PRIMARY TYPE 2 Diabetes (1)

8/3/2019 PRIMARY TYPE 2 Diabetes (1)

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Case 23:

Type 2 Diabetes MellitusCasey Flowers

Vaishali Keshani

Punam PatelRuchi Patel


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Introduction

Patient: Eileen Douglas is 71 years old African

American female.

Her chief complaint is a cut on her foot that

happened over 2 months ago and has yet to

heal.

Sx: Unhealed wound, frequent bladder

infections, slight tingling and numbness in her

feet, retinopathy.


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Nutrition Assessment


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Domain 5: Client History

Age: 71 (DOB 7/27)

Sex: Female

Education: Less then high school (10th grade)

Occupation: Homemaker

Sister age 80 was Dx with T2DM 10 years ago.

Non-smoker

Frequent bladder infections and HTN(currently on medication).


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Domain 1: Food and Nutrition Related

History

Medications: Capoten (captopril), 50 mg PO bid

Tx of HTN

Side effects: Dizziness, salty taste, cough, sore throat,

fever, mouth sores, unusual bruising, fast heartbeat,excessive tiredness.

Analysis of Dietary Intake via Diet Recall

Kcalories 1274 kcalProtein 54.770 gramsFat 48.191 gramsCarbohydrates 159.704 gramsFiber 24.893 gramsCholesterol 307 milligramsSodium 3822 milligrams


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History

Lifestyle Knowledge/Beliefs/Attitudes

Believes her sister has sugar

Behaviors Doesnt buy sweets

Avoids all starchy foods

Factors Affecting Access Low-income housing

Physical Activity Not reported, likely to be sedentary

-No Nutrition-Related Patient/Client-CenteredMeasures************


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History

Lifestyle cont..

-Nutrition-Related Patient/Client-Centered

Measures

Acquainted with Diabetes from her sister.

Believes she should avoid all starchy foods and

sugars

Has good intentions, but lacks knowledge to take

appropriate measures.


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Usual Dietary Intake

AM 1 egg, fried in bacon fat, two strips of bacon or sausage. 1 cup

of coffee black, cup orange juice unsweetened.

Lunch

Lunch meat sandwich [2 slices of enriched white bread, 1 slice(1oz) bologna, 1 slice (1oz) American cheese, mustard], 1 glass(8oz) ice tea unsweetened.

PM 1 cup turnip greens, seasoned with 1oz fat back, salt and

pepper; 2 small new potatoes, boiled, seasoned with salt andpepper; 2in square of cornbread w/teaspoon butter; 1 c beansand ham (~ c beans and c ham); 1 cup coffee black.

Snack 2 vanilla wafers.


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Domain 2: Anthropometric

Measurements

Ht 50 (152.4 cm)

Wt 155lbs (70.5 kg)

BMI 30.34 (Obese Class I) Weight Change N/A


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Domain 3: Biochemical Data, Medical

Tests, and Procedures***Parameter Normal Value Patients Value Reason for

Abnormality NutritionalImplicationsGlucose (mg/dL) 70-110 325 Hyperglycemia,

having high blood

glucose without

sufficient insulin.

1. Monitor blood

glucose

2. Insulin

regiment

HbA1c(%) 3.9-5.2 8.5 High concentrationof glucose in the

blood, so more

hemoglobin is

glycated

1. Long-term

monitoring of

blood glucose.

2. Monitor

glycemic index

Cholesterol

(mg/dL)120-199 300 High intake of fatty

foods, BMI 30.34,

poorly controlled

T2DM

1. Control daily

fat intake,

specifically sat.

fat and trans

fat.

2. Increase

physicalactivity.


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Parameter Normal Value Patients Value Reason forAbnormality

Nutritional

ImplicationsLDL-Cholesterol

(mg/dL)55 35 Too muchsaturated fats and

not sufficient

amounts of

polyunsaturated.

Same as above


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Parameter Normal Value Patients Value Reason forAbnormality

Nutritional

ImplicationsTriglycerides 35-135 400 BMI of 30.34, plus

poor control of

T2DM.

Same as above

BUN (mg/dL) 8-18 26 Poor kidney

function and

dehydration.

1. Increase fluid

intake.

