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Diabetes and Heart Failure
FSHN 450
Fall 2015
Rachel Mostek
“I have not given, received, or used any unauthorized assistance.”
________________________________________________
Diabetes and Heart Failure
FSHN 450
Fall 2015
Due Date: October 23, 2015
Presentation:
Mrs. Douglas is a 76 year old female who presented with shortness of breath (SOB) and
progressive weakness and fatigue of 2 weeks duration, swelling of both legs and tightness in
chest which is not relieved by nitroglycerine. She is having difficulty ambulating.
Admission Dx: CHF and Diabetes
Medical History:
Gall bladder removal eight years ago. Htn diagnosed fifteen years ago controlled with
medication. Anterior MI with LV 10 years ago . Type 2 diabetes since age 50 controlled with
OHA and insulin.
Family History:
Family history is positive for CHD. Father had a heart attack at age 50 and died from heart
disease. Her mother was obese and had type 2 diabetes and hypertension.
Social History:
Elderly female lives with husband in own home. 3 grown children, married and all living out of
state. Denys alcohol consumption and has never smoked cigarettes. Patient states that she
follows an 1800 Kcal ANo Salt@ exchange type diabetic diet at home.
Physical:
Ht 5'6", Current BW 230 #, Usual Body Weight 220#. HR 100 BPM, S3 heart sound, respiration
15 with rales, Temp. 99.8 BP 155/95, orthopnea, dyspnea upon exertion, extremities: 2+ bipedal
edema.
Laboratory:
Glucose (not fasting) 185 mg/dl Triglycerides 290 mg/dl
Sodium 122 mEq/L Cholesterol 243 mg/dl
Potassium 4.5 mEq/L HDL-cholesterol 38 mg/dl
Chloride 101 mEq/L LDL-cholesterol 147 mg/dl
Hgb 11.1 g/dl
Hct 33.3 %
Albumin 3.2 g/dl HA1c 7.5%
Diagnostic Tests: Echo cardiogram reveals L Ventricular Hypertrophy. UGI series WNL.
Impression: Obesity, Type 2 Diabetes, Bilateral Pulmonary Effusion, Heart Failure
Medications:
Diovan
Toprol XL 50 mg/d
Glucophage (metformin) 1000 mg bid
Glucotrol (glipizide) 20 mg bid
Lopid (gemfibrizole) 600 mg bid
Sublingual NTG prn
Mediations ordered in hospital:
Furosemide 20 mg qd
Oxygen by nasal prongs
Sliding Scale Insulin
Diet Rx: 1500 Kcal, 2 gram sodium cardiac diet
Nutrition Consult:
The following information was obtained during the dietary interview:
Mrs. Douglas eats three meals per day and no snacks. She takes a multi-vitamin supplement. The
following 24 hour dietary intake was obtained by recall:
Breakfast Coffee with 2oz 2% milk
3/4 cup Bran Flakes with 6 oz 2% milk
Whole Grain Bread (1 slice, toasted)
Margarine (1 tsp)
Diet jelly
Lunch 1 cup Campbell=s chicken rice soup
1 cup Skim Milk cottage cheese
2 peach halves
6 Triscuit crackers (unsalted tops)
Hot tea with 2oz 2% milk
Dinner 4 oz. broiled chicken breast or sliced turkey breast
1 slice bread with 1 tsp butter
1 cup instant mashed potatoes or rice
2 cup canned peas
Orange Sherbet - 1 cup
5 Nilla Vanilla wafer
PREPARE CASE REPORT INCLUDING:
I. Interpret the patient’s laboratory values and compared to recommended ranges. (Use
table format)
Value Normal Range Patient Value Reason for Deviation
Hematocrit 34-45% 33% Anemia
Hemoglobin 12.1-15.6 g/dL 11.1% systematic diseases
Serum albumin 3.5-5.0 g/dL 3.2 g/dL MI, obesity
Triglycerides Desirable = <150
mg/dL
290 mg/dL COPD
Glucose 70-99 mg/dL 80 mg/dL Within normal range
Cholesterol 120-199 mg/dL 243 mg/dL DM, obesity, acute MI
HDLc Low <40 mg/dL 38 mg/dL Obesity, DM
LDLc Optimal <100mg/dL 147 mg/dL DM
HA1c 4-6% 7.5% Poorly controlled DM
Sodium 136-144 mEq/ L 122 mEq/L hyperglycemia
Potassium 3.5-5.0 mEq/L 3.8 mEq/L Within normal range
Chloride 98-107 mEq/L 102 mEq/L Within normal range
BMI 19-25 37.2 Obesity
Heart Rate 75-125BPM 100BPM and S3
sound
CHF
Body temperature 98.6F 99.8 Within normal range
Blood pressure <120/80 155/95 Hypertension
II. Present your nutrition assessment, and intervention and monitoring plan and evaluation in
"ADIME" format. Develop one PES statement in each of the behavioral, intake and clinical
domains.
