Student Name: Kristen Perrella Case: 17- Adult Type 2 Diabetes Mellitus: Transition to Insulin

Transcription

1 Sage NCP Frm Student Name: Kristen Perrella Case: 17- Adult Type 2 Diabetes Mellitus: Transitin t Insulin Patient: M.F. NUTRITION ASSESSMENT Referred fr: advancement, ttal carbhydrate Rx, and distributin and fr selfmanagement training f diabetes educatin Fd and Nutritin Related Histry: PT states he desn t really fllw a strict diet besides nt adding salt PT tries t avid high-chlesterl fds as well as high-sugar desserts Has recently experienced vmiting fr the past hurs and s has nt eaten anything ther than sips f water PT has never seen anyne fr diabetes educatin beynd his physician Based n usual intake, diet appears t be lw in fruit and vegetables and high in fat as evidenced by the half and half in the cffee, the cream cheese n the bagel, eating ut fr lunch and ging ut fr dinner. Appears t ck well, grilling at hme and including rice r ptates and a salad. Cnsumes 3-4 cups f cffee per day. PT in Hyperglycemic Hypersmlar State High glucse level (475 mg/dl) Lw sdium (134 meq/l) High HbA1C (15.2%) BMI = 31.8 (bese) Anthrpmetric Measurements Age: 53 y.. Gender: Male Ht: 69 Wt: 214 lb/2.2kg/lb = 97.3 kg BMI: 97.3 kg / (1.75 m) 2 = 31.8 = bese Wt Hx: Bimedical Data, Medical Tests & Prcedures Labs/Date Albumin Glucse HbA1C BUN Creat Na+ K+ Hgb Hct MCV Osmlalit y 4/ % 20 mg/dl % (hi) 304 mg/dl (hi) (hi) mg/dl meq/l (4/12) mml/kg (hi) (4/12) (hi) (lw) /H 2 O (hi) Medical Diagnsis/Relevant Cnditins Type 2 diabetic Acute hyperglycemia Hypertensin Hyperlipidemia Gut Pertinent Medicatins/Supplements/Herbs: Glyburide 20 mg daily Metfrmin 500 mg 2x daily Dyazide (25 mg hydrchlrthiazide and 27.5 mg triamterene) nce daily Lipitr 20 mg daily Skin status: x Intact Pressure Ulcer/Nn-healing wund; Cmments: Patient/Client/Family Medical/Health/CAM Histry: Father hypertensin, CAD Mther type 2 DM PT- des nt regularly take diabetes medicatin Estimated Nutritinal Needs Based n Cmparative Standards: Calries: Mifflin-St. Jer Prtein: 20% f kcal [10 (wt.) (ht) 5 (age) + 5]*PA = kcal/day [10 (97.3 kg) (175.3 cm) 5 (53 years) + 5]*1.2 = kcal/day 0.20 * 2170 kcal = 434 kcal / 4 kcal/g = 108.g prtein Fluid ml after rehydratin 2170 = kcal/day

2 Current Diet Order NPO then prgress t clear liquids and then cnsistent carbhydratecntrlled diet N Nutritinal Diagnsis at this time Feeding Ability x Independent Limited Assistance Extensive/Ttal Assistance Oral Prblems Chewing Prblem Swallwing Prblem Muth Pain x Nne f the Abve x Prceed t Nutritin Diagnsis Belw Intake Gd (> 75%) Fair (apprx. 50%) Pr (<50%) x Minimal (<25%) (currently NPO) NUTRITION DIAGNOSIS P (prblem) Fd and nutritin related knwledge deficit (NB-1.1) related t: P (prblem) related t: INTERVENTION E (Etilgy) lack r prir nutritin-related educatin evidenced by: E (Etilgy) as evidenced by: S (Signs & Symptms) HHS High glucse level (475 mg/dl) Lw sdium (134 meq/l) High HbA1C (15.2%) BMI = 31.8 (bese) S (Signs & Symptms) Recmmended Nutritin Prescriptin: Once he prgresses t clear liquids Mitch can begin a cnsistent carbhydrate diet. Fd r Nutrient Delivery: Nutritin educatin: NPO, then clear liquids, then cnsistent CHO diet fr DM. Type 2 diabetes mellitus management educatin -Diabetic exchanges and carbhydrate cunting -hw t prperly distribute carbhydrates Nutritin Cunseling: Crdinatin f Care (refer t): Gal(s): Lse 5 t 10% f weight (4.9 t 9.7 kg / 10 t 20 lb) Increase t 5 servings f fruit and vegetables. Pack lunch 3 times per week. Distribute carbhydrates evenly ver the curse f the day (eat breakfast as ppsed t mid-mrning meal. Begin exercising t imprve glucse levels. MONITORING & EVALUATION Indicatrs: Presence r absence f HHS. Lab values: glucse, sdium, HbA1C BMI Criteria: Absence f HHS. Glucse mg/dl Sdium meq/l HbA1C % BMI <30

