Final Case Study

Caden Mitchell
University of Southern Mississippi
Purpose

The purpose of this assignment was to pick a patient at UPMC

Susquehanna and determine the following
Primary disease or condition
Secondary disease on condition
From there
Conduct a full assessment and follow the patient through the stay at the
facility
Conduct a review of literature including the care and recommendation of
the patient
Compare the findings to the actual care of the patient in the acute
setting
Make recommendations for future practice
Basic Patient info.

Name: C.S.
Primary diagnosis
Diabetic ketoacidosis (DKA)
Secondary diagnosis
Acute renal failure (ARF) secondary to dehydration
Notes:
Patient appears confused and disorientated
Unable to answer questions that require more than Yes or No at initial
assessment due to encephalopathy
Part 1: Review of Literature
Primary Diagnosis: DKA
DKA

Characterized by the accumulation of ketones in the blood

causing it to become more acidic and eventually toxic. This
typically happens when the body lacks sufficient insulin
required to absorb enough glucose into its cells (Mayo Clinic,
2015)
Under normal conditions insulin is used to open the cell
similar to a lock and key system and allows glucose to be taken
up for energy purposes, however, in DKA the glucose cant get
absorbed, putting the body into starvation mode, which results
in gluconeogenesis for energy (American Diabetes Association
[ADA], 2015b)
Ketones are produced as a by-product of this reaction
Most common with Type 1 Diabetes Mellitus (T1DM)
Diagnosis: DKA

Elevated blood glucose (BG) (typically > 250 mg/dL)

Serum ketones > 5 mEq/L
Blood pH < 7.3

**Presence of ketones in the urine ( > 0 mg/dL) may be used

as a simple test at home if early DKA is suspected
(Hamdy, 2016)
DKA: Signs and Symptoms

According to the American Diabetes Association

[ADA] (2015b), signs and symptoms are close to
that of hyperglycemia and include:
Elevated blood glucose
Thirst and or dry mouth
Frequent urination
Elevated ketones in the urine
DKA: Signs and Symptoms (cont.)

As the condition progresses the following may occur:

Recurrent fatigue
Dry, flushed skin
Nausea/Vomiting (N/V)
abdominal pain
difficulty breathing (related to compensatory processes)
fruity odor on breath
Trouble paying attention or confusion
Diabetic coma
EVEN DEATH!
DKA: When to Seek Medical Attention

Seek immediate medical attention if:

Any of the aforementioned clinical signs and symptoms
are observed with diabetes mellitus (DM) along with a
positive test for ketones in the urine (urinary ketones >
0 mg/dL) (ADA, 2015a).
Testingfor urinary ketones may be done at home using an over-
the-counter urinary ketone testing kit or at most in-patient and
acute care facilities.
DKA: Treatment

According to the Mayo Clinic (2015), treatment

involves these 4 steps:
Immediate insulin therapy
Fluid replacement
Electrolyte replacement
Continuous monitoring of blood glucose levels

**these will be explain in more detail in the upcoming

treatment section
DKA: Comorbidities

DKA has no direct comorbidities, but diabetes mellitus

(DM) does due to the altered blood osmolarity. They
include:
Hyperlipidemia
Atherosclerosis
Hypertension
Diabetic retinopathy (Mayo Clinic, 2015)
Type 1 DM (T1DM) specific
Autoimmune conditions such as Renal Disease and Celiac
disease (ADA, 2015b)
DKA: Complications

According to the Mayo Clinic (2015),

complications of DKA include the following:
Hypokalemia

acute renal failure

acute respiratory distress syndrome (ARDS)
cerebral edema
Part 1: Review of Literature
Secondary Diagnosis: Acute Renal Failure (ARF)
ARF

A common condition, especially in critical care patients

within the hospital due to added stress on the body
Develops from compromised blood flow to the kidneys,
injury to the kidneys, or a urinary blockage in the acute
setting
Any of the following will inhibit the kidney from filtering the blood
adequately
This will result in a build-up of toxic substances in the
blood, thus, causing the kidneys to decrease efficiency
until the point of kidney failure
ARF: Signs and Symptoms

According to the Mayo Clinic (2015),

Decreased urine output
Retention of fluid
Shortness of breath (SOB)
Confusion
Fatigue
nausea
ARF: Diagnosis

No one single diagnostic criteria according to DaVita Dialysis (2016)

Urinalysis
Urine output measurement
Abnormalities in the urine due to altered filtration
Blood tests
Urea (BUN)
Creatinine
Imaging tests
Ultrasound to examine kidney
If necessary, a biopsy may be done
ARF: Treatment

Treatment of ARF involves treating the underlying cause according to the

Mayo clinic (2015)
Reversal of altered blood flow from
Hyperlipidemia
Blood loss
Heart attack
Consistent over use of aspirin or similar medications
Correcting damage to the kidneys from
Blood clots
Glomerulonephritis
Multiple myeloma
Alcohol abuse
Autoimmune conditions that target the cells of the kidney
ARF: Treatment (cont.)

