Last Name _______________Soper____________ First Name____________Tess_________

Diabetes Mellitus
DUE Wednesday 12/17/14 (by 4:00 pm in Meyer 3241)

Pt. Summary: Mr. B is a 48-yo Native American man admitted from the ER to the endocrinology
service.
Hx:
Onset of disease: pt transported to ER when found ill in his house by his wife. During ER assessment, pt
was noted to have a S. glucose of 610 mg/dL. Mr. B was diagnosed with T2DM one year ago and has
been on metformin since that dx. He does not take the medication regularly as he felt it really wasn’t
necessary.
Medical hx: product of nl pregnancy and delivery; NKA
Surgical hx: none
Tobacco use: Smoked 1 ppd x 10 years (no longer smokes)
Alcohol use: occasional
FH: Father – MI; mother – ovarian CA, T2DM
Demographics:
Social hx: married, 3 children, works driving trucks
Years education: 12
Language: English & O'odham
Ethnicity: Pima Native American
Religious affiliation: Catholic

Admitting Hx/PE:
Chief complaint: Wife states that Mr. B had not been feeling well the previous day. He thought he was
fighting off a virus. When he didn’t answer the phone this morning, his wife went to check on him and
found him groggy and almost unconscious at home. She called 911 and the pt was transported to
University Hospital.
General appearance: Slim male, in obvious distress.
no
General: WDWN 48 yo male; 5’10” 160#
Vitals: T 99.6°F; P 100; RR 24; BP 100/78 mm Hg
Chest/Lungs: Respirations are rapid – clear to percussion and auscultation
Heart: Tachycardia
HEENT: Head: WNL, Eyes: PERRLA, Ears: clear, Nose: clear, Throat: dry mucous
membranes w/o exudates or lesions
Abdomen: Active bowel sounds x4; tender, non-distended
Extremities: +4 ROM; DTR 2+
Neurologic: Lethargic but able to arouse. Follows commands appropriately. Glasgow Coma
Scale: 13.
Skin: Smooth, warm, dry, no edema
Peripheral Pulse 4+ bilaterally, warm, no edema
Vascular:
Genitalia: Deferred

Admission Orders:
1. Regular insulin 1 unit/mL in NS 40mEq KCl/liter @ 300 mL/hr. Begin infusion at 0.1 unit/kg/hr =
3.7 units/hr and increase to 5 units/hr. Flush new IV tubing with 50mL of insulin drip solution prior
to connecting to pt and starting insulin infusion.
2. Labs: stat
3. NPO except for ice chips and medications. After 12 hours, clear liquids when stable. Then
advance to consistent CHO diet order: 70-80g breakfast and lunch; 85-95 g dinner; 30 g snack pm
and HS.

1
 4. Consult diabetes education team for self-management training to begin education after stabilized.

Nursing Assessment:
12/9/14
Abdominal appearance (concave, flat, rounded, obese, distended) Flat
Palpation of abdomen (soft, rigid, firm, masses, tense) Tense w/ guarding
Bowel function (continent, incontinent, flatulence, no stool) continent
Bowel sounds (P=present, AB=absent, hypo, hyper)
RUQ P
LUQ P
RLQ P
LLQ P
Stool color Light brown
Stool consistency Soft
Tubes/ostomies NA
Genitourinary
Urinary continence Catheter in place
Urine source Clean specimen
Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, Cloudy, amber
blue, tea)
Integumentary
Skin color Pale
Skin temperature (DI=diaphoretic, W=warm, dry, DL=cool, DI; CLM
CLM=clammy, CD+=cold,
M=moise, H=hot)
Skin turgor (good, fair, poor, TENT=tenting) Fair
Skin condition (intact, EC=ecchymosis, A=abrasions, P=petechiae, Intact
R=rash, W=weeping,
S=sloughing, D=dryness, EX=excoriated, T=tears, SE=subcutaneous
emphysema, B=blisters,
V=vesicles, N=necrosis)
Mucous membranes (intact, EC=ecchymosis, A=abrasions, P=petechiae, Intact
R=rash, W=weeping,
S=sloughing, D=dryness, EX=excoriated, T=tears, SE=subcutaneous
emphysema, B=blisters,
V=vesicles, N=necrosis)
Other components of Braden Scale: special bed, sensory pressure, 20
moisture, activity, friction/shear (>18=no risk, 15-16=low risk, 13-
14=moderate risk, <12=high risk)

