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Student’s Name: Laryssa Grguric Patient/Client’s Initials: W.H.

Date: 02/04/14

ASSESSMENT:

S: Pt. Went to ED of NUMC after experiencing blurry vision during the Super Bowl game. Pt. had
previously “weaned” himself off of insulin and was insulin free x1 year (primary MD aware per pt.) Due
to blurry vision, pt. checked his FSBG and monitor registered ~500 mg/dL. Pt. then used “leftover insulin”
and gave himself 10U of insulin to attempt to lower blood sugar so he could finish watching the game. BG
did not improve even though he “only ate salad” after administering insulin. Pt. also experienced nausea &
vomitting PTA but it has since subsided. Pt reports his UBW is within the 140s.

O: 45 y/o ! c " admitting Dx of hyperglycemia. Ht. 74” Wt. 108.6 kg/239# BMI 31.1 kg/m
2
. Previous
admission wt (11/2011): 267#. PMH TIA x 2, HTN, DM type 2, dyslipidemia, GERD. Biochemical data
assessment shows ! FSBG 2/2: >600 (admission), 2/4: 336, 116, 317, ! chol 240, !TG 285, " HDL 32,
!LDL 156. Hemoglobin A1c 11.1%.

Ht. Current Wt UBW/%UBW IBW range /%IBW BMI
74” 239# (2/2) 240s/100% 158.4-193.6#/136% 30.7


Estimated energy needs (note equation used):
Adj BW= 199.9#
MSJ 2° to obesity (BMI 31.1) using Adj BW, SF 1.2-1.3:
2224-2409 kcal/day
Estimated protein needs (note g/kg):
1.0-1.2 g/kg
31.1-37.32 g/day
Other nutrient needs: N/A Fluid needs: 35-40 mL/kg
1088.5-1244 mL/day

Diet History (24 recall):
Diet hx obtained in hospital:
Dinner: ~50% vegetable soup, 75% jerk chicken, 100% mashed potato c " gravy, 0% collard greens (due to
GERD sx), 100% pound cake dessert

Breakfast: 1 apple, 100% grits, 1 hardboiled egg – pt. reported being hungry after breakfast.

Lunch (observed at bedside): ~50% split pea soup, ~50% lasagna (due to pasta sauce causing GERD Sx),
0% spinach (due to GERD Sx), 100% pineapple fruit cup

Evaluation of Diet History (brief, e.g., limited in calcium and vitamin D, consumes ! amount of sugar, etc.)
Pt. avoids foods that can cause GERD sx (obtained prefs related to GERD and relayed information to
kitchen).

PTA pt. reports following a “regular” diet but told me he watches his diet to control BG (does not want to
be on insulin) – may be contradictive statement. Pt. is aware of DM diet and has received prior education
but speaking with pt. it appears DM diet is followed loosely.
Pt. reports adding extra fruit and avoiding sweets/soda in his diet. Pt. also chooses to bake foods vs. fry.
Recall of "usual" foods reveal a lot of carbohydrate rich foods such as breads, pasta, starchy vegetables, etc.
Pt. did not seem aware of portion control when discussed.

Physical Activity (describe patient’s physical activity): Low active; pt. reports wt. gain s/p TIA but he is
slowly increasing activity

Diet Order:
Intake approximately 75% at meals / observed at lunch, per pt.


Pertinent lab values (Date, # or $; why you think it may be high or low)
! FSBG 2/2: >600 (admission), 2/4: 336, 116, 317, ! chol 240, !TG 285, " HDL 32, !LDL 156.
Hemoglobin A1c 11.1%.
2/3: BUN 10 WNL, Creat 0.8 WNL

FSBG & A1c reveals uncontrolled DM possibly 2° to d/c insulin & metformin and non-compliance to DM
diet.
TG levels may be related to uncontrolled DM, chol (HDL, LDL) may be related to

