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Andrews University

Department of Public Health and Wellness

Diabetic Ketoacidosis Case Study

Preceptor: Christina Parce RD By: Christine Chalnguri Milmine

Dietetic Intern

1 Introduction Diabetes affects 25.8 million people (8.3%) in the United States. Ninety to ninety-five percent of all diagnosed cases of diabetes are type II (1). Unfortunately, one may not know he/she has type II diabetes until complications occur. My case study focuses on a patient who had a serious complication due to uncontrolled diabetes. The focus of this study was to research the disease process, make appropriate recommendations, and to equip the patient with the information to prevent further complications from Diabetes. The study began 2/17/14, and ended 3/10/14. Patient Profile Initials Principle Problem Past Medical Problems/Year: DH Diabetic Ketoacidosis Diabetes Mellitus: ~2007 Reports Hypertension. (UTA because there were no past medical records). Height 5 8 Number of children BMI Weight 18.4 54.5 kg Health Insurance Smoking Tobacco Use Age Sex 60 y/o Male Alcohol Use Drug Use None currently. Yes, hx of marijuana in the past. None. Never smoked. 1 Son Occupation Marital Status Living Arrangement Social History Unemployed Divorced Single family home, top floor, with his son, sons wife, and brother.

2 Normal Anatomy and Physiology of Applicable Body Functions When carbohydrates are consumed in a diabetes-free individual, the body secretes a hormone called insulin from the beta cells of the pancreas. Insulin uses glucose, which is the broken down form of carbohydrates, to be stored for later use or used as energy right away. In type II diabetes, insulin is either not secreted properly, thus making the individual insulin deficient, and/or the body is resistant to insulin because insulin cannot use or store glucose. The lack of insulin and/or insulin resistance causes increased production of counter-regulatory hormones, (ex: glucagon, catecholamine, cortisol and growth hormone) which increases glucose levels in the blood glucose to build up in the body, otherwise known as hyperglycemia. The individual may also have fatigue, excessive thirst, and/or frequent urination. Individuals with type II diabetes may or may not need exogenous insulin to survive. If diabetes is not controlled with lifestyle modifications, (such as consuming consist carbohydrates evenly spaced throughout the day, losing weight if needed, etc.), then insulin and frequent blood sugar checks are needed to prevent complications. Complications from uncontrolled diabetes may include kidney disease, blindness, gastroparesis, which is delayed gastric emptying without obstruction of the stomach, and Diabetic Ketoacidosis (DKA). The principal admitting diagnosis of this study is DKA. DKA results from persistent hyperglycemia in diabetic persons, and occurs when excess glucose is continually consumed without adequate insulin. Since the body cannot use the glucose as energy, the body goes into starvation mode, and depends on fat for energy. This produces ketones, which results in acidosis, causing severe electrolyte imbalances. DKA is detected by ketones in the urine and blood glucose levels ranging from 250-600 mg/dL. A person with DKA may present with a distinctive fruity odor of ketones on the mouth, excessive thirst and urination,

3 hyperventilation, and dehydration. While DKA can lead to coma and even death, if treated properly, it can be reversed (2, 3). Initial Medical Status and Treatment On February 17, 2014, DH was found on his bathroom floor, breathing heavily. The 60 year-old Caucasian, cachectic appearing, man was immediately taken to the ER by his brother. DH was found to have a blood glucose level of 600 mg/dL (see admission labs on pages 5-6). The patient was started on aggressive fluid boluses and an insulin drip, and he was made NPO, nothing by mouth, with the exception of water. This is the common protocol for patients with DKA. The administration of insulin is given to correct dangerously high blood sugars. Normal saline was provided through an IV to promote rehydration, since the patient was dehydrated, a common DKA symptom, likely due to glycosuria, and the excretion of glucose in the urine, which increases water and sodium losses (5). The dehydration DH experienced most likely contributed to his acute kidney injury(AKI), as evidenced by his declining renal function labs (see elevated creatinine and lowered eGFR labs on p. 4) due to DKA. Hydration and fluid status were monitored to prevent further renal decline. Since the patients potassium levels were with in normal limits, the electrolyte was not added to the IV fluids. DHs phosphorus level was abnormally high. In response, the parathyroid hormone levels was checked to see if DH had hyperparathyroidism. The parathyroid hormone is an important hormone produced in the thyroid that helps regulate calcium and phosphorus in the bones. DHs thyroid stimulating hormone and parathyroid hormone levels came back with in normal limits on the same day (DHs level was 1.93 uIU/mL. The normal range is 0.46-4.68 uIU/mL. Based the physicians physical exam and lab draws on DH, the patient was found to have onychomycosis, (a type of fungal infection) his right foot, and a non-healing lower extremity

