Diabetes Mellitus. Nursing Assessment: 12/9/14 Flat Tense w/ guarding continent

Transcription

1 Last Name wang First Name wan Diabetes Mellitus Pt. Summary: Mr. B is a 48-yo Native American man admitted from the ER to the endocrinology service. Hx: Onset of disease: pt transported to ER when found ill in his house by his wife. During ER assessment, pt was noted to have a S. glucose of 610 mg/dl. Mr. B was diagnosed with T2DM one year ago and has been on metformin since that dx. He does not take the medication regularly as he felt it really wasn t necessary. Medical hx: product of nl pregnancy and delivery; NKA Surgical hx: none Tobacco use: Smoked 1 ppd x 10 years (no longer smokes) Alcohol use: occasional FH: Father MI; mother ovarian CA, T2DM Demographics: Social hx: married, 3 children, works driving trucks Years education: 12 Language: English & O'odham Ethnicity: Pima Native American Religious affiliation: Catholic Admitting Hx/PE: Chief complaint: Wife states that Mr. B had not been feeling well the previous day. He thought he was fighting off a virus. When he didn t answer the phone this morning, his wife went to check on him and found him groggy and almost unconscious at home. She called 911 and the pt was transported to University Hospital. General appearance: Slim male, in obvious distress. PE: General: WDWN 48 yo male; # Vitals: T 99.6 F; P 100; RR 24; BP 78/100 mm Hg Chest/Lungs: Respirations are rapid clear to percussion and auscultation Heart: Tachycardia HEENT: Head: WNL, Eyes: PERRLA, Ears: clear, Nose: clear, Throat: dry mucous membranes w/o exudates or lesions Abdomen: Active bowel sounds x4; tender, non-distended Extremities: +4 ROM; DTR 2+ Neurologic: Lethargic but able to arouse. Follows commands appropriately. Glasgow Coma Scale: 13. Skin: Smooth, warm, dry, no edema Peripheral Vascular: Pulse 4+ bilaterally, warm, no edema Genitalia: Deferred Admission Orders: 1. Regular insulin 1 unit/ml in NS 40mEq 300 ml/hr. Begin infusion at 0.1 unit/kg/hr = 3.7 units/hr and increase to 5 units/hr. Flush new IV tubing with 50mL of insulin drip solution prior to connecting to pt and starting insulin infusion. 2. Labs: stat 3. NPO except for ice chips and medications. After 12 hours, clear liquids when stable. Then advance to consistent CHO diet order: 70-80g breakfast and lunch; g dinner; 30 g snack pm and HS. 4. Consult diabetes education team for self-management training to begin education after stabilized. Nursing Assessment: Abdominal appearance (concave, flat, rounded, obese, distended) Palpation of abdomen (soft, rigid, firm, masses, tense) Bowel function (continent, incontinent, flatulence, no stool) Bowel sounds (P=present, AB=absent, hypo, hyper) RUQ LUQ RLQ 12/9/14 Flat Tense w/ guarding continent P P P 1

