Kaitlyn Dickson

TR5321-B

June 11, 2015

Nutrition First Office Call

Pt Initials: HD

Appointment length: 30 min

ASSESSMENT
Client History
Reason for visit: Referral from a nephrologist to discuss implementing a renal diet for ESRD.
Pts daughter present at visit.
Personal hx: 70 yo German American male. Quit smoking 5 yrs ago.
Medical hx: Recently started HD 3 x/wk. Dxd with T2DM 10 yr ago. Wears dentures. Current Sx
include fatigue, muscle cramps, and constipation.
Family Med hx: Not assessed.
Social hx: Lives alone and mostly homebound. Relies on fixed income. Daughter lives close and
is supportive. Pt relies on daughter and Access Ride medical transportation for travel to dialysis
pts.
Food and Nutrition-Related History
Food and Beverage Intake and/or Nutrition Intake Analysis Results:
Typical day recall:
B: Often skips as sleeps late and doesnt have much of an appetite lately. Drinks 1 cup coffee
with 2 Tbs half and half when wakes up.
S: (11 am) 8 ounces orange juice and 2 slices toast with butter
L (1:00 pm): 2 cups canned tomato soup (favorite is tomato) 12 saltine crackers with 1 ounce
sliced cheddar cheese and 8 ounces 2% milk.
D (8 pm): Hungry man TV dinner (favorite is Salisbury steak) and 12 oz iced tea.
S: (10 pm) 1 cup chocolate ice cream
Typical day reflects five serving equivalent of dairy foods (recommended 1 serving), 1830 mL
fluids (244%), and dependence on convenience foods for lunch and dinner. Intake indicates no
limitation on foods high in PO4, K, Na, or fl. Dietary analysis demonstrates low kcal (75%), low
PRO (84%), and high in saturated fat (212%). Analysis indicates Fe and Ca WNL, high K (120%),
high PO4 (127%), and high Na (204%). Fluid intake is 46 fl oz (144%). No drugs or ETOH.
Food and Nutrition History: Eats mostly canned and frozen meals because they are easy to
prepare. Attended renal diet class but doesnt remember the material.
Knowledge/Beliefs/Attitudes/Behaviors: Enjoys eating convenience foods. Willing to heat up
food. Daughter described pt as set in his ways.
Food Access and Preparation: Limited means to shop and cook. Daughter brings groceries
from Safeway or Grocery Outlet and occ prepares meals and brings them to pt.
Food allergies/Intolerances: NKFA.
Physical Activity: Sedentary.
Medications and Dietary Supplements: Atenolol, Erythropoetin, Maralax, Sertraline, Ferrlecit,
Insulin, Naphrocaps, Zemplar, Tums: dislikes flavor and occ forgets to take with meals.
Anthropometric Measurements
Height (in/cm): 70 in/177.8 cm
Weight (lb/kg): 153 lb/69.5 kg (dry weight)
BMI: 22.0 (normal)
Weight hx: Weight 1 yr ago: 170 lb. Weight 3 mo ago: 159 lbs. Weight a last dialysis session:
165 lbs. Weight p last dialysis session: 160 lbs.
Other measurements: Urine output: 250 mL
Ideal/reference weight: 144-176 lb/66-80 kg
%ideal/reference weight: 87%
Usual weight: Unknown. 1 year ago: 170 lb/77.3 kg %usual weight: 90%
% Wt change: 6.5% loss in 9 months. 4% weight loss between dialysis. Weight change
classification: Of concern.

Kaitlyn Dickson

TR5321-B

June 11, 2015

Desired weight: Maintain current weight

Biochemical Data, Medical Tests and Procedures
Pertinent labs/tests/procedures: BUN 20 mg/dL (), albumin 3.0 gm/dL (), K+ 6.4 mEq/L (),
Na+ 126 mEq/L (), PO4 7.2 mg/dL (), serum Ca+ 8.1 mg/dL (), HCT 36% (), HGB 12.2 g/dL
(), Ferritin 21 ng/mL (), TIBC 455 mcg/dL (), Triglycerides 244 mg/dL (), HbA1C 7.2 % (), all
other lab values WNL.
Nutrition Focused Physical Exam Findings
GI Function: Chronic constipation. BM q 2-3 days. Does not concern pt.
Sleep hx: Often sleeps during dialysis which causes trouble sleeping at noc. C/o muscle cramps
that also cause difficulty sleeping at noc. Tends to sleep in late.
Energy: Very low.
Stress: Not assessed.
Blood pressure: 143/92 mmHg (stage 1 hypertensive)
Overall clinical observation: Pt is fatigued and slow in movements and reaction time. Nods off
during pt. Wears dentures that fit loosely. Swollen ankles. Daughter is attentive.

