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KNH 413 DKA Case Study Brittany Wrasman 1. There are precipitating factors for diabetic ketoacidosis. List at least seven possible factors. A. Precipitating factors for diabetic ketoacidosis include missing an insulin dose, not injecting enough insulin, eating poorly, feeling stressed, having an illness, having an infection such as pneumonia or an urinary tract infection, and being under the age of 19. (FamilyDoctor.org, 2010) 2. Describe the metabolic events that lead to the symptoms associated with DKA. A. The main cause of DKA is a lack of insulin. This results in a rise in the body’s glucose levels because the sugar is not able to get into your cells. To get energy, the body begins to burn fat causing the build up of ketones. Ketones can poison the body resulting in nausea, vomiting, abdominal pain, confusion, and fatigue. Other symptoms of hyperglycemia include: extreme thirst, dry mouth and skin, fruity smelling breath, frequent urination, and dehydration. (FamilyDoctor.org, 2010). 3. Assess Susan’s physical examination. What is consistent with diabetic ketoacidosis? Give the physiological rationale for each that you identify. A. Symptoms of DKA include nausea and/or vomiting, stomach pain, fruity or acetone breath, Kussmaul respirations, and mental status change. When
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adequate insulin is not available, glucose production is stimulated via gluconeogenesis and lipolysis in an effort to avoid starvation. Ketones are produced as a result of lipolysis. As the glucose and ketones accumulate in the bloodstream, osmostic diuresis occurs, resulting in dehydration and electrolyte imbalances (Nelms, Sucher, Lacey & Roth, 2011, p. 496). In Susan’s physical examination, it was noted that she was feeling irritable and lethargic, her skin was dry and flushed, she had deep, rapid Kussmaul’s respirations, and her abdomen was tender, all of which correspond to the symptoms of DKA. 4. Examine Susan’s biochemical indices both in the chemistry section and in her ABG report. Which are consistent with DKA? Why? A. Susan’s biochemical lab results indicate that her potassium, chloride, PO4, magnesium, osmolality, and BUN levels were high. All of which are indicative of dehydration that is associated with DKA. Susan’s creatinine level was also elevated upon admission, representing the presence of kidney issues. Diagnostic criteria for DKA include a blood glucose level above 250 and Susan’s was consistent with this at a reading of 425. A low arterial pH level also corresponds with the diagnosis of DKA, which also matches Susan’s admitted pH level of 7.31. Susan’s urine also tested positive for ketones and glucose, further supporting her diagnosis of DKA. (American Diabetes Association, 2002)
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5. If Susan’s symptoms were left untreated, what would happen? A. If DKA is left untreated, ketones continue to build up in the blood disrupting the normal working of many parts of the body. DKA is potentially fatal, causing severe dehydration, coma, and swelling of the brain. (NHS choices, 2013) 6. Assuming Susan’s SMBG records are correct, what events seem to have precipitated the development of DKA? A. Based off of Susan’s blood glucose monitoring record, it appears that her blood glucose remained normal up until the start of her period. From that day on it increased steadily and spiked to 300 the day her volleyball tournament. The following day was her birthday and her levels continued to remain in the high 200’s reaching a high of 375 on her last recorded day. 7. What, if anything, could Susan have done to avoid DKA? A. To avoid DKA, Susan could have adjusted her insulin intake to account for her increased level of physical activity the day of her volleyball tournament. She could have also anticipated an increased consumption of simple carbohydrates the day of her birthday. She would have needed to monitor her carbohydrate intake and glucose levels more closely and give herself appropriate amounts of insulin to compensate for the higher levels. 8. While Susan is being stabilized, Tagamet is being given IV piggyback. What does “IV piggyback” mean? What is Tagament, and why has it been prescribed?