3 1. What are the standard diagnstic criteria fr T2DM? Which are fund in Mitch s medical recrd? Standard diagnstic criteria include: A1C > r = 6.5% r Fasting plasma glucse > r = 126 mg/dl r 2-hur plasma glucse > r = 200 mg/dl during an ral glucse tlerance test In patients with classic symptms f hyperglycemia r hyperglycemic crisis, a randm plasma glucse > r = 200 mg/dl Mitch has a HbA 1c f 15.2% when it shuld be 3.9 t 5.2% His glucse n 4/12 was 1524 mg/dl (nrmal is 70 t 110 mg/dl) On 4/13 it was 475 mg/dl (which is still high) 2. Mitch was previusly diagnsed with T2DM. He admits that he ften des nt take his medicatins. What types f medicatins are metfrmin and glyburide? Describe their mechanisms as well as their ptential side effects/drug nutrient interactins. Metfrmin and glyburide are glucse-lwering medicatins Metfrmin is a biguanide which suppresses hepatic glucse prductin Decreases GI glucse absrptins, decreases hepatic glucse prductin It may cause small weight lsses at first Mst cmmn side effects are GI which eventually cease T minimize this, medicatin shuld be taken with fd and the smallest dse (500 mg) shuld be given twice a day fr a week and then gradually increased t maximum dses Patients wh excessively cnsume alchl, have renal dysfunctin, r liver impairments usually experience acidsis Take guar gum at least 6 hurs after the drug it can decrease the drug s absrptin Glyburide is a sulfnylurea Oral hypglycemic It prmtes insulin secretin by the beta cells f the pancreas Weight gain and hypglycemia are side effects Take with first meal f the day Cautin with high dse nictinic acid increases glucse Can increase r decrease appetite Can increase weight Bth medicatins decrease A1C up t 2% 3. What ther medicatins des Mitch take? List their mechanisms and ptential side effects/drug nutrient interactins. Dyazide nce daily (25 mg hydrchlrthiazide and 37.5 mg triameterene) Hydrchlrthiazide Antihypertensive, diuretic Take in the mrning with fd r milk May need t decrease sdium and calries and increase ptassium and magnesium in the diet Avid natural licrice Risk f hypercalcemia with calcium r vitamin D supplement Can cause anrexia and increased thirst Can cause decreased bld pressure