Assessment:
Demographics: 76 y/o female who presented with SOB, weakness and fatigue for 2 weeks.
Patient has been experiencing swelling in both legs, making is hard to walk and unrelieved
tightness in chest. Patient was admitted to the hospital with a dx of CHF and DM. Patient history
involves removal of gall bladder, Htn, and previous MI. Patient has a family history of CHD, MI,
obesity, type 2 DM, and Htn.
Patient had notable lab values of high levels of triglycerides (290mg/dL), cholesterol
(243mg/dL), LDLc (147 mg/dL), and HA1c (7.5%). Notable lab values also included low levels
of HDLc (38 mg/dL), hematocrit (33%), hemoglobin (11.1%), albumin (3.2 g/dL), and sodium
(122 mEq/L). Her diet intake was notable for high sodium and added sugar intake from
processed food choices, and consuming high fat dairy products including 2% milk and butter.
Patient reports a regular diet of 1800kcal, using CHO exchanges, no smoking and no drinking.
Current medications include Diovan, Toprol XL (50mg/d), Glucophage/metformin (1000mg
bid), Glucotrol/ glipizide (20 mg bid), Lopid/ gemfibrizole (600mg bid), multi-vitamin
supplement, and sublingual NTG prn.
Anthropometrics: Ht: 5’6” (167.6cm); Current wt: 230# (104.5kg); BMI: 37.2 kg/m2
; IBW: 130#
(59.1kg)
Assessment of nutritional needs:
Kcal needs: 1868kcal/day (Mifflin [1557]x 1.2)
Protein: 118.2g (2.0g/kg IBW)
Fluid: 1300-1478 mL/day (1ml/kcal)
Diagnosis:
Behavioral domain: Undesirable food choices related to high intake of sodium and added sugar
as evidence by hypertension (155/95), high levels of LDLc (147mg/dL), low levels of HDLc
(38mg/dL), BMI of 37.2kg/m2
, and a high percentage of HA1c (7.5%).
Intake domain: Excessive carbohydrate intake related to high intake of foods with added sugar as
evidence by Hgb-A1c 7.5%, LDLc of 147mg/dL, HDLc of 38mg/dL, and total cholesterol of
243mg/dL.
Clinical domain: Obese, class II related to a BMI 37.2 kg/m2
as evidence by weight of 230#.
Intervention:
1. Intake a maximum intake of 2,000mg of sodium a day by decreasing the amount of
process foods and foods with added salt being consumed.
2. Consume only a maximum of 6% of saturated fat a day. Based on diet prescription of
1500 kcal/ day, that would be mean to consume less than 10g of saturated fat/ day.
3. Follow the diet prescription of 1500kcal/day.
4. Consume 4-5 servings of fruits and vegetables/day.
5. Consume a maximum of 100kcal of “added sugar” per day.
Monitoring/Evaluation:
Will evaluate weight changes, diet record, and lab values with close attention to the levels that
were out of normal range.
III. Answer the following questions:
1. What is sliding scale insulin and why was it ordered for Mrs. Douglas in the hospital
even though she has type 2 diabetes controlled with oral hypoglycemic agents? Would
this be appropriate to control her diabetes at home? Explain why or why not.