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A. An IV piggyback solution is hung above the main IV, but is administered through the same line. When administration of the IV piggyback solution is needed, the main IV fluid flow is stopped until infusion of the IV piggyback is complete. IV piggybacks are used only for intermittent drug administration (InnovateUs Inc., n.d.). Tagament is the brand name of Cimetidine, which is used to treat ulcers, gastroesophageal reflux disease, and control excessive stomach acid production. It is also administered to critically ill patients to prevent upper gastrointestinal bleeding (MedlinePlus, 2010). Susan’s lab results indicated that her pH level was below normal, or more acidic, which is why the doctor prescribed her to receive Tagament. 9. 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. A. Conventional or standard insulin therapy consists of a constant dose of basal insulin combined with short- or rapid-acting insulin. Individuals using conventional method must synchronize administration of their insulin and food intake to avoid hypoglycemia. Intensive or flexible
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insulin therapy requires multiple daily injections of bolus insulin before meals in addition to basal insulin once or twice daily. (Nelms, Sucher, Lacey & Roth, 2011, p. 487- 488) 10. List the microvascular and neurologic complications associated with type 1diabetes. A. Long-term hyperglycemia from type 1 DM leads to microvascular and neurological complications. Microvascular complications include cardiovascular disease, nephropathy, and retinopathy. Cardiovascularrelated illnesses are the most common cause of premature death in individuals with diabetes. This is a result of hyperglycemia making all blood vessels prone to endothelial damage and directly affecting the structure of the basement membrane of the vessels. Nephropathy arises from unmanaged hyperglycemia, which changes the structure of the blood vessels in the glomerulus, the functioning unit of the kidney. This leads to increased permeability and decreased filtering ability of the kidneys. Retinopathy causes blindness and is related to hyperglycemic damage to blood vessels in the eyes. Glaucoma and cataracts also occur earlier in individuals with diabetes. Glycemic control and lowering blood pressure are ways to prevent the progression of retinopathy. In individuals with diabetes, nervous system damage is attributed to the continued presence of hyperglycemia. The accumulation of abnormal substances such as sorbitol and glycated proteins results in cellular damage, disrupting the normal nervous system pathways. The gastrointestinal tract can be affected,
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including gastroparesis resulting from damage to the vagnus nerve. Lower GI problems may be evident in the presence of constipation or diarrhea. Bladder and/or sexual dysfunction are common genitourinary tract disturbances associated with autonomic neuropathy and may manifest to recurrent tract infections, pyelonephritis, or incontinence. Controlling blood glucose levels is crucial in preventing the development of both microvascular and neurological complications of diabetes. (Nelms, Sucher, Lacey & Roth, 2011, p. 496-497) 11. What are the advantages of intensive insulin therapy? A. A major advantage of intensive insulin therapy is the flexibility to adjust insulin to correspond to food intake, in response to hyperglycemia, or an altercation in usual physical activity. In addition, intensive insulin therapy can prevent or slow the progression of complications such as retinopathy, nephropathy, and neuropathy in patients with type 1-diabetes. (Nelms, Sucher, Lacey & Roth, 2011, p. 488) 12. What are the risks of intensive insulin therapy (tight control)? A. The risks of intensive insulin therapy include low blood sugar and weight gain. When you have tight blood sugar levels, a change in daily routine may result in hypoglycemia. When using insulin to lower your blood sugar, the sugar in the bloodstream enters cells in your body instead of being excreted in your urine. The sugar that is not used for energy by the cells is then converted to fat, which may lead to weight gain. (Mayo Clinic, 2014)
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13. 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? A. Intensive insulin therapy is generally not recommended for children or older adults. It requires frequent doses of insulin, regular monitoring of blood sugar, and closely followed dietary and exercise plans, which are typically more difficult for children and older adults to adhere to. Intensive insulin therapy is also not typically encouraged for individuals who struggle with frequent or severe bouts of low blood sugar or have heart disease, blood vessel disease, or severe diabetes complications. (Mayo Clinic, 2014) 14. Explain how an insulin pump works. Is Susan a candidate for an insulin pump? A. An insulin pump is a pager-sized device powered by batteries. A catheter is placed in the individual and attached to the insulin pump by flexible tubing, which then delivers rapid or short acting insulin to the individual 24 hours a day. Basal insulin is administered continuously over 24 hours while the insulin pump allows you to administer bolus to cover the carbohydrate after each meal or snack (American Diabetes Association, 2013). Based on Susan’s active lifestyle and ability to monitor her blood glucose levels, I would consider her a candidate for an insulin pump.
