University of the Philippines Los Banos

College of Human Ecology

Institute of Human Nutrition and Food

A Case study on a 52-year-old female patient diagnosed with Type II Diabetes

Mellitus with uncontrolled Hypokalemia1

HNF 42 A-3L

Alcon, Cherry Lyn

Victa, Jamella Jeanne

5 December 2019

1A case study submitted in partial fulfillment of the requirements in HNF 42: Medical Nutrition Therapy II
under Mrs. Aiza Kris Bernardo, 1st semester, 2019-2020.
I. Introduction
Electrolyte disorders are common in clinical practice and it is associated with
increased morbidity and mortality. Nutritional status, gastrointestinal absorption capacity,
coexistent acid-base abnormalities, pharmacological agents, other comorbid diseases
(mainly renal disease) or acute illness, alone or in combination are the various
pathophysiological factors that play a key role (Liamis, et al., 2013).

Liamis, et al. (2014) stated that Diabetes Mellitus is included among the diseases
with increased frequency of electrolyte abnormalities. Moreover, the aforementioned
factors are often present in diabetics. In a study conducted by Gunanithi and Sakthi Dasan
(2016), it is found that serum potassium levels were significantly lower in Type II Diabetic
patients than in normal individuals. Potassium depletion was associated with a decrease
in pancreatic beta-cell sensitivity to hyperglycemia with a reduction in insulin release.
Normal serum potassium levels are between 3.5 mEq/L to 5 mEq/L. Serum potassium
falling below 3.5 mEq/L is defined as hypokalemia (Mahan & Raymon, 2017).

Causes of hypokalemia in diabetic patients include gastrointestinal loss of

potassium (K+) due to malabsorption syndromes such as diabetic-induced motility
disorders, bacterial overgrowth, and chronic diarrheal states; and renal loss of K+ due to
osmotic diuresis and/or coexistent hypomagnesemia (Liamis, et al., 2014).

Exogenous insulin can induce mild hypokalemia because it promotes the entry of
K+ into skeletal muscles and hepatic cells by increasing the activity of the Na+-K+-
ATPase pump. The increased secretion of epinephrine due to insulin-induced
hypoglycemia may also play a contributory role (Liamis, et al., 2014).

Medical Nutrition Therapy (MNT) is one of the essentials for effective diabetes
management (Morris and Wylie-Rosett, as cited in Barakatun Nisak, 2012). Favourable
outcomes in individuals with type 2 diabetes mellitus can be achieved through
individualization of MNT administered by a dietician. A consensus report on nutrition
therapy for adults with diabetes and prediabetes was summarized in Figure 1 (Evert et

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al., 2019). The different dietary patterns included below poses variation of health benefits.
The key to successful nutrition therapy for diabetes is individualization. This information
can contribute to the avoidance of several deleterious effects associated with type 2
diabetes mellitus and electrolyte disorders for treatment of the disease.

Figure 1. Dietary patterns and health benefits

The patient in this study was diagnosed with Type 2 Diabetes with uncontrolled
hypokalemia. Biochemical test results of the patient were altered, specifically in the blood
chemistry test.
Significance of the study
International Diabetes Federation stated that 425 million people have diabetes in
the world and 159 people in the WP Region. They said that by 2045, this number will rise
to 183 million. The prevalence of diabetes in adults in the Philippines is 6.2% for the year
2017 (International Diabetes Federation, 2017).

Diabetes cannot be detected immediately without consultation to physicians and having

laboratory tests for confirmation. Moreover, awareness is significant in decreasing the risk
for this disease. Medical Nutrition Therapy plays a role to prevent or control diabetes.

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Thus, this study is important to fully understand the course of the condition to ensure the
health and nutrition of individuals at risk of diabetes and with diabetes through medical
nutrition therapy.

Objectives of the study

General Objectives
This case study aims to assess the existing disease condition of the patient
and provide a set of interventions through addressing the identified problems using
the concepts and techniques learned in HNF 41: Medical Nutrition Therapy II.

Specific Objectives
This case study specifically intends to:
1. To describe the pathophysiology of the patient’s disease condition;
2. To assess the patient’s diseases condition through examination of
anthropometric, biochemical, clinical, and dietary assessment;
3. To provide nutrition interventions specific for the case patient; and
4. To provide a one-day sample menu according to the patient’s diet
prescription.

Limitations of the study

This case study only discusses the specific disease condition of the case
patient and the appropriate nutritional assessment, diagnosis, interventions, and
monitoring and evaluation procedures. The dietary assessment may provide inaccurate
data on the patient’s energy and nutrient intake since only a single 24-hour food recall
was administered to the patient. Some of the data were purely reliant on the patient’s
subjective that may result in biased data results. Since individualization is needed to
provide a meal plan and interventions appropriate for the patient, these might not cater
the needs of the patient if there are biased data results.

The study focuses on a specific patient; thus, evaluations should not be used for self-
diagnosis or for diagnosing other people’s condition. The recommendations and sample

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diet plan provided are individualized and is limited only for the case patient and should
not be used for general population with the same diagnosis.

II. Theoretical Considerations

Pathophysiology of the Disease Condition
Diabetes Mellitus
Diabetes Mellitus is not a single medical condition, but a combination of
different disorders such as hypertension, uricemia, hypokalemia, and other more.
Diabetes Mellitus is commonly caused by high concentrations of blood glucose
often referred to as hyperglycemia. Diabetes can be classified as Type 1 Diabetes,
Type 2 Diabetes, and Gestational Diabetes (Nelms et al., 2010).

The main organ that is involved in Diabetes is the pancreas. The pancreas
plays two different roles, as endocrine and exocrine functions. For digestion, it
functions with the exocrine system to produce enzymes. For controlling blood
sugar in the bloodstream, the pancreas functions with the endocrine system. The
pancreas has endocrine cells called islets of Langerhans. These cells can be alpha
or beta cells which is responsible for producing glucagon and insulin, respectively,
that is essential in energy utilization (Harold, 2006).

Type 1 Diabetes occurs when the beta cells in the pancreas do not produce
enough insulin for the body to transport glucose from the bloodstream to the cell
for energy utilization. This type of diabetes proceeds at birth when there is already
a defect in beta-cells resulting in impaired insulin production. The rate of beta-cell
destruction proceeds rapidly during infancy and childhood. The capacity of the
pancreas to secrete insulin is not enough for the normal body needs to utilize
glucose in the blood (Mahan et al., 2014). Thus, the clinical onset of diabetes type
1 is mostly asymptomatic throughout the years.

