Download Case Study #23 Type 2 Diabetes Mellitus 1. What is the difference

Case Study #23 Type 2 Diabetes Mellitus 1. What is the difference between type 1 diabetes mellitus and type 2 diabetes mellitus? The main difference between type 1 and type 2 diabetes is the way insulin plays a part in these diseases. In type 1, the beta cells in the pancreas are usually destroyed through an autoimmune response. Therefore, the body has an inability to produce its very own insulin. On the other hand, in type 2 diabetes, a person still produces their very own insulin but their cells start to become resistant to it. As a result, of both types of diabetes, blood glucose levels remain high. 2. How would you clinically distinguish between type 1 and type 2 diabetes mellitus? Clinically, type 1 diabetes is immune-­‐mediated and results from a cellular-­‐mediated autoimmune destruction of the beta cells in the pancreas. Therefore, type 1diabetes patients need exogenous insulin for survival. As for type 2 diabetes, this can be caused by many factors such as, heredity, obesity, and lack of physical activity, which can lead to insulin resistance of tissues, or relative insulin deficiency from the pancreas working too hard over time to compensate for the insulin resistance and providing more insulin in the blood. The insulin resistance is also caused by a cell-­‐
receptor defect. 3. What risk factors is Mrs. Douglas present with from her type 2 diabetes? The risk factors present with Mrs. Douglas to lead her to her diagnosis of type 2 diabetes is the disease runs in her family history, she is heavily over weight, she is of African American descent, and she is elderly. 4. What are the common complications associated with diabetes mellitus? Describe the pathophysiology associated with these complications, specifically addressing the role of chronic hyperglycemia. There are several major common complications associated with diabetes mellitus. For type 1 diabetes, diabetic ketoacidosis is one complication and this happens when no insulin is present, so, cells cannot use sugar for energy and use lipolysis instead to use fat as an energy source. Because of this, osmotic diuresis occurs which can lead to dehydration and an electrolyte imbalance. In type 2 diabetes, hyperglycemic hyperosmolar syndrome is much more common. This complication happens because of blood glucose levels reaching about 600mg/dL and a serum osmolality above 320 mOsm/kg of water and can lead to dehydration along with infection. Other complications that are associated with both types of diabetes are atherosclerosis, microangiopathies of the kidney and retina, and neuropathy. The atherosclerosis can happen because with constant hyperglycemia the subendothelial layer of blood vessels are thickened and changed in composition because of a sludge created. This hardening of the arteries also leads to high blood pressure. For retinopathy and nephropathy, the little capillaries within the retina and kidney are damaged because of high blood pressures, which will cause damage and deteriorate function of these capillaries. Lastly, neuropathy is caused by an accumulation of sorbitol and glycated proteins resulting in cellular damage, which in turn interrupts normal function of the nervous system pathways. Some other complications that could occur are glycosuria which occurs when the blood glucose exceeds the renal threshold (160-­‐200 mg/dl). Polyuria is a complication with increased urine volume with an increased osmotic activity of urinary glucose and Polydipisia can happen because of dehydration from increased fluid losses. Weight loss can happen because of a decreased protein sysnthesis, ad an increased loss of energy and glucose through the urine (polyphagia). Lastly, lipemia, which is a decreased LPL activity that can lead to decreased removal of chylomicrons and VLDL from circulation. Also leads to an increase if FA from adipose tissue (high lipids in the blood). 5. Is Mrs. Douglas present with any complications of diabetes mellitus? If yes, which ones? Yes, Mrs. Douglas is present with complications of retinopathy, possibly atherosclerosis because of her hypertension, and she also has neuropathy in her feet. 6. Identify at least four features of the physician’s physical examination as well as her presenting signs symptoms that are consistent with her admitting diagnosis. Describe the pathophysiology that might be responsible for each physical finding. (Physical finding and physiological change/etiology) • Overweight: patients with obesity sometimes develop a resistance to insulin leading to type 2 diabetes • Mild retinopathy: the high blood sugars are causing high blood pressure within the capillaries of her retina, causing a loss of precise vision • Sensation mildly diminished in feet: nerve damage has happened in this area from poor circulation in the area and then accumulating sorbitol and glycated proteins • 2-­‐3 cm ulcer on lateral foot: because of the loss of feeling in her feet from the neuropathy, patient is unaware of the break down of tissues 7. Prior to admission, Mrs. Douglas had not been diagnosed with diabetes mellitus. How could she present with complications? Type 2 diabetes can go undiagnosed for years because symptoms do not show right away. It takes time for the body to gain a resistance against insulin so it would take an overall longer time for complications such as neuropathies, and eye sight to be effected. 12. Calculate Mrs. Douglas’s body mass index (BMI). BMI=(155 x 703)/ (60 x 60)= 30.2 13. What are the health implications for a BMI in this range? The health implications for BMI in this range is that the patient is obese and at a higher risk for chronic disease. 14. Calculate Mrs. Douglas’s energy needs using Harris Benedict with the correct activity or stress factor. Should Mrs. Douglas’s weight be adjusted for obesity? REE= 655 + ( 9.6 x 45.45 kg ) + ( 1.8 x 152.4 cm ) - ( 4.7 x 71)= 1032 cals
Activity factor of 1.3
TEE= 1032 x 1.3= 1341 cals
The patients weight was adjusted during the calculation of her energy needs to take into
consideration her obesity. Therefore, her ideal body weight was used instead to aim for a
healthier weight. I also used an activity factor of 1.3 because she is not totally bed ridden,
but she does need extra energy to heal her debridement.