Nutrition:
Meal type: NPO then progress to clear liquids and then consistent CHO-controlled diet
Fluid requirement: 2200mL
Hx: Does not follow traditional tribal eating pattern, with a few exceptions; likes fry bread and prepares
wojapi seasonally. Pt does not tolerate milk and only eats cheese when obtained through government
commodities. Fresh vegetables are grown at home: squash, peppers, beans, corn, and some greens. There
is very little fruit in his diet and meat is only eaten at dinner.
Usual intake (for past several months):
AM: toast, jelly, coffee, scrambled egg, juice
Lunch: soup or stew or corn tortillas with cheese
Dinner: Wife usually cooks rice or cornmeal, some type of meat (pork, beef, poultry, venison),
vegetables, cornbread or fry bread.

MD Progress Note:
2
12/9/14 07:00
Subjective: Mr. B previous 24 hours reviewed. Previously diagnosed with T2DM; treated with metformin
but appears to not have taken it regularly.
Vitals: Temp: 99.5, Pulse: 82, RR: 25, BP 101/78
Urine Output: 2660 mL (71.8mL/kg)
PE: General: Alert and oriented to person, place, time
HEENT: WNL
Neck: WNL
Heart: WNL
Lungs: Clear to auscultation
Abdomen: Active bowel sounds
Assessment: Results: + ICA, GADA, IAA consistent with T1DM. Negative c-peptide.
Dx: T1DM
Plan: Begin Novolog 0.5 u every 2 hour until glucose is 150-200 mg/dL. Tonight begin Glargine 15 u
at 9 pm. Progress Novolog using ICR 1:15. Continue bedside glucose checks hourly. Notify MD if BG>
200 or < 80. RDN consult on SMBG.
C. Johnston, MD

Intake/Output
Date 12/9/14 0701 – 12/10/14 0700
Time 07001-1500 1501-2300 2301-0700 Daily Total
P.O. NPO NPO 720 720
I.V. 2,400 2,400 2,400 7,200
(mL/kg/hr) (4) (4) (4) (4)
IN I.V. piggyback 0 0 0 0
TPN 0 0 0 0
Total itake 2,400 2,400 3,120 7,920
(mL/kg) (32) (32) (41.6) (105.6)
Urine 2,150 2,671 3,000 7,821
(mL/kg/h) (3.58) (4.45) (5) (4.34)
Emesis output 150 0 0 150
OUT Other 0 0 0 0
Stool 0 x1 0 x1
Total output 2,300 2,671 3,000 7,971
(mL/kg) (30.7) (35.6) (40) (106.3)
Net I/O + 100 -271 +120 -51
Net since admission (12/9) + 100 -271 +120 -51

Laboratory Results
Ref. Range 12/9/14 1780
Chemistry
Sodium (mEq/L) 136-145 130 ! ê
Potassium (mEq/L) 3.5-5.5 3.6
Chloride (mEq/L) 95/105 101
Carbon dioxide (CO2, mEq/L) 23-30 31 ! é
BUN (mg/dL) 8-18 18
Creatinine serum (mg/dL) 0.6-1.2 1.1
Glucose (mg/dL) 70-110 683 ! é
Phosphate, inorganic (mg/dL) 2.3-4.7 2.1 ! ê
3
Magnesium (mg/dL) 1.8-3 1.9
Calcium (mg/dL) 9-11 10
Osmolality (mmol/kg/H2O) 285-295 306 ! é
Bilirubin total (mg/dL) ≤1.5 0.2
Bilirubin, direct (mg/dL) <0.3 0.01
Protein, total (g/dL) 6-8 6.9
Albumin (g/dL) 3.5-5 4.4
Prealbumin (mg/dL) 16-35 32
Ammonia (NH3, umol/L) 9-33 9
Alkaline phosphatae (U/L) 30-120 110
ALT (U/L) 4-36 6.2
AST (U/L) 0-35 21
CPK (U/L) 30-135 F 61
55-170 M
Lactate dehydrogenase (U/L) 208-378 229
Cholesterol (mg/dL) 120-199 210 ! é
Triglycerides (mg/dL) 35-135 F 175 ! é
40-160 M
T4 (ug/dL) 4-12 8
T3 (ug/dL) 75-98 81
HbA1C (%) 3.9-5.2 12.5 ! é
C-peptide (ng/mL) 0.51-2.72 0.09 ! ê
ICA - + !é
GADA - + !é
IA-2A - -
IAA - + !é
tTG - -
Hematology
WBC (x 103/mm3) 4.8-11.8 10.6
RBC (x 106/mm3) 4.2-5.4 F 5.8
4.5-6.2 M
Urinalysis
Collection method - Catheter
Color - Yellow
Appearance - clear
Specific Gravity 1.003-1.030 1.008
pH 5-7 4.9 ! ê
Protein (mg/dL) Neg +1 ! é
Glucose (mg/dL) Neg +3 ! é
Ketones Neg +4 !é
Blood Neg Neg
Bilirubin Neg Neg
Nitrites Neg Neg
Urobilinogen (EU/dL) <1.1 Neg
Leukocyte esterase Neg Neg
Protein check Neg tr ! é
WBCs (/HPF) 0-5 0
RBCs (/HPF) 0-5 0
Bacteria 0 0
Mucus 0 0
Crys 0 0
Casts (/LPF) 0 0
Yeast 0 0
4
Arterial Blood Gases (ABGs)
pH 7.35-7.45 7.31 ! ê
pCO2 (mm Hg) 35-45 35
SO2 (%) ≥95 97
CO2 content (mmol/L) 25-30 28
O2 content (%) 15-22 21
pO2 (mm Hg) ≥80 89
Base excess (mEq/L) >3 -
Base deficit (mEq/L) <3 -
HCO3- (mEq/L) 24-28 22 ! ê
COHb (%) <2 1.1

