Natalie Rohr

KNH 413
Professor Matuszak
Type I DM Case Study
1. There are precipitating factors for diabetic ketoacidosis. List at least seven
possible factors.
The main cause of DKA is not enough insulin. Some precipitating factors contributing to
DKA would be missing an insulin dose, eating poorly, drug abuse, pregnancy, feeling
stressed, an infection (such as a urinary tract infection), any other illness (such as
pneumonia), having type I DM, and having type 2 DM during an acute illness (Nelms
505).
Cited: DiabeticKetoacidosis|Causes&RiskFactors.(n.d.).RetrievedFebruary18,
2016,fromhttp://familydoctor.org/familydoctor/en/diseasesconditions/diabetic
ketoacidosis/causesriskfactors.html
2. Describe the metabolic events that led up to the symptoms associated with DKA.
When adequate insulin is not available, glucose production via gluconeogenesis and
lipolysis are stimulated by counter-regulatory hormones in an effort to avoid starvation.
One of the by-products of lipolysis is the generation of ketones. As glucose and ketones
accumulate in the bloodstream, osmotic diuresis occurs, resulting in dehydration and
electrolyte imbalances. As fluid is lost, the blood becomes concentrated, further
contributing to hyperglycemia (Nelms 505).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Endocrine System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 469-520). Boston, MA:
Cengage Learning.
3. Assess Susans physical examination. What is consistent with diabetic
ketoacidosis? Give the physiological rationale for each that you identify.

Some things noted from Susans physical examination that are consistent with diabetic
ketoacidosis include vomiting, dry, flushed skin, poor turgor, dry mucous membranes of
the nose and ears, and deep, rapid Kussmauls respirations (these were only a few of her
symptoms listed). Her dry, flushed skin, and poor turgor as well as her dry mucous
membranes of the nose and ears are due to her dehydration status caused by the onset of
DKA and fluid loss. The smell of acetone on her breath also contributes to the onset of
DKA. Her deep, rapid Kussmauls respirations are indicative of the later states of DKA
and it shows her bodys involuntary attempt to offset metabolic acidosis (Nelms 506).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Endocrine System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 469-520). Boston, MA:
Cengage Learning.
4. Examine Susans biochemical indices both in the chemistry section and in her
ABG report. Which are consistent with DKA? Why?
Susans potassium, chloride, PO4, osmolality and BUN levels were all elevated upon her
admission to the hospital at 5.8 mEq/L, 110 mEq/L, 4.9 mEq/L, 336 mg/dL, and 29
mg/dL respectively. These values are indicative of her electrolyte imbalance as well as
her fluid loss that has led to dehydration. Her plasma glucose level was high at 475
mg/dL. Her urine was also positive for both ketones and glucose. Her low pH (7.31 L)
also shows DKA since pH levels lower when the disease is present. All of these factors
are consistent with her DKA diagnosis. The excess of ketones and glucose in her body are
why both are being found in her urine, the body is trying to dispose of the extra amounts.
Her lack of insulin is the reason for the high glucose levels in the blood and the raised
levels of potassium, chloride, PO4, osmolality, and BUN are all caused by her
dehydration (Nelms 506).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Endocrine System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 469-520). Boston, MA:
Cengage Learning.

5. If Susans symptoms were left untreated, what would happen?

DKA must be treated quickly and accurately to prevent coma and even death. The
presence of Kussmaul respirations is indicative that she is in the latter stages of DKA. If
left untreated, her levels of serum blood glucose would continue to rise to dangerously
high amounts. Due to complications caused by that, her condition could become fatal
(Nelms 153).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Endocrine System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 469-520). Boston, MA:
Cengage Learning.
6. Assuming Susans SMBG records are correct, what events seem to have
precipitated the development of DKA?
The events that seem to have precipitated the development of DKA include the start of
her menstrual cycle as well as her volleyball tournament and her birthday all within the
same week/weekend. These three things can cause lots of emotional stress, which in
return can cause her insulin to be ineffective. With her insulin being ineffective, her
serum blood glucose levels will rise, causing DKA.
7. What, if anything, could Susan have done to avoid DKA?
Susan could have done multiple things in order to avoid DKA. She already seems to do a
pretty good job at managing her diabetes, but when she knew she was going to be under a
lot of stress within a few days, she should have monitored her blood sugar level more
than four times a day when under a lot of stress. She could have adjusted her insulin
dosage as needed since she was going to be highly active that weekend with the
tournament. She could have purchased an over-the-counter urine ketone test, that way she
could have easily and effectively tested her urine ketone levels to know if and when they
started to rise.

