Patrick Burrows

KNH 413
Prof. Matuszak
2/18/16

Type 1 Diabetes Mellitus with Diabetic Ketoacidosis

1. There are precipitating factors for diabetic ketoacidosis.

List at least seven possible factors.

Precipitating factors for DKA are an illness, a problem with insulin

therapy, physical trauma, emotional trauma, heart attack,
alcohol abuse, drug abuse, and medication reactions (Diabetic
ketoacidosis).
2. Describe the metabolic events that led up to the
symptoms associated with DKA.

Due to the lack of insulin, caused by decreased pancreas

function, which causes decreased glucose uptake. This state of
being also promotes lipolysis and fatty acid oxidation. Ketonemia
is caused as blood concentrations of acids rise. As the
concentrations overpower the bodies natural buffering system
the ketones overflow into the urine. If this is left untreated the

body goes into metabolic acidosis. Hyperglycemia often exceeds

the renal ability for glucose absorption. As water loss in the urine
is increased the patient will experience dehydration, vomiting,
thirst, and altered mental status (Metabolic Acidosis).

3. Assess Susans physical examination. What is consistent

with diabetic ketoacidosis? Give the physiological
rationale for each that you identify.

Susan is exhibiting tachycardia, which is a symptom of

dehydration caused by the mass fluid loss. Susan is also irritable
and lethargic, which are caused by the hyperglycemia causing an
altered mental status. Susan is also exhibiting Kussmauls
respirations and that is a sign that the body is trying to cope with
the metabolic acidosis caused by the high concentration of
ketones in the blood.

4. Examine Susans biochemical indices both in the

chemistry section and in her ABG report. Which are
consistent with DKA? Why?

When assessing Susans lab values it was noted that her BGL
level was high and her CO2 level was low. Her BGL was very high

and it is due to the fact that the body is unable to cope with the
concentration of BGL since the cells are not uptaking glucose.
The low CO2 level is associated with her Kussmaul respirations as
the body is trying to cope with acidosis.

5. If Susans symptoms were left untreated, what would

happen?

Due to increased blood glucose concentration, because the

pancreas is not producing insulin, Susan would begin to
experience many complications that would ultimately end in a
comatose state followed by death. Some of the complications
that she will endure prior to death are ketonemia, frequent
urination, metabolic acidosis, severe dehydration, thirst,
vomiting, altered mental status, and electrolyte imbalance
(Metabolic Acidosis).

6. Assuming Susans SMBG records are correct, what events

seem to have precipitated the development of DKA?

It appears that Susans recorded SMBG values increased as she

began her period and remained on the rise after her period. Her

eating habits on her birthday may have also attributed to her

chronically high BGL.

7. What, if anything, could Susan have done to avoid DKA?

To avoid DKA Susan could have checked her blood glucose level
more often so that she would know if she was running at a high
level or not. She also could have worked with her doctor to
change up her insulin regimen so that her blood glucose level
was more stable. Risk for DKA is also increased with emotional
stress so it is possible that her DKA was out of her realm of
control (505).

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 IV piggyback is placed above the main infusion fluid and is set

up this way so that when it is time for the piggyback medication
to be given, the flow from the main fluid is stopped and the
piggyback medication is given (What is an IV Piggyback?).
Tagamet is a H2 blocker, which means that it blocks the
production of acid in the stomach. She was prescribed this

because she complained of abdominal tenderness accompanied

with guarding when assessed (Cimetidine, Tagamet).

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 insulin therapy is where basal insulin is given with one

or two long acting insulin injections. Along with this, rapid acting
insulin is given prior to meals and snacks. This method allows
more flexibility with meal timing nad the rapid acting insulin can
be increased or decreased based on meal composition.
Conventional insulin therapy is broken down into two therapy
regimens. In one regime rapid acting insulin is mixed with
intermediate acting insulin and is administered prior to breakfast

and an evening meal. In the second option rapid acting insulin is

given with intermediate acting insulin before breakfast, rapid
acting insulin is given before dinner, and intermediate acting
insulin is given at bedtime (492).

10.

List the microvascular and neurologic complications

associated with Type 1 diabetes.

Diabetes mellitus is the single leading cause of kidney failure.

This nephropathy results from hyperglycemia changing the
structure of the blood vessels of the glomerulus. The change that
hyperglycemia causes is increased permeability of the structure,
which decreases filtering ability. Retinopathy is another
microvascular complication that occurs due to Type 1 diabetes.
The exact cause in its association to diabetes is unclear but it
appears that the blood vessels are altered by hyperglycemic
damage. There is a strong association with retinopathy and the
duration of diabetes. Chronic hyperglycemia also leads to
neurologic damage. Type 1 diabetics can have a range of
damage to different areas of the body such as impaired
sensation in the feet or hands, slowed digestion of food in the
stomach, carpal tunnel syndrome, impaired wound healing,
motor dysfunction, and bone fractures. This cellular damage to

the neurologic cells is caused by accumulation of sorbitol and

glycated proteins (507-508).

11.

What are the advantages of intensive insulin

therapy?

Intensive insulin therapy delays the onset and slows progression

of diabetic related neuropathy, nephropathy, and retinopathy.
This type of insulin therapy also allows patients the ability to step
outside of their normal meal plan and adjust their insulin dosages
appropriately. This type of therapy also replicated insulin
secretion of someone who does not have diabetes (491-492).

12.

What are the risks of intensive insulin therapy (tight

control)?