2 LLQ Stool color Stool consistency Tubes/ostomies Genitourinary Urinary continence Urine source Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, blue, tea) Integumentary Skin color Skin temperature (DI=diaphoretic, W=warm, dry, DL=cool, CLM=clammy, CD+=cold, M=moise, H=hot) Skin turgor (good, fair, poor, TENT=tenting) Skin condition (intact, EC=ecchymosis, A=abrasions, P=petechiae, R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated, T=tears, SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis) Mucous membranes (intact, EC=ecchymosis, A=abrasions, P=petechiae, R=rash, W=weeping, S=sloughing, D=dryness, EX=excoriated, T=tears, SE=subcutaneous emphysema, B=blisters, V=vesicles, N=necrosis) Other components of Braden Scale: special bed, sensory pressure, moisture, activity, friction/shear (>18=no risk, 15-16=low risk, 13-14=moderate risk, <12=high risk) P Light brown Soft NA Catheter in place Clean specimen Cloudy, amber Pale DI; CLM Fair Intact Intact 20 Nutrition: Meal type: NPO then progress to clear liquids and then consistent CHO-controlled diet Fluid requirement: 2200mL Hx: Does not follow traditional tribal eating pattern, with a few exceptions; likes fry bread and prepares wojapi seasonally. Pt does not tolerate milk and only eats cheese when obtained through government commodities. Fresh vegetables are grown at home: squash, peppers, beans, corn, and some greens. There is very little fruit in his diet and meat is only eaten at dinner. Usual intake (for past several months): AM: toast, jelly, coffee, scrambled egg, juice Lunch: Dinner: soup or stew or corn tortillas with cheese Wife usually cooks rice or cornmeal, some type of meat (pork, beef, poultry, venison), vegetables, cornbread or fry bread. MD Progress Note: 12/9/14 07:00 Subjective: Mr. B previous 24 hours reviewed. Previously diagnosed with T2DM; treated with metformin but appears to not have taken it regularly. Vitals: Temp: 99.5, Pulse: 82, RR: 25, BP 101/78 Urine Output: 2660 ml (71.8mL/kg) PE: General: Alert and oriented to person, place, time HEENT: WNL Neck: WNL Heart: WNL Lungs: Clear to auscultation Abdomen: Active bowel sounds Assessment: Results: + ICA, GADA, IAA consistent with T1DM. Negative c-peptide. Dx: T1DM Plan: Begin Novolog 0.5 u every 2 hour until glucose is mg/dl. Tonight begin Glargine 15 u at 9 pm. Progress Novolog using ICR 1:15. Continue bedside glucose checks hourly. Notify MD if BG> 200 or < 80. RDN consult on SMBG. C. Johnston, MD Intake/Output Date 12/9/ /10/

3 Time Daily Total P.O. NPO NPO I.V. (ml/kg/hr) 2,400 (4) 2,400 (4) 2,400 (4) 7,200 (4) IN I.V. piggyback TPN Total itake (ml/kg) 2,400 (32) 2,400 (32) 3,120 (41.6) 7,920 (105.6) Urine (ml/kg/h) 2,150 (3.58) 2,671 (4.45) 3,000 (5) 7,821 (4.34) Emesis output OUT Other Stool 0 x 1 0 x 1 Total output (ml/kg) 2,300 (30.7) 2,671 (35.6) 3,000 (40) 7,971 (106.3) Net I/O Net since admission (12/9) Laboratory Results Ref. Range 12/9/ Chemistry Sodium (meq/l) ! Potassium (meq/l) Chloride (meq/l) 95/ Carbon dioxide (CO 2, meq/l) ! BUN (mg/dl) Creatinine serum (mg/dl) Glucose (mg/dl) ! Phosphate, inorganic (mg/dl) ! Magnesium (mg/dl) Calcium (mg/dl) Osmolality (mmol/kg/h 2 O) ! Bilirubin total (mg/dl) Bilirubin, direct (mg/dl) < Protein, total (g/dl) Albumin (g/dl) Prealbumin (mg/dl) Ammonia (NH 3, umol/l) Alkaline phosphatae (U/L) ALT (U/L) AST (U/L) CPK (U/L) F M Lactate dehydrogenase (U/L) Cholesterol (mg/dl) ! Triglycerides (mg/dl) F 175! M T 4 (ug/dl) T 3 (ug/dl) HbA 1C (%) ! C-peptide (ng/ml) ! ICA - +! GADA - +! IA-2A - - IAA - +! ttg - - Hematology WBC (x 10 3 /mm 3 )

4 RBC (x 10 6 /mm 3 ) F M Urinalysis Collection method - Catheter Color - Yellow Appearance - clear Specific Gravity ph ! Protein (mg/dl) Neg +1! Glucose (mg/dl) Neg +3! Ketones Neg + 4! Blood Neg Neg Bilirubin Neg Neg Nitrites Neg Neg Urobilinogen (EU/dL) <1.1 Neg Leukocyte esterase Neg Neg Protein check Neg tr! WBCs (/HPF) RBCs (/HPF) Bacteria 0 0 Mucus 0 0 Crys 0 0 Casts (/LPF) 0 0 Yeast 0 0 Arterial Blood Gases (ABGs) ph ! pco 2 (mm Hg) SO 2 (%) CO 2 content (mmol/l) O 2 content (%) po 2 (mm Hg) Base excess (meq/l) >3 - Base deficit (meq/l) <3 - HCO - 3 (meq/l) ! COHb (%) <

