Diabetes Case Study Presentation

1
Diabetes Case Study Presentation

• Presented By
• Josie Lodrigue

2
Why I Chose This Patient?

• I thought this was one of the most thorough and
  well planned case studies that I had done.
• The education with the patients wife went really
  well and she was very interested in learning.
• Patient showed continued improvement.

3
Admit Diagnosis

• Intracerebral Hemorrhage
• CVA
• Type 2 DM

4
Intracerebral Hemorrhage Etiology

• Describes a bleed in the brain caused by the
  rupture of a blood vessel within the head.
• Can be caused by traumatic brain injury or
  abnormalities of blood vessels.
• Can also be caused by HTN.

5
Intracerebral Hemorrhage Signs/Symptoms

• Headache
• Nausea/Vomiting
• Change in alertness
• Vision Changes
• Sensation Changes
• Difficulty writing

• Difficulty speaking
• Difficulty swallowing
• Movement changes
• Loss of coordination
• Seizures

6
Intracerebral Hemorrhage Complications

• Cerebral Edema
• Cerebral Hematoma
• Collection of blood surrounding brain
• Side effects of medications

• Depends on extent of damage and location
• Hydrocephalus
• Permanent loss of brain function
• Seizures
• Surgery complications

7
Intracerebral Hemorrhage Treatment Goals

• Goals of treatment include lifesaving
  interventions, supportive measures and control of
  symptoms.
• Treatment can vary, depending on the specific
  location, extent, and cause of bleeding.

8
Intracerebral HemorrhagePrognosis

• Long-term outcome is variable.
• Death may occur quickly despite medical
  treatment.
• Recovery may occur completely or with any level
  of permanent loss of brain functions.
• Meds, surgery and other treatments may have
  severe damaging side effects.

9
Intracerebral Hemorrhage Prevention

• Treatment and control of other risk factors
  associated with developing brain hemorrhages such
  as
• Treatment/control of HTN
• Medications such as blood thinners

10
Cerebrovascular Accident Etiology

• Type of CVD involving the arteries leading to the
  brain.
• Occurs when a blood vessel that carries oxygen
  and nutrients to the brain is either blocked or
  ruptured.
• Risk factors include atherosclerosis, HTN, age,
  family history, smoking, diabetes, high
  cholesterol and heart disease.

11
Cerebrovascular Accident Signs/Symptoms

• Sudden numbness or weakness of face, arm, or leg,
  usually on one side
• Trouble seeing
• Slurred speech
• Vertigo

• Trouble walking
• Loss of coordination
• Confusion
• Severe headache
• Mood changes
• Uncontrolled eye movements

12
Cerebrovascular Accident Complications

• May experience problems due to loss of mobility
• Permanent loss of movement or sensation of a part
  of the body
• Bone fractures (due to falls)
• Muscle spasticity
• Permanent loss of brain functions

13
Cerebrovascular Accident Complications Cont

• Reduced communication or social interaction
• Reduced ability to function or care for self
• Decreased life span
• Side effects of medications
• Aspiration
• Malnutrition

14
Cerebrovascular Accident Treatment Goals

• Goal is to immediately treat or care for patient
  to save life/reduce disability. Will depend on
  location, extent and cause of stroke.
• Aspirin/blood thinners
• Removal of blockage
• Surgical interventions

15
Cerebrovascular Accident Treatment Goals Cont

• Adequate nutrition and fluids to prevent
  malnutrition from swallowing difficulties.
• Life support and coma treatment as needed.
• Physical, occupational, and speech therapy as
  needed to restore function.

16
Cerebrovascular Accident Prognosis

• Depends on extent of damage and location of
  stroke, as well as other associated risk factors,
  and likelihood of recurring strokes.
• Many have long-term disabilities, but about 10
  recover most or all function.
• 50 able to be at home with assistance and 40
  become residents of a long-term care facility.

