1. Diabetes and Heart Failure Case Study
FSHN 450
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Alysse Milano

2. Patient’s Value Normal Range Reason for variance
BMI: 37.1 18.5-24.9 Obese
Blood Pressure
155/95 mm Hg
120/80 mm Hg High from diabetes:
could indicate onset
of nephropathy
HA1c 7.5% 4.5-6% High due to diabetes
HR 100 BPM 60-100 BPM Slightly high
Orthopnea N/A Decompensated CHF
Dyspnea upon
exertion
N/A Decompensated CHF
2+ bipedal edema N/A Decompensated CHF
Albumin 3.2 g/dL 3.4-5.4 g/dL Low
Hgb 11.1 g/dL <12 g/dL Normal
Hct 33.3% <36% Normal
Glucose
185 mg/dL
<140 mg/dL High due to diabetes
Sodium 122 mEq/L 135-145 mEq/L Low
Potassium 4.5 mEq/L 3.7-5.2 mEq/L Normal
Chloride 101 mEq/L 97-107 mEq/L Normal
Triglycerides 290
mg/dL
<150 mg/dL High
Cholesterol 243
mg/dL
<200 mg/dL High
HDL 38 mg/dL 60+ mg/dL Low
LDL 147 mg/dL <100 mg/dL High

3. Assessment:
76 yo female. DX: type 2 DM, CHF
Ht: 5’6” Wt: 230 lbs BMI: 37.1 (Obese)
Meds: Diovan, Toprol XL 50 mg/d, Glucophage 1000 mg bid, Glucotrol 20 mg bid,
Lopid 600 mg bid, Sublingual NTG prn, Furosemide 20 mg qd, Oxygen by nasal prongs,
sliding scale insulin
Kcal from diet Rx: 1500 kcal
Protein: 1.2 (230) = 125 g
Fluid: 35 mL/kg/day = 3659 mL
1) Diagnosis:
Predicted suboptimal sodium intake related to current no salt diet as evidence by low
sodium lab values.
Intervention:
Encourage a 2 g sodium cardiac diet versus current no salt diet. Give patient examples of
foods containing the appropriate amount of sodium she needs daily, and a diet plan that
meets the needs of her diabetes and cardiac control.
Monitoring/Evaluation:
After 2-3 week on 2 g sodium, 1500 kcal cardiac diet, identify any changes in sodium
levels and weight loss. Make subsequent alterations to diet as necessary.
2) Diagnosis:
Obese, Class 11 related to inappropriate energy/nutrient intake, family history of diabetes
as evidenced by type 2 diabetes diagnosis and 24 hour dietary recall.
Intervention:
Encourage 1 lb/week weight loss through alterations in diet including reduction of
nutrient poor foods and maintenance of 1500 kcal diet. Explain the importance of
physical activity of 30 minutes at least 3-5 days/week to aid in weight loss.
Monitoring/Evaluation:
By one month, identify any changes in patient’s weight. Make subsequent alterations to
diet and physical activity requirements as necessary.
3) Diagnosis:
Self-monitoring deficit related to high cholesterol lab values and high blood pressure as
evidenced by CHF diagnosis and previous MI.