5 1. What are the differences between T1DM and T2DM? Explain the pathophysiology, dx, and treatment of each. (4 pts) Type 1 diabetes: this is an autoimmune disorder which attacks the beta cells of the pancreas. Pancreas beta cell is destroying so they won t produce insulin. Patient with type 1 diabetes will have to depend on insulin. Only Type 1 DM has IAA, ICA, and GADA antibodies present due to autoimmune disease and C-peptide. If there is a lower level of lacking of c-peptide then it is type 1 DM. meaning there is insulin produced by pancreas. Lacking insulin contribute to decrease levels of cellular glucose because insulin plays a significant role in transporting glucose into the cells. So, when glucose is build up in the blood, it will increase breakdown of glycogen (glycogenolysis); this will cause cell to starve. In addition, hepatic glucose production (gluconeogenesis) also goes up. The glucose buildup in cell will lead to eyes, kidney, nerves and heart damages. Type 1 DM lack insulin production, so glucose lowering medications is not effective. Type 1 DM usually have the onset in childhood, but the disease can also develop in adults in their late 30s and early 40s Type 1 and Type 2 diagnose and symptoms: symptoms of Diabetes plus casual plasma glucose >200 mg/dl Fasting Plasma Glucose Test>126 mg/dl 2-Hour Postprandial Glucose Test >200 mg/dl Hemoglobin A1c value of 6.5% Polyphagia (excess hunger), Polydipsia (excess thirst),polyuria (excess urination) ( reference: Nut 116A Diabetes Mellitus lecture ) Type 2 diabetes is associated with lifestyle and nutrition related disease. There is defect in the glucose transportation into the cells, receptor in cells such as muscle cells, and adipocytes are not responsive to insulin; while the pancreas is able to produce insulin (different in type 1 DM). Thus glucose is not transport and uptake by cells. Type 2 DM is not insulin dependent as a consequence from peripheral insulin resistance. There is excess glucose production in the liver when there is malfunctioning insulin releasing response. The management of type 2 DM and blood glucose patient needs to take glucose-lowering medication along with dietary change, and increase physical activity. As the pancreas become exhausted when there is chronic overproduction of insulin, patient need to start insulin. Type 2 DM have stronger genetic predisposition than type 1 diabetes. Some predisposing factors are: age, obesity, and sedentary life style. Type 2 DM was also known as adult onset diabetes, on average people diagnose of type 2 DM are age 35. Type 1 and Type 2 diagnose and symptoms: symptoms of Diabetes plus casual plasma glucose >200 mg/dl Fasting Plasma Glucose Test>126 mg/dl 2-Hour Postprandial Glucose Test >200 mg/dl Hemoglobin A1c value of 6.5% Polyphagia (excess hunger), Polydipsia (excess thirst),polyuria (excess urination) ( reference: Nut 116A Diabetes Mellitus lecture ) 2. Why do you think Mr. B was originally diagnosed with T2DM? Why does the MD now state that he has T1DM? (2 pts) Mr. B has a family history of T2 DM, because his mother has T2DM. So that is a risk factor can possibly indicated he is more likely to develop T2DM. So with present of hyperglycemia and family history of T2DM with absent of history for T1 DM, and diagnosed of diabetes at age 47 years old ( now 48 years old), so he was diagnosed type 2 DM. However, currently his lab shows increasing level of antibodies GADA, IAA, and ICA and his c-peptide. Mr. has a c-peptide of 0.6 ng/ml, which is consider low, representing that only small amount of insulin are produced because T1 DM, pancreas beta cell is destroyed and won t produce insulin. 5