17
Cerebrovascular Accident Prevention

• Proper screening for HTN and cholesterol,
  especially if there is a family history.
• Treat HTN, DM, high cholesterol and heart
  disease, if present.
• Follow low-fat diet.

• Smoking cessation
• Regular exercise
• Weight loss
• Medications (blood thinners, aspirin)
• Prevention of falls and injuries

18
Type 2 Diabetes Etiology

• Disease in which the body does not produce enough
  insulin, or the cells cannot properly use
  insulin.
• Blood sugar levels rise because insulin cannot
  properly store glucose in the cells.
• Specific cause unknown, but genetics and
  environmental factors may play a roll in
  development of disease.

19
Type 2 Diabetes Signs/Symptoms

• Often no symptoms
• Increased thirst
• Increased urination
• Increased appetite

• Fatigue
• Blurred vision
• Frequent/slow healing infections
• Abnormal fasting blood glucose/oral glucose
  tolerance test

20
Type 2 Diabetes Complications

• Heart disease and stroke
• Kidney disease
• Eye damage
• Nerve damage
• Foot problems
• Skin problems (non-healing wounds)
• Diabetic coma (rare in Type 2)

21
Type 2 Diabetes Treatment Goals

• Main goal is to eliminate symptoms and control
  blood sugars.
• Other goals to prevent long-term complications
  and prolong treatment.
• Diet and weight control.
• Regular exercise
• Medication
• Foot care

22
Type 2 Diabetes Prognosis

• Risk of death, stroke, heart disease and other
  complications can be reduced by control of blood
  sugar and blood pressure.
• Reduction of HbA1c by even 1 can reduce risk of
  complications by 25

23
Type 2 Diabetes Prevention

• Anyone over 45 should have regular blood glucose
  checks (more often if person is at risk)
• Maintain healthy body weight
• Maintain active lifestyle
• Weight loss

24
Review Of Patient Information
25
Socioeconomic Information

• 65 year old black male
• Currently retired, still works part-time
  delivering newspapers
• Remains active
• Lives with wife
• High School Diploma, some college

• Stopped smoking 1968 - previously smoked 1-2ppd
• Rare alcohol use, no illicit drug use
• Family history
• Mother - HTN, hyperlipidemia, MI age 72
• Brother DM

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Past Medical History

• CHF
• HTN
• DM
• Chronic A-Fib
• Hyperlipidemia
• Osteoarthritis
• Peptic Ulcer Dz

• Lumbar Disk Dz
• H. pylori
• CAD
• Peripheral Vascular Dz
• Cataracts
• Colon Polyps
• Previous CVA

27
Physical Assessment

• Ht 58
• Wt 178 lbs
• IBW 154 lbs
• IBW 116 - Slightly Overweight
• Usual Wt 178 lbs
• UBW 100 - Maintaining weight however 2-3 lb
  wt loss noted due to poor appetite since CVA

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Physical Assessment Cont

• Skin Smooth, slightly pale
• Nails - Firm, smooth, pink
• Mouth Lips smooth, gums pink, teeth no dentures
• Face/Neck Symmetrical, blank expression, visual
  field defect with hemianopsia (blindness caused
  by stroke) of left visual field, no carotid
  bruits, gag reflex intact

29
Physical Assessment Cont

• Musculoskeletal in wheelchair, moving
  extremities well - Pt had poor standing balance,
  decreased coordination and balance and poor
  vision
• Heart Controlled A-Fib
• Abdomen Benign to gentle touch
• Hydration No edema
• General No apparent distress confused

30
Physical Assessment Cont

• Food Intake (1/10) 50 dinner, (1/9) 15
  breakfast, 100 lunch, 50 dinner, (1/8) 0
  breakfast, 90 lunch, refused dinner, (1/7) 50
  dinner
• I/O (1/10) 480/x1, (1/9) 730/800, (1/8)
  700/900, (1/7) 240/700, (1/6) 0/500
• BM 1/10, 1/9, 1/6
• Admit wt 178 lbs (80.7 kg)
• Admit Diet 2000 ADA