4. Intervention:
Encourage nutrient rich, cardiac diet such as DASH to emphasize nutrient rich foods.
Make sure patient’s multivitamin supplement is inclusive of EPA and DHA.
Monitoring/Evaluation:
By one month, identify changes in patient’s fatigue and SOB. Seek changes to diet if
blood pressure has not been reduced.
1. Sliding scale insulin is a type of insulin therapy where insulin is given based on
an individual’s pre-prandial blood sugar level. The appropriate amount of insulin
to control this level is given to the patient; amount of insulin given is totally
dependent on blood sugar levels before eating, which could obviously vary quite a
bit. This is different than other methods of insulin because there is no basal
dosage or fixed amount.
2. The cardiac diet is important for patient’s to deter cardiovascular disease. The
emphasis in a cardiac diet is to eat nutrient rich foods that aid in control of blood
pressure, cholesterol, and weight. These foods include: Fruits and vegetables, low
fat dairy, whole grains, fish and skinless poultry, nuts, and non-tropical vegetable
oils. Additionally, cardiac patients should eliminate/restrict red meat, trans and
saturated fats, sodium and sugar. A patient with high blood pressure should
restrict sodium to <1500 mg/day. Otherwise, a 2400 mg/day sodium
recommendation is implemented. Alcohol should be drank in moderation and
caffeine should be eliminated.
3. Mrs. Douglas’ current dietary intake could use some improvements in comparison
to these guidelines. For breakfast, she should avoid coffee/caffeine and replace
2% milk with low-fat dairy. I would encourage Mrs. D to include at least a
serving of fruit in her breakfast. The margarine and butter she consumes contains

5. bad fats (trans/saturated) that will not help in cholesterol or blood pressure
control. For lunch, soup is a bad choice because of its high sodium content. I
would swap soup for a serving of fish and add vegetables to this meal. It appears
Mrs. Douglas should also reduce her carbohydrate intake for aid in her diabetic
control. She eats bread/bran flakes for breakfast, crackers for lunch, and
bread/mashed potatoes for dinner. I would replace each of these for a more
nutrient-dense food like sweet potato versus a mashed potato. Finally, Mrs.
Douglas does not need the sugar in the orange sherbet or Nilla vanilla wafers. I
would replace these foods with some berries or other fruit.
4. Mifflin St. Jeor for Kcal: 1045+1047.5-380-161 = 1551 kcal
Protein: (1.2)(230) = 125 g
Upon discharge, the 1500 kcal diet prescription is appropriate for Mrs. Douglas’s
needs. First, this diet is appropriate for both adult weight management and cardiac
failure. Mrs. Douglas requires both of these to control her type 2 diabetes and CHF.
1500 kcal should aid in Mrs. Douglas’s weight loss, which will ultimately help with
all the issues she has presented with.
5. As mentioned above, Mrs. Douglas is not eating enough nutrient-rich foods in her
diet and eating too many nutrient-poor foods. She should switch to decaf coffee in
the morning to avoid caffeine and replace any of her 2% dairy with low-fat dairy.
Additionally, she needs to include more servings of fruits and vegetables each
day. For breakfast, I would emphasize this and reduce her intake of carbohydrates
(in toast and bran cereal). Mrs. Douglas should also eliminate the
butter/margarine and added sugars from sherbet and cookies. I would add healthy
fats to her diet like fish, olive oil (maybe in a salad), avocados, nuts, etc. I think

6. Mrs. Douglas would benefit from the inclusion of snacks, like a handful of nuts,
to her daily routine. The mashed potatoes and bread for dinner should be swapped
for something like a sweet potato and a vegetable like broccoli.
6.
Drug Purpose Drug/Nutrient Interaction
Diovan Angiotensin receptor
blocker: for high blood
pressure and heart failure
Do not use potassium
supplements, diabetic
medications containing
aliskiren
Toprol XL Beta blocker: for high
blood pressure and angina
Avoid alcohol.
Multivitamins with
minerals can reduce
effects. Food can enhance
levels. Can alter serum
cholesterol levels
Glucophage OHA to control blood
sugar
In combination with
alcohol can cause lactic
acidosis
Glucotrol OHA for type 2 diabetes to
help pancreas produce
insulin
Alcohol should be avoided
because of its effects on
blood sugar
Lopid Lowers high cholesterol
and triglycerides
Can interact with blood
thinners
Sublingual NTG Treat congestive heart
failure
Avoid grapefruit juice and
alcohol
Furosemide is a loop diuretic that was used in the hospital to treat Mrs. Douglas’s
edema and hypertension. Furosemide causes potassium loss, so it is important to
emphasize an increased potassium intake when taking this drug. In addition, it is
important to emphasize the intake of calcium and magnesium.