November
4th, 2011
Complications
of Diabetes
Case Study 24
• Andrew Middleton
• Chelsea Guetherman
• Jennifer Hubbard
1
Complications of Diabetes
November 4th, 2011
Assessment
2
Complications of Diabetes
3
November 4th, 2011
Meet Mrs. M
Complications of Diabetes
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November 4th, 2011
Client History
Personal Data
64 y/o female
Cuban American residing in Miami, FL
Lives at home with her son who is also
obese
She enjoys watching her son bowl 2 or 3
times per week
Complications of Diabetes
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November 4th, 2011
Client History
Admitted to ER, with Dx of DVT in right leg and
hyperglycemia
DVT was treated with IV heparin therapy,
insulin, potassium and phosphorous
supplementation with a 1000 kcal, 2g Na diet
Past Dx include Type 2 DM, PVD, retinopathy,
neuropathy, nephropathy, hypertension
Fifth admission in the last year
Complications of Diabetes
6
November 4th, 2011
Client History
Health Hx
Poor vision, but not blind
Kidney function slightly effected by weight
and hypertension
Nephrotic syndrome with proteinuria &
edema is slight
Slight myocardial infarction (MI) one year ago
as a complication of atherosclerosis
Angioplasty was successful, but warned that
she could have more severe blockages
Complications of Diabetes
7
November 4th, 2011
Client History
Health Hx
Told by cardiologist that she would need
open-heart surgery if she didn’t lose
weight
Emphasis on meal plan was ignored
Gained 40 lbs. after MI due to decreased
activity
Complications of Diabetes
8
November 4th, 2011
Anthropometric Data
Height -5’3
Weight-252 lbs , 114.4 kg
84% increase in weight
BMI – 44.7 kg/m2
Complications of Diabetes
9
November 4th, 2011
Biochemical Data
Test Result Reference Units
Blood Glucose 203 mg/dl 70-110 mg/dl
BUN 27 mg/dl 6-20 mg/dl
Creatinine 1.2 mg/dl 0.6-1.1 mg/dl
Ca 9.1 mg/dl 8.8-10.0 mg/dl
Ser Alb 3.7 g/dl 3.5-4.8 g/dl
Na 144 mEq/L 136-145 mEq/L
K 3.1 mEq/L 3.5-5.2 mEq/L
Cl 98 mEq/L 96-106 mEq/L
Mg 1.9 mEq/L 1.8-2.6 mEq/L
P 4.4 mg/dl 2.7-4.5 mg/dl
Complications of Diabetes
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November 4th, 2011
Lab Data
Kidney Disease/Nephrotic Syndrome
proteinuria
hypoalbuminemia
increased BUN
Type 2 DM
Increased blood glucose
HbA1c
Complications of Diabetes
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November 4th, 2011
Lab Data
Hyperglycemia,
increasing:
Blood Glucose levels
TG levels
Osmolarity
HbA1c
Complications of Diabetes
12
November 4th, 2011
Nutrition-Focused Physical
Findings
Eyesight poor, but
not blind
Slight visible edema
Complications of Diabetes
13
November 4th, 2011
Food and Nutrient Related Hx
Medication and Supplement Intake
Heparin
Anti-coagulant used to decrease blood clotting
May cause N/V, constipation, bleeding of gums and
wounds
Inactivates thrombin and prevents fibrin formation
http://atvb.ahajournals.org/content/21/7/1094.full
Complications of Diabetes
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November 4th, 2011
Food and Nutrient Related Intake
Medication and Supplementation
Potassium/Phosphorus
Supplementation
Hypokalemia can lead to
serious cardiac dysrhythmia
and complications
Phosphate
supplementation
Used for immediate
treatment of DVT
Complications of Diabetes
15
November 4th, 2011
Food and Nutrient Related Hx
Medication and Supplement Intake
Insulin
May cause headache,
hunger, weight gain, and skin
irritation if injected
Phosphorylatesproteins to
decrease blood glucose http://www.rsc.org/chemistryworld/_denial.asp
concentration
Complications of Diabetes
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November 4th, 2011
Food and Nutrient
Related Intake
Favorites include :
Arroz con pollo
Fried plantains
Black beans and chick peas
Vegetables are cooked in
salt pork, ham, and lard
Excess sugar is used in coffee, on
plantains, and yams
Complications of Diabetes
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November 4th, 2011
Food and Nutrition Related Hx
Dietary Intake
Consumed on a Frequently
Consumed
daily basis Arroz
Fried plantains Yams
Dried black beans French fries
Chicken and pork
Chick peas
Fried eggplant
Beets
Greens
Orange juice
Hamburgers
Beer
Soda
*A more comprehensive dietary intake is
needed for a full assessment
Complications of Diabetes
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November 4th, 2011
Food Fat CHO Energy Protein
*Arroz (con 23g 51g 500kcal 23g
pollo)
1/3 cup
Yucca 6.5g 49.5g 277 Kcal .7g
1cup
*Plantains 21.5g 58.43g 408kcal 2.38g
(fried)
1 cup
*Black Beans 1g 23g 120kcal 7g
½ cup
Chick-peas 1.3 27g 143kcal 5.9g
½ cup
*Fried 13.9g 46.2g 359kcal 12.5g
Eggplant
1cup
*estimated consumed in one meal 1387
kcal,179g CHO, 60g fat
Complications of Diabetes
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November 4th, 2011
Food and Nutrient Related Hx
Knowledge/Beliefs/Attitude
Physician suggested meal plan is
complicated d/t multiple medical
problems
