Chapter 19 - Nutrition and Diet Therapy for Nurses

Tucker and Dauffenbach Chapter 19 Learning Outcome 1 To differentiate between classifications of diabetes in terms of age of onset, etiology, risks, typical symptoms, and treatment plans. 1. Mrs. K is concerned about her 14-year-old daughter’s weight gain over the past year. Following a thorough assessment the nurse practitioner informs her that her daughter has a BMI of 28 and fasting glucose level of 125, which classifies her as pre-diabetic. She recommends: Weight loss of 5–10%, low-fat diet, and moderate exercise for prevention of type 2 diabetes. A high-fiber diet, strenuous exercise daily, and weight loss of > 20%. Immediate referral to an endocrinologist for further evaluation. No action since a fasting blood sugar of 125 is not abnormal. Answer: 1 Rationale: The American Diabetes Association recommends lifestyle changes including weight loss of 5 to 10%, following a diet for reducing cardiovascular risk, and 150 minutes/week of moderate exercise to prevent the development of type 2 diabetes. In the Nurses’ Health study, a healthy diet high in cereals and polyunsaturated fats was more strongly associated with lower risk of diabetes among minorities. An immediate referral to the endocrinologist is not warranted unless the nurse practitioner suspects another underlying condition contributing to the problem. Pre-diabetes is defined as a fasting blood sugar between 100 and 125. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application 2. Tom is an 18-year-old high school student who came to the clinic with complaints of frequent urination. He has been feeling more tired than usual. He reports losing 13 pounds unintentionally in the past three months, and is more hungry than usual. Lab results showed no bacteria or white blood cells in the urine, but ketones were present. The CBC was normal with no elevation in white blood cells. A metabolic profile was normal except for glucose which was 132. At his follow-up visit the nurse should ask about: Recent weight gain, sexual activity, and frequent thirst. A family history of diabetes, recent weight gain, and blurred vision. Recent weight loss, frequent thirst, and increased hunger. A family history of diabetes, lack of thirst, and recent weight loss. Answer: 3 Rationale: Urinary tract infections can cause increased urination but are uncommon among adolescent males, and when they occur the causative agent is often E coli, resulting from anal sex. The nurse should inquire about a family history of diabetes and blurred vision which is a symptom of hyperglycemia if diabetes is suspected. Lack of thirst is not a symptom of diabetes. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application 3. John is a 9-year-old recently diagnosed with type 1 diabetes. He was referred to the diabetic nurse educator to learn more about diabetes and how to inject him with insulin. During the class he asks the nurse why he can’t take oral medication instead of giving himself injections. The best response from the nurse would be: “Medications available in pill form only work if your body makes some insulin, and in type 1 diabetes the cells that make insulin do not work.” “Medications available in pill form can be used for type 1 diabetes if the treatment is started early enough in the disease.” “The type of medication you need depends on your blood sugar levels, and yours meet the criteria for insulin.” “Younger clients diagnosed with diabetes are prescribed insulin because it is long lasting and easier to keep track of than pills.” Answer: 1 Rationale: Medication available in pill form works with the endogenous insulin that is present in the body. Type 1 diabetics are always treated with insulin because their bodies do not have a supply of endogenous insulin. Types of insulin with a range of rapid acting to long acting are available and can be prescribed alone or in combination according to the metabolic needs of the individual. Age at diagnosis does not affect the type of treatment used for type 1 diabetes. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Synthesis Learning Outcome 2 To compare carbohydrate, fat, and protein metabolism occurring in diabetes mellitus to that of normal metabolism. 1. Mr. P is a newly diagnosed diabetic client in for his first visit with the nurse educator. His biggest complaint is frequent urination that interferes with his job and his sleep. The best response the nurse can make is that: “Once your blood sugar is less than 200 you won’t be as thirsty and so won’t urinate as frequently.” “Without enough insulin, glucose is not absorbed into the cells but is excreted by the kidneys along with large amounts of water causing frequent urination.” “Frequent urination is a common event with diabetes and should be expected to continue regardless of how well your blood sugar is controlled.” “Limiting the amount of fluids in the evening may help to decrease the number of times you wake up during the night to urinate.” Answer: 2 Rationale: Blood sugars of 200 or more are an indicator of poor glucose control and considered hyperglycemic, causing symptoms of polyuria, polydipsia, and polyphagia. High amounts of glucose without sufficient insulin from endogenous or chemical sources result in excessive glucose circulating in the blood without being absorbed into cells which the kidneys to eliminate along with large amounts of water resulting in frequent urination. Polyuria is a symptom of hyperglycemia and does not occur when there is a balance between glucose intake and insulin availability. Limiting the amount of fluids consumed in the evening will usually help to decrease nocturia in the absence of pathology. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application 2. Ms. G is a 40-year-old diabetic who is a professional with a hectic schedule. She has difficulty controlling her blood sugar because she eats out frequently and consumes large amounts of calories from fast food. You suspect that she also enjoys being able to overeat while continuing to lose weight. At her last three clinic visits the provider discussed the importance of good glucose control but today her blood sugar was again 320 and a dipstick for ketones in her urine was positive, a condition referred to as ketoacidosis. You explain that: Uncontrolled glucose resulting in ketoacidosis is a very serious medical problem that can lead to comma or even death. Ketones are a by-product of glucose metabolism and occur in varying amounts in the urine depending on the caloric intake of the client. Ketones are naturally found in large numbers in the urine and are not a sign of pathology. Ketoacidosis results when there is an over compensation of insulin by the body in response to a large consumption of complex carbohydrates. Answer: 1 Rationale: Uncontrolled ketoacidosis is a serious medical problem that can lead to coma and/or death if not corrected. Ketones are a by-product of fat metabolism, a source of energy used by the body when glucose is not available due to insufficient amounts of insulin or starvation. Ketones are eliminated by the kidneys at a rate that is slower than they are produced and can be measured in the blood and/or urine as an indicator of fat catabolism. Ketoacidosis refers to a state in which there are metabolic alterations including altered blood pH and fluid and electrolyte imbalances. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Synthesis 3. In the presence of diabetes, a client presenting with muscle wasting should be suspected of poorly controlled blood sugar with resulting: Fat catabolism. Protein catabolism. Glucose metabolism. Ketone metabolism. Answer: 2 Rationale: Fat catabolism occurs when the body can’t use or lacks a supply of glucose for energy and results in weight loss. Protein catabolism also occurs under the same circumstances, but in this case, skeletal muscle is broken down and the resulting amino acids are used to meet energy needs. Glucose metabolism is the preferred energy source for the body, but depends on an adequate supply of carbohydrates and insulin. Ketones are a by-product of fat catabolism and are eliminated by the kidneys, not metabolized in the body. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Application Learning Outcome 3 To summarize the specific dietary recommendations across the lifespan for individuals with type 1 or type 2 diabetes, including those with co-morbid conditions. 1. When helping an adult client plan a diabetic diet, it is important to include: At least 130 gm of carbohydrates because they are a critical source of energy for the brain. Only a small amount of foods with high fiber content (< 1%) to avoid constipation. No fewer than 100 grams of simple carbohydrates because complex carbohydrates take much longer to metabolize. Low-fiber foods to improve insulin sensitivity. Answer: 1 Rationale: The American Diabetic Association does not specify a maximum amount of carbohydrates to be consumed daily, but the minimum recommendation is 130 grams/day from various fruits, vegetables, legumes, and whole grains. The addition of high-fiber foods is an important component in healthy bowels. Complex carbohydrates are recommended over simple carbohydrates which are high in calories and low in nutritional value. High-fiber foods are highly recommended as a source of complex carbohydrates and have been associated with improved insulin sensitivity. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application 2. When discussing diet planning with a type 2 diabetic who uses insulin, the nurse should encourage him to: Subtract several servings of carbohydrates from his daily meals and use them for snacks. Add several servings of carbohydrates as snacks throughout the day without adjustments to meals. Adjust his carbohydrates for snacks, but only eat them if he feels hungry between meals. Eat a larger snack if he gets hungry in the middle of the day and skip his next meal. Answer: 1 Rationale: Daily insulin doses are calculated on the number of calories consumed per day, so snacks should be subtracted from the carbohydrates allowed for meals to maintain the same intake. Adding additional calories throughout the day may necessitate an insulin adjustment to maintain good glucose control. Skipping meals can result in an overabundance of insulin and result in a hypoglycemic episode. Calorie intake should be as consistent as possible to maintain optimized levels of blood sugar. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Application 3. Mr. D is an African American diabetic who is 60 years old. His weight is 190 pounds and his BMI > 25. He has several co-morbid conditions including hypertension, hyperlipidemia, and smoking. His most recent lipid panel results showed cholesterol 242, triglycerides 240, LDL 200, and HDL 23. The nurse should inform him that he has several risks for developing heart disease including: Race, age, and moderate weight. Obesity, low LDL, and diabetes. Diabetes, tobacco cessation, and obesity. Diabetes, hypertension, and age. Answer: 4 Rationale: Being African American, being male, and increasing age are all risk factors for developing heart disease. Obesity and diabetes are also risk factors, but can be modified with diet, exercise, and good blood sugar control. Cigarette smoking is an independent risk for heart disease. The current recommendation for LDL in clients with other risk factors for heart disease is 70–100 mg/dl. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application 4. The client is diabetic and is estimated to need 3,200 kilocalories per day. How many grams of carbohydrates does this client need to ingest each day? Round answer to a whole number. Answer: 400 grams Rationale: Diabetic clients need to receive 50% of their kilocalories from carbohydrates. This client needs 3,200 kilocalories each day. Fifty percent of 3,200 is 1,600 kilocalories each day from carbohydrates. There are 4 kilocalories in each gram of carbohydrate. This means that the client needs 400 grams of carbohydrates each day. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Learning Outcome 4 To assess cultural and lifespan variations when assisting clients to set goals and manage change in their nutritional patterns. 1. Maria is a 38-year-old Hispanic female recently diagnosed with type 2 diabetes. She has a family history of obesity, tobacco abuse, cardiac disease, and diabetes. She and her significant other (SO) and three children live with her parents, an aunt, and several nieces and nephews in a duplex house. The family members share household responsibilities. Both she and her SO work at a local factory and their incomes are used to support the entire family. Her mother prepares traditional food and is responsible for all meal preparation. Maria always listens attentively when the provider discusses diabetes management but never makes the lifestyle changes recommended. After talking with her you suspect: Maria depends on her mother to prepare daily meals and she is hesitant to make suggestions to her mother about her dietary needs since she cooks for the whole family. Maria does not understand the importance of following a balanced diet and chooses to eat whatever is the easiest for her. Maria may have limited money to spend on food and so relies on her mother to feed them all. Maria prefers traditional food and is just looking for a reason not to change her dietary habits. Answer: 1 Rationale: In the Hispanic culture it is not unusual for the client to be unwilling to put her medical needs above the needs of family members. Assuming that she is able to speak and comprehend English, there is no indication that Maria is not able to understand the information provided to her. Since both she and her SO work at a local factory and share a house with other family members they should be able to afford food for themselves and their children or be eligible for public assistance. Dietary changes can be made while still eating many traditional foods by substituting low-fat and low-calorie traditional food alternatives. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application 2. Ho is a middle-aged diabetic male of Asian descent. He moved to the United States about three years ago and continues to practice his traditional Asian cultural traditions. During his clinic visit the nurse reviewed his current medications, and was not too surprised when he told her that he also uses ginseng to help control blood sugar. It is important for the nurse to: Advise Ho to only take the amount prescribed by his traditional healer. Review possible interactions with his current medications. Inform him that ginseng has been shown to be effective in clinical trials. Ginseng can’t hurt you because it is a natural plant-based remedy. Answer: 2 Rationale: Ginseng, like other traditional remedies has not been studied extensively in controlled clinical trials and so the effects and appropriate dosing are not clearly understood even by traditional healers. Ginseng is known to interact with several prescription medications. Reports show that ginseng has not been effective in controlling blood sugar more effectively than placebo. Plant-based remedies can have both positive and negative effects on the client and are not well understood. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application 3. The school nurse is responsible for developing a health plan for the diabetic student as well as educating other school staff about the student’s individual needs. One example of this would be: Monitoring immunizations to be sure the child is up to date. Providing the student a snack before gym period. Closely monitoring eating habits at school. Storing any medication that will be administered during school hours in a safe place. Answer: 2 Rationale: The school nurse is responsible for monitoring the immunization status of all students in her care. Students with diabetes should be encouraged to eat a snack before strenuous activity to prevent hypoglycemia. Although the school nurse should provide diabetic education to the student and discuss ways to improve eating habits, she is not responsible for monitoring eating habits at school. Storing medication in a safe place refers to medication for all students, not only those with diabetes. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Learning Outcome 5 To counsel clients regarding use of sweeteners, alcohol, dietary supplements, and vitamins. 