31
Laboratory Assessment

• Na 130 L, could be low possibly due to hx of
  CHF and low Na intake.
• K WNL
• BUN WNL
• Creatinine WNL
• Glucose 123 H, could be high due to DM or
  stress from CVA
• Albumin 3.2 L, May indicate mild depletion of
  visceral protein stores, however PAB WNL

32
Laboratory Assessment Cont

• Ca WNL
• Hgb WNL
• Hct WNL
• WBC - WNL
• Alkaline Phosphatase 146 H, could be due to
  osteoarthritis
• Glucoscans 111, 150, 149, 166, 224, 247, 141, 177

33
Course of Present Illness
34
Course of Present Illness Cont

• Pt admitted to Rehab unit 1/6/06
• Had recent CVA on Christmas
• MD discovered intracerebral hemorrhage as result
  of CVA
• Transferred to Rehab for strengthening and
  conditioning to restore normal physical and
  cognitive functioning
• Pt developed left sided blindness and weakness as
  a result of CVA

35
Course of Present Illness Cont

• Decreased coordination, balance, cognitive
  functioning, orientation, and ability to perform
  ADLs was noted
• OT, ST, PT were consulted to evaluate and treat
  pt for any present disturbances
• Urology Clinic was also consulted for noted
  urinary retention
• Nutrition was consulted for diabetes education
  and assessment

36
Course of Present Illness Cont

• Pt developed decreased appetite as result of CVA,
  however wife reported appetite was improving. No
  problems with appetite previously.
• Has had previous CVA and has CHF, however wife
  reports improving diet and activity levels to
  prevent further complications.
• Wife very supportive and willing to help with his
  progress.
• No other problems noted with pts history

37
Medical Treatment
38
Medications

• Lanoxin Antiarrhythmic/Anti-CHF pt may
  experience anorexia, weight loss, N/V, and
  diarrhea.
• Lantus Insulin Hypoglycemic May experience wt
  gain with higher insulin doses
• Levaquin Antibiotic May experience taste
  loss, N/V, dyspepsia, abdominal pain, diarrhea,
  flatulence
• Novolin R Insulin Hypoglycemic May experience
  wt gain with higher insulin doses

39
Medications Cont

• Zocor Antihyperlipidemic May experience
  dyspepsia, constipation
• Theragran Multivitamin may experience nausea,
  constipation, black stools, diarrhea
• Dilantin Anticonvulsant May experience gum
  hyperplasia, altered taste, dysphagia, N/V,
  constipation
• Cardizem Antihypertensive May experience dry
  mouth, dyspepsia, N/V, constipation, diarrhea

40
Medications Cont

• Quinapril Antihypertensive may experience N/V
• Darvocet Analgesic May experience dry mouth,
  N/V, abdominal pain, constipation
• Surfak Laxative/Stool Softener May experience
  GI upset, bloating, abdominal cramps

41
Related Disciplines
42
Occupational Therapy

• Noted impaired orientation, judgment, insight,
  problem solving and memory.
• OT working with pt to restore ADLs, specifically
  with grooming, feeding and toileting abilities,
  as well as lower body dressing due to decreased
  ability to perform these tasks
• Goals were to improve visual/hearing status and
  ADLs by supervision of feeding, grooming,
  bathing, toilet use and dressing.

43
Physical Therapy

• PT noted that assistance was needed with bed
  motility, functional transfers, ambulation and
  stair use.
• Noted decreased coordination and standing
  balance.
• Patient had minimum ability to use wheelchair.
• PT provided education on endurance and balance.

