Name: _______________________

Instructions: This not a group case study; it is an individual assignment!

Remember RDs are experts in researching evidence-based practice for their patients so
you can use other credible sources. ***Be sure to reference your answers and provide a
Work Cited page at the end.***
1.

What are the standard diagnostic criteria for T2DM? Identify those found in Mrs. Deweys medical
record?

Standard criteria for type 2 diabetes includes a fasting plasma glucose greater than 125 mg/dL, Hemoglobin A1C
greater than 6.5%, and random plasma glucose greater than 200mg/dL in individuals with symptoms of
hyperglycemia or hyperglycemic crisis. Jamies glucose levels were 1,420mg/dL and her HgA1c was 13.2%, both
indications of diabetes.
2.

Pt was previously diagnosed with T2DM. She admits that she often does not take her medications. What
types of medications are metformin and glyburide? Describe their mechanisms as well as their potential
side effects/drug-nutrient interactions.

Metformin is used for patients with diabetes because it works as an anti-hyperglycemic agent to lower plasma
glucose. It decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin
sensitivity by increasing peripheral glucose uptake and utilization. Metformin can cause diarrhea, nausea/vomiting,
flatulence, and indigestion. When taking metformin, patients should also take a B12, folate, and calcium
supplement to replenish these nutrients that are likely to be depleted. Glyburide slightly lowers blood glucose by
stimulating the release of insulin from the pancreas. The mechanism is still unclear but is complimentary to
metformin and often the two are used together for optimal effects. The side effects of glyburide include difficulty
swallowing, dizziness, fast heartbeat, and hives. Glyburide could lead to either hypoglycemia or hyperglycemia
when coupled with alcohol. It is therefore best to keep alcohol intake limited to one drink per day for women and
two drinks per day for men.
3.

What are the common acute complications associated with type 2 diabetes mellitus? What are the
chronic complications? Describe the pathophysiology associated with the chronic complications,
specifically addressing the role of chronic hyperglycemia.

Acute complications associated with type 2 diabetes mellitus include hypoglycemia, dawn phenomenon, diabetic
ketoacidosis, hyperglycemic hyperosmolar syndrome, illness, and stress which contribute to unstable glycemic
control. They can be managed by the patient but severe cases are life threatening. Chronic complications include
hyperglycemia, nephropathy, retinopathy, and nervous system diseases. Chronic hyperglycemia can result in
microvascular and macrovascular complications that can increase morbidity and mortality, as well as reduce quality
of life. These conditions occur because hyperglycemia causes all blood vessels prone to endothelial damage,
leading them to thicken and decrease flexibility which increases blood pressure and risk of atherosclerosis.
Hyperglycemia changes the structure of the glomerulus to increase its permeability and decreases filtering ability.
This causes chronic kidney disease and must be treated with dialysis. Hyperglycemia damages blood vessels in the
eyes and limits oxygen supply. This can result in blindness and must be treated by lowering blood pressure and
controlling blood glucose. Chronic hyperglycemia causes the accumulation of sorbitol and glycated proteins that
result in cellular damage. This can cause pain and loss of sensation in the hands and feet, as well as slowed
digestion.

4.

5.

Here are four features of the physicians physical examination as well as her presenting signs and symptoms
that are consistent with her admitting diagnosis. Describe the pathophysiology that might be responsible for
each physical finding.
Physical Finding

Physiological Change/Etiology

Unhealed ulcer on
foot

Neuropathy causes loss of sensation and loss of coordination of muscle groups in the
extremities which increase stress when walking. When a diabetic person loses this
sensation, they do not realize their feet are forming wounds. These can progress down to
the bone if untreated.

Frequent bladder
infections

Diabetes causes high blood glucose levels which must be filtered through the kidneys.
When they exceed their capacity, the glucose is excreted in the urine. High glucose
content in the kidneys contributes to impaired immune function and resistant pathogens
which makes urinary tract infections common in diabetic patients.

