Caroline Mooney

KNH 413
Case Study #2
2/17/15

Case Questions
1. There are precipitating factors for diabetic ketoacidosis. List at least seven
possible factors.
The most common precipitating factor in the development of DKA is infection.
Other precipitating factors include discontinuation of or inadequate insulin
therapy, pancreatitis, myocardial infarction, cerebrovascular accident, and drugs.
Diabetic ketoacidosis. (n.d.). Retrieved February 16, 2015, from
http://www.mayoclinic.org/diseases-conditions/diabeticketoacidosis/basics/symptoms/con-20026470
2. Describe the metabolic events that led to the symptoms associated with DKA.
The metabolic events that led to the symptoms associated with DKA include: high
blood sugar associated with inadequate amounts of insulin, extreme thirst and/or
dry mouth, dehydration, frequent urination, abdominal pain, and vomiting.
3. Assess Susans physical examination. What is consistent with diabetic
ketoacidosis? Give the physiological rationale for each that you identify.
Symptoms of DKA include: excessive thirst, frequent urination, nausea and
vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented
breath, and confusion. Some things that were consistent with this on Susans
physical examination include: having breath that smelled funny, fatigue, intense
thirst nausea, vomiting and she had sore abdomen, which are both symptoms of
DKA.
Medscape Log In. (n.d.). Retrieved February 16, 2015.
4. Examine Susans biochemical indices both in the chemistry section and in her
ABG report. Which are consistent with DKA? Why?
After examining Susans biochemical and ABG report some things that are
consistent with DKA include: potassium, PO4, BUN, glucose, osmolality,
cholesterol, WBC, HGB, and HCT were all high, which shows that she is
dehydrated. She also had high creatinine, which may show that she is having
kidney issues. Her urine also tested positive for glucose and ketones, which could
mean she has DKA.
(American

Diabetes Association, 2002)

5. If Susans symptoms were left untreated, what would happen?

If Susans symptoms were left untreated, her risks would be much greater.
Diabetic ketoacidosis can lead to loss of consciousness. Eventually, diabetic
ketoacidosis can be fatal.
Diabetic ketoacidosis. (n.d.). Retrieved February 16, 2015, from
http://www.mayoclinic.org/diseases-conditions/diabeticketoacidosis/basics/symptoms/con-20026470
6. Assuming Susans SMBG records are correct, what events seem to have
precipitated the development of DKA?
Susans record shows that when her period started her blood glucose levels went
up, and went up even more the day of her volleyball tournament. The levels also
remained high after this.
7. What, if anything, could Susan have done to avoid DKA?
Since Susan has type 1 diabetes, she is already at risk for DKA. Missing insulin
doses could have also helped avoid DKA. Susan should have eaten more
carbohydrates, and increased her insulin, especially when playing volleyball.
8. While Susan is being stabilized, Tagamet is being given IV piggyback. What
does IV piggyback mean? What is Tagamet, and why has it been
prescribed?
An IV piggyback is a way to administer medication through an intravenous tube
that is inserted into a patients vein. This can be an antibiotic or another type of
medication that needs to be diluted and administered slowly. The medication in an
IV piggyback is mixed in a small amount of compatible fluid, such as normal
saline or dextrose with saline. Tagamet is used to manage heartburn, and relieves
pain, acid indigestion, and sour stomach. Tagamet has been prescribed since
Susans pH levels were below normal.
What Is an IV Piggyback? (n.d.). Retrieved February 16, 2015.
About Tagamet. (n.d.). Retrieved February 16, 2015, from
http://tagamet.com/en/about-tagamet.aspx
9. The Diabetes Control and Complications Trial was a landmark multicenter
trial designed to test the proposition that complications of diabetes mellitus
are related to elevation of plasma glucose. It is the longest and largest
prospective study showing that lowering blood glucose concentration slows
or prevents development of complications common to individuals with
diabetes. The trial compared intensive insulin therapy (tight control)
with conventional insulin therapy. Define intensive insulin therapy.
Define conventional insulin therapy.
Intensive insulin therapy is a therapeutic regimen for diabetes mellitus treatment.
This newer approach contrasts with conventional insulin therapy. Rather than
minimize the number of insulin injections per day, the intensive approach favors

