Running Head: Final Case Study

Final Case Study

Caden Mitchell

University of Southern Mississippi

Final Case Study

Abstract:

The purpose of this paper is to examine the clinical and nutritional diagnoses and

treatment provided to a patient at University of Pittsburgh Medical Center (UPMC)

Susquehanna. To do so, research was conducted on the primary diagnosis of diabetic

ketoacidosis (DKA) and the secondary diagnosis of acute renal failure (ARF). From

there, appropriate current medical and nutritional treatment methods were identified

based on research findings and compared to the treatment methods used within the

actual acute care of the patient. Findings concluded that the patient did receive

appropriate medical care as he was stabilized regarding his altered hydration status and

altered electrolyte levels. This resolved the immediate threat of mortality, which is not

uncommon in those with severe DKA, especially as it worsens causing impaired kidney

function due to oliguria followed by dehydration. The nutritional care was also suitable

given that an NPO diet was ordered followed by a full liquid diet and then finally a

carbohydrate (CHO) controlled diet. This was done to ensure kidney function was

restored to normal capacity as quick as possible to eliminate the risk of complications,

while tending to his nutritional needs as necessary. A dietary education was also

provided on a CHO controlled diet to ameliorate success at managing blood sugar

levels, thus, preventing re-admission. In the future, recommendations for the same level

of care and interventions are recommended in order to best treat the same condition

both medically and nutritionally.

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Diagnosis: DKA

DKA is a condition that occurs most commonly in those who have type 1

diabetes mellitus (T1DM), and under certain conditions in those who have type 2

diabetes mellitus (T2DM). According to the Mayo Clinic (2015), this condition effects

over 200,000 individuals in US alone, each year. DKA is characterized by the

accumulation of ketones in the blood. This typically happens when the body lacks

sufficient insulin required to absorb enough glucose into its cells. Under normal

conditions, insulin is needed to carry glucose into the tissues, where it will there be

metabolized as the primary source of energy (American Diabetes Association [ADA],

2015b). When the body lacks insulin, this process is unable to occur, resulting in the

catabolism of stored fat and eventually protein, as an alternative source of energy.

However, this method creates by-products known as ketones. These compounds are a

type of blood acid and when too many of them build up in the blood, the kidneys are

unable to filter them out and the blood becomes toxic. If the condition is not properly

treated, it will steadily progress and can lead to severe acute weight loss, diabetic coma

and even death (Mayo Clinic, 2015).

Early symptoms of DKA, according to the American Diabetes Association [ADA]

(2015b), are similar to that of hyperglycemia and include the following: thirst or a very

dry mouth, frequent urination, high blood glucose (blood sugar) levels, and a high levels

of ketones in the urine (ADA, 2015b, para. 5). As the condition progresses, later

symptoms such as constantly feeling tired, dry or flushed skin, nausea, vomiting,

abdominal pain, difficulty breathing, fruity odor on breath, [having] a hard time paying

attention or confusion may occur (ADA, 2015b, para. 6). If any of the aforementioned

clinical signs and symptoms are observed in those with diabetes mellitus (DM) along
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with a positive test for ketones in the urine (urinary ketones > 0 mg/dL), medical care

should be sought out immediately (ADA, 2015a). Testing for urinary ketones may be

done at home using an over-the-counter urinary ketone test kit or most in-patient care

facilities.

Primary treatment for DKA, according to the Mayo Clinic (2015), includes

immediate insulin therapy, fluid replacement, electrolyte replacement, and continuous

monitoring of blood glucose levels (every 1-2 hours) until the blood sugars drop to a

safe range (< 120 mg/dL). If the patient is already taking insulin, their previous insulin

routine will normally see an adjustment both during stabilization and or permanently, if

the current regimen does not suffice. The doctor will help make that decision along with

the help of a certified diabetes educator (CDE).

The underlying condition of DKA, known as diabetes mellitus (DM) does have

several comorbidities. Common examples of these include hyperlipidemia,

atherosclerosis, and hypertension, but depend on which type of diabetes is the

underlying cause. There are some common complications of DKA and these include

hypokalemia, acute renal failure, acute respiratory distress syndrome (ARDS), and

cerebral edema (Mayo Clinic, 2015)

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References

American Diabetes Association (2015, March 18a). Checking for Ketones. Retrieved

November 21, 2016, from http://www.diabetes.org/living-with-diabetes/treatment-

and-care/blood-glucose-control/checking-for-ketones.html

American Diabetes Association (2015, March 18b). DKA (Ketoacidosis) & Ketones.