DIAGNOSIS
Problem: Altered nutrition related lab values (potassium NC-2.2).
Etiology: Difficulty retaining information relating to ESRD and preference for high
potassium foods.
Signs and Symptoms: lab values indicating high blood potassium (6.4 mEq/L) and
dietary intake reflecting 120% recommended potassium for renal diet.
Problem: Excessive Fluid Intake (NI-3.2).
Etiology: Knowledge deficit regarding sodium and fluid restriction for renal diet.
Signs and Symptoms: Dietary intake reflecting 204% recommended sodium for renal
diet and 195% fluid equivalent recommended for renal diet, sodium retention
indicated by low Na+ lab (126 mEq/L), and edema of the extremities.

INTERVENTION
Nutrition Prescription
REE/ Kcals: 69.5 kg (35-40 kcal/kg) = 2433-2780 kcal
Protein (g/kg): 69.5 kg (1.2 g/kg) = 83.4 g
Fluids (ml/kg): Urine output (240) + 3 cups (711 mL) = 951 mL
Other: Reduce dietary potassium to 2-3 g/d and reduce dietary sodium to less than 2000 mg/d.
Reduce fluid intake to 950 mL.
Intervention 1: Nutrition Education - Content - Nutrition relationship to health/disease
(E-1.4): Educated pt and daughter on how high blood levels of potassium can lead to
cardiac arrest in people with ESRD. Reviewed typical day intake and identified sources
of high potassium. Made suggestions to switch tomato soup to chicken noodle and
orange juice to apple or cranberry juice. Gave daughter handout with high, medium,
and low potassium foods. Daughter agreed to highlight daily serving
recommendations and post handout on pt refrigerator. Pt agreed to switch juice and
soup to low-potassium options.
Intervention 2: Nutrition Education Content Recommended modifications (E-1.2):
Discussed importance of decreasing sodium and fluid intake wth pt and daughter.
Identified sources of fluid in diet (coffee and cream, ice tea, OJ, soup, ice cream).
Daughter agreed to assist in decreasing pt fluid intake by using a sharpie to make a

Kaitlyn Dickson

TR5321-B

June 11, 2015

mark at six ounces on all of pts cups and coffee mugs. Pt agreed to only drink 3 6-oz
portions of fluid/d: coffee in the morning, and juice/gingerale at lunch and dinner.
Suggested pt switch to low sodium frozen dinners and canned soups. Pt agreed and
daughter offered to choose low-sodium options when shopping for pt. Educated on
checking label of low sodium products for potassium substitutes for sodium.

MONITORING /EVALUATION
Professional goal#1: To reduce risk of ESRD related cardiac arrest, on f/u pts, K+ lab
values will be between 3.5-5.5 mEq/L and 24 hr recall will show no more 2-3 serving of
low-potassium foods, 2 servings of medium-potassium foods, and 1 serving of highpotassium foods.
Professional goal#2: To reduce risk of ESRD related cardiac arrest, on f/u pts, Na+ lab
values will be between 135-145 mEq/L and 24 hour recall will demonstrate low sodium
frozen dinner, low sodium canned soup, and less than 950 mL fluid.
Follow up: Recheck blood levels and continue support with maintaining appropriate
levels of potassium, fluid, and sodium in diet. Address orange juice and Atenolol DNI.
Increase protein and calories (small, frequent meals). Address non-compliance with
phosphate binders and explore other brands that might be more palatable or
decrease dietary phosphorus. Monitor BS. Address loose denture and discuss
resources for replacement. Address low lifecycle nutrients: B1, B3, B6, B12, Biotin.
Handouts provided: Renal diet hand-out, low, medium, and high potassium foods
handout, and list of common potassium substitutes for sodium.
Clinician signature: __Kaitlyn Dickson____________________________________________