flexible meal times with variable carbohydrate as well as flexible physical

activities. Conventional insulin therapy is an older method of insulin therapy and
is still in use in some cases. It uses insulin injections performed two times a day,
meals are scheduled to match the anticipated peaks in the insulin profiles, the
target range for blood glucose is higher than desired than the intensive regimen,
and frequent measurements of blood glucose are not used.
Conventional insulinotherapy. (n.d.). Retrieved February 16, 2015, from
http://en.wikipedia.org/wiki/Conventional_insulinotherapy
Intensive insulinotherapy. (n.d.). Retrieved February 16, 2015, from
http://en.wikipedia.org/wiki/Conventional_insulinotherapy
10. List the microvascular and neurologic complications associated with type I
diabetes.
Neurologic complications associated with type 1 diabetes include kidney disease,
kidney failure, nerve disease, and death. Microvascular complications associated
with type 1 diabetes include: retinopathy, nephropathy, and neuropathy.
Microvascular Complications of Diabetes. (n.d.). Retrieved February 16, 2015,
from
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrin
ology/microvascular-complications-of-diabetes/Default.htm
11. What are the advantages of intensive insulin therapy?
Two primary advantages to intensive insulin therapy are 1) greater flexibility of
meal times, carbohydrate quantities, and physical activities, and 2) better
glycemic control to reduce the incidence and severity of the complications of
diabetes.
Intensive insulinotherapy. (n.d.). Retrieved February 16, 2015, from
http://en.wikipedia.org/wiki/Intensive_insulinotherapy
12. What are the risks of intensive insulin therapy (tight control)?
Risks of intensive insulin therapy include: needing to know more education and
effort to achieve the goals, and it increases the cost for glucose monitoring four or
more times a day. The more frequent hypoglycemia (low blood sugar) is also a
disadvantage of the intensive regimen. Weight gain is also risks of intensive
insulin therapy.
Intensive insulinotherapy. (n.d.). Retrieved February 16, 2015, from
http://en.wikipedia.org/wiki/Intensive_insulinotherapy
13. Dr. Green consults with you, and the two of you decide that Susan would
benefit from insulin pump therapy combined with CHO counting for
intensive insulin therapy. This will give Susan better glycemic control and

more flexibility. What are some of the key characteristics of candidates for
intensive insulin therapy?
Intensive insulin therapy is recommended for most people who have type 1
diabetes, and some with type 2 diabetes. Intensive insulin therapy may not be for
you if: you struggle with frequent or severe bouts of low blood sugar, if you are a
child, if you are an older adult, or if you have heart disease, blood vessel disease
or severe diabetes complications.
Diabetes. (n.d.). Retrieved February 16, 2015, from
http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/intensiveinsulin-therapy/art-20043866?pg=2
14. Explain how an insulin pump works. Is Susan a candidate for an insulin
pump?
Insulin pumps deliver rapid or short-acting insulin 24 hours a day through a
catheter placed under the skin. This keeps your glucose levels in range between
meals and overnight. When you eat, you use buttons on the insulin pump to give
additional insulin called a bolus. You take a bolus to cover the carbohydrate in
each meal or snack. If you eat more than planned, you can simply program a
larger bolus of insulin to cover it. I think Susan would be a candidate for an
insulin pump because she is old enough to learn how to use it, and with education
could benefit from having an insulin pump.
How Do Insulin Pumps Work? (n.d.). Retrieved February 16, 2015, from
http://www.diabetes.org/living-with-diabetes/treatment-andcare/medication/insulin/how-do-insulin-pumps-work.html
15. How would you describe CHO counting to Susan and her family?
Carbohydrate counting is a meal planning technique for managing your blood
glucose levels. Carbohydrate counting helps you to keep track of how much
carbohydrate you are eating. You are set a limit for your maximum amount of
carbohydrate to eat for a meal, and with the right balance of physical activity and
medicine, if you need it, can help to keep your blood glucose levels in your target
range. You should start with around 45-60 grams of carbohydrate at a meal.
Carbohydrate Counting. (n.d.). Retrieved February 16, 2015, from
http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understandingcarbohydrates/carbohydrate-counting.html
16. How is CHO counting used with intensive insulin therapy?
Carbohydrate counting helps those on intensive insulin therapy determine their
food intake and insulin doses needed to reach their target blood glucose levels.
Carbohydrate counting can be adjusted based on how much and what is
consumed.
17. Estimate Susans daily energy needs using the Harris-Benedict equation.