Retrieved November 21, 2016, from http://www.diabetes.org/living-with-

diabetes/complications/ketoacidosis-dka.html?referrer=https://www.google.com/

Mayo Clinic. (2015, August 21). Diabetic ketoacidosis. Retrieved November 21, 2016,

from http://www.mayoclinic.org/diseases-conditions/diabetic-

ketoacidosis/basics/definition/con-20026470

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Secondary Disease(s) Description (ARF)

ARF is a common condition in patients currently admitted to the hospital,

especially those in critical care. According to DaVita Dialysis (2016), ARF develops from

impaired blood flow to the kidneys, injury to the kidneys, or a urinary blockage. When

this happens, the kidneys are no longer able to filter out the blood. This causes the

buildup of toxic substances. Often times, this can be exacerbated by dehydration due to

the changes in serum osmolarity, typically, when a urinary blockage is not the

underlying cause (DaVita Dialysis, 2016). This may result from excessive urination,

inadequate fluid intake, edema, or any combination of the aforementioned. Any patient

with DKA should be closely monitored for ARF as severe dehydration is common in this

condition due to polyuria (Mayo Clinic, 2015).

Treatment for ARF is based on the underlying condition that caused it. Common

methods of treatment include fluid repletion (normally done IV), medication (or

supplements) to stabilize electrolytes, and dialysis (Mayo Clinic, 2015). Dialysis may not

be required for every pt. especially those with a resolved urinary blockage.

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References

DaVita Dialysis (2016). Acute Renal Failure-When Kidneys Suddenly Stop Working.

Retrieved November 22, 2016, from https://www.davita.com/kidney-

disease/kidney-failure/acute-renal-failure

Mayo Clinic (2015, June 5). Acute Kidney Failure. Retrieved November 21, 2016, from

http://www.mayoclinic.org/diseases-conditions/kidney-

failure/basics/treatment/con-20024029

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DKA secondary to T1DM

Treatment for DKA relies mainly on two areas; stabilization and prevention. To

stabilize the patient nutritionally, a combination of a few interventions should be utilized.

The first is repletion of fluids. Since DKA is often accompanied with nausea, vomiting

and confusion, the patient may not be able to take fluids safely by mouth (Mayo Clinic,

2015). Fluids should be administered intravenously, per the attending physicians

orders. According to the ADA (2015), a recommended isotonic saline solution should be

administered at 15 20 mL per kg of body weight for the first hour. From there,

hydration status should be re-evaluated and fluids should be adjusted accordingly.

The next course of treatment is repletion of electrolytes. This may be done

through oral intake or supplementation based on the current condition of the patient.

Once renal function is stabilized, if needed, potassium may be given at 20 30 mEq/L if

serum K+ is < 5.5mg/dL, until oral supplementation is possible (ADA, 2015). According

to a study conducted by Jang et al., (2015), this is not commonly required however,

since low potassium (K+ > 3.5 mg/dL) occurs in only about 4% of patients admitted to

the ER with DKA. When it does occur, it is almost always due to another health

condition, since most patients will have decreased potassium excretion that occurs

when DKA worsens and effects the kidneys ability to excrete electrolytes in the urine.

Phosphorus supplementation may appear necessary in these patients, but is not

recommended in this population as it may trigger hypoglycemia. Although, according to

a meta-analysis conducted by Fayad, Buamscha, and Ciapponi, (2016) on a cohort of

3,185 patients with acute kidney injury, serum phosphate levels should be closely

monitored as they are indicative of low intracellular phosphate. If low intracellular

phosphate levels persist for too long, rhabdomyolysis (a condition of toxic metabolites
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leeching into the blood from cell degradation) may occur. This leads to worsening renal

function, which is already commonly decreased in DKA (Fayad, Buamscha, & Ciapponi

2016).