High blood glucose around bedtime increasing insulin in premeal or bedtime insuline
2. What are the guidelines for a cardiac diet (American College of Cardiologists and
American Heart Association) based. Discuss in terms of diet recommendations and
implementation (food based guidelines).
• Consume less than 6% of saturated fat from your diet. Consume low fat dairy products
and limit the amount of red meat and dark meat poultry that is being eaten.
• Consume less than 2,400mg of sodium per day. Avoid foods with a lot of added salt such
as processed foods and meals from fast food restaurants.
• Follow a DASH diet.
o Consume 4-5 servings of fruits and vegetables a day.
o Consume 7-8 servings of whole grains a day.
o Consume 2-3 servings of low fat dairy products a day.
o Consume 4-5 servings of legumes, nuts, or seeds per week.
o Stress consumption of non-tropical vegetable oils.
o Limit consumption of added sugar.
3. How does Mrs. Douglas current dietary intake compare to these guidelines?
• Salt intake in the patients current diet is high based on consumption of a lot of
processed foods. The foods that would be high in sodium include: canned peas,
Campbell’s soup, instant mashed potatoes, and cottage cheese.
• Added sugar in patient’s current diet is high based on the consumption of orange
sherbet, nilla wafers and peach halves.
• Grains being consumed are not all whole grains.
• Consumption of fruits and vegetables is good, I would recommend frozen or fresh
fruits and vegetables for the patient to avoid added sugar and salt.
• In regards to the consumption of low fat dairy products, patient is drinking 2%
milk with tea. This is better than half and half, but I would still recommend the
switch to lower fat milk. Consumption of skim-milk cottage cheese is good on fat,
but is very high in salt. I would lastly encourage the patient to keep consuming
butter in only small quantities.
• The consumption of broiled chicken or turkey is within the guidelines. I would
encourage the consumption of fish as well.
4. Assess Mrs. Douglas’ protein and Kcal needs. Is the 1500 Kcal diet diet prescription
appropriate for Mrs. Douglas upon discharge (explain why or why not).
Kcal needs: 1868kcal/day (Mifflin [1557]x 1.2)
Protein: 118.2g (2.0g/kg IBW)
Yes this would be an appropriate diet prescription because this is appropriate as this level of
energy intake will lead to a weight loss and decrease the amount of stress being put on the heart
and lungs.
5. Make suggestions for modifications to Mrs. Douglas dietary intake to achieve MNT goals for
a patient with CHF and type 2 DM.
• I would suggest lowering the amount of processed foods being consumed as that is
increasing the amount of sodium and added sugar in her diet. Examples of these
processed foods include soup, sherbet, nilla wafers, canned peas, and canned peach
halves. Keeping sodium low in a patient with CHF is important as they retain sodium and
fluid more.
• I would show the patient the plate method, as the types of foods being consumed are
more important in patients with type 2 DM.
• I would suggest adopting a DASH diet as well as that would be helpful with the
hypertension.
6. What is the purpose of each medication which Mrs. Douglas takes at home? What are
the drug: nutrient interactions. Why was furosemide used in the hospital? What is the
important drug: nutrients interaction with this medication?
• Diovan treats hypertension; the diet: drug interactions include taking caution with
potassium supplements and intake of grapefruit, and lowering intake of sodium and
calcium.
• Toprol XL treats hypertension; the diet: drug interactions include lowering sodium and
calcium.
• Glucophage treats hyperglycemia; the diet: drug interactions include following a
prescribed diabetic diet, take guar gum after 6 hours after drug is taken, and lower
calcium if losing weight.
• Glucotrol is a oral hypoglycemic; the diet: drug interactions include following prescribed
diet and exercise, and be careful with >3g nicotinic acid because that can increase
glucose.
• Gemfibrozil is a antihyperlipidemic; the diet: drug interactions include lowering fat and
sucrose intake, as well as lowering overall energy intake.
• Sublingual nitroglycerin is an antiangina; there are no specific drug: diet interactions.