Correcting a urinary blockage from

Kidney stones
Cancer of Urinary tract
Blood clots in the urinary tract
Nerve damage in the bladder
ARF: Link to Primary Diagnosis

When elevated BG levels trigger reactive polyuria

dehydration is common
This may alter the blood osmolality causing stress on the kidney
Given that increased BG levels have already made filtration more
difficult, resulting decreases of filtration rate (measured as GFR)
commonly ensue
Evidence Based Nutrition
Recommendations
DKA secondary to T1DM
Major Recommendations

According to the Nutrition Care Manual [NCM], a few

interventions are necessary and include two objects
Stabilization of the patient
Insulin therapy
Fluid replacement
Electrolyte replenishment
Prevention of recurrent issues
Appropriate carbohydrate intake
Balanced macro- and micro- nutrient recommendations
Insulin Therapy

In order to stabilize the patient, insulin therapy is

required because DKA is caused by insulin deficiency
When given, insulin will do the follow:
Prevent glycogenolysis and lipolysis
inhibit gluconeogenesis (thus suppressing ketone production as a by-
product)
Aid in the conservation of fluid and electrolytes
Insulin Therapy

Insulin prescription is out of the scope of practice for a standard RD/RDN so

the physician should order an appropriate amount of insulin based on the
needs of the individual patient
The Academy of Nutrition and Dietetics NCM does recommend the use of
Continuous IV administered insulin (at a predetermined rate) as this has been
shown to produce the best results in acute hyperglycemia
Fluid Replacement

Replacement of fluids is necessary to treat dehydration resulting from osmotic

diuresis secondary to elevated BG levels
Without fluid replacement insulin therapy has been shown to not suffice in
stabilizing BG levels
The ADA (2015), recommends an isotonic saline solution be administered at 15
20 mL per kg of body weight for the first hour. From there, hydration status
should be re-evaluated and continuous fluids should be adjusted accordingly
Electrolyte replenishment

Since losses of sodium, potassium, and phosphorus are all common, standard
labs should be drawn to assess the electrolyte status
The patient should receive normal saline solution for fluid replacement, this
will cover any sodium losses
If potassium is low ( < 3.5 mg/dL) it may be given at 20 30 mEq/L via IV in
normal saline solution
Not always necessary since potassium excretion is inhibited in some DKA patients
(Jang et al., 2015)
If phosphorus is low ( < 2.5 mg/dL) use clinical judgement when replacing.
According to a Meta Analysis conducted by Fayad, Buamscha, and Ciapponi,
(2016), phosphorus supplementation can affect renal function in certain
patients. Since ARF is common, this should be avoided if possible.
Macronutrient Recommendations

Carbohydrates
Restriction of 3 5 servings (one serving = 15g) of carbohydrates per meal and 1 2
servings for snacks works for most adults (AND EAL, 2015).
Protein
Once any acute renal issues are resolved, if present, recommended protein is 1.0-
1.2 g/kg (AND EAL, 2015).
Lipid
fats should make up 27-40% of total calories (AND EAL, 2015).
Caloric Restriction
May benefit those with elevated fasting BG and A1c levels
A diet consisting of 1,400 and 1,700 kcal/day was shown to decrease A1c over a six
month and twelve month period (Ash et al., 2003).
Patient Information

C.S.
Race: Caucasian
Sex: M
Age: 58
Admission date: 11/13
Discharge date: 11/19
Current status: unmarried, receives disability
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
NKDA; NKFA
Assessment
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
Date Wt. (kg) Status
~10/13 79.9 Reported by pt. x 4 weeks
prior
11/13 77.7 Admission

11/15 78.5 Nursing update

11/18 80.1 Nursing update (day prior to

discharge)
Needs Assessment
Nutrition Assessment Terms
Estimated energy needs
Recommendations:
Estimated protein needs
Estimated carbohydrate needs 165-255 g CHO per day
Estimated fluid needs
Indicate the Comparative Provide a referenced
Calculate, as needed Standard Used rationale for the Comparative
Standard Used
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.
72-87 g Pro 1-1.2 g/kg (ARF resolved) 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.
3-5 servings per meal; 2 According to the Mahan,
snacks spaced out between Escott-Stump, Raymond,
meals 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.
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.
Biochemical Data
Labs measured Admission (11/13) Reassessment (11/15) Misc.

