Title: Diabetes Case Study Presentation
1Diabetes Case Study Presentation
- Presented By
- Josie Lodrigue
2Why 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.
3Admit Diagnosis
- Intracerebral Hemorrhage
- CVA
- Type 2 DM
4Intracerebral 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.
5Intracerebral 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
6Intracerebral 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
7Intracerebral 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.
8Intracerebral 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.
9Intracerebral 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
10Cerebrovascular 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.
11Cerebrovascular 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
12Cerebrovascular 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
13Cerebrovascular 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
14Cerebrovascular 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
15Cerebrovascular 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.
16Cerebrovascular 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.
17Cerebrovascular 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
18Type 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.
19Type 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
20Type 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)
21Type 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
22Type 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
23Type 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
24Review Of Patient Information
25Socioeconomic 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
26Past 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
27Physical 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
28Physical 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
29Physical 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
30Physical 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
31Laboratory 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
32Laboratory 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
33Course of Present Illness
34Course 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
35Course 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
36Course 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
37Medical Treatment
38Medications
- 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
39Medications 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
40Medications 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
41Related Disciplines
42Occupational 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.
43Physical 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.
44Speech Therapy
- SLP completed barium swallow no signs/symptoms
of aspiration - Recd supervision of meals
- Continued to address auditory processing/cognitive
deficits
45Medical Nutrition Therapy
46Nutrition 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
47Nutrition 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
48Nutrition 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
49Nutrition 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
50Nutrition 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
51Nutrition 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
52Rationale 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
53Evaluation 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
54Follow Up Visit
- Pt continued to improve overall status
- Appetite continued to increase
- Progressing with OT and PT
55Nutrition Education Plan
56Nutrition 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
57Nutrition Education Plan Summary Cont
58Nutrition 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.
59Nutrition 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.
60Prognosis
- 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.
61Related Literature
62Whole-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.
63Intake 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.
64Relationship 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.