REE Female: 655 + 9.6 (wt) +1.85 (ht)-4.7(age)

655+(9.6+57.2)+(1.85 x 160)-(4.7x16)=~1,420 kcals x 2=~2,800 kcals
18. Using the 1-week food diary from Susan, calculate the average amount of
CHO usually consumed each meal and snack.
___70-80___gm. CHO breakfast
__~90____gm CHO lunch
__~30_____gm CHO snack
__90-100____gm CHO dinner
__15-20_____gm CHO HS
19. After you have calculated Susans usual CHO intake from her food record
(Question 18), develop a CHO-counting meal plan that she could use. Include
menu ideas.
Daily Total:
CHO: _~350____g (Around 60%)
Protein _~65___g (Around 10%)
Fat __~75___g (Around 30%)
kcalories _~2000-2,300__
20-25 CHO exchanges needed
Menu Ideas:
Breakfast5 CHO, protein, 1 fat
A piece of fruit, oatmeal, turkey bacon, milk (with some fat)
Snack2 CHO, no meat
Peanut butter, banana (or apple, or other fruit), crackers
Lunch6 CHO, protein, 1 fat
Turkey & cheese sandwich, salad with dressing
Dinner7 CHO, protein, 1 fat
Whole-wheat spaghetti with meatballs and cheese, mixed vegetables, fruit salad
Snack2 CHO
Hummus and vegetables, or hummus and pretzels
20. Just before Susan is discharged, her mother asks you, My friend who owns
a health food store told me that Susan should use stevia instead of artificial
sweetener or sugar. What do you think? What will you tell Susan and her
mother?
I would tell Susan and her mother that stevia is a good choice rather than sugar.
Using stevia or some other type or brand of artificial sweetener is a better choice
for Susan because it was no calories, is much sweeter than real sugar (will not

need much). I would tell her to be careful to not use too much, however, and make
sure whichever artificial sweetener she is using is approved by the FDA.

References
About diabetes. (n.d.). Retrieved February 16, 2015, from
http://www.who.int/diabetes/action_online/basics/en/index3.html
About Tagamet. (n.d.). Retrieved February 16, 2015, from http://tagamet.com/en/abouttagamet.aspx
(American Diabetes Association, 2002)
Carbohydrate Counting. (n.d.). Retrieved February 16, 2015, from
http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understandingcarbohydrates/carbohydrate-counting.html
Conventional insulinotherapy. (n.d.). Retrieved February 16, 2015, from
http://en.wikipedia.org/wiki/Conventional_insulinotherapy
Diabetic ketoacidosis. (n.d.). Retrieved February 16, 2015, from
http://www.mayoclinic.org/diseases-conditions/diabeticketoacidosis/basics/symptoms/con-20026470
Diabetes. (n.d.). Retrieved February 16, 2015, from http://www.mayoclinic.org/diseasesconditions/diabetes/in-depth/intensive-insulin-therapy/art-20043866?pg=2
How Do Insulin Pumps Work? (n.d.). Retrieved February 16, 2015, from
http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/howdo-insulin-pumps-work.html
Intensive insulinotherapy. (n.d.). Retrieved February 16, 2015, from

http://en.wikipedia.org/wiki/Intensive_insulinotherapy
Medscape Log In. (n.d.). Retrieved February 16, 2015.
Microvascular Complications of Diabetes. (n.d.). Retrieved February 16, 2015, from
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/
microvascular-complications-of-diabetes/Default.htm
What Is an IV Piggyback? (n.d.). Retrieved February 16, 2015.