Type 2 Diabetes, on the other hand, is mostly caused by insulin resistance

due to obesity and excessive visceral fats. The risk factors for Type 2 DM includes

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heredity, race/ethnicity (American Indians, African Americans, Hispanics/Latinos,
Asians, and Pacific Islanders), physical inactivity, age (specifically those above 45
years old), cardiovascular diseases, polycystic ovarian syndrome, and acanthosis
nigricans which is a condition related to insulin resistance (NIDDK - NIH, 2016),
and is mostly preceded by pre-diabetes. A sedentary lifestyle has also been linked
to an increased propensity to develop type 2 diabetes (Saunders, 2014). Some
non-obese individual is diagnosed by Type 2 diabetes due to increased body fat
percentage distributed mostly in the visceral part of the body (Holt, et al., 2010).

Gestational Diabetes occurs only during pregnancy, where blood sugar

levels are increased due to an increase in weight and elevated hormones.
Gestational diabetes also may result in neonatal diabetes that may occur after
giving birth. If not managed, gestational diabetes may develop type 2 diabetes.

The lack of insulin that the pancreas is producing, the destruction of beta-
cells, and insulin resistance prevent the entry of glucose into the cells for energy
utilization. Consequently, glucose will build up in the bloodstream causing a
condition called hyperglycemia or glucose accumulation in the blood. Elevated
levels of glucose in the blood, if left untreated can cause damage to the blood
vessels, nerves and organs, which leads to long-term health problems.

Hypokalemia
Aside from hyperglycemia, diabetic patients frequently develop a
constellation of electrolyte disorders. Patients are often potassium-, magnesium-,
and phosphate-depleted. Severe and life-threatening hypokalemia is defined when
potassium levels are <2.5 mEq/L. In outpatient population undergoing laboratory
testing, mild hypokalemia can be found in almost 14%. Furthermore, as many as
20% of hospitalized patients are found to have hypokalemia but only in 4–5% this
is clinically significant (Udensi, 2017).

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 Diabetes is linked to chronic hypokalemia which is characterized as low in
serum potassium levels in the blood. Hypokalemia is caused by different factors
such as insulin administration, gastrointestinal loss of potassium due to
malabsorption, and acidosis. Hypokalemia mostly occurs in diabetic patients or
those with impaired insulin secretion and decreased peripheral glucose utilization
resulting in carbohydrate intolerance and hyperglycemia (Liamis, et al., 2014). It is
also associated with diarrhea and malnutrition. According to a case study
conducted by Rowe et. al., Hypokalemia is associated with impaired insulin
secretion and decreased peripheral glucose utilization resulting in carbohydrate
intolerance and hyperglycemia (Gunanhiti & Sakthi, 2016). These infers that
hypokalemia can contribute to hyperglycemia and vice versa.

Potassium is predominantly intracellular where it is the most abundant

cation and involved in cell regulation. Homeostasis of potassium levels are
maintained through a combination of adjustments in acute cellular shifts between
extracellular and intracellular fluid compartments. The incidence of hypocalcemia
is caused by decreased potassium intake, increased cellular uptake, or increased
potassium loss (Castro, 2019).

Clinical Signs and Symptoms

Type 2 diabetic patients mostly experience symptoms of hyperglycemia,
fatigue, excessive thirst, and frequent urination. Most of the patients diagnosed
with T2DM are overweight or obese, and high body fat distribution in the visceral
area. Some of the patients have hypertension, dyslipidemia, decreased cellular
uptake of glucose and increased postprandial glucose. For hypokalemia, clinical
symptoms do not become evident until the serum potassium level becomes less
than 3 mmol/L. Significant muscle weakness, feeling of paralysis in some parts of
the body, and symptoms of nausea, vomiting, and abdominal distension (Schrier,
n.d).

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Diagnosis
Diabetes can be diagnosed in four ways, including medical history, physical
examination, laboratory examination, and referrals. Medical history comprises the
history of diabetes-related diseases such as microvascular disease (retinopathy,
neuropathy), and macrovascular disease (CHD, cerebrovascular diseases, and
PAD). Physical examination, on the other hand, includes anthropometric
assessment, blood pressure determination, and clinical assessment. Laboratory
examination comprises of different laboratory exams including different blood
sugar tests. These laboratory tests include HbA1C, Fasting Blood Glucose
including LDL, HDL, triglycerides, Liver function tests, a test for urine albumin
excretion serum creatinine (Mahan, et.al. 2017; Nelms, et.al. 2010; ADA, 2007)

Glycosylated Hemoglobin (HbA1c)

Glycosylated Hemoglobin measures the amount of glucose bound to
hemoglobin protein. The higher the glucose concentration in the blood, the
more hemoglobin is glycated, making he HbA1c test valid to measure the
degree of hyperglycemia. The normal level of HbA1C is within the range of
4.5 to 6.4%. Exceeding the normal range means the individual is
hyperglycemic and may be positive for Diabetes Mellitus. (Nelms, et. al.,
2010; Mahan, et.al, 2017)

Oral Glucose Tolerance Test

This is rarely needed to diagnose diabetes due to a sudden onset of
symptoms accompanied by hyperglycemia, but it is considered as the
standard for gestational diabetes. This test is administered after three days
of an unrestricted diet providing at least 150 grams of carbohydrate. For 2-
hour postprandial glucose during an oral glucose tolerance test involving
administration of 75 grams of glucose, the normal value is less than 140
mg/dl, within the range of 140-199 mg/dL is considered prediabetes and
exceeding a value of 200 mg/dL indicates diabetes (Nelms, et. al., 2010).

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 Fasting Plasma Glucose
Fasting plasma glucose is administered after fasting for at least 8
hours. Fasting is defined as no caloric intake, either food or beverage for a
period of time. The normal value for Fasting Blood Glucose is less than 100
mg/dL and is considered prediabetes with values less than or equal to 126
mg/dL, beyond 126 mg/dL is considered diabetic (ADA, 2007).

Testing or screening for diabetes should be considered for all individuals at

age 45 years and above, particularly with a BMI of 25 kg/m² or more (ADA, 2006).
For individuals with younger age, testing should be considered if he/she has the
following risk factors—habitually physically inactive, have a first-degree relative
with diabetes, hypertensive, high HDL levels, have polycystic ovary syndrome,
history of vascular disease, and other conditions associated with insulin resistance
(Saunders, 2010)

Prognosis
Type 2 diabetes when not managed can increase the likelihood of major
cardiovascular, renal, and nervous system-related diseases and sometimes, even
death. But the risks are variable depending on the patient’s characterization (age,
lifestyle, behavior, etc.). Since diabetes does not have treatment, life-long
medication and maintenance are needed. The treatment plan may include diet
modification, oral medications, insulin shots, and lifestyle change which is likely to
require adjustments over time. Insulin resistance increases with age, and insulin-
producing cells in the pancreas may wear out (Mahan, et.al; Nelms, et.al; Holt,
et.al.)