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15. How would you describe CHO counting to Susan and her family? A. I would start by explaining to Susan and her family that carbohydrate counting is a meal planning approach that focuses on daily carbohydrate intake, not its source. Carbohydrate counting helps a person decide the percentage of carbohydrates they should consume daily and distribute that amount to be consumed throughout the day. This allows the patient to know the amount of insulin that needs to be used at each meal, improving glycemic control. Food carbohydrate sources include starches, fruits, milk/yogurt, and sweets. One carbohydrate choice equals the amount of these food items containing 15 g of carbohydrates. The nutrition label on the food items can be used to gather the total grams of carbohydrate in each food item. Although fats do not contribute to a carbohydrate choice, an individual should be aware that they contribute calories and fat leading to weight gain and/or lipid abnormalities if left unmanaged. Carbohydrate counting allows an individual to manage their diabetes and learn the relationship between food, insulin, physical activity, and blood glucose levels. (Nelms, Sucher, Lacey & Roth, 2011, p. 492-493) 16. How is CHO counting used with intensive insulin therapy? A. Carbohydrate counting is used with intensive insulin therapy to help the patient match their food intake and insulin doses to achieve their target blood glucose levels. Carbohydrate counting allows insulin needs to be
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adjusted depending on what is being consumed and how the patient’s body reacts. (Novo Nordisk, 2003) 17. Estimate Susan’s daily energy needs using the Harris-Benedict equation. A. Estimated energy needs= 2,800- 2,900 kcal/day o Harris-Benedict Equation
REE for females= 655.1 + 9.6 W + 1.9 H- 4.7 A •
Weight= 115#/2.2kg= 52.27 kg
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Height= 63 inches x 2.54 cm= 160 cm
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Age= 16 years
655.1 + 9.6(52.27) + 1.9(160) – 4.7(16)= 1,386 kcal x 2.0 = 2,772 kcal
(Nelms, Sucher, Lacey & Roth, 2011, p. 492-493) 18. Using the 1-week food diary from Susan, calculate the average amount of CHO usually consumed each meal and snack. A. o 100 gm CHO breakfast o 90 gm CHO lunch o 30 gm CHO snack o 90 gm dinner o 17 gm CHO HS Monday
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AM
1.5 c. Rice Krispies= 30 g 1 c. 2% Milk= 12 g 1 c. Orange Juice= 30 g 1 med. Banana= 30 g
102 g
Lunch
6-inch Personal Vegetarian Pizza= 120 g 12 oz. Diet Coke= 0 g 1 Large Apple=30 g Snack 2 Slice Whole Wheat Bread= 30 g 2 tbsp. Crunch PB= 0 g 1 tsp. Grape Jelly= 7 g 12 oz. Diet Coke= 0 g Dinner 3 c. Cooked Spaghetti= 136 g ½ c. Sauce= 15 g 2 oz. Ground Beef= 0 g Large Tossed Salad= 0 g Diet Dressing= 5 g 12 oz. 2% Milk= 14 g 2 Stalks Cooked Broccoli= 5 g 6 Vanilla Wafers= 15 g HS ½ c. Vanilla Ice Cream= 15 g Tuesday AM 1.5 c. Rice Krispies= 30 g 1 c. 2% Milk= 12 g 1 c. Orange Juice= 30 g 1 med. Banana= 30 g Lunch 1 Bun= 30 g 1 slice American