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
Nutrition Focused Physical Exam (NPFE)

NPFE was performed and due to the acute nature of the

condition present, no significant findings of muscle or fat loss
noted. It was observed that the patient had adequate fat and
muscle store. These results were then validated by the
following:
BMI - 24.42
Pt. report of moderate physical activity
2.8% (non-significant) x 4 weeks PTA
MNT and Diet Orders

Date: Diet order entered % of needs met status

or 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 met Discontinued (11/16)
for calories,
protein, and
fluid.
11/16 CHO controlled, heart 100% of needs Discontinued (11/19)
healthy diet met for calories, upon discharge
protein, and fluid
from this point
until discharge
11/17 Follow-up assessment Completed (11/17)
completed. CHO
controlled diet
education completed.
PES Statements

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 Intervention
Describe the actual Discuss the rationale/justification for recommendations, including Describe if this was
List Specific
Nutrition intervention that was references, as appropriate the most
Nutrition
Intervention completed appropriate
Intervention
Terminology intervention
Term(s)
Medical Food Inadequate Continuation of Glucerna is recommended for patients who have DM type 1 or This intervention
Supplement oral intake Glucerna was 2 to prevent blood sugar levels from peaking (Glucerna, n.d.). was the most
Therapy offered to the Glucerna Shake. (n.d.). Retrieved November 23, 2016, from appropriate for
patient after http://abbottnutrition.com/brands/products/glucerna-shake- the patient,
resuming PO diet; retail however, the
patient denied patient denied
supplement the supplement.

Nutrition Nutrition Nutrition education Nutrition education was provided to the patient on a CHO According to the
Education- related was provided on a controlled diet and according the Academy of Nutrition and research this
Application knowledge CHO controlled diet Dietetics Evidence Analysis Library [ANLEAL] (2015), intervention is
deficit with verbal teaching intervention with an RD/RDN has been shown to decrease clinically shown
and written fasting blood glucose and A1c values. to decrease
materials provided. fasting BG and
A recommendation Academy of Nutrition and Dietetics Evidence Analysis Library. A1c and for that
of a no added salt "DM: Effectiveness of MNT Provided by RD/RDN. (2015) reason was an
(NAS) diet was also Academy of Nutrition and Dietetics, Accessed 11 October appropriate
made to the patient 2016, intervention.
based on his PMH.

Collaboration Swallowing M.D. ordered the N/A as this was not a recommendation from the intern and has This was the
and Referral of difficulty patient NPO until been listed just for reference. correct
Nutrition Care altered mental state intervention as
was resolved the patient was
getting
rehydrated via
IV.
Monitoring and Evaluation

Energy intake: monitor PO intake

Due to inadequate oral intake x 2-4 days noted PTA he was monitored for
any intake and what it was providing
A goal was set to resume PO feedings as medically feasible while admitted to
the hospital
Goal met, ongoing; 11/15, dinner time

A diet education on a CHO controlled diet was provided to address his

excessive CHO intake and a no added salt recommendation was made due
to his PMH
Goal: Pt. verbalized understanding of diet teaching
Goal met at conclusion of education
Monitor for further questions
The patient was provided information on the out-patient diabetes care
center and how to set up an appointment if additional follow-up is desired
Monitoring and Evaluation

Biochemical data: monitor labs

Labs were evaluated at the initial assessment and follow-up assessment
A goal range for fasting BG level was set for 80-120 mg/dL
Goal met after patient was stabilized in the ER (BG > 500 ml/dL upon admission)

Electrolyte levels were closely monitored (goal ranges were used)

BUN and Cl out of range during initial assessment
Goal met upon follow-up assessment (except calcium)

Wt./wt. status: monitor wt.

Goal of wt. gain with rehydration was set
Goal met
Key Takeaways

When a patient with DKA is admitted, they must be immediately stabilized

with:
Insulin therapy administered by the attending M.D. and or CDE
Fluid repletion
Electrolyte replenishment
CHECK FOR SIGNS OF ARF!
Adjust protein recommendations accordingly

Then Prevention should be addressed

Provide CHO counting education
Refer to Out-patient DM center if possible
Questions?
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
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/
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
References

Hamdy, O. (2016, July 20). Diabetic Ketoacidosis. Retrieved November 27,

2016, from http://emedicine.medscape.com/article/118361-overview
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
Academy of Nutrition and Dietetics. Diabetic ketoacidosis and hyperosmolar,
hyperglycemic state. Nutrition Terminology Reference Manual (eNCPT):
Dietetics Language for Nutrition Care. From
https://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=272190#