Tingling &
numbness in
feet

High blood glucose, prolonged diabetes, old age, uncontrolled blood glucose, high blood
fat, and high blood pressure can cause neuronal impairment which limits oxygen delivery
to the nerves in the extremities. This can lead to pain, tingling, and numbness in the feet.

Blood glucose
1420 mg/dL

Type 2 diabetes is characterized as insulin resistance. This is causing severe

accumulation of glucose in the blood because no glucose is being taken out of the blood
stream and into the liver to be broken down and utilized. Mrs. Dewey most likely does
not have adequate glycemic control or consistent carbohydrate intake because her blood
glucose is 1,420 mg/dL.

HTN

Hyperglycemia makes blood vessels thicken and become less flexible. This will cause
vasoconstriction which will increase blood pressure.

Retinopathy

Hyperglycemia can cause damage to the blood vessels in the eyes. The eyes have a high
oxygen demand and when sorbitol accumulates from hyperglycemia and the blood
vessels are damaged, the eyes do not get enough oxygen. The lack of oxygen will cause
the retinopathy, and eventually, blindness. Hypertension also causes macular edema
which contributes to retinopathy.

Describe the metabolic events that led to Pts symptoms and subsequent admission to the ER with the
diagnosis of uncontrolled T2DM with HHS (be sure to include the information in Pt's chart that supports
her diagnosis). Compare and contrast HHS with the other common clinical emergency condition of diabetes
- diabetic ketoacidosis (DKA).

Mrs. Deweys hyperglycemia is caused from inconsistent intake of her medications, metformin, glyburide, Capoten,
and Lipitor, as well as inconsistent daily carbohydrate intake that increased her blood glucose to dangerously high
levels of 1,420 mg/dL and HgA1c at 13.2%. Her recent vomiting has caused an imbalance of osmolality of 335
mmol/kg/H2O and therefore, dehydration and confusion. Hyperglycemia, confusion, and dehydration are
contributing to her HHS diagnosis. HHS is seen in diabetic patients who do not have their disease under control.
The kidneys try to make up for high glucose levels in the blood by allowing the extra glucose to leave the body in
the urine. This rids the body of glucose, but also, of water. The kidneys become overwhelmed when too much
sugar and not enough water is entering the body, and they are no longer able to excrete the excess glucose, leading

to extremely high blood glucose levels. Dehydration makes the blood more concentrated, known as hyperosmolality, which will draw water out of organs, including the brain, causing the confusion Mrs. Dewey
experienced. DKA occurs when the body cannot use glucose for fuel due to a lack of insulin or insulin resistance.
The system will then breakdown fat to use for fuel and cause ketones to build up in the blood and urine. Illness,
missing insulin doses, or having uncontrolled blood sugar can lead to DKA. It can result in nausea and vomiting,
decreased alertness, and dry skin, all symptoms seen in Mrs. Dewey.
6.

HHS is often associated with dehydration. After reading Mrs. Dewys chart, list the data that are consistent
with dehydration. What factors in Mrs. Dewys history may have contributed to her dehydration?

Mrs. Deweys chart shows consistency with dehydrations because her blood pressure is low, she has dry skin and
mucous membranes, she has a poor skin turgor and fast respirations. Mrs. Dewey has mild confusion which is
related to the water in the brain being taken out and utilized elsewhere, another symptom of dehydration. Her lab
values indicate high BUN (31mg/dL) which signifies poor kidney function and her osmolality is 355 mmol/kg/H2O
which signifies water imbalance. Her recent vomiting and illness have led to her dehydration.
7.

Mrs. Dewy was started on normal saline with potassium as well as an insulin drip. Why are these fluids a
component of her rehydration and correction of the HHS?

When patients are in a Hyperosmolar Hyperglycemic State, it is imperative that they are rehydrated and their
electrolyte balance is maintained. It is also important that their hyperglycemia is corrected and controlled. Saline
and potassium will rehydrate the body and balance electrolytes while the insulin drip will balance glucose levels and
keep them consistent, resolving the HHS.
8.