4 ulcer. The patient also had Hematuria, which is blood in the urine, and leukocytosis, which is a high white blood cell count. The patients levels was 30.0 thous/cmm. These were hypothesized to be due to an infection. A blood sample was drawn and sent to the lab to determine if antibiotics were needed. DH was diagnosed with DKA secondary to non-compliance to treatment plan of type II diabetes. DH could only mumble a few strained words due to tachypnea which is defined as any breathing rate above the normal 12-20 breaths per minute (bpm) for a healthy adult. DH had 2832 bpm upon admission). He managed to tell the doctor that he never checked his blood sugars prior to admission (PTA) despite difficulty breathing. Although there were no medical records to confirm past diagnoses, the patient also stated he had a history of hypertension. The patients blood pressure was 120/85 mm Hg on admission. The patients brother stated that DH requires a lot of assistance due to weakness, has chronic urinary incontinence, was not taking any medications, and refused to see a doctor. The patient had no complaints of nausea or vomiting, but had diarrhea occasionally. DKA was confirmed by the presence 300 mg/dL of ketones in his urine sample with associated metabolic acidosis as evidenced by a pH of 6.92. The normal level is 7.35-7.45. To correct the hyperglycemia, the insulin drip was increased slowly, until the patients blood sugars dropped to 70 mg/dL. At that point, and the insulin infusion was stopped and rechecked thereafter, through his hospital course. Later on that evening, the patient was put back on the insulin drip at a lower rate, as his blood sugars were 109 mg/dL. His insulin was increased slowly throughout the night due to increasing blood sugar levels.

5 DH Labs, Admission: 2/17/14 Lab Normal (based on Lakelands Lab references via EPIC) Glucose Random BUN Creatinine BUN/Creat Ratio EGFR Sodium Potassium Chloride CO2 Albumin Total Calcium Magnesium 65-100 mg/dL 6-24 mg/dL 0.7-1.3 mg/dL 7-25 >60 mL/min 136-143 mEq/L 3.6-5.0 mEq/L 96-107 Mmol/L 22-31 Mmol/L 3.4-5.0 g/dL 8.4-10.2 mg/dL 1.8-2.4 mg/dL 600 mg/dL 32 mg/dL 2.4 mg/dL 13 28 mL/min 129 mEq/L 4.9 mEq/L 89 Mmol/L 4 Mmol/L 4.2 g/dL 10.4 mg/dL 2.5 mg/dL Very High High High WNL Low Low WNL Low Very Low WNL High Slightly High Patient Values Interpretation

6 Phosphorus Hgb A1C Medications (3) Drug Name Novolin N Purpose Antidiabetic Nutritional Impact Glucose, Hb A1c. Potassium, Magnesium, Phosphorus, Total Throxine. Humulin R Antidiabetic Glucose, Hb A1c. Potassium, Magnesium, Phosphorus, Total Throxine. Milk of Magnesia Laxative (Osmotic), Antacid (Recommend a high fiber diet with 1500-2000 mL fluid to prevent constipation) Chalky taste, nausea, cramping, diarrhea. Protonix AntiGERD, Antisecretory May iron and vitamin B12 absorption, Gastric acid secretion, Gastric pH, nausea, abdominal pain, diarrhea. Medical Nutrition Therapy, Initial Assessment. Events (2/18/14): The patient quickly improved in the ER. Therefore, the patient was admitted to the ICU. DHs DKA was resolving, however, the patient continued to have frequent hyperglycemia, with glucose random tests ranging ~100-300 mg/dL despite increases in the insulin drip. DH was taken off the insulin drip and put on NPH, also known as intermediateacting insulin, with an effective duration of approximately 10-16 hours, and regular insulin. The patients lower extremity ulcer was thought to be secondary to uncontrolled blood sugars and 2.4-4.5 mg/dL 4.8-5.9% 9.4 mg/dL 19.2% High High