6 (Reference: 3. Describe the metabolic events that led to Mr. B s symptoms and subsequent admission to the ER (polyuria, polydipsia, polyphagia, fatigue, and weight loss), integrating the pathophysiology of T1DM into your discussion. (2 pts) First no insulin is produced because autoimmune destruction of beta cells in pancreas. Then, gluconeogenesis and glycogenolysis are elevated as absence of insulin to help suppress hepatic gluconeogenolysis. Next, hyperglycemia developed as glucose are unable to transport to cell without insulin available and development of polyphagia (excess hunger) when there is no energy in cells. Excess glucose not uptake by cell is left in the blood. So in order to get rid of the excess glucose, the body triggers frequent urination (polyuria). Next, as there is excess of fluid loss due to polyuria, it lead to dehydration and increase thirst (polydipsia). Additionally, the patient s fatigue might be cause by the lack of insulin production, so low amount/ no glucose gets uptake by the cells where it is converted into energy. Finally, weight loss occurs as a consequence of insufficient amount of insulin to glucose into the cells to convert to energy. The body now needs to burn fat (adipocytes), tissue, and muscle in place of glucose, which contributes to the body s overall weight loss. Another contributing factor to weight loss could be high level of amino acids in the blood, increased the rate of protein degradation; leads to muscle wasting, fatigue, and possible weight loss. (Reference: 4. Describe the metabolic events that result in the signs and symptoms associated with DKA. Was Mr. B in this state when he was admitted? What precipitating factors may lead to DKA? (2 pts) Diabetic ketoacidosis (DKA) usually occurs in individual with type 1 DM. Metabolic even that contributes to DKA are high blood glucose level as a result of ineffective suppression of gluconeogenesis in the liver. Then, lipolysis follows when insulin is not present to help triglyceride storage. Thus, there is a development of ketosis as the rate of fatty acid metabolism increased. Next, there is glucose and ketones buildup, the body want to get rid of it, cause polyuria. Frequent urination contributes to electrolyte imbalance and dehydration. Some symptom and signs of DKA are: poor skin turgor, hypothermia, hyperapnea, kussmaul breathing, acetone breath and orthostatic hypotension. Some precipitating factors that could lead to DKA are: illness/ infection, insufficient insulin dosage, initial manifestation of T1DM and emotional and physical stress. Hyperglycemia, hypertketonemia, and metabolic acidosis, vomiting, abdominal pain that can elevated to edema and coma, possibly death. Yes, Mr. B was in this state when he was admitted. He possesses many of the signs and symptom for DKA. For example, Mr.B was found almost unconscious at home. According to the lab result, his urinalysis has high ketones and glucose values. Mr. B also have a glucose level of 683 mg/dl (extremely high), low electrolyte imbalance ( Na: 130 meq/l, K: 3.6 meq/l), high level of CO 2 ( 31 meq/l) indicate there was too much acid in the body, and low blood pressure, ( 100/78 mmhg) cause orthostatic hypotension. (Reference : Nelms, M., Sucher, K. P., Lacey, K., and Roth, S. L. (2011). Nutrition Therapy & Pathophysiology, Second Edition. Belmont, CA: Brooks/Cole Cengage Learning. Page 483,486) 5. What is the relationship of HgbA1c values to the micro- and macro-vascular complications of diabetes? List 3 micro-vascular complications of DM. (2 points) Increase HgbA1c values indicate hyperglycemia, which can cause CVD, a macrovascular complication, and nephropathy, a microvascular complication. Hyperglycemia changes the structure of blood vessel membranes, makes blood vessels more vulnerable to endothelial damage, and causes thickening and decreased flexibility in the vessels. Hyperglycemia causes changes in the glomerulus blood vessel structure, which causes functional changes in the kidney, ultimately leading to nephropathy, leading to chronic kidney disease. Microvascular consequences are: nephropathy, retinopathy and neuropathy problems such as peripheral 6