Describe the insulin therapy that was started for Mrs. Dewy. What is Lispro? What is glargine? Explain what
ICR means? How likely is it that Mrs. Dewy will need to continue insulin therapy?

The insulin therapy ordered for Mrs. Dewey includes .5 units of Lispro every two hours until glucose levels are
normalized and stable between 150 and 200 mg/dL. At night, 19 units of glargine will be given with hourly bedside
glucose checks to ensure normalization. Mrs. Dewey is dehydrated and it is important to rehydrate with Lispro.
Lispro is an insulin analog that results in faster absorption, earlier and higher insulin peak, and shorter duration of
action to greatly reduce blood glucose. It is given so frequently throughout the day due to its fast acting and short
lived effects. Glargine is a long acting insulin injection to help move glucose from the blood into other body tissues
which is why it is given at night over a long period of time. It stops the liver from producing more glucose to
prevent hyperglycemia. Lispro and glargine act together to control blood glucose and manage type 2 diabetes. ICR
refers to an insulin to carbohydrate ratio. It is used to calculate the units of insulin necessary for the amount
carbohydrate grams consumed in order to maintain glycemic control. Mrs. Dewey is ordered one unit of glucose for
every 15 grams of carbohydrates. It is likely that Mrs. Dewey will need to continue with insulin therapy because her
diabetes is very uncontrolled. She needs to manage her glucose levels with continuous insulin therapy.
9.

Mrs. Dewy was NPO when admitted to the hospital. Why was this done? What are the signs that will alert the
RD and physician that Mrs. Dewy may be ready to eat?

Because Mrs. Dewey was admitted to the hospital after vomiting, dehydration, and under stress, she was put on
NPO, which means nothing by mouth. When Mrs. Deweys glycemic levels are more controlled, and vomiting has
stopped for a significant amount of time, she can move gradually from NPO to clear liquids, and eventually to a
consistent carbohydrate diet.
10. Is the hospital diet order of 1,200 kcal appropriate? Explain why or why not?
A 1,200 calorie diet order for Mrs. Dewey is slightly low. It is best to have her caloric goal to be less than 1,750
because she is obese and losing weight will improve her health status and glycemic control. Although a 500 calorie

deficit each day is a healthy weight loss plan, Mrs. Dewey is accustomed to a 2,200 calorie diet and is also
recovering from injury. It would be better to order a diet plan for around 1,500 calories to start her weight loss plan
but also give her enough calories to recover from her wounds.
11. Assess Mrs. Dewys weight and BMI. What would be a healthy weight range for Mrs. Dewy and why?
Mrs. Dewey is only 50 and weights 155 lbs. This puts her in obesity class 1 according to her BMI of 30. I would
recommend that Mrs. Dewey weigh between 130-140lbs. This would support a BMI between 25 and 27 which is
recommended because of her elderly age.
12. Identify and discuss any abnormal laboratory values measured upon her admission (6/10). How did they
change after hydration and initial treatment of her HHS (6/11)?
Upon admission, Mrs. Deweys lab values reported low sodium at 133mEq/L where it should be between 136 and
145 mEq/L and low potassium at 3.4 mEq/L where it should be between 3.5 and 5.5 mEq/L likely from vomiting
and dehydration. Mrs. Deweys BUN was high at 31mg/dL where it should be between 8 and 18 mg/dL. Her
Creatinine serum was also high at 1.9 mg/dL where it should be between .6 and 1.2 mg/dL. Phosphate levels are
low at 1.8 mg/dL where they should be between 2.3 and 4.7 mg/dL. These values indicate kidney malfunction and
their inability to filter out certain substances or excrete too much of a substance, like phosphate. Mrs. Deweys
water balance is impaired as indicated by her osmolality of 355 mmol/kg/H2O which is above the norm of 285-295
mmol/kg/H2O. This indicates significant concentration in the blood due to dehydration. Her glucose levels are
extremely high due to her inconsistent carbohydrate intake and uncontrolled blood glucose levels. Mrs. Dewey
needs fluids and electrolytes. After one day of rehydration, her lab levels show a slight improvement. Potassium is
within the normal range; however, all other values continue to be abnormal. They have improved and are closer to
the recommendations, however, Mrs. Dewey needs to continue to rehydrate and correct her lab results.
13. Determine Mrs. Deweys energy and protein requirements for weight maintenance. (Remember to provide
rationale)
I used the Mifflin St. Jeor equation should be used because it is most accurate.
Energy Requirements = 10 x weight (kg) + 6.25 x height (cm) 5 x age (y) 161
= (10 x 70) + (6.25 x 152) (5 x 70) 161
= 700 + 950 350 161
= 1650 189
= 1461 x 1.2 (activity factor because patient is not completely sedentary) = 1753.2 = 1,750 kcal/day
Protein Requirements = 1.2g protein/kg body weight because patient is elderly and has wounds on her feet.
= 1.2 x 70 = 84g protein/day
14. Using a computer dietary analysis program or food composition table, calculate the kcalories, protein, fat,
CHO, fiber, cholesterol, and Na content of Mrs. Deweys diet. Fill-in the blanks.
kcal =