7 possible infection. The patients AKI was resolving due to rehydration with IV fluids. DH was taken of IV fluids. PO medications and fluids were encouraged and tolerated well. Physical therapy (PT) saw the patient and assessed his ambulatory status. Based on their assessment, DH was found to be very weak with severe debility. PT recommended for the patient to be discharged to a short term nursing home when clinically stable. Later on that evening, DH saw podiatry for his onchomysosis. The importance of foot care was discussed, due to his suspected diabetic peripheral neuropathy, which was diagnosed on 2/20/14. Diabetic peripheral neuropathy causes loss of sensation and can cause infections and amputations may be necessary if undetected over a long period of time. This is a common and unfortunate complication associated with uncontrolled diabetes that can be prevented by checking feet daily and practicing proper foot care (7). Since DH had onchomysosis of his toenails, debridement or removal of the toenails was performed. DH also had a non-infected blister on his big toe and callouses, partial thickness of the right foot. Proper foot care instructions were discussed with DH, and then the patient was sent to the surgical floor. Nutritional Impact: DH was no longer NPO and had just ordered lunch when he was seen for the initial nutrition assessment. DH received a 5 carb (2000-2400 calories) diet order since DHs glucose levels were under better control since admission (fasting glucose was 94 mg/dL (2/18) vs 600 mg/dL (2/17/14). DH appeared very thin, and had noticeable muscle wasting in the arms and legs. DH was asked if he had unintentionally lost weight PTA and he reported an unintentional weight loss of 70 pounds in the past 2 years. However, DH reported no decrease in appetite, and no gastrointestinal complaints PTA. Unfortunately, the significant weight loss DH reported is common in patients with DKA. This is because the body does not burn energy the same way. Instead of burning glucose, the bodys preferred source of energy, fat

8 is burned, leading to weight loss despite adequate caloric intake (5). DH said his usual body weight was 86.44 kg. Since DH weighed 54.8 kg at admission, he was only at 63% his usual body weight. DHs percent ideal body (His ideal body weight is 70 kg based on Hamwis ideal body weight equation for a man of 58) is only 78%. Furthermore, DHs BMI is 18.4, putting him at risk for malnutrition. A BMI <18.5 is underweight. This was considered in calculations of estimated needs (see p. 9). DH was asked to give a usual daily intake history. DH said that he has never adhered to a special diet, and rarely cooks. The patient stated that he relies on microwave meals every day. He reported to eat the same microwave meal for breakfast, lunch, and dinner. The meal consists of salisbury steak, mashed potatoes with gravy, and green peas. DH also drinks 12 Code Red Mountain Dew soda cans every day. Based on the information given, DHs estimated usual intake may be ~2730 kcals, 630 gm carbohydrates, 30 gm protein (6, 7). DH said that he had seen a dietitian in 2006, but did not recall receiving any diabetic diet information. Based on this information, DH was taught basic diabetic diet education, using his current diet order of 5 carbohydrates per meal. Five carbohydrates servings per meal is and appropriate diet for DH because needs about 2000 kcals per day, and a 5 carbohydrate serving per meal plan is equivalent to 2000-2400 kcals per day. DH was very motivated to learn about following a carb controlled diet, because he realized that not checking blood sugars and eating too many carbs was stressing his body, as evidenced by an A1C of 19.2%, taken on admit. We discussed which foods do and do not have carbohydrates, portion sizes, and reading nutrition facts labels to determine how many carbohydrates are in each serving. At the end of our educational session, DH made a few goals for himself: 1. Stop drinking code red mountain dew.

9 2. Get 5 or fewer carbs per meal. Diabetic diet educational handouts were given to the patient, as well as dietitian contact information in case of further questions. Based on the information obtained, DH has the following nutrition related problems: Excessive carbohydrate intake related to food and nutrition-related knowledge deficient concerning appropriate amount of carbohydrate intake as evidenced by Hgb A1C of 19.2%, chronic diarrhea, and diet history including excessive amounts of drinks high in carbohydrates. Self-monitoring deficient related to knowledge deficient regarding monitoring of blood glucose levels as evidenced by Hgb A1C of 19.2%, and reports of not checking glucose regularly per patient. Estimated nutritional needs for DH are (using actual body weight: 54.8 kg, (8)): 1,644-1,918 kcals 30-35 kcals/kg. (calorie level is slightly under the 5 carb diet order range of 2000-2400 calories due to precaution of over feeding a malnourished patient (2)) 82-110 g. protein 1.5-2.0 g. /kg. (Pt needs repletion from body loss of protein from muscle wasting due to insulin not using consumed energy (8)) ~1,644-1,918 mL fluids 1 mL/kcal (baseline hydration for adults per the Nutrition Care Manual (8)

A nutritional supplement, Glucerna, was ordered once per day for DH to increase caloric intake and promote weight gain. Glucerna is a specialized nutritional supplement that is high in calories and protein (220 calories, 9.9 g protein), while lower in carbs than most nutritional supplements. For example, Ensure has 51 g carbs per 8 ounces, while Glucerna has 29.3 g carbs per 8 ounces.

