Care Plan Presentation

Bonnie Caulfield
Patient Introduction: CD
Age: 47 years
Gender: Male
Admit dx: Patient had been experiencing frequent urination and increased thirst during the
week leading to admission. Visited his PCP who recommended he come to the ED for
hyperglycemia. Patient reported no recent SOB, N/V, weight change or diet change.
Diagnosed with Type 2 Diabetes since his admission.
Medical History: Patient has an active gunshot wound in lower left abdomen, hypertension,
CKD-stage 3 and a history or pneumonia, pulmonary embolism and asthma. Patient
learned that he has hypertension a few years ago and takes mediation at home to manage it.
Social History: Patient lives at home with his wife and children. Patient reports that his
wife handles all of the groceries and food preparation. Patient is noticeable upset by
diagnosis and reports that he is discouraged since he was just starting to heal from his
gunshot wound. Patient states that he has no prior knowledge regarding the diagnosis.
 Medical Diagnosis: Type 2 Diabetes

Etiology: Type 2 Diabetes occurs when your cells do not respond normally to insulin
or are insulin resistant. Insulin is the hormone that allows glucose to move from your
bloodstream into your cells to provide energy. Your pancreas will in turn produce
more insulin to try to get your cells to respond, but it cannot keep up forever. This
causes your blood sugar to rises.
Signs and Symptoms: frequent urination, thirst, increased risk of infection and
longer healing time, fatigue, blurry vision, increased hunger, numbness of hands and
feet
 MNT for Type 2 Diabetes
Consistent carbohydrate diet with meals spaced out through the day, avoid meal skipping
Moderate weight loss in obese patients may help to manage it
Low sodium diet for hypertension
In hospitalized patients their fasting blood glucose should remain close to 90-130 mg/dL and after a
meal less than 180 mg/dL with the use of insulin when necessary
Education on diabetes and importance of controlling blood sugar levels with food choices, physical
activity, and medication
 Anthropometrics
•Height:
  5’7”
Weight: 169 lbs/77 kg
BMI: 26.5 kg/ , overweight
IBW: 148 lbs
%IBW: 114%
History of weight changes: limited weight history, stable weight
 Treatments and Therapies
X-ray of the chest: normal clear lungs, no abnormality in heart

Still receiving wound care for gunshot wound in abdomen, has not fully
healed

Insulin injections to control his blood glucose levels

 Nutritional Requirements

Mifflin-St. Jeor (SF of 1.2)= 1,910 kcal/day

25-35 kcal/kg x actual body weight of 77 kg= 1,925-
2,695 kcal/day
1-1.5 g pro/kg x actual body weight of 77 kg= 77-
115 g pro/day
1 mL fluid/kcal= 1,900-2,700 mL = 1.9-2.7 L
fluid/day
 Current Diet Order

Current Diet: Regular Diet Consistent Carbohydrate/Diabetic

Assessment of appropriateness: Since the patient has T2D and hypertension,

he should follow a diabetic diet with low sodium and carb counting (60
g/meal).
 Lab Data
Lab Test Patient Value Interpretation
Glucose 1,074 mg/dL (3/24) HIGH, due to T2D
207 mg/dL (3/25) Closer to normal due to insulin administered
Creatinine 2 mg/dL (3/24) HIGH, indicates loss of kidney function
WBC 4.3 Thou/uL (3/24) Normal, rules out potential infection from wound
GFR 50.2 (3/24) LOW, indicates loss of kidney function
BUN 38 mg/dL. (3/24) HIGH, indicates loss of kidney function
Could also be elevated from increased protein intake for
wound healing
 Medications
Drug Purpose Nutrition Concerns
Ascorbic acid To help the body absorb iron and promote Inadequate intake due to N/V or
(vitamin C) RBC production dehydration due to diarrhea
Ipratropium-albuterol Bronchodilator to relax airways to allow Inadequate intake due to swallowing
(inhaler) more air flow difficulty
Avoid high caffeine intake
Chlorthalidone Diuretic and antihypertensive Decreases vitamin K+, so monitor for
deficiency
Diltiazem Ca channel blocker to treat tachycardia Inadequate intake due to N/V
Losartan Angiotensin II receptor agonist /vasodilator Inadequate intake due to N/V or
dehydration due to diarrhea
Melatonin Sleep aid Loss of appetite leading to inadequate
intake
Minocycline antibiotic Inadequate intake due to N/V or inability to
swallow
Decreases vitamin K+
Insulin Lowers blood glucose Can cause hypoglycemia if used improperly
 Nutrition Focused Physical Findings
Appearance: no wasting noted
Edema: none noted
GI: no recorded BM
Skin: gunshot wound in abdomen, pressure injury on sacrum