Unready to change nutrition related
behaviors
“knows it is bad for her but does it
anyway”
Complications of Diabetes
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November 4th, 2011
Food and Nutrient Related Hx
Access to Food Behaviors
Easy access to food Previous meal plan
at anytime
suggestions ignored
Son facilitates
inappropriate 40 pound weight gain,
dietary leading to decreased
employed as short physical activity
order cook
“goes along with Attending son’s bowling
whatever she night 2-3 times per week
wants”
allows opportunity for
“makes dishes for
her that she likes” excessive energy intake,
and alcohol
Complications of Diabetes
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November 4th, 2011
Comparative Standards
Energy Requirements for
Estimated
Maintenance: 2000 kcal/day
Mifflin-St. Jeor equation
Activity factor of 1.2
Recommended Intake Range for Gradual
Weight Loss:1000-1500 kcal/day
500-1000 kcal/day deficit appropriate
according to ADA recommendations
Complications of Diabetes
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November 4th, 2011
Comparative Standards
Macronutrient Needs
Protein requirement: 42 g/day
42 g/day based on .8g/kg IBW
Estimated Fat Needs: 22-58 g/day
20-35% of total kcals
<7% from saturated fats
Keep trans fats as minimal as possible
Estimated CHO Needs: 113-244 g/day
45-65% total kcals
At least half complex carbs
Estimated Fiber needs: 14-21 g/day
14g/1000 kcal
All macronutrient needs based on the Dietary Guidelines for
Americans 2010.
Complications of Diabetes
November 4th, 2011
Diagnosis
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Complications of Diabetes
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November 4th, 2011
Nutrition Diagnoses
Overweight/Obesity related to excessive energy
intake as evidenced by a BMI of 44.74 kg/m2.
Limited adherence to nutrition-related
recommendations related to lack of readiness to
change diet/lifestyle as evidenced by, patient
statement “I know it’s bad for me but I do it
anyway.”
Complications of Diabetes
November 4th, 2011
Prescription
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Complications of Diabetes
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November 4th, 2011
Nutrition Prescription
Reduce intake to 1200-1500
kcal (with 135-244g CHO) per
day
Nutrition Counseling using the
Cognitive Behavioral Theory,
focusing on relapse
prevention
Complications of Diabetes
November 4th, 2011
Intervention
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Complications of Diabetes
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November 4th, 2011
Intervention
Comprehensive Nutrition Education
Nutrient-dense foods vs. energy-dense
foods
Low-carbohydrate, low-fat/calorie-
restricted diet
Variety of foods i.e. vegetables, whole
grains, fruits, low-fat dairy foods, healthy
fats, and lean meats
Appropriate carbohydrate choices to
improve her glycemic control
Complications of Diabetes
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November 4th, 2011
Intervention
Nutrition Counseling
Self-monitoring
Encourage Mrs. M to keep a daily food record
Goal setting
Making small changes is key for Mrs. M
Modest weight loss has been shown to improve
insulin resistance
Weight loss of 7% of body weight
Increasing physical activity to at least 150
min/week of moderate activity, such as walking
Rewards should be non food related
Complications of Diabetes
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November 4th, 2011
Intervention
Nutrition Counseling cont.
Social support
It is most important that her son understands her condition
and the importance of her adherence to the meal plan
Both must be fully committed in order for change to
successfully occur
Her son should limit the amount of high cholesterol and
energy-dense foods that he is cooking for his mother during
the day
Stimulus control
Remove heavily processed foods that are high in added fats
and sugars from her environment
Mrs. M, should avoid snack foods at the bowling alley and try
to eliminate them from her environment unless they adhere
to her meal plan
Relapse prevention
Follow-up counseling is important for success
Complications of Diabetes
November 4th, 2011
Monitoring and
Evaluation
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Complications of Diabetes
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November 4th, 2011
Monitoring and Evaluation
Continued counseling is essential for
maintaining discipline and preventing
relapse, preferably once a week
Food diary
Physical activity log
Discuss home life
Monitorcomparative standards like BMI,
blood glucose, lipid profiles, and HbA1C
Complications of Diabetes
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November 4th, 2011
ADIME
Assessment: Admitted with DVT and Diagnoses:
hyperglycemia • Overweight/Obesity related to
• Ht. 5’3” Wt. 252 lbs excessive energy intake as
• 64 y.o. Cuban-American evidenced by a BMI of 44.74
female kg/m2.