10 A baseline prealbumin was also ordered for DH to assess his nutritional status due to the patients report of significant unintentional weight loss of 70 pounds in the past 2 years, a BMI of 18.4, and 78% ideal body weight. Prealbumin is often used in the clinical setting as a protein and/or calorie deficiency marker because it has a shorter half-life and is not as influenced by intravascular fluid volume when compared to albumin (9). Medical Nutrition Therapy, 2nd Encounter. Events (2/19-20/14): DH was showing continued resolution of DKA (25 mmol/L ketones in the urine), was experiencing less weakness, and was ambulating more per PT. However, he still required assistance due to slight tachypnea. The occupational therapist assessed the patient, and documented that DH would need assistance after discharge due to inability to perform all aspects of self-care. Later on that day, DHs RN found >1 liter of residuals on the bladder scanner. A Foley catheter was inserted per the physicians permission. Later on that day, blood was found in the Foley. A further history of the patients living conditions were discussed. DH reported that he sleeps on the floor on a urine soaked mattress, rather than sleep on the ground. DH had to wear a diaper because of chronically leaking urine. A urology consult was suggested by the physician, but never scheduled until discharge. By the 20th of February, DHs DKA had fully resolved with no ketones in the urine, but the patient continued to have hyperglycemic episodes. He had a significantly elevated blood glucose level of 408 mg/dL on the 20th. In response, the patients NPH and prandial insulin were increased. Upon the physicians examination that day, the patients AKI had resolved with rehydration however, the patient was found to have microcytic anemia, which can include iron deficiency anemia and anemia of chronic disease. The patient was also found to have neurogenic

11 bladder, lack of bladder control, due to the patients poorly controlled diabetes. In response, iron studies were ordered for the next day and a urine sample was collected. DHs leukocytosis was not improving. Repeat blood cultures were taken and sent to the lab, as blood cultures were negative to date. Nutritional Impact: On the February 20, DH was seen in regards to any remaining diet questions and nutritional supplement acceptance. DH reported that he liked Glucerna and would like to keep receiving it. Therefore, the Glucerna supplement was continued. The patients prealbumin results were returned on the 19th, and DHs level was 5 mg/dL indicating that DH may not have been receiving adequate calories and protein to meet his needs with consideration of DKA. Normal prealbumin levels: 16-40 mg/dL (9). When asked if the patient had any questions related to his prescribed diet order of 5 carbohydrate servings per meal, the patient said that he knew everything. The patient was referred to classes and counseling by a specialized diabetes educator in St Joseph, Michigan, but the patient said it was unlikely that he would go due to lack of insurance. Medical Nutrition Therapy, Reassessment Events (2/21/2014): DH was still experiencing wide variances in blood sugars despite resolution of DKA. NPH insulin was increased accordingly. When the patient was seen by the physician, DH complained of pain on the left hip and flank. The physician noted erythema, redness on the area. The patients leukocytosis was getting worse. Due to these findings, the physician suspected cellulitis, a bacterial skin infection, and ordered a surgery consult. A CT scan of the abdomen and pelvis was ordered for the next day to determine the source of probable cellulitis. Per the physicians order, the patient was started on Vancomycin, a common antibiotic treatment for infections.