The cumulative prevalence of vision-threatening diabetic retinopathy in the

US is about 4.4 % among adults. Prevalence of an end-stage renal disease is
about 1% in those patients diagnosed with type 2 DM, but cumulative prevalence
of nephropathy and/or chronic kidney disease is much higher (CDC, 2004).
Effective treatment requires a motivated and informed patient who actively takes

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 responsibility for his or her individualized care together with the health care
provider to prevent further complications of the disease condition.

III. Methodology
A letter of request for a case-patient was submitted to St. John the Baptist Medical
Center. After the approval of the letter, a case-patient was found through the help of the
nurses on duty in the ward. The case-patient was admitted on November 3, 2019 due to
her diabetic condition and dizziness. The data collection that was conducted on
November 5, 2019 has three parts—1) information collected from the patient’s medical
chart; 2) interview with the patient; and 3) consultation with the attending Nutritionist-
Dietician.

Information such as the patient’s diagnosis, anthropometric data, and laboratory

tests findings, medications, IV fluid prescription was obtained from the medical chart. Data
such as personal data, 24-hr food recall, food likes and dislikes, eating behaviors, food
preferences, and factors affecting food intake was gathered during the interview through
the use of nutrition assessment forms. Food intake and diet prescription for the patient
was confirmed through consultation with the attending Nutritionist-dietician. Furthermore,
the researchers provided informed consent which states that the case-patient is allowing
the researchers to use her personal/medical information for academic use only in
compliance with the Data Privacy Act of 2012.

Data analysis of the information obtained was done by the researchers, and further
reading on the condition was also done to comprehensively assess the disease case of
the patient for medical nutrition therapy consideration. The anthropometric
measurements obtained were used in assessing the patient's nutritional status. The
nutritional status of the patient was evaluated using her dry body weight. Her body mass
index was computed using the World Health Organization (WHO) formula and was also
assessed and classified according to the WHO cut-off points for BMI (WHO, 2019):

BMI = body weight in kg / height in m2

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 Table 1. The International Classification of adult underweight, overweight, and
obesity according to BMI.

The patient’s biochemical results and medications were obtained through her
medical chart that was provided by the attending nurse. For the clinical assessment, the
considerations included the patient’s signs and symptoms and signs of nutrient
deficiencies, which served as the basis of addressing nutrient-related problem. As for her
dietary intake, food frequency questionnaire and a 24-hour food recall were assessed
qualitatively and quantitatively by comparing the recommended intake from the actual
intake and by using the menu eval plus software from the Food and Nutrition Research
Institute (FNRI).

The desirable body weight of the patient in kilograms was calculated using the
Tanhausser’s method for adults stated in the Diet Manual of the Nutritionist-Dietitians’
Association of the Philippines by Tanchoco and Jamorabo-Ruiz (2010) following the
formula:

DBW (kg) = [Height in cm - 100] - 10% [Height in cm - 100]

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 The Total Energy Requirement (TER) of the patient was computed using Krause’s
Formula, with a physical activity identified as light since the patient does not usually
engage to physical activity. Computations is summarized on Appendix A of the
appendices.

TER (kcal) = kg BW x PA kcal/kg/BW

Lastly, a nutritional care plan was formulated. In this part, the standard NCP format
was used, which was ADIME (Assessment, Diagnosis, Intervention, Monitoring and
Evaluation). Diet recommendations were given based on the results from the
assessments and from the nutrient-drug interaction supported by different literatures. The
suggested sample menu plan was highly individualized, patterned to the patient’s current
condition, food preferences, and socio-economic status.

IV. The Patient

Personal Information
Mrs. F.N. is a 52 years old widow who is diagnosed with Diabetic Type II
upon admission at the St. John the Baptist Medical Center last November 13,
2019. She has a standing height of 157.48 cm and weight of 49 kg. The patient
has a moderate physical activity prior to admission for she engages in activities
such as walking and light household chores for 1 hour twice a week. Her highest
educational attainment is High School Graduate and worked as a Barangay Health
Worker in their community before her condition worsened.

The Physical State of Health

According to the interview conducted with the patient, the patient currently
has a loss of appetite due to her present condition. Upon admission, the patient
was conscious and afebrile but was experiencing some vomiting and dizziness.
There has been a history of hospitalization with the same symptoms but there has
been a loss of consciousness.

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 Present illness and chief complaint
She was admitted to the hospital with a chief complaint of severe dizziness.
Her laboratory results show a high Fasting Blood Glucose level of 142.50 mmol/L,
high Blood Urea Nitrogen (BUN) of 89.73 mg/dl, and high blood pressure of
140/90. Thus, the patient was diagnosed with Diabetes with uncontrolled
hypokalemia. Other laboratory results are summarized in Table 2.

Other health and nutrition data

The patient frequently skips breakfast and lunch and only eats afternoon
snacks and dinner. She particularly likes to eat rice before but due to her current
condition, she is now monitoring the intake of white rice. Her food dislikes include
chicken and other fishy foods. The patient seldom eats out and prepares her own
food at home. Before admission, the patient has low water intake but always drinks
caffeinated beverages such as coffee. Mrs. F.N. has poor food intake and only
eats when hungry or because she has to.

The blood pressure of the patient upon admission is 140/90 which classifies
her as high blood pressure or Stage 1 hypertension according to the American
Heart Association. Due to the recent findings, the attending physician ordered a
low fat, low carbohydrate, high potassium diet for the patient. An increase in fluid
intake is also administered to the patient.

Table 2. Blood chemistry, urinalysis, and other laboratory test results.

Complete Blood Count (CBC)

Test Test Findings Normal Values Interpretation

Hemoglobin 12.0 12-16 Normal

Hematocrit 35% 36-57% Normal

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White Blood Cell (WBC) 8.7 3.4-9.6 Normal

Red Blood Cell (RBC) 4.0 3.90-5.03 Normal

Segmenters 77% 50-67% Elevated

Lymphocytes 235 23-35% Normal

Blood Chemistry

FBS 142.50 mg/dL 75-115 mg/dL High

HbA1c 9.2% 4.5-6.4% High

BUN 89.78 mg/dL 10-50 mg/dL High

Creatinine 2.38 0.5-1.0 High

Uric Acid 6.81 mf/dL 2.4-5.7 mg /dL High

Cholesterol 251 dL <190 dL High

TCG 508.71 dL <150 dL High

HDL 50 mg/dL > 65 mg/dL Low

LDL 90.26 mg/dL <130 mg/dL Normal

SGPT 13.73 μ/L <31 μ/L Normal

AST/SGOT 26 μ/L <31 μ/L Normal

Electrolytes

Potassium 2.19 3.5-5.1 mmol/L Low

Urinalysis

Specific gravity 1.010 1.002-1.030 Normal

pH 6.5 4.5-8.0 Normal

Albumin 3+ Positive for Albuminuria

Sugar 4+ High

WBC 0.3/HPF 0-5/HPF Normal

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 RBC 2.3/HPF 0-5/HPF Normal

Amorphous Urate Moderate Moderate

**Reference for normal values were from the reference values used by the hospital

Table 2. Medications prescribed by the attending physician to manage the patient’s current
condition, amount and frequency per medication, and rationale of use