The final acute treatment method is reversal of hyperglycemia. The ADA (2015)

recommends that regular insulin be given continuously through an IV at 5 7 units per

hour, unless otherwise specified by the attending physician. In cases where the patient

is able to take food by mouth, oral intake should be withheld until the above three

conditions have been resolved, except for oral supplementation of electrolytes when

indicated. Once oral intake has resumed, the Academy of Nutrition and Dietetics

Evidence Analysis Library [AND EAL] (2014) recommends that CHO counting, using

insulin to CHO ratios be utilized to determine the appropriate amount of additional

insulin needed as this method was proven to significantly decrease fasting BG and A1c

in type 1 and type 2 DM patients.

The next treatment method presented to patients with DKA secondary to

diabetes (specifically T1DM) is preventative educational care. Often times, DKA is a

recurring problem in T1DM patients. Since uncontrolled DM is the underlying cause,

control of blood glucose levels is crucial in educating the patient on preventative

nutritional care. According to the AND EAL (2015), one intervention that should be

completed by all patients who are admitted with DKA is Medical Nutrition Therapy

(MNT). Although not always feasible, monthly MNT focused on CHO counting and CHO

restriction has been shown in over 20 study arms to decrease fasting blood glucose

(BG) and A1c levels when conducted for three to eleven months (AND EAL, 2015). One

study took it even one step further and looked at the effect of caloric restriction

incorporated in with the other interventions mentioned above. It was concluded that a
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restriction of between 1,400 and 1,700 kcal/day was shown to decrease A1c even

further along with body fat percentage when used for a period of 6 months or longer

(Ash et al., 2003). It is also important to note that the other macronutrients, protein and

fat, should be adjusted to meet the needs of patients in this population. According to the

AND EAL (2015), protein should be recommended at 1.0-1.2 g/kg and fat should make

up 27-40% of total calories.

Adjusting dietary patterns is not the only way to successfully avoid hyperglycemia

though. Educating patients to properly adjust their insulin ratios as opposed to only

adjusting dietary patterns to fit set insulin regimens may further decrease

hyperglycemia. One study, completed by the DAFNE Study Group (2002), conducted

on 136 Type 1 diabetics, found that a one-week class administered by a group of

certified diabetes educators (CDE), decreased A1c values in the intervention group from

9.4 +/- 1.2 to 8.4 +/- 1.2 after six months. This was compared to the control group who

saw an increase of .1 +/- 1.3 in A1c over the same time frame.

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References

Academy of Nutrition and Dietetics Evidence Analysis Library. (2015) " How effective is

MNT provided by Registered Dietitians in the management of type 1 and type 2

diabetes?". Academy of Nutrition and Dietetics, Accessed 11 October 2016,

http://andeal.org/topic.cfm?pcat=5491&menu=5305&cat=5161

Academy of Nutrition and Dietetics Evidence Analysis Library. (2014) " In adults with

type 1 and type 2 diabetes, what carbohydrate management strategies (such as

carbohydrate counting alone; carbohydrate counting using insulin-to-

carbohydrate ratios; carbohydrate consistency; plate method; exchange lists/food

lists/carbohydrate choices) are effective, in terms of glycemia (A1C or glucose)?".

Academy of Nutrition and Dietetics, Accessed 11 October 2016,

https://www.andeal.org/topic.cfm?menu=5305&pcat=5488&cat=5471

American Diabetes Association (2015, March 18). DKA (Ketoacidosis) & Ketones.

Retrieved November 21, 2016, from http://www.diabetes.org/living-with-

diabetes/complications/ketoacidosis-dka.html?referrer=https://www.google.com/

Ash, S., Reeves, M. M., Yeo, S., Morrison, G., Carey, D., & Capra, S. (2003). Effect of

intensive dietetic interventions on weight and glycaemic control in overweight

men with Type II diabetes: A randomized trial. International Journal of Obesity,

27(7), 797-802. doi:10.1038/sj.ijo.0802295

DAFNE Study Group (2002, October 05). Training in flexible, intensive insulin

management to enable dietary freedom in people with type 1 diabetes: Dose

adjustment for normal eating (DAFNE) randomized controlled trial. British Journal

of Medicine, 325(7367), 746-746. doi:10.1136/bmj.325.7367.746

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Fayad, A., Buamscha, D. G., & Ciapponi, A. (2016, October 4). Intensity of continuous

renal replacement therapy for acute kidney injury. Cochrane Database of

Systematic Reviews, 22(2), 151-154. doi:10.1002/14651858.CD010613.pub2

Jang, T. B., Chauhan, V., Morchi, R., Najand, H., Naunheim, R., & Kaji, A. H. (2015,