• Furosemide is used in the hospital in order to treat the fluid build up and swelling that is
caused by congestive heart failure. The diet: drug interactions include increasing intake
of potassium and magnesium, and decrease intake of calcium and sodium.

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case study T2DM

  • 1. Diabetes and Heart Failure FSHN 450 Fall 2015 Rachel Mostek “I have not given, received, or used any unauthorized assistance.” ________________________________________________
  • 2. Diabetes and Heart Failure FSHN 450 Fall 2015 Due Date: October 23, 2015 Presentation: Mrs. Douglas is a 76 year old female who presented with shortness of breath (SOB) and progressive weakness and fatigue of 2 weeks duration, swelling of both legs and tightness in chest which is not relieved by nitroglycerine. She is having difficulty ambulating. Admission Dx: CHF and Diabetes Medical History: Gall bladder removal eight years ago. Htn diagnosed fifteen years ago controlled with medication. Anterior MI with LV 10 years ago . Type 2 diabetes since age 50 controlled with OHA and insulin. Family History: Family history is positive for CHD. Father had a heart attack at age 50 and died from heart disease. Her mother was obese and had type 2 diabetes and hypertension. Social History: Elderly female lives with husband in own home. 3 grown children, married and all living out of state. Denys alcohol consumption and has never smoked cigarettes. Patient states that she follows an 1800 Kcal ANo Salt@ exchange type diabetic diet at home. Physical: Ht 5'6", Current BW 230 #, Usual Body Weight 220#. HR 100 BPM, S3 heart sound, respiration 15 with rales, Temp. 99.8 BP 155/95, orthopnea, dyspnea upon exertion, extremities: 2+ bipedal edema. Laboratory: Glucose (not fasting) 185 mg/dl Triglycerides 290 mg/dl Sodium 122 mEq/L Cholesterol 243 mg/dl Potassium 4.5 mEq/L HDL-cholesterol 38 mg/dl Chloride 101 mEq/L LDL-cholesterol 147 mg/dl Hgb 11.1 g/dl Hct 33.3 % Albumin 3.2 g/dl HA1c 7.5% Diagnostic Tests: Echo cardiogram reveals L Ventricular Hypertrophy. UGI series WNL. Impression: Obesity, Type 2 Diabetes, Bilateral Pulmonary Effusion, Heart Failure
  • 3. Medications: Diovan Toprol XL 50 mg/d Glucophage (metformin) 1000 mg bid Glucotrol (glipizide) 20 mg bid Lopid (gemfibrizole) 600 mg bid Sublingual NTG prn Mediations ordered in hospital: Furosemide 20 mg qd Oxygen by nasal prongs Sliding Scale Insulin Diet Rx: 1500 Kcal, 2 gram sodium cardiac diet Nutrition Consult: The following information was obtained during the dietary interview: Mrs. Douglas eats three meals per day and no snacks. She takes a multi-vitamin supplement. The following 24 hour dietary intake was obtained by recall: Breakfast Coffee with 2oz 2% milk 3/4 cup Bran Flakes with 6 oz 2% milk Whole Grain Bread (1 slice, toasted) Margarine (1 tsp) Diet jelly Lunch 1 cup Campbell=s chicken rice soup 1 cup Skim Milk cottage cheese 2 peach halves 6 Triscuit crackers (unsalted tops) Hot tea with 2oz 2% milk Dinner 4 oz. broiled chicken breast or sliced turkey breast 1 slice bread with 1 tsp butter 1 cup instant mashed potatoes or rice 2 cup canned peas Orange Sherbet - 1 cup 5 Nilla Vanilla wafer