Drug Dosage Rationale of Use

Human Biphasic Insulin 20 units SQ in AM Control sugar level

10 unites SQ in PM

Fenofibrate 200 mg/cap Control high LDL levels

Telmisartan 20 mg/tab OD Not specified

K-Lyte 2 tabs OD Control serum potassium levels

Losartan 100 mg/tab PO Control HPN

Catapres 75 mg/tab Control HPN

Amlodipine 10 mg/tab Not specified

Betahistine 10 mg/tab as needed Manage dizziness

Humulin 8 units SQ Not Specified

V. Results and Discussion

Anthropometric Assessment
The patient’s height and weight were collected upon admission with 157.48
cm and 49 kg respectively. The patient’s Body Mass Index (BMI) was computed
using her present body weight with a BMI value of 19.76. Based on her computed
BMI, the patient’s nutritional status is classified as normal, according to the WHO
cut-off points.

Although the patient’s nutritional status is interpreted as normal, caution

must be considered since the patient’s BMI value is near the value for underweight.
Moreover, the patient has inadequate intake of fat, sugar, eggs, and vegetables

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(See Table 5) and inadequate intake of high caloric foods and nutrient dense food
(See Table 6). There is a risk of decreased weight if the food intake of the patient
remains inadequate. Therefore, the patient’s nutritional status being underweight.

Biochemical Assessment
According to the patient’s laboratory tests, she has high blood sugar with
high creatinine levels of 2.38, high BUN levels of 89.78 mg/dL, high HbA1c of 9.2%,
and high FBS level of 142.50 mmol/L which indicates the positive for diabetes. The
patient is also positive for albuminuria with an albumin level of 3+ and high uric
acid levels of 6.81 mf/dL.

The patient has elevated segmenters based on the CBC result. Segmenters
are also called neutrophils. Neutrophils participate as mediators of inflammation
(Rosales, 2018). They are a type of white blood cells that helps heal damaged
tissues and resolve infections. High percentage of neutrophils indicates that the
body has an infection or injury. However, it can also be high due to medications
such as corticosteroids and epinephrine; some cancers; physical or emotional
stress; surgery or accidents; and smoking tobacco.

According to the American Diabetes Association, a person has diabetes if

his/her HbA1c is ≥6.5% or FBS ≥126 mg/dl or 2-hour PG ≥200 mg/dl. The patient’s

results on fasting blood sugar (FBS) and HbA1c are both higher than the normal
levels. This indicates that the patient is diagnosed as diabetic.

Blood urea nitrogen (BUN) measure the amount of urea nitrogen found in
the blood. Urea’s waste product is nitrogen. The kidneys filter the urea to be
excreted through urination. If the BUN level is high, it is an indicator that the
kidneys are not functioning well. Creatinine is a waste product of muscle
metabolism. It is transported through the bloodstream, filtered in the kidney, and
excreted through urination. High creatinine level also indicates that the kidney is
not functioning well (Hosten, 1990).

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 Table 3. Indications for use of the prescribed medications, its nutrient-drug interaction,
and the dietary strategies to manage nutrient interaction

Drug Indications Nutrient Dietary

Interaction Strategies

Human Biphasic Helps in lowering high levels of blood Do not take in NA

Insulin glucose. Biphasic insulin 70/30 has a together with
single peak, which comes from its aspirin, and
soluble component. furosemide

Fenofibrate Helps reduce cholesterol and It is used along

triglycerides (fatty acids) in the blood with a proper
diet to help to
Should not be taken if a person has liver treat high
disease, gallbladder disease, severe cholesterol and
kidney disease or if breastfeeding a high triglyceride
baby levels

Can cause breakdown of muscle tissue

leading to kidney failure

Telmisartan Used to treat high blood pressure, to NA NA

lower the chance of heart attack, stroke,
and death in some people

Should not be taken when a person is

pregnant

K-Lyte Mineral supplement used to treat or NA NA

prevent low amounts of potassium in the
blood

Losartan Keeps blood vessels from narrowing, Should not be NA

which lowers blood pressure and used together with
improves blood flow; used to treat high any medication
blood pressure (hypertension). It is also that contains
used to lower the risk of stroke in certain aliskiren
people with heart disease.

Used to slow long-term kidney damage

in people with type 2 diabetes who also
have high blood pressure

Catapres Clonidine, a drug that blocks signals in Alcohol should not Strict adherence
the brain controlling heart rate and be taken when to the prescribed
blood pressure. Lowers blood pressure taking in clonidine. frequency of

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 by decreasing the levels of certain intake to prevent
chemicals in your blood; Allows your side effects.
blood vessels to relax and your heart to
beat more slowly and easily

Used to treat hypertension (high blood

pressure)

Amlodipine A calcium channel blocker that dilates Drinking alcohol Do not use
(widens) blood vessels and improves can further lower together with a
blood flow; used to treat chest pain your blood multivitamin with
(angina) and other conditions caused by pressure and may minerals since it
coronary artery disease; also used to increase certain decreases the
treat high blood pressure (hypertension) side effects of effect of
amlodipine amlodipine.
For use in adults and children who are
at least 6 years old

Betahistine Used to treat dizziness (vertigo) in those Do not take in with NA

who have Meniere's disease. antihistamine.
Take note of
allergies before
giving beta
histamine.

Humulin An insulin that is used to control high Alcohol intake is May cause
blood sugar in adults and children with not allowed while hypokalemia if
diabetes mellitus who need more than using Humulin given in high
200 units of insulin in a day dosages/ mis
dosage.
Cannot be taken if blood sugar is too
low

Clinical Assessment
The patient was admitted due to a chief complaint of dizziness. The
attending physician primarily diagnosed the patient with diabetes, suspected for
renal disease. The attending physician ordered laboratory tests including complete
blood chemistry, urinalysis, and blood tests to confirm the patient’s current
condition. With the high blood pressure of the patient, of 150/90, the patient is
considered hypertensive. The final diagnosis of the attending physician,
considering the patient’s clinical manifestations supported by her laboratory
results, was type 2 diabetes mellitus with uncontrolled hypokalemia. Further

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observation on the patient’s condition was conducted by the attending physician
to confirm initial suspicion of having renal disease.

