Krause\'s Food & the Nutrition Care Process 14th edition Chapter 30 Case Study M
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Question
Krause's Food & the Nutrition Care Process 14th edition Chapter 30 Case Study
Maria P is a 65 year old, non-smoker Hispanic female who is coming to see you for management of her Type 2 diabetes. Her blood glucose levels are uncontrolled as evidenced by an A1C 10, and she complains of increasing numbness in her feet and occasionally in her fingers, and frequent urination during the day and overnight. From interviewing her and reviewing her health record, you learn the following about her:
Education: Did not complete high school, attended through middle school. Occupation: Not employed outside the home, babysits infant grandchild on a daily basis
Household Members: Lives with her husband and with one of her four adult children.
Ethnic Background: Latin American, born in Mexico, emigrated to US in 1980
Religious Affiliation: Catholic
Language: Native Spanish, speaks English – has difficulty reading English
Patient History: Weighed more than 9 lb at birth.
Maria was diagnosed with T2DM, 10 or 15 years ago and her diabetes management history is as follows:
Type of Treatment: Nutrition therapy plus oral diabetes medication and long-acting insulin at bedtime (HS)
Medications: Meds: glargine 80 units at HS, metformin XR 1000 mg BID, enalapril 10 mg daily, simvastatin 40 mg daily, levothyroxine 75 mcg daily
Family history: Mother had type 2 diabetes, 12 year old grandson recently diagnosed with prediabetes
Medical History: type 2 diabetes, hypertension, hyperlipidemia, hypothyroidism, episodic migraines (last occurrence 2012)
PE shows the following:
Weight: 201 lbs.
Height: 5’2” inches
Temp: 98.6 F
BP: 143/88 mm Hg
Heart rate; 80 bpm
Labs: A1C 9.8%, TSH 8, FT4 0.3; Total cholesterol 144 mg/dL, LDL 116 mg/ dL, HDL 54 mg/dL; Triglycerides 545 mg/dL, BUN 14
Self-monitoring of blood glucose record shows: Aggregate mean: 218 mg/dL, Standard deviation: 48 (n 68) over last 30 days
Frequency – 2 x/day
Fasting (6 AM) 173 mg/dL, Standard deviation: 35 (n 21)
Prebreakfast (9 AM): 248 mg/dL, Standard deviation: 30 (n 6)
Prelunch (1 PM): 193 mg/dL, Standard deviation: 47 (n 17)
Predinner (6 PM): 195 mg/dL, Standard deviation: 33 (n 11)
Bedtime (n 9): 260 mg/dL, Standard deviation 34 (n 13)
Range: 69 mg/dL to 304 mg/dL
Nutrition History:
General: Good appetite, with wide consumption of foods and beverages native to the region in Mexico where she was born. She plans and prepares meals for the household.
Performed a 24-hour diet recall:
Breakfast: coffee with milk and sugar (several spoons) sweet bread 3 to 4 pieces
Lunch: chicken and vegetable soup corn tortillas (4-6), home-prepared fruit juice (1-2 x 16 ounce glass)
Dinner: Largest meal – chicken/beef, rice ( 2 cups) and beans (112 - 2 cups), corn tortillas (4-6), home-prepared fruit juice (1-2 x 16 ounce glass)
Afternoon snack: 1 can “natural” cola 3 to 4 sugar-free cookies
HS snack: cereal milk
Food allergies/intolerances/aversions: None
Previous nutrition therapy: Several years ago when diagnosed
Vitamin/supplement intake: Vitamin D3 – 2000 IU per day, One A Day vitamin supplement
Tx Plan:
1. Referral to RDN, CDE for instruction on carbohydrate counting for use with a basal-bolus insulin plan.
2. Physician prescribed:
A) Rapid-acting insulin analog lispro
Premeal dose
breakfast 10 units
lunch 15 units
dinner 20 units
Correction insulin (insulin sensitivity factor) 1 unit to drop blood glucose level 50 mg/dL when premeal blood glucose 150 mg/dL
B. Increased self-monitoring of blood glucose premeal (breakfast, lunch and dinner) and 2 hour postprandial blood glucose after dinner.
Nutrition Diagnostic Statements: PES Statements:
1) Food and nutrition-related knowledge deficit related to lack of previous diabetes nutrition education as evidenced by patient’s nutrition history.
2) Limited adherence to nutrition-related recommendations related to poor understanding as evidenced by elevated hemoglobin A1C and food records that indicate that patient is consuming excessive amounts of carbohydrate and calories.
3) Altered blood glucose levels related to inability to match insulin to carbohydrate intake as evidenced by patient’s nutrition history and glucose monitoring download data report.
1. Why did Maria’s physician prescribe mealtime insulin?
2. What is the proposed mechanism of action for metformin?
3. Why would you recommend regular physical activity for Maria?
4. What causes the numbness and tingling in Maria’s feet and fingers?
5. Calculate Maria’s BMI, %UBW and %IBW
6. Is Maria’s vegetable and fruit intake adequate?
7. What are Maria’s pre/post meal glucose targets?
8. What are appropriate interventions for Maria?
9. What will you assess in a follow-up visit?
10. What would you recommend if Maria develops an acute illness? How would her treatment change?
Explanation / Answer
Answer 1:
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