5
1. What are the differences between T1DM and T2DM? Explain the pathophysiology, dx, and
treatment of each. (4 pts)
NTP p.489-499, Diabetes Lecture
Type 1 diabetes: T1DM occurs when the beta cells of the pancreas no longer make insulin because
the body’s immune system has attacked and destroyed them. T1DM is an autoimmune disease which
causes the lack of insulin production. T1DM Diagnosis is based on one of the following- casual (non-
fasting) plasma glucose > 200 mg/dl + symptoms of uncontrolled diabetes, fasting plasma glucose
>126 mg/dl, or a 2-hour post-prandial glucose>200mg/dl during an oral glucose tolerance test
(OGTT). As compared to type 2 diabetes, the presence of islet cell cytoplasmic autoantibodies (ICA),
glutamic acid decarboxylase autoantibodies (GADA), insulinoma-2-associated autoantibodies (IA-
2A), insulin autoantibodies (IAA) and/or zinc transporter 8 autoantibodies (ZnT8A) in the serum of
patients who have been biochemically diagnosed with diabetes mellitus indicates the presence of
T1DM. Symptoms of uncontrolled diabetes include for T1DM in particular- weight loss, nausea and
vomiting, and ketoacidosis. Other symptoms of uncontrolled diabetes include polyuria, polyphagia,
polydipsia, blurry vision, feeling tired, slow healing of cuts and wounds, and more frequent
infections. It is usually diagnosed in childhood with a rapid onset. Treatment includes diet, physical
activity, and insulin. People with T1DM must take insulin to live.

NTP p.498-500, Diabetes Lecture

Type 2 diabetes: T2DM occurs with insulin resistance in peripheral tissues (muscle, liver, and fat)
when cells do not use insulin properly. The body then needs more insulin to help glucose enter cells
for energy, but the pancreas beta cells loose the ability to produce enough insulin overtime, and blood
glucose levels rise. Altered adipocyte biology occurs and this type of diabetes is typically diagnosed
in adulthood at middle age or later, and is associated with overweight and obesity, and may have
genetic contribution. Testing is done with people who have BMI’s greater than 25 and have any of
these symptoms: have low HDL (<35mg/dl), are hypertensive (greater than or equal to 140/90mmHG,
have a history of vascular disease, have other clinical conditions associated with insulin resistance,
had IFT of IFG on previous testing, have a first degree relative with diabetes, are physically inactive
or are members of a high risk community. Diagnosis is based on one of the following- casual (non-
fasting) plasma glucose > 200 mg/dl + symptoms of uncontrolled diabetes, fasting plasma glucose
>126 mg/dl, or a 2-hour post-prandial glucose>200mg/dl during an oral glucose tolerance test
(OGTT). HbA1c can also be taken into consideration as it measures the blood glucose levels
overtime. Treatment includes diet, physical activity, pills and/or insulin as needed.