Dietary Assessment
A 24-hour recall form was conducted to determine the nutrient intake of the
patient 24-hours prior to the interview. It was quantitatively evaluated using the
FNRI-Menu Eval Plus to efficiently determine the energy and nutrient adequacy of
the patient’s food intake. The diet history and other necessary information, as well
as, the 24-hour food recall was obtained November 5, 2019 at the St. John the
Baptist Medical Inc. The attending physician ordered a “DM diet”, which is a
controlled carb, low fat, low salt diet. It was also advised to increase oral fluid
intake. The resident dietician instructed the patient to drink only on the given
container to easily monitor the patient’s fluid intake. Summarized in table 4 is the
analysis of the diet prescribed by the attending physician.

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 Table 4. Analysis of the doctor’s prescription
Nutrient Amount Remarks Remarks
(A/D)
Low Normal High

Calories ✔ Agree Increase gradually to manage decreasing

weight

Macronutrients Control carbohydrate, carbohydrate

CHO - counting is recommended due to insulin
CHON - administration. Provide healthy fats rich in
Fats ✔ Agree LDL.

Micronutrients Monitor potassium levels; may increase

Potassium ✔ Agree blood pressure levels when given in
Sodium ✔ Agree excess.

Consistency of mechanic Agree Since the patient has no appetite, give

Meals al soft food that are tasty and easy to chew since
the patient does not have a complete set
of teeth.

Fluid ✔ Agree Good strategy to have a container

specifically or oral liquid intake, as well as
foods with soup.

Aside from the diet recommendation from the attending physician, administration
of IV fluid was also prescribed to facilitate increase intake of potassium. Upon admission,
the patient was given 1 L PNSS with 40 mEQ of KCL administered intravenously.
Potassium by IV infusion should only be used for the treatment of severe hypokalemia as
it cannot be rapidly corrected via the oral route (Olson, et. al, n.d)

As seen in table 5, where the dietary intake of the patient was assessed
quantitatively using the Men Eval Plus software, the patient has inadequate intake of all
the macronutrients with energy intake of only 32% and macronutrient intake adequacy
of 35% for carbohydrate, 32% for protein, and 30% for fat intake. There is also an
inadequate intake of micronutrients with only niacin and vitamin C intake is assessed as
adequate with percent adequacy of 95% and 85%, respectively.

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 Table 5. Quantitative Dietary Analysis Evaluation of the Patient’s Typical Food Intake
Food Amount Energy Protein Fat CHO Ca Phos Iron Vit A Vit Vit Niacin Vit C SFA PUF MUF Chol
Eaten (kal) (g) (g) (g) (mg) (mg) (mg) (ug B1 B2 (mg (mg) (mg) A A (mg)
RE) (mg) (mg) RE) (mg) (mg)
Breakfast
Rice ½ cup 103 1.7 0.2 23.8 9 29 0.5 0 0.02 0.02 0.7 0 - - - -
Nilagang 1 mbs 52 9.9 1.4 0 31 46 0.8 6 0.01 0.01 3 0 0.32 0.22 0.38 25
Manok
Cabbage 22.5 g 5 0.1 0 1.1 8 3 0.1 1 0 0.01 0 3 - - - -
Potato 15 g 9 0.3 0 2.1 5 7 0.1 0 0.01 0.01 0.3 4 - - - -
Milk, 45 g 54 2.7 0.5 1.8 0 0 0 0 0 0.01 0 0 - - - 7
Bbrand
Lunch
Nilagang 1 slice 32 5.4 1.1 0 22 55 0.2 20 0.02 0 2.3 0 0.27 0.36 0.25 11
Tilapa
Pechay ½ cup 9 0.8 0.2 1.1 70 14 1.2 102 0.03 0.06 0.4 24 - - - -
Rice ½ cup 103 1.7 0.2 23.8 9 2.9 0.5 0 0.02 0.05 0.07 0 - - - -
Apple 1 slice 10 0.1 0 2.4 1 1 0 1 0 0 0 0 - - - -
Singkamas 5g 2 0.1 0 0.5 1 1 0 0 0 0 0 1 - - - -
Cucumber 5g 1 0 0 0.1 1 1 0 0 0 0 0 1 - - - -
Dinner
Rice ½ cup 103 1.7 0.2 23.8 9 29 0.5 0 0.02 0.02 0.07 0 - - - -
Nilagang 1 mbs 6 4.7 5 0 8 48 0.4 84 0.07 0.08 1.7 0 0.36 0.09 0.42 32
Baboy
Cabbage 22.5 g 5 0.1 0 1.1 8 3 0.1 1 0 0.01 0 3 - - - -
Potato 15 g 9 0.3 0 2.1 5 7 0.1 0 0.01 0.01 0.3 4 - - - -
Watermelon 60 g 19 0.1 0.1 4.3 5 4 0.1 10 0.01 0.02 0.1 4 - - - -
Diet Intake 581 29.5 8.9 87.8 191 275 4.7 225 0.22 0.29 10.4 44 0.95 0.67 0.71 75
Diet Rx 1800 90 40 270 600 580 26 433 0.90 0.90 11.0 52 2.1 3 6 200
%Adequacy 32.28 32.78 29.67 35.12 31.83 47.41 18.08 51.96 24.44 32.22 94.55 84.62 45.24 22.33 11.83 37.5
**SFA, PUFA, MUFA, Cholesterol content was based on the Diet Manual, NDAP 2010
*Red-Inadequate; Green-Adequate; Blue-Within recommendation for current condition

21
 In table 6, the patient’s dietary intake was assessed qualitatively. It can be
observed that most of the food groups are taken inadequately. The patient has
inadequate intake of fat, sugar, eggs, and vegetables. However, she has actual intake of
3 servings of meat, poultry, and fish, 1 glass of milk, 3 servings of fruit, and a liter of water,
which is within the recommended intake of food groups.

Table 6. Qualitative Dietary Analysis Evaluation of the Patient’s Typical Food Intake

The patient needs to increase intake of high caloric foods and nutrient dense food
to increase the patient’s adequacy and decrease the risk of micronutrient deficiency.
Multivitamin supplementation may be recommended to increase intake of different
micronutrients especially for calcium and vitamin A to provide the needs of the patient in
her elderly years.

VI. Nutritional Care Plan (See Appendix B)

With the final diagnosis of type II diabetes mellitus with uncontrolled hypokalemia, the
nutritional care plan was made. The primary nutrition diagnosis that was identified was

22
the presence of hypoglycemia or the increase of blood glucose level of 9.2% HbA1c.
Since the attending physician already administered Humulin, an intermediate-acting
insulin, to the patient to control hyperglycemia, the nutritional interventions identified was
to give a diet prescription of 1800 kcal diet, 270 g Carbohydrates, 90 g Protein, and 40 g
fat wherein carbohydrate counting based on insulin type is advised. According to the
American Diabetic Association, monitoring carbohydrate intake, whether by carbohydrate
counting or experience-based estimation, remains a key strategy in achieving glycemic
control (Nelms, 2010). Summarized in Table 7 are the diet recommendation and its
rationale for the case patient.