March 10). Hypokalemia in diabetic ketoacidosis is less common than previously

reported. Journal of Emergency Medicine, 10(2), 177-180. doi:10.1007/s11739-

014-1146-8

Mayo Clinic. (2015, August 21). Diabetic ketoacidosis. Retrieved November 21, 2016,

from http://www.mayoclinic.org/diseases-conditions/diabetic-

ketoacidosis/basics/definition/con-20026470

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Part II: Nutrition Care Process

Nutrition Care Process: Assessment

Anthropometric:
Pt. C.S.
Race: Caucasian
Sex: M
Age: 58
Ht. 175.26 cm. (estimated, per pt.)
Wt. 77.7 kg. (170.94#) bed scale
Wt. hx. 79.9 kg. x 4 weeks prior (-2.8%)
BMI 24.42
IBW 72.2 kg, (105%)
UBW 79.9 kg
Biochemical:
Na 144
K 3.7
Cl 113 high
BUN 23 high
Cr. 0.9
Glu 79 (stabilized) > 500 (Upon Admission)
Ca 7.8 low
Mg 1.8
A1c 7.8
GFR < 30
Clinical:
Admission date: 11/13
Discharge date: 11/19
Current status: unmarried, receives disability
Dx: DKA secondary to uncontrolled DM, ARF secondary to dehydration (resolved at
follow-up)
Hx of current disease state: DKA acute onset x1-3 days; DM x 2 years; ARF acute
onset x 1-2 days
PMH: T1DM, hypothyroidism, hyperlipidemia, HTN, GERD with remote H/O duodenal
ulcer (resolved), gastroparesis
FMH: Pt. unaware of family medical Hx
Meds: Norvasc, Sliding scale insulin, NSS @ 100ml/H, heparin, synthroid, nicoderm,
protonix
* food drug interaction (do not take with grapefruit juice or product)
BS: +BSx4
Edema: none
Other: history of alcohol/tobacco use (mild)
NKDA
Dietary:
Diet order CHO controlled
Appetite Pt. reports appetite PTA was good
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NPFE All areas WNL.

NKFA
Recommendations:
Based on IBW (72.2 kg.)
25-30kcal/kg 1805-2166 kcal/day
1-1.2g Pro/kg 72-87 g/day
Fluid needs 1805-2166 ml/day
Bolus feed will provide:
1900 kcal total (100%)
80g Pro (92%)
Fluid: 664 ml (with 800ml water flush per MD)

Nutrition Dx:
Decreased nutrient needs (CHO) r/t DKA and T1DM aeb blood sugar > 500 mg/dL on
admission and need for CHO controlled diet.
Unintended wt. loss r/t DKA, dehydration, and T1DM as evidenced by 2.8% wt. loss x 4
weeks (with wt. loss suspected over a much more recent time frame).
Intervention/Goal:
1. Supplement: Pt. denied off of a supplement
Goal: pt. will accept supplement if PO intake is < 50% of needs at next visit
2. General healthful diet: provide CHO controlled diet
Goal: pt. will consume > 50% of meals
M/E
Energy intake: monitor PO intake
Biochemical data: monitor labs
Wt./wt. status: monitor wt.
Pt. scored as a moderate level of care; will follow as a high level of care per
clinical judgement