44
Speech Therapy

• SLP completed barium swallow no signs/symptoms
  of aspiration
• Recd supervision of meals
• Continued to address auditory processing/cognitive
  deficits

45
Medical Nutrition Therapy
46
Nutrition Care Plan Summary

• Subjective Info
• 2000 ADA Diet
• Decreased appetite past 2-3 weeks since CVA
• Currently improving
• Nausea reported at times
• No dentures/difficulty chewing or swallowing
• NKFA
• No food preferences

47
Nutrition Care Plan Summary Cont

• Objective Info
• 65 y/o black male
• Ht 58
• Wt 178 lbs
• IBW 154 lbs
• IBW 116
• UBW 178 lbs
• UBW 100

• Dx Intracerebral hemorrhage, CVA
• PMH CHF, DM, HTN, A-Fib, hyperlipidemia,
  osteoarthritis, PUD, lumbar disk dz, H. pylori,
  CAD, PVD, cataracts, Colon Polyps, CVA

48
Nutrition Care Plan Summary Cont

• Objective Info Cont
• Labs Na 130 L, K 4.2, BUN 13, Crea 1.0, Gluc 123
  H, Alb 3.2 L, PAB 28.3, Ca 8.7, Alk Phos 146 H,
  Hgb 16.0, Hct 46.8
• Meds Surfak, Lanoxin, Lantus, Levaquin, Novolin
  R, Zocor, Theragran, Dilantin, Cardizem,
  Quinapril, Darvocet
• PO Intake 50 x 7 meals
• Wounds - Skin Intact

49
Nutrition Care Plan Summary Cont

• Assessment
• Est Needs 1926-2119 kcals (24-26 kcal/kg), 81-97
  g protein (1.0-1.2 g/kg), 2427 ml fluid (30
  ml/kg)
• Labs Low alb may indicate mild depletion of
  visceral protein stores, high glucose may be due
  to DM or stress from CVA, Na low possibly from
  decreased Na intake for CHF, High Alk Phos
  possibly due to osteoarthritis

50
Nutrition Care Plan Summary Cont

• Assessment Cont
• Pt currently slightly overwt, however still WNL
• Slight wt loss noted (2-3 lbs over 2-3 wks)
• Pts wife reports appetite improving, however may
  benefit from oral supplement to provide
  additional kcals and protein
• Current 2000 ADA diet appropriate for meeting
  needs, however 2000 ADA, 2 gm Na diet recd due
  to CHF/HTN history

51
Nutrition Care Plan Summary Cont

• Plan
• 1) Change diet to 2000 ADA, 2 gm Na
• 2) Recd add Boost Diabetic 2 times daily to meal
  plan
• 3) Continue to monitor PO intake, labs, and
  weight
• 4) Educate pt on 2000 ADA diet
• 5) Will follow one time per week

52
Rationale for Nutrition Care Plan

• Recd Boost Diabetic to provide additional
  kcal/pro since PO intake 50
• 2 gm Na recd for CVA, CHF, HTN
• Continue 2000 ADA for diabetes
• Increased protein 2º low albumin
• Monitor PO intake to record pts tolerance and
  acceptance of diet
• MD consulted nutrition for DM education

53
Evaluation of Nutrition Care Plan

• Worked well, pts wife very accepting of changes
  to diet
• Improved appetite and nutrition
• Accepted oral supplement
• Interested in diet education and asked questions
  as appropriate

54
Follow Up Visit

• Pt continued to improve overall status
• Appetite continued to increase
• Progressing with OT and PT

55
Nutrition Education Plan
56
Nutrition Education Plan Summary

• Pt admitted on 2000 ADA diet
• MD recd diabetes diet education
• Designed meal plan according to pts typical
  dietary intake at home
• Provided Survival Skills for Diabetes and basic
  diabetic diet education to patients wife
• Left RD name and number for further questions

57
Nutrition Education Plan Summary Cont
58
Nutrition Education Plan Rationale

• I wanted to discuss the importance of diet in
  preventing further complications with his dx.
• Along with the 2000 ADA meal plan, I also
  encouraged the pts wife to follow a sodium
  restricted diet due to his PMH of CHF, CVA and
  HTN. I discussed limiting the use of added fat in
  cooking as well as limiting cholesterol
  consumption.
• I discussed including Boost DM when pts PO
  intake was reduced to include some kcal and pro.