Cheese= 0 g 2 oz. Beef Patty= 0 g 1 oz. Potato Chips= 18 g 12 oz. Diet Mt. Dew= 0g 1 Med. Orange= 20 g Snack 6 Saltines= 15 g 2 oz. Colby Jack Cheese= 0 g 12 Grapes=15 g Water= 0 g Dinner 3 Tacos= 23 g ¼ c. Refried Beans= 8 g 1 c. 2% Milk= 12 g HS ½ c. Orange Sherbet= 15 g Wednesday AM 1.5 c. Cap’n Crunch Cereal= 45 g 1 c. 2% Milk= 12 g 1 c. Orange Juice= 30 g Lunch 4 Tacos= 30 g 12 oz. Diet Coke= 0 g Snack 6 Saltines= 15 g 2 Tbsp. PB= 0 g 12 oz. Diet Coke= 0 g Dinner 3 oz. Baked Chicken= 0 g 1 Large Baked Potato=60 g 1 tsp. Butter= 0 g 1 tsp. Sour Cream= 0 g 10
150 g 37 g
190 g
15 g 102 g
68 g
30 g
43 g 15 g 87 g 30 g 15 g 80 g
Thursday
Friday
Saturday
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1 c. Green Beans= 5 g 2 Fig Newtons= 15 g HS 1.5 oz. Pretzels= 30 g 2 tsp. Mustard= 0 g 12 oz. CF Diet Coke= 0 g AM 1.5 c. Rice Krispies= 30 g 1 c. 2% Milk= 12 g 1 c. Orange Juice= 30 g 1 med. Banana= 30 g Lunch 2 Slice Whole Wheat Bread= 30 g 3 oz. Ground Beef= 0 g 1 c. Mashed Potatoes= 30 g ½ c. Cooked Carrots= 0 g 1 c. 2% milk= 12 g Snack ½ c. Cottage Cheese= 0 g 1 c. Unsweetened Canned Peaches= 30 g Dinner 3 oz. Baked Pork Chops= 0 g 1 Large Baked Potato= 60 g 2 tsp. Butter= 0 g Large Tossed Salad= 0 g Diet Dressing=5 g 12 oz. 2% Milk= 14 g 1 Small Slice Angel Food Cake (no icing)= 30 g HS ½ c. Vanilla Ice Cream= 15 g AM 1.5 c. Rice Krispies= 30 g 1 c. 2% Milk= 12 g 1 c. Orange Juice= 30 g 1 med. Banana= 30 g Lunch 6-inch Personal Vegetarian Pizza= 120 g 12 oz. Diet Coke= 0 g 1 Large Apple=30 g Snack 2 Tbs. PB= 0 g 1 English Muffin= 30 g 1 c. 2% milk= 12 g Dinner 3 oz. Fried Fish= 0 g 1 Bun= 30 g Baked Fries= 15 g 1 c. Raw Broccoli and Cauliflower= 5 g LF Ranch Dressing= 5 g 12 oz. 2% milk= 14 g 2 Fig Newtons= 15 g HS 3 c. Popcorn= 15 g 12 oz. CF Diet Coke= 0 g AM 3 Buttermilk Pancakes= 45 g 2 tbsp. Maple Syrup= 30 g 2 tsp. Butter= 0 g
30 g 102 g
72 g
30 g 109 g
15 g 102 g
150 g 42 g 84 g
15 g 117 g
Sunday
3 Strip Bacon= 0 g 1 c. 2% milk= 12 g 1 c. Orange Juice= 30 g Lunch 1 oz. Cubed Ham= 0 g 1 oz. Cubed Cheese= 0 g 1 oz. Cubed Turkey= 0 g LF Ranch Dressing= 5 g 12 Saltine Crackers= 30 g 1 c. 2% Milk= 12 g 1 Large Apple= 30 g Snack 1 c. Diary Queen ice cream in a cone= 30 g Dinner 1 Slice Deep Pan Broccoli and Canadian Bacon Pizza= 60 g 1 Dinner Salad= 0 g 1 tsp. LF Italian Dressing= 5 g 12 oz. Diet Coke= 0 g HS 3 c. Popcorn= 15 g 6 oz. CF Diet Coke= 0 g AM 1 Slice French Toast= 15 g 2 tbsp. Maple Syrup= 30 g 1 c. 2% milk= 12 g 1 c. Orange Juice= 30 g ½ c. Sliced Strawberries= 5 g Lunch 3 oz. Fried Chicken= 0 g 1 c. Mashed Potatoes= 30 g 1 tbsp. Gravy= 0 g 1 c. 2% Milk= 12 g 1 c. Cooked Carrots= 5 g 1 Small Angel Food Cake= 30 g Snack 1 med. Banana= 30 g Dinner 2 oz. Sliced Beef= 0 g 1 Hoagie Bun= 30 g 2 oz. WOW Potato Chips= 30 g 1 Dill Pickle= 0 g 12 oz. Diet Coke= 0 g HS 3 c. Popcorn= 15 g 6 oz. Diet Coke= 0 g
77 g
30 g 65 g
15 g 92 g
77 g
30 g 60 g
15 g
(Nelms, Sucher, Lacey & Roth, 2011, p. A-110-A-123) 19. After you have calculated Susan’s usual CHO intake from her food record, develop a CHO-counting meal plan that she should use. Include menu ideas.