12 The patients iron studies that came back supported the diagnosis of iron deficiency and anemia of chronic disease (see labs on page 12), however, the patient had no active bleeding at the time. The physicians plan was to continue to monitor for bleeding, and prescribe an iron supplement as necessary. Unfortunately, no more lab studies were taken for the patient during his hospital stay, and the only intervention for the patients iron deficiency was a prescription for ferrous sulfate tablets at discharge on 3/5/14. Since the patients usual intake included 3 servings of beef (a good source of iron), the iron deficiency was expected to improve with resolution of disease and compliance with iron supplements. Improvement in iron status can take 4-30 days. It would be worthwhile for iron studies to be checked if the patient returns in the future (2). Component Normal Range (EPICs Reference Range) Iron Transferrin Iron Binding Iron Saturation 49-181 mcg/dL 206-381 mg/dL 250-450 mcg/dL 13-59% 15 mcg/dL (L) 115 mg/dL (L) 164 mcg/dL (L) 9 mcg/dL (L) Patients Value

Nutritional Impact: When the patient was seen on the nutritional reassessment on the 21st, DH complained of left hip pain. However, the patient said he was eating well, and was consistently keeping his meals within his 5 carb servings per meal allotment. The patients intake records showed that he was eating 100% of all his meals, and was drinking his Glucerna supplement. Based on the new information obtained since the initial assessment, a new nutrition diagnosis was documented as follows:

13 Malnutrition r/t physiological causes previously affecting ability to use energy from food

AEB dx of DKA, uncontrolled diabetes, prealbumin: 5 (2/19/14), weight loss of 70 pounds x 2 years PTA. Despite adequate caloric intake (per pt), and BMI of 18.4. The nutrition goal did not change, as DH still needed to continue to eat >75% of his estimated needs to help correct malnutrition. Due to the patients, low prealbumin, and nonhealing wounds, the same calorie and protein goals as the initial assessment was indicated (see pg. 9). Therefore, the 5 carb diet was still appropriate, as well as the Glucerna supplement for added protein and calories. An extra nutritional supplement, Healthy Shot was ordered for DH, to prevent further muscle wasting with malnutrition, and to help improve healing of DHs ulcer. Protein plays an important role in growth of new, healthy connective tissue from the wound base (8). Healthy Shot 2.5 oz (100 calories, 24 g. protein) was ordered for the patient once, daily (10). Daily weights were also ordered to monitor the patients weight trend. Medical Nutrition Therapy, 3rd Encounter Events (2/22-24/14): On the 22nd of February, DH went to surgery for a consult due to continued left hip/flank pain, non-healing lower extremity ulcer, and continued leukocytosis. The CT scan of the abdomen and pelvis revealed bladder wall thickening and edema of the trochanter, part of the femur, and iliac crest, the uppermost portion of the pelvis. These findings were suggestive of cellulitis vs necrotizing, flesh eating infection. The patient had continued erythema where the lower extremity ulcer was located. The surgeon removed 2 small eschars, pieces of dead tissue on the left trochanteric area, and sent a blood culture to the lab. Since the patient was still on Vancomycin, the patient was given instructions to continue the antibiotic and to further explore the area if the erythema continued. The patient was returned to the surgical floor afterwards.

14 After lunch the same day, DH had a blood sugar of 444 mg/dL range due to a missed morning insulin dose. The patients blood sugars were brought back within normal limits when regular insulin was given. The next day, DH had continued swelling and erythema of the left iliac crest and trochanteric area. The lab results from the aspartate of the left trochanteric abscess revealed many white blood cells, and gram positive cocci in chains. Gram positive cocci are a bacteria species that usually indicates Streptococcus or Enterococcus (11). Due to the patients continued leukocytosis with a WBC count of 20 thous/cmm, despite continued use of antibiotics, DH was sent back to the surgeon for incision and debridement of the left trochanteric area, which had accumulated pus due to an unknown cause. The patient was placed under anesthesia for the procedure. Due to the surgeons findings, the patient was found to have subcutaneous necrotizing infection, flesh eating subcutaneous infection, with the infection starting at the iliac crest area to the mid lateral thigh. All necrotic, dead tissue was removed. The fascia did not appear infected however, and debrided tissue and aspirate of the left trochanteric ulcer was sent to the lab. After the procedure, DH was taken back to the surgical floor, with a follow up scheduled if the infection spread, and erythema around the area continued. The next day, February 24, the patient reported less left hip/lower leg pain, however, the wound appeared to have pocketed deeper. Lab results from the aspirate of the left trochanter area showed group B streptococcal infection with lots of white blood cells as well. Group B Streptococcus is a normal bacteria found in the gastrointestinal tract. It can be a source of infection in certain individuals, such as those with diabetes. Group B Streptococcus infection can put one at an increased risk of urinary tract infections, soft tissue infections, and even death (12).