59
Nutrition Education Plan Evaluation

• The education went very well. The pts wife
  expressed interest in her husbands improvement.
• Seemed to understand concepts I reviewed with her
  and stated follows diabetic diet at home.
• Expressed concerns and asked questions
  appropriate to pts case and I understood that
  they would be very compliant.

60
Prognosis

• Pt continued to have poor coordination and visual
  defects due to the stroke, and had more advances
  to make in his therapy, however continued to
  improve.
• Prognosis at that time was fair, but if the pts
  appetite continued to improve and if he continued
  to progress with therapy, his outcome looks good
  for the future.

61
Related Literature
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Whole-grain and fiber intake and the incidence of
type 2 diabetes.

• Bibliographical Information
• Montonen, J, Knekt, P, Jarvinen, R, Aromaa, A,
  and Reunanen, A. Whole-grain and fiber intake and
  the incidence of type 2 diabetes. American
  Journal of Clinical Nutrition 2003 77 622-629.
• Summary of Findings
• Typically obesity and lack of physical activity
  are the hallmarks of diabetes, however, there was
  not much research that stated preventative
  factors in diabetes. This study was completed to
  determine whether dietary fiber may protect
  against the development of diabetes or
  complications from diabetes. They presented food
  questionnaires and retained dietary recalls to
  obtain their information. In the end, it was
  determined that refined grains and fiber,
  especially cereal fiber, would reduce the risk
  and complications of type 2 diabetes. Refined
  fibers reduce transit time of carbs in the
  stomach, decreasing insulin demand.

63
Intake of Fruit and Vegetables and the Risk of
Ischemic Stroke in a Cohort of Danish Men and
Women.

• Bibliographical Information
• Johnsen, SP, Overvad, K, Stripp, C, Tjonneland,
  A, Husted, SE, Sorensen, HT. American Journal of
  Clinical Nutrition 2003 78 57-64.
• Summary of findings
• Certain dietary factors may influence the
  development of stroke. The creators of this study
  wanted to know if fruit and vegetable intake
  would decrease the risk of developing stroke.
  Food frequency questionnaires were passed out to
  determine intake. They determined that
  consumption of fruit, specifically citrus fruit,
  was associated with reduced risk of stroke.
  Vegetable intake did not show any relation to the
  reduced risk of stroke. It produced the same
  results as other studies, however it may not have
  been really effective because it was a very short
  study that only assessed their intake before
  hospitalization.

64
Relationship of Helicobacter pylori Infection to
Arterial Stiffness in Japanese Subjects.

• Bibliographical Information
• Saijo, Y, Utsugi, M, Yoshioka, E, Horikawa, N,
  Sato, T, Gong, Y, Kishi, R. Relationship of
  helicobacter pylori infection to arterial
  stiffness in Japanese subjects. Hypertension
  Research 2005 28 283-292.
• Summary of Findings
• H. Pylori has been noted to be a risk factor in
  CVD and cerebrovascular dz. This study reviewed
  pts with known H. pylori infection and their
  development of arterial stiffness. Once all data
  was collected it was noted that those with this
  infection had increased arterial stiffness, even
  after taking into consideration other risk
  factors for atherosclerosis. They were not able
  to determine why it caused stiffness, but it was
  correlated with higher levels of CRP due the
  inflammatory state it created. It is known that
  inflammation following the infection as well as
  elevated CRP can increase CVD risk, however they
  were unable to determine this from the study.
  Other studies will be done in the future to fully
  understand the relationship of H. pylori and
  atherosclerosis and whether antibiotic therapy
  can decrease that risk.