2. Why do you think Mr. B was originally diagnosed with T2DM? Why does the MD now state
that he has T1DM? (2 pts)
Mr. B was originally diagnosed with T2DM. This is most likely because he is an adult and T2DM is
normally diagnosed in adults while T1DM is diagnosed when young, due to T1DM symptoms
including weight loss, nausea and vomiting, and ketoacidosis. Mr.B was also put on metformin
when diagnosed which means that he had high blood sugar levels and needed help in controlling
them. His mother was also diagnosed with T2DM. The MD now states that he has T1DM due to
his assessment results of islet cell cytoplasmic autoantibodies (ICA), glutamic acid decarboxylase
autoantibodies (GADA), insulin autoantibodies (IAA in the serum of patient, which indicates the
presence of T1DM. He also has high hbA1C levels at 12.5 percent, where normal is less than 7
percent. He had T1DM all along, but due to his mother’s T2DM, and his older age he was
overlooked and diagnosed with T2DM.

3. Describe the metabolic events that led to Mr. B’s symptoms and subsequent admission to the
ER (polyuria, polydipsia, polyphagia, fatigue, and weight loss), integrating the pathophysiology
of T1DM into your discussion. (2 pts)

6
 NTP p.483, 485, 499,

The metabolic events that led to Mr. B’s symptoms and subsequent admission to the ER include
weight loss, fatigue, polyuria, polydipsia, and polyphagia. His weight loss occurred due to having
T1DM, and loss of sugar in the urine, which means a loss of calories; many people with high sugars
lose weight. T1DM also causes insufficient insulin that prevents the body from getting glucose from
the blood into the body's cells to use as energy which causes the body to start burning fat and muscle
for energy, causing a reduction in overall body weight. As Mr.B’s T1DM was uncontrolled and his
blood glucose levels remained very high, glucose form the blood could not enter the cells due to lack
of insulin, and his body could not convert the food he ate to energy. This caused for an increase in
hunger, polyphagia. Polyuria occurs when the kidneys cannot filter all the hyper-concentrated glucose
in the blood and therefore is absorbed out of the bloodstream and excreted it in the urine. Polydipsia
occurs due to loss of lots of water through the urine that needs to be replenished. Fatigue occurs when
cellular shrinking and dehydration occurs when glycemia is extreme, causing nervous system
malfunction

4. Describe the metabolic events that result in the signs and symptoms associated with DKA. Was
Mr. B in this state when he was admitted? What precipitating factors may lead to DKA? (2 pts)
NTP p. 145, 503, Nut 116a Lecture
DKA, or diabetes ketoacidosis, is a serious complication of diabetes that occurs when your body
produces high levels of blood acids called ketones that can lead to diabetic coma or death. When the
body doesn’t get the glucose it needs for energy, the body will begin to burn fat for energy which
produces ketones. Ketones are acids that build up in the blood and are found in the urine when the
body doesn’t have enough insulin. DKA usually occurs very slowly, with early symptoms including
thirst or a very dry mouth, frequent urination, high blood glucose levels, and high levels of ketones in
the urine. Other symptoms include constantly feeling tired, nausea, abdominal pain,difficulty
breathing, fruity odor breath, and a hard time paying attention. Vomiting is a symptom that shows
DKA will develop soon, in a few hours. Mr.B was in this state when admitted. As seen in his lab
results, he had ketones in his blood (+4), a low urine pH of 4.9 where normal is 5-7, had high hbA1C
levels at 12.5 percent where normal is 3.9-5.2 percent, and was lethargic and had a dry throat
indicating dehydration. Factors that lead to DKA include not having enough insulin, not eating
enough, and having low blood glucose.

5. What is the relationship of HgbA1c values to the micro- and macro-vascular complications of
diabetes? List 3 micro-vascular complications of DM. (2 points)
Nut116a Diabetes Lecture
Long term complications of diabetes result in microvascular and macrovascular complications.
HgbA1c measures the glycated hemoglobin control over 3 months with a goal of hgbA1c less than 7
percent for diabetes patients. The relationship of HgbA1c values to micro and macrovascular is that
HgbA1c values show one’s blood sugar levels over time, and if one has elevated blood sugar levels
for an extended period of time, complications can occur. These complications include Micro-vascular
(effects certain parts of the body) complications of diabetes include retinopathy, nephropathy and
neuropathy. Macro-vascular (effects the entire body) complications of diabetes include CVD,
atherosclerosis, and hypertension.

