James D. is referred to your outpatient clinic following a recent admit for comp
ID: 126520 • Letter: J
Question
James D. is referred to your outpatient clinic following a recent admit for complications related to his DM type 2. James is a 38 YOWM, 5’9” 210# with a L BKA. He has had multiple admissions to the hospital due to PVD, peripheral neuropathy and dehydration. His most recent admission was for treatment of a non-healing ankle wound that began as a blister and has progressed into a stage 3-pressure ulcer. His foot is cyanotic and the admission was for the purpose of debridement. The physician is quite concerned due to the advanced level of complications in such a young patient. She has referred the patient to your clinic for aggressive outpatient intervention and education.
Lab values:
Albumin: 2.2 mg/dl
Prealbumin 8.9 mg/dl
BUN 52 mg/dl
Creatinine 3.1 mg/dl
Anion gap 12
H/H 10.8/32
Fasting Blood glucose: 210 mg/dl
K+ 4.2 mg/dl
Na + 136
Osmolality 289 mMol/dl
24 hour recall:
2 scrambled eggs
3 slices bacon
2 slices toast with butter
2 tsp jelly
8 ounces orange juice
1 cup whole milk
Large cheeseburger (Mcdonald’s or Burger King)
Large fries
2-3 pkgs ketchup
apple pie
24 ounce coke
4 slices deep dish pepperoni pizza
3-12 ounce beers
oreo cookies
Develop a nutritional problem list (2 problems) for this patient in the order of highest to least priority
Complete a calorie count based on the 24 hour recall
Complete a nutritional assessment on this patient. This includes anthropometric, dietary and biochemical parameters. Include estimates of Kcal, protein and fluid needs. Assess the needs compared to the intakes. Is his diet adequate
Determine a plan of care based on your problem list and assessment. What would be the two most important topics for the patient’s nutritional education
Explanation / Answer
James had type 2 diabetes mellitus and observing his food intake for 24hrs before was totally a high calories food and also high glucose intake is done.This results in having these foods results in non healing of foot as the glucose level is more.The diet should be strictly followed by him as to reduce such kind of major complications.The calorie count exceeds 4100 calories /day based on his 24 hour recall which is very unusual to his health.According to his age,height and weight given he should nor pertain more than 2,255 calories per day.To lose 1 to 2 pounds per week (a safe rate of weight loss), subtract 500 to 1000 calories from the total number of calories needed to maintain weight.As an example, an overweight man who weighs 250 lbs would need to eat 2500 calories per day to maintain his weight. To lose 1 to 2 pounds per week, he should eat 1500 to 2000 calories per day. As weight is lost, the recommended calorie intake should be recalculated.
To effectively manage glycated hemoglobin (A1C) and blood sugar levels, it is important to understand how to balance food intake, physical activity, and medication. Making healthy food choices every day has both immediate and long-term effects. With education, practice, and assistance from a dietitian and/or a diabetes educator, it is possible to eat well and control diabetes.Eating a consistent amount of food every day and taking medications as directed can greatly improve blood sugar control and decrease the risk of diabetes-related complications, such as coronary artery disease, kidney disease, and nerve damage. In addition, these measures impact weight control.Measure your weight on a regular basis (eg, once weekly). Weight gains of more than 2 to 3 pounds indicate a need to decrease the amount you eat or increase activity. Do not wait until weight increases by 10 or more pounds to take action.Exercising regularly can help to lose weight and keep it off.
Two main topics for patients education,
Carbohydrate count:Carbohydrates are the main energy source in the diet and include starches, vegetables, fruits, dairy products, and sugars. Most meats and fats do not contain any carbohydrates.Carbohydrates have a direct impact on the blood glucose level whereas proteins and fat have little to no impact. Eating a consistent amount of carbohydrates at each meal can help to control blood glucose levels, especially in people who take oral diabetes medications or long-acting insulin .A dietitian usually helps to determine the number of carbohydrates you need at each meal and snack, based upon an individual's usual eating habits, diabetes medications, body weight, nutritional goals, and activity level. In most people, between 45 and 55 percent of the day's total calories typically come from carbohydrates
Meal timing — Consistently eating at the same times every day is important for some people, especially those who take long-acting insulin (eg, NPH) and oral medications that decrease blood sugar levels (sulfonylureas or meglitinides). If a meal is skipped or delayed while on these regimens, you are at risk for developing low blood glucose.
Avoid junk food:Foods or meals that are high in fat (eg, pizza,burgers) may be eaten very occasionally, although blood sugar levels should be monitored more closely. High-fat meals are broken down more slowly than low-fat meals. When using rapid-acting insulin before a meal, the blood sugar level may become low shortly after eating a high-fat meal and then rise hours later.
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