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Food/Nutrition-Related History (FH) this subsection should discuss food and nutrient intake, medication/herbal
supplement intake (including rationale behind usage and drug-nutrient interactions), knowledge/belief/attitudes and
behaviors, food and supply availability, physical activity, and nutrition quality of life, as applicable
List Specific Nutrition Describe the actual information gathered from the
Assessment Term (e.g. patient/patients family/medical record
Nutrition Assessment Terms
Oral fluids, food allergies,
etc.)
Energy Intake
Fluid/Beverage Intake
Food Intake Inadequate oral intake Pt. was found unconscious in his home where he had
been for an unknown amount of time and was NPO x 2
days in the hospital
Breastmilk/infant formula
intake
Enteral nutrition intake
Parenteral nutrition intake
Alcohol intake
Bioactive substance intake
Caffeine intake
Fat and cholesterol intake
Protein intake
Carbohydrate intake Excessive carbohydrate Pt. over consumes CHO, per diet history provided by the
intake pt.
Fiber intake
Micronutrient intake
Vitamin intake
Mineral intake
Diet Order Excessive carbohydrate CHO controlled diet order, per MD
intake (was NPO x 2 days
post admission)
Diet Experience
Eating Environment
Enteral and parenteral
administration
MedicationsInclude the use
for each medication as it
pertains to the patient/clients
medical condition(s)
Complementary/Alternative
medicine
Food and nutrition Food and nutrition related Pt. is unaware of what foods contain CHO and what one
knowledge/skill knowledge deficit serving of CHO looks like in different foods, per pt.
assessment
Beliefs and attitudes
Adherence
Avoidance behavior
Binging and purging behavior
Mealtime behavior
Social network
Food/nutrition program
participation
Safe food/meal availability
Safe water availability
Food and nutrition-related
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supplies available
Breastfeeding
Nutrition-related ADLs and
IADLs
Physical activity
Factors affecting access to
physical activity
Nutrition quality of life
Anthropometric Measurements (AD)Calculate as needed this subsection should discuss height, weight, body
mass index, growth pattern indices/percentile ranks, and weight history, as applicable
List Specific Nutrition Describe the information Provide calculations and
Assessment Term (e.g. gathered from the interpretation (e.g. Obese,
Nutrition Assessment Terms
Oral fluids, food allergies, patient/patients significant weight loss,
etc.) family/medical record etc.) of anthropometrics
Body Inadequate oral intake Ht. 175.26 cm. (estimated) Normal BMI
composition/growth/weight Wt. 77.7 kg. (standing - 2.2 kg. (2.8%) x 4 weeks
history scale) (presumably less of a time
Wt. Hx. 79.9 kg. frame for wt. loss,
BMI 24.42 however, pt. could only
provide a more accurate
wt.)
Non-significant wt. loss
If pt. lost wt. only from
DKA x 1 week it would
qualify as severe acute wt.
loss
Biochemical Data, Medical Tests, and Procedures (BD)Indicate if abnormal this subsection should discuss
relevant nutrition-related laboratory data and tests, as applicable
List Specific Describe the Describe the cause of the abnormal
Nutrition information gathered lab values, specifically as it relates to
Nutrition Assessment Terms Assessment Term from the the patients medical condition(s)
(e.g. Oral fluids, patient/patients
food allergies, etc.) family/medical record
Acid-base balance Altered nutrition Blood pH altered Due to DKA
related lab values
Electrolyte and renal profile Altered nutrition Standard labs Altered serum labs related to ARF
related lab values conducted; Chloride, secondary to DKA with polyuria
BUN high. Calcium
low. Potassium
issues resolved.
Essential fatty acid profile
Gastrointestinal profile
Glucose/endocrine profile Altered nutrition Elevated BG Elevated blood glucose related to
related lab values uncontrolled DM
Inflammatory profile
Lipid profile
Metabolic rate profile
Mineral profile
Nutritional Anemia profile
Protein profile
Urine profile
Vitamin profile
Carbohydrate metabolism
profile
Fatty acid profile
Nutrition-Focus Physical Findings (PD) this subsection should discuss findings from an evaluation of body systems,
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muscle and subcutaneous fat wasting, oral health, suck/swallow/breathe ability, appetite, and affect, as applicable
List Specific Describe the
Nutrition information gathered Provide a narrative that explains your
Nutrition Assessment Terms Assessment Term from the findings from a NFPE that you
(e.g. Oral fluids, patient/patients conducted on your patient/client
food allergies, etc.) family/medical record
Nutrition-focused physical All findings WNL. N/A N/A
findings BMI validates these
findings.
Client History (CH) this subsection should discuss current and past information related to personal, medical, family,
and social history, as applicable
List Specific Nutrition Describe the information gathered from the
Assessment Term (e.g. patient/patients family/medical record
Nutrition Assessment Terms
Oral fluids, food allergies,
etc.)
Personal data
Patient/client OR family H/O decreased nutrient Pt. has a clinically diagnosed H/O of T1DM
nutrition-oriented medical needs (CHO)
history
Treatments/therapy H/O decreased nutrient Pt. takes insulin daily for management of CHO intake
needs (CHO)
Social history
Comparative Standards (CS)--Calculate as needed this subsection should provide estimations of the patients
nutritional requirements with identification of methods used for calculations. At a minimum, calculations should include
kcal, protein, and fluid requirements. Note, the intern should include an evidence-based rationale behind which
predictive equation for calories is used. Requirements for individual substrates (carbohydrates, saturated fat, etc)
and/or individual nutrients (potassium, phosphorus, sodium, etc.) can be included, as applicable.
Indicate the Comparative Provide a referenced
Standard Used rationale for the
Nutrition Assessment Terms Calculate, as needed
Comparative Standard
Used
Estimated energy needs 1805-2166 kcal/day 25-30 kcal/kg According to Mahan,
Escott-Stump, Raymond,
and Krause (2012b), a
calorie range may be used
to determine the energy
needs of a patient in the
acute care setting if no
contraindications.