Cited: Diabeticketoacidosis.(n.d.).RetrievedFebruary18,2016,from
http://www.mayoclinic.org/diseasesconditions/diabetic
ketoacidosis/basics/prevention/con20026470
8. While Susan is being stabilized, Tagamet is being given IV piggyback. What does
IV piggyback mean? What is Tagamet, and why has it been prescribed?
An intravenous (IV) piggyback is a way to administer medication through an intravenous
tube that is inserted into a patient's vein. This can be an antibiotic or another type of
medication that needs to be diluted and administered slowly. The medication in an IV
piggyback is mixed in a small amount of compatible fluid, such as normal saline or
dextrose with saline. Tagamet, also known as cimetidine, is normally used to treat and
prevent symptoms of heartburn. It is being subscribed to Susan because it alternatively
can be used to prevent aspiration pneumonia due to her Kussmaul respirations. It will
also help settle her stomach from the effects of vomiting.
Cited: WhatisanIVPiggyback?(n.d.).RetrievedFebruary18,2016,from
http://www.wisegeek.org/whatisanivpiggyback.htm
Cimetidine.(n.d.).RetrievedFebruary18,2016,from
http://www.everydayhealth.com/drugs/cimetidine
9. The Diabetes Control and Complications Trial was a landmark multicenter trial
designed to test the proposition that complications of diabetes mellitus are related to
elevation of plasma glucose. It is the longest and largest prospective study showing
that lowering blood glucose concentrations slows or prevents development of
complications common to individuals with diabetes. The trial compared intensive
insulin therapy (tight control) with conventional insulin therapy. Define
intensive insulin therapy. Define conventional insulin therapy.
Intensive, or flexible, insulin therapy is the most common form of insulin deliverance. It
requires multiple daily injections of rapid-acting insulin before meals in addition to basal
insulin once daily. The insulin is adjusted to correspond with food intake. Conventional

insulin therapy consists of a premixed of fixed insulin plan. Usually, a prescribed dose of
basal or intermediate-acting insulin is combined with short- or rapid-acting (or bolus)
insulin. This is referred to as mixed dose (Nelms 490).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Endocrine System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 469-520). Boston, MA:
Cengage Learning.
10. List the microvascular and neurologic complications associated with Type 1
diabetes.
Some microvascular complications associated with Type 1 diabetes include retinopathy,
which is the leading cause of blindness in the US, and neuropathy, which affects the
nerves in the legs and feet. It produces a tingling, numbness, and even a pain feeling.
Another microvascular complication is nephropathy kidney disease. A neurologic
complications associated with Type 1 diabetes is peripheral polyneuropathy impaired
sensation and pain in the hands and feet. Autonomic neuropathy and
hyperglycemia/hypoglycemia are also all neurologic complications.
Cited: NeurologicalComplicationsofDiabetes.(n.d.).Retrievedfrom
https://www.uthsc.edu/endocrinology/documents/Haykal_NeurologicalComplicationsofD
iabetes.pdf
Complications.(n.d.).RetrievedFebruary18,2016,from
http://www.diabetesforecast.org/diabetes101/complications.html
11. What are the advantages of intensive insulin therapy?
The advantages of intensive insulin therapy include being able to use syringes, pens, or a
pump to deliver the insulin. The insulin is corresponded to food intake, thus replicating
endogenous insulin secretion in a person without diabetes. This also allows for
adjustment of insulin doses in response to hyperglycemia, variable carbohydrate intake,
or alteration in usual physical activity (Nelms 492). It has also been shown to reduce the

