Mrs. Douglas, a 76-year-old female with type 2 diabetes, hypertension, and a history of heart failure and myocardial infarction, was admitted to the hospital for shortness of breath and swelling in her legs. Her lab values show elevated glucose, sodium, cholesterol, and triglycerides. A nutrition assessment found she consumes around 1800 calories daily but could benefit from following a cardiac diet lower in sodium, saturated fat and refined carbohydrates. A 1500 calorie diet is recommended for weight loss and heart health upon discharge.

1. COLORADO STATE UNIVERSITY
Diabetes and Heart Failure
Case Study
FSHN 450
Emma Kett
10/23/2015
“I have not given, received or used any unauthorized assistance on this assignment.”

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"(167.64cm), Current BW 230 #,(104.3kg) 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

3. 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 wafers
PREPARE CASE REPORT INCLUDING:
I. Interpret the patient’s laboratory values and compared to recommended ranges. (Use
table format)
Lab Pt Value Normal Range Reason for change
Glucose (not fasting) 185 mg/dL <140 mg/dL Increased because of
DM
Sodium 122 mEq/L 136-144 mEq/L Decreased because of
edema, hyperglycemia
Potassium 4.5 mEq/L 3.5-5.0 mEq/L normal
Chloride 101 mEq/L 98-107 mEq/L normal

4. Hgb 11.1 g/dl 12.1-15.6 g/dL Decreased because of
hyperthyroidism
Hct 33.3 % 34-45% Decreased because of
blood loss,
hyperthyrodism
Albumin 3.2 g/dl 3.5-5.0 gm/dL Decreased because of
aging
Triglycerides 290 mg/dl <150 mg/dL Increased because of
hyperlipidemia,
poorly controlled DM,
MI
Cholesterol 243 mg/dl 120-199 mg/dL Increased because of
hyperlipidemia, DM,
acute myocardial
infarction, obesity
HDL-cholesterol 38 mg/dl 40-60 mg/dL Decreased because of
obesity, DM
LDL-cholesterol 147 mg/dl <100 mg/dL Increased because of
DM
HA1c 7.5% 4.0-6.0% Increased because of
poorly controlled DM
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: 76 year old female has been admitted to the hospital and presents with shortness of
breath (SOB), progressive weakness, fatigue that she has been experiencing for 2 weeks,
swelling in both legs, angina and chest tightness that is not relieved by nitroglycerine. The pt is
also having trouble walking. She has been diagnosed with CHF, type 2 diabetes and
hypertension. She had a MI 10 years ago and had her gallbladder removed 8 years ago. She has
family history of CHD, obesity and type 2 diabetes. Pts BMI is 37.5 and her BP is 155/95. Pt
does not smoke or drink alcohol, she follows an 1800kcal/day w/no added salt diet. She also
presents with S3 heart sounds, fever and chest sounds(rales).
Energy requirements: Mifflin St. Jeor: 10(104.3kg)+ 6.25(167.64cm)- 5(75)- 161= 1043+
1047.125-375-161= 1554.125 kcal/day
Protein requirements: .9g/kg/day= 93.87kg of protein per day
Diagnosis:
1) Excessive energy intake R/T poorly controlled diabetes and physical inactivity AEB
increased BMI and dietary recall.
2) Overweight/obesity R/T excess caloric intake AEB weight, BMI, diet recall.
3) Self-monitoring deficit R/T high carbohydrate diet AEB hyperglycemia, diet recall.
Intervention:
1) Reduce the daily caloric intake to ~1500.
2) Reduce daily calorie intake to ~1500, implement the DASH diet to make sure that pt is
getting the right proportion of each macronutrient and integrating healthy fats into the
diet.