6. Mr. B will be started on a combination of Glargine given in the pm with Novolog prior to meals
and snacks. Describe the onset, peak, and duration for each of these types of insulin. (2 pts)

7
 NTP P.488
Glargine: Glargine is an extended long-acting analog that has an onset of action of 2-4 hours, is
peakless, and has a duration of 20-24 hours.

Nut 116al Diabetes Lecture

Novolog: Novolog is a rapid acting insulin with an onset action of less than 15 minutes, has a peak of
0.5-1 hours, and has a duration of 1-3 hours.

7. Identify any abnormal laboratory values measured upon Mr. B’s admission. Explain how they
may be related to his newly diagnosed T1DM. Discuss only relevant labs. (2 pts)
NTP p.A-28, 483-485
Some abnormal labs include his high hgbA1c value at 12.5 %, where diabetics should aim for less
than 7 percent. This value shows the glycated hemoglobin level over 3 months, showing that he
has had high blood glucose over a period of time, an overall marker of average levels over the
three months. Overtime, he has had very high glycated hemoglobin and is a concern. His
metformin was not working for him and he needed insulin in order decrease the glycated
hemoglobin levels, and to survive, which is an aspect of T1DM. His non-fasting plasma glucose
is very high at 683 mg/dl, while diabetes is diagnosed with a non-fasting plasma glucose of >
200 mg/dl. His non-fasting plasma glucose indicates his plasma glucose at that point in time,
which can not be so reliable if the patient has eaten. In this case, the patient was found ill and
noted to have a very high plasma glucose, which was concerning as he was diagnosed with
T2DM. This test is useful because random testing with normal results show blood glucose values
that do not vary much. This could be an indicator that he has a problem with his insulin
production, and that he needs insulin in order to survive, to keep his blood sugar low, which is an
aspect of T1DM. He also had high levels of glucose in his urine (+3mg/dl) as well as ketones in
his urine. Glucose in his urine indicates a loss of sugar in his urine which may also indicate
weight loss due to loss of calories, where weight loss is an indicator of T1DM. The ketones in his
urine indicate diabetic ketoacidosis, which occurs when the body doesn’t get the glucose it needs
for energy and it begins to burn fat for energy which produces ketones, which are acids that build
up in the blood and are found in the urine when the body doesn’t have enough insulin. This is an
indicator of T1DM, as the patient does not have enough insulin because he is not producing any
on his own. The presence of antibodies ICA, GADA, IAA, and low c-peptides indicate he has
T1DM and not T2DM.

8. You meet with Mr. B before d/c and review SMBG. Based on the information above, write your
initial nutrition assessment ADIME note for Mr. B, including 2 PES statements (include
calculations & references on an attached sheet). (12 points)
A:
Pt states he does not take the metformin medication regularly although prescribed for his T2DM. Pt
was found groggy and almost unconscious before admitted to the hospital. His appearance was slim in
obvious distress with a S. glucose of 610 mg/dL.
Family Hx: PT’s mother diagnosed with T2DM. Father had MI.
Diet Rx: Pt put on NPO meal type, then clear liquids, and then consistent CHO-controlled diet with a
fluid requirement of 2200 mL. Pt does not follow traditional tribal eating pattern, with a few
exceptions; eats fry bread. Pt does not tolerate milk, eats little cheese, no fruits, and meat once per
day as indicated by his usual intake log.
Anthropometrics: 48 year old male, Ht 5’10’’, Wt 160 pounts (72.73kg), BMI 23.2 kg/m^2, IBW
75.5kg, %IBW 97%
Labs: Plasma Glucose (non fasting blood glucose) 683 mg/dl (very high), hbA1c 12.5% (high),

8
ketones +4 (indicator of ketoacidosis), BP 101/78 (tachycardia: elevated heart rate), presence of
antibodies ICA, GADA, IAA, and low c-peptides (indicates T1DM)
Nutrient Needs: Protein requirement 58-138g/d or 232-552 kcal/d, Fluid intake requirement 2182-
2546 ml/day, Calorie Requirements to maintain bodyweight 2249-2410 kcal/day

Assessment: Pt is likely not consuming enough calories to maintain his body weight as is consuming
too little whole grains and fruits, and should replace refined grains with these foods. Potential
problems of his current diet include not enough whole grains, protein, and calories consumed in
general. Pt recently diagnosed with T1DM not T2DM and should maintain body weight by
consuming enough calories as well as eating the right carbs (fruits, complex carbs) in order to
maintain glucose levels which should be less than 7% for hbA1c and less than 200mg/dl for plasma
glucose. His BP is elevated indicating tachycardia, which can be due to insufficient fluid intake. He
should increase his fluid intake to meet his requirement, which is 2182-2546 ml/day.