15. Calculate Mrs. Douglas’s protein needs. Protein needs for IBW= 100/2.2= 45.45 x 1.0=45 gm 16. Is the diet order of 1,200 kcal appropriate? No, the diet order for approximately 1,200 calories is not appropriate since her TEE comes close to 1,350 calories. Therefore, she should be put on a 1,300 calorie plan. 19. Calculate the kcalories, protein, fat, and CHO of Mrs. Douglas’s diet. AM: 14 gm protein, 15 gm fat, 15 gm CHO= 56+135+60= 251 cals Lunch: 14 gm protein, 17 gm fat, 30 gm CHO= 56+153+120= 329 cals PM: 19 gm protein, 35 gm fat, 94 gm CHO= 76+315+376= 767 cals Snack: 1 gm fat, 5 gm CHO= 9+20= 29 cals Total protein= 47 gm Total fat= 72 gm Total CHO= 144 gm Total calories= 1376 cals 20. How would you compare Mrs. Douglas’s “usual” dietary intake to her current nutritional needs? First off, Mrs. Douglas is taking in a bit of too many calories versus her calculated TEE. From my dietary assessment as compared to her TEE the calorie difference is not huge, but over time a daily intake of calories above TEE could lead to obesity later in life, such as what could have been the case for Mrs. Douglas. Also, most of her calories are coming from fat, which can be contributing to her obesity and high blood pressure as well. Yet, she is in within range for her current protein needs. 22. Identify two lab values that should be monitored regularly. Blood glucose levels is an obvious lab value that should be monitored regularly, along with HbA1C every few months to see overall evidence of blood glucose management by Mrs. Douglas herself. 30. Select two high-­priority nutrition problems and complete the PES statement for each. First statement: Excessive energy intake related to obesity as evidenced by a BMI of over 30. Second statement: Food and nutrition related knowledge deficit related to the diagnosis
of type 2 diabetes as evidenced by a weight 55 pounds over ideal body weight. 31. What was the most important nutritional concern when the patient was originally admitted to the hospital (time of Dx)? The most important nutritional concern when the patient was originally admitted to the hospital was the regulation and control over her CHO intake to help relieve her blood glucose levels. Mrs. Douglas had stated her and her sister avoid all starchy and sugary food whenever possible. 33. For each of the PES statements that you have written, establish and ideal goal (based on the signs and symptoms) and appropriate intervention (based on etiology). First Statement Goal: Decrease energy intake by implementing a 1300-­‐calorie plan to lower BMI. Intervention: For patient meal times, encouraging plenty of vegetables and a serving of fruit, or high fibrous foods will help to keep the patient satiated along with helping maintain her blood sugars. Also, encouraging lean animal protein sources to lower her fat intake. Second statement Goal: Give education about the importance of exercise and nutrition together before patient is discharged. Intervention: Give in depth education about how exercise can directly affect her type 2-­‐diabetes prognosis, along with a well balanced diet filled with fruits, vegetables, and lean protein sources. Also referring her to a specialist who could help her with physical activity appropriate for her age.