  • 4. PREPARE CASE REPORT INCLUDING: I. Interpret the patient’s laboratory values and compared to recommended ranges. (Use table format) Value Normal Range Patient Value Reason for Deviation Hematocrit 34-45% 33% Anemia Hemoglobin 12.1-15.6 g/dL 11.1% systematic diseases Serum albumin 3.5-5.0 g/dL 3.2 g/dL MI, obesity Triglycerides Desirable = <150 mg/dL 290 mg/dL COPD Glucose 70-99 mg/dL 80 mg/dL Within normal range Cholesterol 120-199 mg/dL 243 mg/dL DM, obesity, acute MI HDLc Low <40 mg/dL 38 mg/dL Obesity, DM LDLc Optimal <100mg/dL 147 mg/dL DM HA1c 4-6% 7.5% Poorly controlled DM Sodium 136-144 mEq/ L 122 mEq/L hyperglycemia Potassium 3.5-5.0 mEq/L 3.8 mEq/L Within normal range Chloride 98-107 mEq/L 102 mEq/L Within normal range BMI 19-25 37.2 Obesity Heart Rate 75-125BPM 100BPM and S3 sound CHF Body temperature 98.6F 99.8 Within normal range Blood pressure <120/80 155/95 Hypertension II. Present your nutrition assessment, and intervention and monitoring plan and evaluation in "ADIME" format. Develop one PES statement in each of the behavioral, intake and clinical domains. Assessment:
  • 5. Demographics: 76 y/o female who presented with SOB, weakness and fatigue for 2 weeks. Patient has been experiencing swelling in both legs, making is hard to walk and unrelieved tightness in chest. Patient was admitted to the hospital with a dx of CHF and DM. Patient history involves removal of gall bladder, Htn, and previous MI. Patient has a family history of CHD, MI, obesity, type 2 DM, and Htn. Patient had notable lab values of high levels of triglycerides (290mg/dL), cholesterol (243mg/dL), LDLc (147 mg/dL), and HA1c (7.5%). Notable lab values also included low levels of HDLc (38 mg/dL), hematocrit (33%), hemoglobin (11.1%), albumin (3.2 g/dL), and sodium (122 mEq/L). Her diet intake was notable for high sodium and added sugar intake from processed food choices, and consuming high fat dairy products including 2% milk and butter. Patient reports a regular diet of 1800kcal, using CHO exchanges, no smoking and no drinking. Current medications include Diovan, Toprol XL (50mg/d), Glucophage/metformin (1000mg bid), Glucotrol/ glipizide (20 mg bid), Lopid/ gemfibrizole (600mg bid), multi-vitamin supplement, and sublingual NTG prn. Anthropometrics: Ht: 5’6” (167.6cm); Current wt: 230# (104.5kg); BMI: 37.2 kg/m2 ; IBW: 130# (59.1kg) Assessment of nutritional needs: Kcal needs: 1868kcal/day (Mifflin [1557]x 1.2) Protein: 118.2g (2.0g/kg IBW) Fluid: 1300-1478 mL/day (1ml/kcal) Diagnosis: Behavioral domain: Undesirable food choices related to high intake of sodium and added sugar as evidence by hypertension (155/95), high levels of LDLc (147mg/dL), low levels of HDLc (38mg/dL), BMI of 37.2kg/m2 , and a high percentage of HA1c (7.5%). Intake domain: Excessive carbohydrate intake related to high intake of foods with added sugar as evidence by Hgb-A1c 7.5%, LDLc of 147mg/dL, HDLc of 38mg/dL, and total cholesterol of 243mg/dL. Clinical domain: Obese, class II related to a BMI 37.2 kg/m2 as evidence by weight of 230#. Intervention: 1. Intake a maximum intake of 2,000mg of sodium a day by decreasing the amount of process foods and foods with added salt being consumed. 2. Consume only a maximum of 6% of saturated fat a day. Based on diet prescription of 1500 kcal/ day, that would be mean to consume less than 10g of saturated fat/ day. 3. Follow the diet prescription of 1500kcal/day. 4. Consume 4-5 servings of fruits and vegetables/day. 5. Consume a maximum of 100kcal of “added sugar” per day. Monitoring/Evaluation: Will evaluate weight changes, diet record, and lab values with close attention to the levels that were out of normal range.