• Labs – blood glucose 203 • Limited adherence to nutrition-
mg/dl, BUN 27 mg/dl, ser Alb. related recommendations
3.7 g/dl, K 3.1 mEq/L, P 4.4 related to lack of readiness to
mg/dl change diet/lifestyle as
• EER = 2000 kcal/day evidenced by, patient
• Estimated protein requirement statement “I know it’s bad for
= 42g/day me but I do it anyway.”**
**highest priority
Intervention: Monitoring and Evaluation:
• Reduce intake to 1200-1500 • Continued counseling is
kcal (with 135-244g CHO) per essential for maintaining
day discipline and preventing
• Nutrition Counseling using the relapse, preferably once a
Cognitive Behavioral Theory, week
focusing on relapse prevention • Food diary
• Physical activity log
• Discuss home life
• Monitor comparative standards
like BMI, blood glucose, lipid
profiles, and HbA1C
November
4th, 2011
Upon
discharge…
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Complications of Diabetes
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November 4th, 2011
Client History
Clot resolved & RNs started getting her
out of bed & ambulating her twice daily
When preparing for discharge, she
refused her food tray & then began
vomiting
N/G tube had to be placed
Complications of Diabetes
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November 4th, 2011
Client History
New condition dx as gastroparesis
PEJ (percutaneous endoscopic
jejunostomy) performed and feeding tube
placed
Reglan prescribed for when p.o.(by
mouth) feedings resumed
Complications of Diabetes
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November 4th, 2011
Nutrition-Focused Physical
Findings
Distended abdomen suggesting compromised GI
function
An esophagogastroduodenoscopy
was performed
negative for a gastric ileus
(decreased motility of bowel)
or obstruction
Venography studies indicated
ischemia of gastric arteries
Restricted blood flow to stomach resulting in
decreased gastric function
Complications of Diabetes
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November 4th, 2011
Diagnosis
Inadequate food/beverage intake
related to gastroparesis as evidenced by
nausea and vomiting.
Complications of Diabetes
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November 4th, 2011
Nutrition Prescription
Begin a 2000 kcal/day continuous drip
tube feeding using Suplena with
carbsteady.
Once p.o. (by mouth) feeding resumes,
continue 2000 kcal/day diet and transition
to a lower Calorie diet while focusing on
nutrition education and counseling.
Complications of Diabetes
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November 4th, 2011
Intervention
Enteral Feeding
Suplena with carbsteady provides 1.8 kcal/ml
and 45g protein/liter
Mrs. M needs ~1.1L of formula per day (50g
protein total), or 46 ml/hr (~83 kcal and 2.07g
protein)
Begin feedings at 25 ml/hr and advance by 10
ml/hr, every eight hours, up to the final flow rate
Bolus feedings for PEJ patients are not
recommended because this may clog the
feeding tube
Complications of Diabetes
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November 4th, 2011
Monitoring and Evaluation
We should monitor Mrs. M’s lipid profiles,
renal function, and protein intake
Ensure the feeding tube doesn’t clog
Complications of Diabetes
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November 4th, 2011
ADIME
Assessment: Admitted with DVT and auxiliary Diagnoses:
condition of gastroparesis • Inadequate food/beverage intake
• Ht. 5’3” Wt. 252 lbs related to gastroparesis as evidenced by
• 64 y.o. Cuban-American female nausea and vomiting.
• Labs – blood glucose 203 mg/dl, BUN 27
mg/dl, ser Alb. 3.7 g/dl, K 3.1 mEq/L, P
4.4 mg/dl
• EER = 2000 kcal/day
• Estimated protein requirement = 37-
42g/day
Intervention: Monitoring/Evaluation:
• Initiation of enteral feeding • We should monitor Mrs. M’s lipid profiles,
• Suplena with carbsteady provides 1.8 renal function, and protein intake
kcal/ml and 45g protein/liter • Ensure the feeding tube doesn’t clog
• Mrs. M needs ~1.1L of formula per day
(50g protein total), or 46 ml/hr
• Begin feedings at 25 ml/hr and advance
by 10 ml/hr up to the final flow rate
• Bolus feedings for PEJ patients are not
recommended because this may clog
the feeding tube
November
4th, 2011
Questions?
43
Complications of Diabetes
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November 4th, 2011
Works Cited
American Diabetes Association. Available at:
www.diabetes.org. Accessed October 27, 2011.
American Dietetic Association. Available at:
www.eatright.org. Accessed October 27, 2011.
National Kidney Foundation. Available at:
www.kidney.org/professionals/kdoqi/guideline_dia
betes/guide5.htm
Nelms MN, Sucher K, Lacey Karen, et al. Nutrition
Therapy and Pathophysiology. Second Edition.
Belmont, Calif: Wadsworth: 2011, 2007.