Table 7. Diet recommendation and rationale for the case patient

Diet Recommendation Rationale
Adequate energy intake to maintain
reasonable body weight and
Energy 1800 kcal
prevent risk for muscle wasting
(NDAP, 2010)
50-60% of total calories is
recommended and that there
should be sucrose limitation in
Carbohydrate 270 g support with weight management;
and carbohydrate counting to
control hyperglycemia (Krause,
2016; Nelms, 2010)
Has minimal acute effects on
glycemic response, lipids, and
hormones, and no long-term effect
on insulin requirements. (Krause,
Protein 90 g
2016) Moderate protein intake to
control high levels of BUN and
Creatinine (Krause, 2016; Nelms;
2010)
Fat 40 g To decrease risk in developing
SFA <7% CVD. Can raise LDL and lower HDL
PUFA <10% Cholesterol levels.
MUFA Provides essential fats that the
<20%
Cholesterol body can’t produce; decrease bad
<200 mg cholesterol (LDL)
(Krause, 2016)

23
 To manage hypertension (Sanei et.
Sodium <2,300 mg
al, 2014)
To help increase potassium levels
that may alleviate hypokalemia;
Potassium 40 - 100 mmol/d
replenish potassium excreted
(Cohn, 2000)
To decrease risk of developing or
Fluid 1.5-2L further development of renal
disease (Retner, 2018)
Vitamins and Minerals To achieve micronutrient adequacy
Vitamin E RDA Values Some studies reported that
Vitamin D RDA Values recommending doses of
Magnesium RDA Values antioxidant, magnesium, and
Chromium RDA Values chromium improves glycemic
control and treatment of
complications. Chromium
supplementation was also studied
to help in the management of
insulin resistance for T2DM (ADA,
2019)
Other Recommendations Improvement in glycemic and lipid
Probiotics 125-250 g parameters, and possibly prevent
various disorders including
diarrhea, irritable bowel
movements, etc. (Barengolts, 2019)

Plant stanols and 1.6-3 g Individuals with diabetes and

sterols dyslipidemia may be able to
modestly reduce total and LDL
cholesterol.

For the second nutrition diagnosis, control of hypokalemia related to the patient’s
diabetic condition shall be addressed by an increase of dietary potassium intake. Since
the attending physician already administered an IV fluid with 40 mEq KCL, monitoring of
the potassium electrolyte levels is recommended. If the potassium level is still low, provide
potassium-rich food is to aid in alleviating hypokalemia. For the third nutrition diagnosis,
inadequate energy and nutrition status due to the patient’s loss of appetite should be
addressed. The patient’s energy and nutrient intake is relatively very low as evidenced
by the quantitative dietary assessment where most of the macro- and micronutrient intake
is below 50%. This shall be addressed by adherence on the recommended dietary
prescription. According to the American Diabetics association, a modest weight loss may

24
provide clinical benefits (improved glycemia, blood pressure, and/or lipids) in some
individuals with diabetes, especially those early in the disease process (Nelms et. al,
2010). However, even if the patient’s nutritional status is normal, adequate calorie should
be given to prevent weight loss that may be detrimental to the patient’s current condition.

Nutrition Education is important in medical nutrition therapy to provide awareness

to the patient’s condition and to offer some strategies on how to improve health and
nutrition status. Nutrition education is also vital for the patient’s lifestyle change and in
changing behavior towards food. Since the patient is currently anorexic, nutrition
education with her family is recommended to give awareness on the complications that
may arise if the energy and nutrient intake is not managed well. Short discussions on the
glycemic index, sodium, and potassium content of food is also significant in demystifying
misconceptions about nutritional benefits.

Nutritional care plan and dietary recommendations was based on the summarized
findings of nutrition related problems from anthropometric, biochemical, clinical, dietary,
and nutrient-drug interaction found on table 8.
Table 8. Identification of nutrition and nutrition-related problems

Parameters Nutrition Related Problems Other Related Problems

Anthropometry NA NA

Biochemical High Lipid levels, Suspected renal disease

High Blood Sugar,
Low HDL Cholesterol level, Low
potassium levels

Clinical Thinning appearance NA

Weakness

Dietary Inadequate intake of macronutrients Anorexia, Difficulty of

and micronutrients eating due to incomplete
set of teeth

Drug and Humulin and other insulin medication May be the reason for
Nutrient may have adverse side effects on hypokalemia
Interactions electrolyte levels

25
VII. Recommendations
Nutrition therapy is important in managing a patient’s diabetic condition, especially
in controlling high blood sugar or hypoglycemia. The goal of nutrition therapy is to
maintain an acceptable range of blood glucose level with HbA1c test result of <7%,
achieve a normal blood pressure of 120/80, lower levels of LDL cholesterol to prevent the
increase risk of developing cardiovascular disease , and to achieve or maintain the ideal
body weight to prevent or delay development of complications. Addressing the
individual’s individual nutritional needs based on their food preferences, dietary
restrictions, and to make behavioral changes on food intake is also a goal of nutrition
therapy.

There is increasing evidence that aggressive glycemic control for patients admitted
into the hospital improves clinical outcomes, especially for patients with cardiovascular
disease. The patient’s blood glucose is very high with an HbA1C of 9.2% and FBS of
142.50 mg/dL, thus the main priority is to lower the blood glucose levels. Carbohydrate
counting is advised based on the type insulin that was given by the attending physician.
The sample menu plan was patterned according to the patient’s needs. A low-fat diet was
given to decrease high lipid levels, moderate carbohydrate to control blood glucose levels
and provide adequate energy, moderate protein to provide rest for kidneys for protein
metabolism, and high potassium rich foods to increase potassium levels.

Since the patient has poor appetite and has a difficulty in chewing food, the sample
menu plan recommended a mechanical soft diet to facilitate chewing and help the patient
in increasing her energy and nutrient needs. Increased amounts of fruits and vegetables
was also given to increase antioxidants and plant sterols that may aide in managing
glycemic levels.