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A. Based on Susan’s estimated energy needs of 2,100- 2,200 kcal/day, her goal is to consume around 55% of her calories from carbohydrates, 20% from protein, and 25% from fat. o 2,800-2,900 x .55= 1,549- 1,595 kcal of CHO/ 4 kcal/g= 390- 400 g CHO
26- 27 CHO choices
o 2,800-2,900 x .20= 560- 580 kcal of PRO/4 kcal/g= 140-145 g PRO o 2,800-2,900 x .25= 700- 725 kcal of Fat/ 9 kcal/g= 78- 80 g Fat Daily Total: o CHO 390- 400 g o Protein 140-145 g o Fat 78- 80 g o Kcalories 2,800-2,900 Time 7:30-8:00 AM (Breakfast)
CHO Choice or Grams CHO 6 CHO Choices
11:30-12 PM (Lunch)
6 CHO Choices
2:30-3:00 PM
4 CHO Choices
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Menu Ideas 1 cup Oatmeal (2 CHO choices) 1 Tbs. Sugar (1 CHO choice) ¾ cup Blueberries (1 CHO choice) 1 cup 2% Milk (1 CHO choice) 1 Slice Whole Wheat Toast (1 CHO Choice) 1 tsp. Butter 2 Slices Whole Wheat Bread (2 CHO choices) 3 oz. LS Deli Ham 1 oz. American Cheese 2/3 cup Yogurt (1 CHO choice) ¼ Granola (1 CHO choice) 1 ¼ cup Whole Strawberries (1 CHO choice) 1 cup Chocolate Milk (1 CHO choice) 1 Medium Apple (2 CHO choices)
(Snack) 5:30-6:00 PM (Dinner)
7 CHO Choices
8:00- 8:30 PM (HS)
3 CHO Choices
3 tsp. Peanut Butter 12 Saltine Crackers (2 CHO choices) Water 1 cup Cooked Whole Wheat Pasta (3 CHO choices) 3 oz. Ground Beef ½ cup Pasta Sauce (1 CHO choice) ½ cup Peas (1 CHO choice) 17 small Grapes (1 CHO choice) ½ cup sugar free Chocolate Pudding (1 CHO choice) 1 ½ cups raw carrots (1/2 CHO choice) 1/3 cup Hummus (1 CHO choice) 1 cup Apple Juice (2 CHO choice)
20. Just before Susan is discharged, her mothers 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? A. The U.S. Food and Drug Administration (FDA) has tested and approved five artificial sweeteners to be used by consumers: acesulfame potassium, aspartame, saccharin, sucralose, and neotame. Stevia was banned in the U.S. until late 2008 when the FDA approved the purified part of the Stevia leaf for American consumption (American Diabetes Association, 2014). I would tell Susan and her mother that Stevia is generally recognized as safe by the FDA, but should not be consumed in proportions greater than 4mg of steviol equivalents per kg of body weight daily (Koelemay, 2014).
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References American Diabetes Association (2013). How do insulin pumps work? Retrieved from http://www.diabetes.org/living-with-diabetes/treatment-andcare/medication/insulin/how-do-insulin-pumps-work.html\ American Diabetes Association (2014). Low-calorie sweeteners. Retrieved from http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understandingcarbohydrates/artificial-sweeteners/ American Diabetes Association (2002). Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Diabetes Spectrum, 15(1), 28-36. Retrieved from http://spectrum.diabetesjournals.org/content/15/1/28/T1.expansion.html FamilyDoctor.org (2010). Diabetic Ketoacidosis. Retrieved from http://familydoctor.org/familydoctor/en/diseases-conditions/diabeticketoacidosis/causes-risk-factors.html InnovateUs Inc. (n.d.). What is an IV Piggyback? Retrieved from http://www.innovateus.net/innopedia/what-iv-piggyback Koelemay, J. (2014). Stevia sweeteners: Safety, ADI and metabolism | Beverage Institute. Retrieved from http://beverageinstitute.org/us/article/stevia-sweeteners-safetyadi-and-metabolism/ Mayo Clinic (2014). Intensive insulin therapy: Tight blood sugar control. Retrieved from http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensiveinsulin-therapy/art-20043866?pg=2 MedlinePlus (2010). Cimetidine. Retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682256.html NHS choices (2013). Diabetic ketoacidosis. Retrieved from http://www.nhs.uk/conditions/diabetic-ketoacidosis/Pages/Introduction.aspx Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning. Novo Nordisk (2003). Intensive insulin therapy- A way to keep blood glucose close to normal. Keeping well with diabetes, 1-20. Retrieved from http://www.aafpfoundation.org/hepp_files/files/intensive102104.pdf
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