7 neuropathy, especially foot problems. (Reference: NTP page 56, 483). 6. Mr. B will be started on a combination of Glargine given in the pm with Novolog prior to meals and snacks. Describe the onset, peak, and duration for each of these types of insulin. (2 pts) Glargine: is a long acting type of insulin and is also recognized as background insulin. Its onset of action is about 2-4 hour and doesn t have a peak of action. Its duration is between 20 to 26 hours. It s typically use during night time. But it can be use in the morning as well, which the drug can remain effective for the whole day. Novolog: is rapid-acting insulin and is also recognized as bolus insulin. Its onset is 5-15 minutes and peak when at minutes. That is commonly when the highest level of insulin in the blood is reached. Its duration is 3-5 hours. So this drug is typically taken during meals and may be used in pump therapy Identify any abnormal laboratory values measured upon Mr. B s admission. Explain how they may be related to his newly diagnosed T1DM. Discuss only relevant labs. (2 pts) Chemistry Mr.B s lab value Interpretation Sodium meq/l 130 meq/l This is low level. Hyperglycemia and DKA cause polyuria (frequent urination) leads dehydration and electrolyte imbalance. Carbon Dioxide 31 (meq/l) Excess normal range and possible cause by DKA. Indicates (CO2 meq/l) Phosphate, inorganic (mg/dl) ketoacidosis. 2.1 (mg/dl) Low level. Dehydration causes electrolyte imbalance. Glucose (mg/dl) 683(mg/dL) (High level) hyperglycemia cause by insulin resistance or lack of insulin production. Triglycerides (mg/dl) 175(mg/dL) ( high level) T1DM, there is no insulin, increase break down of adipose tissue and increase fatty acid release into blood. Osmolality 306(mmol/kg/H2O) (High level) result from dehydration and hyperglycemia. (mmol/kg/h2o) Cholesterol (mg/dl) 210(mg/dL) (high level) due to diet intake and family history, his lipid profile doesn t seem to be normal. HbA1C (%) 12.5% ( high level) glycosylated hemoglobin ( % of glucose that has hemoglobin in it). Reflects the average blood glucose over the past 3 months. High level might be cause by hyperglycemia. C-peptide (ng/ml) 0.09(ng/mL) ( low level) Help to show if there is any insulin produce and in the blood. Low level of c-peptide can signified that there is no insulin or very little in blood thus the pancreas might be dysfunction. ICA + It s an autoantibody that indicates if the Beta cell in pancreas is being attack. So this is marker for T1DM. GADA + It s an autoantibody that indicates if the Beta cell in pancreas is being attack. So this is marker for T1DM. IAA + It s an autoantibody that indicates if the Beta cell in pancreas is being attack. So this is marker for T1DM. Urinalysis Ketone +4 As evidence by ketoacidosis, blood glucose >180 mg/dl which is hyperglycemia. Kidney is not working property, large molecule such as protein are being transport into the urine. Glucose (mg/dl) +3 As a result of hyperglycemia and kidney malfunction. There was excessive glucose present in the urine. Protein (mg/dl) +1 As a result of hyperglycemia and kidney malfunction. The fluid volume decrease as there is polydipsia. (Reference: MedlinePlus - Health Information from the National Library of Medicine. U.S National Library of Medicine. Retrieved from 7