Estimated protein needs
Estimated carbohydrate
needs
72-87 g Pro
165-255 g CHO per day
1-1.2 g/kg (ARF resolved)
3-5 servings per meal; 2
snacks spaced out
between meals
According to Mahan et al.
(2012b), 1-1.2 g/kg may
be used in adult patients
who require additional
protein to prevent muscle
breakdown.
According to the Mahan,
Escott-Stump, Raymond,
and Krause (2012c), 3-5
servings (one serving =
15g) of CHO should be
consumed at each meal
with 2 snacks daily
providing one serving
each, for those with
diabetes.

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Estimated fluid needs 1805-2166 ml/day 1 ml/kcal According to Mahan et

at. (2012b), 1 kcal/ml
is appropriate for all
patients without
specific fluid related
conditions.
Estimated vitamin needs
Estimated mineral needs
Recommended body 72.2 kg (IBW) 106lb + 6lb (inches over
weight/body mass 5ft) According to Mahan,
index/growth Escott-Stump,
(Hamwi Method)
Raymond, and
Krause (2012a), the
Hamwi method should be
used to calculate IBW in a
clinical setting.

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References

Mahan, L. K., Escott-Stump, S., Raymond, J. L., & Krause, M. V. (2012a). Krause's food

& the nutrition care process (12th ed.). In: Clinical: Inflammation, Functional, and

Physical Assessment. (pp. 163-172) St. Louis, MO: Elsevier/Saunders.

Mahan, L. K., Escott-Stump, S., Raymond, J. L., & Krause, M. V. (2012b). Krause's food

& the nutrition care process (12th ed.). In: Energy Intake. (pp. 19-31) St. Louis,

MO: Elsevier/Saunders.

Mahan, L. K., Escott-Stump, S., Raymond, J. L., & Krause, M. V. (2012c). Krause's food

& the nutrition care process (12th ed.). In: Medical Nutrition Therapy. (pp. 652-

739) St. Louis, MO: Elsevier/Saunders.

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Malnutrition Identification:

No signs of malnutrition were documented as evidenced by the lack of decreased

intake for > 5 days, NFPE findings and percent wt. loss reported.

Medical Nutrition Therapy & Diet Orders:

Date: Diet order entered or % of needs met status

Action completed (if applicable)
11/13 (admission) NPO 0% of needs met Discontinued (11/15)
while NPO
11/14 Initial assessment of Completed (11/14)
patient completed
11/15 Full liquid diet 50% of needs Discontinued (11/16)
met for calories,
protein, and
fluid.
11/16 CHO controlled, 100% of needs Discontinued (11/19)
heart healthy diet met for calories, upon discharge
protein, and fluid
from this point
until discharge
11/17 Follow-up Completed (11/17)
assessment
completed. CHO
controlled diet
education
completed.

Recommendations:

Based on IBW (72.2 kg.)