15 The patient was diagnosed as having a necrotizing soft tissue infection, and the patient went to the hyperbaric chamber that day. Hyperbaric oxygen treatments (HBO) are a fairly new treatment method used for a variety of circumstances, in this case, for non-healing, hypoxic, low oxygenated wounds. Since diabetic patients are especially prone to ulcers, hyperbaric oxygen treatments have been used, with much success when used in conjunction with debridement and irrigation of the wound. In this treatment, the patient is placed in a high pressured room which is up to 3 times higher than normal air pressure. The high pressure improves healing of hypoxic wounds because new blood cell and connective tissue synthesis is enhanced, while promoting white blood cells ability to fight infection (13). Due to the patients good tolerance to the procedure, the patient was scheduled for HBO treatments for the next few days. Nutritional Impact: On the 24th of February, a dietary consult for a follow up related to DHs significant weight loss PTA, and DM education was sent to the Dietitian. By this time, the patient had gained 3.2 kg since admission, which was a positive sign because the weight gain was most likely not due to edema, as the no edema was noted per the physicians exam that day. The patient was still taking his supplements, and understood the importance of getting enough protein and calories for healing. The 5 carb diet plan was reviewed with the patient, who expressed understanding of getting consistent carbohydrates at each meal, and was still very motivated to change his diet when discharged. DH had no further questions about his diet at this time. Medical Nutrition Therapy, 3rd Reassessment Events (2/25-26/14): On the 25th, DH went back to surgery for extensive irrigation and debridement because of continued areas of necrotic tissue around the left hip. During the procedure, the surgeon found that both the subcutaneous and muscle fascia appeared to be

16 infected, however, the infection did not spread laterally past the mid-thigh. Therefore, no new specimens were sent to the lab. The patient was diagnosed with Necrotizing Fasciitis, a flesh eating disease involving inflammation of the fascia: connective tissue around the muscles. After debridement, the wound was irrigated with saline packed with sodium chloride gauzes. The patient returned back to the surgical floor after the procedure. The patient returned to the surgical floor after the procedure, but did not remain there long due to another appointment to HBO. The next day, February 26th, the infection seemed to have stopped spreading, as evidenced by no observations of new pus, decreasing leukocytosis, and clean wound bed based on the physicians examination. Regardless of these improvements, DH was started on Ciprofloxin, an antibiotic for used for a variety of bacterial infections including streptococcal infections. DHs expressed complaints of continuing nocturia, increased urination of the bladder, and mentioned that he slept on the floor for 3-4 months PTA, due to fear of soiling the bed. The patient reported he went through 4 Depends, adult underwear per night. The Foley catheter was ordered to remain until it was closer to the patients discharge. Nutritional Impact: The patient had a nutrition reassessment on the 26thof February. DHs weight was now 57.5 kg, and remained approximately at this weight throughout the rest of his hospital stay. The patient said he was still motivated to change his diet and to pay careful attention to his carbohydrate intake when he is discharged. The patient complained that he was having diarrhea after eating, which may be due to antibiotics. The patients occasional diarrhea was not affecting intake, as the patient was eating 100% of his meals, and still enjoying his Glucerna. He was also tolerating the Healthy shot supplement.

17 With consideration of the patients food intake records, weight, and findings of necrotizing fasciitis, a new nutrition diagnosis was documented as follows: Increased protein needs related to increased demand for nutrients due to wound healing as evidenced by necrotizing fasciitis to the left hip. Based on the patients new weight: (57.5 kg rounded to 58 kg), calorie, protein and fluid needs were changed as follows: 1,740-2030 kcals 87-116 g. protein 30-35 kcals/kg. (To promote weight gain for the malnourished patient (2)) 1.5-2.0 g. /kg. (Repletion for malnourished patient and for wound healing (2)) ~1,740-2030 mL fluids 1 mL/kcal (baseline hydration for adults per the Nutrition Care Manuel (8)

The patients 5 Carb diet order was not changed, and Glucerna was continued (once daily). The 2.5 ounce Healthy Shot supplement was increased to twice a day, (providing 48 grams of protein and 200 calories) to further promote wound healing. The importance of protein with wound healing was explained to the patient, and high protein foods were encouraged with each meal. Lastly, a new preablumin lab was ordered for the next day. The nutrition reassessment on the 26th of February was the last reassessment, since the patient was given less priority points based on the Ongoing Nutrition Monitoring screen, due to the patients improvements nutritionally. DHs preablumin results came the next day, and had increased from 5 mg/dL (2/19/14), to 8 mg/dL on the 2/27/14, indicating that the patients nutritional intake was improving. Events (2/27-3/5/14): During the next five days, the patient continued to receive HBO, wound care, and examinations for pus and worsening infection. The patients leukocytosis improved with each day, as evidenced by a downward trend of white blood cell counts. DHs leg and hip