1. Mary is a 45-year-old with type 2 diabetes. At her clinic visit the diabetic nurse educator asked to review her diet log for the past two weeks. She noted a large intake of diet beverages and asked Mary if she knew what type of artificial sweeteners they contained. Mary responded that the beverages she drank contained aspartame which she had read would help with glycemic control. The nurse informed her that: Sugar alcohols used as sweetener alternatives contain more calories because they substitute sorbitol for sugar. Artificial sweetener alternatives provide fewer calories because they are not fully absorbed in the intestines. Non-nutritive sweeteners are safe for diabetes when consumed within the recommended intake. Non-nutritive sweeteners have been shown to be beneficial with long-term glycemic and weight control. Answer: 3 Rationale: Sugar alcohols, such as sorbitol and xylitol, are used as sweetener alternatives by some manufacturers because they contain fewer calories than sugar. Sugar alcohols are not readily absorbed in the intestines. Non-nutritive sweeteners, such as saccharine, aspartame, and sucralose, are considered safe for diabetics when used as recommended. There is no evidence that non-nutritive sweeteners have any long-term benefit on glucose or weight control. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application 2: A client who is diabetic should limit alcohol consumption to one to two drinks/day with food to avoid: A hypoglycemic effect resulting from the inhibition of gluconeogenesis by alcohol. A hypoglycemic effect resulting from protein catabolism. A hyperglycemic effect resulting from the extra calories added from the alcohol. A hyperglycemic effect resulting from the deletion of nutritious foods from the diet. Answer: 1 Rationale: Excessive alcohol consumption can result in the inhibition of gluconeogenesis resulting in hypoglycemia. Protein catabolism results when the body can’t utilize or does not have a sufficient supply of glucose for energy, but is not a reaction to alcohol intake. The number of calories from alcohol should be incorporated into the total daily intake but are quickly metabolized and have no nutritional content. Nutritious foods should not be eliminated from the daily diet in order to accommodate the empty calories from alcohol. Nursing Process: Knowledge Client Need: Physiological Integrity Cognitive Level: Assessment 3. Hank is a 52-year-old professional who has type 2 diabetes. He is very health conscious and carefully follows his diet and exercises regularly. He has good glycemic control and his BMI is < 25. When reviewing his medication list, the nurse notices that he has numerous vitamins and natural supplements listed. He tells her that he spends about $300 online each month for these items. The best response for the nurse would be: Vitamins and other supplements that are “natural” are safe for consumers to use. Extra vitamins and minerals are not routinely recommended for clients with diabetes unless there is an special medical reason. Taking extra vitamins is a good practice, but supplements may interact with other medications. Only the B vitamins have been shown to result in improvements with glucose control. Answer: 2 Rationale: Although many consumers consider any products labeled as “natural” to be safe, excessive vitamin supplementation can produce unwanted side effects, and other natural supplements may interact with prescribed medications. Extra vitamins are not routinely recommended for clients with diabetes unless there is an underlying medical problem or the client is an older adult or pregnant female. In clinical trials, the addition of vitamins and other nutritional supplements have not been shown to produce any improvement in diabetes management. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Learning Outcome 6 To develop nursing interventions to assist the client and family in self-management of diabetes in aspects of nutritional intake, carbohydrate counting, weight loss strategies, maintenance of good health, and food intake during exercise. 1. When working with overweight clients with diabetes the nurses should suggest the following strategies for weight loss: Low-carbohydrate diet, increased exercise, and surgery. Increased exercise, reduction of daily calories, and ways to avoid behaviors that have been barriers in the past for weight loss. Low-protein diet, coping strategies to avoid overeating, and exercise. High-fiber diet, surgery, and exercise. Answer: 2 Rationale: Low-carbohydrate diets should be avoided in clients with diabetes to avoid increases in LDL cholesterol since they are already at risk for cardiac disease. The best initial strategy for clients with or without diabetes is increased exercise, reduction of daily calories, and developing ways to avoid behaviors that have been barriers to past attempts at weight loss. Clients wanting to lose weight should continue to eat a balanced diet that includes the recommended calories for each food group rather than restricting calories from specific food groups. High-fiber diets are recommended for diabetics based on the metabolism rate for fiber, but surgical intervention should be reserved for clients who have repeatedly been unsuccessful at weight loss attempts and are morbidly obese. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application 2. Joe comes in to see the diabetic nurse educator with questions about his diet. He is 6’3” tall and weighs 200 pounds. He walks to and from work (about 2 miles) daily and tries to eat a healthy diet. He recently changed jobs and now is involved with fieldwork that involves much more exercise. He is concerned because recently he has begun to feel fatigued during the day and several times felt dizzy in the afternoon. He is following a low-carbohydrate low-fat diet. The nurse explains that: A low-carbohydrate diet is good for diabetics and has been shown to improve glucose control. A low-fat diet has been proven to increase the rate of metabolism in diabetic clients and help with weight control. Increased exercise is beneficial for clients with diabetes but should be increased very slowly over time. Diets that restrict calories from specific food groups are not recommended for diabetics and could result in hypoglycemia especially with increased exercise. Answer: 4 Rationale: Low carbohydrate diets should be avoided by client’s with diabetes because of the increase of LDL cholesterol that results and the increased risk for developing heart disease. The American Diabetic Association recommends that 60–70% of daily calories are comprised of carbohydrates and monounsaturated fats, while trans fat should be avoided. Increased exercise, reduction in daily calories, and developing strategies to avoid barriers to previous weight loss attempts are the recommended initial steps for a successful weight loss program. Diets that restrict calories from specific food groups are not recommended for diabetics and could result in episodes of hypoglycemia especially with the increased energy demands during increased exercise. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application 3. The school nurse is concerned about Jim, a 12-year-old student with type 1 diabetes. He has recently had three episodes of hyperglycemia during school hours and had to be brought to the nurse’s office for care. When discussing Jim’s food choices the nurse realizes that he does not understand what foods are classified as carbohydrates because he told her he could eat an unlimited amount of: Orange juice. Hot dogs. Peanut butter. Popcorn. Answer: Orange juice Rationale: Orange juice has high-fructose content and may contain added sugar and would be classified as a carbohydrate. Hot dogs contain protein, fat, and a moderate amount of filler that could include carbohydrates. Peanut butter is considered fat and protein, but can also have added sugar. Popcorn is a carbohydrate but because of the high-fiber content will be metabolized slower than orange juice. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application 4. The client is diabetic and has been noncompliant. The client has hypoactive bowel sounds. The client frequently eats high-fat, low-fiber foods. Which of the following areas of the body may be affected by these types of behaviors? Click in the figure to indicate your selection. Answer: Small and large intestines Rationale: These types of behaviors place this client at high risk for developing bezoars due to gastroparesis. High-fat, high-fiber meals, smoking, and drinking alcohol delay gastric emptying. Bezoars are undigested food masses that occur when food remains in the intestine too long. Bezoars can result in intestinal blockage if untreated. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Learning Outcome 7 To relate the strategies for prevention and treatment of hypoglycemia and hyperglycemia. 1. Kelly is a 10-year-old type 1 diabetic brought to the school nurses office complaining of feeling “sweaty and shaky” which she recognizes as symptoms of hypoglycemia. The nurse should: Provide 15 grams of glucose and recheck her finger stick in 15 minutes. Provide a large candy bar and send her back to class. Send someone to get a bottle of soda from the vending machine and tell her to drink it until she feels better. Call the ambulance if her finger stick is less than 200. Answer: 1 Rationale: Episodes of hypoglycemia should be treated by administering 15 grams of glucose and rechecking finger sticks until stable. A candy bar and soda contain more than 15 grams of glucose, and either could result in a hyperglycemic episode. Finger sticks should be checked every 15 minutes until stable to assess if the correction for the additional carbohydrates is only temporary, and if so additional doses of 15 grams of carbohydrates should be given. A blood sugar of 200 is considered hyper- not hypoglycemia. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application 2. The best method to prevent a hypoglycemic episode in a diabetic school child is to: Provide three large meals daily but avoid snacks. Send candy bars to school with the student in case hypoglycemia symptoms occur. Provide snacks during the day and prior to exercise. Avoid extra calories and closely maintain the prescribed diet plan. Answer: 3 Rationale: Children with diabetes should adjust their calories to include three meals a day plus snacks to maintain a balanced glucose level. The student should have glucose in their possession to use in the case of hypoglycemia, but candy bars might be a temptation to eat and could cause hyperglycemia. Providing snacks during the day and before exercise, such as gym, will help to ensure a steady supply of glucose. Extra calories may be needed for children because of the additional calories needed for growth but should be recommended by their dietician. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application 3. A client is brought into the urgent care clinic with complaints of weakness and confusion. A finger stick reveals blood glucose of 480. What response would be most likely to help make a diagnosis? The client always takes his insulin as prescribed and follows a healthy diet. The client drank a bottle of beer last night before bed. The client did not eat breakfast this morning because he was late for work. The client has not taken insulin for the past four days because of a flu-like illness. Answer: 4 Rationale: The fact that the client always takes his insulin as prescribed and follows a healthy diet does not provide any clues for his current condition. Although alcohol in excess may result in a hypoglycemia episode, one bottle of beer would not be considered excessive even for a diabetic client. Skipping meals after taking insulin could result in a hypoglycemia episode. Illness is the most likely cause of hyperglycemic episodes among clients with usual good glucose control. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application