5. 3) Test blood glucose at least 6 times daily to ensure proper control of blood glucose
(<180mg/dL random testing). Have pt participate in a diabetes management class and
teach her about CHO counting, exchanges, reading labels and making sure that she uses
the proper amount of insulin for the amount of CHO she is consuming.
Monitoring:
1) Monitor weight and BMI to make sure that pt is losing weight at an appropriate rate. I
would also ask the pt to keep a food diary to help me or another dietitian determine if she
is actually meeting the 1500kcal/day goal.
2) Monitor pts food diary to see that she is meeting her 1500kcal/day goal and that she is
effectively implementing the DASH diet.
3) Monitor pts blood glucose readings and her food diary. The blood glucose readings will
help doctors and dietitians help her adjust her insulin dosing and usage. The food diary
will help the dietitian to make sure that the pt is understanding and using the concepts of
CHO counting and exchanges.
Evaluation:
1) Eventually the goal will be to get the pts weight down so that her BMI is between the
normal range (18.5-24.9). The pt should be meeting the 1500 kcal/day goal.
2) Pt should be meeting the 1500kcal/day goal. The dietitian can assess the food diary to see
if pt is following a DASH diet which includes 4-5 servings of fruits and vegetables, 2-3
servings of low fat dairy, 7-8 servings of grains and 4-5 servings of nuts, seeds, and
legumes.
3) Blood glucose should be <180 mg/dL when take at a random time during the day (not
fasting) and between 80-130mg/dL fasting level. The dietitian can also assess the food
diary to make sure that the pt is correctly CHO counting and using the 15g of CHO as 1
exchange.
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.
Sliding scale insulin is a progressive increase in the pre-prandial or nighttime insulin
dose. I do not think this would be appropriate for the pt to control her diabetes at home
because it does not take into account the amount of insulin that might be needed to adjust
for changes in snacks, stress or activity. Is ok for her in the hospital because her daily
routine is very much the same from day to day but when she goes home her days will be
more varied so this will be less suitable for her needs.
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).
Diet recommendations include eating a balanced diet. Some of the best ways to
implement a balanced diet is to follow a DASH diet or a Mediterranean diet; these are
both high in vegetables and fruits, healthy fats (omega-3s), lean proteins, and low fat
dairy. Other dietary recommendations are to consume no more than 5-6% of total calories
from saturated fats and to consume less than 2400 mg of sodium per day. You can cut
down on both saturated fat and sodium by eating less pre-processed foods and eating

6. more fresh food. You can cook more food at home, use more fresh produce and cut back
on cooking with salt to help lower your intake.
3. How does Mrs. Douglas current dietary intake compare to these guidelines?
The pt is consuming some pre prepared foods still so her sodium and saturated fat intake
could still be a little on the high end. She is preparing some of her food at home so that is
a good start, but she can do more to have a healthier diet. She is consuming some fruits
and vegetables but not the recommended amount and she is not consuming the amount of
healthy fats that she needs to be and should could increase her intake of those things by
eating more fish and/or nuts and seeds, and healthy oils.
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).
Mifflin St. Jeor: 10(104.3kg)+ 6.25(167.64cm)- 5(75)- 161= 1043+ 1047.125-375-161=
1554.125 kcal/day
Based off of this calculation I would say that the 1500kcal/day prescription is appropriate
after the pt is discharged. I think this is a reasonable goal for the pt to work towards
because this will help her to not gain more weight and it will not add any stress to her
heart though increasing her RQ. I think this amount of kcal/day will also help the pt to
lose some of her weight so that she is at a healthier BMI and weight status.
5. Make suggestions for modifications to Mrs. Douglas dietary intake to achieve MNT
goals for a patient with CHF and type 2 diabetes.
I would suggest that the pt incorporate more healthy fats like fish, nuts and seeds into her
daily routine. I would also recommend that she starts trying to manage her carbohydrate
intake. She can start using carbohydrate exchanges to help her manage this.
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: antihypertensive Interactions: caution w/ K supplement or salt
substitutions, decrease sodium, decrease kcal might be recommended. Avoid natural
licorice.
Toprol XL 50 mg/d: antihypertensive, antiangina Interactions: decrease sodium
intake, decrease kcal may be indicated, avoid natural licorice.
Glucophage (metformin) 1000 mg bid: antihyperglycemic agent Interactions: decrease
kcal if weight loss is needed, taking guar gum >/=6hr after drug can decrease drug
absorption
Glucotrol (glipizide) 20 mg bid: oral hypoglycemic Interactions: caution with
high doses of nicotinic acid, increase glucose
Lopid (gemfibrizole) 600 mg bid: antihyperlipidemic Interactions: decrease fat, low
sucrose, kcal controlled
Sublingual NTG prn: antiangina Interactions: take on empty stomach, 1 hour
before meals or 2 hours after meals, swallow whole
Furosemide: diuretic, antihypertensive Interactions: increase K consumption, increase
Mg consumption, decrease kcal and sodium consumption, avoid natural licorice.
She was given furosemide in the hospital because of its antihypertensive properties. Her
blood pressure was high when she was admitted so they wanted to add the extra
medication in order to help control that.