4 Triamterene Chemically related t flic acid Take after meals r with milk t decrease GI irritatin Avid excessive ptassium intake Decrease sdium, decreasing calries is recmmended Lipitr 20 mg daily Antihyperlipidemic (t decrease chlesterl r triglycerides Inhibits HMG-CA Reductase (statin) Prevents r decreases risk f cardivascular events, slws prgressin f athersclersis Take withut regard t fd r time f day Decrease fat and chlesterl in diet and decrease calric intake if needed Cautin with grapefruit/releated citrus Affects the frmatin f cenzyme Q10 (ubiquinne) 4. Describe the metablic events that led t Mitch s symptms and subsequent admissin t the ER with the diagnsis f uncntrlled T2DM with HHS. Mitch was drwsy, cnfused, dehydrated and was hyperglycemic with a glucse f mg/dl He was nt taking his diabetes medicatin and his diet did nt have carbhydrates spread evenly ver the curse f the day This cmbinatin led Mitch t be in a hyperglycemic hypersmlar state 7. Assess Mitch s intake/utput recrd fr the first 24 hurs f his admissin. What des this tell yu? Assuming that Mitch tells yu that his usual weight is 228 lbs, can yu estimate the vlume f his dehydratin? His first 24 hurs, his net was 2,140 while he tk in 4,335. Therefre, his utput was rather high, lsing kcal thrugh his urine ttaling 2,075. Mst f this was attributed t his IV, prvide 1.86 ml/kg/hr while he excreted 0.89 ml/kg/hr. Assuming Mitch usually weight 228 lb, that wuld mean that he lst 14 lb by the time he was admitted t the hspital The vlume f his dehydratin is mst likely directly related t the 14 lb that he lst. 14 lb. cnverted t L wuld be 6.6 L 8. Mitch was started n nrmal saline with ptassium as well as an insulin drip. Why are these fluids a cmpnent f his rehydratin and crrectin f the HHS? The insulin is t crrect Mitch s hyperglycemia while the nrmal saline with ptassium addresses his dehydratin as well as his sdium levels. 9. Describe the insulin therapy that was started fr Mitch. What is Lispr? What is glargine? Hw likely is it that Mitch will need t cntinue insulin therapy? The insulin therapy started fr Mitch was t begin Lispr 0.5 u every 2 hurs until glucse is mg/dl. Then at night, begin glargine 19 u at 9 pm. Prgress Lispr using insulin t carbhydrate rati (ICR) f 1:15. Cntinue bedside glucse checks hurly. Ntify MD if glucse is >200 r <80. Lispr is a rapid-acting insulin with an nset f actin f less than 15 minutes, a peak actin in 1-2 hurs, typically lasting 3-5 hurs, and effects shuld be mnitred in 1-2 hurs. Rapid-acting/blus insulin is typically taken befre a meal r during an therwise hyperglycemic state. Glargine is a lng-acting insulin, with an nset f actin f 2-4 hurs, is effective fr hurs, and effect shuld be mnitred in hurs. Lng-acting insulin, r basal insulin, is effective thrughut the day as the insulin in a persn withut diabetes functins. Fr nw, nce Mitch manages his glucse levels, insulin is prbably nt necessary. It is, hwever, likely that he will eventually need t the insulin as the pancreas typically stps secreting insulin. He shuld cntinue t

5 mnitr his glucse nce it is cntrlled, and return t the insulin therapy under the supervisin f his physician if he is unable t cntrl his diabetes thrugh diet/if his pancreas ceases t secrete insulin. 10. Mitch was NPO when admitted t the hspital. What des this mean? What are the signs that will alert the RD and physician that Mitch may be ready t eat? NPO means nil per s in Latin, r nthing by muth 11. Outline the basic principles fr Mitch s nutritin therapy t assist in cntrl f his DM. Mitch shuld cnsume a cnsistent amunt f carbhydrates, spread ut between each meal/snack He shuld have insulin n hand in case f hyperglycemic episdes It wuld be ideal fr Mitch t lse 5 t 10% f his bdy weight in hpes f better DM cntrl Mitch shuld begin exercising, perhaps a beginning gal f walking 30 minutes 4 times per week t better cntrl glucse Mitch is currently NPO and then will prgress t clear liquids fllwed by cnsistent carbhydrate cntrlled diet 12. Assess Mitch s weight and BMI. What wuld be a healthy weight range fr Mitch? 214 lb / 2.2kg/lb = 97.3 kg 5 9 = 69 * 2.54 cm/in. = cm = 1.75 m BMI = 97.3 kg / (1.75 m) 2 = 31.8 = bese A healthy (and realistic) weight range fr Mitch wuld be a BMI f between 20 and 24.9 BMI f 20 = kg / (1.75 m) 2 = 20 * = kg * 2.2 lb/kg = lb BMI f 24.9 = kg / (1.75 m) 2 = 24.9 * = 76.3 kg * 2.2 lb/kg = lb Therefre, a healthy weight range fr Mitch wuld be lb t lb Ideal bdy weight = 106lb (fr first 5 ft.) + 6 lb * 9 = = 160lb. 13. Identify and discuss any abnrmal labratry values measured upn his admissin. Hw did they change after hydratin and initial treatment f his HHS? Upn admissin, abnrmal lab values included: Sdium (lw) BUN (high) Creatinine serum (high) Glucse (high) Phsphate, inrganic (lw) Osmlality (high) Chlesterl (high) Triglycerides (high) HbA1C (high) WBC (high) Hematcrit (high) After hydratin and initial treatment, thugh all values listed abve remained abnrmally high r lw, every abnrmal value imprved Sdium increased 2 meg/l BUN decreased 11 mg/dl Creatinine serum decreased 0.6 mg/dl Phsphate, inrganic increased 0.3 mg/dl Osmlality decreased 54 mml/kg/h 14. Determine Mitch s energy and prtein requirements fr weight maintenance. What energy and prtein intakes wuld yu recmmend t assist with weight lss?