  • 6. III. Answer the following questions: 1. What is sliding scale insulin and why was it ordered for Mrs. Douglas in the hospital even though she has type 2 diabetes controlled with oral hypoglycemic agents? Would this be appropriate to control her diabetes at home? Explain why or why not. High blood glucose around bedtime increasing insulin in premeal or bedtime insuline 2. What are the guidelines for a cardiac diet (American College of Cardiologists and American Heart Association) based. Discuss in terms of diet recommendations and implementation (food based guidelines). • Consume less than 6% of saturated fat from your diet. Consume low fat dairy products and limit the amount of red meat and dark meat poultry that is being eaten. • Consume less than 2,400mg of sodium per day. Avoid foods with a lot of added salt such as processed foods and meals from fast food restaurants. • Follow a DASH diet. o Consume 4-5 servings of fruits and vegetables a day. o Consume 7-8 servings of whole grains a day. o Consume 2-3 servings of low fat dairy products a day. o Consume 4-5 servings of legumes, nuts, or seeds per week. o Stress consumption of non-tropical vegetable oils. o Limit consumption of added sugar. 3. How does Mrs. Douglas current dietary intake compare to these guidelines? • Salt intake in the patients current diet is high based on consumption of a lot of processed foods. The foods that would be high in sodium include: canned peas, Campbell’s soup, instant mashed potatoes, and cottage cheese. • Added sugar in patient’s current diet is high based on the consumption of orange sherbet, nilla wafers and peach halves. • Grains being consumed are not all whole grains. • Consumption of fruits and vegetables is good, I would recommend frozen or fresh fruits and vegetables for the patient to avoid added sugar and salt. • In regards to the consumption of low fat dairy products, patient is drinking 2% milk with tea. This is better than half and half, but I would still recommend the switch to lower fat milk. Consumption of skim-milk cottage cheese is good on fat, but is very high in salt. I would lastly encourage the patient to keep consuming butter in only small quantities. • The consumption of broiled chicken or turkey is within the guidelines. I would encourage the consumption of fish as well. 4. Assess Mrs. Douglas’ protein and Kcal needs. Is the 1500 Kcal diet diet prescription appropriate for Mrs. Douglas upon discharge (explain why or why not). Kcal needs: 1868kcal/day (Mifflin [1557]x 1.2) Protein: 118.2g (2.0g/kg IBW) Yes this would be an appropriate diet prescription because this is appropriate as this level of energy intake will lead to a weight loss and decrease the amount of stress being put on the heart and lungs.
  • 7. 5. Make suggestions for modifications to Mrs. Douglas dietary intake to achieve MNT goals for a patient with CHF and type 2 DM. • I would suggest lowering the amount of processed foods being consumed as that is increasing the amount of sodium and added sugar in her diet. Examples of these processed foods include soup, sherbet, nilla wafers, canned peas, and canned peach halves. Keeping sodium low in a patient with CHF is important as they retain sodium and fluid more. • I would show the patient the plate method, as the types of foods being consumed are more important in patients with type 2 DM. • I would suggest adopting a DASH diet as well as that would be helpful with the hypertension. 6. What is the purpose of each medication which Mrs. Douglas takes at home? What are the drug: nutrient interactions. Why was furosemide used in the hospital? What is the important drug: nutrients interaction with this medication? • Diovan treats hypertension; the diet: drug interactions include taking caution with potassium supplements and intake of grapefruit, and lowering intake of sodium and calcium. • Toprol XL treats hypertension; the diet: drug interactions include lowering sodium and calcium. • Glucophage treats hyperglycemia; the diet: drug interactions include following a prescribed diabetic diet, take guar gum after 6 hours after drug is taken, and lower calcium if losing weight. • Glucotrol is a oral hypoglycemic; the diet: drug interactions include following prescribed diet and exercise, and be careful with >3g nicotinic acid because that can increase glucose. • Gemfibrozil is a antihyperlipidemic; the diet: drug interactions include lowering fat and sucrose intake, as well as lowering overall energy intake. • Sublingual nitroglycerin is an antiangina; there are no specific drug: diet interactions. • Furosemide is used in the hospital in order to treat the fluid build up and swelling that is caused by congestive heart failure. The diet: drug interactions include increasing intake of potassium and magnesium, and decrease intake of calcium and sodium.