18 pain was also improving, along with increases in ambulation. By the 28th, DH was ambulating by himself. However, the patient had several episodes of hypoglycemia and hyperglycemia despite adequate intake. DH missed a few HBO treatments due to hypoglycemia. The patient went back to surgery on 3/3 for further exploration and debridement of the hip area. The surgeon found scattered areas of pus filled tissue under the iliac crest, and the muscle fascia appeared edematous and infected. All necrotic tissue found was debrided, but there was much less to remove compared to the last debridement on 2/25/14. The debrided tissue was sent to the lab and results came back the next day, revealing group B Streptococcus and gram positive cocci in chains and pairs. These findings indicated that streptococcal infection was still present. The physician found some necrotic tissue under the iliac flap and distal wound. Based on these findings, the patient was diagnosed with septic bursitis, infection and inflammation of the bursa, or small fluid filled sacs that cushion the bone, muscle, and tendons around the joints. This is typically treated with strengthening exercises, reduction of inflammation, and medication (14). The patient was doing well post-surgery, and his wound appeared to be healing. Therefore, it was decided for the patient to be discharged on the 5th of March to an extended care facility, and to come back on the 10th of March for possible closure of the wound, and a wound vac thereafter. Due to expected discharge, the Foley catheter was taken out, however, the patient continued to have difficulty urinating due to urinary retention. Therefore, the Foley catheter was reinserted, and an outpatient urology appointment was scheduled for the patient. By the 5th of March, the patient was discharged. The patient was sent home with ferrous sulfate tablets for unresolved iron deficiency anemia. Per the physicians notes, no further intervention was needed since there was no active bleeding throughout his hospital admission.

19 The patient had less hyper/hypo glycamia towards the end of his hospital stay, and his prealbumin had increased to from 8 mg/dL (2/2714) to 14 mg/dL on discharge (3/5/14) likely indicating improved nutritional intake. Prognosis When DH came back for final debridement and closure of the wound on 3/10/14, the patient had a better prognosis. The surgeon documented that the wound was starting to heal, and that the infection was controlled. No new necrotic tissue except for a scant amount of yellow appearing tissue. The wound and yellow appearing tissue was debrided, and then the wound was closed, with drains sutured into the wound. Though DH had frequent episodes of hyperglycemia and hypoglycemia during his hospital stay, it is likely that these complications occurred for two reasons: 1. the patient had never been on insulin or insulin secretagogues before. Therefore, staff had no baseline dose. Since every individual is different and requires different amounts of insulin, the insulin dose had to be modified several times in the presence of other factors, such as wound healing and malnutrition. 2. The patient had frequent surgeries during his hospital stay, and thus, insulin administration was completely stopped and restarted at times. DH was sent to an extended care facility with NPH insulin to be injected prior to meals, and regular insulin. Management of diabetes through consistent timing of eating and pharmacological intervention is an effective intervention for preventing future hyperglycemic episodes (15). DH appeared very motivated to change his lifestyle after such a traumatic event. Unfortunately, the patients lack of health care may hinder follow up with a dietitian or diabetes specialist, as evidenced by the patients own spoken concerns.

20 The patients weight (57.4 kg) had not changed when he was seen for a wound care follow up on 3/7/14. It is probable that the patients malnutrition might resolve if the patient continues to control his diabetes through adequate calories and protein in regards to consistent carbohydrate intake and insulin. Summary & Conclusions If money was not a factor, nutrition education would likely be sought out more frequently. However, those without insurance, or the means to pay for insurance can prevent themselves from receiving the education they need. While I was able to provide some basic information on carbohydrate counting and consistency, DH would benefit from a counseling session with a diabetic specialist, epically since DH may be sent home with insulin, and has never administered insulin by himself. I learned that serious complications can be a strong motivator for people to make lifestyle changes. DH was able to recognize what he needed to changed, and what he needed to do to change it. While words do not always equate to action, the expected health improvements as a result of better glucose control through medication and consistent timing of carbohydrates may be the motivation DH needs make a permanent lifestyle change.

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