2. Control blood

glucose

levels.HCT (%) 37-47 30.4 Anemia Bone marrow

problems and

kidney failure


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Domain 4: Nutrition-Focused Physical

Findings

Physical Findings Physiological Change/EtiologyOverweight High cholesterol, BMIMild Retinopathy Hyperglycemia, small vessel damagePoor wound healing HyperglycemiaDiminished sensation in feet Hyperglycemia, nerve damage


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Domain 6: Comparative Standards

According to the Mifflin-St. Jeor equation Energy Needs: 1,367 calories/day for her sedentary lifestyle.

Protein Needs

56.36 grams/day.

Weight Recommendations Decrease weight by 10lbs (4.5kgs)

Optimal BMI 24.9 or 125lbs (56.8kgs)

Fluid Needs 2.5+L


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Macronutrient Recommendations

Macronutrient Recommended Current diet Needs

Protein 10-35% 17% Within

recommended

range

Fat 20-35% 43% Decrease by13% to 30%

Carbohydrates 45-65% 45% Increase

complex

carbohydrates


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Micronutrient Recommendations****

Micronutrient Recommended Why

Chromium

Vitamin B12 500mcg 3x daily Correction of nerve

function to help improve

peripheral neuropathy.

Vitamin C 1-3g daily. Helps decrease sorbitol.

Zinc


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MyPlate Recommendations Current Diet

Fruits 1.5 cups .5 cup of orange juice

(Does not meetrecommendations)

Vegetables 1.5 cups 1 c turnip greens +2 new

potatoes

(Does meet

recommendations)Grains 5 ounces 2oz of enriched white

bread + 2in sq. cornbread

+2vanilla wafers

(Does not meet

recommendations)

Dairy 2.5 cups 1oz American cheese

(Does not meet

recommendations)

Protein 4 ounces 1 egg+2 strips

bacon/sausage+1oz

bologna+1oz ham+ 3/4cbeans


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Nutrition Diagnosis


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PES 1

Excessive fat intake related to frequent

consumption of high fat meals as evidenced by

average daily intake of 48.2 grams of fat, HDL of

35 mg/dL, and LDL of 140 mg/dL.

PES 2 Food and nutrition related knowledge deficit

related to excessive carbohydrate intake as

evidenced by average daily intake of 159.7 grams

of carbohydrate and blood glucose of 325 mg/dL.

PES 3


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PES 1 Goal is to get within recommended ranges of fat

HDL > 55 mg/dL

LDL


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Monitoring and Evaluation


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Doctors Recommendation

Tx plan

Debride wound

Normalize blood glucose levels

Begin self-management training on nutrition

prescription, meal planning, signs/symptoms, and

Tx of hypo-/hyperglycemia, SMBG, appropriate

exercise, potential food-drug interaction. Initiate Lipitor 10 mg gd, continue 50 mg bid


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Nutrition Recommendations

Mrs. Douglas was d/c with the following

instructions:

Non-kilocaloric-restricted

Low-fat (less than or equal to 30% total kcal)

High-CHO (greater than or equal to 50% total kcal)

diet

Walking program Continue prescription for captopril to control her

HTN.


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Evaluation

Glucose levels were well controlled for 6 months, but shebecame unable to afford the necessary supplies to checkher BG or urine acetone levels

After 6 months, she was readmitted with a BG of 905mg/dL, a slight temperature, BP of 68/100 mm Hg,tachycardia, and shallow, tachypneic breathing (Kussmalrespirations).

She was Dx with pneumonia, dehydration, andhyperglycemic hyperosmolar nonketotic syndrome (HHNS).

The medical nutrition therapy for patients with HHNS iscorrecting high glucose levels via insulin therapy, replacingelectrolytes through fluid therapy, and monitoring labresults frequently.


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Evaluation continued

She was Dx with pneumonia, dehydration, and

hyperglycemic hyperosmolar nonketotic

syndrome (HHNS).

The medical nutrition therapy for patients with

HHNS

Correcting high glucose levels via insulin therapy

Replacing electrolytes through fluid therapy Monitoring lab results frequently


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ADIME cont..

Diagnosis

T2DM

HTN

Excessive fat and carbohydrate intake

Intervention

Get fat intake and BMI within recommended

range.

Lower glucose levels


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ADIME cont

Monitor

Normalize blood glucose levels

Fat, CHO, and kcal intake

Physical activity Evaluation

Follow up with pt regarding previousrecommendations

Discuss better strategies to control blood glucoselevels and prevent HHNS


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PRIMARY TYPE 2 Diabetes (1)