risk of eye damage by more than 75%, reduce the risk of nerve damage by 60%, and
prevent or slow the progression of kidney disease by 50%.
Cited: Diabetes.(n.d.).RetrievedFebruary18,2016,from
http://www.mayoclinic.org/diseasesconditions/diabetes/indepth/intensiveinsulin
therapy/art20043866?pg=2
Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Endocrine System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 469-520). Boston, MA:
Cengage Learning.
12. What are the risks of intensive insulin therapy (tight control)?
Intensive insulin therapy may lead to low blood sugar. When you have tight blood sugar
levels, any change in your daily routine such as exercising more than usual or not
eating enough may cause low blood sugar. It may also cause weight gain. When you
use insulin to lower your blood sugar, the sugar in our bloodstream enters cells in your
body instead of being excreted in your urine. Your body converts the sugar your cells
dont use for energy into fat, which can lead to weight gain.
Cited: Diabetes.(n.d.).RetrievedFebruary18,2016,from
http://www.mayoclinic.org/diseasesconditions/diabetes/indepth/intensiveinsulin
therapy/art20043866?pg=2
13. Dr. Green consults with you, and the two of you decide that Susan would benefit
from insulin pump therapy combined with CHO counting for intensive insulin
therapy. This will give better glycemic control and more flexibility. What are some
of the key characteristics of candidates for intensive insulin therapy?
Important characteristics of candidates for intensive insulin therapy include individuals
with Type 1 diabetes and those willing to take frequent doses of insulin. They should be
able to check blood sugar levels often and be able to closely follow an eating and exercise

plan. It is recommended that older adults follow this plan since it is such an intensive
therapy.
Cited: Diabetes.(n.d.).RetrievedFebruary18,2016,from
http://www.mayoclinic.org/diseasesconditions/diabetes/indepth/intensiveinsulin
therapy/art20043866?pg=2
14. Explain how an insulin pump works. Is Susan a candidate for an insulin pump?
Insulin pumps are approximately the size of pagers and are powered by batteries. Regular
or rapid-acting insulin is delivered at a basal rate and then the individual is able to bolus
additional insulin for meals and snacks. Continuous subcutaneous insulin infusion allows
creation of variable and adjustable insulin dosing to meet specific, individual insulin
needs (Nelms 492). Since Susan needs flexibility in her insulin regimen due to her
activity and stress level, an insulin pump would be a great idea for her. The only thing
that Susan should be cautious about is wearing the pump during volleyball.
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Endocrine System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 469-520). Boston, MA:
Cengage Learning.
15. How would you describe CHO counting to Susan and her family?
I would start by explaining how CHO counting is a new diet plan that Susan must follow
along with her insulin regimen. It focuses on counting the servings of carbohydrates in a
meal rather than counting the source of carbohydrates. It will help Susan calculate how
many servings she needs throughout the day and then be able to evenly distribute them
among her meals and snacks. Knowing this information is also important because it can
allow Susan to better distribute her insulin for better glycemic control. I would then
explain how sources of carbohydrates include starches, fruits, milk/yogurt, and sweets.
One serving of a carbohydrate is equal to 15 grams. I would then teach her and her family
how to properly read a nutrition label in order to accurately be able to tell how many
servings of carbohydrates a specific food contains.

16. How is CHO counting used with intensive insulin therapy?

CHO counting is essential when using a pump with intensive insulin therapy. Individuals
know how many grams/servings of carbohydrates that they are receiving along with their
insulin dosages. It allows their insulin dosages to be more flexible. It also makes it easier
to keep tract of how much insulin the individuals should give themselves at a time.
Cited:OverviewofCarbohydrateCounting.(n.d.).Retrievedfrom
http://www.diabetesinscotland.org.uk/Publications/9224OverviewofCarbohydrate
Counting.pdf
17. Estimate Susans daily energy needs using the Harris-Benedict equation.
Harris-Benedict, women = 655 + (9.56 x wt kg) + (1.85 x ht cm) - (4.68 x age yrs)
REE = 655 + (9.56 x 50 kg) + (1.85 x 160.02 cm) - (4.68 x 16 yrs)
REE = 1354.16 kcal x 2.0 PAL = 2708.32 kcal = 2700 kcal (2650 2750 kcal).
18. Using the 1-week food diary from Susan, calculate the average amount of CHO
usually consumed each meal and snack.
Monday
AM

Lunch

Snack

Dinner

1.5 c Rice Krispies = 30 g

1 c 2% milk = 12 g
1 c orange juice = 30 g
I med. banana = 30 g
6-inch vegetarian pizza =
120 g
1 large apple = 30 g
12 oz diet Coke = 0 g
2 slices whole wheat bread
= 30 g
2 tbsp crunchy PB = 0 g
1 tsp grape jelly = 7 g
12 oz diet Coke = 0 g
3 c cooked spaghetti = 136
g
c sauce = 15 g
2 oz ground beef = 0 g
large tossed salad = 0 g
diet dressing = 5 g