D:
PES:
Less than optimal intake of CHO, whole grains and fruits, (NI-5.8.3) R/T undesirable carbohydrate
choices of refined grains including fry bread and cornmeal, and no fruit intake AEB his usual intake
log over several months.
PES:
Self-monitoring deficit (NB-1.4) R/T lack of deliberate metformin medication use AEB his laboratory
results of high hb1Ac of 12.5% and high plasma glucose of 683 mg/dl.

I: Overall MNT goal includes to decrease pt’s blood glucose levels (hbA1c and plasma glucose), and
create goals to increase his calorie consumption, maintain his IBW, and improve his diet. Pt should
decrease his hbA1c to less than 7 percent over the next 3 months. Behavioral goals set with the pt
include increasing fruit and vegetable consumption, replacing simple carbs with complex carbs, and
increasing water consumption. PT will receive handouts on different types of whole grains, as well as
a handout on how complex carbohydrates benefit one greater than simple carbs as well as its help in
diabetes. Pt will be taught basic carbohydrate counting as well as taught how to adjust insulin for
meals. Change in diet Rx is needed once pt becomes stable. Pt should consume 2249-2410 kcal/day to
maintain his weight, consume 58-138 g Protein/day, and consume 2182-2546 ml fluid per day. These
levels will allow for him to maintain body weight, ensure sufficient fluid intake, and ensure sufficient
protein intake. Concerns with labs include high hbA1c, high plasma glucose, ketones in the urine, and
elevated BP. Pt will work to make these levels normal with his insulin therapy prescribed to him as
well as changing his diet to more complex carbs as well as ensuring enough fluids to maintain a
healthy and normal BP. The presence of antibodies ICA, GADA, IAA, and low c-peptides also was
concerning as it shows pt has T1DM and needs insulin. Pt will have compliance and understanding of
diet instructions and will be motivated to change his diet and take his insulin due to his new diagnosis
of T1DM, to combat the serious complications that can result in not taking insulin. As pt has had
trouble taking medications in the past, he will understand that as a T1 diabetic, insulin is necessary to
survive.

M/E:
Pt will keep a food diary for the next to weeks, writing down each food item eaten and the amount,
amount of insulin taken before and after the meal, and how the pt feels. Pt will also begin to exercise
twice a week for 30 minutes by walking to control blood glucose levels for the next two weeks. Pt
will also swap out fry bread once a day for a whole grain including oats, whole wheat bread, or brown
rice for the next two weeks. I will evaluate progress at the next in person appointment visit in 2
weeks.
9
Tess Soper

Wednesday, December 17, 2014

Nutrition Student

9. Mr. B comes back to clinic 2 weeks after his new diagnosis. List the important questions you
will ask him in order to plan the next steps for providing the additional education that he might
need. (2 pts)
Some questions I will ask include:

Have you been monitoring your blood glucose?

What changes have you made in your diet since our last visit?
Have you been exercising to help maintain blood glucose levels, and if so do you see excersiing
regularly to decrease insulin taken apart of your lifestyle?
Do you understand how carb counting and how to determine your insulin dosage?
Do you understand the serious potential complications of unmanaged T1DM?
Do you know how different foods affect blood glucose, including simple and complex carbohydrates?

10. Mr. B’s usual breakfast consists of 2 slices of toast, butter, 2 T jelly, 2 scrambled eggs, and
orange juice (~1 cup). Using the ICR 1:15, how much Novolog should he take to cover the
carbohydrate in this meal? (1 pt)
ICR is insulin:carbohydrate ratio
1 unit of insulin (Novolog) for 15 g CHO
2 slices toast: 30g carbs
2 T Jelly: 30g carbs
2 Scrambled eggs: 0g carbs
1 cup orange juice: 30g carbs

30+0+30+30=90g carbs/ 15 g CHO

=6 units Novolog

11. You determine that Mr. B needs ___2321_____ kcals/day based on EER calculations. You want
to follow his normal eating pattern as much as possible while still meeting his protein requirements
and keeping the kcal from fat at 30% or less of total kcals. Using the Diabetes Exchange/Food List
and the worksheet below, develop a “pattern” for Mr. B’s diet. (15 points)