Nutritional Risk Factors (GI, chewing/swallowing difficulties, etc.)
N/A; pt. has good appetite and PO intake is %75%

Usual Meds or Dietary supplements; implications/pertinent side effects

Pt. has weaned himself off of insulin @ home but takes Metformin, Norvasc & Crestor

Medications in Hospital –
Medication Implications/Pertinent Side Effects
Humalog
Levemir
Norvasc
Crestor
Metformin

Food allergies: Shellfish
Food intolerances: Pasta sauce, collard greens, spinach (other dark leafy greens) due to GERD
Stage of Change: Contemplation: pt. aware diet can affect DM but not motivated to change at this point.
Other Comments: Current diet Rx DM 1800 kcal – recommend changing diet to 2000 kcal, " na, " chol,
" fat plus addition of HS snack (1/2 sandwich – turkey/tuna) due to pt. reports of hunger & calculated EEN.


NUTRITION DIAGNOSIS(ES):

Problem Etiology (related to) Signs and Symptoms (as evidenced by)

P-E-S Statements:
Excessive carbohydrate intake related to food and nutrition compliance limitations evidenced by !
hemoglobin A1C of 11.1%, ! FSBG >120 mg/dL and verbalization of incomplete knowledge during
interview c " pt.

Limited adherence to nutrition-related recommendations related to food and nutrition related knowledge
deficit concerning how to make nutrition-related changes evidenced by expected laboratory outcomes not
achieved (A1c 11.1%), inability to recall DM diet, uncertainty as to how to consistently apply
food/nutrition information and lack of appreciation of the importance of making recommended nutrition-
related changes.
*Chosen due to RD’s note in chart indicating that pt received “extensive nutrition education regarding DM
diet”. This is also the 2
nd
time pt. has been admitted to NUMC from ED for hyperglycemia. Pt. also
disclosed, “he would rather die” than miss the Super Bowl.

INTERVENTIONS (Food/and/or Nutrient Delivery; Nutrition Education; Nutrition Counseling;
Coordination of Nutrition Care)*

GOALS PLANS
Weight reduction 1# per week towards 215# (10%
wt. loss, BMI of 27.6).
• Educate pt. on portion control (using DM
exchanges) – 2000kcal diet pattern
• Educate pt. on label reading – make pt. aware
of serving sizes on label
• Educate pt. on how wt. loss can benefit DM
To improve HbA1c of 11.1% towards 7%. • Educate pt. to engage in carbohydrate counting
using DM exchanges (2000kcal diet pattern)
• Educate on proper snacking, meals for ! BG
levels
• Encourage pt. to continue to engage in self-
monitoring of blood glucose levels (pt. has
monitor @ home).
• Recommend MD to discuss continuance of DM
diet education for pt. in NUMC Outpatient
Diabetes Clinic.

Using the Evidence Analysis Library – evaluate one of your interventions and note the evidence for your
intervention.

SMBG is shown to be effective in improving HbA1c if subjects are aware of how to use the information to
make changes in their diabetes management (Grade II). H.W. has a blood glucose monitor at home but was
not aware of how helpful it can be in the management of diabetes. During education, we discussed how to
test blood sugars pre and post meals to see how the meals/certain foods affect the blood sugar level. I
encouraged H.W. to become a “detective” by keeping a log of foods and BG. I told H.W. this can help him
to become more hands on in his diabetic treatments (since his previous self-weaning of insulin indicates he
wants to be more in control of his disease). I wondered if he had self-weaned off of insulin because he did
not like needles but when asked the patient said he had no problem. Therefore, I think with this new
reinforcement and knowledge (including portion control), H.W. will be successful and have a more
managable HbA1c (~7%) in the near future. I have encouraged him to utilize the outpatient clinic at
NUMC for follow up.



MONITORING: # all that apply

___X_Weight __X___food intake at meals __N/A___supplement intake

__X___Labs (specify): FSBG to access DM control, BUN/Creat to access renal sufficency