25-30kcal/kg 1805-2166 kcal/day

1-1.2g Pro/kg 72-87 g/day

Fluid needs 1805-2166 ml/day

Actual PO intake not recorded by nursing staff but the full liquid diet provides ~1500

total calories or about 75% of the patients needs and CHO controlled, Heart healthy

diet provides 100% of the patients needs.

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If oral feeding was not resumed after 5 days a recommendation for the following would

have been made:

1 can Glucerna 1.5 via NG tube Q.I.D. @ 0800, 1200, 1600, 2000 with 50 ml flushes

after each feed

Providing:

1,424 kcals (79%) with anticipated weaning off of formula upon acute stabilization

78.4 g Pro (100%)

720 ml fluid (40%) with additional fluid provided intravenously to meet needs

50 ml water flushes (51% total fluid) to avoid over-hydration further stressing the

kidneys

Anthropometric and Biochemical Trends:

Date Wt. (kg) Status
10/13 79.9 Reported by pt.
11/13 77.7 Admission
11/15 78.5 Nursing update
11/18 80.1 Nursing update (day prior
to discharge)

Labs measured Admission (11/13) Reassessment Misc.

(11/15)
Na 144 146
K 3.7 4.4
Cl 113 High 108
BUN 23 High 12
Creatinine 0.9 0.84
Glucose 79* 85
Ca 7.8 low 8.1 low
Mg 1.8 1.9
A1c 7.8

*Glucose finger stick on admission to ER, prior to stabilization and admission

labs, was > 500.

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The patient was admitted to the ER unconscious and with a glucose finger stick reading

greater than 500. Given that and the acidity of the blood along with a medical hx of

T1DM the patient was treated for DKA. Alterations in labs are in part due to ARF, which

developed after the kidneys attempted to correct the altered serum concentrations with

polyuria, but ended up dehydrating the blood and only causing further complications

and alterations in serum values.

Nutrition Care Process: Nutrition Diagnoses

1. Decreased nutrient needs (CHO) r/t DKA and T1DM aeb blood sugar > 500

mg/dL on admission and need for CHO controlled diet.

2. Unintended wt. loss r/t DKA, dehydration, and T1DM as evidenced by 2.8% wt.

loss x 4 weeks (with wt. loss suspected over a much more recent time frame).

Nutrition Care Process: Intervention(s)

Medical interventions:

Pt. medically stabilized in the following areas: Hydration status, electrolyte status, blood

glucose levels through the use of IV and medications

Norvasc Ca channel blocker used to treat pt.s HTN

Sliding scale insulin anti-diabetic agent used to control BG and bring the patients

levels back within the normal range

NSS @ 100ml/H used for fluid and electrolyte replenishment

Heparin used as a blood thinner

Synthroid used to control thyroid hormones and secretions

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Nicoderm used for tobacco withdrawal since pt. had hx of smoking and could not

verify current usage of tobacco

Protonix PPI used to treat GERD by inhibiting gastric secretions

List Describe the Discuss the rationale/justification for Describe if

Nutrition Specific actual recommendations, including references, as this was the
Intervention Nutrition intervention that appropriate most
Terminology Intervention was completed appropriate
Term(s) intervention
Medical Inadequate Glucerna was Glucerna is recommended for patients who have This
Food oral intake offered to the DM type 1 or 2 to prevent blood sugar levels from intervention
Supplement patient; patient peaking (Glucerna, n.d.). was the most
Therapy denied Glucerna Shake. (n.d.). Retrieved November 23, appropriate
supplement 2016, from for the
http://abbottnutrition.com/brands/products/glucerna- patient,
shake-retail however, the
patient
denied the
supplement.
Nutrition Nutrition Nutrition Nutrition education was provided to the patient on a According to
Education- related education was CHO controlled diet and according the Academy of the research
Application knowledge provided on a Nutrition and Dietetics Evidence Analysis Library this
deficit CHO controlled [ANLEAL] (2015), intervention with an RD/RDN has intervention
diet with verbal been shown to decrease fasting blood glucose and is clinically
teaching and A1c values. shown to
written materials decrease
provided. A Academy of Nutrition and Dietetics Evidence fasting BG
recommendation Analysis Library. "DM: Effectiveness of MNT and A1c and
of a no added Provided by RD/RDN. (2015) Academy of Nutrition for that
salt (NAS) diet and Dietetics, Accessed 11 October 2016, reason was
was also made an
to the patient appropriate
based on his intervention.
PMH.
Collaboration Swallowing M.D. ordered N/A as this was not a recommendation from the This was the
and Referral difficulty the patient NPO intern and has been listed just for reference. correct
of Nutrition until altered intervention
Care mental state as the patient
was resolved was getting
rehydrated
via IV.
Discharge
and Transfer
of Nutrition
Care