CHO Protein Fat

Food group Exchanges grams grams grams
Breakfast
Starch 2 starch 30 6 2
Fruit 1 fruit 15 0 0
2 carbohydrate
Milk (circle: whole, 2%, 1%, or NF or Soy) choice + 2 fat 30 0 10
10
Meat (circle: lean, med or high fat) 3 lean protein 0 21 6
3 nonstarchy
Non-starchy vegetables vegetables 15 6 0
Fat 0 fat 0 0 0
Morning Snack (list food groups)
Cooked Cereal, (oatmeal) 1 starch 15 3 1

Lunch
Starch 4 starch 60 12 4
Fruit 2 fruit 30 0 0
Milk (circle: whole, 2%, 1%, or NF) 0 milk 0 0 0
3 non-starchy
Non-starchy vegetables veg 15 6 0
1 med fat
Meat (circle: lean, med or high fat) protein 0 7 5
Fat
Afternoon Snack (list food groups)
1 starch + 1
Baked beans, canned lean protein 15 10 13
Peas, green 1 starch 15 3 1

Dinner
Starch 2 starch 30 6 2
Fruit 1 fruit 15 0 0
Milk (circle: whole, 2%, 1%, or NF or Soy) 1 carb + 1 fat 15 0 5
0 non starchy
Non-starchy vegetables veg 0 0 0
Meat (circle: lean, med or high fat) 2 lean protein 0 14 4
Fat 1 fat 0 0 5
HS Snack (list food groups)
almonds 1 fat 0 0 5
Granola cereal 2 starch 30 6 2
Soy “bacon” strips 1 lean protein 0 7 2
Total grams: 330 107 67
X4 X4 X9
kcal from each macronutrient: 1320 428 603

% kcal from each macronutrient: 56.14% 18.20% 25.64%

% kcal GOAL: 55-65% 10-20% <30%
TOTAL KCAL: 2351 kcals

12. You review Mr. B’s diet, insulin injections, SMBG, and other self-care issues. He continues on
injections of Glargine and Novolog. You reinforce teaching Mr. B about carbohydrate counting.
How many CHO “points” or servings are in his daily diet from question 11? (1 point)
Mr.B has 22 points or servings CHO in his daily diet.
6 veg=5g carb x 6= 30 carbs
13 starch= 15 g carbx13= 195 carbs
11
 4 fruits= 15g carbx 4= 60 g carb
3 milks substitutes= 15gx3= 45g carb
15 carbs=1CHO point/serving
330 carbs/15 CHO= 22 points or servings CHO in daily diet

13. If Mr. B’s pre-prandial BG was measured at 200 mg/dL and he plans to eat a lunch consisting of
a cup of vegetable bean soup, a piece of fry bread, a piece of fruit and a diet soda, how much insulin
should he take to cover the meal, and how should it be adjusted to compensate for the BG level?
Assume that the correction dose of 1 unit of insulin decreases blood glucose by 50 mg/dl, correct to
150 mg/dl, and an ICR of 1:15. (2 points)
Veg bean soup: 22.5 carbs
1 fry bread: 15 carbs
1 fruit: 15 carbs
22.5+15+15= 52.5 carbs/ 15 CHO per unit of insulin
=3.5 CHO per unit of insulin to cover meal
683 mg/dL Blood Glucose
Correction Dose: 200 mg/dl-150mg/dl= 50 mg/dl
50 mg/dl / 50 mg/dl/unit insulin = 1 units insulin
3.5 units + 1 units = 4.5 units round to 5 units
=5 units

14. Describe the Native American foods, fry bread and wojapi. These would be categorized as what
type of exchange? Include the reference used. (1 point)

Fry bread is a flat dough fried or deep fried in oil, shortening, or lard and leavened by sour milk,
baking powder or yeast. It is generally eaten with toppings like jams or meat or is eaten alone.
Frybread would be categorized as a starch with added fat and would call for 1 starch choice and 1 fat
choice. Wojapi is a thick berry dish, which is made today with flour, sugar and berries. Wojapi has the
consistency of pudding and looks like berry jelly. Wojapi would be a fruit and starch mixture, which
would call for 1 starch and 1 fruit choice.

References:
1. "Frybread." Wikipedia. Wikimedia Foundation, n.d. Web. 17 Dec. 2014.
2. "Traditional Indigenous Recipes." American Indian Health. N.p., n.d. Web. 17 Dec. 2014.

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