Josh Naumann

Nutrition Assessment: Medical Diagnosis Hyperosmolar Nonketotic State

Age: 52 y.o.
Labs:
Gender: Male
Weight: 156 lbs. = 70.9 kg
Height: 66 in. = 167.6 cm
BMI: 26.0 (Overweight)
UBW: 185 lbs.
IBW: 136 lbs.
%IBW: 115%

PMH:
Depression
DM2
HTN
Amputation of 4 distal digits d/t work accident

Symptoms:
Nausea
Vomiting
Lightheadedness
Tremors

Diet History:

Na 133 (Low)
Potassium 5.8 (High)
Chloride 87 (Low)
Anion Gap 20 (High)
Glucose 603 (Extremely High)
BUN 26 (High)
Cr 1.6 (High)
Bilirubin 1.8 (High)
A1c 10.5 (High)

Medications:
Metformin (decrease hepatic glucose production)
Levemir (long-acting insulin)
Metoprolol (treat HTN & CHF)
Lovenox (blood thinner)
Ativan (treats anxiety & depression)

Current Diet:
Carbohydrate-Controlled

Breakfast: Breakfast sandwich (from convenience store);

Raisin Bran & 2% milk
Lunch: 6 in. turkey sub (from convenience store) w/ mustard,
mayo, lettuce, tomato, onion
Dinner: Chili, steak, pork chops, hot dog; vegetable
Drinks: 4-5 cans of soda at work; 4-5 cans of soda at home;
usually regular but sometimes diet; 2% milk (goes through a
gallon in one week)
Alcohol: 6 beers 3 days/week
Appetite Fair (50-75%)

Nutrition Diagnosis utilize PES Statements

Limited adherence to nutrition-related recommendations (NB-1.6) related to dietary recall high in carbohydrates as evidenced
by diabetes education received 7 years ago (per patient) & elevated A1c.

Nutrition Intervention Nutrition prescription, Interventions with goals

Nutrition Prescription
Intervention with goals
60 g CHO per meal TID
15 g CHO per snack (midmorning & midafternoon)

Recommended modifications (E-1.5)

Carb-controlled diet for achieving glycemic control
throughout the day.
Switching from regular soda to diet soda will reduce the
amount of carbohydrates he consumes.
Avoiding alcohol will prevent blood glucose
fluctuations.

Nutrition Monitoring and Evaluation

Indicator

Criteria

Carbohydrate intake (FH-1.5.3)

Patient Alc will decrease in 3-6 months

Josh Naumann
Hyperosmolar Nonketotic State
Mechanism:
Accumulation of excess glucose in the blood due to insulin deficiency leads to osmotic diuresis. As fluid
is lost in this process, the blood becomes more concentrated resulting in dehydration & hyperglycemia.
Ketosis is absent because the presence of some insulin inhibits fat breakdown.
Diagnostic Criteria
Glucose
>600 mg/dL
Osmolality >320 mOsm/kg
Serum Ketones
Negative
Urine Ketones
Negative
Signs & Symptoms

Polyuria
Polydipsia
Polyphagia
Weight Loss

Long-Term
Complications

Cardiovascular Disease Hyperlipidemia & Hypertension

Retinopathy Blindness
Nephropathy Kidney Failure
Neuropathy Amputation

Medical Treatment

Medication to lower glucose

Insulin may be required to normalize blood sugar
IVF to correct dehydration & diuresis of blood sugar
Supplemental electrolytes that may have been lost during osmotic diuresis

Prevention

Adequate hydration
Routine blood glucose monitoring

Nutrition

Carb-controlled diet for glycemic control

Protein ~20% of calories to prevent development of neuropathy
Fat ~25-35% of calories to reduce risk of CVD
Fiber helps slow the absorption of glucose
Alcohol in combination with medication may cause hypoglycemia

Josh Naumann
Energy Requirements:
Source
Facility standards

EAL

Kcal requirements
1787 kcals

Protein requirements
85-106 g

Fluid requirements
2127-2482 mL

[BEE using Mifflin-St. Jeor

x Activity Factor of 1.2
(confined to bed)]

(Moderate depletion 1.2-1.5

g/kg)

(Patient <65 yo, 30-35

mL/kg)

N/A

134 g

N/A

(30% kcals from protein)

Online nutrition care

manual

1787 kcals
(BEE using Mifflin-St. Jeor
+ 20%)

85-106 g

N/A

(1.2-1.5 g/kg)

References:
1. Nelms M, Sucher K, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont,
CA: Wadsworth, Cengage Learning; 2011.
2. Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th ed.
St. Louis, MO: Elsevier Saunders; 2012.
3. Stoner GD. Hyperosmolar Hyperglycemic State. Am Fam Physician. 2005; 71(9):1723-1730.
4. MedlinePlus: Diabetic hyperglycemic hyperosmolar syndrome. U.S. National Library of Medicine
Web site. https://www.nlm.nih.gov/medlineplus/ency/article/000304.htm. Updated May 10, 2014.
Accessed October 6, 2015.
5. Evidence Analysis Library: Diabetes Type 1 and 2. Academy of Nutrition and Dietetics.
http://www.andeal.org/topic.cfm?menu=5305&cat=1619. Accessed October 6, 2015.