102 g

150 g

37 g

190 g

HS
Tuesday
AM

Lunch

Snack

Dinner
HS
Wednesday
AM
Lunch
Snack
Dinner

HS

12 oz 2% milk = 14 g
2 stalks cooked broccoli = 5
g
6 vanilla wafers = 15 g
c vanilla ice cream = 15 g 15 g
1.5 c Rice Krispies = 30 g
1 c 2% milk = 12 g
1 c orange juice = 30 g
I med. banana = 30 g
1 bun = 30 g
1 slice cheese = 0 g
2 oz beef patty = 0 g
1 oz potato chips = 18 g
12 oz diet Mt. Dew = 0 g
1 med orange = 20 g
6 saltines = 15 g
2 oz Colby jack cheese = 0
g
12 grapes = 15 g
water = 0 g
3 tacos = 23 g
c refried beans = 8 g
1 c 2% milk = 12 g
c orange sherbet = 15 g

102 g

1.5 c Capn Crunch = 45 g

1 c milk 2% = 12 g
1 c orange juice = 30 g
4 tacos = 30 g
12 oz diet Coke = 0 g
6 saltines = 15 g
2 tbsp PB = 0 g
12 oz diet Coke = 0 g
3 oz baked chicken = 0 g
1 large baked potato = 60 g
1 tsp butter = 0 g
1 tsp sour cream = 0 g
1 c green beans = 5 g
2 fig newtons = 15 g
1.5 pz pretzels = 30 g
2 tsp mustard = 0 g
12 oz diet Coke = 0 g

87 g

68 g

30 g

43 g
15 g

30 g
15 g
80 g

30 g

Thursday
AM

Lunch

Snack
Dinner

HS
Friday
AM

Lunch

Snack
Dinner

HS

1.5 c Rice Krispies = 30 g

1 c 2% milk = 12 g
1 c orange juice = 30 g
I med. banana = 30 g
2 slice whole wheat bread =
30 g
3 oz ground beef = 0 g
1 c mashed potatoes = 30 g
c cooked carrots = 0 g
1 c milk 2% = 12 g
c cottage cheese = 0 g
1 c canned peaches = 30 g
3 oz baked pork chops = 0 g
1 large baked potato = 60 g
2 tsp butter = 0 g
large tossed salad = 0 g
diet dressing = 5 g
12 oz milk 2% = 14 g
1 small angel food cake =
30 g
c vanilla ice cream = 15 g

102 g

1.5 c Rice Krispies = 30 g

1 c 2% milk = 12 g
1 c orange juice = 30 g
I med. banana = 30 g
6-inch vegetarian pizza =
120 g
1 large apple = 30 g
12 oz diet Coke = 0 g
2 tbs PB = 0 g
1 English muffin = 30 g
1 c milk 2% = 12 g
3 oz fried fish = 0 g
1 bun = 30 g
baked fries = 15 g
1 c broccoli = 5 g
LF ranch = 5 g
12 oz milk 2% = 14 g
2 fig newtons = 15 g
3 c popcorn = 15 g
12 oz diet Coke = 0 g

102 g

72 g

30 g
109 g

15 g

150 g

42 g
84 g

15 g

Saturday
AM

Lunch

Snack
Dinner

HS
Sunday
AM

Lunch

Snack
Dinner

HS

3 buttermilk pancakes = 45
g
2 tbsp syrup = 30 g
2 tsp butter = 0 g
3 strips bacon = 0 g
1 c milk 2% = 12 g
I c orange juice = 30 g
1 oz cubed ham = 0 g
1 oz cubed cheese = 0 g
1 oz cubed turkey = 0 g
LF ranch = 5 g
12 saltine crackers = 30 g
1 c milk 2% = 12 g
1 large apple = 30 g
1 c ice cream = 30 g
1 slice pizza = 60 g
1 dinner salad = 0 g
1 tsp LF Italian dressing = 5
g
12 oz diet coke = 0 g
3 c popcorn = 15 g
6 oz CF diet Coke = 0 g

117 g

1 slice French toast = 15 g

2 tbsp syrup = 30 g
1 c milk 2% = 12 g
1 c orange juice = 30 g
c strawberries = 5 g
3 oz fried chicken = 0 g
1 c potatoes = 30 g
1 tbsp gravy = 0 g
1 c milk 2% = 12 g
1 c cooked carrots = 5 g
1 small angel food cake =
30 g
1 med banana = 30 g
2 oz sliced beef = 0 g
I bun = 30 g
2 oz potato chips = 30 g
1 dill pickle = 0 g
12 oz diet Coke = 0 g
3 c popcorn = 15 g
6 oz diet Coke = 0 g