26
 Sample Menu Plan
Mealtime Food list # of Sample Menu HH Measure CHO Na
exchange (g) (mg)
Breakfast (6AM)
Fish stir-fry with
vegetable soup
Meat (LF) 1 Galunggong Flakes 1 pc, (14 x 3-1/2 0 87.5
cm)
Veg B 1 asparagus tips 1/2 cup 3 0
Veg B 1 mung bean sprout, 1/2 cup 3 3.4
soup
Rice 1 brown rice 1/2 cup 23 4
Fat 1 oil, cooking 1 tsp 0 0.1
Fruit 1/2 apple slices 1/4 pc 5 0.18
34
AM Snack (9AM)
Rice 1 binatog 1/2 cup 23 0
milk 1 powdered, low fat milk 4 tbsp 12 13.1
Rice 1 pandesal 3 pcs 23 270
sugar 1 1/2 brown sugar 1 1/2 tsp 8 2.1
fruit 1/2 mango, ripe 1/2 slice 5 1.65
71
Lunch (12PM)
Pork and beef
sinigang
meat (LF) 1 pork, lean 1 matchbox size 0 17
meat (LF) 1 beef, lean 1 matchbox size 0 21.6
Veg A 1 kangkong 1/2 cup 3 0
Veg A 1 eggplant 1/2 cup 3 0.6
fat 1 oil, cooking 1 tsp 0 0.1
rice 1 brown rice, boiled 1/2 cup 23 4
Fruit 1/2 banana, lakatan 1/2 pc 5 0.2
34
PM Snack (3PM)
milk (LF) 1 powdered 4 tbsp 12 13.1
Rice 2 lugaw, thick 2 cup 46 0
consistency
Meat (MF) 2 wings, chicken 2 pcs, medium 0 47
sized
sugar 1 1/2 brown sugar 1 1/2 tsp 8 2.1
fruit 1/2 apple slices 1/4 pc 5 0.18
71
Dinner (6PM)

27
 Fried bangus w/
soup
meat (LF) 2 bangus, fried 2 slices 0 50.4
fat 1 oil, cooking 1 tsp 0 0.1
Rice 1 brown rice, boiled 1/2 cup 23 4
fruit 1 mango, ripe 1 slice 10 3.3
33

After Hospitalization

After the patient is discharged, continuous monitoring is still advised to prevent

hyperglycemia or hypoglycemia. Monitoring can be done using a Self-Monitoring Blood
Glucose Level Test. Daily home glucose monitoring records the individual’s glucose level
at the very moment the measurement is taken. Information provided by the SMBG may
be used to adjust food or carbohydrate intake, physical activity level, eating patterns, and
medications to control glycemic level.

Diet Recommendation should also be continuously followed to achieve ideal body

weight and to promote energy and nutrient adequacy. Adherence to the diet may
decrease risk for nutrient deficiency, risk for muscle wasting, and other related diseases.
Carbohydrate counting is advised to monitor glycemic levels. The American Diabetes
Association (ADA) states that monitoring carbohydrate remains a significant tactic in
realizing glycemic control (Nelms et. al., 2010).

Increase in Physical activity is also recommended. Studies show that increase in

Physical Activity improved glycemic control, improved blood lipids and blood pressure,
with subsequent lower cardiovascular risks and overall mortality.

28
VIII. Literatures Cited

E-Journals
American Diabetes Association. Diabetes Care. 2019 Jan;42 Supplement 1:S46–S60.
https://doi.org.

Barengolts E., et al. (2019)The Effect of Probiotic Yogurt on Glycemic Control in Type
2 Diabetes or Obesity: A Meta-Analysis of Nine Randomized Controlled Trials.
Nutrients.11(3):671.

Barakatun Nisak, M. Y., Ruzita, A. T., Norimah, A. K., & Azmi, K. N. (2013). Medical
Nutrition Therapy Administered by a Dietitian Yields Favourable Diabetes
Outcomes in Individual with Type 2 Diabetes Mellitus. Med J Malaysia, 68(1).

Castro D, Sharma S. Hypokalemia. [Updated 2019 Feb 17]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK482465/

Centers for Disease Control (CDC). State-specific trends in chronic kidney failure -
United States, 1990-2001. MMWR Morb Mortal Wkly Rep. 2004 Oct 8;53(39):918-
20

Ellis, Harold. (2007). Anatomy of the Pancreas. Journal for Surgery (Oxford). 2 (25),
72-73. DOI: https://doi.org/10.1016/j.mpsur.2006.12.005

Evert, et al. (2019). Nutrition Therapy for Adults With Diabetes or Prediabetes: A
Consensus Report. Diabetes Care. 42(5), 731-754. DOI:
https://doi.org/10.2337/dci19-0014

Guanithi, K. and Sakthi Dasan, S. (2016). Asymptomatic Hypokalemia in Uncontrolled

Type II Diabetes Mellitus. Journal of Dental and Medical Sciences, 15(4), 36–38.

Holt, R., Cockram, C., Flyvbjerg, A., & Goldstein, B. (2010). Textbook of diabetes. 4th
Ed. Wiley-Blackwell Publication: West Sussex, United Kingdom. 161-165.

29
 Hosten, A. O. (1990). Chapter 193: BUN and Creatinine. In H. K. Walker, W. D. Hall,
& J. W. Hurst (Eds.), Clinical Methods: The History, Physical, and Laboratory
Examinations (3rd ed.). Boston: Butterworths.

Liamis, G., Liberopoulus, E., Barkas, F., & Elisaf, M. (2014). Diabetes Mellitus and
Electrolyte Disorders. World Journal of Clinical Cases, 2(10), 488–496. Retrieved
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4198400/

Liamis, G., Rodenburg, E. M., Hofman, A., Zietse, R., Stricker, B. H., & Hoorn, E. J.
(2013). Electrolyte Disorders in Community Subjects: Prevalence and Risk
Factors. The American Journal of Medicine, 126(3), 256–263. Retrieved from
https://www.sciencedirect.com/science/article/abs/pii/S0002934312007899

Rosales, C. (2018). Neutrophil: A Cell with Many Roles in Inflammation or Several Cell
Types? Frontiers in Physiology, 9(113).

Saneei, P. et al.; Influence of Dietary Approaches to Stop Hypertension (DASH) diet

on blood pressure: A systematic review and meta-analysis on randomized
controlled trials Nutrition, Metabolism and Cardiovascular Diseases 2014 (24):12,
1253–1261.

Udensi UK, Tchounwou PB. (2017) Potassium homeostasis, oxidative stress, and
human disease. International Journal of Clinical and Experimental Physiology. 4
111–122. DOI: 10.4103/ijcep.ijcep_43_17

Websites

Food and Nutrition Research Institute (2015). Philippine Dietary Reference Intakes
[PDF]. Retrieved from
http://www.fnri.dost.gov.ph/images/sources/PDRI-Tables.pdf.

Olson, D., et. al. (n.d.) Administration of IV potassium (KCL). Médecins Sans
Frontières. Retrieved from
https://medicalguidelines.msf.org/viewport/CHOL/english/appendix-8-
administration-of-iv-potassium-kcl-25297281.html on November 30, 2019.

Schrier, (n.d.) Hypocalcemia: Clinical Manifestations. ADK1 1(3) Retrieved from

https://www.cybernephrology.ualberta.ca/cn/Schrier/Volume1/Chapt3/ADK1_3_1
0-12.PDF on 13 November, 2019.