8 8. You meet with Mr. B before d/c and review SMBG. Based on the information above, write your initial nutrition assessment ADIME note for Mr. B, including 2 PES statements (include calculations & references on an attached sheet). (12 points) A: 48 yo pima Native American, Ht: 70 in. Wt. 160lb, BMI 23.0 ( normal) IBW: 75.5 kg %IBW: 96.3, smoker 1 ppd x 10 yr, work as truck driver, Family Hx:Father-MI; mother-ovarian CA, T2DM PMH: previous type 2 diabetes diagnosis Medications: discontinued use of metformin Dx:T1DM Cardiac: tachycardia Medical Hx: T2DM (1 yr ago)-improper metformin use Estimate energy requirement: kcal Fluid requirement: ml Generalized dietary strategies ( a recommended diet plan intake): CHO:232.1 g- 290 g protein: 116 g fat: g Labs: HbA 1c : 12.5% (high level); fasting glucose 683 mg/dl (extremely high); low sodium (130 meq/l) and phosphate 2.1 mg/dl ( low level) ; CO 2 meq/l ( high level); osmolality 306 mmol/kg/h2o (high level); phosphate 2.1mg/dL (low level); TG 175 mg/dl ( high level); presence of ICA, GADA; and IAA ( all positive); negative c-peptide 0.09 ng/ml ( low level, biomarker for T1DM), Cholesterol 210 mg/dl ( high level), Urine ph 4.9 ( low), Protein +1 mg/dl ( high), Glucose +3 mg.dl ( high), Ketones +4 ( (high) Prot chk tr.( high) D: (1): Food and nutrition related knowledge deficient (NB-1.1) related to lack of past education when diagnosed as evidence by diagnosis of Type 1 Diabetes and symptoms of polyuria, polydipsia, polyphagia, fatigue, and weight loss. (2) Altered nutrition-related laboratory values (NC-2.2) related to poor management of DM and improper and inconsistent use medication use as evidenced by elevated serum glucose level of 610 mg/dl (very high level). I: Goal: education Mr. B how to do CHO count and food exchange because pt s blood glucose is 683 mg/dl and HbA1c of 12.5% (both high values) and work with Mr. B to develop a way to assist pt take medication daily and properly. Recommendation: 1. Refer patient to a certified diabetes educator to learn more about blood glucose management. 2. encourage Mr. B to incorporate physical activity such as walking, jogging, and other activities for 150 min./week 3. Provide education to recognize and management of hypoglycemia. 4. Encourage to stop smoking 5. advice the importance of taking medication Behavior goals: 1. Increase fiber intake through fruits and vegetables 2. Set up goal with Mr. B to get 30 min/ day of exercise at night after work or in between breaks. 3. check blood glucose 3 x day 4. Encourage Mr. B to set alarms for time to take medication. 5. Keep food and exercise journal Diet Rx: 1. substitute whole grain carbohydrates, legumes 2. eat small frequent meals ( 4-5 meal/ day) 3. eat less saturated fats/ processed foods/ cholesterol 4. eat a kcals/day 8

9 Goal lab values : A1C levels be below 7%, BP below 140/80 mmhg, LDL below 100 mg/dl, triglycerides below 150 mg/dl, and HDL cholesterol above 40 mg/dl Compliance: Mr. B needs more education on how to manage diabetes. More guidance is needed for pt to take medicine and advise the importance of taking medication. M/E: 1. SMBG- 3x a day 2. Lab values- blood glucose, ketones, lipids, protein, HbA1c, C-peptide, urinalysis, micronutrients 3. Food and exercise journal 4. Analyze adherence to diet and glycemic response Follow up: Get patient s HbA1C in about 3 months and a monthly visit to the clinic Date: 12/15/2014 Nutrition student 9. Mr. B comes back to clinic 2 weeks after his new diagnosis. List the important questions you will ask him in order to plan the next steps for providing the additional education that he might need. (2 pts) 1. Has the patient use carbohydrate counting and eat frequent meals of the day with consistent amount of carbs in each day. 2. Has the patient start exercise 30 minutes a day? 3. What is the patient s new HbA1C value? 4. Is the glycemic control better or worse than before? 5. Does the patient feel confident and ready to move forward? 6. Does the patient felt comfortable about self-monitoring glucose level? 7. Does the patient still feel dizzy, nauseous at any time of the day? 8. Have the patient select high fiber foods and control fat intake? 10. Mr. B s usual breakfast consists of 2 slices of toast, butter, 2 T jelly, 2 scrambled eggs, and orange juice (~1 cup). Using the ICR 1:15, how much Novolog should he take to cover the carbohydrate in this meal? (1 pt) 2 slices of toast: 30 g carbs, 2 T jelly: 28 g carbs; 1 cup orange juice:30 g carbs; 2 scrambled eggs: 0 g carbs ( )= 90 carb. 90carb/ 15 gram crabs from ICR = 6 units of insulin OR. 5 units of Novolog rapid-acting insulin. 11. You determine that Mr. B needs _kcals/day based on EER calculations. You want to follow his normal eating pattern as much as possible while still meeting his protein requirements and keeping the kcal from fat at 30% or less of total kcals. Using the Diabetes Exchange/Food List and the worksheet below, develop a pattern for Mr. B s diet. (15 points) Food group Exchanges CHO grams Protein grams Fat grams Breakfast Starch Fruit