2232.5; compared to kcal needs of 175 (127% of needs)

protein =
fat =

76g and 14% kcal; compared to protein needs of 84g (17% of needs)

84g and 34% kcal; compared to fat needs of 33% kcal

Saturated fat = 31g and 13% kcal; compared to SFA needs of less than 10% kcal
CHO = 291g and 52% kcal; compared to CHO needs of 50% kcal
Assess consistency of CHO intake?

fiber = 17g; compared to fiber needs of 25-35g (56% of needs)

chol =

307mg; compared to cholesterol needs of less than 200mg (153% of needs)

Na =

4,088mg; compared to Na needs of 2300mg 177% of needs)

15. Mrs. Dewey asked you about the use of herbal supplements like cinnamon and antioxidants to help control
her blood sugar. What evidence-based information would you tell her?
Although some studies have shown that herbal supplements, like cinnamon and antioxidants, help control blood
sugar, they are not to be relied on. These studies say that daily intakes can reduce serum glucose and reduce risk of
cardiovascular disease for type diabetic patients by increasing phosphorylation of the insulin receptor to trigger the
insulin system to uptake glucose and lower blood glucose. I would not, however, recommend this to a patient
because there is minimal evidence based research that correlates with this accusation. It would be best to follow a
consistent carbohydrate diet with mostly whole grain, high fiber sources and incorporate physical activity into
everyday life.
16. Prioritize two nutrition problems and complete the PES statement for each.
1. Inconsistent carbohydrate intake related to food and nutrition knowledge deficit, especially regarding glycemic
control, as evidenced by usual dietary intake of minimal carbohydrate intake in the morning and excessive
carbohydrate intake at night, as well as high blood glucose levels of 1,420 mg/dL, HgA1c of 13.2%, and glucose in
the urine.
2. Overweight and obese related to food and nutrition knowledge deficit as evidenced by usual dietary intake of high
fat containing foods, BMI of 30, 205 mg/dL cholesterol, 50 mg/dL HDL, and 185 mg/dL triglycerides.
17. Write Nutrition Prescription for patient. Include Diet type, kcal level, and key components. What goal are
you trying to achieve?
Consistent carbohydrate diet with recommended portion sizes at 3 meals and 1 evening snack daily to meet 1,500
calories. Half of these calories are from carbohydrate sources (218g), 20%/75g/ 300kcal protein, and 30%/50g/
450kcal fat. Three meals contain 3-4 carbohydrate servings and snack contains 1-2 carbohydrate servings to meet
her allotted 12.5 exchanges each day. Carbohydrate sources are from whole grain, high fiber, minimally processed
foods. This diet will improve Mrs. Deweys glycemic control, manage her weight, and minimize her health risks.
18. Outline the steps you would use to teach Mrs. Dewy about nutrition and diabetes during an initial 15-minute
nutrition education session at bedside. (Hint: what are key concepts you want her to leave with that will help
her in the week or two before she sees an outpatient RD/CDE).
Because nutrition counseling at bedside is so limited and fast, I would be sure to focus on the importance of
glycemic control through ideal components of a daily diet, portion control, inform her about foods to limit, educate
her about analyzing blood glucose levels, and the importance of insulin doses. The diet should have consistent
carbohydrates throughout the day. These carbohydrates should mostly be from whole grain, high fiber sources to
slow the absorption of glucose into the blood. It is best to consume the same amount of carbohydrates at each meal
and half of that for an evening snack to avoid glucose imbalances in the middle of the night. When high sugar
containing foods are eaten, blood glucose sky rockets fairly quickly which is not ideal for a controlled blood glucose
meal plan. I would inform Mrs. Dewey that it is best to avoid high sugar sweetened beverages and keep at a
minimum pastries and such that consist of simple sugars. Replacing saturated fats with unsaturated fat sources is
best to control weight, glycemic index, and risk factors for health complications linked to uncontrolled diabetes.
Small food portions throughout the day will also help control blood glucose, as well as weight management.