30
 The Philippines. (2017). Retrieved December 4, 2019, from https://idf.org/our-
network/regions-members/western-pacific/members/116-the-philippines.html.

Books

Food and Nutrition Research Institute. (1997). The Philippine food composition
tables. Metro Manila, PH: DOST

Food and Nutrition Research Institute. (2012). Food exchange lists for meal
planning. Philippines: Food and Nutrition Foundation.

Mahan, L. K., & Raymond, J. L. (2017). Krause’s food & the nutrition care process
(14th Ed.) St. Louis, MO: Elsevier

Nelms, M. N., Sucher, K. P., & Roth, S. L. (2010). Nutrition therapy & pathophysiology
(2nd Ed.). Belmont, CA, USA: Wadsworth CENGAGE Learning

Tanchoco, C.C., Ruiz, A.J. (2010). Diet manual recommended for use in the
Philippines (5th Ed). Makati, Metro Manila: NDAP

31
Appendices

32
Appendix A: Computation of Total Energy Requirement and Diet Prescription

Computation of Diet Prescription:

Using Tannhauser’s
DBW = (157.48 cm - 100) - 10%
= 51.73 kg or 52 kg

Using Krause Method

TER = 52 kg x 35 kcal/kgBW
= 1820 kcal or 1800 kcal

Carbohydrates = 1800 kcal x 60%/ 4 = 270 g

Protein = 1800 kcal x 20% / 4 = 90 g
Fat = 1800 kcal x 20% / 9 = 40 g

Diet Rx: 1800 kcal; 270 g CHO; 90 g CHON; 40 g Fat

33
 Appendix B: Nutritional Care Plan
Assessment Diagnosis Intervention Monitoring Evaluation
Patient Information Increased blood [Goal] Provide a food diary Conduct a 24-hour food
Age: 52 years old sugar levels Achieve and maintain and record all foods recall upon next sessions.
Female, Barangay Health related to the normal glycemic levels. eaten throughout the • If Carbohydrate
Worker patient’s Diabetic day to monitor food levels are within
Condition as Maintain normal nutrition intake. prescribed range and
Diagnosed with Diabetes with evidenced by status to prevent risk for carbohydrate
uncontrolled hyperkalemia high laboratory complications Blood glucose levels counting is followed,
results for FBS should be duly noted then the intervention
Anthropometric Assessment with 142.50 [Plan] to monitor any is successful;
Height: 5’2” or 157.48 mg/dL and an Diet Rx: changes. Self- otherwise reassess
Weight:49 kg HbA1C value of 1800 kcal; C270 P90 F40 Monitoring Blood diet prescription.
BMI: 19.76, Normal WHO 9.2%. Glucose test can be • If the Glucose levels
classification Adhere to the used for monitoring decreases, then the
recommended diet blood glucose intervention is
prescription to achieve successful;
Biochemical Assessment normal blood glucose levels. Ask the patient after otherwise, reassess.
Recommend the use of two weeks if she is
TCG, 508.71 dL High carbohydrate counting. adhering to the Conduct a simple test on
Cholesterol, 251 dL High recommended diet glycemic index of different
Uric Acid, 6.81 mf/dL High Discuss the effects of prescription. foods.
Creatinine, 2.38 High diabetic condition on health • If the test results are
BUN, 89.78 mg dL High
especially on comorbidities satisfactory, then
HbA1c, 9.2% High
FBS, 142.50 mg/dL High
that might develop. the intervention is
Segmenters, 77% Elevated successful;
Albumin, 3+ Positive Educate the patient otherwise, reassess
Amorphous Urate Moderate on foods with high glycemic
HDL Low index that can easily
K+ 2.9 mmol/L Low increase blood glucose.
Suggest other alternatives
Clinical Assessment on items with high glycemic
Dizziness index.

34
Thinning Appearance Hypokalemia [Goal] Monitor potassium Conduct a 24-hour food
Anorexia related to Control low levels of levels through blood recall upon next sessions.
diabetic potassium level tests, urinalysis, and • If potassium rich
Dietary Assessment condition due to ECG tests to foods taken are
Energy and Nutrient impaired insulin [Plan] determine any within prescribed
Intake Adequacy secretion as Increase potassium level by detrimental amounts, then the
Energy: 32.28% evidence by dietary intake of potassium- changes. intervention is
CHO: 35.12% potassium rich foods, if not effective, successful;
CHON: 32.78% electrolyte levels then consider administering Provide 24-hour otherwise reassess.
Fats: 29.67% of 2.9 mmol/L. IV fluid with KCL. food recall on food • If the potassium
consumption level increases, then
Calcium: 31.83% Discuss the effects of throughout the day the intervention is
Vitamin A: 51.96% hypokalemic condition on to monitor successful;
Iron: 18.08% health especially on potassium rich food otherwise, reassess.
Vitamin C: 84.62% comorbidities that might intake.
develop—Renal Disease. Conduct a simple test on
The patient usually skips potassium content of
breakfast and lunch before Educate on the potassium different foods.
hospitalization. She usually content of different foods • If the test results are
eats only one or twice a day and its effects on alleviating satisfactory, then
when hungry. current health problem. the intervention is
Educate patient and family successful;
on how to properly read otherwise, reassess
nutrition labels to help them
in preparing food according
to the diet prescription.

35
Inadequate food [Goal] Provide a food diary Review food diary after 3
and nutrient Increase food intake and to track weeks:
intake related to achieve recommended recommended food • If food intake is
anorexia or loss percent adequacy on intake of the patient. increased and
of appetite as energy and nutrient intake. energy and nutrient
evidenced by 24- Monitor weight if percent adequacy
hour food recall [Plan] increasing or increased, then the
and quantitative Adhere recommended diet decreasing to intervention is
dietary prescription to increase manage and loss or successful,
assessment of energy and nutrient food gain of weight. otherwise reassess
32.8% adequacy intake. the diet prescription.
for energy Conduct interview
intake. Provision of nutrient dense after 3 weeks to Determine weight after 3
food with a mechanical soft assess the patient’s weeks:
diet to facilitate chewing. food intake. • If the patient gain
weight by a kilo or a
Educate the patient and her half, then the
family about the importance intervention is
of adequate food intake and successful;
how it can affect the otherwise, reassess
patient’s current condition. the diet rx and
review strategies.
Give examples of strategies
or tips on how to increase Review the patient’s
the patient’s food intake knowledge by asking
such as giving calorie- questions:
dense food or adding • If the family
protein and caloric members gave
supplements on food. example of
strategies, then the
intervention is
successful,
otherwise, reassess.

36
Appendix C. Data Collection Tools

37