Patient appearance seemed normal, no difficulty swallowing or eating,

talkative
 Nutrition History and Current Intake
Home diet:
• Healthy/balanced diet at home with high protein for wound healing
• Wife follows a keto diet, which he also eats but less restricted
• Not a picky eater
• Drinks sprite and ginger ale but does not think that it is excessive
• Physical activity is limited, but was active before gunshot wound
Supplements: Takes vitamin C and zinc in the morning, iron at night
Allergies: strawberries
Intake: No recorded intake data, but patient does not enjoy the food he has been served and requested a shake
 Diagnosis

Food and nutrition related knowledge deficit related to new Type 2 Diabetes
diagnosis and lack of diabetes management education as evidenced by
elevated blood glucose levels of 1,074 mg/dL on admit and patients self
reported diet history.
 Intervention
• Nutrition education on carbohydrate counting, food label reading for diabetics, and
more counseling with an RDN. Involve his wife in education since she handles
most of the cooking.
• Referral to diabetes education classes
• Continue Diabetic diet with a total calorie intake of 1,925-2,695 kcal/day, 77- 115
g pro/day, 1.9-2.7 L fluid/day and roughly 60 grams of carbohydrate per meal.
• Mix in one Glucerna shake as a snack each day while in the hospital to help meet
energy requirements.
 Monitoring and Evaluation
Nutrition education outcomes knowledge based:
• patient will be able to name 3 foods that contain carbohydrates and understand that 1 serving has
15 grams of carbohydrates.
Biochemical data:
• blood glucose levels should be monitored and for the majority remain in the normal range below
140 mg/dL.
• Obtain an A1C value and monitor it (<7%)
• Monitor BUN and Creatinine
• Monitor serum Na levels for hypertension and CKD3
 Sample Meal Plan
Breakfast: Lunch: Dinner: Snacks:
• 3 eggs scrambled • Vegetable soup • 3 ounces chicken • Glucerna shake
with 1 cup spinach, made with: 1 cup breast with ½ cup • 1 cup carrots with 2
½ onion and ½ Tbsp low sodium chicken brown rice Tbsp hummus
olive oil broth, ½ cup kidney • 1/2 cup acorn squash
• 1 slice toast beans, 1 medium and 1 cup brussel
• 1 medium banana tomato, ½ cup sprouts roasted with
• 1 cup nonfat milk zucchini, 1 cup 1 Tbsp olive oil, ¼
• 1 cup water cooked pasta and ½ cup dried
cup carrots cranberries and 1/8
• 1 cup water cup pecans
• 2 cups water

Calories: 1,959 Protein: 105 g Carbs: 227 g Fat: 48 g Fluid: 1,880 mL Sodium: 1,206
mg
 What would I do differently?

• Look more into CKD-Stage 3

• Speak to wife if she was available
 Thank you!
References:
“Prescription Drug Information, Interactions & Side Effects.” Drugs.com, Drugs.com, 3 February 2021, www.drugs.com/.
Mahan, L. Kathleen, Escott-Stump, Sylvia, Raymong, Janice L. Krause, Marie V., eds Krause’s Food & The Nutrition Care
Process. St. Louis, Mo.: Elseveir/Saunders, 2012. Print.
American Dietetic Association. Nutrition Care Manual®. http://www.nutritioncaremanual.org. Accessed [February 16, 2021].