92 g

77 g

30 g
65 g

15 g

77 g

30 g
60 g

15 g

Average amount of CHO for

Breakfast: 100 grams
Lunch: 89 grams
Snack: 31 grams
Dinner: 90 grams
HS: 17 grams

19. After you have calculated Susans usual CHO intake from her food record,
develop a CHO-counting meal plan that she could use. Include menu ideas.
Since Susans caloric allowance each day is 2650-2750 kcal, she will receive 55% of her
daily calorie needs from carbohydrates, 20% from protein, and 25% from fat. Based on
these percentages, here are her daily allowances:
CHO 2650 2750 x 0.55 = 1458 1513 kcal / 4kcal/g = 365 - 378 grams
PRO 2650 2750 x 0.20 = 530 550 kcal / 4kcal/g = 133 138 grams
FAT 2650 2750 x 0.25 = 663 688 kcal / 9kcal/g = 74 76 grams
365 378 grams of CHO / 15 grams per serving 24 25 servings of CHO/day
Time
Breakfast
7:30-8:00 AM

CHO servings
7

Lunch
11:30-12:00 pm

Snack
2:30-3:00 pm
Dinner
5:30-6:00 pm

3
6

Menu Ideas
1 cup oatmeal (2)
cup strawberries (1)
2 slice wheat toast (2)
1 tsp butter
1 cup milk 2% (1)
1 tbsp brown sugar (1)
2 slices wheat bread (2)
3 oz deli ham
1 oz cheese
1 banana (1)
1 cup milk 2% (1)
1 cup yogurt (1)
cup granola (1)
1 apple (1)
10 crackers (2)
1 cup pasta (3)
1 cup cooked broccoli (1)
cup apple juice (1)

HS
8:00-8:30 pm

1 wheat roll (1)

cup pasta sauce (1)
1/3 cup hummus (1)
1 cup carrots (0.5)
1 cup milk 2% (1)

20. Just before Susan is discharged, her mother asks you My friend who owns a
health food store told me that Susan should use stevia instead of artificial sweeteners
or sugar. What do you think? What will you tell Susan and her mother?
Stevia is a highly purified product that comes from the stevia plant and is several hundred
times sweeter than sugar. According to the US Food and Drug Administration (FDA), it is
generally recognized as safe as a food addictive and table-top sweetener. This means that
experts have agreed that it is safe for use by the public in appropriate amounts. So, I
would tell Susan and her mother that stevia is fine to use in the correct amount.
Cited:LowCalorieSweeteners.(n.d.).RetrievedFebruary18,2016,from
http://www.diabetes.org/foodandfitness/food/whatcanieat/understanding
carbohydrates/artificialsweeteners/?referrer=https://www.google.com/

References:
Cimetidine. (n.d.). Retrieved February 18, 2016, from
http://www.everydayhealth.com/drugs/cimetidine
Complications. (n.d.). Retrieved February 18, 2016, from
http://www.diabetesforecast.org/diabetes-101/complications.html
Diabetes. (n.d.). Retrieved February 18, 2016, from http://www.mayoclinic.org/diseasesconditions/diabetes/in-depth/intensive-insulin-therapy/art-20043866?pg=2
Diabetic Ketoacidosis | Causes & Risk Factors. (n.d.). Retrieved February 18, 2016, from
http://familydoctor.org/familydoctor/en/diseases-conditions/diabeticketoacidosis/causes-risk-factors.html
Diabetic ketoacidosis. (n.d.). Retrieved February 18, 2016, from
http://www.mayoclinic.org/diseases-conditions/diabeticketoacidosis/basics/prevention/con-20026470
Low-Calorie Sweeteners. (n.d.). Retrieved February 18, 2016, from
http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understandingcarbohydrates/artificial-sweeteners/?referrer=https://www.google.com/
Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Endocrine System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 469-520). Boston, MA:
Cengage Learning.
Neurological Complications of Diabetes. (n.d.). Retrieved from
https://www.uthsc.edu/endocrinology/documents/Haykal_NeurologicalComplicatio
nsofDiabetes.pdf
Overview of Carbohydrate Counting. (n.d.). Retrieved from
http://www.diabetesinscotland.org.uk/Publications/9224 Overview of Carbohydrate
Counting.pdf
What is an IV Piggyback? (n.d.). Retrieved February 18, 2016, from
http://www.wisegeek.org/what-is-an-iv-piggyback.htm