Because Mrs. Dewey is obese, she is likely consuming heavy portions. I would inform her of a normal carbohydrate
serving and compare/contrast it to her usual dietary intake. This will put into perspective Mrs. Deweys dietary
intake and better her understanding of the reasons she has been hospitalized and how to prevent it from happening
again. It is important that Mrs. Dewey knows the importance of maintaining glucose and the risk factors that come
with uncontrolled blood glucose. I would inform her about HHS and DKA and that hyperglycemia causes them and
that they are both fatal conditions. However, following a carbohydrate consistent diet and monitoring her blood
glucose will avoid these complications and support a healthy diabetic lifestyle. Insulin dosage should be kept up
throughout the day before meals to balance the carbohydrate consumption and keep blood glucose in order to avoid
similar complications in the future. Self-monitoring is key to glycemic control. Knowing and understanding what
her blood glucose is will help her chose what foods to incorporate in her diet and when she needs an insulin shot to
resolve high glucose levels. The more she is comfortable with monitoring her glycemic index and understanding
how to maintain optimal blood glucose levels, the healthier she will be in regards to controlling her diabetes and
avoiding recurrences of hyperglycemia.
19. What would you monitor at a 3-day follow-up in the hospital? What would you monitor at a 3-month followup at an out-patient diabetes clinic?
After 3 days, I would analyze her lab results to ensure her dehydration is being corrected and that her glucose levels
are normalizing. After 3 months, in an outpatient setting, I would analyze her regular dietary intake to evaluate her
understanding and maintenance of a consistent carbohydrate diet. At this point, if her glucose is not under control
and her usual diet is not reflective of a consistent carbohydrate diet, I would further educate Mrs. Dewey about the
exchange list, carbohydrate counting, and portion sizes. During this 3-month post-hospitalization visit, I would also
analyze her weight. Controlling weight can decrease her risk for cardiovascular disease and further control blood
glucose. If her weight is still in the obese category, I would further counsel Mrs. Dewey into adding exercise to her
daily lifestyle or modifying certain aspects of her diet that are inhibiting her from reaching a healthier weight.
Lastly, I would analyze her self-monitoring abilities in glycemic control. This is key to living a healthy lifestyle
with diabetes. I would educate Mrs. Dewey on the importance and benefits of self-monitoring and ensure that she
understands and is able to control her diabetes.

References:
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from https://www.diabeteshealth.com/insulin-to-carbohydrate-ratios/
Diabetic ketoacidosis: MedlinePlus Medical Encyclopedia. (2016, November 1). Retrieved November 16, 2016,
from https://medlineplus.gov/ency/article/000320.htm
Glucophage, Glucophage XR (Metformin HCl) Drug Information: Clinical Pharmacology-Prescribing Information
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Khan, A., Safdar, M., Khan, M. M., Khattak, K. N., & Anderson, R. A. (2003, December 21). Cinnamon Improves
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