Nutrition Care Process: Monitoring and Evaluation

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Final Case Study

*UPMC Susquehanna uses a standardized monitoring and evaluation system including

the bolded sections below for all patients.

An initial assessment was conducted on 11/14 and a follow-up assessment and

education on a CHO controlled diet was provided on 11/17.

The patient was provided with information on the out-patient diabetes center for further

education if desired after discharge. No patient information was available after

discharge other than no new admissions to A UPMC Susquehanna facility being noted

in the patients electronic medical record.

Energy intake: monitor PO intake

Due to inadequate oral intake x2-4 days noted PTA and while the patient suffered the

worst of the DKA symptoms he was monitored for any intake and what it was providing.

This was intended to monitor the aforementioned PES statement. A goal was set to

resume PO feeding as medically feasible. The patient did resume eating food PO by

11/15. A diet education on a CHO controlled diet was provided to address his excessive

CHO intake and a no added salt recommendation was made. The patient was made

aware of and provided with information on the outpatient diabetes center if further

education is desired after discharge.

Biochemical data: monitor labs

Labs were evaluated upon the initial assessment and on the day of the follow-up visit to

address the altered nutrition related lab values. A goal range for fasting BG level was

set for 80-120 mg/dL. The patient remained in the goal range after being stabilized.
24
Final Case Study

Other labs were expected to return to their respective (standardized) goal ranges.

Almost all labs were propyl addressed and resolved while admitted.

Wt./wt. status: monitor wt.

No exact goal wt. was set but a wt. gain was expected with rehydration. A healthy wt.

gain was observed and this goal was considered met.

Conclusion

This patient presented to the ER with ARF and DKA. Inadequate oral intake x 2-4 days

was noted along with several altered nutrition related lab values including electrolytes,

BUN and BG. According the AND EAL (2015), intervention with an RD/RDN in those

who have DM has been shown to decrease BG and A1c. A goal range for BG was set

at 80-120 mg/dL. The patient remained within this range both subsequent times that

labs were drawn. Education on a CHO controlled diet was also provided. The patient

was receptive and is expected to make a fair effort at change. Information for the

outpatient diabetes was also provided if addition information is needed after discharge.

Other lab values were monitored and compared to their standard goal range for

evaluation.

Oral intake was monitored each day based on current diet and how many

calories the diet provides. The needs assessment was used for comparison and once

the patient was put on a CHO controlled diet all appropriate needs were met. Wt. was

also monitored. No specific number was set outside of the ideal body weight used for

the needs assessment. A wt. gain was anticipated, however, with rehydration. This goal

was met.

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Final Case Study

Future recommendation for practice include continuation of current nutrition

interventions based on the research referenced above and practical experience.

Patients with DKA should be kept NPO for the shortest amount of time possible, based

on the recommendations of the physician and Speech Therapist. Once PO intake is

approved, a full liquid diet should be given until nausea and vomiting have subsided. If

possible, a referral to the out-patient diabetes center should be made and added to the

discharge orders. Research shows continuous follow-up with a RD/RDN is known to

decease A1c and BG (AND EAL, 2015). This will allow for further RD/RDN intervention

and increase the likelihood of follow-up with the patient, thus, decreasing risk for

readmission.

26
Final Case Study

References

Academy of Nutrition and Dietetics Evidence Analysis Library. (2015) " How effective is

MNT provided by Registered Dietitians in the management of type 1 and type 2

diabetes?". Academy of Nutrition and Dietetics, Accessed 11 October 2016,

http://andeal.org/topic.cfm?pcat=5491&menu=5305&cat=5161

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