10 Milk (circle: whole, 2%, 1%, or NF) Meat (circle: lean, med or high fat) Non-starchy vegetables Fat Morning Snack (list food groups) Sweets, Desserts, and other CHO Fruit Milk (2%) Lunch Starch Fruit Milk (circle: whole, 2%, 1%, or NF) Non-starchy vegetables Meat (circle: lean, med or high fat) Fat Afternoon Snack (list food groups) Starch Fruit Dinner Starch Fruit Milk (circle: whole, 2%, 1%, or NF) Non-starchy vegetables Meat (circle: lean, med or high fat) Fat HS Snack (list food groups) Fruit choice Sweets, dessert, and other carbohydrates Total grams: X4 X4 X9 kcal from each macronutrient: % kcal from each macronutrient: 57.8% 16.8% 22.2% % kcal GOAL: 40-50% 30-40% 20% TOTAL KCAL: 2353 Kcals/day 12. You review Mr. B s diet, insulin injections, SMBG, and other self-care issues. He continues on injections of Glargine and Novolog. You reinforce teaching Mr. B about carbohydrate counting. How many CHO points or servings are in his daily diet from question 11? (1 point) (370 g CHO/ 15 g CHO)* 1 serving of CHO = 25 points or average serving 13. If Mr. B s pre-prandial BG was measured at 200 mg/dl and he plans to eat a lunch consisting of a cup of vegetable bean soup, a piece of fry bread, a piece of fruit and a diet soda, how much insulin should he take to 10

11 cover the meal, and how should it be adjusted to compensate for the BG level? Assume that the correction dose of 1 unit of insulin decreases blood glucose by 50 mg/dl, correct to 150 mg/dl, and an ICR of 1:15. (2 points) A cup of vegetable bean soup : 22.5g CHO, 7 g protein A piece of fruit: 15g CHO Diet soda: 0 g CHO A piece of fry bread: 15 g CHO Total CHO in meal: gram Insulin needed to cover 52.5 grams of CHO/ 15 = 3.5 units of insulin ( ICR of 1:15) The insulin should be adjusted to compensate for the blood glucose level by adding a certain amount of Insulin as a correction dose because the blood glucose of 200 mg/dl is already pretty high. There should be some insulin taken to get that number below 150 mg/dl. correction does: ( 200mg/dL-150mg/dL)= 50 mg/dl (50 mg/dl)/ ( 50 mg/dl/ 1 unit of insulin)= 1 unit of insulin 3.5unit of insulin + 1 unit= 4.5 = 5 unit of insulin 14. Describe the Native American foods, fry bread and wojapi. These would be categorized as what type of exchange? Include the reference used. (1 point) Frybread: looks just like fried dough or like an unsweetened funnel cake, but thicker and softer, full of air bubbles and reservoirs of grease. This dish would be categorized as a starch dish. ( reference: Wojapi: traditional berry soup, now it s often considers a dessert or pudding. It made of fresh wild berries collected during that season and also dried berries. Then it was with flour or sugar. ( reference: 11

12 Calculation: BMI: kg/m2 1kg=2.2lbs 1 inch= 2.54 cm 160lbs (1kg/2.2lbs) = 72.7kg 5 10 = 70 inches= 177.8cm=1.778m BMI= 72.7/(1.778cm)2 = 23 (PR pg. 18) IBW: 106 # + (6 # x 10in)= 166# = 75.5 kg ( PR p. 15 and 16) % IBW: (actual body weight / IBW) x 100 = (72.7 kg/ 75.5 kg)x 100 = 96.3% Fluid requirement: Method 2: ( kg body weight -20)x ( 72.7 kg-20) x = ml EER for males 19 and older= X age + PA X (15.91 X weight X height) PA= 1.11 for low active = X 48 +( 1 X (15.91 X X 1.778) = kcal/day EER Formula Reference: (Nutrition, Therapy, and Pathophysiology, pg. 242) CHO 40-50% kcal x.40= kcals x 1 g/ 4 kcal= g kcal x.50= kcal x 1 g/ 4 kcal= 290 g Protein: 20% kcal x.20= kcals x 1 g/ 4 kcal = 116 g Fat: 30%-40% kcal x.30= kcal x 1/9kcal =77.41 g kcal x.40= kcal x 1/9 kcal= g 12

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