Running this tight of an insulin regimen possesses some risks

when a patient deviates from their normal routine. It is possible
that if someone who is on intensive insulin therapy exercises too
little or too much they may end up with hypoglycemia. Other
deviations from the normal daily routine and other metabolic
stressors can also cause hypoglycemia. Another risk is weight
gain due to the fact that when using insulin to lower your blood

sugar, the sugar that is in your blood stream enters the cells and
is not excreted via urine. Your body then converts these excess
sugars into fats, which is then stored (Diabetes).

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?

Some of the key characteristics are the ability to count

carbohydrates, patient willing to test blood glucose levels
multiple times a day, some one without heart disease, eager to
learn and tightly control their diabetes, and a patient that is
mentally competent and aware enough to keep track of their BGL
and provided various doses of insulin to themselves (How Do
Insulin Pumps Work?). Susan is a good candidate because she is
young and doing an intensive treatment plan will help her not
have as many complications associated with DM in the future.
Additionally her previous method of doing split doses was not
working effectively.

14.

Explain how an insulin pump works. Is Susan a

candidate for an insulin pump?

Insulin pumps work by providing someone with rapid or short

acting insulin 24 hours a day. The insulin is delivered through a
catheter that is placed in a pump site under the skin. The
insulin doses are separated into basal rates, bolus doses to cover
carbohydrates in meals, and correction or supplemental doses.
The pump is a device that attaches to the pump site and is
controlled by the user. The pump allows for the user to maintain
better control of their blood glucose level. Susan is a candidate
for an insulin pump because she is young and the pump reduces
the symptoms that accompany daily injections since she will be
using insulin for the rest of her life (How Do Insulin Pumps
Work?).

15.

How would you describe CHO counting to Susan and

her family?

I would begin by explaining the rationale for CHO counting to

Susan and her family. I would tell them that the basis of the idea
is a meal planning approach that concentrates on the total
amount of CHO consumed at meals and snacks. I would also be

sure to tell them that the process is based on research that

shows that monitoring CHO intake is a significant method in
glycemic control. I would tell them that based on the AMDR for
Susan approximately 55% of her calories will need to come from
CHO. I would then multiply 1300(her daily energy need) by 0.55
and get a result of 715. I would then divide that result by 4 and
determine that Susan will eat approximately 178g CHO daily. This
daily total will be divided by choices, which are 15g of CHO, and
the result is 12 CHO choices per day. This will then be divided
between 3 meals and 3 snacks meaning Susan will be allowed 2
CHO choices per meal. Susan will then provided 1 unit of insulin
per choice of CHO, which means that she will give herself 2 units
per meal or snack. If Susan tests her BGL post meal and it is
above 150mg/dL she will need to provide herself with an
additional dose of insulin called correction factor. She will need to
provide herself with 1 unit of insulin for every 50mg/dL that she
is over 150mg/dL. If BGL levels are over 300mg/dL Susan will
require and additional 4 units of insulin. I would make sure that
Susan understood this and possibly quiz her by asking her how
much insulin she would give herself in each meal in her meal
plan to make sure she does not under or overdose herself (502).

16.

How is CHO counting used with intensive insulin

therapy?

CHO counting is used to determine the amount of insulin that a

patient is supposed to dose themselves with after consuming
CHO. The ratio used for dosing is 1 unit of insulin for every 1015g of CHO that is consumed (502).

17.

Estimate Susans daily energy needs using the

Harris-Benedict equation.

BMR= 655.1+(9.563x50)+(1.850x160.02)(6.676x16)=1322.47x2=2644.94
Susans daily energy needs are approximately 2600-2700
calories/day.

18.

Using the 1-week food diary from Susan, calculate

the average amount of CHO usually consumed each meal

and snack.

According to SuperTracker:

100g CHO breakfast

60g CHO lunch

30g CHO snack
75g CHO dinner
45g CHO HS

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.
Meal
Breakfast

Macronutrients
3 CHO choices
1 oz protein
1-2 servings of fat

Lunch

3 CHO choices
2 oz protein
1-2 servings fat

Snack

2 CHO choices

Dinner

3 CHO choices
3 oz protein
1-2 servings fat

HS

1 CHO choice

20.

Food Ideas
1 cup cereal with cup 2%
milk, serving fruit with 1 T
peanut butter or other
source of fat
Deli sandwich on 2 pieces of
whole wheat bread, 1
serving of fruit, 1 oz baby
carrots, 2 T salad dressing
1 oz pretzels with 1 T peanut
butter
3 oz chicken breast- grilled,
salad with dressing, 1 sweet
potato or 1 slice of bread, 1
8-oz glass of 2% milk
1 serving of fruit or cup of
ice cream

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?

I would tell Susan and her mother that Stevia could be used as
an alternative for sugar when necessary. I would educate them
on what Stevia is by telling them that it is Reb-A and is a highly
purified substance that comes from a Stevia plant. Reb-A is
recognized by the FDA as safe, but this does not make it a better
option than other low calorie sweeteners (Low-Calorie
Sweeteners).

References
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Diabetic ketoacidosis. (n.d.). Retrieved February 16, 2016, from
http://www.mayoclinic.org/diseases-conditions/diabeticketoacidosis/basics/causes/con-20026470

How Do Insulin Pumps Work? (n.d.). Retrieved February 12, 2016, from
http://www.diabetes.org/living-with-diabetes/treatment-andcare/medication/insulin/how-do-insulin-pumps-work.html
Insulin Pumps in Diabetes Management. (n.d.). Retrieved February 14,
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http://www.todaysdietitian.com/newarchives/021313p50.shtml
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Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.).
Belmont, CA: Wadsworth, Cengage Learning.
Metabolic Acidosis, DKA: Acid Base Tutorial, University of Connecticut
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an intravenous piggy back?