meet the patient’s needs at a specific time and physical state. (Nelms 489)I believe Susan is a candidate for an insulin pump because she is an active individual. Having a pump that can calculate the proper amount of insulin she needs, can be helpful in her active lifestyle. In addition, an insulin pump can give her greater control over her glucose levels, ultimately her DKA.How would you describe CHO counting to Susan and her family?I would describe CHO counting as following:Carbohydrate counting is a simple and easy way to understand the balance between insulin in your body with the foods you are taking in – easily said: manage your blood glucose levels. Rather than focusing on many numbers and variables, this process makes it simple! In our counseling session, we will determine and set a limit of the maximum amount of carbohydrates to eat per meal and snacks. You can keep track of the carbs you eat in this manner. Our main goal is to keep your blood glucose level in the target range; therefore, managing your carbohydrate intake, physical activity levels and medications will absolutely help you feel better and live a healthier life. A typical carbohydrate serving has 15 carbohydrates – this would include a serving of carbohydrates, starchy vegetables and fruits. Dairy products, such as milk, contain 12 carbs per serving. We can create a meal plan together based on foods you like to manage your carbohydrate intakes. (American Diabetes Association)How is CHO counting using with intensive insulin therapy?CHO counting is used to understand the amount of carbohydrates consumed during each meal and snack. Intensive insulin therapy regulates the amount of insulin needed in the body. Susan can tell the pump what she has eaten or is about to eat. Then, the insulin pump automatically calculates the amount of insulin needed. Therefore, carb counting is beneficial for the use of intensive insulin therapy. (Nelms, American Diabetic Association)Estimate Susan’s daily energy needs using the Harris-Benedict equation. Weight = 110lb/ 2.2 = 50 kgStature = 5’3” = 63” * 2.54 = 160.02 cmAge = 16REE = 655.096 + 9.563W + 1.850 S – 4.676 AREE = 655.096 + 9.563(50) + 1.850 (160.02) – 4.676 (16)REE = 1354.467Activity Level: 1.31 for active1354.467*1.31 = 1774.35Susan’s daily energy needs: 1700 kcalories to 1800 kcalories(Nelms 241, 2422)Using the 1-week food diary from Susan, calculate the average amount of CHO usually consumed each meal and snack.102 gm CHO Breakfast105 gm CHO Lunch42 gm CHO Snack109 gm CHO Dinner36 gm CHO HSAverage daily total = 394 gm CHO(American Diabetes Association)After you have calculated Susan’s usual CHO intake from her food record (question 18), develop a CHO-counting meal plan that she could use. Include menu ideas.Daily Total: CHO 210 - 255 gAverage for Estimations: CHO 232gProtein 130 - 150 g Protein 140gFat 18 – 20 g Fat 19gKilocalories 1700-1800 Kcal 1750232/3 = 77g CHO per meal140/3 = 37 g Protein per meal / 7 = 5oz19 / 3 = 6 g Fat per mealTimeCHO Choice or Grams CHOMenu IdeasMorning4 CHO choices or 62 grams CHO5 oz meat/meat substitutes6 g fat1 CHO choices or 15 grams 2 slices toast (30g CHO)1.5 TBSP Peanut butter (5g CHO, 6g fat, 12g protein)1 med apple (18 g CHO)16 oz skim milk (24 CHO, 16g protein)Afternoon4 CHO choices or 62 grams CHO5 oz meat/meat substitutes6 g fat1 CHO choices or 15 gramsSandwich:1 Large Bun (45g)3 oz sliced turkey (3 CHO, 21g Protein)1 slice Provolone (7g fat, 7g protein)6oz Yogurt (8g protein)8oz lemonade (30 g CHO)Evening4 CHO choices or 62 grams CHO5 oz meat/meat substitutes6 g fat1 CHO choices or 15 grams1 cup macaroni (45g CHO)1 cup vegetables (10g CHO)3oz grilled chicken (21g protein)8oz Skim Milk (12g CHO, 8g protein)? vanilla ice cream (16g CHO, 7g fat, 6g protein)(American Diabetic Association, Nelms)Just before Susan is discharged, her mother asks you, “My friend who owns a health food store told me that Susan should use stevia instead of artificial sweeteners or sugar. What do you think?” What will you tell Susan and her mother?I would inform Susan and her mother: Although Stevia is appropriate to use for some, it may not be for all. Research has shown that some chemicals in Stevia have the ability to lower blood sugars and thus, interfere with blood sugar control. I would recommend a “test run” under a strict watch (done by her mother) to verify this product will not cause harm to Susan. A situation like this would reflect a person to person basis; therefore, I can not say a definite yes or no answer. Each person’s body reacts differently to natural sweeteners. Although I am not one to encourage artificial sweeteners, if it works best for Susan’s case, then she should take that route if the doctor approves. (WebMD, American Diabetic Association)ReferencesAcademy of Nutrition and Dietetics (2013).?International dietetics and nutrition terminology (IDNT) reference manual: Standardized language for the nutrition care process. Chicago, IL: Academy of Nutrition and Dietetics.Nelms, Marcia Nahikian.?Nutrition therapy and pathophysiology. 2nd ed. Belmont, CA: Wadsworth, Cengage Learning, 2011. Print.Raghavan, V. (2013, February 25). Diabetic ketoacidosis?.?Medscape. Retrieved February 14, 2014, from IV. (n.d.).?WebMD. Retrieved February 14, 2014, from Carbohydrates. (n.d.).American Diabetes Association. Retrieved February 16, 2014, from , B. (2013, June 7). Diabetic Ketoacidosis.?Medline Plus. Retrieved February 14, 2014, from ................
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