6 Fr weight maintenance: Kcal: Mifflin-St. Jer [10 (wt.) (ht) 5 (age) + 5]*PA = kcal/day [10 (97.3 kg) (175.3 cm) 5 (53 years) + 5]*1.2 = kcal/day 2170 = kcal/day Prtein: 20% f kcal 0.20 * 2170 kcal = 434 kcal / 4 kcal/g = 108.g prtein Fr weight lss: Kcal: 2170 kcal 500 kcal = 1670 kcal/day t lse 1 lb per week Prtein: 0.20 * 1670 kcal = 334 kcal / 4 kcal/g = 83.5 g prtein 15. Priritize tw nutritin prblems and cmplete the PES statement fr each. Fd and nutritin related knwledge deficit (NB-1.1) (P) related t lack r prir nutritin-related educatin as evidenced by hyperglycemic hypersmlar state (HHS) (S). Incnsistent carbhydrate intake (NI ) (P) related t fd and nutritin-related knwledge deficit cncerning apprpriate timing f carbhydrate intake (E) as evidenced by usual fd intake recall demnstrating uneven distributin f carbhydrate cnsumptin thrughut a typical day (S). 16. Determine Mitch s initial CHO prescriptin using his diet histry as well as yur assessment f his energy requirements. Carbhydrates shuld make up 50% f Mitch s diet. Fr him t maintain his current weight, that wuld be 2170 kcal/2 = 1085 kcal / 4kcal/g CHO = 271 g f carbhydrates. Fr Mitch t lse weight, he wuld want t take in 1670 kcal /2 =835 kcal / 4kcal/g CHO = 208 g CHO. Therefre, Mitch shuld cnsume between 208g and 271g f carbhydrates, depending n whether he is ready t begin t lse weight. 17. Identify tw initial nutritin gals t assist with weight lss. Add a serving f fruit t breakfast and t lunch. Pack a lunch three times a week instead f eating ut. 18. Mitch als has hypertensin and high chlesterl levels. Describe hw yur nutritin interventins fr diabetes can include nutritin therapy fr his ther cnditins. If Mitch ut t eat less, he can reduce the amunt f saturated fat in hid diet (cntributing t high chlesterl) Having Mitch cnsume fruit culd help his hypertensin, as that is a cmpnent f the DASH diet. Lsing 5 t 10% f his weight can als imprve bth hypertensin and hyperchlesterlemia Becming educated regarding the management f his diabetes shuld end up imprving nt nly his diabetes management but his hypertensin and high chlesterl as he is likely t ultimately lse weight if he makes small changes t diet like substituting half and half fr lw-fat r nn-fat milk in his cffee r adding fruit and vegetables t his diet.